Background
Clinicians in the United States have rapidly adopted opportunistic salpingectomy for ovarian cancer prevention. However, little is known about racial and ethnic differences in opportunistic salpingectomy adoption. Surgical innovations in gynecology may be adopted differentially across racial and ethnic groups, exacerbating current disparities in quality of care.
Objective
This study aimed to evaluate racial and ethnic differences in opportunistic salpingectomy adoption across inpatient and outpatient settings and assess the effect of national guidelines supporting opportunistic salpingectomy use on these differences.
Study Design
A sample of 650,905 women aged 18 to 50 years undergoing hysterectomy with ovarian conservation or surgical sterilization from 2011 to 2018 was identified using the Premier Healthcare Database, an all-payer hospital administrative database, including more than 700 hospitals across the United States. The association between race and ethnicity and opportunistic salpingectomy use was examined using multivariable-adjusted mixed-effects log-binomial regression models accounting for hospital-level clustering. Models included race and ethnicity by year of surgery (2011–2013 [before guideline] and 2014–2018 [after guideline]) interaction term to test whether racial and ethnic differences in opportunistic salpingectomy adoption changed with the release of national guidelines supporting opportunistic salpingectomy use.
Results
From 2011 to 2018, 82,792 women underwent hysterectomy and opportunistic salpingectomy (non-Hispanic White, 60.3%; non-Hispanic Black, 18.8%; Hispanic, 12.2%; non-Hispanic other race, 8.7%) and 23,398 women underwent opportunistic salpingectomy for sterilization (non-Hispanic White, 64.7%; non-Hispanic Black, 10.8%; Hispanic, 16.7%; non-Hispanic other race, 7.8%). The proportion of hysterectomy procedures involving an opportunistic salpingectomy increased from 6.3% in 2011 to 59.7% in 2018 (9.5-fold increase), and the proportion of sterilization procedures involving an opportunistic salpingectomy increased from 0.7% in 2011 to 19.4% in 2018 (27.7-fold increase). In multivariable-adjusted models, non-Hispanic Black (risk ratio, 0.94; 95% confidence interval, 0.92–0.97), Hispanic (risk ratio, 0.98; 95% confidence interval, 0.95–1.00), and non-Hispanic other race women (risk ratio, 0.93; 95% confidence interval, 0.90–0.96) were less likely to undergo hysterectomy and opportunistic salpingectomy than non-Hispanic White women. A significant interaction between race and ethnicity and year of surgery was noted in non-Hispanic Black compared with non-Hispanic White women ( P <.001), with a reduction in differences in hysterectomy and opportunistic salpingectomy use after national guideline release (risk ratio 2011–2013 , 0.80 [95% confidence interval, 0.73–0.88]; risk ratio 2014–2018 , 0.98 [95% confidence interval, 0.95–1.01]). Moreover, non-Hispanic Black women were less likely to undergo an opportunistic salpingectomy for sterilization than non-Hispanic White women (risk ratio, 0.91; 95% confidence interval, 0.88–0.95), with no difference by year of surgery ( P =.62). Stratified analyses by hysterectomy route and age at surgery revealed similar results.
Conclusion
Although opportunistic salpingectomy for ovarian cancer prevention has been rapidly adopted in the United States, our findings suggested that its adoption has not been equitable across racial and ethnic groups. Non-Hispanic Black, Hispanic, and non-Hispanic other race women were less likely to undergo opportunistic salpingectomy than non-Hispanic White women even after adjusting for sociodemographic, clinical, procedural, hospital, and provider characteristics. These differences persisted after the release of national guidelines supporting opportunistic salpingectomy use. Future research should focus on understanding the reasons for these differences to inform interventions that promote equity in opportunistic salpingectomy use.
Why was this study conducted?
This study aimed to evaluate racial and ethnic differences in the adoption of opportunistic salpingectomy (OS) for ovarian cancer prevention in the United States, overall and before and after the release of national guidelines supporting OS use.
Key findings
Non-Hispanic Black, Hispanic, and non-Hispanic other race women were less likely to undergo OS than non-Hispanic White women. Racial and ethnic differences in OS use were not fully explained by sociodemographic, clinical, procedural, hospital, and provider characteristics and persisted after the release of national guidelines supporting OS use.
What does this add to what is known?
Although OS has been rapidly adopted for ovarian cancer prevention in the United States, its adoption has not been equitable across racial and ethnic groups.
