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GYNECOLOGY
Disparities in the management of ectopic pregnancy
Jennifer Y. Hsu, MD; Ling Chen, MD, MPH; Arielle R. Gumer, MD; Ana I. Tergas, MD; June Y. Hou, MD;
William M. Burke, MD; Cande V. Ananth, PhD, MPH; Dawn L. Hershman, MD; Jason D. Wright, MD

BACKGROUND: Ectopic pregnancy is common among young women. Use of methotrexate increased from 14.5% in 2006 to 27.3% by 2015
Treatment can consist of either surgery with salpingectomy or sal- (P<.001). Among women who underwent surgery, salpingostomy
pingostomy or medical management with methotrexate. In addition to decreased over time from 13.0% in 2006 to 6.0% in 2015 (P<.001).
acute complications, treatment of ectopic pregnancy can result in long- Treatment in more recent years, at a teaching hospital and at higher
term sequelae that include decreased fertility. Little is known about the volume centers, were associated with the increased use of metho-
patterns of care and predictors of treatment in women with ectopic trexate (P<.05 for all). In contrast, Medicaid recipients (adjusted risk
pregnancy. Similarly, data on outcomes for various treatments are limited. ratio, 0.92; 95% confidence interval, 0.87-0.98) and uninsured women
OBJECTIVE: We examined the patterns of care and outcomes for (adjusted risk ratio, 0.87; 95% confidence interval, 0.82-0.93) were
women with ectopic pregnancy. Specifically, we examined predictors of less likely to receive methotrexate than commercially insured patients.
medical (vs surgical) management of ectopic pregnancy and tubal con- Among those who underwent surgery, black (adjusted risk ratio, 0.76;
servation (salpingostomy vs salpingectomy) among women who under- 95% confidence interval, 0.69-0.85) and Hispanic (adjusted risk ratio,
went surgery. 0.80; 95% confidence interval, 0.66-0.96) patients were less likely to
STUDY DESIGN: The Perspective database was used to identify undergo tubal conserving surgery than white women and Medicaid
women with a diagnosis of tubal ectopic pregnancy treated from recipients (adjusted risk ratio, 0.69; 95% confidence interval, 0.64-
2006e2015. Perspective is an all-payer database that collects data on 0.75); uninsured women (adjusted risk ratio, 0.60; 95% confidence
patients at hospitals from throughout the United States. Women were interval, 0.55-0.66) less frequently underwent salpingostomy than
classified as having undergone medical treatment, if they received commercially insured patients.
methotrexate, and surgical treatment, if treatment consisted of sal- CONCLUSION: There is substantial variation in the management of
pingostomy or salpingectomy. Multivariable models were developed to ectopic pregnancy. There are significant race- and insurance-related
examine predictors of medical treatment and of tubal conserving sal- disparities associated with treatment.
pingostomy among women who were treated surgically.
RESULTS: Among the 62,588 women, 49,090 women (78.4%) were Key words: disparity, ectopic pregnancy, methotrexate, salpingectomy,
treated surgically, and 13,498 women (21.6%) received methotrexate. salpingostomy

T he incidence of ectopic pregnancy,


dened as the implantation of
a fertilized ovum outside of the endo-
Women with ectopic pregnancy typi-
cally are treated either medically with
methotrexate or surgically. Methotrexate
conservation, with some studies sug-
gesting no difference in intrauterine
pregnancy rates between conservative
metrium, varies between 1e2% in is administered via intramuscular injec- management and salpingectomy,7-9
the general population.1,2 Despite ad- tion and offers a noninvasive route of but others reecting signicant
vances in early diagnosis and manage- treatment. Surgical treatment most improvement in fertility with conser-
ment, complications that arise from commonly consists of either salpingec- vative management.6 At minimum,
ectopic pregnancy remain a signicant tomy or salpingostomy with tubal the results support a thoughtful dis-
cause of morbidity and death in the preservation. With conservative man- cussion with patients about the risk-
rst trimester. Using pregnancy-related agement via methotrexate or salpingos- benet calculus in the context of
death estimates from 1991e1999, mor- tomy, close follow up with serial their reproductive goals and personal
tality rate was calculated to be 31.9 measurements of quantitative beta preferences.
per 100,000 cases of ectopic pregnancy.3 human chorionic gonadotropin is To date, little is known about the
In addition to acute morbidity, imperative to ensure resolution.4 patterns of care for management of
ectopic pregnancy may decrease future Multiple clinical criteria are used ectopic pregnancy in the United
fertility. to evaluate the suitability of patients States. We performed a population-
for medical vs surgical treatment.5 based analysis to examine the pat-
There are recent data that promote terns of care and outcomes for women
Cite this article as: Hsu JY, Chen L, Gumer AR, et al. the benets of tubal conservation with ectopic pregnancy. Specically,
Disparities in the management of ectopic pregnancy. Am to optimize future fertility without we examined factors that are associ-
J Obstet Gynecol 2017;217:49.e1-10.
excessive risk of recurrent ectopic ated with medical management of
0002-9378/$36.00 pregnancy.6,7 However, data are ectopic pregnancy and tubal conser-
2017 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2017.03.00 conicting with regard to actual vation among women who underwent
1 fertility outcomes in cases of tubal surgery.

