Association of Patient Race With Surgical Practice and Perioperative Morbidity After Myomectomy. September 26, 2018 Charis Noteboom PGY2

Transcription

1 Association of Patient Race With Surgical Practice and Perioperative Morbidity After Myomectomy September 26, 2018 Charis Noteboom PGY2

2 Overview Stentz MD et al. University of Pennsylvania University of Wisconsin Supported by National Institutes of Health Published in Obstetrics and Gynecology Journal Vol 132, No. 2, August 2018 No financial disclosures

3 Overview Approximately one in five reproductive age women have leiomyomas Leiomyoma burden varies by race African American population present at younger age with larger and more numerous leiomyomas Greater disease burden = significantly higher perioperative morbidity Little reported information on other ethnic backgrounds

4 Objective 1. Compare rates of abdominal and laparoscopic myomectomy 2. Compare the morbidity after abdominal and laparoscopic myomectomy Racial Groups Compared African American Asian American Hispanic American Caucasian Women - Control

5 Methods Retrospective Cohort Study American College of Surgeons National Quality Improvement Program database Inclusion Criteria: 8,438 premenopausal women younger than 55 years Between January 1, 2012 and December 31, 2015 Exclusion Criteria: Emergent Non-gynecologist Vaginal myomectomy Myomectomy with hysterectomy Malignancy Recent chemotherapy

6 Methods Retrospective Cohort Study Demographics Age Smoking BMI Diabetes HTN Myoma Burden Anemia Outcomes OR time Length of Stay Reoperative Readmission Medical Morbidity Surgical Morbidity Composite Morbidity Adjusted Composite Morbidity Medical Morbidity - DVT, PE, UTI and sepsis Surgical Morbidity - Blood transfusion, surgical site infection and wound dehiscence

7 Analysis χχ2 -Unadjusted comparisons of baseline characteristics, surgical approach and perioperative morbidity Two-sample t test - Age, BMI, operative time Propensity score matching - Identify minority patients who were most similar to Caucasian counterparts to reduce selection bias Multivariable logistic regression - Adjusted odds ratios for approach and composite morbidity

8 Results - Demographics Smoking Caucasian women more likely to smoke. BMI African American and Hispanic American Women had higher BMI Asian American women had lower BMIs Hypertension African American women three times as likely (OR 2.9) Myoma Burden African American women had a greater myoma burden Anemia African and Hispanic American greater prevalence of anemia

9 Results - Demographics

10 Results - Surgical Approach All races more likely to undergo abdominal myomectomy Propensity Score Adjusted Analysis - to undergo abdominal myomectomy African American twice as likely Asian American more than twice as likely Hispanic American 50% more than likely

11 Results - Abdominal Myomectomy Operating room time Significantly longer for African American and Asian American women Length of Stay African American and Hispanic American women stayed longer Reoperation and Readmission African American women twice as likely to return to OR or be readmitted Medical Morbidity African American women more likely to experience thromboembolism Surgical Morbidity All minorities more likely to receive transfusion

12 Results - Abdominal Myomectomy

13 Results - Laparoscopic Myomectomy Length of Stay All minorities stayed longer Surgical Morbidity All minorities more than twice as likely to receive transfusion Composite Morbidity Asian American women more than three times as likely to experience morbidities

14 Results - Laparoscopic Myomectomy

15 Take Home Points 1. Minority women substantially more likely to undergo laparotomy 2. African American women had 50% greater odds of morbidity after abdominal myomectomy 3. Asian American women had greater than three times risk of morbidity after laparoscopic myomectomy

16 Discussion Why the increased risk of morbidity in minority populations? Not completely due to myoma burden Cultural differences in tolerance of menorrhagia or pelvic pressure Treatment at low-resource hospitals or surgeons who lack advanced laparoscopic training

17 Discussion What are the limitations of this study? Data is only collected for 30 days postoperative Does not differentiate between laparoscopic and robotic or converted to abdominal Does not allow for geographic trends Race was missing for 13.2% of population Disease burden evaluated using CPT codes