Introduction
Accumulating evidence showing that high-grade serous ovarian cancer may originate in the fallopian tubes has led to the emergence of opportunistic salpingectomy (OS), the removal of the fallopian tubes during benign gynecologic surgery, as a novel strategy for ovarian cancer prevention. Data from 3 observational studies have suggested that OS is associated with a 42% to 64% reduction in ovarian cancer risk. In the United States, both the American College of Obstetricians and Gynecologists (ACOG) and the Society of Gynecologic Oncology (SGO) now recommend OS for ovarian cancer prevention in average-risk women at the time of a benign hysterectomy or in place of tubal ligation for sterilization. ,
Several studies have shown that clinicians in the United States have rapidly adopted OS. The most recent study found that the proportion of OS during hysterectomy increased from 2.4% in 2001 to 58.4% in 2015. However, these studies provide an incomplete picture of OS adoption and have limited generalizability because they were restricted to inpatient settings, which is not reflective of where most benign gynecologic surgeries are performed in the United States. , A study examining OS adoption in a national sample of inpatient and outpatient procedures found that the proportion of OS during hysterectomy increased from 1% in 2010 to 32% in 2017 and the proportion of OS for sterilization increased from 1% in 2010 to 20% in 2017. Here, 23% of hysterectomy and OS and 80% of OS for sterilization were performed as outpatient procedures, underscoring the importance of including inpatient and outpatient data when assessing changing trends in gynecologic surgeries.
To the best of our knowledge, no study has examined racial and ethnic differences in OS adoption. As with other medical innovations, surgical innovations in gynecology may be adopted differentially among racial and ethnic minorities, exacerbating disparities in quality of care. , Racial and ethnic differences in gynecologic surgical care are pervasive and have been well documented. Previous studies have shown that Black, Hispanic, and Asian or Pacific Islander women are more likely to undergo open abdominal hysterectomies and less likely to undergo minimally invasive hysterectomies, which are associated with fewer postoperative complications and a shorter hospital stay. These differences in hysterectomy route persist even after accounting for insurance coverage, surgical indications, uterus size, body mass index, surgeon training and experience, hospital volume, and history of previous pelvic surgery. In addition, although Black and Hispanic women are more likely to rely on surgical sterilization for contraception than White women, , they are also more likely to experience barriers to accessing postpartum surgical sterilization than White women. These documented differences may also impede the dissemination of novel preventive surgeries, such as OS. Furthermore, age-adjusted ovarian cancer incidence rates vary across race and ethnicity groups, with White women having the highest incidence (11.3 per 100,000), followed by Hispanic (10.3 per 100,000), Asian or Pacific Islander (9.4 per 100,000), and Black women (9.0 per 100,000). Although ovarian cancer incidence rates declined significantly between 2014 and 2018, the rate of decline has been the greatest in White women (average annual percent change, −3.7%) than in all other race and ethnicity groups (Hispanic, −0.9%; Black, −0.8%; Asian or Pacific Islander, −0.3%). Given that OS has rapidly diffused into clinical practice, if its adoption is not equitable, racial and ethnic disparities in ovarian cancer incidence may emerge in the future.
This study aimed to evaluate racial and ethnic differences in OS adoption among women undergoing benign hysterectomies or surgical sterilization in a large and geographically diverse sample of inpatient and outpatient procedures and assess the effect of national guidelines supporting OS use on these differences.
Materials and Methods
Data source and study population
We analyzed data from the Premier Perspective Healthcare Database, a deidentified, all-payer hospital administrative database with inpatient and outpatient services rendered at more than 700 hospitals across the United States. Premier contains information on sociodemographic and clinical characteristics and provider and hospital-specific data, including all diagnoses and procedures. The study was deemed exempt by the Columbia University Institutional Review Board.
Figure 1 shows the criteria used to identify the study population. Women without cancer aged 18 to 50 years old with an inpatient or outpatient claim for hysterectomy, tubal ligation, or bilateral salpingectomy between January 2011 and June 2018 were identified (n=1,142,913). Both elective and emergent surgeries were included. Women with a concomitant bilateral oophorectomy or salpingo-oophorectomy (n=225,974), those with hysterectomy codes without detail regarding the removal of additional adnexal structures (n=81,696), those undergoing tubal ligation or OS for indications other than sterilization (n=20,253), and those with unknown race and ethnicity (n=164,085) were excluded. After exclusions, 650,905 women were included in the study population, 247,787 with benign hysterectomy procedures and 403,118 with surgical sterilization procedures. Women were classified into 4 distinct groups by surgery type: hysterectomy alone without OS (n=164,995), hysterectomy and OS (n=82,792), tubal ligation (n=379,720), and OS for sterilization (n=23,398).
