Why does race affect surgery procedures?

 

I found this article interesting.  It discusses how race seems to be a factor in type of hysterectomy surgery performed.  These numbers are American so I would be interested to know if such statistics would be true elsewhere.

Race, ethnicity influence chances of minimally invasive hysterectomy

By: MICHELE G. SULLIVAN, Internal Medicine News Digital Network

NATIONAL HARBOR, MD. – Race and ethnicity still appear to play a role in determining which patients receive a minimally invasive hysterectomy, and which undergo a traditional abdominal procedure.

Black, Hispanic, and Asian women were up to 50% less likely to have either a laparoscopic or vaginal hysterectomy, compared with whites, Dr. Katharine Esselen reported at the AAGL global congress.

The findings remained statistically significant even after Dr. Esselen and her colleagues controlled for a variety of patient, financial, and hospital characteristics.

“Racial disparities exist in the mode of hysterectomy in endometrial and cervical cancer, and must be further investigated to better understand the contributing factors so that they may be eradicated,” said Dr. Esselen, a clinical fellow in gynecologic oncology at Brigham and Women’s Hospital, Boston.

The researchers extracted their data from the 2009 National Inpatient Sample. It included 1,000 hospitals and more than 8 million patient stays – representing 20% of the discharges in the country for that year.

In 2009, there were 64,410 hysterectomies performed for gynecologic malignancy. More than half (54%) were for endometrial cancer, followed by cervical cancer (23%), and ovarian cancer (19%). Other cancers made up the remainder.

The majority of surgeries in all these categories were abdominal: 72% of the endometrial cases, 56% of the cervical cases, and 95% of the ovarian cases. Laparoscopic hysterectomy was the surgical mode in 26% of endometrial cases, 23% of cervical cases, and 4% of ovarian cases. Vaginal hysterectomies were performed for 2% of endometrial cases, 21% of vaginal cases, and just 1% of ovarian cases.

A multivariate regression analysis controlled for demographic factors (age, race/ethnicity, insurance); patient factors (cancer diagnosis, fibroids, endometriosis, prolapse, menstrual disorders, age, severity of comorbidities, obesity); and hospital factors (urban/rural, teaching status, size, and region of country).

After adjustment for all of these factors, black women were 43% less likely to have a minimally invasive hysterectomy for endometrial cancer than were white women – a significant difference. Hispanic and Asian women were also significantly less likely to have minimally invasive surgery (MIS), with odds ratios of 0.61 and 0.63, respectively. Native American women, however, were more than five times as likely to have such a procedure compared with white women (OR, 5.26).

Insurance also played a role, Dr. Esselen said. Those with Medicaid were significantly less likely to have a minimally invasive procedure (OR, 0.64) than were those with private insurance.

The findings were similar for ovarian cancer. Black and Asian women were significantly less likely to have MIS than were whites (OR, 0.41 and 0.44, respectively). There was no significant difference seen for Hispanic women.

Medical comorbidities were significantly related to the chance of MIS as well. MIS was significantly less likely in women with moderate loss of function due to comorbid conditions (endometrial OR, 0.47; cervical OR, 0.62; ovarian OR, 0.38). Those with major to extreme loss of function had an even smaller chance (endometrial OR, 0.23; cervical OR, 0.21; ovarian OR, 0.10). The P values on these were all less than .0001.

Obesity only affected MIS odds in endometrial cancer, significantly increasing the chance of such a procedure (OR, 1.27).

Types of Hysterectomy Surgeries

There are several types of hysterectomy surgeries that can be performed and they all have certain benefits as well as challenges/risks.

Abdominal hysterectomy:  As the name suggests, this surgery involves an incision in your abdomen, often 5-7 inches long.  It may be vertical or horizontal depending on a number of factors.  The recovery time for this type of surgery tends to be the longest out of all of the options.

Vaginal hysterectomy:  The surgeon will make a cut in the vagina and remove your uterus that way.

Laparoscopically-assisted vaginal hysterectomy:  The uterus is still removed through a cut in the vagina but the surgeon will use a laparoscope to assist in this process.  It involves 3-4 small abdominal incisions in order to insert the laparoscope.  The recovery time tends to be shorter with this type of surgery.  This is the procedure I had.

