Racial gap nearly disappears during project to train surgeons and establish best practices
Kaiser Permanente’s northern California hospitals significantly increased minimally invasive surgery for hysterectomy and found the change also reduced racial disparities in the types of hysterectomies patients get.
“We were able to make significant changes in our integrated health system and found that afterwards, women of color did not have a higher rate of open hysterectomies as is seen elsewhere in the country,” said study lead author Eve Zaritsky, MD, a gynecologist with Kaiser Permanente Northern California (KPNC). “This is possible when you have the kind of integrative health care system where people are working in groups and teams to make changes that are better for patients overall.”
The analysis was published as a research letter Dec. 6 in JAMA Network Open.
The authors associated the changes with a quality improvement project begun in 2008 and involving 4 main efforts: leadership engagement, surgeon training, establishing metrics, and developing obstetric and gynecologic teams in which fewer surgeons do hysterectomies.
The study examined trends in hysterectomy — removal of the uterus — for benign reasons, such as fibroids or abnormal bleeding; the analysis did not consider hysterectomies associated with cancer. The procedure can be done with a full abdominal incision or through a minimally invasive method, either through the vagina or with small keyhole abdominal incisions. Over the past 20 years, gynecologists have been moving away from open hysterectomies and toward minimally invasive techniques, which have benefits to both patients and hospitals, said Zaritsky, who is also a member of The Permanente Medical Group.
In 2008, KPNC was like most other health care organizations; most hysterectomies used the open abdominal method, with rates particularly high among black and Hispanic patients. The quality improvement project sought to reduce the abdominal hysterectomy rate; minimally invasive hysterectomies (MIH) steadily increased from 2008 to 2015, going from 41% to 93% of uterus removals.
The greatest gains were among black and Hispanic women. The relative rate of increase over the study period was 1.147 among African American patients compared with 1.088 for white women.
Some of the difference in route of hysterectomy by race could be explained by biological differences, such as larger fibroids which are more common in black women; a larger uterus is harder to remove from a small incision. However, research on disparities in hysterectomy adjusted for uterine size and still found differences.
The authors did not speculate in the research letter on the source of the disparities, but senior author Tina R. Raine-Bennett, MD, MPH, a research scientist at the Kaiser Permanente Division of Research, said there were a few possibilities. Surgeons might be afraid of taking on more difficult cases and assume black or Hispanic patients might present greater surgical challenge, she said; or the disparities could relate to inherent biases.
Whatever the cause, racial/ethnic disparities in provision of improved medical techniques are harmful, Zaritsky and Raine-Bennett said. Minimally invasive hysterectomies offer advantages both to the patient and health system; they involve less blood loss, fewer infections, shorter recovery times, and shorter lengths of hospital stay.
The quality improvement project included sending 6 skilled surgeons around the northern California region to teach minimally invasive surgical techniques to gynecologists; sharing best practices from high-performing centers; establishing ob/gyn teams; asking gynecologists to choose one of 5 practice types, including ones that do not include surgery; and establishing a credentialing standard of 15 hysterectomies per year. The project was detailed in a 2018 paper in the Journal of Minimally Invasive Gynecology.
The study was funded by the Kaiser Permanente Northern California Community Benefit Program and the Women’s Health Research Institute, funded through The Permanente Medical Group.
Other authors were Anthonia Ojo, MD, obstetrician-gynecologist at the Kaiser Permanente Medical Center, and Lue-Yen Tucker, senior data consultant with the Kaiser Permanente Division of Research.