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Understanding Variation in Availability and Provision of Minimally Invasive Hysterectomy: A Qualitative Study of Department of Veterans Affairs Gynecologists

  • Kristen E. Gray
    Correspondence
    Correspondence to: Kristen Gray, PhD, MS, Health Services Research and Development, VA Puget Sound Health Care System, 1660 S. Columbian Way S-152, Seattle, WA 98108. Phone: (206) 764-2056; fax: (206) 768-5343.
    Affiliations
    Department of Veterans Affairs Center of Innovation for Veteran-Centered and Value Driven Care, Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington

    Department of Health Services, University of Washington School of Public Health, Seattle, Washington
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  • Erica W. Ma
    Affiliations
    Department of Veterans Affairs Center of Innovation for Veteran-Centered and Value Driven Care, Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
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  • Lisa S. Callegari
    Affiliations
    Department of Veterans Affairs Center of Innovation for Veteran-Centered and Value Driven Care, Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington

    Department of Health Services, University of Washington School of Public Health, Seattle, Washington

    Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington
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  • Sara L. Magnusson
    Affiliations
    Department of Veterans Affairs Center of Innovation for Veteran-Centered and Value Driven Care, Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
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  • Erica V. Tartaglione
    Affiliations
    Department of Veterans Affairs Center of Innovation for Veteran-Centered and Value Driven Care, Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
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  • Alicia Y. Christy
    Affiliations
    Women's Health Services, Office of Patient Care Services, Department of Veterans Affairs, Washington, District of Columbia
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  • Jodie G. Katon
    Affiliations
    Department of Veterans Affairs Center of Innovation for Veteran-Centered and Value Driven Care, Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington

    Department of Health Services, University of Washington School of Public Health, Seattle, Washington
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Published:April 03, 2020DOI:https://doi.org/10.1016/j.whi.2020.02.003

      Abstract

      Background

      Approximately one-half of women undergoing hysterectomy in the Department of Veterans Affairs health care system receive minimally invasive hysterectomies (MIH), with Black women less likely than White women to receive MIH. We sought to characterize gynecologists’ perspectives on factors contributing to the availability and provision of MIH and on the role of race/ethnicity in decision making.

      Methods

      Between October 2017 and January 2018, we conducted 16 in-depth semistructured telephone interviews with Department of Veterans Affairs gynecologists exploring practice characteristics and barriers and facilitators to providing MIH, including clinical and nonclinical characteristics of patients impacting surgical decision making. We identified key themes using simultaneous deductive and inductive thematic analysis.

      Results

      Gynecologists identified provider-, facility-, and patient-level barriers and facilitators to MIH. Provider-level factors included gynecologists' skills and training in MIH, and facility factors included access to qualified surgical assistants, availability of surgical equipment, and operating room resources, particularly time. On the patient level, clinical characteristics, including uterine size, were the most common determinants of surgical approach, but nonclinical factors such as patients’ attitudes toward surgery also contributed. Race/ethnicity was identified by a minority of respondents as influencing hysterectomy route through clinical presentation and surgical attitudes.

      Conclusions

      Given the range of factors identified, efforts to promote MIH in the Department of Veterans Affairs will likely require a multipronged approach that includes support for MIH training, increased access to surgical assistants with MIH skills, and reduced barriers to obtaining equipment. Patient perspectives are needed to more fully capture nonclinical patient-level contributors to MIH and differences in MIH between Black and White Veterans.
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      Biography

      Kristen E. Gray, PhD, MS, is a Core Investigator, VA Puget Sound Health Services Research & Development, and Research Assistant Professor, University of Washington Department of Health Services. Her research focuses on veterans' reproductive health and health behaviors.

      Biography

      Erica W. Ma, BA, is a Project Manager, VA Puget Sound Health Services Research & Development Center of Innovation. Her research interests include women veterans' reproductive health.

      Biography

      Lisa S. Callegari, MD, MPH, is Core Investigator, VA Puget Sound Health Services Research & Development Center of Innovation, and Assistant Professor, University of Washington Department of Obstetrics & Gynecology. Her research focuses on women veterans' reproductive health and health disparities.

      Biography

      Sara L. Magnusson, BA, is a Project Manager, VA Puget Sound Health Services Research & Development Center of Innovation. Her research interests include comprehensive reproductive health care for all, reproductive autonomy, and expanding access to reproductive health services.

      Biography

      Erica V. Tartaglione, BS, is a Project Manager, VA Puget Sound Health Services Research & Development Center of Innovation. Her research interests include women veterans' reproductive health and maternity care services.

      Biography

      Alicia Y. Christy, MD, MHSCR, is the Acting Director and Deputy Director of Reproductive Health, Women's Health Services, Veterans Health Administration. Her research interests are in leiomyoma and health disparities, and the reproductive health of women veterans.

      Biography

      Jodie G. Katon, PhD, MS, is a Core Investigator, VA Puget Sound Health Services Research & Development Center of Innovation, and Research Assistant Professor, University of Washington Department of Health Services. Her research focuses on reproductive health of women veterans.