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approximately 15% of hospitalizations


FIGURE
Trends in management of ectopic pregnancy nationally.10 Hospitals included in
the dataset report data on all patients
who were treated within the given
A facility (inpatient and outpatient).
100%
Perspective captures data on clinical
90%
and demographic characteristics of
patients and diagnoses and pro-
80% cedures billed through International
Classication of Diseases, ninth revi-
70%
sion (ICD-9), codes. Additionally,
60% Perspective captures drugs received by
patients and services rendered
50% through capture of billing and use
40%
codes.
Treatment was classied as either
30% medical with methotrexate or surgical
with salpingostomy or salpingectomy.
20%
Methotrexate use was identied
10%
from hospital billing records; sal-
pingostomy (ICD-9 codes 66.01,
0% 66.02) and salpingectomy (ICD-9
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
codes 65.41, 65.49, 66.4, 66.5, 66.51,
Surgery Methotrexate
66.52, 66.62, 66.63, 66.69) were
identied based on ICD-9 procedure
B codes. Patients with codes for both
salpingostomy and salpingectomy
100%
were classied as having undergone
salpingectomy.
90% Demographic and clinical data
included age at the time of the treat-
80%
ment (<20, 20-24, 25-29, 30-34,
70% 35-39, 40-44, and 45 years), year of
the treatment, marital status (married,
60% single, and other/unknown), and pri-
mary insurance status (commercial,
50%
Medicare, Medicaid, uninsured, and
40% unknown). Race was self-reported and
categorized as white, black, Hispanic,
30%
and other/unknown. The Elixhauser
20%
comorbidity index, a measure of un-
derlying medical comorbidity based
10% on dened coding, was used to
classify
comorbid diseases in patients. The
0%
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 index was classied into 0, 1, and 2

Salpingectomy Salphingostomy based on the number of comorbid


A, Use of medical vs surgical treatment for ectopic pregnancy. B, Use of salpingectomy vs sal- medical conditions.
pingostomy among women with ectopic pregnancy who underwent surgical treatment. Hospitals were categorized based
Hsu et al. Disparities in the management of ectopic pregnancy. Am J Obstet Gynecol 2017. on location (urban or rural), teaching
status (teaching or nonteaching),
hospital bed size (<400, 400e600,
Methods
Patients and procedures

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We used the Perspective database pregnancy who were treated from and >600 beds), and region of
(Premier, Charlotte, NC) to identify 2006 to the rst quarter of 2015. the country dened within the dataset
women 15e60 years old with ectopic This all-payer database captures in- (Northeast, Midwest, West, and
surance claims data from >500 acute South). Annualized hospital vol- ume
care hospitals, which represent was calculated for each