18 Questions?

19 Gynecologic Surgery: Original Research Association of Patient Race With Surgical Practice and Perioperative Morbidity After Myomectomy Natalie C. Stentz, MD, Laura G. Cooney, MD, Mary D. Sammel, ScD, and Divya K. Shah, MD, MME Downloaded from by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3K8IvHCABgh8HVb8LQc+bG/wigRY1xn7leXLHnc9Q2TE= on 08/14/2018 OBJECTIVE: To compare surgical approach, operative time, and perioperative morbidity after myomectomy by patient race. METHODS: In this retrospective cohort study, data were abstracted from the American College of Surgeons National Surgical Quality Improvement Program database on 8,438 women undergoing myomectomy between January 1, 2012, and December 31, Myoma burden and approach to myomectomy were determined based on Current Procedural Terminology coding. Surgical approach and perioperative morbidity were examined in African American, Asian American, and Hispanic American women using non-hispanic Caucasian women as the referent population. Adjusted means and odds ratios (ORs) with 95% CI were calculated using propensity score matching accounting for age, ethnicity, body mass index (BMI), myoma burden, preoperative anemia, hypertension, smoking, and operative time. RESULTS: Data were available for 2,533 Caucasian, 3,359 African American, 664 Asian American, and 700 Hispanic American women. Smoking, BMI, hypertension, myoma From the University of Pennsylvania, Philadelphia, Pennsylvania; and the University of Wisconsin, Madison, Wisconsin. Supported by National Institutes of Health 2T32HD Presented at the American Society for Reproductive Medicine Scientific Congress, October 28 November 1, 2017, San Antonio, Texas. The American College of Surgeons National Surgical Quality Improvement Program and its participating hospitals are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. Each author has indicated that she has met the journal s requirements for authorship. Received March 9, Received in revised form May 4, Accepted May 17, Corresponding author: Divya K. Shah, MD, MME, 3701 Market Street, #800, Philadelphia, PA 19104; Divya.Shah@uphs.upenn.edu. Financial Disclosure The authors did not report any potential conflicts of interest by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: /18 burden, and anemia varied by race (P,.001, all comparisons). In adjusted analysis, African American women were twice as likely to undergo abdominal myomectomy (adjusted OR 1.9, 95% CI ), Asian American women were more than twice as likely (adjusted OR 2.3, 95% CI ), and Hispanic American women were 50% more likely to undergo abdominal myomectomy (adjusted OR 1.5, 95% CI ) when compared with Caucasian women. African American women were 50% more likely to experience composite morbidity after abdominal myomectomy (adjusted OR 1.5, 95% CI ) and Asian American women were more than three times as likely to experience composite morbidity after laparoscopic myomectomy (adjusted OR 3.7, 95% CI ) compared with Caucasian women. There were no differences in composite morbidity in other racial groups. CONCLUSION: Minority women are substantially more likely to undergo abdominal myomectomy when compared with Caucasian women. African American women had 50% increased odds of morbidity after abdominal myomectomy, andasianamericanwomenweremorethanthreetimesas likely to experience morbidity after laparoscopic myomectomy. Further examination into the etiology and prevention of these racial disparities is needed. (Obstet Gynecol 2018;132:291 7) DOI: /AOG Leiomyomas are among the most common benign tumors, affecting approximately one in five reproductive-aged women. 1 Leiomyoma incidence and disease burden vary by race. Several studies have found that the incidence of leiomyomas in the African American population is approximately three times that noted in Caucasian women. 2,3 Moreover, African American women present at a younger age with larger, more numerous, and more rapidly growing leiomyomas. 2,4 7 This greater disease burden has been associated with a significantly higher perioperative morbidity after myomectomy in African American as compared with Caucasian women. Comparatively little has been VOL. 132, NO. 2, AUGUST 2018 OBSTETRICS & GYNECOLOGY 291 Copyright ª by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

