Examining Disparities in Route of Surgery and Postoperative Complications in Black Race and Hysterectomy

Racial/Ethnic Disparities/Differences in Hysterectomy Route in Women Likely Eligible for Minimally Invasive Surgery.

Race, gender, and language concordance in the care of surgical patients: A systematic review.

This paper addresses why the three dominant alternatives to compensating physicians (fee-for-service, capitation, and salary) fall short of what is needed to support enhanced primary care in the patient-centered medical home and the relevance of payment reforms, such as pay-for-performance and episodes/bundling.

US Approaches to Physician Payment: The Deconstruction of Primary Care

Background In the general population, Black and Latina women are less likely to undergo minimally invasive hysterectomy than White women, which may be related to racial/ethnic variation in fibroid prevalence and characteristics. Whether similar differences exist in the Department of Veterans Affairs Healthcare System (VA) is unknown. Methods Using VA clinical and administrative data, we identified all women veterans undergoing hysterectomy for benign indications in fiscal years 2012–2014. We identified hysterectomy route (laparoscopic with/without robot-assist, vaginal, abdominal) by International Classification of Diseases, 9th edition, codes. We used multinomial logistic regression to estimate associations of race/ethnicity with hysterectomy route and tested whether associations varied by fibroid diagnosis using an interaction term. Models adjusted for age, income, body mass index, gynecologic diagnoses, medical comorbidities, whether procedure was performed or paid for by VA, geographic region, and fiscal year. Results Among 2,744 identified hysterectomies, 53% were abdominal, 29% laparoscopic, and 18% vaginal. In multinomial models, racial/ethnic differences were present among veterans with but not without fibroid diagnoses (p value for interaction  Conclusions Receipt of minimally invasive hysterectomy among women veterans with fibroids varied by race/ethnicity. Further investigation of the underlying mechanisms and potential interventions to increase minimally invasive hysterectomy among minority women veterans is needed.

Associations between Race/Ethnicity, Uterine Fibroids, and Minimally Invasive Hysterectomy in the VA Healthcare System.

Does Universal Insurance Mitigate Racial Differences in Minimally Invasive Hysterectomy

Background
Expectant mothers who are beneficiaries of TRICARE (universal insurance to United States Armed Services members and their dependents) can choose to receive care within direct (salary-based) or purchased (fee-for-service) care systems. We sought to compare frequency of intrapartum obstetric procedures and outcomes such as severe acute maternal morbidity (SAMM) and common postpartum complications between direct and purchased care systems within TRICARE.

Methods
TRICARE (2006-2010) claims data were used to identify deliveries. Patient demographics, frequency of types of delivery (noninstrumental vaginal, cesarean, and instrumental vaginal), comorbid conditions, SAMM, and common postpartum complications were compared between the two systems of care. Multivariable models adjusted for patient clinical/demographic factors determined the odds of common complications and SAMM complications in purchased care compared with direct care.

Results
A total of 440 138 deliveries were identified. Compared with direct care, purchased care had higher frequency (30.9% vs 25.8%, P<.001) and higher adjusted odds (aOR 1.37 [CI 1.34-1.38]) of cesarean delivery. In stratified analysis by mode of delivery, purchased care had lower odds of common complications for all modes of delivery (aOR[CI]:noninstrumental vaginal: 0.72 [0.71-0.74], cesarean: 0.71 [0.68-0.75], instrumental vaginal: 0.64 [0.60-0.68]) than direct care. However, purchased care had higher odds of SAMM complications for cesarean delivery (aOR 1.31 [CI 1.19-1.44]) compared with direct care.

Conclusion
Direct care has a higher vaginal delivery rate but also a higher rate of common complications compared with purchased care. Study of direct and purchased care systems in TRICARE may have potential use as a surrogate for comparing obstetric care between salary-based systems and fee-for-service systems in the United States.

Bart Staat

Papers

Does Universal Insurance Mitigate Racial Differences in Minimally Invasive Hysterectomy

Intrapartum obstetric care in the United States military: Comparison of military and civilian care systems within TRICARE.