Health disparities in perioperative complications associated with pelvic organ prolapse surgeries

This article is an invited editorial commentary on the study by Rozycki et al., which examined the associations between pelvic organ prolapse (POP) operative complications and health disparities using a United States nationwide analysis (1). Health disparities refer to systemic, avoidable health differences that disproportionately burden populations with socioeconomic disadvantages or those historically marginalized (2,3). This systemic reinforcement of discrimination renders individuals vulnerable to an inequitable distribution of resources in education, employment, income levels, healthcare, and criminal justice, which perpetuates residential segregation and reliance on public insurance (4). A large body of evidence has established a link between health disparities and an increased risk of morbidity and mortality (5).

Among women with POP, women of racial and ethnic minorities were less likely to undergo POP surgeries compared to their White counterparts, and those who did undergo surgery were more likely to receive an obliterative procedure (6-8). Complication rates for POP surgery range from 3.1% to 15.1%, with studies reporting disproportionately worse surgical outcomes among socially disadvantaged women (1,6-13). Despite this, less is known about the specific social determinants of health that may impact surgical outcomes.

The present study by Rozycki et al. examines the associations between POP surgical complications and various social determinants of health, including race, annual income, insurance type, and geographical location (1). The analysis utilizes data from the National Inpatient Sample (NIS) database [2008–2018] that included the deidentified records of 172,483 women, aged 18 years and older of different racial backgrounds (75.3% White, 6.1% Black, 12.7% Hispanic, 5.8% other races) (1). The authors found that women who were non-White, had lower socioeconomic status, underwent surgery in smaller hospitals, and hospitals located in rural settings experienced higher odds of postoperative complications, while White women and women undergoing surgery in the Midwest, South, and West experienced higher odds of intraoperative complications (1).

Race

While data on health disparities among different racial and ethnic subgroups is inconsistent, there is a consistent trend across studies in terms of the susceptibility of Black women to complications associated with POP surgery compared to their White counterparts (1,6-13). Specifically, Rozycki and colleagues observed higher rates of postoperative complications, including urinary tract infections (UTI), sepsis, and acute renal failure (1) among Black women in their study. Similarly, several other studies report poorer perioperative outcomes, including longer hospital stays and increased risk of blood transfusions and surgical failures, in women of all racial and ethnic minority groups (1,6-13). Interestingly, Rozycki et al. also noted that White women and those with higher socioeconomic status had higher odds of intraoperative complications such as hemorrhage and abdominopelvic injuries (1). Although this study could not control for the specific type of POP surgery being performed, other studies report that White women are more likely to undergo sacrocolpopexies, a procedure associated with higher rates of perioperative complications when compared to vaginal native tissue reconstructive surgeries and obliterative repairs (14).

Income and insurance type

Rozycki et al. noted significant income disparities among women with Black and Hispanic individuals 60% and 44% less likely, respectively, to report a higher annual income (defined as USD >46,000 in the study). Women from racial and ethnic minority groups are also more likely than White women to rely on public insurance (Medicaid) over private insurance for health insurance coverage (1). Both lower income status and dependence on public insurance are associated with increased perioperative complications particularly, UTI, sepsis, acute renal failure, and abdominopelvic injury (1).

Geographic location

Rozycki and colleagues also report that women residing in the South, West, and Midwest regions experience higher odds of perioperative complications compared to those in the East (1), similar to the study findings by Brown et al. (11). This geographic distribution partly reflects the distribution of women of racial and ethnic minority in the US. Notably, a higher proportion of Black women reside in the South, and more Hispanic women live in the West, both of whom belong to minority groups that are more likely to sustain perioperative complications. While Rozycki and colleagues did not have access to data on residential segregation in each region, other studies highlighted that factors associated with racial residential segregation such as exposure to substandard housing and inadequate access to quality education, employment, transportation, and healthcare services, contribute to poorer health outcomes (15). Furthermore, additional studies report that hospitals located in urban and densely populated regions, such as the East, tend to have higher surgical volumes (16), and higher-volume surgeons and hospitals are associated with lower rates of perioperative complications (17).

Other

While the role of age and gender as social determinants of health were not addressed in the Rozycki et al. study, these factors are especially relevant in the context of POP. POP predominately affects older women who may experience additional barriers to accessing quality and timely care, including issues with mobility, financial constraints, difficulty with self-care, social isolation, and dependence on caregivers (18,19).

Recommendations for addressing health disparities at the individual and systemic level applicable to POP and other women’s health conditions

• Engage women from diverse backgrounds—including those from communities with socioeconomic disadvantages and a history of marginalization—in the development of health communication campaigns to effectively raise awareness.
• Educate primary-care physicians on the need for routine and culturally appropriate screening.
• Recruit more culturally and socioeconomically diverse individuals into the field of medicine, thereby fostering gender and racial concordance among health professionals providing care.
• Enhance the structural competency and cultural humility of health professional students and professionals by implementing standardized curricula specifically tailored to address the intersection of social determinants of health.
• Promote studies with diverse populations to inform racially and socioeconomically equitable intervention strategies.
• Advocate for social policies aimed at mitigating disparities in crucial areas related to addressing social determinants of health, including but not limited to education, employment, housing, and transportation.