20 reported on leiomyoma incidence, burden of disease, and perioperative morbidity after myomectomy for women of other ethnic backgrounds. This retrospective cohort study aims to 1) compare rates of abdominal and laparoscopic myomectomy in African American, Asian American, and Hispanic American women as compared with Caucasian women; and 2) compare the morbidity after abdominal and laparoscopic myomectomy in each of these populations using data abstracted from the American College of Surgeons (ACS) National Quality Improvement Program database. We hypothesized that surgical approach to myomectomy and operative time would vary by patient race and that there may be racial disparities in perioperative morbidity after myomectomy. MATERIALS AND METHODS The ACS National Surgical Quality Improvement Program was established in 2004 as a nationally validated database intended to measure and improve surgical outcomes across specialties. Preoperative, intraoperative, and 30-day postoperative data are abstracted directly from patient medical records by specially trained personnel at each of the more than 600 participating hospitals nationwide. Data collection methods for the ACS National Surgical Quality Improvement Program have been described in detail in other publications In brief, trained surgical clinical reviewers at each site prospectively collect preoperative and postoperative morbidity and mortality data from each patient s medical record during the course of hospital admission and for up to 30 days after surgery. Regular audits ensure the quality of the information, which has been shown to have an overall interrater variability in data elements of less than 1.6% in recent years. 11 Data were abstracted on 8,438 women undergoing myomectomy between January 1, 2012, and December 31, The cohort was restricted to premenopausal women younger than 55 years of age based on the nationally reported mean age of menopause at age 51 years 12 with a SD of 4.15 years. 13 Emergent cases, myomectomies performed by a nongynecologist, vaginal myomectomy, and myomectomy completed at the time of cesarean delivery or hysterectomy were excluded. Women with underlying malignancy, recent chemotherapy, or radiation were also excluded. This study of existing publically available data was granted category 4 exemption by the institutional review board of the University of Pennsylvania. Current Procedural Technology codes were used to classify abdominal and laparoscopic myomectomy. Current Procedural Terminology codes and were considered low myoma burden (one to four myomas or total weight 250 g or less), and and were considered high myoma burden (more than five myomas or myoma weight greater than 250 g). Analyses focused on a selected subset of outcome variables within the ACS National Surgical Quality Improvement Program database thought to capture the majority of patient morbidity after myomectomy. Assessed outcomes included operative time, length of stay, and rates of reoperation and readmission within 30 days of the initial surgery. Medical morbidity (deep venous thrombosis [DVT], pulmonary embolus [PE], urinary tract infection, and sepsis) and surgical morbidity (blood transfusion, wound infection, and wound dehiscence) were also assessed. A composite variable for wound infection was created combining superficial, deep and organ-space surgical site infections; a composite for thromboembolism was created combining DVT and PE; and a composite for sepsis was created combining sepsis and septic shock. A composite morbidity score was created combining blood transfusion, wound dehiscence, wound infection, urinary tract infection, sepsis, and DVT or PE. Unadjusted comparisons of categorical baseline characteristics, surgical approach, and perioperative morbidity by patient race were performed with x 2 tests. Age, body mass index (BMI, calculated as weight (kg)/[height (m)] 2 ), and operative time were evaluated for normality and compared using twosample t tests. Propensity score matching was used to identify minority patients who were most similar to their Caucasian counterparts to reduce selection bias and balance population characteristics including age, ethnicity, BMI, myoma burden, preoperative anemia, hypertension, smoking, and operative time. Adjusted odds ratios (ORs) and 95% CIs for approach and composite morbidity were calculated using multivariable logistic regression. Morbidity analysis was stratified by surgical approach given known differences in morbidity of abdominal compared with laparoscopic procedures. Given the limited number of events and lack of convergence, adjusted analyses for rates of reoperation, DVT or PE, urinary tract infection, sepsis, surgical site infections, and wound dehiscence were not completed. All analyses were completed using STATA 14.2 with two-sided P values of #.05 considered statistically significant. 292 Stentz et al Race and Myomectomy OBSTETRICS & GYNECOLOGY Copyright ª by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

