Supportive interventions may alleviate ‘disconcerting’ disparities in hysterectomy
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Key takeaways:
- Black women have lower odds of undergoing minimally invasive hysterectomy in the U.S.
- Interventions focusing on education, referrals and case sharing may alleviate minimally invasive hysterectomy barriers.
SAN FRANCISCO — Supportive interventions to improve knowledge of options and barriers for patients and surgeons may reduce racial disparities in minimally invasive hysterectomy, researchers reported.
The American College of Obstetricians and Gynecologists recommends minimally invasive surgery for hysterectomy, such as laparoscopy or vaginal hysterectomy, whenever possible as these procedures result in less pain and opioid use, fewer recovery days and fewer incisional complications compared with abdominal hysterectomy.
“I've been in practice as a fellowship-trained minimally invasive surgeon for 12 years now at two different institutions within the Boston area, and I, along with many colleagues, have had this experience where we'll be operating in one room on a patient and doing a laparoscopic procedure, for example, for a very large hysterectomy, and in the room right next door, a patient is undergoing an open hysterectomy for an even smaller uterus with fewer potential reasons for that patient to have had to go forward with open as opposed to laparoscopic surgery. And it's disconcerting,” Louise P. King, MD, JD, assistant professor in the division of minimally invasive gynecologic surgery in the department of obstetrics and gynecology at Brigham and Women’s Hospital, said during a presentation at the ACOG Annual Clinical & Scientific Meeting.
King and colleagues investigated why some patients were offered a variety of options for hysterectomy while others were offered different options within their hospital system.
Racial disparities in minimally invasive surgery
Several U.S. studies have demonstrated racial disparities in access to minimally invasive hysterectomy, according to King.
One study from 2020, published in Journal of Minimally Invasive Gynecology, found a lower rate of minimally invasive hysterectomy for Black women, even when excluding those with uterine fibroids, obesity and prior surgery, which are the main factors that drive the decision for open vs. laparoscopic hysterectomy. Another study looked at hysterectomy rates at Cedars-Sinai from 2015 to 2020 and found an adjusted OR for minimally invasive surgery of 0.35 (95% CI, 0.25-0.48) for Black women and 0.41 (95% CI, 0.27-0.61) for Hispanic women compared with white women.
At Kaiser Permanente, researchers reviewed 31,385 benign hysterectomies performed from 2008 to 2015 and used a quality improvement initiative with leadership engagement, surgeon training, reduction of low-volume surgeons and encouragement of best practices to increase the rate of minimally invasive hysterectomies. As they stratified the workforce and encouraged higher volume among surgeons, researchers observed an increase in the rate of laparoscopic hysterectomy with decreases in racial disparities in access to minimally invasive hysterectomies.
Finally, a study from Newton-Wellesley Hospital, which looked at hysterectomies performed for benign conditions from 2004 to 2012, evaluated whether having a department of minimally invasive gynecologic surgery would impact the number of minimally invasive procedures performed. Researchers observed an increase in laparoscopic hysterectomies from 8% in 2004 to more than 93% in 2012 with the implementation of a department of minimally invasive gynecologic surgery.
According to King, encouraging incorporation of high-volume surgeons and pushing towards minimally invasive surgery resulted in increased access to and numbers of these procedures. However, King noted, minimally invasive surgery rates at Brigham and Women’s Hospital were not as high as those observed in other local institutions, like Newton-Wellesley Hospital.
“We had two things that we wanted to investigate very carefully: to understand the underlying numbers behind our experience of being in one operating room and doing something by scope and next door, a seemingly easier case was being done open and why was that happening; and the disparities that we were experiencing and seeing,” King said. “What were they in a quantifiable sense? And then, how can we drill down to figure out within our system what exactly was driving the disparities that we were seeing, and thus, how can we find solutions to it?”
Findings at a single institution
King, Louisa Chatroux, MD, MPH, minimally invasive gynecologic surgery fellow at Brigham and Women’s Hospital, and Parmida Maghsoudlou, BA, research assistant in the department of obstetrics and gynecology at Brigham and Women’s Hospital, conducted a retrospective chart review at their institution of 4,663 cases of laparoscopic, robotic and open hysterectomy for benign indications performed from 2009 to 2022.
They found Hispanic women were the youngest at the time of hysterectomy (mean age, 44.4 years). Black women had the highest BMI (31.6 kg/m2), followed by Hispanic (29.6 kg/m2) and white (28.4 kg/m2) women. Hispanic women had the highest prevalence of prior surgery (79.8%), followed by Black (63.4%), white (61%) and Asian (55.3%) women. In addition, average uterine weight was highest for Black women (560.7 g) and lowest for white women (337.8 g).
Black women had an average of 90 cc more estimated blood loss vs. white women, Maghsoudlou said during the presentation, which may be attributed to the larger uterine size observed in that group. Operating time was also significantly longer for Black vs. white women (165.1 vs. 123.7 minutes).
