Disparities in Benign Gynecologic Surgical Care : Clinical Obstetrics and Gynecology

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Racial Disparities in OB/GYN

Disparities in Benign Gynecologic Surgical Care

Laughman, Kimberly MD*; Ogu, Nkechinyelum Q. MD*; Warner, Kristina J. MD; Traylor, Jessica MD

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Clinical Obstetrics and Gynecology 66(1):p 124-131, March 2023. | DOI: 10.1097/GRF.0000000000000755
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Abstract

Introduction

Symptoms of benign gynecologic disorders have been shown to negatively affect the quality of life and productivity for the patients that experience them.1 Some patient populations, particularly racial minorities, are further marginalized by disparate provision of care, access to high-volume surgeons and hospitals, and increased perioperative morbidity.2,3 A growing body of research has demonstrated that Black patients experience significant disparities in their access to quality gynecologic care. Given the changing demographics of the United States, with non-White race individuals projected to become the majority by 2050, it is imperative that we address these overwhelming inequities.4 Unpacking the current landscape of disparities in benign gynecologic surgical care warrants a look at historical influences on our field.

The field of gynecology is fraught with a tainted history of exploitation of women of color dating back as far as its inception. James Marion Sims, often revered as the “father of gynecology,” developed his understanding of the subject through experimentation on the bodies of enslaved Black women. The names of only 3 of his myriad experimental subjects are known: Lucy, Betsey, and Anarcha.5 These women, and ∼9 others, were forced to work in Sims’ hospital as surgical nurses and surgical patients. Although anesthesia was available and used for the White patients on whom Sims operated, Black women were subject to lengthy unanesthetized surgeries during which their bodies were on display for dozens of observing physicians while they screamed in what Sims himself described as “extreme agony.” He perfected his technique for the repair of vesicovaginal fistulas after over 30 surgeries on Anarcha, and Lucy reportedly fell ill for several months due to Sims’ use of a sponge to drain her bladder, which led to bacteremia.6 Thus, the very birth of our surgical field was built on the torture of Black women.

Generations after Sims’ experiments, Black women continued to endure gynecologic injustices in the form of eugenics-based sterilization programs that targeted the “feebleminded” and disproportionately impacted Black women.7 Teaching hospitals throughout the US were also known for coercing women into sterilization procedures, or simply performing them without informing the patient beforehand. Dorothy Roberts, author of Killing the Black Body: Race, Reproduction and the meaning of Liberty, writes “It was a common belief among Blacks in the South that Black women were routinely sterilized without their informed consent and for no valid medical reason. Teaching hospitals performed unnecessary hysterectomies on poor Black women as practice for their medical residents. This sort of abuse was so widespread in the South that these operations came to be known as ‘Mississippi appendectomies.’” As recently as 2014, Black inmates in the state of California similarly described undergoing unindicated hysterectomies and sterilization without informed consent.8

Given this disturbing social context, it is not surprising that many Black women experience difficulty trusting medical professionals. This article seeks to outline several key areas of health inequity and to offer solutions to begin to address them.

SURGICAL VOLUME

The association between higher surgical volume and fewer perioperative complications has been well-described across numerous surgical disciplines.9–12 Within benign gynecologic surgery, the volume-outcome relationship has been studied most robustly for hysterectomy. Approximately 500,000 hysterectomy procedures are performed annually in the United States, making it one of the most common surgical procedures performed.13 In a review of the literature addressing the volume-outcome relationship for benign hysterectomy, authors found that morbidity outcomes consistently favored high-volume surgeons.14

The volume-outcome relationship is also important when considering how it interacts with issues of equitable care and access to health care. A retrospective analysis of factors associated with minimally invasive hysterectomy (MIH) in Illinois found hospital volume to be the single most important factor influencing the likelihood of undergoing a MIH, but a higher proportion of Black patients underwent hysterectomies at hospitals with a lower proportion of MIH.15

A study examining disparities in access to care and outcomes for patients undergoing hysterectomy at high-volume hospitals in New York found that patients treated by low-volume surgeons were more often Black [19.4% vs. 14.3%; adjusted odds ratio (aOR)=1.26; 95% confidence interval (CI), 1.09-1.46].2 The same study found that low-volume surgeons were also more likely to perform abdominal hysterectomy versus MIH (77.8% vs. 54.7%; aOR=1.91; 95% CI, 1.62-2.24) and had a higher complication rate (31% vs. 10.3%; P<0.001). By studying hysterectomy outcomes within high-volume hospitals, this study demonstrated how the benefits of receiving care at a high-volume center may be dampened when the procedure is performed by a low-volume surgeon.

