ABSTRACT
Objective: The effects of demographic and socioeconomic characteristics on delay of minimally invasive gynecologic surgery (MIGS) before and during the COVID-19 pandemic were studied. The primary outcome was interval between first MIGS appointment and date of surgery. Materials and Methods: This retrospective cohort study used electronic medical record data of a historical cohort who had benign MIGS in 2014-2016 (n = 370) and a cohort in 2020 during the COVID pandemic (n = 249). Included procedures were laparoscopic hysterectomy, myomectomy, adnexal surgery, or endometriosis excision. Patient demographics (race, ethnicity, age, marital status, language, insurance, and socioeconomic factors) were evaluated for associations with surgery delay (> 90 days from initial consultation to operating room date). Results: Median time to surgery was 21 days faster during the pandemic. In the historical cohort, 61% patients waited >90 days, and in the pandemic cohort, 47% patients waited >90 days. In the pandemic cohort, race and primary language were new factors associated with surgery delays. During the pandemic, a greater proportion of patients having surgery delays were Black or other races, compared to White, and a greater proportion did not speak English. After adjusting for referral indications, in multivariable logistic regression, patients who reported Other race had 3 times the odds of surgery delay, compared to White patients. Black patients had higher odds of surgery delay, although this estimate was less precise. Patients with a non-English primary language had >4 times the odds of surgery delay. Ethnicity, insurance and employment status, median household income, neighborhood segregation, and distance to hospital were not associated with surgery delay. Telemedicine accounted for 71% of visits in the pandemic cohort and was associated with a significant decrease in surgery delays with a median wait time of 87 days for patients seen via telemedicine, compared to 101 days for patients seen in-person. A higher proportion of patients using telemedicine were White and spoke English. Hispanic/Latino ethnicity, non-English primary language, and unemployment were associated with in-person versus telemedicine visits. Visit type was not correlated with insurance status, median household income, neighborhood segregation, and distance from the hospital. A risk score was calculated to summarize the estimated effect of intersectionality of multiple identities;multiple minority characteristics were correlated with surgery delays. Time to benign MIGS decreased from historical baselines during the pandemic, indicating improved access to surgical care. This benefit did not apply equally. Disproportionately, White patients who spoke English had no delays and used telemedicine;racial minority patients who did not speak English had greater odds of surgery delays and in-person appointments. Conclusions: Telemedicine can improve access to both MIGS care and surgical outcomes;additional strategies are needed to ensure that all patients receive care advances equitably. (J GYNECOL SURG 20XX:000)
ABSTRACT
Study Objective To examine how demographic and socioeconomic characteristics impact timing of minimally invasive gynecologic surgery (MIGS) before and during the COVID-19 pandemic. Design Retrospective cohort study using electronic medical record data. Primary outcome was interval between referral to MIGS and date of surgery. Setting Tertiary-level MIGS division in the southeast US. Patients or Participants Historical cohort undergoing surgery with MIGS 2014-2016 (n=377) and cohort in 2020 referred during the pandemic (n=191). Interventions Laparoscopic hysterectomy, myomectomy, adnexal surgery, or excision of endometriosis. Measurements and Main Results Patient demographics (race, age, marital status, language, insurance, and socioeconomic factors) were evaluated for significant associations with surgical delay. Patients with fibroids and abnormal uterine bleeding had a shorter interval to surgery (median 95 days, range 66-133) compared to patients with chronic pelvic pain (median 127 days, range 73-274). Our model adjusting for surgical indication revealed that single patients were 2.13 times as likely to wait >90 days (95% CI 1.35-3.36) compared to partnered patients prior to the pandemic. Additionally, those in the lowest quartile of median household income (<$42,572 vs > $75,020;OR 2.42, 95% CI 1.32, 4.46) and those from zip codes with the highest proportion of population in poverty (≥ 0.20 vs <0.07;OR 1.93, 95% CI 1.04, 3.6) were more likely to wait > 90 days. However, all of these differences disappeared during the pandemic. There were no differences in time to surgery by race, ethnicity, language, population density, markers of education by zip code, or insurance before or during the pandemic. Conclusion Historically, race and socioeconomic factors are associated with decreased access to MIGS and vulnerable populations were disproportionately affected by the COVID-19 pandemic. Despite this, we found decreased time to surgery at our institution, and previous socioeconomic disparities associated with scheduling delays were improved during the pandemic, suggesting improved equitable access to tertiary-level MIGS.
ABSTRACT
Study Objective To evaluate patient characteristics that affect access to minimally invasive gynecologic surgery (MIGS) and identify changes during the COVID-19 pandemic. Design Retrospective cohort study of patients referred to MIGS in 2014-2016 compared to 2020. Demographic and appointment information was abstracted from the electronic medical record. Primary outcome was interval between referral and first appointment. Setting Academic, tertiary-care MIGS division. Patients or Participants Historical cohort referred to MIGS 2014-2016 (n=1082) and cohort referred during the pandemic (n=770). Interventions N/A. Measurements and Main Results Demographic characteristics (race, age, language, insurance, employment, socioeconomic factors by census tract) were evaluated for associations with a longer referral interval. Being unemployed and living in an area with lower income, less population density (rural), or less education were associated with referral interval >30 days in 2014-2016 (p<0.05). In 2020, only unemployment was associated with referral interval >30 days and new risk factors were: primary language Spanish versus English (OR 2.92, 95% CI: 1.45-5.88) and public insurance versus commercial (OR 1.48, 95% CI: 1.00-2.18). Average referral intervals were significantly shorter in 2020 versus 2014-2016 (p<0.01). The odds of waiting >30 days increased by 7% with the addition of one demographic risk factor (95% CI: 1.02-1.11) and 22% for three risk factors (95% CI:1.07-1.38) in 2014-2016 whereas there was no significant association identified in 2020 for one (OR 1.02, 95% CI: 0.97-1.07) or three risk factors (OR 1.05, 95% CI: 0.91-1.22). Telemedicine appointments had a shorter referral interval versus in-person appointments (p<0.01). Hispanic and unemployed patients were less likely to have telemedicine appointments (p<0.01). Conclusion Time from referral to first appointment at a tertiary-care MIGS practice during the COVID-19 pandemic was faster than in 2014-2016. Differences in the prevalence of socioeconomic and demographic factors suggest that telemedicine improved access to care for most patients and decreased access disparities for many vulnerable populations, but not for Spanish-speaking, publicly-insured, or unemployed patients.