Classification of surgeries
A set of International Classification of Diseases (ICD) procedure codes was used to classify inpatient surgeries, and Current Procedural Terminology (CPT) codes were used to classify outpatient surgeries ( Supplemental Table 1 ). Women with at least 1 code in group 1 and none in groups 2 or 3 were classified as hysterectomy alone without OS, those with at least 1 code in groups 1 and 3 and none in group 2 were classified as hysterectomy and OS, those with at least 1 code in group 2 and none in groups 1 or 3 were classified as tubal ligation, and those with at least 1 code in group 3 and none in groups 1 or 2 were classified as OS.
Classification of race and ethnicity
Race and ethnicity were derived from the uniform medical billing form associated with the surgery claim. Race was classified as Black, White, other, or unknown, and ethnicity was classified as Hispanic, non-Hispanic, or unknown. A composite race and ethnicity variable was created and classified as non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic any race, non-Hispanic other race (NHO), and unknown. Women with unknown race and/or ethnicity were not included in the analysis.
Covariates
Sociodemographic, clinical, procedural, hospital, and provider characteristics were ascertained for all women. Sociodemographic characteristics included age, year of surgery (2011–2013 and 2014–2018), marital status (married, single, other, or unknown), and insurance type (commercial, Medicare, Medicaid, uninsured, or unknown). Clinical and procedural characteristics included comorbidities (0, 1, or ≥2), type of sterilization (interval or postpartum), hysterectomy route (abdominal, laparoscopic, robotic assisted, or vaginal), and indications for hysterectomy (uterine fibroids, endometriosis, abnormal bleeding, benign neoplasms and cysts, or pelvic organ prolapse). Comorbidities were ascertained using the Elixhauser Comorbidity Index, , and type of sterilization, hysterectomy route, and indications for hysterectomy were identified on the basis of the ICD and CPT codes associated with the surgery claims ( Supplemental Table 1 ). Hospital and provider characteristics included location (rural or urban), region (Midwest, Northeast, South, or West), teaching status (non-teaching or teaching), bed size (<300, 300–499, or >499), place of service (inpatient or outpatient), hospital volume (low [≤200 procedures per year], intermediate [201–403 procedures per year], high [≥404 procedures per year]), proportion of Medicaid and uninsured patients (low [≤33%], intermediate [34%–46%], high [≥46%]), and provider specialty (obstetrics and gynecology, gynecologic oncology, or other). Hospital volume was determined by dividing the total number of women undergoing surgery at each hospital by the number of years each hospital contributed at least 1 surgery and categorized into tertiles. The proportion of Medicaid and uninsured patients was determined by dividing the number of Medicaid and uninsured women undergoing surgery at each hospital by the number of hospitals that contributed at least 1 Medicaid or uninsured patient and categorized into tertiles.
Statistical analysis
Descriptive analyses by race and ethnicity and type of OS were performed, and the proportion of benign hysterectomy and surgical sterilization procedures involving OS were plotted by race and ethnicity and year. Multivariable mixed-effects log-binomial regression models were used to examine the association between race and ethnicity and OS during hysterectomy (hysterectomy and OS vs hysterectomy alone) and OS for sterilization (OS alone vs tubal ligation). Models included a random intercept term for the hospital in which the surgery was performed to account for hospital-level clustering. All models were adjusted for sociodemographic characteristics (age, year, marital status, and insurance type), clinical and procedural characteristics (comorbidities, type of sterilization, hysterectomy route, and indications for hysterectomy), and hospital and provider characteristics (location, region, teaching status, bed size, place of service, hospital volume, proportion of Medicaid and uninsured patients, and provider specialty). These covariates were selected on the basis of clinical rationale and previous literature. , , Moreover, all models included a multiplicative interaction term between race and ethnicity and year of surgery (2011–2013 [before guideline] and 2014–2018 [after guideline]) to test if racial and ethnic differences in OS adoption changed after the release of national guidelines supporting OS use. The year cut point was based on the November 2013 release of the SGO clinical practice statement. Results were reported as risk ratios (RRs) and 95% confidence intervals (CIs).