Despite potential challenges such as financial limitations, staffing and time constraints, and political resistance, it is imperative that we develop systemic endeavors to address health disparities (20). A promising way forward could involve establishing a multidisciplinary task force comprising of policymakers, healthcare providers, patient advocacy groups, racial and ethnic advocacy organizations, and public health professionals. This task force would aim to design and implement effective, equitable, and sustainable interventions addressing health disparities, adaptable to specific contexts. As more studies emerge, ongoing dialogue on this topic will continue to inform our ability to develop effective policies and interventions.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gynecology and Pelvic Medicine. The article has undergone external peer review.

Peer Review File: Available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-1/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-1/coif). C.C.G.C. reports unpaid education consultation with Johnson and Johnson (Ethicon). The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Rozycki SK, Rutledge EC, Nisar T, et al. Healthcare disparities and pelvic organ prolapse operative complications: a nationwide analysis. Int Urogynecol J 2023;34:2893-9. [Crossref] [PubMed]
2. Healthy People 2020. Overview of Health Disparities [Internet]. Centers for Disease Control and Prevention; 2023 [cited 2023 Dec 14]. Available online: https://www.cdc.gov/nchs/healthy_people/hp2020/health-disparities.htm
3. Braveman P. What are health disparities and health equity? We need to be clear. Public Health Rep 2014;129:5-8. [Crossref] [PubMed]
4. Bailey ZD, Krieger N, Agénor M, et al. Structural racism and health inequities in the USA: evidence and interventions. Lancet 2017;389:1453-63. [Crossref] [PubMed]
5. Marmot M, Friel S, Bell R, et al. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet 2008;372:1661-9. [Crossref] [PubMed]
6. Roberts K, Sheyn D, Emi Bretschneider C, et al. Perioperative Complication Rates After Colpopexy in African American and Hispanic Women. Female Pelvic Med Reconstr Surg 2020;26:597-602. [Crossref] [PubMed]
7. Cardenas-Trowers OO, Gaskins JT, Francis SL. Association of Patient Race With Type of Pelvic Organ Prolapse Surgery Performed and Adverse Events. Female Pelvic Med Reconstr Surg 2021;27:595-601. [Crossref] [PubMed]
8. Erekson E, Murchison RL, Gerjevic KA, et al. Major postoperative complications following surgical procedures for pelvic organ prolapse: a secondary database analysis of the American College of Surgeons National Surgical Quality Improvement Program. Am J Obstet Gynecol 2017;217:608.e1-608.e17. [Crossref] [PubMed]
9. Shah AD, Kohli N, Rajan SS, et al. The age distribution, rates, and types of surgery for pelvic organ prolapse in the USA. Int Urogynecol J Pelvic Floor Dysfunct 2008;19:421-8. [Crossref] [PubMed]
10. Boyd BAJ, Winkelman WD, Mishra K, et al. Racial and ethnic differences in reconstructive surgery for apical vaginal prolapse. Am J Obstet Gynecol 2021;225:405.e1-7. [Crossref] [PubMed]
11. Brown O, Mou T, Kenton K, et al. Racial disparities in complications and costs after surgery for pelvic organ prolapse. Int Urogynecol J 2022;33:385-95. [Crossref] [PubMed]
12. Gurayah AA, Mason MM, Grewal MR, et al. Racial and socioeconomic disparities in cost and postoperative complications following sacrocolpopexy in a US National Inpatient Database. World J Urol 2023;41:189-96. [Crossref] [PubMed]
13. Ringel NE, Brown O, Moore KJ, et al. Disparities in Complications After Prolapse Repair and Sling Procedures: Trends From 2010-2018. Urology 2022;160:81-6. [Crossref] [PubMed]
14. Yadav GS, Rutledge EC, Nisar T, et al. Health Care Disparities in Surgical Management of Pelvic Organ Prolapse: A Contemporary Nationwide Analysis. Female Pelvic Med Reconstr Surg 2022;28:207-12. [Crossref] [PubMed]
15. White K, Borrell LN. Racial/ethnic residential segregation: framing the context of health risk and health disparities. Health Place 2011;17:438-48. [Crossref] [PubMed]
16. Losina E, Kessler CL, Wright EA, et al. Geographic diversity of low-volume hospitals in total knee replacement: implications for regionalization policies. Med Care 2006;44:637-45. [Crossref] [PubMed]
17. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346:1128-37. [Crossref] [PubMed]
18. Mikton C, de la Fuente-Núñez V, Officer A, et al. Ageism: a social determinant of health that has come of age. Lancet 2021;397:1333-4. [Crossref] [PubMed]
19. Sasser AC, Taylor M, Birnbaum HG, et al. Assessing the economic impact of chronic conditions in postmenopausal women. Expert Opin Pharmacother 2005;6:1803-14. [Crossref] [PubMed]
20. Warnecke RB, Oh A, Breen N, et al. Approaching health disparities from a population perspective: the National Institutes of Health Centers for Population Health and Health Disparities. Am J Public Health 2008;98:1608-15. [Crossref] [PubMed]