Disparities in Access to Minimally Invasive Surgery for Women Undergoing Hysterectomy in California

摘要

INTRODUCTION: The objective of this study was to analyze the effect of race and other demographic variables on access to minimally invasive surgery for hysterectomy performed in California. METHODS: Retrospective population-based analysis of patients undergoing hysterectomy was identified by International Classification of Diseases, 9th Revision codes from the California Office of Statewide Health Planning and Development discharge database between January 1, 2008, and December 31, 2011. The frequencies of minimally invasive hysterectomy (vaginal, laparoscopic, robotic-assisted) and total abdominal hysterectomy were calculated and multivariate logistic regression analysis was used to identify independent predictors of access to minimally invasive hysterectomy including race, insurance type, Charlson comorbidity score, and hospital hysterectomy volume. RESULTS: A total of 174,325 hysterectomies were included in the analysis; 67.5% were white, 8.4% were African American, and 8.7% were Asian or Pacific Islander. The median age was 45 years (range 10–98 years). The majority of patients (74.4%) had managed care or private insurance, whereas 12.7% had Medicare and 12.8% had Medi-Cal insurance. Overall, 48.4% of hysterectomies were performed by minimally invasive surgery. After controlling for age, Charlson score, and year of surgery, independent predictors of a lower likelihood of minimally invasive hysterectomy were African American race (odds ratio [OR] 0.40, 95% confidence interval [CI] 0.38–0.41), Asian or Pacific Islander race (OR 0.53, 95% CI 0.51–0.55), Medicare insurance (OR 0.71, 95% CI 0.69–0.73), and hospital hysterectomy volume less than 44 cases per year (OR 0.89, 95% CI 0.87–0.91). CONCLUSION: Approximately 50% of hysterectomies in California are performed through a minimally invasive surgical approach; however, significant disparities in access to minimally invasive surgery exist according to race, insurance type, and hospital characteristics. Further studies should be aimed at identifying barriers to access to minimally invasive surgery for hysterectomy.