ROUTE OF SURGERY

Myriad factors contribute to the inequitable landscape of health care. Among these are hospital policies, health care professionals’ prerogative, patient knowledge, and access to care.16 These disparities span all specialties with obstetrics and gynecology as no exception. Studies show that in the management of endometrial cancer, patients who identify as White and utilize private insurance are more likely to receive robotic surgery.16,17 This leads us to investigate the disparities of the surgical route in regard to benign gynecologic conditions.

Hysterectomy is the most commonly performed nonobstetric surgery for women and can be performed via open abdominal (AH), laparoscopic (LH), or vaginal (VH) routes. Per the American College of Obstetricians and Gynecologists (ACOG) guidelines, the recommended practice for operative management of benign disease is a minimally invasive technique, which has been associated with fewer complications, shorter hospital stays, and lower risk of transfusion.16–18

There are numerous factors that impact the surgical management of benign gynecologic conditions, including disease burden, surgical history, and patient comorbidities. When considering patient demographics, Black and other minorities have poorer surgical outcomes and undergo fewer minimally invasive surgical procedures.3 Researchers have hypothesized that the discrepancy in fibroids, uterus size, socioeconomic status, medical comorbidities, and medical access may explain the disparity in MIHs.3 However, recent studies have revealed that even when accounting for these factors, Black women experience more postoperative complications. Ko and colleagues, in a study of 20,133 women undergoing hysterectomy, described significant differences in surgical route by race. Black women (aOR=2.22; 95% CI, 2.07-2.38), as well as Hispanic women (aOR=1.76; 95% CI, 1.58-1.96), were more likely to undergo AH versus MIH. Similarly, Hispanic women were more likely to experience open surgery; AH versus MIH (aOR=1.76).3,19 Some may inquire whether access to medical care resulted in the discrepancy. Ranjit et al20 investigated the effect of insurance coverage on patients’ access to care and discovered that 36.7% of White patients received AH compared with 53.4% of Black patients and 51.01% of Asian patients despite universal insurance coverage and equal access. After adjusting for Black women’s increased likelihood of having larger uteri (median=262 vs. 123 g), higher body mass index (32.7 vs. 30.4), and history of prior pelvic surgery, Alexander et al21 demonstrated that Black women were still more likely to undergo AH (aOR=2.02, 95% CI, 1.85-2.20). As laparoscopic surgery becomes the standard of care and provider experience with minimally invasive techniques increases, the total number of laparoscopic cases increases exponentially. Unfortunately, the rates are increasing at statistically significantly lower rates for Black and Hispanic patients. AH rates decreased 1.7-fold for White patients (P=0.011) and 1.6-fold for Black patients (P=0.008) and Hispanics (P=0.032) from 2010 to 2014.22 With the well-documented disparities in surgical route, it is no surprise that minority patients are further negatively impacted by the associated postoperative outcomes.

PERIOPERATIVE OUTCOMES

Research has shown that surgical route and surgeon volume are crucial determinants for surgical outcomes.19 Perioperative outcomes and complications are those that occur during surgery (ie, blood transfusion and injury to surrounding structures), as well as those that occur postoperatively (ie, transfers to intensive care unit, unplanned reoperations, surgical site infections, and deep venous thrombosis/pulmonary embolism). Ko et al3 discovered that of 20,133 women who underwent hysterectomy for fibroids in the American College of Surgeons National Surgical Quality Improvement Database (NSQIP), Black patients were more likely to experience postoperative complications than White patients, across surgical routes: AH (aOR=1.54; 95% CI, 1.31-1.80); VH (aOR=1.65; 95% CI, 1.02-2.68); LH (aOR=1.37; 95% CI, 1.13-1.66). In addition, Black women were more likely to have a prolonged hospital stay compared with White women for both AH and LH (2.6 vs. 2.3 d and 1.1 vs. 0.9 d, respectively). When compared with White women, Black women experience more major and minor complications even when stratified by the surgical route.3 These complications and adverse outcomes greatly impact health care costs and patient quality of life.