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TABLE 1
Clinical and demographic characteristics of the cohort stratified by methotrexate and surgery and multivariable
analysis of use of methotrexate
Methotrexate, Surgery, Methotrexate: adjusted
Variable n (%) n (%) P value risk ratio (95% confidence interval)
All 13,498 (21.6) 49,090 (78.4)
Age, y .02
<20 611 (22.1) 2,150 (77.9) Referent
20e24 2,667 (22.0) 9,443 (78.0) 0.96 (0.89e1.04)
25e29 3,927 (21.8) 14,096 (78.2) 0.93 (0.87e1.01)
30e34 3,653 (21.7) 13,156 (78.3) 0.92 (0.85e0.99)a
35e39 2,048 (20.4) 7,977 (79.6) 0.88 (0.81e0.96)a
40e44 548 (20.4) 2,145 (79.7) 0.89 (0.80e1.00)a
45 44 (26.4) 123 (73.7) 1.20 (0.91e1.56)
Year <.001
2006 784 (14.5) 4,626 (85.5) Referent
2007 856 (15.3) 4,744 (84.7) 1.08 (0.97e1.19)
2008 1,034 (17.6) 4,837 (82.4) 1.24 (1.09e1.40)a
2009 1,252 (20.7) 4,805 (79.3) 1.46 (1.29e1.64)a
2010 1,405 (21.0) 5,291 (79.0) 1.48 (1.32e1.65)a
2011 1,749 (22.5) 6,034 (77.5) 1.57 (1.40e1.76)a
2012 2,110 (24.8) 6,383 (75.2) 1.73 (1.54e1.94)a
2013 1,974 (24.7) 6,030 (75.3) 1.72 (1.52e1.95)a
2014 1,932 (26.8) 5,271 (73.2) 1.89 (1.67e2.14)a
2015 402 (27.3) 1,069 (72.7) 1.97 (1.70e2.28)a
Marital status <.001
Married 5,292 (22.7) 18,060 (77.3) Referent
Single 6,665 (21.4) 24,471 (78.6) 0.98 (0.93e1.02)
Other/unknown 1,541 (19.0) 6,559 (81.0) 0.87 (0.77e0.99)a
Race <.001
White 6,445 (22.2) 22,615 (77.8) Referent
Black 3,369 (21.3) 12,448 (78.7) 0.96 (0.90e1.03)
Hispanic 729 (19.4) 3,024 (80.6) 1.00 (0.87e1.16)
Other/unknown 2,955 (21.2) 11,003 (78.8) 0.95 (0.88e1.03)
Insurance status <.001
Commercial 6,800 (23.1) 22,680 (76.9) Referent
Medicare 144 (20.3) 567 (79.8) 1.05 (0.90e1.22)
Medicaid 4,053 (20.5) 15,725 (79.5) 0.92 (0.87e0.98)a
Uninsured 2,044 (19.9) 8,245 (80.1) 0.87 (0.82e0.93)a
Unknown 457 (19.6) 1,873 (80.4) 0.87 (0.78e0.97)a
Hospital location <.001
Urban 12,324 (21.8) 44,293 (78.2) Referent

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Rural 1,174 (19.7) 4,797 (80.3) 1.03 (0.88e1.22)


Hsu et al. Disparities in the management of ectopic pregnancy. Am J Obstet Gynecol 2017. (continued)

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TABLE 1
Clinical and demographic characteristics of the cohort stratified by methotrexate and surgery and multivariable
analysis of use of methotrexate (continued)
Methotrexate, Surgery, Methotrexate: adjusted
Variable n (%) n (%) P value risk ratio (95% confidence interval)
Hospital teaching status <.001
Nonteaching 8,130 (20.8) 31,042 (79.3) Referent
Teaching 5,368 (22.9) 18,048 (77.1) 1.16 (1.02e1.33)a
Hospital bed size .01
<400 7,450 (21.1) 27,798 (78.9) Referent
400-600 3,549 (21.9) 12,649 (78.1) 0.94 (0.81e1.08)
>600 2,499 (22.4) 8,643 (77.6) 0.84 (0.70e1.01)
Hospital region <.001
Northeastern 1,817 (20.6) 7,011 (79.4) Referent
Midwest 2,258 (21.5) 8,254 (78.5) 1.11 (0.90e1.36)
South 7,024 (22.3) 24,488 (77.7) 1.06 (0.88e1.27)
West 2,399 (20.4) 9,337 (79.6) 1.01 (0.82e1.23)
Comorbidity (Elixhauser <.001
comorbidity index)
0 12,322 (24.6) 37,802 (75.4) Referent
1 947 (9.9) 8,602 (90.1) 0.41 (0.38e0.44)a
2 229 (7.9) 2,686 (92.1) 0.32 (0.28e0.37)a
Annualized hospital volumeb 28 (18-43) 25 (15-37) <.001 1.010 (1.007e1.013)a
Generalized estimating equations were fitted to account for hospital-level clustering.
a
P<.05; b Data are given as median (interquartile range).
Hsu et al. Disparities in the management of ectopic pregnancy. Am J Obstet Gynecol 2017.

