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Eisenstein D, Shukr GH, Carlow JJ, Kemp L, Yu S. Comparison of Costs, Re-Intervention Rates, and Length of Hospital Stay for Three Uterus Sparing Interventions for Uterine Fibroids: A 2-Year Retrospective Claims Analysis. CLINICOECONOMICS AND OUTCOMES RESEARCH 2024; 16:523-536. [PMID: 39100656 PMCID: PMC11296368 DOI: 10.2147/ceor.s437353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 07/10/2024] [Indexed: 08/06/2024] Open
Abstract
Purpose To describe two-year post-operative outcomes, and healthcare utilization of three uterus-sparing interventions used to treat women with intramural and/or subserosal uterine fibroids. Subjects and Methods This was a post-market, randomized, prospective, multi-center, longitudinal, interventional, and comparative clinical study to evaluate the costs and health outcomes of LAP-RFA vs the standard uterine conserving technologies (myomectomy and UAE) for the treatment of symptomatic uterine fibroids in women who desire uterine conservation. For this RCT study, 54 subjects were randomized on a 1:1 ratio across the three procedures and followed out to two years. Their results were compared to retrospective US insurance claims from the IBM MarketScan® Commercial Database from 2017-2020 for 96,854 women who underwent a uterus-sparing procedure for fibroids. Results Mean ambulatory surgical center costs and the mean out-patient hospital costs were lowest for LAP-RFA ($13,134 and $14,428) and highest for UAE ($28,214 and $19,131). The total two-year re-intervention rate of any subsequent procedure (AM, LM, LAP-RFA, or UAE) was lowest in AM group (0%) followed by LM (4.2%), LAP-RFA (11%), and UAE (33%). Mean peri-operative reintervention costs and the mean reintervention total costs were $2429 and $5939 for LAP-RFA, $2122 and $8368 for LM, $4410 and $11,942 for AM, and $8113 and $46,692 for UAE subjects. In the RCT study, the average length of hospital stay was significantly less for the LAP-RFA group subjects (8.2 hours) in contrast to both the laparoscopic myomectomy group subjects (16.0 hours) and the abdominal myomectomy group subjects (33.6 hours). Despite the small numbers, two-year reintervention rates followed a similar pattern as the IBM MarketScan data. Conclusion In comparing these three non-invasive approaches, LAP-RFA was associated with the lowest peri-operative cost, and UAE was associated with the highest peri-operative cost. Further studies are needed to assess the cost, effectiveness, and subject satisfaction with each procedure.
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Affiliation(s)
- David Eisenstein
- Department of Urology, Trinity/IHA Medical Group, Detroit, MI, USA
| | - Ghadear H Shukr
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa Bay, FL, USA
| | | | - Laura Kemp
- Kemp Clinical Consulting Co LLC, Carlsbad, CA, USA
| | - Steve Yu
- Department of Urology, Hoag Hospital, Newport Beach, CA, USA
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Martinez C, Olig E, Pachalla S, Findley A. Racial Disparities in Medical Management of Uterine Fibroids Prior to Myomectomy or Hysterectomy. J Racial Ethn Health Disparities 2024:10.1007/s40615-024-02048-3. [PMID: 38886279 DOI: 10.1007/s40615-024-02048-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 05/28/2024] [Accepted: 05/31/2024] [Indexed: 06/20/2024]
Abstract
The symptomatic burden of uterine fibroids has been demonstrated to disproportionately affect Black and Hispanic women. The primary aim of this study was to evaluate if racial disparities seen in disease severity in regards to bleeding symptoms and surgical management also applied to presurgical medical management. A retrospective chart review evaluated women aged 18-50 with the diagnosis of fibroids who underwent a myomectomy or hysterectomy between 2012 and 2021. Black and Hispanic women were more likely to have preoperative hemoglobin values under 10 mg/dL (p < 0.001) and had higher rates of preoperative blood transfusions than White women (p = 0.001). Black women utilized the highest number of medications before excisional procedures, followed by Hispanic women. Asian women reported the lowest average (p = 0.037). There was no preferential use of GnRH analogues, intrauterine devices, or oral hormonal therapies between races. Minor procedures were infrequently utilized without statistically significant variations among races. This study confirms previous evidence that Black and Hispanic women are more severely affected by uterine fibroids. This severity is mirrored in increased utilization of medications, but patients continue to be under optimized prior to surgery. Further research should identify factors preventing these groups from achieving better symptom control preoperatively.
