Ethnoracial Differences in Premenopausal Hysterectomy: The Role of Symptom Severity.

Objective: To evaluate whether greater symptom severity can explain higher hysterectomy rates among premenopausal non-Hispanic Black compared with White patients in the U.S. South rather than potential overtreatment of Black patients.
Methods: Using electronic health record data from 1,703 patients who underwent hysterectomy in a large health care system in the U.S. South between 2014 and 2017, we assessed symptom severity to account for differences in hysterectomy rates for noncancerous conditions among premenopausal non-Hispanic Black, non-Hispanic White, and Hispanic patients. We used Poisson generalized linear mixed modeling to estimate symptom severity (greater than the 75th percentile on composite symptom severity scores of bleeding, bulk, or pelvic pain) as a function of race-ethnicity. We calculated prevalence ratios (PRs). We controlled for factors both contra-indicating and contributing to hysterectomy.
Results: The overall median age of non-Hispanic White (n=1,050), non-Hispanic Black (n=565), and Hispanic (n=158) patients was 40 years. The White and Black patients were mostly insured (insured greater than 95%), whereas the Hispanic patients were often uninsured (insured 58.9%). White and Black patients were mostly treated outside academic medical centers (nonmedical center: 63.7% and 58.4%, respectively); the opposite was true for Hispanic patients (nonmedical center: 34.2%). Black patients had higher bleeding severity scores compared with Hispanic and White patients (median 8, 7, and 4 respectively) and higher bulk scores (median 3, 1, and 0, respectively), but pain scores differed (median 3, 5, and 4, respectively). Black and Hispanic patients were disproportionately likely to have severe symptoms documented on two or more symptoms (referent: not severe on any symptoms) (adjusted PR [Black vs White] 3.02, 95% CI 2.29-3.99; adjusted PR [Hispanic vs White] 2.61, 95% CI 1.78-3.83). Although Black and Hispanic patients were more likely to experience severe symptoms, we found no racial and ethnic differences in the number of alternative treatments attempted before hysterectomy.
Conclusion: We did not find evidence of overtreatment of Black patients. Our findings suggest potential undertreatment of Black and Hispanic patients with uterine-sparing alternatives earlier in their disease progression.
Competing Interests: Financial Disclosure Whitney R. Robinson receives research funding and support as a co-investigator (1R01AG077947-01) from the National Institute of Aging (NIA). She has received honoraria (<$1,000) for speaking at institutions such as the University of Wisconsin School of Medicine and Public Health, and she has received honoraria for serving on a standing study section for the National Institutes of Health (NIH). Erin T. Carey provides expert witness testimony for Southern Insurance, Beytin McLaughlin, and Wagstaff. She has received payment from BriannaCope, StockmanConnor, and McBridehall. She also has two provisional patents unrelated to this work:421/518 PCT; U.S. Provisional No. 63/322,886; DEC POA UNC 19-0083 U.S. 17/769,042 (Our Ref. 421/465 PCT/US). Evan R. Myers disclosed receiving payment from Merck for HPV vaccination and Moderna for CMV vaccination. He has received payment from AbbVie, Inc. and Hologic, Inc. (cervical cancer screening). Til Stürmer receives investigator-initiated research funding and support as Principal Investigator (R01AG056479) from the National Institute of Aging (NIA). He owns stock in Novartis and Roche and received payment from Novo Nordisk. The other authors did not report any potential conflicts of interest.
(Copyright © 2023 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)