21 RESULTS A total of 8,438 women underwent laparoscopic or abdominal myomectomy between January 2012 and December All demographic variables were complete with the exception of ethnicity (missing for 3.07%) and BMI (missing for 0.44%). Race was missing for 13.2% of the population (n51,110). Complete case analysis was used stratifying by race (African American, Asian American, Hispanic American), using non-hispanic Caucasian women as the comparator population. Given limited numbers, women identifying as Native American or Alaskan Native (n536) and Native Hawaiian or Pacific Islander (n536) were excluded from analysis. Baseline demographics and comorbidities are displayed in Table 1. Smoking, BMI, hypertension, myoma burden, and anemia varied by race (P,.001, all comparisons). Caucasian women were more likely to smoke than all minority populations (P,.05, all comparisons). African American and Hispanic American women had higher BMIs than Caucasian women (P,.001), whereas Asian American women had lower BMIs than all other groups (P,.001). African American women were three times as likely as Caucasian women to have hypertension (OR 2.9, 95% CI ). There was no difference in hypertension prevalence between other groups. African American women had a greater myoma burden compared with Caucasian women (OR 1.8, 95% CI ). Myoma burden was comparable between other groups. African American and Hispanic American women had a greater prevalence of anemia compared with Caucasian women (OR 1.9, 95% CI ; OR 1.2, 95% CI , respectively). Asian American and Caucasian women had a comparable prevalence of anemia. Surgical approach to myomectomy differed by race. In unadjusted analyses, African American, Asian American, and Hispanic American women were all more likely to undergo abdominal as opposed to laparoscopic myomectomy compared with non- Hispanic Caucasian women (62.1%, 56.5%, 51.1% vs 43.8%, P,.001; Table 2). In propensity score-adjusted analysis, African American women were twice as likely to undergo abdominal myomectomy (adjusted OR 1.9, 95% CI ), Asian American women were more than twice as likely (adjusted OR 2.3, 95% CI ), and Hispanic American women were 50% more likely to undergo abdominal myomectomy (adjusted OR 1.5, 95% CI ) when compared with Caucasian women. When considering abdominal myomectomy, operative time, length of stay, reoperation, and readmission varied by race (P,.05; Table 3). Abdominal myomectomy took significantly longer for African American and Asian American women compared with Caucasian women with (P,.05, all). Hospital stay was longer for African American and Hispanic American women compared with Caucasian women (P,.05, all). African American women were twice as likely to return to the operating room and be readmitted compared with Caucasian women (OR 2.3, 95% CI ; OR 1.9, 95% CI , respectively). There were no differences in reoperation or readmission for Asian American and Hispanic American women compared with Caucasian women. When examining morbidity, all minority populations were Table 1. Demographic Characteristics of All Women Undergoing Myomectomy, Stratified by Race ( ) Demographic Characteristic Caucasian (n52,533) African American (n53,359) Asian American (n5664) Hispanic American (n5700) Other (n572) Missing (n51,110) P* Age (y) Smoking status 303 (12.0) 342 (10.2) 29 (4.4) 51 (7.3) 12 (16.7) 101 (9.1),.001 BMI (kg/m 2 ) ,.001 Diabetes 54 (2.1) 91 (2.7) 12 (1.8) 17 (2.4) 4 (5.6) 22 (2.0).214 HTN 146 (5.8) 499 (14.9) 34 (5.1) 42 (6.0) 4 (5.6) 51 (4.6),.001 High myoma 854 (33.7) 1,590 (47.3) 234 (35.2) 235 (33.6) 24 (33.3) 401 (36.1),.001 burden Anemia 569 (22.5) 1,206 (35.9) 167 (25.2) 186 (26.6) 19 (26.4) 300 (27.0),.001 BMI, body mass index; HTN, hypertension. Data are mean6sd or n (%) unless otherwise specified. *All comparisons are in reference to non-hispanic Caucasian women. Hypertension requiring medications. More than five myomas or myoma weight greater than 250 g. Preoperative hematocrit less than 35%. VOL. 132, NO. 2, AUGUST 2018 Stentz et al Race and Myomectomy 293 Copyright ª by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