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Affiliation(s)
- Camryn Martinez
- University of Kansas School of Medicine, Kansas City, KS, USA.
| | - Emily Olig
- Department of Medical and Surgical Gynecology, Mayo Clinic, Phoenix, AZ, USA
| | - Sarani Pachalla
- University of Kansas School of Medicine, Kansas City, KS, USA
| | - Austin Findley
- Department of Obstetrics and Gynecology, Kansas University Medical Center, Kansas City, KS, USA
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Srinivas T, Lulseged B, Mirza Aghazadeh Attari M, Borahay M, Weiss CR. Patient Characteristics Associated With Embolization Versus Hysterectomy for Uterine Fibroids: A Systematic Review and Meta-Analysis. J Am Coll Radiol 2024; 21:729-739. [PMID: 38191081 DOI: 10.1016/j.jacr.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/18/2023] [Accepted: 12/21/2023] [Indexed: 01/10/2024]
Abstract
INTRODUCTION Black and underinsured women in the United States are more likely than their counterparts to develop uterine fibroids (UFs) and experience more severe symptoms. Uterine artery embolization (UAE), a uterine-sparing therapeutic procedure, is less invasive than the common alternative, open hysterectomy. To determine whether demographic disparities persist in UF treatment utilization, we reviewed patient characteristics associated with UAE versus hysterectomy for UF among studies of US clinical practices. METHODS A systematic literature review was conducted via PubMed, Embase, and CINAHL (PROSPERO CRD42023455051), yielding 1,350 articles (January 1, 1995, to July 15, 2023) that outlined demographic characteristics of UAE compared with hysterectomy. Two readers screened for inclusion criteria, yielding 13 full-text US-based comparative studies specifying at least one common demographic characteristic. Random effects meta-analysis was performed on the data (STATA v18.0). Egger's regression test was used to quantify publication bias. RESULTS Nine (138,960 patients), four (183,643 patients), and seven (312,270 patients) studies were analyzed for race, insurance status, and age as predictors of treatment modality, respectively. Black race (odds ratio = 3.35, P < .01) and young age (P < .05) were associated with UAE, whereas private insurance (relative to Medicare and/or Medicaid) was not (odds ratio = 1.06, P = .52). Between-study heterogeneity (I2 > 50%) was detected in all three meta-analyses. Small-study bias was detected for age but not race or insurance. CONCLUSIONS AND IMPLICATIONS Knowledge of demographic characteristics of patients with UFs receiving UAE versus hysterectomy is sparse (n = 13 studies). Among these studies, which seem to be racially well distributed, Black and younger women are more likely to receive UAE than their counterparts.
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Affiliation(s)
- Tara Srinivas
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Mohammad Mirza Aghazadeh Attari
- Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Vascular and Interventional Radiology, the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mostafa Borahay
- Associate Professor of Gynecology and Obstetrics, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland; Director of the Division of General Gynecology & Obstetrics, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Clifford R Weiss
- Division of Vascular and Interventional Radiology, the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland; Director of the Johns Hopkins HHT Center of Excellence and Professor of Radiology and Radiological Science, Baltimore, Maryland.
