Healthcare disparities and pelvic organ prolapse operative complications: a nationwide analysis

The article titled “Healthcare disparities and pelvic organ prolapse operative complications: a nationwide analysis” by Rozycki et al., highlights how racial and socio-economic disparities in healthcare influence peri-operative complications in pelvic organ prolapse (POP) surgery (1). Drawing from the National Inpatient Sample (NIS) database from 2008 to 2018, the study highlights a concerning trend of increased postoperative complications. Most notably are increased urinary tract infections, sepsis, and acute renal failure, particularly among Black, Hispanic, and other non-White patients and individuals with an annual income of less than $46,000. These findings contrast with that of lower intraoperative complications among Black and Hispanic patients, suggesting a nuanced disparity in surgical outcomes. Especially since POP surgical treatment has become more common over the past decade, this study draws attention to the pressing need to address systemic healthcare inequalities to democratize surgical outcomes in POP procedures (2).

While this study has some minor limitations, when compared with other research, consistent patterns of healthcare disparities emerge. For example, the study’s methodology does not adjust for confounders such as patient comorbidities, variations in surgical techniques, and the experience of individual surgeons, which are known to affect surgical outcomes (3,4). Many comorbidity measures and physician numbers are available through the NIS, which could allow for more detailed understanding and analysis. Currently, these limitations may obscure the true extent of national healthcare disparities. Furthermore, the absence of longitudinal follow-up data hinders deeper understanding of the long-term outcomes and complications, an aspect that is crucial for a comprehensive overview of surgical outcomes across diverse populations (5).

Moreover, other studies have observed similar outcomes regarding the effects on socioeconomic status and race on POP care. Brown et al. identified higher rates of postoperative POP complications among Black women undergoing inpatient POP compared to all other racial groups (6). Another study by Boyd et al. reported a higher incidence of post-operative blood transfusion and deep vein thrombosis or pulmonary embolus in Black women following colpopexy, as well as an increased complication rate in Latina women (7). A study by Shah et al. found significantly higher complication and morbidity rates in Black women (8). As such, several published studies suggest that patient race is associated with significant differences in surgical outcomes, which likely stem from systemic issues in healthcare access, quality and timeliness of care (greater duration and stage of disease), as well as provider biases.

To advance the understanding of these disparities, future studies are needed. The explicit evaluation of socioeconomic status merits further investigation to get a more detailed understanding of its effect on care. Additionally, evaluation of surgical techniques and surgeon experience is paramount to highlight how they influence outcomes among diverse populations. Longitudinal studies with extended follow-up are essential for assessing the durability of surgical repairs and long-term complications. Finally, incorporating patient-reported outcomes can provide a more patient-centered perspective on the impact of surgery on quality of life. In summary, the study not only calls for concerted efforts to investigate and address healthcare disparities in POP surgery, but also underscores the necessity for systemic reforms and targeted research initiatives to ensure equitable healthcare for all.

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-23-48/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-23-48/coif). B.C. is a consultant for Olympus, Boston Scientific, Femselect, ARMs, Prodeon Medical, Sumitomo, Zenflow, and Teleflex. He is an advisor for Promaxo, Bright Uro, COSM, and Soundable. D.E. is a consultant for Olympus, Boston Scientific, Procept BioRobotics, and investigator for Zenflow. K.C.Z. is a consultant and proctor for Boston Scientific, Procept BioRobotics, and investigator for Zenflow. N.B. is a consultant for Olympus, Boston Scientific, and Procept BioRobotics. 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/.

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