Health Disparities
Investigating Practice-Level Surgery Tendency: Racial/Ethnic Differences among Premenopausal Hysterectomy Patients Joacy Gerard Mathias* Joacy Gerard Mathias Natalie A Rivadeneira Lauren G Anderson Michael Green Annie Green Howard Mollie E Wood Erin Carey Timothy S Carey Wanda Nicholson Til Sturmer Kemi Doll Whitney R Robinson
Intro: In the US, benign premenopausal hysterectomy is disproportionately common in the South and among Black women. Much research investigates provider factors associated with hysterectomy approach and outcomes. Little research investigates practice-level factors associated with greater hysterectomy rates. Methods: We characterized practices by proportions of hysterectomy patients with low pre-surgical symptom severity, indicating practices’ High Surgery Tendency (HST). Then, we investigated whether Black, White, and Hispanic patients were differentially likely to be treated by HST practices. The Carolina Hysterectomy Cohort used electronic health record (EHR) data from premenopausal benign hysterectomy patients (aged 18-44 years) treated in the South from 2014-2017. EHR data were linked to state physician licensing data to obtain surgeon and practice demographics. We ranked practices by % of patients below the study median on measures of pre-surgical symptom severity (bulk, bleeding, and pain). Practices with >18% of patients below median on all 3 symptoms were called HST. In multivariable-adjusted (MV-adj) Poisson regression models, dichotomized HST was modeled as a function of patient race/ethnicity (Non-Hispanic White [referent], non-Hispanic Black, Hispanic). Covariates were patient age, BMI, Charlson Comorbidity Index, symptom severity scores, and insurance payor (public, private, and uninsured). Results are presented as MV-adj PR (95% CI). Results; The analytic dataset included 1640 patients, 100 providers, and 20 practices. The 6 HST practices treated 531 patients. Hispanic patients were most likely to be treated at academic centers and least likely to be treated by HST practices (PR: 0.60 [0.40, 0.91]). Black and White patients were similarly likely to be at HST practices (PR=1.08 [0.95, 1.23]). After excluding academic practices because they were unlikely to operate on low-severity patients, in non-academic practices, Black and Hispanic patients were twice as likely to be treated at HST practices: PRs=1.86 (1.19, 2.89) and 1.53 (1.15, 2.04), respectively. Conclusion: Outside of academic centers, Black and Hispanic patients were more likely than White patients to be treated at practices with a lower threshold for performing surgery.