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Orellana M, DSouza KN, Yap JQ, Sriganeshan A, Jones ME, Johnson C, Allyse M, Venable S, Stewart EA, Enders F, Balls-Berry JE. "In our community, we normalize pain": discussions around menstruation and uterine fibroids with Black women and Latinas. BMC Womens Health 2024; 24:233. [PMID: 38610011 PMCID: PMC11010402 DOI: 10.1186/s12905-024-03008-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 02/28/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Uterine fibroids are non-cancerous neoplasms that arise from the uterus affecting over 75% of women. However, there is a disparity with Black women having an increased prevalence of nearly 80%. Black women also experience increased symptom burden, including younger age at the time of diagnosis and increased number and volume of fibroids. Less is known about other ethnoracially diverse women such as Latinas and the potential cultural impacts on fibroid burden and treatment. METHODS Community engagement studios were conducted to facilitate discussions with stakeholders on their uterine fibroid and menstruation experience. We recruited Black women (n = 6) diagnosed with uterine fibroids and Latinas (n = 7) without uterine fibroids. We held two virtual community engagement studios split by uterine fibroid diagnosis. The studios were not audio recorded and notes were taken by four notetakers. The notes were thematically analyzed in Atlas.ti using content analysis. RESULTS Participants felt there was a lack of discussion around menstruation overall, whether in the home or school settings. This lack of menstruation education was pronounced when participants had their first menstruation experience, with many unaware of what to expect. This silence around menstruation led to a normalization of painful menstruation symptoms. When it came to different treatment options for uterine fibroids, some women wanted to explore alternative treatments but were dismissed by their healthcare providers. Many participants advocated for having discussions with their healthcare provider about life goals to discuss different treatment options for their uterine fibroids. CONCLUSION Despite uterine fibroid diagnosis, there is silence around menstruation. Menstruation is a normal biological occurrence and needs to be discussed to help prevent delayed diagnosis of uterine fibroids and possibly other gynecological disorders. Along with increased discussions around menstruation, further discussion is needed between healthcare providers and uterine fibroid patients to explore appropriate treatment options.
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Affiliation(s)
- Minerva Orellana
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Karen N DSouza
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN, USA
| | - Jane Q Yap
- Department of Quantitative Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | | | - M Elena Jones
- Department of Neurology, Washington University School of Medicine, 4488 Forest Park, St. Louis, MO, 63108, USA
| | - Charis Johnson
- Department of Neurology, Washington University School of Medicine, 4488 Forest Park, St. Louis, MO, 63108, USA
| | - Megan Allyse
- Department of Quantitative Health Sciences Research, Mayo Clinic, Rochester, MN, USA
- Program in Biomedical Ethics Research, Mayo Clinic, Rochester, MN, USA
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
| | | | - Elizabeth A Stewart
- Division of Reproductive Endocrinology, Department of Obstetrics & Gynecology, Mayo Clinic, Rochester, MN, USA
- Mayo Clinic College of Medicine & Science, Rochester, MN, USA
| | - Felicity Enders
- Department of Quantitative Health Sciences Research, Mayo Clinic, Rochester, MN, USA
- Mayo Clinic College of Medicine & Science, Rochester, MN, USA
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Joyce E Balls-Berry
- Department of Neurology, Washington University School of Medicine, 4488 Forest Park, St. Louis, MO, 63108, USA.
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Bossick AS, Abood JA, Oaks A, Vilkins A, Shukr G, Chamseddine P, Wegienka GR. Racial disparities between measures of area deprivation and financial toxicity, and uterine volume in myomectomy patients. BMC Womens Health 2023; 23:603. [PMID: 37964227 PMCID: PMC10648622 DOI: 10.1186/s12905-023-02761-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 11/03/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND At time of myomectomy, a surgical procedure to remove uterine fibroids, Black women tend to have larger uteri than White women. This makes Black patients less likely to undergo a minimally invasive myomectomy which has been shown to have less postoperative pain, less frequent postoperative fever and shorter length of stay compared to abdominal myomectomies. The associations between individual financial toxicity and community area deprivation and uterine volume at the time of myomectomy have not been investigated. METHODS We conducted a secondary data analysis of patients with fibroids scheduled for myomectomy using data from a fibroid treatment registry in [location]. We used validated measures of individual-level Financial Toxicity (higher scores = better financial status) and community-level Area Deprivation (ADI, high scores = worse deprivation). To examine associations with log transformed uterine volume, we used linear regression clustered on race (Black vs. White). RESULTS Black participants had worse financial toxicity, greater deprivation and larger uterine volumes compared with White participants. A greater Financial Toxicity score (better financial status) was associated with lower uterine volume. For every 10 unit increase in Financial Toxicity, the mean total uterine volume decreased by 9.95% (Confidence Interval [CI]: -9.95%, -3.99%). ADI was also associated with uterine volume. A single unit increase in ADI (worse deprivation) was associated with a 5.13% (CI: 2.02%, 7.25%) increase in mean uterine volume. CONCLUSION Disproportionately worse Financial Toxicity and ADI among Black patients is likely due to structural racism - which now must be considered in gynecologic research and practice. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Andrew S Bossick
- Department of Public Health Sciences, Henry Ford Health, 48202, Detroit, MI, USA.
