Morbidity and mortality after hysterectomy show large difference by race

Family Planning Perspectives, May 1994 by Althaus, Frances A

Black women who have a hysterectomy are more likely than white women to have the surgery before age 50. They are also more likely to experience medical or surgical complications, to stay in the hospital more than 10 days and to die before discharge, according to a recent study based on hospital data from Maryland. (1) In the sample as a whole, factors independently related to higher mortality following hysterectomy were older age, absence of fibroids, abdominal or subtotal hysterectomy, surgical or medical complications and serious coexisting medical conditions.

The study used discharge summary data from the Maryland Health Services Cost Review Commission on all hysterectomies performed in nonmilitary hospitals in the state between 1986 and 1991. The pooled data contained information on 53,159 hysterectomies; 70% had been performed on white women, 26% on black women and 3% on women of other races. Only white women and black women were included in the analyses because there were too few women of other races for meaningful comparisons to be made. The investigators calculated age-specific hysterectomy rates for each racial group, adjusted for age distribution.

Each hysterectomy was classified according to one of 10 mutually exclusive principal diagnoses: uterine fibroids, uterine prolapse, endometriosis, cancer, menstrual disorders, infectious conditions, adnexal conditions (e.g., benign neoplasms of the ovary and ovarian cysts), obstetric conditions (e.g., ectopic pregnancy and postpartum hemorrhage), noninfectious conditions (e.g., endometrial hyperplasia and dysplasia of the cervix) and other conditions (e.g., mental disorders and sterilization).

For each woman, the investigators calculated a total comorbidities score--a weighted score that takes into account the number and seriousness of coexisting diseases that affect the risk of mortality--based on her primary diagnosis and as many as four secondary diagnoses. Each diagnosis was weighted on a scale of 0 (no comorbidity) to 6 (serious comorbidity). The investigators also calculated the number of coexisting diseases per woman and the frequency the most common diseases among black women and white women.

The average length of hospital stay for black women and white women was adjusted for relevant principal diagnoses (fibroids and cancer), year, surgical procedure (abdominal, vaginal or subtotal), age, comorbidities, source of payment and hospital characteristics (size and teaching status). The investigators then used multiple logistic regression to calculate adjusted odds ratios, by race, for the probability of staying in the hospital more than 10 days.

The investigators calculated the percentages of black women and white women with complications of surgical and medical care following their hysterectomy and the adjusted odds ratios among black women for the probability of having one or more complications and the probability of dying before discharge.

Between 1986 and 1991, the average annual age-adjusted hysterectomy rates in Maryland were 50 per 10,000 black women and 41 per 10,000 white women. Women aged 40-49 had the highest rates--138 per 10,000 blacks and 109 per 10,000 whites. Among women younger than 59 the hysterectomy rate was higher among black women than among white women, but the reverse was true for women older than 50.

The distribution of principal diagnoses varied sharply by race. For example, 65% of the hysterectomies performed on black women were for fibroids, compared with 29% of those performed on white women. White women were more likely than black women to have had a hysterectomy for uterine prolapse, endometriosis, cancer or menstrual disorders.

On average, white women were older than black women at hysterectomy, both overall (46.1 years vs. 42.0 years) and for nearly all diagnostic categories. This difference was particularly pronounced among women whose hysterectomy had been performed because of adnexal conditions, cancer, noninfectious conditions or fibroids.

Black women were more likely than white women to have had an abdominal hysterectomy, both overall (86% vs. 72%) and for diagnoses of fibroids, prolapse, menstrual disorders, infectious conditions, obstetric conditions and other conditions. Black women were also more likely than white women to have had a subtotal hysterectomy.

Black women were more likely than white women to have had a hysterectomy at a teaching hospital (47% vs. 35%) or at a hospital with more than 400 beds (52% vs. 40%). They were also more likely to be covered by Medicaid (19% vs. 6%) or to belong to a health maintenance organization (17% vs. 9%), and less likely to be covered by Medicare (5% vs. 12%) or to have private insurance (57% vs. 73%).

The great majority of the women having a hysterectomy were otherwise in good health: More than 90% of the black women and 87% of the white women had a comorbidity index score of 0. The mean index score for blacks was significantly lower than the mean score for whites (0.34 vs. 0.54; p