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Examining Disparities in Route of Surgery and Postoperative Complications in Black Race and Hysterectomy

Alexander, Amy L., MD, MS; Strohl, Anna E., MD, MA; Rieder, Stephanie, MD, PhD; Holl, Jane, MD, MPH; Barber, Emma L., MD, MS

doi: 10.1097/AOG.0000000000002990
Health Disparities: Original Research: PDF Only

OBJECTIVE: To estimate the associations among race, route of hysterectomy, and postoperative complications among women undergoing hysterectomy for benign indications.

METHODS: A cohort study was performed. All patients undergoing hysterectomy for benign indications, recorded in the National Surgical Quality Improvement Program and its targeted hysterectomy file in 2015, were identified. The primary exposure was patient race. The primary outcome was route of hysterectomy and the secondary outcome was postoperative complication. Associations were examined using both bivariable tests and logistic regression.

RESULTS: Of 15,136 women who underwent hysterectomy for benign indications, 75% were white and 25% were black. Black women were more likely to undergo an open hysterectomy than white women (50.1% vs 22.9%; odds ratio [OR] 3.36, 95% CI 3.11–3.64). Black women had larger uteri (median 262 g vs 123 g; 60.7% vs 25.6% with uterus greater than 250 g), more prior pelvic surgery (58.5% vs 53.2%), and higher body mass indices (32.7 vs 30.4). After adjusting for these and other clinical factors, black women remained more likely to undergo an open hysterectomy (adjusted OR 2.02, 95% CI 1.85–2.20). Black women experienced more major complications than white women (4.1% vs 2.3%; P<.001) and more minor complications (11.4% vs 6.7%; OR 1.78, P<.001). Again these disparities persisted with adjustment (major adjusted OR 1.56, 95% CI 1.25–1.95; minor adjusted OR 1.27, 95% CI 1.11–1.47).

CONCLUSIONS: Black women undergo a higher proportion of open hysterectomy and experience more major and minor postoperative complications. These differences persisted even after adjusting for confounding medical, surgical, and gynecologic factors.

Black women undergoing hysterectomy for benign indications undergo a higher proportion of open surgery and have more surgical complications when compared with white women.

Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, and the Center for Healthcare Studies, Institute for Public Health in Medicine, Chicago, Illinois.

Corresponding author: Emma L. Barber, MD, MS, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Northwestern University, Suite 05-2168, Chicago, IL 60611; email:

Supported by National Institutes of Health K12 HD050121-12.

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented at the annual meeting of the Society of Gynecologic Oncology, March 24–27, 2018, New Orleans, Louisiana.

The data used in the study are derived from a deidentified National Surgical Quality Improvement file. The American College of Surgeons has not verified and is not responsible for the analytic or statistical methodology used or the conclusions drawn from these data by the investigators.

Each author has confirmed compliance with the journal's requirements for authorship.

Peer reviews and author correspondence are available at

Received July 29, 2018

Received in revised form September 17, 2018

Accepted October 20, 2018

© 2018 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.