Understanding Racial/Ethnic Disparities in Uterine Fibroid Outcomes among Women Veterans: A mixed-methods study

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Background: Uterine fibroids (UF) are a common and costly gynecologic condition that disproportionately affect Black women with regard to incidence, severity, treatment, and outcomes. UF result in debilitating symptoms including pelvic pressure and pain, problems with reproduction, heavy menstrual bleeding, and severe anemia, and are the leading cause of hysterectomy among women Veterans in VA. Although VA is a model healthcare system regarding health equity in many areas, recent data suggest that substantial Black/White disparities in UF treatment and outcomes exist within VA. As one-third of women Veterans using VA health care are Black and this proportion is increasing, understanding the underlying drivers of these disparities within VA is of critical importance. Limited research has examined these mechanisms either outside or within VA. Building a comprehensive understanding of UF disparities and potential opportunities to address them will require examining the role of race and racism in women Veterans’ pathways to diagnosis and treatment of UF and their UF treatment patterns and experiences. Objectives: Our objective is to investigate the mechanisms underlying Black/White disparities in UF-related outcomes among women Veterans receiving VA care. Guided by the Public Health Critical Race Praxis, which asserts that race is a social construct and that ubiquitous patterns and structures of contemporary racism shape racial disparities in health, we propose: (1) To examine Black/White differences in treatment patterns for women Veterans with UF and identify modifiable determinants; (2) To examine Black/White differences in clinical and post-surgical outcomes among women Veterans receiving treatment for UF in VA and identify modifiable determinants; and (3) To understand and contextualize differences identified in Aims 1 and 2 using qualitative exploration of Black women Veterans’ experiences with UF symptoms, care seeking behaviors, and treatment and how they differ from those of White women Veterans. Methods: We will use a mixed methods approach to address our study objectives. All three aims, will draw from a single cohort of Black and White women Veteran users of VA healthcare with newly diagnosed symptomatic UF between Fiscal Year 2010 (FY10) and FY12, identified through the Corporate Data Warehouse (CDW). Aims 1 and 2 are retrospective cohort analyses. We will examine administrative data and chart-abstracted medical record data through FY18 to compare Black/White differences in treatment and outcomes. Aim 1 will compare time from diagnosis to initial treatment and surgical treatments; type of initial treatment (medical, non-definitive procedure, hysterectomy); and mode of surgery (minimally invasive vs abdominal). Aim 2 will examine Black/White differences in clinical (emergency room visits, hospitalization for anemia, blood transfusion) and surgical outcomes (surgical complications, 30-day readmission) for UF. Aim 3 is a qualitative study with a purposively selected sample of up to 30 Black and 30 White women Veterans to inform and contextualize our quantitative findings from Aims 1 and 2. Content analysis will be used to understand and identify how the constructs of race and gender may interact to impact women Veterans’ experiences with UF, pathways to treatment, treatment decision making, and treatment patterns. Our dissemination plan includes a stakeholder engagement process which will engage Veterans, providers, and operational partners in translating our findings into actionable practice and policy recommendations to reduce disparities. Innovation and Next Steps: This proposal addresses key HSR&D priorities of women’s health, health equity, and healthcare access. The innovative approach ensures substantial impact by moving beyond documenting racial/ethnic disparities to building understanding of underlying and potentially modifiable causes. Next steps following completion of the research and stakeholder engagement process will include partnering with VA Women’s Health Services and VA Office of Health Equity to develop targeted interventions, programs, and policies to address UF disparities. Ultimately, this research has the potential to accelerate progress towards quality and equity in gynecology and reproductive healthcare both within and beyond VA.