- Department of Obstetrics, Gynecology, and Reproductive Biology, College of Human Medicine, Michigan State University, 965 Wilson Rd, 48224, East Lansing, MI, USA.
| | - Joelle Aoun Abood
- Department of Obstetrics and Gynecology, Henry Ford Health, 48202, Detroit, MI, USA
| | - Ashlee Oaks
- Department of Public Health Sciences, Henry Ford Health, 48202, Detroit, MI, USA
| | - Annmarie Vilkins
- Department of Obstetrics and Gynecology, Henry Ford Health, 48202, Detroit, MI, USA
| | - Ghadear Shukr
- Department of Obstetrics and Gynecology, Henry Ford Health, 48202, Detroit, MI, USA
| | - Petra Chamseddine
- Department of Obstetrics and Gynecology, Henry Ford Health, 48202, Detroit, MI, USA
| | - Ganesa R Wegienka
- Department of Public Health Sciences, Henry Ford Health, 48202, Detroit, MI, USA
- Department of Obstetrics, Gynecology, and Reproductive Biology, College of Human Medicine, Michigan State University, 965 Wilson Rd, 48224, East Lansing, MI, USA
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Agarwal SK, Stokes M, Kung T, Tilney R, Lickert C. Describing the Patient Journey of Women with Claims for Uterine Fibroids and Heavy Menstrual Bleeding Using a Commercial Database (2011-2020). Int J Womens Health 2023; 15:1561-1575. [PMID: 37867928 PMCID: PMC10588720 DOI: 10.2147/ijwh.s420612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 09/26/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction This retrospective database claims analysis describes the clinical characteristics and treatment patterns of commercially insured United States women with uterine fibroids (UF) and heavy menstrual bleeding (HMB). Methods Women age 18-55 years with an incident UF diagnosis (index date) between 1/1/2012 and 12/31/2019 and ≥1 claim for HMB (UF-HMB), were identified from the Optum® Clinformatics® database. Outcomes included clinical characteristics, pharmacologic therapy use, and surgeries/procedures. Regression models were used to identify factors associated with time to post-diagnosis hormonal therapy and hysterectomy. Results A total of 85,428 women had UF-HMB (mean [SD] age, 43.7 [6.4] years). The median follow-up was 3.2 years. After HMB, the most common symptoms were pelvic pressure/pain (27.6%) and backache (17.5%). Within 6 months of UF diagnosis, 40.2% of patients had received only pharmacologic therapy; 25.5% had received no treatment; 24.3% had a hysterectomy, and 10.0% had other procedures. By the end of follow-up, 50.0% had received a hysterectomy. Multiple factors were predictive of a higher likelihood of receiving hormonal therapy (geographic region, infertility, pre-index pregnancy) or hysterectomy (older age, prior hormonal treatment, specific bulk symptoms, White race). Conclusion Within 6 months of UF diagnosis, fewer than one-half of women with UF-HMB had received hormonal therapy, one-quarter received no treatment, and one-quarter had received a hysterectomy or another gynecologic procedure. Patients who received a hysterectomy were more likely to be older, White, and to have bulk symptoms.