Researchers observed significantly more estimated blood loss (366.5 vs. 89.6 cc), intraoperative complications (9.7% vs. 3%), postoperative complications of three or more (1.1% vs. 0.4%) and longer median hospital length of stay (2 vs. 0 days) in the open vs. minimally invasive surgery group.
After adjusting for age, BMI, uterine weight, procedure year and prior surgery, investigators found Black women had lower odds of undergoing minimally invasive surgery compared with white women (OR = 0.78; 95% CI, 0.64-0.96).
“With this first round of analysis, we confirmed that the national trend described in prior studies applied to our own patient population as well,” Maghsoudlou said. “That is, that when even controlling for common clinical confounders, including uterine weight and surgical history, racial disparities exist, and our African American patients have significantly lower odds of undergoing minimally invasive surgery than their white counterparts.”
King and colleagues collaborated with a quality and safety council within Brigham and Women’s Hospital to receive guidance on how to identify the origin of these disparities and what could account for their findings. The council encouraged the researchers to incorporate the social vulnerability index (SVI) in their analysis to determine whether the racial inequities observed were structural or institutional.
SVI data incorporated into multivariate regression analysis of hysterectomies performed from 2016 to 2022 demonstrated that racial disparities in hysterectomy rates resolved, indicating no significant racial disparity in minimally invasive surgery rates of the procedure at the hospital.
“This suggests that, although racial disparity does exist, the disparity likely originates outside of the hospital, and it’s a product of structural racism instead of institutional racism,” Maghsoudlou said.
According to King, appropriate referral patterns, better outreach and support to overcome barriers from structural racism are essential.
“What we gathered from that is that there is something going on in our hospital system that is not affording everybody that option of seeing us if they have a large uterus or have a larger BMI or something else that's pushing toward an open procedure through some of our other surgical colleagues,” King said.
In addition, when removing uterine weight from the analysis, the researchers found the racial disparities reappeared. This means there is an opportunity for further training and education for more surgeons to perform surgery at higher uterine weights, higher BMI and by a minimally invasive approach, King said.
“Disparities do exist. They are a product of structural racism, but it’s being perpetuated within our system,” King said. “It might not originate in it, per se, but our inability to truly structure the referral patterns within our system and ensure that every patient has the same access is absolutely contributing to it.”
Addressing racial disparities
To address these disparities, King held stakeholder meetings and lectures to identify barriers her colleagues experienced in referring or counseling patients about the benefits of minimally invasive surgery. The meetings were modeled after mediation with an aim to understand where patients come from and what holds surgeons back from achieving equity and access.
In an ongoing case-control study, King and colleagues observed a relationship between lower surgical volume and open hysterectomy cases. Therefore, the researchers wanted to ensure that lower-volume surgeons were supported by higher-volume surgeons to provide aid or surgical coaching. After a chart review of counseling and case-matching open and laparoscopic cases, King and colleagues noted that women who underwent an open hysterectomy were told they were not candidates for laparoscopy, despite having similar characteristics to patients offered minimally invasive surgery.
Therefore, King and colleagues are considering standardized patient education materials on the benefits of minimally invasive surgery. In addition, they are working to create centralized case sharing to ensure the right surgeon works with the right patient and that there is appropriate volume for surgeons with options for surgical coaching.
According to King, stakeholders wanted a process centered around uniform education and knowledge of options. A committee of people from different training and practice backgrounds designed educational materials to describe minimally invasive surgery benefits and options available at Brigham and Women’s Hospital. This created a streamlined system for minimally invasive surgery referrals and case sharing. The process will be audited to see whether these interventions improve minimally invasive surgery rates and address racial inequities. According to King, the 6-month audit of the case-control study and stakeholder meetings will occur at the end of 2024.
“It really shouldn't matter whether you walk into one of our community clinics, one of our private clinics, one of our subspecialty clinics — everybody should have equitable access to information about the benefits of minimally invasive surgery and how prevalent and accessible it is within our system, and then they can make informed choices from there,” King said.
In the future, King noted, the goal is to streamline referral processes and examine processes and barriers to access. The work could create a blueprint for other institutions to use similar stakeholder processes and mediated meetings to develop solutions to address racial disparities.
For more information:
Louise P. King, MD, JD, can be reached at lperkinsking@bwh.harvard.edu.
Louisa Chatroux, MD, MPH, can be reached at louisachatroux@gmail.com.
Parmida Maghsoudlou, BA, can be reached at pmaghsoudlou@bwh.harvard.edu.
References:
- Loring M, et al. J Soc Laparoscopic Robotic Surg. 2015;doi:10.4293/JSLS.2014.00221.
- Pollack LM, et al. J Minim Invasive Gynecol. 2020;doi:10.1016/j.jmig.2019.09.003.
- Schneyer RJ, et al. J Minim Invasive Gynecol. 2022;doi:10.1016/j.jmig.2022.06.025.
- Zaritsky E, et al. JAMA Netw Open. 2019;doi:10.1001/jamanetworkopen.2019.17004.