title: Does Universal Insurance Mitigate Racial Differences in Minimally Invasive Hysterectomy?
abstract: To determine if racial differences exist in receipt of minimally invasive hysterectomy (defined as total vaginal hysterectomy [TVH] and total laparoscopic hysterectomy [TLH]) compared with an open approach (total abdominal hysterectomy [TAH]) within a universally insured patient population.
  
  
  
  Retrospective data analysis (Canadian Task Force classification II-2).
  
  
  
  The 2006-2010 national TRICARE (universal insurance coverage to US Armed Services members and their dependents) longitudinal claims data.
  
  
  
  Women aged 18 years and above who underwent hysterectomy stratified into 4 racial groups: white, African American, Asian, and "other."
  
  
  
  Receipt of hysterectomy (TAH, TVH, or TLH).
  
  
  
  We used risk-adjusted multinomial logistic regression models to determine the relative risk ratios of receipt of TVH and TLH compared with TAH in each racial group compared with referent category of white patients for benign conditions. Among 33 015 patients identified, 60.82% (n = 20 079) were white, 26.11% (n = 8621) African American, 4.63% (n = 1529) Asian, and 8.44% (n = 2786) other. Most hysterectomies (83.9%) were for benign indications. Nearly 42% of hysterectomies (n = 13 917) were TAH, 27% (n = 8937) were TVH, and 30% (n = 10 161) were TLH. Overall, 36.37% of white patients received TAH compared with 53.40% of African American patients and 51.01% of Asian patients (p < .001). On multinomial logistic regression analyses, African American patients were significantly less likely than white patients to receive TVH (relative risk ratio [RRR], .63; 95% confidence interval [CI], .58-.69) or TLH (RRR, .65; 95% CI, .60-.71) compared with TAH. Similarly, Asian patients were less likely than white patients to receive TVH (RRR, .71; 95% CI, .60-.84) or TLH (RRR, .69; 95% CI, .58-.83) compared with TAH. Analyses by benign indications for surgery showed similar trends.
  
  
  
  We demonstrate that racial minority patients are less likely to receive a minimally invasive surgical approach compared with an open abdominal approach despite universal insurance coverage. Further work is warranted to better understand factors other than insurance access that may contribute to racial differences in surgical approach to hysterectomies.
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Harvard School of Public Health, Boston, Massachusetts. Electronic address: aranjit@bwh.harvard.edu.
authors.forename: Anju
authors.initials: A
authors.lastname: Ranjit
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Harvard School of Public Health, Boston, Massachusetts.
authors.forename: Meesha
authors.initials: M
authors.lastname: Sharma
authors.affiliation: Division of Gynecology, Department of Surgery, VA Boston Healthcare System, Boston, Massachusetts.
authors.forename: Aasia
authors.initials: A
authors.lastname: Romano
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Harvard School of Public Health, Boston, Massachusetts.
authors.forename: Wei
authors.initials: W
authors.lastname: Jiang
authors.affiliation: Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
authors.forename: Bart
authors.initials: B
authors.lastname: Staat
authors.affiliation: Department of Preventive Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
authors.forename: Tracey
authors.initials: T
authors.lastname: Koehlmoos
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Harvard School of Public Health, Boston, Massachusetts.
authors.forename: Adil H
authors.initials: AH
authors.lastname: Haider
authors.affiliation: Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Little
authors.affiliation: Department of Preventive Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
authors.forename: Catherine T
authors.initials: CT
authors.lastname: Witkop
authors.affiliation: Department of Preventive Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
authors.forename: Julian N
authors.initials: JN
authors.lastname: Robinson
authors.affiliation: Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Sarah L
authors.initials: SL
authors.lastname: Cohen
mesh_terms: D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data; D005260:Female; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data; D054625:Healthcare Disparities / Q000191:economics* / Q000208:ethnology / Q000706:statistics & numerical data; D006801:Humans; D007044:Hysterectomy / Q000009:adverse effects / Q000191:economics* / Q000706:statistics & numerical data*; D007045:Hysterectomy, Vaginal / Q000191:economics / Q000706:statistics & numerical data; D019458:Insurance Coverage / Q000706:statistics & numerical data; D010535:Laparoscopy / Q000191:economics / Q000706:statistics & numerical data; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D066067:Military Family / Q000191:economics / Q000706:statistics & numerical data; D008889:Military Personnel / Q000706:statistics & numerical data; D019060:Minimally Invasive Surgical Procedures / Q000191:economics* / Q000706:statistics & numerical data*; D016017:Odds Ratio; D044469:Racial Groups / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology; D019472:Universal Health Insurance / Q000191:economics / Q000706:statistics & numerical data*; D044465:White People / Q000706:statistics & numerical data
keywords: Minimally invasive hysterectomy; Racial disparities; Universal insurance