Identifying potentially modifiable risk factors associated with racially disparate postoperative outcomes following benign hysterectomy.

BACKGROUND: Among patients undergoing hysterectomy for benign indications, Black patients experience higher rates of perioperative complications across both abdominal and minimally invasive surgical routes. This disparity persists after adjusting for factors such as uterine weight, medical comorbidities, and other patient-level perioperative risk factors. Given the persistence of racial disparities, it is essential to identify potentially modifiable surgeon- and hospital-level factors that may be contributing to the disproportionate morbidity experienced by Black patients. Literature regarding strategies to reduce racially disparate outcomes in benign hysterectomy is scant. Except for minimally invasive surgical approach and surgeon volume, racial disparities in access to perioperative clinical and surgical best practices have not yet been explored. OBJECTIVE: This study aimed to identify potentially modifiable clinical and surgical practices that could reduce racial disparities in postoperative outcomes following hysterectomy for benign indications. STUDY DESIGN: This was a retrospective cohort study using the Michigan Surgical Quality Collaborative database. Patients who self-reported race as White (n=15,164) or Black (n=3231) and underwent hysterectomy for benign, nonobstetrical indications between January 2015 and December 2018 were included. We evaluated the association between major postoperative complications (primary outcome) and patient-level factors, perioperative clinical practices, surgical and intraoperative factors, and hospital and surgeon characteristics. Variables associated with postoperative complications were classified as potentially modifiable or nonmodifiable, and we explored racial disparities relative to these risk factors. We investigated the independent effect of potentially modifiable risk factors for postoperative complications, adjusting for differences in nonmodifiable risk factors. RESULTS: Of the 18,395 included patients who underwent hysterectomy, 82.4% (n=15,164) reported White race and 17.6% (n=3231) reported Black race. The total rate of major postoperative complications was 1.6% (n=303). The rate of major postoperative complications was higher among Black patients (n=90; 2.8%) than White patients (n=213; 1.4%; P<.001). Black race remained independently associated with higher risk for major postoperative complications (adjusted odds ratio, 1.39; 95% confidence interval, 1.04-1.85; P=.026) after adjusting for insurance type, body mass index, preoperative anemia, diabetes, and uterine weight in multivariable logistic regression. Potentially modifiable risk factors that remained independently associated with higher risk for major postoperative complications in multivariable logistic regression included operative time (adjusted odds ratio, 1.13; 95% confidence interval, 1.01-1.25; P=.033), laparotomy surgical approach (adjusted odds ratio, 1.39; 95% confidence interval, 1.03-1.84; P=.026), use of hemostatic agents (adjusted odds ratio, 1.55; 95% confidence interval, 1.22-1.96; P<.001), use of nonpreferred preoperative antibiotic regimen (adjusted odds ratio, 1.50; 95% confidence interval, 1.15-1.94; P=.002), and low surgeon volume tertile (adjusted odds ratio, 1.45; 95% confidence interval, 1.00-2.04; P=.041). CONCLUSION: Potentially modifiable factors that may help to reduce racially disparate postoperative outcomes following benign hysterectomy include the use of a minimally invasive surgical approach whenever possible, use of preferred antibiotic prophylaxis regimens, minimizing operative time, and access to high-volume surgeons. It is essential to continue to explore factors that contribute to racial disparities in postoperative outcomes following hysterectomy given the persistence of these disparities after adjusting for potentially modifiable and nonmodifiable risk factors.