It has long been a statistical fact that open surgeries are associated with greater complications than laparoscopic procedures.18,19 A Cochrane review of 47 studies on AH, LH, and VH that included 5102 patients reported that compared with AH, VH was associated with a faster return to normal activities and better quality of life. When compared with LH, VH was associated with shorter operating time and hospital stay.18,23 Pollack et al24 showed that posthysterectomy hospitalization was highest after AH and lowest for VH (4.5% 30 d and 5.7% 90 d vs. 3.3% 30 d and 4.5% 90 d, respectively). Similarly, Mehta et al19 discovered that among a statewide database comprising 5600 hysterectomies, AH is associated with longer hospital stays, surgical site infections, postoperative respiratory failure, and pneumonia (P<0.38).

Open surgery is often undertaken for anatomic limitations such as large uteri, but as Alexander and colleagues revealed, after adjusting for uterine size, prior pelvic surgery, and body mass index, Black women have more major and minor postoperative complications.3,21,24 In fact race, specifically Black race, was independently associated with posthysterectomy admission, surgical site infections, and gastrointestinal complications. Hispanic heritage was similarly associated with 30-day hospitalizations, while patients of Asian/Pacific Islander descent had increased rates of urological injury.24 Countless studies have confirmed a higher risk of complications among non-White women after hysterectomy.3,19,21,24,25 We must acknowledge that patients’ preexisting conditions impact surgical outcomes. Black women often present with preexisting conditionings that include obesity, diabetes, and larger uterine weight, which increase the risk for adverse surgical outcomes.3 Despite this, studies have found that when accounting for some of these factors, Black women continue to experience more postoperative complications. This suggests that a multifactorial model, including surgical route, influences this outcome.

BENIGN GYNECOLOGIC SURGICAL SUBSPECIALTIES

While there are many surgical procedures performed for patients seeking fertility and family planning, we choose to highlight urogynecologic surgeries within the scope of this article. Within the subspecialty of Female Pelvic Medicine and Reconstructive Surgery (FPMRS), similar racial-ethnic disparities exist in surgical route and postoperative outcomes for patients undergoing anti-incontinence and prolapse surgery. While prior epidemiological studies describe a lower prevalence of these pelvic floor disorders in racial and ethnic minorities when compared with White women, more contemporary data illustrates that urinary incontinence and pelvic organ prolapse are equally common for all women and estimated to increase nearly 50% by the year 2050 due to normal population aging.26

Stress Urinary Incontinence (SUI)

SUI, the involuntary loss of urine with transient increases in intra-abdominal pressure, is the most prevalent subtype of urinary incontinence and affects nearly 40% of community-dwelling adult women in the United States.27 Since its introduction to the market in 1995, the midurethral sling (MUS) has remained the mainstay of surgical SUI management with high cure rates and low associated morbidity.28 There is little data stratifying the rate of MUS by race and ethnicity, however, in a secondary analysis of the NSQIP database over an 8-year period, Ringel et al29 reported that <25% of MUS were performed in non-White women.

Adverse events after MUS are rare, however, disparate outcomes exist for racial and ethnic minorities, with postoperative complication rates that are highest among Black women when compared with all other groups.29–31 In a database study that sought to examine factors associated with outcomes after MUS within a California health system, the incidence of any 30-day event (emergency department visit, inpatient admission, or surgical revision) was significantly higher among Black and Hispanic (10.5% and 6.5%) women when compared with Asian and White (4.7% and 5.4%) women.30 Similar findings were described in an analysis of Medicare claims data by Anger et al31 in which non-White women were more than twice as likely to develop nonurological complications and urinary obstruction within 1 year postoperatively.

Pelvic Organ Prolapse

Pelvic organ prolapse, the descent of one or a combination of the 3 vaginal compartments, can be managed surgically with native tissue or mesh-based vaginal, laparoscopic, and abdominal approaches with or without concomitant hysterectomy. There is a growing body of literature describing the impact of race and ethnicity on surgical approach for prolapse repair, however, many of these studies include disproportionately small numbers of Black, Hispanic, and other minority populations. When performed at the time of prolapse surgery, similar trends as those reported in other benign gynecology literature generally persist, with Black women being more likely to receive an abdominal approach when compared with all other groups.32 Conversely, in a large national database study including women who underwent primary prolapse surgery, Black women were most likely to undergo MIH with or without concurrent prolapse repair or apical suspension.33 Studies have consistently shown low overall rates of colpopexy for apical suspension. Cardenas-Trowers et al33 reported colpopexy rates that were similar for White and Black women, and lowest for Hispanic women (43.8% vs. 43.7% vs. 36.8%, respectively), whereas Brown et al34 reported a rate of colpopexy for Black women that was nearly 10% higher than that of White women. Differences in route of colpopexy by race and ethnicity were characterized in another study describing higher rates of vaginal colpopexy and lower rates of laparoscopic colpopexy in all groups when compared with non-Hispanic White women.35 In another retrospective study, these associations persisted for Hispanic women but were not described for Black women.36