Sensitivity analyses were performed to test whether overall results changed by excluding 2014 from the analysis to allow time for guideline implementation and changing the year of surgery cut points to the ACOG committee opinion supporting OS use (2011–2014 [before guideline] and 2015–2018 [after guideline]). For hysterectomy and OS, stratified analyses by hysterectomy route were performed as previous studies have shown that Black and Hispanic women are less likely to undergo minimally invasive hysterectomy and more likely to undergo abdominal hysterectomy. , Moreover, additional analyses by age at surgery (18–34, 35–44, and 45–50 years) were performed as rates of hysterectomy and surgical sterilization vary by age. To further assess the sensitivity of our results, missing data on race and ethnicity (n=164,085) were imputed on the basis of observed values, assuming the data were missing at random. Overall, 10 datasets were imputed using the multivariate imputation by chained equations method, and the results were combined across imputations using standard methods. , All analyses were performed using Stata (version 17.0; StataCorp, College Station, TX).
Results
Adoption of opportunistic salpingectomy
Between 2011 and 2018, we identified 247,787 benign hysterectomies and 403,118 surgical sterilizations. Overall, the proportion of hysterectomies involving OS increased from 6.3% in 2011 to 59.7% in 2018 ( Figure 2 , A) and the proportion of sterilizations involving OS increased from 0.7% in 2011 to 19.4% in 2018 ( Figure 2 , B). The adoption of OS increased across all race and ethnicity groups. The proportion of OS during hysterectomy increased from 6.1% to 56.8%, 5.4% to 63.4%, 7.7% to 62.4%, and 7.8% to 64.5%, and the proportion of OS for sterilization increased from 0.8% to 22.8%, 0.7% to 14.5%, 0.5% to 15.1%, and 0.7% to 18.2% from 2011 to 2018 in NHW, NHB, Hispanic, and NHO women, respectively.
Characteristics of women undergoing opportunistic salpingectomy
Overall, 164,995 women underwent hysterectomy alone and 82,792 women underwent hysterectomy and OS ( Table 1 ). Most women were NHW (hysterectomy, 60.3%; hysterectomy and OS, 60.3%). Approximately 19.4%, 12.0%, and 8.3% of women undergoing hysterectomy and 18.8%, 12.2%, and 8.7% of women undergoing hysterectomy and OS were NHB, Hispanic, and NHO, respectively. Women undergoing hysterectomy (mean age: NHW, 40.0 years; NHB, 40.9 years; Hispanic, 40.7 years; NHO, 40.9 years) were younger than those undergoing hysterectomy and OS (mean age: NHW, 40.5 years; NHB, 41.6 years; Hispanic, 41.3 years; NHO, 41.9 years), with minimal differences by race and ethnicity. Substantial differences concerning surgery type and race and ethnicity were observed for the year of surgery, marital status, type of insurance, number of comorbidities, hysterectomy route, indications for hysterectomy, hospital location, hospital region, hospital teaching status, place of service, annualized hospital volume, and hospital proportion of Medicaid and uninsured patients.