22 Table 2. Surgical Approach to Myomectomy, Stratified by Race ( ) Operative Approach Caucasian (n52,533) African American (n53,359) Asian American (n5664) Hispanic American (n5700) P Abdominal approach (%) 1,060 (41.9) 2,085 (62.1) 375 (56.5) 358 (51.5),.001 Adjusted odds of abdominal approach* ( ) 2.3 ( ) 1.5 ( ),.001 for all comparisons Data are n (%) unless otherwise specified. * Results from logistic regression models use propensity score matching to adjust for age, ethnicity, body mass index, myoma burden, preoperative anemia, hypertension, smoking, and operative time, expressed as adjusted odds ratios with 95% CIs. more likely to receive transfusion than Caucasian women (African American OR 2.9, 95% CI ; Asian American OR 1.7, 95% CI ; Hispanic American OR 1.7, 95% CI ). Additionally, African American women were more likely to experience thromboembolic phenomena than Caucasian women (OR 9.2, 95% CI ). In propensity score-adjusted analysis, African American women were 50% more likely to experience composite morbidity after abdominal myomectomy compared with Caucasian women (adjusted AOR 1.5, 95% CI ). No differences in composite morbidity were noted for Asian American and Hispanic American women. When considering laparoscopic myomectomy, racial differences again were noted (Table 4). Hospital stay was longer for all minority populations compared with Caucasian women (P,.05, all). All minority groups were also more than twice as likely to receive blood transfusions when compared with Caucasian women (African American OR 2.5, 95% CI ; Asian American OR 3.6, 95% CI ; Hispanic American OR 2.0, 95% CI ). In propensity score-adjusted analysis, Asian American women were more than three times as likely to experience composite morbidities compared with Caucasian women (adjusted OR 3.7, 95% CI ). There were no differences in composite morbidity in African American or Hispanic American women. DISCUSSION Minimally invasive gynecologic surgery has increased in the United States over the past several years, 14 despite a recent drop after concerns over power morcellation. 15 Racial and socioeconomic disparities have been previously noted for patients undergoing minimally invasive Table 3. Surgical Morbidity After Abdominal Myomectomy, Stratified by Race ( ) Operative Variable Caucasian (n51,060) African American (n52,085) Asian American (n5375) Hispanic American (n5358) P* OR time (min) ( ) 26.0 ( ) 11.0 ( ) 25.5 (213.4 to 2.5),.001 Length of stay (d) 2 (1 2) 2 (2 3) 2 (1 2) 2 (2 3),.001 Reoperation within 30 d 7 (0.7) 32 (1.5) 1 (0.3) 3 (0.8).045 Readmission within 30 d 16 (1.5) 59 (2.9) 1 (0.3) 11 (3.1).003 Medical morbidity DVT or PE 1 (0.1) 18 (0.9) 2 (0.5) 2 (0.6).069 UTI 10 (0.9) 35 (1.7) 2 (0.5) 6 (1.7).165 Sepsis 3 (0.3) 19 (0.9) 0 (0.0) 2 (0.6).066 Surgical morbidity Blood transfusion 76 (7.2) 383 (10.4) 44 (11.7) 42 (11.7),.001 Surgical site infection 18 (1.7) 38 (1.8) 2 (0.5) 4 (1.1).265 Wound dehiscence 1 (0.1) 8 (0.4) 0 (0.0) 0 (0.0).200 Composite morbidity 103 (9.7) 454 (21.8) 48 (12.8) 48 (13.4),.001 Adjusted composite morbidity ( ), P, ( ), P ( ), P5.205 OR, operating room; DVT, deep venous thrombosis; PE, pulmonary embolism; UTI, urinary tract infection. Data are median (interquartile range), n (%), or adjusted odds ratio (95% CI) unless otherwise specified. * All comparisons in reference to non-hispanic Caucasian women. Morbidity represents a composite of blood transfusion, wound dehiscence, wound infection, UTI, sepsis or septic shock, and DVT or PE. Results from logistic regression models use propensity score matching to adjust for age, ethnicity, body mass index, myoma burden, preoperative anemia, hypertension, smoking, and operative time, expressed as adjusted odds ratios with 95% CIs. 294 Stentz et al Race and Myomectomy OBSTETRICS & GYNECOLOGY Copyright ª by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