The overall rate of postoperative complications following prolapse surgery is low, however, this observation does not hold for all groups. Despite accounting for a minority of all population-based study participants, women belonging to racial and ethnic groups often experience more postoperative complications relative to non-Hispanic White women.29,32–34,36 In one study, Black race was independently associated with significantly increased odds of any postoperative complication, blood transfusion, sepsis, and length of stay when compared with all racial groups.33 In another study, Boyd et al35 similarly reported a 3-fold higher odds of receiving a blood transfusion after minimally invasive colpopexy and a higher incidence of vascular complication (deep venous thrombosis, pulmonary embolism, blood transfusion) for Black women relative to their White counterparts. Conversely, after prolapse surgery, Hispanic women were often reported to experience lower rates of any complication, major complication, and reoperation across all racial groups.33,34

GYNECOLOGIC RESEARCH

While one aspect of the disparate care for Black and White women in the United States lies in patient access, another key component is the lack of inclusion of Black women in gynecologic research. While Lucy, Betsey, and Anarcha were forced to be included in Sims’ trials, Black women today are significantly less likely to participate in research trials when compared with Whites.37 At least some portion of this lack of involvement may be secondary to patient mistrust and hesitance to participate in research due to the generational trauma of Black patients being used as unwilling subjects in unethical trials throughout our nation’s history. In their 2007 study, Smith et al38 explored the perceptions of Black women regarding clinical research and found several common themes including a patient perception that research is biased to benefit Whites, that community involvement and education from the research team improved recruitment, and that research directly relevant to Black patients and their community increased participation. Research has shown that physicians and researchers of color are more likely to study topics directly related to patient care such as health disparities, and a lack of funding for these researchers may contribute to less involvement from patients of color.39 Ginther and colleagues studied the association between researchers self-reported race and NIH grant funding and found that when controlling for factors such as training level, research award history, and previous publication history, Black researchers remain 10 percentage points (−0.107, P<0.001) less likely to receive NIH funding than their White counterparts. Hoppe et al40 suggest that this difference may be at least in part due to a difference in topic of choice, but that some influence of implicit bias likely also plays a role.

Conclusions

With this understanding of the numerous obstacles that impede Black women’s equitable access to quality gynecologic care, we are left with the question of what can be done to improve the state of our field. We posit that the answer lies in a multilevel approach focused on research, protocols, and education that tackles each of the various contributors to the current state of inequity. First, given our understanding of the importance of inclusion and representation in research, efforts must be made to improve community outreach and address the concerns within the Black community regarding the historical mistreatment of people of color for research purposes. We must also understand that a significant component of improving access and inclusion for patients of color is to increase access and inclusion for investigators and providers of color, as they are statistically more likely to engage in care for this population.39

With respect to access, we must seek out ways to ensure equitable management of patients of color. With such significant racial disparities in the choice of hysterectomy route and postoperative complications as a result, it is paramount that we develop a solution. In 2014, Linkov et al41 at the University of Pittsburgh Medical Center successfully implemented a hysterectomy route pathway that emphasized the use of diagnostic laparoscopy. Over the 2-year implementation period, AH decreased from 27.8% to 17% (P<0.001). Sanei-Moghaddam et al42 confirmed the improved surgical outcomes through a 47% reduction in surgical site infections and statistically significant shorter hospital stays. Similar protocol-driven quality improvement programs can be utilized in other hospitals to drive up appropriate utilization of MIH.

Furthermore, we must educate our providers on the long history of injustices toward people of color within the field of medicine and provide them with the context to understand why patients may be hesitant to trust aspects of their care. We must also train providers to engage patients in their medical health and utilize shared decision-making to facilitate better communication between patients and providers. This improved communication can help to dampen some of the negative effects that historical injustices have had on minority communities’ interactions with the health care system. Implementation of this multifaceted approach is paramount to reducing the unjust disparities that exist in benign gynecologic surgery.