hospital and estimated as 4 times The demographic and clinical char- women with medical vs surgical
the quarterly mean of the number of acteristics were compared between treatment and between salpingostomy
patients with any treatment at a given vs salpingectomy using c2 and Wil-
hospital. coxon rank-sum tests. Trends in
treatment were compared using the
Outcomes Cochran-Armitage trend test. To
The outcomes of the analysis included examine predictors of medical treat-
medical vs surgical treatment and ment, generalized estimating equa-
salpingostomy vs salpingectomy tions that included all demographic
among women who were treated sur- and clinical characteristics that
gically. A composite metric of any were available in the dataset were
complication was analyzed among used to account for hospital-level
surgical patients and included hem- clustering. Given that previous studies
orrhage, venous thromboembolism, of other surgical procedures often have
shock, transfusion, renal failure, res- noted that race and insurance status are
piratory failure, bacteremia, sepsis, associated with treatment choice, a
pneumonia, other infection, and other priori we hy- pothesized that these
complications. factors may also be associated with
treatments for ectopic pregnancy.
Statistical analysis However, given the limited previous data

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that have described predictors of ectopic pregnancy, we included all


treatment for of the clinical, demographic, and
hospital characteristics in our multi-
variable models. Similar generalized
estimating equations models were
developed to examine predictors of
salpingostomy and complications
among women who underwent surgi-
cal treatment. All analyses were con-
ducted with SAS software (version 9.4;
SAS Institute, Cary, NC). All
statistical tests were 2-sided. A
probability value of <.05 was
considered statistically signicant.

Result
s
Among the 62,588 women who were
identied with ectopic pregnancy,
49,090 women (78.4%) underwent
surgery with salpingectomy or sal-
pingostomy, and 13,498 women
(21.6%) received medical treatment

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TABLE 2
Clinical and demographic characteristics of surgery patients stratified by salpingostomy and salpingectomy and
multivariable analysis of predictors of salpingostomy
Salpingostomy, Salpingectomy, Salpingostomy: adjusted
Variable n (%) n (%) P value risk ratio (95% confidence interval)
All 5719 (11.7) 43,371 (88.3)
Age, y <.001
<20 379 (17.6) 1,771 (82.4) Referent
20e24 1373 (14.5) 8,070 (85.5) 0.82 (0.74e0.90)a
25e29 1770 (12.6) 12,326 (87.4) 0.66 (0.59e0.73)a
30e34 1425 (10.8) 11,731 (89.2) 0.53 (0.48e0.59)a
35e39 682 (8.6) 7,295 (91.5) 0.42 (0.37e0.47)a
40e44 85 (4.0) 2,060 (96.0) 0.19 (0.15e0.25)a
45 5 (4.1) 118 (95.9) 0.19 (0.08e0.44)a
Year <.001
2006 600 (13.0) 4,026 (87.0) Referent
2007 721 (15.2) 4,023 (84.8) 1.16 (1.05e1.29)a
2008 621 (12.8) 4,216 (87.2) 1.00 (0.88e1.13)
2009 606 (12.6) 4,199 (87.4) 0.98 (0.87e1.11)
2010 632 (11.9) 4,659 (88.1) 0.96 (0.85e1.08)
2011 697 (11.6) 5,337 (88.5) 0.91 (0.81e1.03)
2012 706 (11.1) 5,677 (88.9) 0.86 (0.76e0.97)a
2013 612 (10.2) 5,418 (89.9) 0.81 (0.71e0.92)a
2014 460 (8.7) 4,811 (91.3) 0.72 (0.62e0.83)a
2015 64 (6.0) 1,005 (94.0) 0.51 (0.39e0.67)a
Marital status <.001
Married 2293 (12.7) 15,767 (87.3) Referent
Single 2751 (11.2) 21,720 (88.8) 0.92 (0.87e0.97)a
Other/unknown 675 (10.3) 5,884 (89.7) 0.90 (0.76e1.07)
Race <.001
White 3043 (13.5) 19,572 (86.5) Referent
Black 1068 (8.6) 11,380 (91.4) 0.76 (0.69e0.85)a
Hispanic 325 (10.8) 2,699 (89.3) 0.80 (0.66e0.96)a
Other/unknown 1283 (11.7) 9,720 (88.3) 0.86 (0.77e0.96)a
Insurance status <.001
Commercial 3150 (13.9) 19,530 (86.1) Referent
Medicare 49 (8.6) 518 (91.4) 0.70 (0.53e0.93)a
Medicaid 1596 (10.2) 14,129 (89.9) 0.69 (0.64e0.75)a
Uninsured 722 (8.8) 7,523 (91.2) 0.60 (0.55e0.66)a
Unknown 202 (10.8) 1,671 (89.2) 0.74 (0.64e0.86)a
Hospital location .89
Urban 5163 (11.7) 39,130 (88.3) Referent

