Differences in Route of Benign Hysterectomy in Black Patients for Abnormal Uterine Bleeding with Exclusion of Fibroid Diagnosis

Abstract

<h3>Study Objective</h3> To investigate whether racial disparities still exist in rates of minimally invasive hysterectomy (MIH) performed for abnormal uterine bleeding (AUB) when fibroid diagnosis is excluded. <h3>Design</h3> Cross-sectional survey with a target population of all ambulatory discharges in the United States. <h3>Setting</h3> 2019 Nationwide Ambulatory Surgery Sample (NASS) and National Inpatient Sample (NIS). <h3>Patients or Participants</h3> Female patients age ≥18 years undergoing hysterectomy for primary indication of abnormal uterine bleeding (AUB), excluding malignancy and uterine fibroids. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> A multivariate logistic regression model with appropriate weighting, primary sampling units and strata was utilized. Primary outcome was odds ratio (OR) of abdominal hysterectomy (AH) vs MIH (vaginal/endoscopic) in Black patients compared to white patients. Of 487,008 (SE=11,530) hysterectomies performed for benign indications, 64,681 (SE=1,483) were AH (13.3%), 422,327 (SE=10,047) were MIH (86.7%). After filtering the survey design dataset for hysterectomies performed primarily for AUB using the international classification of diseases 10^th edition, and further excluding those with an associated code for uterine fibroids, the sample size was 75,838 (SE=2,103). Of these, MIH: 68,206 (SE=1,812) (89.9%) and AH: 7,632 (SE=291) (10.1%). After controlling for comorbidities, demographic data, hospital, regional and payer factors, the OR for a Black patient to undergo AH vs MIH for all benign diagnoses was 2.7 (CI-2.44,2.98; p<0.001). For Black patients undergoing benign hysterectomy for AUB excluding fibroids, this trend persisted though was less extreme with OR=1.38 (CI-1.12,1.70; p<0.001). <h3>Conclusion</h3> For the primary indication of AUB excluding malignancy and fibroids, Black patients were still 38% more likely than white patients to undergo AH. It has previously been proposed that rates of MIH are lower in Black patients due to a larger prevalence of fibroids, and by extension, larger uterine sizes. Given that we excluded fibroids and still found a difference in MIH rates, our study suggests there may be other factors leading to disparity in surgical route.