1036 — Unequal Treatment? Racial/Ethnic Differences in Receipt of Minimally Invasive Hysterectomy in the Veterans Health Administration

Lead/Presenter: Lisa Callegari, COIN - Seattle/Denver
All Authors: Callegari LS (HSR&D, Seattle/Denver COIN) Gardella CM (VA Puget Sound Health Care System) Gray KE (HSR&D, Seattle/Denver COIN) Zephyrin L (VA Women's Health Services) Uchendu US (VA Office of Health Equity) Katon JG (HSR&D, Seattle/Denver COIN)

Objectives:
Studies in the general population demonstrate racial/ethnic differences in receipt of minimally invasive surgical techniques for hysterectomy, one of the most commonly performed surgeries in women. Similar disparities in use of minimally invasive techniques for common surgeries such as cholecystectomy have been previously documented in the Veterans Administration (VA), but whether such disparities exist for gynecologic surgery in VA is unknown. Our objective was to investigate associations between race/ethnicity and receipt of minimally invasive hysterectomy, including laparoscopic and vaginal approaches, in VA.

Methods:
We identified all women Veterans undergoing hysterectomy provided or paid for by VA for benign gynecologic conditions in fiscal years 2012-2014. Race/ethnicity was categorized as non-Hispanic White, non-Hispanic Black, Hispanic, other. Hysterectomy mode (laparoscopic with or without robot-assist, vaginal, or abdominal) was classified by ICD-9 codes. We used modified Poisson regression to estimate associations of race/ethnicity with mode of hysterectomy (laparoscopic versus abdominal; vaginal versus abdominal), controlling for age, income, body mass index, clinical indication, medical and mental health conditions, whether the procedure was provided or paid for by VA, and fiscal year.

Results:
Among 2,744 hysterectomies, 53% were abdominal, 29% laparoscopic, and 18% vaginal. After adjustment, compared to non-Hispanic White women, non-Hispanic Black women were less likely to have minimally invasive hysterectomy (laparoscopic versus abdominal relative risk [RR]:0.71, 95%CI 0.58-0.87; vaginal versus abdominal RR:0.74, 95%CI 0.60-0.90). Compared with White women, Hispanic women were equally likely to have laparoscopic versus abdominal hysterectomy (RR:1.17, 95%CI 0.95, 1.45), but less likely to have vaginal versus abdominal hysterectomy (RR:0.51, 95%CI 0.32-0.81).

Implications:
Despite equal access to health care through the VA, women Veterans of minority race/ethnicity are less likely to receive a minimally invasive hysterectomy, independent of socioeconomic factors or clinical diagnoses.

Impacts:
These data suggest that the benefits of minimally invasive hysterectomy, such as lower morbidity and faster recovery, may not be equitably distributed in VA. Given the projected rise in numbers of female and racial/ethnic minority Veterans, further study to understand and address the causes of this apparent disparity will be critical to achieving VA's health equity goals as outlined in the Health Equity Action Plan.