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Rural 556 (11.6) 4,241 (88.4) 0.94 (0.75e1.17)


Hsu et al. Disparities in the management of ectopic pregnancy. Am J Obstet Gynecol 2017. (continued)

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TABLE 2
Clinical and demographic characteristics of surgery patients stratified by salpingostomy and salpingectomy and
multivariable analysis of predictors of salpingostomy (continued)
Salpingostomy, Salpingectomy, Salpingostomy: adjusted
Variable n (%) n (%) P value risk ratio (95% confidence interval)
Hospital teaching status <.001
Nonteaching 3797 (12.2) 27,245 (87.8) Referent
Teaching 1922 (10.7) 16,126 (89.4) 0.95 (0.79e1.15)
Hospital bed size <.001
<400 3,409 (12.3) 24,389 (87.7) Referent
400e600 1453 (11.5) 11,196 (88.5) 0.91 (0.75e1.12)
>600 857 (9.9) 7,786 (90.1) 0.97 (0.75e1.25)
Hospital region <.001
Northeastern 635 (9.1) 6,376 (90.9) Referent
Midwest 1215 (14.7) 7,039 (85.3) 1.51 (1.20e1.88)a
South 2318 (9.5) 22,170 (90.5) 0.99 (0.79e1.24)
West 1551 (16.6) 7,786 (83.4) 1.62 (1.26e2.08)a
Comorbidity (Elixhauser <.001
comorbidity index)
0 4,691 (12.4) 33,111 (87.6) Referent
1 812 (9.4) 7,790 (90.6) 0.82 (0.76e0.88)a
2 216 (8.0) 2,470 (92.0) 0.76 (0.66e0.88)a
Annualized hospital volumeb 25 (15-35) 25 (15-37) .02 1.001 (0.996e1.007)
Generalized estimating equations were fitted to account for hospital-level clustering.
a
P<.05; b Data are given as median (interquartile range).
Hsu et al. Disparities in the management of ectopic pregnancy. Am J Obstet Gynecol 2017.

with methotrexate. As can be seen in with increased use of methotrexate women who were treated at a
the Figure, use of methotrexate (P<.05 for all). Compared with nonteaching facility, patients at
increased signicantly from 14.5% in teaching hospitals were 16% more likely
2006 to 27.3% by 2015; surgical to receive methotrexate (adjusted risk
management declined from ratio [aRR], 1.16; 95% condence
85.5e72.7% over the same time interval [CI], 1.02e1.33). In contrast,
period (P<.001). Among those women with noncom- mercial
women who underwent surgery, sal- insurance were less likely to receive
pingostomy decreased over time from methotrexate. Compared with women
13.0% in 2006 to 6.0% in 2015; the with commercial insur- ance,
rate of salpingectomy rose from 87.0e Medicaid recipients were
94.0% over the time period (P<.001; 8% (aRR, 0.92; 95% CI, 0.87e0.98) less
Figure). likely and uninsured women were
Table 1 displays the clinical and 13% (aRR, 0.87; 95% CI,
demographic characteristics of the 0.82e0.93) less likely to receive
cohort stratied by the receipt of methotrexate.
methotrexate or surgery. Treatment in Factors associated with salpingos-
more recent years, management at a tomy among women who underwent
teaching hospital, and treatment at surgery are displayed in Table 2.
higher volume centers were associated Older age, more recent year of treat-

