2 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. 33 1

Public Health Relevance

Since the 1980s, hysterectomy, or uterus-removal surgery, has been extremely common and marked by large racial differences. It's not clear whether these racial differences are because of legitimate medical need or inequitable treatment by the healthcare system. Analyzing thousands of medical records, we will evaluate what's driving these long-standing racial differences: medical need or the culture of healthcare?

National Institute of Health (NIH)
National Institute on Minority Health and Health Disparities (NIMHD)
Research Project (R01)
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Special Emphasis Panel (ZRG1)
Program Officer
Louden, Andrew
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University of North Carolina Chapel Hill
Public Health & Prev Medicine
Schools of Public Health
Chapel Hill
United States
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Hong, Jin-Liern; Jonsson Funk, Michele; LoCasale, Robert et al. (2018) Generalizing Randomized Clinical Trial Results: Implementation and Challenges Related to Missing Data in the Target Population. Am J Epidemiol 187:817-827