| Characteristic | Hysterectomy alone (n=164,995) | Hysterectomy and OS (n=82,792) | ||||||
|---|---|---|---|---|---|---|---|---|
| NHW | NHB | Hispanic | NHO | NHW | NHB | Hispanic | NHO | |
| Total number of surgeries | 99,530 (60.3) | 31,977 (19.4) | 19,790 (12.0) | 13,698 (8.3) | 49,960 (60.3) | 15,586 (18.8) | 10,121 (12.2) | 7125 (8.7) |
| Age (y), mean (SD) | 40.0 (6.2) | 40.9 (5.4) | 40.7 (5.7) | 40.9 (6.0) | 40.5 (6.0) | 41.6 (5.2) | 41.3 (5.4) | 41.9 (5.5) |
| Year of surgery | ||||||||
| 2011–2013 | 63,809 (64.1) | 20,213 (63.2) | 12,111 (61.2) | 9272 (67.7) | 10,410 (20.8) | 2781 (17.8) | 2018 (19.9) | 1662 (23.3) |
| 2014–2018 | 35,721 (35.9) | 11,764 (36.8) | 7679 (38.8) | 4426 (32.3) | 39,550 (79.2) | 12,805 (82.2) | 8103 (80.1) | 5463 (76.7) |
| Marital status | ||||||||
| Single | 31,236 (31.4) | 17,393 (54.4) | 6227 (31.5) | 4709 (34.4) | 14,803 (29.6) | 8650 (55.5) | 3462 (34.2) | 2429 (34.1) |
| Married | 61,473 (61.8) | 12,589 (39.4) | 9718 (49.1) | 6624 (48.4) | 31,688 (63.4) | 6243 (40.1) | 5533 (54.7) | 3677 (51.6) |
| Other | 6491 (6.5) | 1931 (6.0) | 3741 (18.9) | 2316 (16.9) | 3216 (6.4) | 636 (4.1) | 1050 (10.4) | 971 (13.6) |
| Unknown | 330 (0.3) | 64 (0.2) | 104 (0.5) | 49 (0.4) | 253 (0.5) | 57 (0.4) | 76 (0.8) | 48 (0.7) |
| Type of insurance | ||||||||
| Commercial | 73,144 (73.5) | 21,324 (66.7) | 12,447 (62.9) | 10,248 (74.8) | 38,217 (76.5) | 10,994 (70.5) | 6547 (64.7) | 5643 (79.2) |
| Medicare | 3025 (3.0) | 1434 (4.5) | 557 (2.8) | 321 (2.3) | 1263 (2.5) | 591 (3.8) | 286 (2.8) | 153 (2.1) |
| Medicaid | 16,245 (16.3) | 6531 (20.4) | 4434 (22.4) | 2159 (15.8) | 7336 (14.7) | 2664 (17.1) | 2112 (20.9) | 919 (12.9) |
| Uninsured | 2751 (2.8) | 1425 (4.5) | 1601 (8.1) | 462 (3.4) | 862 (1.7) | 545 (3.5) | 822 (8.1) | 185 (2.6) |
| Other | 4365 (4.4) | 1263 (3.9) | 751 (3.8) | 508 (3.7) | 2282 (4.6) | 792 (5.1) | 354 (3.5) | 225 (3.2) |
| Number of comorbidities | ||||||||
| 0 | 60,816 (61.1) | 16,173 (50.6) | 12,709 (64.2) | 8643 (63.1) | 29,275 (58.6) | 7238 (46.4) | 6048 (59.8) | 4398 (61.7) |
| 1 | 24,755 (24.9) | 9044 (28.3) | 4183 (21.1) | 3184 (23.2) | 12,676 (25.4) | 4357 (28.0) | 2260 (22.3) | 1623 (22.8) |
| ≥2 | 13,959 (14.0) | 6760 (21.1) | 2898 (14.6) | 1871 (13.7) | 8009 (16.0) | 3991 (25.6) | 1813 (17.9) | 1104 (15.5) |
| Route of hysterectomy | ||||||||
| Abdominal | 18,339 (18.4) | 13,421 (42.0) | 6762 (34.2) | 3911 (28.6) | 9278 (18.6) | 7048 (45.2) | 3678 (36.3) | 2117 (29.7) |
| Robotic assistance | 20,652 (20.7) | 5663 (17.7) | 3938 (19.9) | 2138 (15.6) | 16,665 (33.4) | 3673 (23.6) | 2851 (28.2) | 1928 (27.1) |
| Laparoscopic | 35,327 (35.5) | 9384 (29.3) | 4815 (24.3) | 4496 (32.8) | 20,713 (41.5) | 4461 (28.6) | 3009 (29.7) | 2585 (36.3) |
| Vaginal | 25,212 (25.3) | 3509 (11.0) | 4275 (21.6) | 3153 (23.0) | 3304 (6.6) | 404 (2.6) | 583 (5.8) | 495 (6.9) |
