Racial Differences in Treatment with Hysterectomy: a Multilevel Investigation

1 PROJECT SUMMARY/ABSTRACT
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3 Every year, millions of U.S. women must decide whether to have their uteri removed to treat painful and
4 incapacitating gynecologic disorders, such as uterine fibroids, endometriosis, and prolapse. Unfortunately,
5 decisions about hysterectomy may be influenced as much by a woman's race as by objective clinical
6 indications. Despite hysterectomy's prevalence, little is known about how these surgery decisions are made:
7 the existing literature is limited by non-generalizable single-institution studies, racially homogenous samples,
8 inadequate control for symptom severity, and inability to measure the influences of the culture of the healthcare
9 system. The long-term goal of this proposal is to ensure that women of all backgrounds are treated in an
10 equitable manner when it comes to hysterectomy decision-making. To achieve this goal, the objectives of this
11 application are to understand where racial differences in treatment with gynecologic surgery arise and to
12 evaluate the extent to which racial/ethnic differences in hysterectomy treatment constitute surgical disparities.
13 The central hypothesis is that clinical severity will not fully account for all racial/ethnic differences in
14 hysterectomy treatment. We hypothesize that provider-level and practice-level clinical culture can impede
15 equitable dissemination of surgical innovations in hysterectomy. The rationale for the proposed research is that
16 identifying multilevel health care-system influences on hysterectomy receipt will help identify the best targets
17 on which to intervene to achieve equitable surgical care of women's gynecologic conditions. The hypotheses
18 will be tested by pursuing three specific aims: 1) Determine the extent to which the clinical threshold for
19 hysterectomy (uterine weight, pre-operative anemia, pre-operative pain) varies by race/ethnicity; 2) Quantify
20 the extent to which minority patients are differentially likely to be treated by low-volume providers and by
21 practices with high propensity to perform hysterectomy; and 3) Identify drivers of the dissemination of bilateral
22 salpingectomy with ovarian retention (BSOR) at the time of hysterectomy and the extent to which this
23 dissemination varied by race/ethnicity. This approach is innovative because it directly evaluates the
24 longstanding but untested hypothesis that racial differences in clinical severity explain differences in
25 hysterectomy rates. The work also employs an innovative multilevel framework including provider- and
26 practice-level factors. Finally, the work investigates how surgical culture can facilitate or impede the
27 dissemination of a cancer risk-reducing surgical innovation. This work will have sustained impact because it
28 goes beyond documenting racial differences: when this work is completed, we will understand what disparities
29 exist but also how these differences arise. Gynecologic problems are under-investigated relative to their high
30 prevalence, impact on quality of life, and long-term effects of treatment on the health of tens of millions of U.S.
31 women. Fortunately, hysterectomy is both common and amenable to change; therefore, identifying targets to
32 improve equity in the surgery can exert a powerful influence on the gynecologic surgery field.
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