Racial Differences in Treatment with Hysterectomy: a Multilevel Investigation

1 项目概要/摘要 2 3 每年，数百万美国妇女必须决定是否切除子宫以治疗疼痛和疼痛。 4.致残的妇科疾病，如子宫肌瘤、子宫内膜异位症、脱垂等。不幸的是， 关于子宫切除术的 5 个决定可能受到女性种族和客观临床的影响 6个适应症。尽管子宫切除术很普遍，但人们对这些手术决策是如何做出的知之甚少： 7 现有文献受到不可推广的单一机构研究、种族同质样本、 8 对症状严重程度控制不充分，无法衡量医疗保健文化的影响 9系统。该提案的长期目标是确保所有背景的女性都得到平等对待 10 在子宫切除术决策方面采取公平的方式。为了实现这一目标，本次活动的目标 11 应用旨在了解妇科手术治疗中出现的种族差异，并 12 评估子宫切除术治疗中的种族/民族差异在多大程度上构成了手术差异。 13 中心假设是临床严重程度并不能完全解释所有种族/民族差异 14子宫切除治疗。我们假设提供者级别和实践级别的临床文化可能会阻碍 15 公平传播子宫切除术的手术创新。拟议研究的理由是 16 确定多层次医疗保健系统对子宫切除术的影响将有助于确定最佳目标 17 进行干预，以实现女性妇科疾病的公平手术护理。假设 18 将通过追求三个具体目标进行测试： 1) 确定临床阈值的程度 19 子宫切除术（子宫重量、术前贫血、术前疼痛）因种族/民族而异； 2）量化 20 少数族裔患者接受低容量医疗服务提供者和接受医疗服务提供者治疗的可能性存在差异。 21 家高倾向进行子宫切除术的诊所； 3) 确定双边传播的驱动因素 22 子宫切除时进行的输卵管切除术伴卵巢保留 (BSOR) 以及这种情况的程度 23 传播因种族/民族而异。这种方法是创新的，因为它直接评估 24 个长期存在但未经检验的假设，即临床严重程度的种族差异解释了临床严重程度的差异 25 子宫切除率。这项工作还采用了创新的多层次框架，包括提供者和 26 个实践层面的因素。最后，这项工作研究了手术培养如何促进或阻碍 27 传播降低癌症风险的外科创新。这项工作将产生持续的影响，因为它 28 超越记录种族差异：当这项工作完成后，我们将了解什么是差异 29 的存在以及这些差异是如何产生的。相对于其高发病率，妇科问题的研究还不够充分。 30 数千万美国人的患病率、对生活质量的影响以及治疗对健康的长期影响 31 名女性。幸运的是，子宫切除术很常见并且可以改变。因此，确定目标 32 提高手术公平性可以对妇科手术领域产生强大影响。 33 1

1 PROJECT SUMMARY/ABSTRACT 2 3 Every year, millions of U.S. women must decide whether to have their uteri removed to treat painful and 4 incapacitating gynecologic disorders, such as uterine fibroids, endometriosis, and prolapse. Unfortunately, 5 decisions about hysterectomy may be influenced as much by a woman's race as by objective clinical 6 indications. Despite hysterectomy's prevalence, little is known about how these surgery decisions are made: 7 the existing literature is limited by non-generalizable single-institution studies, racially homogenous samples, 8 inadequate control for symptom severity, and inability to measure the influences of the culture of the healthcare 9 system. The long-term goal of this proposal is to ensure that women of all backgrounds are treated in an 10 equitable manner when it comes to hysterectomy decision-making. To achieve this goal, the objectives of this 11 application are to understand where racial differences in treatment with gynecologic surgery arise and to 12 evaluate the extent to which racial/ethnic differences in hysterectomy treatment constitute surgical disparities. 13 The central hypothesis is that clinical severity will not fully account for all racial/ethnic differences in 14 hysterectomy treatment. We hypothesize that provider-level and practice-level clinical culture can impede 15 equitable dissemination of surgical innovations in hysterectomy. The rationale for the proposed research is that 16 identifying multilevel health care-system influences on hysterectomy receipt will help identify the best targets 17 on which to intervene to achieve equitable surgical care of women's gynecologic conditions. The hypotheses 18 will be tested by pursuing three specific aims: 1) Determine the extent to which the clinical threshold for 19 hysterectomy (uterine weight, pre-operative anemia, pre-operative pain) varies by race/ethnicity; 2) Quantify 20 the extent to which minority patients are differentially likely to be treated by low-volume providers and by 21 practices with high propensity to perform hysterectomy; and 3) Identify drivers of the dissemination of bilateral 22 salpingectomy with ovarian retention (BSOR) at the time of hysterectomy and the extent to which this 23 dissemination varied by race/ethnicity. This approach is innovative because it directly evaluates the 24 longstanding but untested hypothesis that racial differences in clinical severity explain differences in 25 hysterectomy rates. The work also employs an innovative multilevel framework including provider- and 26 practice-level factors. Finally, the work investigates how surgical culture can facilitate or impede the 27 dissemination of a cancer risk-reducing surgical innovation. This work will have sustained impact because it 28 goes beyond documenting racial differences: when this work is completed, we will understand what disparities 29 exist but also how these differences arise. Gynecologic problems are under-investigated relative to their high 30 prevalence, impact on quality of life, and long-term effects of treatment on the health of tens of millions of U.S. 31 women. Fortunately, hysterectomy is both common and amenable to change; therefore, identifying targets to 32 improve equity in the surgery can exert a powerful influence on the gynecologic surgery field. 33 1