| Indications for hysterectomy a | ||||||||
| Uterine fibroids | 36,701 (36.9) | 21,773 (68.1) | 10,423 (52.7) | 6771 (49.4) | 20,375 (40.8) | 10,906 (70.0) | 5660 (55.9) | 4100 (57.5) |
| Endometriosis | 22,433 (22.5) | 5019 (15.7) | 3771 (19.1) | 2874 (21.0) | 12,221 (24.5) | 2412 (15.5) | 1954 (19.3) | 1611 (22.6) |
| Abnormal bleeding | 56,522 (56.8) | 17,779 (55.6) | 10,791 (54.5) | 7326 (53.5) | 27,320 (54.7) | 8396 (53.9) | 5698 (56.3) | 3767 (52.9) |
| Benign neoplasms and cysts | 7515 (7.6) | 1964 (6.1) | 1756 (8.9) | 1075 (7.8) | 3853 (7.7) | 960 (6.2) | 831 (8.2) | 598 (8.4) |
| Pelvic organ prolapse | 12,099 (12.2) | 1156 (3.6) | 2333 (11.8) | 1441 (10.5) | 3467 (6.9) | 356 (2.3) | 681 (6.7) | 444 (6.2) |
| Location | ||||||||
| Rural | 14,827 (14.9) | 2515 (7.9) | 2096 (10.6) | 1692 (12.4) | 4270 (8.5) | 755 (4.8) | 816 (8.1) | 430 (6.0) |
| Urban | 84,703 (85.1) | 29,462 (92.1) | 17,694 (89.4) | 12,006 (87.6) | 45,690 (91.5) | 14,831 (95.2) | 9305 (91.9) | 6695 (94.0) |
| Region | ||||||||
| Midwest | 25,605 (25.7) | 5445 (17.0) | 2188 (11.1) | 1576 (11.5) | 10,576 (21.2) | 2965 (19.0) | 1007 (9.9) | 1519 (21.3) |
| Northeast | 8254 (8.3) | 2549 (8.0) | 2047 (10.3) | 1270 (9.3) | 4137 (8.3) | 1315 (8.4) | 1080 (10.7) | 666 (9.3) |
| South | 49,975 (50.2) | 22,870 (71.5) | 10,674 (53.9) | 6295 (46.0) | 22,294 (44.6) | 10,418 (66.8) | 4614 (45.6) | 2354 (33.0) |
| West | 15,696 (15.8) | 1113 (3.5) | 4881 (24.7) | 4557 (33.3) | 12,953 (25.9) | 888 (5.7) | 3420 (33.8) | 2586 (36.3) |
| Teaching status | ||||||||
| Nonteaching | 66,851 (67.2) | 19,435 (60.8) | 13,769 (69.6) | 8594 (62.7) | 32,330 (64.7) | 9090 (58.3) | 6758 (66.8) | 4484 (62.9) |
| Teaching | 32,679 (32.8) | 12,542 (39.2) | 6021 (30.4) | 5104 (37.3) | 17,630 (35.3) | 6496 (41.7) | 3363 (33.2) | 2641 (37.1) |
| Bed size | ||||||||
| <300 | 43,103 (43.3) | 9983 (31.2) | 7999 (40.4) | 4696 (34.3) | 19,525 (39.1) | 4441 (28.5) | 3581 (35.4) | 2240 (31.4) |
| 300–499 | 33,440 (33.6) | 12,315 (38.5) | 5055 (25.5) | 4740 (34.6) | 16,097 (32.2) | 5547 (35.6) | 2999 (29.6) | 2761 (38.8) |
| >499 | 22,987 (23.1) | 9679 (30.3) | 6736 (34.0) | 4262 (31.1) | 14,338 (28.7) | 5598 (35.9) | 3541 (35.0) | 2124 (29.8) |
| Place of service | ||||||||
| Inpatient | 38,805 (39.0) | 18,027 (56.4) | 12,287 (62.1) | 6485 (47.3) | 15,254 (30.5) | 8535 (54.8) | 5483 (54.2) | 2948 (41.4) |
| Outpatient | 60,725 (61.0) | 13,950 (43.6) | 7503 (37.9) | 7213 (52.7) | 34,706 (69.5) | 7051 (45.2) | 4638 (45.8) | 4177 (58.6) |
| Annualized hospital volume | ||||||||
| Low | 42,814 (43.0) | 12,340 (38.6) | 6847 (34.6) | 4772 (34.8) | 20,385 (40.8) | 5942 (38.1) | 3207 (31.7) | 2368 (33.2) |
| Intermediate | 33,061 (33.2) | 9392 (29.4) | 5975 (30.2) | 4956 (36.2) | 15,043 (30.1) | 4355 (27.9) | 3276 (32.4) | 3135 (44.0) |