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Affiliation(s)
| | | | - Tiffany Kung
- Myovant Sciences, Inc (now known as Sumitomo Pharma America, Inc), Marlborough, MA, USA
| | | | - Cassandra Lickert
- Myovant Sciences, Inc (now known as Sumitomo Pharma America, Inc), Marlborough, MA, USA
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Anchan RM, Spies JB, Zhang S, Wojdyla D, Bortoletto P, Terry K, Disler E, Milne A, Gargiulo A, Petrozza J, Brook O, Srouji S, Morton CC, Greenberg J, Wegienka G, Stewart EA, Nicholson WK, Thomas L, Venable S, Laughlin-Tommaso S, Diamond MP, Maxwell GL, Marsh EE, Myers ER, Vines AI, Wise LA, Wallace K, Jacoby VL. Long-term health-related quality of life and symptom severity following hysterectomy, myomectomy, or uterine artery embolization for the treatment of symptomatic uterine fibroids. Am J Obstet Gynecol 2023; 229:275.e1-275.e17. [PMID: 37244458 DOI: 10.1016/j.ajog.2023.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 05/15/2023] [Accepted: 05/21/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Few studies have directly compared different surgical procedures for uterine fibroids with respect to long-term health-related quality of life outcomes and symptom improvement. OBJECTIVE We examined differences in change from baseline to 1-, 2-, and 3-year follow-up in health-related quality of life and symptom severity among patients who underwent abdominal myomectomy, laparoscopic or robotic myomectomy, abdominal hysterectomy, laparoscopic or robotic hysterectomy, or uterine artery embolization. STUDY DESIGN The COMPARE-UF registry is a multiinstitutional prospective observational cohort study of women undergoing treatment for uterine fibroids. A subset of 1384 women aged 31 to 45 years who underwent either abdominal myomectomy (n=237), laparoscopic myomectomy (n=272), abdominal hysterectomy (n=177), laparoscopic hysterectomy (n=522), or uterine artery embolization (n=176) were included in this analysis. We obtained demographics, fibroid history, and symptoms by questionnaires at enrollment and at 1, 2, and 3 years posttreatment. We used the UFS-QoL (Uterine Fibroid Symptom and Quality of Life) questionnaire to ascertain symptom severity and health-related quality of life scores among participants. To account for potential baseline differences across treatment groups, a propensity score model was used to derive overlap weights and compare total health-related quality of life and symptom severity scores after enrollment with a repeated measures model. For this health-related quality of life tool, a specific minimal clinically important difference has not been determined, but on the basis of previous research, a difference of 10 points was considered as a reasonable estimate. Use of this difference was agreed upon by the Steering Committee at the time when the analysis was planned. RESULTS At baseline, women undergoing hysterectomy and uterine artery embolization reported the lowest health-related quality of life scores and highest symptom severity scores compared with those undergoing abdominal myomectomy or laparoscopic myomectomy (P<.001). Those undergoing hysterectomy and uterine artery embolization reported the longest duration of fibroid symptoms with a mean of 6.3 years (standard deviation, 6.7; P<.001). The most common fibroid symptoms were menorrhagia (75.3%), bulk symptoms (74.2%), and bloating (73.2%). More than half (54.9%) of participants reported anemia, and 9.4% women reported a history of blood transfusion. Across all modalities, total health-related quality of life and symptom severity score markedly improved from baseline to 1-year with the largest improvement in the laparoscopic hysterectomy group (Uterine Fibroids Symptom and Quality of Life: delta= [+] 49.2; symptom severity: delta= [-] 51.3). Those undergoing abdominal myomectomy, laparoscopic myomectomy, and uterine artery embolization also demonstrated significant improvement in health-related quality of life (delta= [+]43.9, [+]32.9, [+]40.7, respectively) and symptom severity (delta= [-]41.4, [-] 31.5, [-] 38.5, respectively) at 1 year, and the improvement persisted from baseline for uterine-sparing procedures during second (Uterine Fibroids Symptom and Quality of Life: delta= [+]40.7, [+]37.4, [+]39.3 SS: delta= [-] 38.5, [-] 32.0, [-] 37.7 and third year (Uterine Fibroids Symptom and Quality of Life: delta= [+] 40.9, [+]39.9, [+]41.1 and SS: delta= [-] 33.9, [-]36.5, [-] 33.0, respectively), posttreatment intervals, however with a trend toward decline in degree of improvement from years 1 and 2. Differences from baseline were greatest for hysterectomy; however, this may reflect the relative importance of bleeding in the Uterine Fibroids Symptom and Quality of Life, rather than clinically meaningful symptom recurrence among women undergoing uterus-sparing treatments. CONCLUSION All treatment modalities were associated with significant improvements in health-related quality of life and symptom severity reduction 1-year posttreatment. However, abdominal myomectomy, laparoscopic myomectomy and uterine artery embolization indicated a gradual decline in symptom improvement and health-related quality of life by third year after the procedure.
