Objective

To evaluate multicomponent aspects of hysterectomy-related care in the US Military Health System including the probability of open hysterectomy (versus vaginal or laparoscopic hysterectomy), probability of having a length of stay > 1 day, and discharge milligram morphine equivalent dose (MED). Analyses sought to identify the presence and strength of healthcare inequities between Black and white patients.

Methods

In this retrospective cohort study, records of patients (N = 11,067) ages 18–65 years enrolled in TRICARE who underwent a hysterectomy between January 2017 to January 2021 in US military treatment facilities (direct care) or civilian facilities (purchased care) were included. Graphic representations illustrated provider and facility variation. Generalized additive mixed models (GAMMs) evaluated inequities across outcomes. Sensitivity analyses included only direct care receipt and added a random effect for the facility.

Results

There was significant variation in provider use of open versus vaginal or laparoscopic hysterectomies, as well as provider and facility discharge MED. The GAMMs indicated Black patients were more likely to receive an open hysterectomy [log(OR) −0.54, (95 %CI −0.65, −0.43), p < 0.001] and have a length of stay > 1 day [log(OR) 0.18, (95 %CI 0.07, 0.30), p = 0.002], but had similar discharge MED [-2 mg (95% CI −7 mg, 3 mg), p = 0.51], relative to white patients. Patients receiving care in purchased care, relative to direct care, were more likely to receive a vaginal or laparoscopic hysterectomy [log(OR) 0.28, (95 %CI 0.17, 0.38), p = 0.002] and received approximately 21 mg lower discharge MED (95 %CI 16–26 mg less, p < 0.001), but were more likely to have a hospital stay > 1 day [log(OR) 0.95, (95 %CI 0.83, 0.1.10), p < 0.001]. Additional gynecological conditions (e.g., uterine fibroids) and prescription receipt were associated with some, but not all outcomes.

Conclusion

Improving timely care receipt, especially for uterine fibroids, increasing access to vaginal and laparoscopic hysterectomies, and reducing unwarranted variation in discharge MED could improve care quality and equity in the US Military Health System.

中文翻译：

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美国军队卫生系统中黑人和白人患者子宫切除术的不平等：一项回顾性队列研究

客观的

评估美国军事卫生系统中子宫切除术相关护理的多方面方面，包括开放式子宫切除术的可能性（相对于阴道或腹腔镜子宫切除术）、住院时间 > 1 天的可能性以及出院时的吗啡当量毫克数 (MED)。分析试图确定黑人和白人患者之间医疗保健不平等的存在和强度。

方法

在这项回顾性队列研究中，纳入了 2017 年 1 月至 2021 年 1 月期间在美国军事治疗设施（直接护理）或民用设施（购买护理）中接受子宫切除术的 18-65 岁患者 (N = 11,067) 的记录. 图形表示说明了供应商和设施的变化。广义加性混合模型 (GAMM) 评估了结果之间的不公平性。敏感性分析仅包括直接护理收据，并增加了对设施的随机影响。

结果

提供者使用开放式与阴道或腹腔镜子宫切除术以及提供者和设施出院 MED 存在显着差异。GAMMs 表明黑人患者更有可能接受开放式子宫切除术 [log(OR) −0.54, (95 %CI −0.65, −0.43), p < 0.001] 并且住院时间 > 1 天 [log(OR) 0.18，（95% CI 0.07，0.30），p = 0.002]，但相对于白人患者具有相似的出院 MED [-2 mg（95% CI −7 mg，3 mg），p = 0.51]。与直接护理相比，在购买护理中接受护理的患者更有可能接受阴道或腹腔镜子宫切除术 [log(OR) 0.28，（95 %CI 0.17，0.38），p = 0.002] 并接受约 21 mg 的低排放 MED （95 %CI 减少 16–26 mg，p < 0.001），但住院时间 > 1 天的可能性更大 [log(OR) 0.95，（95 %CI 0.83，0.1.10），p < 0.001]。

结论

改善及时接受护理，尤其是子宫肌瘤，增加阴道和腹腔镜子宫切除术的可及性，以及减少出院 MED 的不必要变化，可以提高美国军事卫生系统的护理质量和公平性。