| High | 23,655 (23.8) | 10,245 (32.0) | 6968 (35.2) | 3970 (29.0) | 14,532 (29.1) | 5289 (33.9) | 3638 (35.9) | 1622 (22.8) |
| Medicaid and uninsured patients | ||||||||
| Low | 42,025 (42.2) | 14,555 (45.5) | 8579 (43.4) | 7480 (54.6) | 23,994 (48.0) | 7537 (48.4) | 4755 (47.0) | 4662 (65.4) |
| Intermediate | 32,892 (33.0) | 9567 (29.9) | 3805 (19.2) | 3678 (26.9) | 16,312 (32.7) | 4711 (30.2) | 2261 (22.3) | 1649 (23.1) |
| High | 24,613 (24.7) | 7855 (24.6) | 7406 (37.4) | 2540 (18.5) | 9654 (19.3) | 3338 (21.4) | 3105 (30.7) | 814 (11.4) |
| Provider specialty | ||||||||
| Obstetrics and gynecology | 91,390 (91.8) | 29,465 (92.1) | 17,860 (90.2) | 12,559 (91.7) | 45,303 (90.7) | 14,061 (90.2) | 9034 (89.3) | 6348 (89.1) |
| Gynecologic oncology | 1538 (1.5) | 531 (1.7) | 533 (2.7) | 326 (2.4) | 1791 (3.6) | 598 (3.8) | 367 (3.6) | 439 (6.2) |
| Other | 6602 (6.6) | 1981 (6.2) | 1397 (7.1) | 813 (5.9) | 2866 (5.7) | 927 (5.9) | 720 (7.1) | 338 (4.7) |
Overall, 379,720 women underwent tubal ligation, and 23,398 women underwent OS for sterilization ( Table 2 ). Most women were NHW (tubal ligation, 53.6%; OS, 64.7%). Approximately 15.0%, 21.8%, and 9.6% of women undergoing tubal ligation and 10.8%, 16.7%, and 7.8% of women undergoing OS for sterilization were NHB, Hispanic, and NHO, respectively. Women undergoing tubal ligation (mean age: NHW, 31.9 years; NHB, 31.0 years; Hispanic, 32.3 years; NHO: 32.9 years) were younger than women undergoing OS for sterilization (mean age: NHW, 34.2 years; NHB, 33.7 years; Hispanic, 33.5 years; NHO, 35.1 years), with minimal differences by race and ethnicity. Substantial differences concerning surgery type and race and ethnicity were observed for the year of surgery, type of insurance, number of comorbidities, type of sterilization, hospital location, hospital region, hospital teaching status, place of service, annualized hospital volume, and hospital proportion of Medicaid and uninsured patients.
| Characteristic | Tubal ligation (n=379,720) | OS for sterilization (n=23,398) | ||||||
|---|---|---|---|---|---|---|---|---|
| NHW | NHB | Hispanic | NHO | NHW | NHB | Hispanic | NHO | |
| Total number of surgeries | 203,798 (53.6) | 56,861 (15.0) | 82,601 (21.8) | 36,460 (9.6) | 15,144 (64.7) | 2518 (10.8) | 3914 (16.7) | 1822 (7.8) |
| Age (y), mean (SD) | 31.9 (5.7) | 31.0 (5.6) | 32.3 (5.3) | 32.9 (5.4) | 34.2 (6.4) | 33.7 (6.0) | 33.5 (5.7) | 35.1 (6.0) |
| Year of surgery | ||||||||
| 2011–2013 | 93,747 (46.0) | 26,334 (46.3) | 37,086 (44.9) | 17,128 (47.0) | 1082 (7.1) | 219 (8.7) | 237 (6.1) | 143 (7.8) |
| 2014–2018 | 110,051 (54.0) | 30,527 (53.7) | 45,515 (55.1) | 19,332 (53.0) | 14,062 (92.9) | 2299 (91.3) | 3677 (93.9) | 1679 (92.2) |
| Marital status | ||||||||
| Single | 73,925 (36.3) | 35,653 (62.7) | 29,316 (35.5) | 10,872 (29.8) | 6071 (40.1) | 1528 (60.7) | 1477 (37.7) | 552 (30.3) |
