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2019 HSR&D/QUERI National Conference Abstract

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1061 — Understanding racial disparities in minimally invasive hysterectomy for uterine fibroids in the VA Healthcare System

Lead/Presenter: Lisa Callegari,  COIN - Seattle/Denver
All Authors: Callegari LS (Center of Innovation for Veteran-Centered and Value-Driven Care, University of Washington Department of Obstetrics & Gynecology, Seattle ), Bossick A (Center of Innovation for Veteran-Centered and Value-Driven Care, University of Washington Department of Health Services, Seattle), Gray KE (Center of Innovation for Veteran-Centered and Value-Driven Care, University of Washington Department of Health Services, Seattle) Washington DL (Center for the Study of Healthcare Innovation, Implementation and Policy, UCLA Geffen School of Medicine, Los Angeles) Christy AY (Women's Health Services, Veterans Administration Central Office, Washington, DC) Lynch K (Informatics, Decision-Enhancement and Analytic Sciences Center, University of Utah, Salt Lake City) Gardella C (VA Puget Sound Health Care System, University of Washington Department of Obstetrics & Gynecology, Seattle) Smith R (Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle) Katon JG (Center of Innovation for Veteran-Centered and Value-Driven Care, University of Washington Department of Health Services, Seattle)

Objectives:
Minimally invasive hysterectomy (MIH), including vaginal and laparoscopic procedures, results in faster recovery and fewer complications than abdominal hysterectomy. In VA, Black women Veterans with fibroids are less likely to have MIH than White women Veterans with fibroids. The extent to which clinical factors that make MIH more challenging, such as large fibroids or prior surgeries, contribute to racial disparities is unclear. Our objective was to examine the association of race and MIH, accounting for clinical factors.

Methods:
We conducted a retrospective cohort analysis among Black and White Veterans with fibroids and hysterectomy in VA between 2012-2014, identified by ICD-9 codes. Abstracted data from charts of 732 Veterans (439 Black, 293 White) were merged with administrative records. Hysterectomy route (vaginal, laparoscopic, abdominal) was identified by ICD-9 codes. We used multinomial logistic regression to estimate associations of race with hysterectomy route. Models accounted for within-facility correlation and adjusted for age, income, body mass index, gynecologic diagnoses, medical comorbidities, geographic region, and surgery year, as well as chart-abstracted parity, surgical history, and uterine size estimated by weight (grams) from pathology reports.

Results:
Compared to White Veterans, Black Veterans with fibroids were more likely to undergo abdominal hysterectomy (62% vs 47%), to be under age 45 (49% vs 44%), and to have low income (60% vs 51%), obesity (56% vs 49%), prior myomectomy (12% vs 4%), and prior cesarean section (28% vs 24%). Black Veterans had nearly two-fold greater median uterine weight (276g versus 143g). After adjusting for clinical and demographic factors, Black Veterans were no less likely than White Veterans to undergo MIH (laparoscopic vs abdominal relative risk ratio(RRR):0.90, 95%CI 0.63-1.27; vaginal vs abdominal RRR:0.80, 95%CI 0.51-1.24).

Implications:
Clinical factors important to decision-making about hysterectomy route differ between Black and White women Veterans with fibroids undergoing hysterectomy. Differences in MIH do not persist after adjustment for these factors.

Impacts:
Additional research is needed to investigate modifiable factors in Black Veterans' pathways to hysterectomy that could underlie observed clinical differences, such as delays in diagnosis or treatment. This information will be critical to inform future interventions to ensure equity and reduce disparities in VA gynecology care.