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ment, the presence of medical noncommercial insurance coverage


comorbidities, nonwhite race, and were all associated with a dec-
reased likelihood of undergoing
salpingostomy. Compared with
white patients, black (aRR, 0.76;
95% CI, 0.69e0.85) and Hispanic
(aRR, 0.80; 95% CI, 0.66e0.96) pa-
tients were less likely to undergo
tubal conserving surgery. Similarly,
Medicaid recipients (aRR, 0.69;
95% CI, 0.64e0.75) and uninsured
women (aRR, 0.60; 95% CI,
0.55e0.66) less frequently under-
went salpingostomy than
commercial insured patients. In
contrast, compared with women
who resided in the Northeastern
United States, patients in the
Midwest (aRR,
1.51; 95% CI, 1.20e1.88) and
West (aRR, 1.62; 95% CI, 1.26e2.08)
were more likely to undergo
salpingostomy.

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TABLE 3
Complications stratified by salpingostomy and salpingectomy among surgery patients
Salpingostomy, Salpingectomy,
Complication n (%) n (%) P value
All 5719 (11.7) 43,371 (88.3)
Any complications 1337 (23.4) 15,150 (34.9) <.001
Hemorrhage 1163 (20.3) 11,950 <.001
Venous 1 (0.02) 13 (0.03) .60
thromboembolism
Shock 32 (0.6) 1,199 (2.8) <.001
Transfusion 238 (4.2) 5,742 (13.2) <.001
Renal failure 1 (0.02) 68 (0.2) .01
Respiratory failure 15 (0.3) 277 (0.6) <.001
Bacteremia sepsis 1 (0.02) 41 (0.1) .06
Pneumonia 2 (0.03) 77 (0.2) .01
Other infection 11 (0.2) 253 (0.6) <.001
Other 113 (2.0) 1,474 (3.4) <.001
complications
Hsu et al. Disparities in the management of ectopic pregnancy. Am J Obstet Gynecol 2017.

The overall perioperative complica- insurance-related disparities that are First reported in 1985, medical man-
tion rate was 23.4% (95% CI, associated with treatment. agement of ectopic pregnancy with
22.3e24.5%) after salpingostomy and methotrexate works via antagonism of
34.9% (95% CI, 34.5e35.4%) after sal- the folic acid pathway in DNA repli-
pingectomy (Table 3). Hemorrhage was cation, which impairs growth of the
the most frequent complication. In a developing trophoblast.11,12 The optimal
multivariable model, complications regimen of systemic methotrexate is
remained 31% less common after sal- debated, although data suggest that the
pingostomy (aRR, 0.69; 95% CI single-dose regimen is as effective as
0.65e0.73; Table 4). Older women were the multi-dose regimen and is associ- ated
less likely than younger women to with lower cost and fewer side-
experience a complication; Hispanic effects.13-15 Wider availability of
(compared with white; aRR, 1.15; 95% methotrexate and use of early sonogra-
CI 1.07e1.24) and uninsured phy have facilitated the growth in
(compared with commercial insurance; medical management, as also seen in other
aRR, 1.12; 95% CI 1.07e1.17) patients studies.16 When surgical manage- ment is
were more likely to experience a selected, the decision of sal- pingostomy
complication. vs salpingectomy is often based on
surgeon preference, patient history, and
Comment intraoperative appearance of the tubes;
We noted substantial variation in the however, when cost- effectiveness,
management of ectopic pregnancy in the recurrence risk, and future fertility are
United States. Although the rate of factored in, neither appears clearly
medical management with methotrexate superior.4,6-9,17
is increasing, among women who un- Previous studies have shown that mi-
dergo surgery, tubal-conserving sal- nority women are not only at increased
pingostomy is being used less frequently. risk for the occurrence of ectopic preg-
There are signicant race- and nancy but also are more likely to expe-

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rience adverse outcomes.18,19 Among California, and Illinois, the relative


Medicaid recipients in New York, risk for ectopic pregnancy among
black women was 1.26 compared with
white women from 2000e2003.20
Further- more, the risk of death from
ectopic pregnancy was 6.8 times higher
for black women compared with
white women from 2003e2007.21
Although more severe underlying
disease in underserved minorities may
account for a portion of the variation
in care that we noted, pathologic
differences are unlikely to account for
all of the variability that we noted.
There has been little previous work
that has examined disparities in the
medical and surgical treatment
of ectopic pregnancy.19 Using the
Nationwide Inpatient Sample,
22
Papillon-Smith et al analyzed the
treatment of 35,000 women with
ectopic pregnancy. The
investigators found that Asian/Pacic
Islanders and those treated in rural
hospitals were less likely to undergo
nonsurgical management. This study
was limited in that the data source
captures only inpatient encounters.
We noted that uninsured women and
Medicaid re- cipients were less
likely to receive