| Married | 114,759 (56.3) | 17,465 (30.7) | 38,902 (47.1) | 20,160 (55.3) | 7691 (50.8) | 817 (32.4) | 1955 (49.9) | 887 (48.7) |
| Other | 14,383 (7.1) | 3652 (6.4) | 13,059 (15.8) | 5335 (14.6) | 1282 (8.5) | 168 (6.7) | 405 (10.3) | 379 (20.8) |
| Unknown | 731 (0.4) | 91 (0.2) | 1324 (1.6) | 93 (0.3) | 100 (0.7) | 5 (0.2) | 77 (2.0) | 4 (0.2) |
| Type of insurance | ||||||||
| Commercial | 100,925 (49.5) | 18,677 (32.8) | 24,946 (30.2) | 19,985 (54.8) | 8557 (56.5) | 1023 (40.6) | 1602 (40.9) | 1178 (64.7) |
| Medicare | 2828 (1.4) | 1134 (2.0) | 587 (0.7) | 316 (0.9) | 253 (1.7) | 46 (1.8) | 56 (1.4) | 21 (1.2) |
| Medicaid | 88,804 (43.6) | 34,318 (60.4) | 51,867 (62.8) | 14,468 (39.7) | 5473 (36.1) | 1327 (52.7) | 2036 (52.0) | 538 (29.5) |
| Uninsured | 2399 (1.2) | 884 (1.6) | 3413 (4.1) | 580 (1.6) | 127 (0.8) | 32 (1.3) | 112 (2.9) | 35 (1.9) |
| Other | 8842 (4.3) | 1848 (3.3) | 1788 (2.2) | 1111 (3.0) | 734 (4.8) | 90 (3.6) | 108 (2.8) | 50 (2.7) |
| No. of comorbidities | ||||||||
| 0 | 155,928 (76.5) | 42,911 (75.5) | 69,783 (84.5) | 29,751 (81.6) | 9902 (65.4) | 1520 (60.4) | 2789 (71.3) | 1381 (75.8) |
| 1 | 36,735 (18.0) | 10,712 (18.8) | 10,496 (12.7) | 5349 (14.7) | 3560 (23.5) | 646 (25.7) | 839 (21.4) | 322 (17.7) |
| ≥2 | 11,135 (5.5) | 3238 (5.7) | 2322 (2.8) | 1360 (3.7) | 1682 (11.1) | 352 (14.0) | 286 (7.3) | 119 (6.5) |
| Type of sterilization | ||||||||
| Interval | 56,649 (27.8) | 12,855 (22.6) | 17,524 (21.2) | 8103 (22.2) | 15,028 (99.2) | 2478 (98.4) | 3797 (97.0) | 1787 (98.1) |
| Postpartum | 147,149 (72.2) | 44,006 (77.4) | 65,077 (78.8) | 28,357 (77.8) | 116 (0.8) | 40 (1.6) | 117 (3.0) | 35 (1.9) |
| Location | ||||||||
| Rural | 30,675 (15.1) | 5094 (9.0) | 8462 (10.2) | 4734 (13.0) | 2317 (15.3) | 228 (9.1) | 369 (9.4) | 118 (6.5) |
| Urban | 173,123 (84.9) | 51,767 (91.0) | 74,139 (89.8) | 31,726 (87.0) | 12,827 (84.7) | 2290 (90.9) | 3545 (90.6) | 1704 (93.5) |
| Region | ||||||||
| Midwest | 38,768 (19.0) | 8969 (15.8) | 7337 (8.9) | 4770 (13.1) | 4519 (29.8) | 683 (27.1) | 443 (11.3) | 424 (23.3) |
| Northeast | 19,150 (9.4) | 4616 (8.1) | 9351 (11.3) | 3982 (10.9) | 1782 (11.8) | 248 (9.8) | 789 (20.2) | 386 (21.2) |
| South | 118,146 (58.0) | 41,859 (73.6) | 46,975 (56.9) | 17,928 (49.2) | 6699 (44.2) | 1509 (59.9) | 1801 (46.0) | 630 (34.6) |
| West | 27,734 (13.6) | 1417 (2.5) | 18,938 (22.9) | 9780 (26.8) | 2144 (14.2) | 78 (3.1) | 881 (22.5) | 382 (21.0) |
| Teaching status | ||||||||
| Nonteaching | 127,620 (62.6) | 30,792 (54.2) | 49,665 (60.1) | 19,480 (53.4) | 10,185 (67.3) | 1375 (54.6) | 2464 (63.0) | 1020 (56.0) |
| Teaching | 76,178 (37.4) | 26,069 (45.8) | 32,936 (39.9) | 16,980 (46.6) | 4959 (32.7) | 1143 (45.4) | 1450 (37.0) | 802 (44.0) |
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