We read with great interest the study by Richardson et al regarding modifiable risk factors associated with racially disparate outcomes following benign hysterectomy. While the authors importantly highlight surgical approach and operative time as targets for intervention, several critical issues warrant further discussion.
First, preoperative anemia must be reframed from a clinical confounder to a failure of preoperative optimization. Black women present with substantially lower hemoglobin levels due to higher fibroid burden, yet they are frequently underoptimized prior to elective surgery. Evidence indicates that untreated preoperative anemia is an independent predictor of 30-day morbidity and mortality, distinct from the risk of transfusion. The modifiable factor here is not the patient’s biology, but the care pathway: implementation of mandatory anemia clinics and intravenous iron protocols weeks prior to surgery could mitigate this disparity before the patient enters the operating room.
Second, the association between hemostatic agents and increased complications requires scrutiny regarding iatrogenic harm. The authors note these agents are associated with a 55% higher likelihood of complications. Given that Black women often undergo more complex surgeries where these agents are frequently employed, they are disproportionately exposed to this risk. Certain hemostatic agents may serve as a nidus for infection, increasing rates of pelvic abscess and readmission. If the tool intended to rescue complex cases is driving infectious morbidity, this represents a specific, modifiable iatrogenic pathway contributing to racial disparities in surgical site infections.
Third, we should address segregation within integration. The authors rightly identify low-volume surgeons as a risk factor. However, previous research demonstrates that even within high-volume, high-quality hospitals, Black women are considerably more likely to be treated by low-volume surgeons than their White peers. This suggests that access to a good hospital is insufficient if internal referral patterns segregate care. A truly modifiable solution requires institutional policies that mandate referral of complex fibroid cases to designated high-volume minimally invasive gynecologic surgery specialists, removing provider discretion and referral bias from the equation.
X.Y. and K.P. contributed equally to this work.
The authors report no conflict of interest.
This work was supported by Chongqing Key Clinical Specialty Construction Project for the Department of Oncology (No. ZDZK-202105).
Data availability: There are no new data generated.
References
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