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treatment with methotrexate and were


TABLE 4
less likely to undergo salpingostomy;
Multivariable model of factors that were associated with complications
black and Hispanic women were also
among surgery (salpingectomy or salpingostomy) patients
less likely to receive tubal-conserving
Any complication: adjusted risk ratio surgery.

Variable (95% confidence interval) The reasons underlying the disparities


Surgery that were seen in our study group, as

Salpingectomy Referent
throughout the obstetric and gyneco-
logic literature, are complex and myriad.
Salpingostomy 0.69 (0.65e0.73)a Without reliable insurance coverage,
Age, y women often experience delays in access
<20 Referent to healthcare, which leads to more
advanced disease at initial presentation
20e24 0.87 (0.82e0.93)a
and, thus, greater risk of morbidity and
25e29 0.88 (0.83e0.93)a death. This may help explain the reason
30e34 0.86 (0.81e0.91)a that uninsured women experienced
35e39 0.86 (0.81e0.92)a more complications in our study popu-
lation. Early diagnosis and treatment is
40e44 0.88 (0.81e0.95)a
particularly crucial, because a small,
45 1.01 (0.81e1.26) unruptured ectopic pregnancy affords
Year women more choice in treatment and
2006 Referent allows them to avoid surgery when
preferred. Additional rationale for the
2007 1.00 (0.95e1.06)
greater incidence of salpingectomy
2008 0.98 (0.91e1.04) among racial minorities may be the
2009 1.03 (0.97e1.10) preponderance of gonorrhea and chla-
2010 0.98 (0.91e1.05) mydia infections; black women are 7
times more likely to contract chlamydia
2011 1.03 (0.96e1.10)
and 14 times more likely to contract
2012 1.01 (0.95e1.07) gonorrhea compared with white women,
2013 0.99 (0.92e1.06) which likely leads to more severe un-
2014 1.02 (0.95e1.10) derlying tubal disease that is related to
pelvic inammatory disease.23,24 Finally,
2015 1.03 (0.93e1.14)
little is known about patient preferences
Marital status and patient reported outcomes for
Married Referent women with ectopic pregnancy. This
Single 0.99 (0.95e1.03) is clearly an area that warrants
further study.
Other/unknown 0.98 (0.91e1.06)
We recognize a number of important
Race limitations. First, administrative data
White Referent lack many important clinical character-
Black 1.02 (0.97e1.06) istics that inuence treatment selection
such as hemodynamic stability, betae
Hispanic 1.15 (1.07e1.24)a
human chorionic gonadotropin levels,
Other/unknown 1.13 (1.08e1.20)a and the size of the ectopic pregnancy. A
Insurance status priori, the goal of our study was not to
Commercial Referent examine the effectiveness of treatment
but rather to explore overall patterns of
Medicare 0.94 (0.83e1.05)
care. Second, current ICD-9 coding does
Medicaid 1.02 (0.98e1.05) not allow for the accurate distinction of
Uninsured 1.12 (1.07e1.17)a laparoscopy or laparotomy. Third, we
Unknown 0.95 (0.87e1.03)

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cannot exclude the possibility that treatment was misclassied


in a small

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pregnancy: results of a population-based study.


TABLE 4 Fertil Steril 2012;98:1271-6.e1-3.
Multivariable model of factors that were associated with complications 7. Fernandez H, Capmas P, Lucot JP, et al.
among surgery (salpingectomy or salpingostomy) patients (continued) Fertility after ectopic pregnancy: the DEMETER
randomized trial. Hum Reprod 2013;28:1247-53.
Any complication: adjusted risk ratio 8. Mol F, van Mello NM, Strandell A, et al. Sal-

Variable (95% confidence interval) pingotomy versus salpingectomy in women with


tubal pregnancy (ESEP study): an open-label,
Hospital location multicentre, randomised controlled trial. Lancet

Urban Referent 2014;383:1483-9.


