From the Journals

Black women more likely to have open hysterectomies

Publish date: December 24, 2018
By
Kari Oakes

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Check your biases to improve care for black women

The discrepancies reported by Dr. Alexander and her colleagues between black and white women undergoing hysterectomy for nonmalignant reasons mirror discrepancies found for other oncologic procedures, including colectomy and prostatectomy.

Findings of the current study show that black women continue to be less likely to receive more modern, minimally invasive procedures, and that outcomes are worse for these women, even after controlling for factors that may contribute to complications.

The American College of Obstetricians and Gynecologists (ACOG) has looked at this issue. In a 2015 opinion, an ACOG committee looked at three categories of factors contributing to racial disparities in women’s health care. Patient-level factors include such things as genetics, medical comorbidities, and patient preferences and adherence. Health care system–level factors include insurance status and geographic barriers to accessing care, while stereotyping and implicit bias on the part of practitioners constitute the third set of factors.

All these factors are likely in play for the discrepancies seen in hysterectomy rates. Those who care for black women need to understand the long, shameful history of how black Americans were mistreated, undertreated, and used for medical experimentation without consent. This past shapes present care and contributes to the difficulty black patients have trusting today’s health care systems.

The important question today is how individual health care providers will address their own biases, learn from the past, and move forward to do better for our black patients.

Shanna N. Wingo, MD , is an ob.gyn. and a gynecologic oncologist in private practice in Phoenix. She had no potential conflicts of interest. These remarks were drawn from an editorial accompanying the study by Dr. Alexander et al.( Obstet Gynecol. 2018 Dec 4;133[1]:4-5 ).


 

FROM OBSTETRICS & GYNECOLOGY

Black women were more likely than white women to undergo open hysterectomy, according to a recent analysis of national surgical data by Amy L. Alexander, MD, MS, of Northwestern University, Chicago, and her colleagues.

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Even after the researchers controlled for many factors that might influence surgical approach, such as comorbidities and body mass index, black women had an odds ratio of 2.02 to receive open, rather than laparoscopic, hysterectomy (95% confidence interval, 1.85-2.20), according to a study in Obstetrics & Gynecology.

The analysis of the targeted hysterectomy file in the National Surgical Quality Improvement Program (NSQIP) database showed that, of 15,316 women who had hysterectomy for nonmalignant indications, the 25% who were black also were more likely to have major complications with open procedures. Such complications as sepsis, wound dehiscence, prolonged intubation, and death were seen in 4% of the black women, versus 2% of the white women receiving open hysterectomy (P less than .001). Minor complications, such as urinary tract infections, superficial wound infections, and blood transfusions, also were more common for black women having open procedures (11% vs. 7%; P less than .001).

The study used a large national database with detailed information about comorbidities and patient characteristics to look at racial disparities in surgical route and complications for the second-most-common surgical procedure women receive on the United States. The results, said Dr. Alexander and her coauthors, confirm and extend previous work showing these disparities.

Black women are known to have more diabetes and hypertension, as well as higher rates of obesity, compared with white women, wrote Dr. Alexander and her coauthors. Even after they controlled for all these variables, black women still had significantly higher odds of having complications from hysterectomy: The odds ratios for major and minor complications were 1.56 and 1.27, respectively.

Uterine weight was included and tracked as a binary variable, with large uteri considered those weighing 250 g or more. Making uterine weight a binary, rather than continuous or categorical variable, didn’t significantly change results, and realistically mirrors a surgeon’s assessment of a uterus as “large” or “small” when making treatment decisions, Dr. Alexander and her coauthors said.

Because the median weight of uteri from black women was more than double the weight of those from white women (262 g vs. 123 g), the investigators also performed an analysis looking just at women with uterine weight less than 250 g, to ensure that uterine weight alone was not accounting for much of the disparity. In this analysis, the black patients still had an adjusted odds ratio of 1.84 for receiving an open procedure.

“Some of the postoperative complications experienced by black women are likely attributable to the fact that black women are more likely to undergo an open hysterectomy,” noted Dr. Alexander and her colleagues. “However, because black race is still associated with a higher odds of complications, even when adjusting for hysterectomy route, there are other contributing factors that warrant further investigation.” Among these factors, they said, may be access to care and quality of care while hospitalized.

The study’s strengths include the use of the NSQIP database’s prospectively collected data to construct the cohort study; the data base included “important patient-level factors such as uterine size, obesity, and comorbidities not previously available in other secondary data set studies,” noted Dr. Alexander and her colleagues. But the possibility of unmeasured bias persists, they said, and such variables as regional practice patterns and surgeon experience and procedure volume could not be detected from the NSQIP data on hand.

“This study suggests that an important step to reduce the disparity in route of surgery and postoperative complications is to increase access to and use of minimally invasive surgery,” wrote Dr. Alexander and her coauthors.

The study was funded by the National Institutes of Health. Dr. Alexander and her colleagues reported no conflicts of interest.

SOURCE: Alexander AL et al. Obstet Gynecol. 2018 Dec 4. doi: 10.1097/AOG.0000000000002990

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