GYN journal 20171218（婦產科期刊閱讀報告）

1. Am J Obstet Gynecol 2017;217:572.e1-10.

2. Introduction
• National investigations of disparities in MIH: younger age, white race,
higher income, and private insurance
independently predict laparoscopic over abdominal hysterectomy.
• Primary aim: to determine the association between race and the odds of
MIH for the treatment of fibroids, adenomyosis, and abnormal bleeding.
• Secondary objective: to assess the relationship between socioeconomic
status, ethnicity, and the odds of MIH
• Hypothesis: nonwhite race and low socioeconomic status would be
associated with diminished utilization of MIH despite adjusting for
confounding due to patient-level clinical predictors of route of
hysterectomy.

3. Materials and methods
• A cross-sectional study
• all hysterectomies performed for fibroids, adenomyosis, and/or
abnormal uterine bleeding
• at the Hospital of the University Of Pennsylvania(HUP), Pennsylvania
Hospital(PAH), and Penn Presbyterian Medical Center(PPMC)
• from January 2010 through December 2013.
• Exclusion criteria: presence of known or suspected cancer, Known
endometriosis, and cases performed jointly with another surgical
service.

4. • Patient-level data: demographic information, primary indication and
mode of hysterectomy, self-identified race and ethnicity, median
household income quartile(based on ZIP code of residence), and insurance.
• Uterine weight and volume
• Modes of hysterectomy according to initial route: abdominal,
MIH(vaginal, laparoscopic, robotic)
• Univariate comparisons(abdominal vs all MIH)
• Four logistic regression(odds of abdominal to any MIH)

5. Result(baseline characteristics)
55%

6. Result(baseline characteristics)
54%
48%
9%
18%
71%(69%) vaginal hysterectomy in AA

7. Result(Clinical and demographic variables according to race)

8. Result(Clinical and demographic variables according to race)
larger uteri

9. Result(univariate analyses)

10. Result(multivariable logistic regression analysis)

11. Comment
• Racial and socioeconomic disparities in MIH
may mitigated by adjusting for patient-level confounding factors
• Controlling for BMI and uterine weight reduced the magnitude and
significance of racial disparities
• The divergent associations of race and income on different modes of MIH
may explain why the combined outcome of MIH overall failed to
demonstrate significant disparity.
• Vaginal hysterectomy over abdominal hysterectomy to low-income women
may be due to:
• employment status, less lenient work or child care schedules, and other economic
considerations. more conservative management

12. Limitations
• Uniform population biased
• Small proportion covered by Medicaid ACA
• Median household income quartile based on ZIP code  imperfect
• Exclude endometriosis due to adhesion may affect decision-making
limit the generalization
• Does not extend to other hospital systems

13. Advices
• Vaginal hysterectomy: preferred route for all patients for whom it is
feasible and safe
• Gynecological training programs should continue to teach vaginal
hysterectomy
• Future: controlling for individual providers or provider characteristics
• Disparities in national analyses may be due to uncontrolled patient-
level confounding factors