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Affiliation(s)
- Raymond M Anchan
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Biostatistics, Yale School of Public Health, New Haven CT.
| | - James B Spies
- Department of Radiology, Georgetown University School of Medicine, Washington, DC
| | - Shuaiqi Zhang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Pietro Bortoletto
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, NY
| | - Kathryn Terry
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Emily Disler
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ankrish Milne
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Antonio Gargiulo
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - John Petrozza
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Olga Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Serene Srouji
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Cynthia C Morton
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Broad Institute of MIT and Harvard, Cambridge, MA; Manchester Centre for Audiology and Deafness, School of Health Sciences, University of Manchester, United Kingdom
| | - James Greenberg
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ganesa Wegienka
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI
| | - Elizabeth A Stewart
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN; Department of Surgery, Mayo Clinic, Rochester, MN
| | - Wanda K Nicholson
- Department of Obstetrics & Gynecology, Center for Women's Health Research, and Center for Health Promotion and Disease Prevention, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Laine Thomas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | | | - Shannon Laughlin-Tommaso
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN; Department of Surgery, Mayo Clinic, Rochester, MN
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, GA
| | - G Larry Maxwell
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, VA
| | - Erica E Marsh
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC
| | - Anissa I Vines
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lauren A Wise
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
| | - Kedra Wallace
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS
| | - Vanessa L Jacoby
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA; Department of Radiology, Georgetown University School of Medicine, Washington, DC
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Katon JG, Bossick A, Carey C, Christy A, Doll K, Gatsby E, Gray KE, Lynch KE, Moy E, Owens S, Washington DL, Callegari LS. Racial Disparities in Uterine Fibroid Treatment Among Veterans Using VA Health Care. Womens Health Issues 2023; 33:405-413. [PMID: 37105835 DOI: 10.1016/j.whi.2023.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 03/10/2023] [Accepted: 03/24/2023] [Indexed: 04/29/2023]
Abstract
INTRODUCTION Uterine fibroids are common, nonmalignant tumors that disproportionately impact Black patients. We aimed to examine Black and White differences in receipt of any treatment and type of first treatment in the Department of Veterans Affairs, including effect modification by severity as approximated by anemia. METHODS We used Department of Veterans Affairs administrative data to identify 5,041 Black and 3,206 White veterans with symptomatic uterine fibroids, identified by International Classification of Diseases, 9th edition, Clinical Modification, codes, between fiscal year 2010 and fiscal year 2012 and followed in the administrative data through fiscal year 2018 for outcomes. Outcomes included receipt of any treatment, hysterectomy as first treatment, and fertility-sparing treatment as first treatment. We stratified all analyses by age (<45, ≥45 years old), used generalized linear models with a log link and Poisson error distribution, included an interaction term between race and anemia, and used recycled predictions to estimate adjusted percentages for outcomes. RESULTS There was evidence of effect modification by anemia for receipt of any treatment but not for any other outcomes. Across age and anemia sub-groups, Black veterans were less likely to receive any treatment than White veterans. Adjusted racial differences were most pronounced among veterans with anemia (<45 years, Black-White difference = -10.3 percentage points; 95% confidence interval, -15.9 to -4.7; ≥45 years, Black-White difference = -20.3 percentage points; 95% confidence interval, -27.8 to -12.7). Across age groups, Black veterans were less likely than White veterans to have hysterectomy and more likely to have a fertility-sparing treatment as their first treatment. CONCLUSIONS We identified significant Black-White disparities in receipt of treatment for symptomatic uterine fibroids. Additional research that centers the experiences of Black veterans with uterine fibroids is needed to inform strategies to eliminate racial disparities in uterine fibroid care.
