Does Universal Insurance Mitigate Racial Differences in Minimally Invasive Hysterectomy?

STUDY OBJECTIVE: To determine if racial differences exist in receipt of minimally invasive hysterectomy (defined as total vaginal hysterectomy [TVH] and total laparoscopic hysterectomy [TLH]) compared with an open approach (total abdominal hysterectomy [TAH]) within a universally insured patient population. DESIGN: Retrospective data analysis (Canadian Task Force classification II-2). SETTING: The 2006-2010 national TRICARE (universal insurance coverage to US Armed Services members and their dependents) longitudinal claims data. PATIENTS: Women aged 18 years and above who underwent hysterectomy stratified into 4 racial groups: white, African American, Asian, and "other." INTERVENTION: Receipt of hysterectomy (TAH, TVH, or TLH). MEASUREMENTS AND MAIN RESULTS: We used risk-adjusted multinomial logistic regression models to determine the relative risk ratios of receipt of TVH and TLH compared with TAH in each racial group compared with referent category of white patients for benign conditions. Among 33 015 patients identified, 60.82% (n = 20 079) were white, 26.11% (n = 8621) African American, 4.63% (n = 1529) Asian, and 8.44% (n = 2786) other. Most hysterectomies (83.9%) were for benign indications. Nearly 42% of hysterectomies (n = 13 917) were TAH, 27% (n = 8937) were TVH, and 30% (n = 10 161) were TLH. Overall, 36.37% of white patients received TAH compared with 53.40% of African American patients and 51.01% of Asian patients (p < .001). On multinomial logistic regression analyses, African American patients were significantly less likely than white patients to receive TVH (relative risk ratio [RRR], .63; 95% confidence interval [CI], .58-.69) or TLH (RRR, .65; 95% CI, .60-.71) compared with TAH. Similarly, Asian patients were less likely than white patients to receive TVH (RRR, .71; 95% CI, .60-.84) or TLH (RRR, .69; 95% CI, .58-.83) compared with TAH. Analyses by benign indications for surgery showed similar trends. CONCLUSION: We demonstrate that racial minority patients are less likely to receive a minimally invasive surgical approach compared with an open abdominal approach despite universal insurance coverage. Further work is warranted to better understand factors other than insurance access that may contribute to racial differences in surgical approach to hysterectomies.

Day 3 embryo shape as a morphologic selection parameter in in vitro fertilization.

PURPOSE: To investigate whether embryo shape is a useful morphologic predictor of developmental competence in IVF cycles. METHODS: Two hundred eighteen day 3 single embryo transfer (SET) cycles and 225 day 3 double embryo transfer (DET) cycles in which only 8-cell non-fragmented embryos with symmetric blastomeres were transferred and in which the developmental fate of each embryo was known were analyzed for IVF outcomes with respect to embryo shape. Embryo shape was quantitatively calculated after digitizing embryo images using MATLAB, where a score of 1.0 represented a perfectly circular embryo. RESULTS: The SET data did not reveal a significant impact of embryo shape on embryo developmental fate. The DET data revealed a trend toward the best outcomes in cycles where both embryos exhibited "roundness" scores in the highest tertiles (T3) for embryo shape. However only one subgroup (T2/T1-one embryo in the middle shape tertile (T2) and one in the lowest shape tertile (T1)) was associated with significantly lower odds of live-birth as compared to the referent group (T3/T3). When SET and DET data were combined, embryo shape was not found to be a predictor of IVF outcome. CONCLUSIONS: Based on this retrospective analysis, the weak association of day 3 embryo shape with implantation potential suggests that this morphological characteristic is unlikely to be a useful additional marker for embryo selection after cell number, fragmentation, and blastomere symmetry. Further studies are planned to assess applicability of these conclusions to embryos of varying stages and grades.