Applying social vulnerability index to examine social disparities in patients undergoing hysterectomy

Abstract

Background

The social vulnerability index (SVI) measures socioeconomic hardship, with high SVI indicating high susceptibility. We applied the SVI to characterize and compare patients who underwent abdominal versus minimally invasive hysterectomy.

Objective

To evaluate whether high social vulnerability, as measured by SVI, was associated with a lower likelihood of undergoing minimally invasive hysterectomy compared to abdominal hysterectomy.

Study Design

This was a retrospective cohort study conducted across 4 hospitals within a single health system in Colorado. The study included patients who underwent hysterectomy for any indication between 2013 and 2018. Patient addresses were geocoded to estimate overall SVI and its 4 sub-domains: Socioeconomic, Housing/Disability, Race/Minority, and Housing/Transportation. These data were analyzed to evaluate for an association between SVI and surgical approach to hysterectomy.

Results

Among 2,619 patients, 86% underwent MIH (87.3% non-Hispanic White [NHW]; 76.6% non-Hispanic Black [NHB]; 82.5% Hispanic). Patients undergoing MIH were more likely to be NHW, ASA class I or II, and less likely to have diabetes, hypertension, or receive care within a tertiary referral center (P<.05). While MIH was not associated with high overall SVI (P=.07), patients undergoing abdominal hysterectomy were more likely to have high SVI in race/minority and housing/transportation sub-domains (P=.006 and P=.01, respectively). Significant differences in age, comorbidities, BMI class, hospital setting, route of hysterectomy were observed across all race/ethnic groups (P<.001).

Multivariable logistic regression analysis showed that high overall SVI or high SVI in either race/minority or housing/transportation sub-domains was not significantly associated with MIH. However, age (aOR 0.97; [0.97−0.98]), NHW race/ethnicity (aOR 1.49; [1.14−1.94]), hospital setting within a tertiary referral center (aOR 0.29; [0.22−0.38]), and ASA class I (aOR 1.6; [1.05−2.46]) were independent predictors of MIH.

Conclusion

Age, race/ethnicity, hospital setting, and ASA class were found to be stronger independent predictors of MIH than SVI. Because race/ethnicity and hospital setting are independently associated with SVI based on prior study, we suspect that including these variables in the analysis weakened the observed independent association between SVI and route of hysterectomy. Further research is required to understand the underlying mechanisms driving surgical disparities, which may include systemic, institutional, or provider-level factors.