Hypothesis / aims of study
Despite evidence that sociodemographic (SES) factors influence surgical treatment of pelvic organ prolapse (POP), literature is lacking on how race, ethnicity, or primary language impact a patient’s likelihood to undergo surgery (1). One study revealed minority women (African American, Hispanic, and Asian) were less knowledgeable regarding the etiology, prevention, and curative treatment options for POP when compared to their White counterparts. Additionally, a 2021 analysis underscored an overrepresentation of White women in POP literature, while Black, Hispanic, and Asian women were notably underrepresented, indicating the urgent need for POP research to investigate potential disparities (2). Although outcomes stratified by race and ethnicity are undoubtedly affected by social determinants of health, cultural nuances, systemic racism, and complex racial trauma rendering them non-linear and intricate to decipher, efforts to identify trends and uncover disparities can serve as an initial step towards identifying more equitable, culturally sensitive targets for improving health outcomes. Our tertiary care center provides urogynecologic care to an area of the US comprising a Hispanic “minority-majority” population, offering unique insight into how SES factors impact surgery rates. We sought to assess how race, ethnicity, and primary language predict surgical treatment for POP in a minority-majority Hispanic population.
Study design, materials and methods
We identified patients with POP ICD 10 codes from Oct 2019-Dec 2022 who received surgical treatment for POP at a Urology/Urogynecology academic practice. A complete documentation of POP-Q examination in the EMR was required for cohort inclusion. Stage and compartment of pelvic organ prolapse were determined using data collected by chart review and inserted into the American Urogynecology Society’s POP-Q Interactive Assessment Tool. Race and ethnicity were self-identified by patients and extracted as listed in the medical record; ethnicity categories were dichotomized as Hispanic or non-Hispanic. Data was collected by chart review. Covariates were obtained by manual data abstraction. Continuous and categorical variables were analyzed using the t-test and chi-square test, respectively. For non-parametric data, Wilcoxon rank-sum test was used. A logistic regression model was fitted to identify independent predictors of surgery utilization. Our study did not receive external funding of the study or grants. Ethical approval was given by our university-affiliated Institutional Review Board.
Results
Of 943 patients over 38 months, 441 (46.8%) underwent surgery. SES characteristics by surgical conversion rates are shown in Table 1. Upon direct comparison patients that were younger, Hispanic or Latino, spoke Spanish as a primary language, had private insurance or were obese were more likely to undergo surgery (Table 1). Upon multivariate regression, however, only age and compartment of prolapse remained predictors of undergoing surgical repair, where younger patients and patients with apical prolapse (alone or in any combination of anterior and/or posterior prolapse) were significantly more likely to undergo surgery (OR=.98 [.96-.99], p=>.001 and R= 2.31 [1.13-4.72], p=>.001, respectively) (Table 2). Race, ethnicity, primary language spoken, ethnicity, BMI, alcohol use, and smoking were not independent predictors of surgical conversion for POP in our patient population.
Interpretation of results
Our analysis suggests that when controlling for confounders, age and prolapse compartment are significant predictors of surgical treatment for POP in a urogynecology practice serving a Hispanic minority-majority population. Previously identified barriers to care including minority status and non-English primary language do not appear to exist in our population. Factors contributing to our results likely include concordance in linguistic, ethnic, and racial attributes between employees of the healthcare system (including physicians) and patients in addition to protective factors associated with ethnic enclaves in our city. Within our Urogynecology clinics, providers are either fluent in Spanish or utilize nurses or nurse practitioners certified in medical Spanish translation. An annual report conducted in the state our study was conducted in found that the state ranks first in the US for the percentage of physicians identifying as Hispanic and other ethnicities with 15% of all licensed physicians being Hispanic. However, existing literature is mixed on whether provider-patient concordance influences patient satisfaction and health outcomes (3). Consequently, further investigation in other areas of the US with different population demographics may yield different results. More research is warranted to gain a more nuanced understanding of whether providers and healthcare system staff sharing similar demographics with their patients indeed impact the quality of care delivered.
Concluding message
In summary, our study found no meaningful associations between race, ethnicity, or primary language with surgical conversation rates for pelvic organ prolapse in a Hispanic majority population, while younger age and apical descent of prolapse to be positively correlated with higher rates of surgical treatment. Further research in areas with different population demographics may yield different results and is an appropriate next step for examination. In addition, examining how cultural barriers in patient-provider relationships, such as provider language, impact the decision to undergo surgery is warranted.