23 Table 4. Surgical Morbidity After Laparoscopic Myomectomy, Stratified by Race ( ) Operative Variable Caucasian (n51,473) African American (n51,274) Asian American (n5289) Hispanic American (n5342) P* OR time (min) ( ) 31.4 ( ) 6.8 (24.1 to 17.7) (220.4 to 20.1).113 Length of stay (d) 0 (0 1) 0 (0 1) 0 (0 1) 1 (0 1),.001 Reoperation within 30 d 8 (0.5) 10 (0.8) 4 (1.4) 1 (0.3).322 Readmission within 30 d 15 (1.0) 21 (1.7) 3 (1.0) 3 (0.9).421 Medical morbidity DVT or PE 2 (0.1) 3 (0.2) 0 (0.0) 0 (0.0).657 UTI 13 (0.9) 9 (0.7) 2 (0.7) 1 (0.3).713 Sepsis 2 (0.1) 3 (0.2) 1 (0.4) 1 (0.3).849 Surgical morbidity Blood transfusion 28 (1.9) 58 (4.6) 19 (6.6) 13 (3.8),.001 Surgical site infection 21 (1.4) 16 (1.3) 2 (0.7) 2 (0.6).502 Wound dehiscence 1 (0.1) 0 (0.0) 0 (0.0) 0 (0.0).731 Composite morbidity 62 (4.2) 84 (6.6) 22 (7.6) 18 (5.3).017 Adjusted composite morbidity ( ), P ( ), P ( ), P5.063 OR, operating room; DVT, deep venous thrombosis; PE, pulmonary embolism; UTI, urinary tract infection. Data are median (interquartile range), n (%), or adjusted odds ratio (95% CI) unless otherwise specified. * All comparisons in reference to non-hispanic Caucasian women. Morbidity represents a composite of blood transfusion, wound dehiscence, wound infection, UTI, sepsis or septic shock, and DVT or PE. Results from logistic regression models use propensity score matching to adjust for age, ethnicity, body mass index, myoma burden, preoperative anemia, hypertension, smoking, and operative time, expressed as adjusted odds ratios with 95% CIs. hysterectomy. 14,16 18 The present study identifies similar racial disparities in women undergoing myomectomy. Minority women were substantially more likely to undergo myomectomy through laparotomy as compared with their Caucasian counterparts. African American women had 50% increased odds of morbidity after abdominal myomectomy and Asian American women were more than three times as likely to experience morbidity after laparoscopic myomectomy. No differences in morbidity were noted for the Hispanic American population. The increased leiomyoma burden in African American women is well established 2,4 7 and has been previously identified as an impediment to minimally invasive gynecologic surgery in this population. 19,20 By contrast, the present study documented persistently increased odds of abdominal myomectomy in African American women despite controlling for leiomyoma burden. Comparatively little is known about leiomyoma treatment in racial and ethnic groups other than African American and Caucasian women. This is attributable in part to comparison of Caucasian women with composite nonwhite groups 19,21 a practice that the Institute of Medicine has identified as one of the greatest limitations of existing research on racial disparities. 22 The few studies independently evaluating Asian American women have demonstrated a comparable likelihood of leiomyoma diagnosis with Caucasian women. 3,7 A single system study of 650,000 hysterectomies also demonstrated that African American and Asian American women were each independently more likely to have surgical complications irrespective of age, insurance, indication, or comorbidities. 21 This is consistent with the present study, in which Asian American women were 3.7 times as likely to experience postoperative morbidity after laparoscopic myomectomy when compared with Caucasian women. If the decreased use of laparoscopic myomectomy and the increased postoperative morbidity among minority women cannot be explained by disease burden or medical comorbidities, one must question what other mechanisms contribute to these racial disparities. One possibility is that cultural differences exist in tolerance of menorrhagia or pelvic pressure, accounting for surgical postponement and differential perioperative outcomes. A second possibility is that minority women disproportionally undergo treatment at low-resource hospitals with limited access to laparoscopic or robotic equipment or with surgeons who lack advanced laparoscopic training. Although there is scarce literature on hospital segregation in gynecology, 23 the general surgery literature indicates that African American women are more likely to receive care at low-resource hospitals and less likely to receive care from board-certified physicians or high-volume surgeons or have access to newer medical technology Whether similar impediments exist for Asian American or Hispanic VOL. 132, NO. 2, AUGUST 2018 Stentz et al Race and Myomectomy 295 Copyright ª by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

24 American women remains unknown. A limitation of the ACS National Quality Improvement database is its inability to capture geographic and health care provider-level data. Future research in racial disparities with this level of fidelity is critical to better understand these findings. A primary strength of this study is its size and associated power with the use of national-level data across private and academic settings. This enables specific evaluation of the previously understudied Asian American and Hispanic American populations and is particularly well suited to study rare outcomes such as postoperative morbidity after myomectomy. As with any study using aggregate data, our study has limitations. The ACS National Surgical Quality Improvement Program only collects data on 30-day postoperative outcomes. Prior studies have demonstrated longer time off work and delayed return to daily activities after abdominal as compared with laparoscopic myomectomy Although significant, these outcomes are not measurable in the present study. Furthermore, the present data set does not differentiate between laparoscopic and robotic approaches, myomectomies converted to the abdominal approach, and does not allow the assessment of regional trends or geographic clustering. Although excluded from complete case analysis, limited amounts of missing data for ethnicity and race may contribute to biased estimates. Finally and significantly, disease burden was evaluated using Current Procedural Terminology coding with high myoma burden defined as greater than 250 g or five myomas. Although this definition captures women with a very low disease burden, it clusters women with higher myoma burden, equating 300 g with 3,000 g of myomas. It is possible that adjusted analyses therefore bias results toward the null, particularly in the African American population. In conclusion, although the greater myoma burden among African American women is known to contribute to the heightened surgical morbidity, the present study demonstrates a persistent increase in morbidity even after controlling for confounders. The present study is novel in its exploration of morbidity after myomectomy in Asian American and Hispanic American women, demonstrating an increased utilization of abdominal myomectomy with markedly increased morbidity after laparoscopic myomectomy in Asian American women. Further examination into the etiology and prevention of these racial disparities is needed. REFERENCES 1. Buttram VC Jr, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril 1981;36: Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM. 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