Robotic-assisted hysterectomy:  This is also referred to as the DaVinci method.  It utilizes a small robotic machine that works through small incisions similar to laparoscopic surgery.

There are numerous factors that impact which of these surgeries is best for any given patient including weight, recovery time, and the reason for the hysterectomy.  I will post more about the benefits and challenges of some of these surgeries in a future post.

Hysterectomy – The Basics

Here is a great summary of the general information that is helpful when considering a hysterectomy.  Over the next several weeks, I hope to break down this information in even more detail. For example, what are the reasons for a hysterectomy and what are the main risk factors.  Check in during this time to get more information on the topics mentioned here.

Hysterectomy

Email this page to a friend Bookmark & Share Printer-friendly versionHysterectomy is surgery to remove a woman’s womb (uterus). The womb is the area where a baby grows when a woman is pregnant.

Description

During a hysterectomy, the surgeon may remove the entire uterus or just part of it. The fallopian tubes and ovaries may also be removed.

Types of hysterectomy:

• Partial (supracervical) hysterectomy: The upper part of the uterus is removed. The cervix is left in place.
• Total hysterectomy: The entire uterus and cervix are removed.
• Radical hysterectomy: The uterus, cervix upper part of the vagina, and tissue on both sides of the cervix are removed. This is most often done if you have cancer.

Your doctor will help you decide which type of hysterectomy is best for you. The choice often depends on your medical history and reason for the surgery.

Why the Procedure is Performed

There are many reasons a woman may need a hysterectomy. The procedure may be recommended if you have:

• Adenomyosis, which causes heavy, painful periods
• Cancer of the uterus, most often endometrial cancer
• Cancer of the cervix or changes in the cervix called cervical dysplasia that may lead to cancer
• Cancer of the ovary
• Long-term (chronic) pelvic pain
• Severe endometriosis that does not get better with other treatments
• Severe, long-term vaginal bleeding that is not controlled with other treatments
• Slipping of the uterus into the vagina (uterine prolapse)
• Tumors in the uterus, such as uterine fibroids
•  Uncontrolled bleeding during childbirth

Hysterectomy is a major surgery. It is possible that your condition may be treated without this major surgery. Talk with your doctor or nurse about all your treatment options. Less invasive procedures include:

• Uterine artery embolization
• Endometrial ablation
• Using birth control pills
• Using pain medicines
• Using an IUD that releases the hormone progestin
• Pelvic laparoscopy

Risks

Risks of any surgery are:

• Allergic reactions to medicines
• Breathing problems
• Blood clots, which may cause death if they travel to the lungs
• Bleeding
• Infection
• Injury to nearby body areas

Risks of a hysterectomy are:

• Injury to the bladder or ureters
• Pain during sexual intercourse
• Early menopause if the ovaries are removed
• Decreased interest in sex
• Increased risk of heart disease if the ovaries are removed before menopause

Ask your doctor if taking estrogen can help lower the risk of heart disease and help menopause symptoms.

Before the Procedure

Before deciding to have a hysterectomy, ask your doctor or nurse what to expect after the procedure. Many women who have had a hysterectomy notice changes in their body and in how they feel about themselves. Talk with your doctor, nurse, family, and friends about these possible changes before you have surgery.

Tell your health care team about all the medicines you are taking. These include herbs, supplements, and other medicines you bought without a prescription.

During the days before the surgery:

• You may be asked to stop taking aspirin, ibuprofen (Advil, Motrin), clopidogrel (Plavix), warfarin (Coumadin), and any other drugs like these.
• Ask your doctor which drugs you should still take on the day of your surgery.
• If you smoke, try to stop. Ask your doctor or nurse for help quitting.

On the day of your surgery:

• You will usually be asked not to drink or eat anything for 8 hours before the surgery.
• Take any medicines your doctor told you to take with a small sip of water.
• Arrive at the hospital on time.

After the Procedure

After surgery, you will be given pain medicines to relieve any discomfort.

You may also have a tube, called a catheter, inserted into your bladder to pass urine. The catheter will likely be removed before you go home.

You will be asked to get up and move around as soon as possible after surgery. This helps prevent blood clots from forming in your legs and speeds recovery.

You will be asked to get up to use the bathroom as soon as you are able. You may return to a normal diet as soon as you can without causing nausea or vomiting.

How long you stay in the hospital depends on the type of hysterectomy.