References

1. Fortin C, Flyckt R, Falcone T. Alternatives to hysterectomy: the burden of fibroids and the quality of life. Best Pract Res Clin Obstet Gynaecol. 2018;46:31–42.
2. Knisely A, Huang Y, Melamed A, et al. Disparities in access to high-volume surgeons within high-volume hospitals for hysterectomy. Obstet Gynecol. 2021;138:208–217.
3. Ko JS, Suh CH, Huang H, et al. Association of race/ethnicity with surgical route and perioperative outcomes of hysterectomy for leiomyomas. J Minim Invasive Gynecol. 2021;28:1403–1410.
4. Colby SL, Ortman JM. Projections of the Size and Composition of the US Population: 2014 to 2060, Current Population Reports, P25-1143. Washington, DC: US Census Bureau; 2014.
5. Holland B. The ‘father of Modern Gynecology’ performed shocking experiments on enslaved women. History.com; 2017. Available at: https://www.history.com/news/the-father-of-modern-gynecology-performed-shocking-experiments-on-slaves. Accessed May 5, 2022.
6. Owens DC. Medical Bondage: Race, Gender, and the Origins of American Gynecology. Athens, GA: University of Georgia Press;; 2017.
7. Roberts DE. Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. New York, NY: Vintage; 1999.
8. Naftulin J. Inside the hidden campaign to forcibly sterilize thousands of inmates in California women’s prisons. Insider; 2020. Available at: https://www.insider.com/inside-forced-sterilizations-california-womens-prisons-documentary-2020-11. Accessed May 5, 2022.
9. Maneck M, Köckerling F, Fahlenbrach C, et al. Hospital volume and outcome in inguinal hernia repair: analysis of routine data of 133,449 patients. Hernia. 2019;24:747–757.
10. Huo YR, Phan K, Morris DL, et al. Systematic review and a meta-analysis of hospital and surgeon volume/outcome relationships in colorectal cancer surgery. J Gastrointest Oncol. 2017;8:534–536.
11. Matsuo K, Youssefzadeh AC, Mandelbaum RS, et al. Hospital surgical volume-outcome relationship in caesarean hysterectomy for placenta accreta spectrum. BJOG. 2022;129:986–993.
12. Akmaz B, van Kuijk S, Nia PS. Association between individual surgeon volume and outcome in mitral valve surgery: a systematic review. J Thorac Dis. 2021;13:4500–4510.
13. Cohen SL, Vitonis AF, Einarsson JI. Updated hysterectomy surveillance and factors associated with minimally invasive hysterectomy. JSLS. 2014;18:e2014.00096.
14. Doll KM, Milad MP, Gossett DR. Surgeon volume and outcomes in benign hysterectomy. J Minim Invasive Gynecol. 2013;20:554–561.
15. Traylor J, Simon M, Tsai S, et al. Patient and hospital characteristics associated with minimally invasive hysterectomy: evidence from 143 Illinois hospitals, 2016 to 2018. J Minim Invasive Gynecol. 2020;27:1337–1343.
16. Sanei-Moghaddam A, Kang C, Edwards RP, et al. Racial and socioeconomic disparities in hysterectomy route for benign conditions. J Racial Ethn Health Disparities. 2018;5:758–765.
17. Moss EL, Morgan G, Martin AP, et al. Surgical trends, outcomes and disparities in minimal invasive surgery for patients with endometrial cancer in England: a retrospective cohort study. BMJ Open. 2020;10:e036222.
18. Committee Opinion No 701: Choosing the route of hysterectomy for benign disease. Obstet Gynecol. 2017;129:e155–e159.
19. Mehta A, Xu T, Hutfless S, et al. Patient, surgeon, and hospital disparities associated with benign hysterectomy approach and perioperative complications. Am J Obstet Gynecol. 2017;216:497.e1–497.e10.
20. Ranjit A, Sharma M, Romano A, et al. Does universal insurance mitigate racial differences in minimally invasive hysterectomy? J Minim Invasive Gynecol. 2017;24:790–796.
21. Alexander AL, Strohl AE, Rieder S, et al. Examining disparities in route of surgery and postoperative complications in Black race and hysterectomy. Obstet Gynecol. 2019;133:6–12.