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Affiliation(s)
- Jodie G Katon
- U.S. Department of Veterans Affairs (VA) Puget Sound Healthcare System, Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development (HSR&D), Seattle, Washington; Department of Health Systems and Population Health, University of Washington, Seattle, Washington.
| | - Andrew Bossick
- U.S. Department of Veterans Affairs (VA) Puget Sound Healthcare System, Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development (HSR&D), Seattle, Washington; Henry Ford Healthcare System, Detroit, Michigan
| | - Cathea Carey
- U.S. Department of Veterans Affairs (VA) Puget Sound Healthcare System, Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development (HSR&D), Seattle, Washington
| | - Alicia Christy
- Office of Women's Health, U.S. Department of Veterans Affairs, Washington, District of Columbia
| | - Kemi Doll
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington
| | - Elise Gatsby
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Kristen E Gray
- U.S. Department of Veterans Affairs (VA) Puget Sound Healthcare System, Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development (HSR&D), Seattle, Washington; Department of Health Systems and Population Health, University of Washington, Seattle, Washington
| | - Kristine E Lynch
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah; Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Ernest Moy
- U.S. Department of Veterans Affairs, Office of Health Equity, Washington, District of Columbia
| | - Shanise Owens
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington
| | - Donna L Washington
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Division of General Internal Medicine & Health Services Research, Department of Medicine, University of California Los Angeles, Los Angeles, California
| | - Lisa S Callegari
- U.S. Department of Veterans Affairs (VA) Puget Sound Healthcare System, Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development (HSR&D), Seattle, Washington; Department of Health Systems and Population Health, University of Washington, Seattle, Washington; Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington
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9
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Amoah A, Quinn SD. Uterine-preserving treatments or hysterectomy reintervention after myomectomy or uterine artery embolisation: A retrospective cohort study of long-term outcomes. BJOG 2023; 130:823-831. [PMID: 36706789 DOI: 10.1111/1471-0528.17412] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 11/22/2022] [Accepted: 11/28/2022] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To assess comparative rates of further uterine-preserving procedures (UPP) or hysterectomy reintervention, after myomectomy or uterine artery embolisation (UAE). DESIGN Population-based, retrospective cohort study. SETTING England. POPULATION Women who underwent myomectomy or UAE between 2010 and 2015 under the NHS. METHODS Data was abstracted from NHS Health Episode Statistics datasets. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using Cox proportional-hazards regression. MAIN OUTCOMES MEASURES 30-day readmission, UPP and hysterectomy reintervention rates. RESULTS 9443 and 6224 women underwent elective myomectomy or UAE, respectively. After 118 136 total person-years of follow-up, the rate of hysterectomy was 8.34 and 20.98 per 1000 patient years for myomectomy or UAE, respectively. There was a 2.4-fold increased risk of undergoing hysterectomy after UAE when compared with myomectomy in adjusted models (HR 2.38 [95% CI 2.10-2.66]) [adjusted for age, ethnicity, multiple deprivation index, geographical region and comorbidities]. The HR for undergoing a UPP reintervention was 1.44 (95% CI 1.29-1.60) in favour of myomectomy. The rate of hysterectomy was increased 22% following UAE compared with laparoscopic myomectomy (0.97-1.52). Age may influence reintervention rates, and there was variation in hysterectomy risk when stratified by geographical region. CONCLUSIONS After a median of 7 years of follow-up, there is a 2.4-fold increased rate of hysterectomy and 44% increased risk of UPPs as reintervention after UAE, relative to myomectomy. These findings will aid pre-procedure counselling for women with fibroids. Future work should investigate the effect of other outcome modifiers, such as fertility intentions and fibroid anatomical characteristics.