• You can likely go home the next day when surgery is done through the vagina using a laparoscope or after robotic surgery.
• When a larger surgical cut (incision) in the abdomen is made, you may need to stay in the hospital 1 to 2 days. You may need to stay longer if the hysterectomy is done because of cancer.

Outlook (Prognosis)

How long it takes you to recover depends on the type of hysterectomy. Average recovery times are:

• Abdominal hysterectomy: 4 to 6 weeks
• Vaginal hysterectomy: 3 to 4 weeks
• Robot-assisted or total laparoscopic hysterectomy: 2 to 4 weeks

A hysterectomy will cause menopause if you also have your ovaries removed. Removal of the ovaries can also lead to a decreased sex drive. Your doctor may recommend estrogen replacement therapy. Discuss with your doctor the risks and benefits of this therapy.

If the hysterectomy was done for cancer, you may need further treatment.

Retrieved from: http://www.nlm.nih.gov/medlineplus/ency/article/002915.htm

Keyhole hysterectomies better for women, could save health budget $50 million

Here’s a recent article I found comparing abdominal and vaginal hysterectomies.  They are using Australian statistics but I know they’re similar here in Canada too.  I’m so happy I had a gynecologist who was comfortable doing the laparoscopic surgery.  It went really well and I only have 4 miniscule incision marks and I don’t doubt those will eventually disappear.  What do you think about these options?

Australian experts say scarce funding for the health budget is being wasted by surgeons continuing to perform open hysterectomies instead of a less invasive procedure.

Every year, around 30,000 Australian women have a hysterectomy.

About 40 per cent of them will undergo an open hysterectomy, which involves a longer stay in hospital and a greater chance of side-effects.

Professor Andreas Obermair from Brisbane’s Greenslopes Hospital says patients who undergo the open procedure have a much longer recovery period and are in more pain after the operation.

He says 50 per cent of women have a vaginal procedure, which is not invasive.

But he says too many women are still undergoing full, open surgery, which has greater risks of infections and readmission to hospital.

Only about 10 per cent of women are offered the minimally invasive, laparoscopic procedure.

“Not a lot of people would have trained in this kind of procedure and I guess there needs to be a new generation of gynaecologists coming through who are more proficient in the new, less invasive procedures that are better for patients,” Professor Obermair said.

He estimates that if the laparoscopic procedure were offered in all cases, the savings to the health system would be enormous.

“We did the numbers and we calculated that straightaway Australia could save $50 million every year,” he said.

Different procedures have pros, cons: Doctor

Dr Stephen Robson, the vice president of the Royal Australian College of obstetricians and gynaecologists, says hysterectomies are much less common these days than 30 years ago.

Dr Robson says the vaginal hysterectomy is the cheapest and least complicated, but he says it is not always appropriate for every patient.

He says both the laparoscopic and abdominal hysterectomies have pros and cons and there are a number of factors that need to be taken into account when deciding which operation to choose.

Brisbane mother Amanda Renton had the minimally invasive procedure after discovering she had a genetic link to breast and ovarian cancer.

Ms Renton says she is pleased with her choice.

“It was really good to be honest, much better than I could have expected. It’s been three weeks since the operation and I feel really good,” she said.

Health funding being ‘wasted’, Professor says

Professor Obermair says health funding needs to be used more effectively.

“We could put a lot more effort into training doctors, so they are able to offer minimally invasive procedures. At the moment we are wasting dollars here,” he said.

Associate Professor Nicholas Graves from the Australian Centre for Health Services Innovation at Queensland University of Technology says health funding is scarce and needs to be used wisely.

“In the current economic climate with healthcare resources under so much pressure we really need to be adopting these smart and useful innovations as quickly as possible,” he said.

Professor Graves has analysed the cost effectiveness of the laparoscopic hysterectomy compared to an abdominal hysterectomy for treating early-stage endometrial cancer.

His research found that adopting laparoscopic procedures would result in savings to health services and an increase in health benefits.

While the initial surgery costs are higher for laparoscopic surgery, overall doctors say it ends up being cheaper as patients are less likely to end up back in hospital with side effects and infections.

Here’s a video link to the same issue: http://www.abc.net.au/news/2013-09-24/surgeons-wasting-funding-on-hysterectomies/4978906