22. Pollack LM, Olsen MA, Gehlert SJ, et al. Racial/ethnic disparities/differences in hysterectomy route in women likely eligible for minimally invasive surgery. J Minim Invasive Gynecol. 2020;27:1167.e2–1177.e2.
23. Aarts JW, Nieboer TE, Johnson N, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2015;2015:CD003677.
24. Pollack LM, Jerry LL, Matt K, et al. Racial/ethnic differences in the risk of surgical complications and posthysterectomy hospitalization among women undergoing hysterectomy for benign conditions. J Minim Invasive Gynecol. 2021;28:1022–1032.
25. Sheyn D, Bretschneider CE, Mahajan ST, et al. Incidence and risk factors of early postoperative small bowel obstruction in patients undergoing hysterectomy for benign indications. Am J Obstet Gynecol. 2019;220:251.e1–251.e9.
26. Dieter AA, Wilkins MF, Wu JM. Epidemiological trends and future care needs for pelvic floor disorders. Curr Opin Obstet Gynecol. 2015;27:380–384.
27. Patel UJ, Godecker AL, Giles DL, et al. Updates prevalence of urinary incontinence in women: 2015-2018 National population-based survey data. Female Pelvic Med Reconst Surg. 2022;28:181–187.
28. Richter HE, Albo ME, Zyczynski HM, et al. Retropubic versus transobturator midurethral slings for stress incontinence. N Engl J Med. 2010;362:2066–2076.
29. Ringel NE, Brown O, Moore KJ, et al. Disparities in complications after prolapse repair and sling procedures: trends from 2010-2018. Urology. 2022;160:81–86.
30. Dallas KB, Sohlberg EM, Elliot CS, et al. Racial and socioeconomic disparities in short-term urethral sling surgical outcomes. Urology. 2017;110:70–75.
31. Anger JT, Rodriguez LV, Wang Q, et al. Racial disparities in the surgical management of stress incontinence among female Medicare beneficiaries. J Urol. 2007;177:1846–1850.
32. Shah AD, Kohli N, Rajan SS, et al. Racial characteristics of women undergoing surgery for pelvic organ prolapse in the United States. Am J Obstet Gynecol. 2007;197:70.e1–8.
33. Cardenas-Trowers OO, Gaskins JT, Francis SL. Association of patient race with type of pelvic organ prolapse surgery performed and adverse events. Female Pelvic Med Reconstr Surg. 2021;27:595–601.
34. Brown O, Mou T, Kenton K, et al. Racial disparities in complications and costs after surgery for pelvic organ prolapse. Int Urogynecol J. 2022;33:385–395.
35. Boyd BAJ, Winkelman WD, Mishra K, et al. Racial and ethnic differences in reconstructive surgery for apical vaginal prolapse. Am J Obstet Gynecol. 2021;225:405.e1–405.e7.
36. Roberts K, Sheyn D, Bretschneider CE, et al. Perioperative complication rates after colpopexy in African American and Hispanic Women. Female Pelvic Med Reconstr Surg. 2022;26:597–602.
37. Loree JM, Anand S, Dasari A, et al. Disparity of race reporting and representation in clinical trials leading to cancer drug approvals From 2008 to 2018. JAMA Oncol. 2019;5:e191870.
38. Smith YR, Johnson AM, Newman LA, et al. Perceptions of clinical research participation among African American women. J Womens Health (Larchmt). 2007;16:423–428.
39. Ginther DK, Schaffer WT, Schnell J, et al. Race, ethnicity, and NIH research awards. Science. 2011;333:1015–1019.
40. Hoppe TA, Litovitz A, Willis KA, et al. Topic choice contributes to the lower rate of NIH awards to African-American/Black scientists. Sci Adv. 2019;5:eaaw7238.
41. Linkov F, Sanei-Moghaddam A, Edwards RP, et al. Implementation of hysterectomy pathway: impact on complications. Womens Health Issues. 2017;27:493–498.
42. Sanei-Moghaddam A, Ma T, Goughnour SL, et al. Changes in hysterectomy trends after the implementation of a clinical pathway. Obstet Gynecol. 2016;127:139–147.
Keywords:

gynecologic surgery; health disparity; surgical volume; perioperative outcomes; minimally invasive surgery; hysterectomy

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