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10
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Katon JG, Plowden TC, Marsh EE. Racial disparities in uterine fibroids and endometriosis: a systematic review and application of social, structural, and political context. Fertil Steril 2023; 119:355-363. [PMID: 36682686 PMCID: PMC9992263 DOI: 10.1016/j.fertnstert.2023.01.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023]
Abstract
IMPORTANCE Uterine fibroids and endometriosis are 2 of the leading causes of morbidity among reproductive-aged women. There are significant racial disparities in disease prevalence, incidence, age of onset, and treatment profile in fibroids. The data on endometriosis are less clear. OBJECTIVE To conduct a systematic review of racial disparities in prevalence of uterine fibroids and endometriosis in the United States and summarize the literature on these 2 highly prevalent benign gynecologic conditions using a framework that explicitly incorporates and acknowledges the social, structural, and political contexts as a root cause of racial disparities between Black and White women. EVIDENCE REVIEW A systematic review regarding racial disparities in prevalence of fibroids and endometriosis was conducted separately. Two separate searches were conducted in PubMed to identify relevant original research manuscripts and prior systematic reviews regarding racial disparities in uterine fibroids and endometriosis using standardized search terms. In addition, we conducted a structured literature search to provide social, structural, and political context of the disparities. FINDINGS A systematic review of the literature indicated that the prevalence of uterine fibroids was consistently higher in Black than in White women with the magnitude of the difference varying depending on population and case definition. Prevalence of endometriosis varied considerably depending on the base population and case definition, but was the same or lower among Black vs. White women. As a result of the social, structural, and political context in the United States, Black women disproportionately experience a range of exposures across the life course that may contribute to their increased uterine fibroid incidence, prevalence, and severity of uterine fibroids. However, data suggest no racial difference in the incidence of endometriosis. Nevertheless, Black women with fibroids or endometriosis experience worse clinical and surgical outcomes than their White counterparts. CONCLUSION AND RELEVANCE Racial disparities in uterine fibroids and endometriosis can be linked with differential exposures to suspected etiologic agents, lack of adequate access to health care, including highly skilled gynecologic surgeons, and bias and discrimination within the health care system. Eliminating these racial disparities will require solutions that address root causes of health disparities through policy, education and programs to ensure that all patients receive culturally- and structurally-competent care.
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Affiliation(s)
- Jodie G Katon
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Torie C Plowden
- Division of Reproductive Endocrinology and Infertility, Department of Gynecologic Surgery and Obstetrics, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Erica E Marsh
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan.
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11
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Ptacek I, Aref-Adib M, Mallick R, Odejinmi F. Each Uterus Counts: A narrative review of health disparities in benign gynaecology and minimal access surgery. Eur J Obstet Gynecol Reprod Biol 2021; 265:130-136. [PMID: 34492607 DOI: 10.1016/j.ejogrb.2021.08.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/11/2021] [Accepted: 08/23/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Health disparities exposed by the Covid-19 pandemic have prompted healthcare professionals to investigate disparities within their own specialty. Racial and ethnic disparities in obstetrics are well documented but inequities in gynaecology are less well known. Our aim is to review the literature on two commonly performed procedures, hysterectomy and myomectomy, and one condition, ectopic pregnancy, to evaluate the prevalence of racial, ethnic and socioeconomic disparities in benign gynaecology and minimal access surgery. METHODS A narrative review of 33 articles identified from a Pubmed using the following search criteria; "race"; "ethnicity"; "socioeconomic status"; "disparity"; "inequity"; and "inequality". Case reports and papers assessing gynaecological malignancy were excluded. RESULTS Despite minimal access surgery having fewer complications and faster recovery than open surgery, US studies have shown that black and ethnic minority women are less likely than white women to have minimally invasive hysterectomies and myomectomies. Uninsured women and patients on Medicaid are also less likely to receive minimally invasive procedures. Contributing factors include fibroid size, geographic location and access to hospitals performing minimal access surgery, and the discontinuation of power morcellation. Ethnic minority women who receive minimally invasive myomectomy have been shown to have a higher risk of complications and prolonged recovery. Black and ethnic minority women also have a higher risk of morbidity and mortality from ectopic pregnancy and are more likely to receive surgical than medical management. CONCLUSION Extensive study from the US has demonstrated disparities in access to minimally invasive gynaecological surgery, whereas in the UK the data is infrequent, inconsistent and incomplete. Little is known about the influence of patient preference and counselling as well as institutional bias on health equity in gynaecology. Further research is necessary to identify interventions that mitigate these disparities in access and outcomes.
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Affiliation(s)
| | | | - Rebecca Mallick
- University Hospitals Sussex NHS Foundation Trust, United Kingdom
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