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.

No Safety Benefit Found in Use of Robot for Hysterectomy

Here is a recent article from Bloomberg News that suggests that robotic-assisted hysterectomies may not be much better for reducing complications than other forms of hysterectomy.  However, there is some disagreement on the type of patients that were studies and whether direct comparisons can be fairly made.  It seems to say there is less chance od needing a blood transfusion but more chance of pneumonia.  I was fortunate enough to not have had any complications after surgery, although I did need a blood transfusion prior to surgery.  What has your experience been with complications after a hysterectomy?  Feel free to post in the comments section below.

Surgery to remove the uterus using a $1.5 million robot from Intuitive Surgical Inc. (ISRG) doesn’t reduce complications and may raise pneumonia risk compared with conventional less-invasive techniques, according to a second extensive study to find no added benefit from the devices.

Researchers examined data from about 16,000 women who had hysterectomies for benign conditions in 2009 and 2010. The robot operations cost hospitals $2,489 more per procedure with a similar complication rate as the standard practice of removing the uterus with minimally invasive equipment, according to the study released in the journal Obstetrics & Gynecology.

“Unfortunately, the greater costs associated with robotic-assisted hysterectomy were not reflected in improvement in outcomes,” said researchers at the University of Texas Southwestern Medical Center at Dallas.

The results released yesterday are from the second large-scale research published this year to find higher costs with no added benefit for robotic hysterectomy. In February, Bloomberg News reported that U.S. health regulators were surveying surgeons on the robots following a rise in reports that included as many as 70 deaths since 2009. In July, Sunnyvale, California-based Intuitive said sales growth slowed in the second quarter and that it had received a regulatory warning letter concerning reporting issues for the devices.

Intuitive fell less than 1 percent to $384.52 at 9:52 a.m. New York time. The shares have declined 33 percent since Feb. 27, the day before Bloomberg News reported the Food and Drug Administration survey of surgeons about the products.

Top Product

The company’s da Vinci system, used in more than 1,300 hospitals, is its primary product. Revenue from the robot and related instruments and supplies generated $1.8 billion in 2012, Intuitive has reported.

In the study released yesterday, while patients who got robotic hysterectomies had a lower rate of needing blood transfusions, they had double the risk of getting pneumonia after the operation.

The pneumonia finding may be related to a trend toward a higher number of robotic hysterectomy patients needing intubation after their operation, the University of Texas Southwestern researchers wrote. Lengthy robotic operations with patients in steep head-down positions may result in fluid buildup in the airways, the authors suggested. The trend was not statistically meaningful.

No Benefit

The net result was no benefit in reducing complications for robotic surgery. The complication rate was 8.80 percent for robotic hysterectomy surgery and 8.85 percent for a standard minimally invasive hysterectomy, according to the study.

Intuitive Surgical, in an e-mail, said patients in the study getting robotic surgery tended to be older, heavier and had a higher rate of chronic conditions.

“Given these facts, it is likely that a substantial percentage of patients who received a robotic-assisted hysterectomy would have otherwise received an open hysterectomy,” Angela Wonson, a spokeswoman for the company, said in the e-mail.

In the study, which culled data from more than 800,000 hysterectomies, the complication comparison was based on a subset of patients with similar ages, obesity rates and health status.

With standard minimally invasive surgery, called laparoscopy, surgeons manipulate instruments through several tiny incisions in the abdomen while looking inside the patient through a camera called a laparoscope.

High-Definition Screen

Robotic surgery is similar, except that the surgeon sits at a console a few feet away and maneuvers robotic arms while looking into a high-definition display. Unlike the standard equipment, the robotic instruments have wrists, potentially enabling finer control and movement.

In February, a study in the Journal of the American Medical Association found that robotic hysterectomies for benign conditions cost hospitals $2,189 more per procedure than the same surgery without the robot. That research, which looked at data from 441 hospitals from 2007 to 2010, showed complication rates were 5.5 percent for the robot surgery and 5.3 percent for a less invasive hysterectomy.

Click here to see the original article.

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