9. Li J, Jiang K, Zhao F. Fertility outcome anal-
Rural 0.91 (0.82e1.01)
ysis after surgical management of tubal ectopic
Hospital teaching status pregnancy: a retrospective cohort study. BMJ
Open 2015;5:e007339.
Nonteaching Referent 10. Lindenauer PK, Pekow PS, Lahti MC, Lee Y,
Teaching 0.92 (0.85e0.99)a Benjamin EM, Rothberg MB. Association of
corticosteroid dose and route of administration
Hospital bed size with risk of treatment failure in acute exacerba-
<400 Referent tion of chronic obstructive pulmonary disease.
JAMA 2010;303:2359-67.
400e600 0.98 (0.90e1.07) 11. Van Mello NM, Mol F, Ankum WM, Mol BW,
>600 1.08 (0.97e1.21) van der Veen F, Hajenius PJ. Ectopic pregnancy:
how the diagnostic and therapeutic management
Hospital region has changed. Fertil Steril 2012;98:1066-73.
Northeastern Referent 12. Chotiner HC. Nonsurgical management of
ectopic pregnancy associated with severe hy-
Midwest 0.90 (0.79e1.02) perstimulation syndrome. Obstet Gynecol
South 0.95 (0.85e1.06) 1985;66:740-3.
13. Lipscomb GH, Givens VM, Meyer NL,
West 1.04 (0.93e1.17) Bran D. Comparison of multidose and single-
Comorbidity (Elixhauser comorbidity index) dose methotrexate protocols for the treatment
of ectopic pregnancy. Am J Obstet Gynecol
0 Referent 2005;192:1844-8.
1 1.49 (1.44e1.55)a 14. Stovall TG, Ling FW. Single-dose metho-
trexate: an expanded clinical trial. Am J Obstet
2 1.68 (1.60e1.77)a Gynecol 1993;168:1759-65.
Annualized hospital volume 0.998 (0.996e1.0004) 15. Alleyassin A, Khademi A, Aghahosseini M,
Safdarian L, Badenoosh B, Hamed EA. Com-
Generalized estimating equations were fitted to account for hospital-level clustering.
parison of success rates in the medical man-
a
P<.05. agement of ectopic pregnancy with single-dose
Hsu et al. Disparities in the management of ectopic pregnancy. Am J Obstet Gynecol 2017. and multiple-dose administration of metho-
trexate: a prospective, randomized clinical trial.
Fertil Steril 2006;85:1661-6.
we selected women with a specic code stand the mechanisms underlying the that is associated with the treatment of
for a tubal ectopic pregnancy, some disparities is needed. Ultimately, targeted ectopic pregnancy are needed. n
women with a pregnancy of unknown interventions to reduce the morbidity
location may have been misclassied.
Fourth, because most complications References
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United States: 1980-2007. Obstet Gynecol Group R. Trends of racial disparities in assisted College of Physicians and Surgeons; the Department of
2011;117:837-43. reproductive technology outcomes in black Epidemiology, Mailman School of Public Health, Columbia
22. Papillon-Smith J, Imam B, Patenaude V, women compared with white women: Society for University (Drs Tergas, Ananth, and Hershman); and New
Abenhaim HA. Population-based study on the Assisted Reproductive Technology 1999 and York Presbyterian Hospital (Drs Tergas, Hou, Burke,
effect of socioeconomic factors and race on 2000 vs 2004-2006. Fertil Steril 2010;93:626-35. Hershman, and Wright), New York, NY.
management and outcomes of 35,535 inpatient Received Jan. 10, 2017; revised Feb. 26, 2017;
ectopic pregnancies. J Minim Invasive Gynecol accepted March 2, 2017.
2014;21:914-20. Author and article information Supported by grants NCI R01CA169121-01A1
23. Newman LM, Berman SM. Epidemiology of From the Departments of Obstetrics and Gynecology (Drs (J.D.W.) and Dr. Hershman NCI R01 CA166084 (D.L.H.)
STD disparities in African American commu- Hsu, Chen, Gumer, Tergas, Hou, Burke, Ananth, and from the National Cancer Institute.
nities. Sex Transm Dis 2008;35:S4-12. Wright) and Medicine (Dr Hershman) and the Herbert The authors report no conflict of interest.
24. Seifer DB, Zackula R, Grainger DA. Society Irving Comprehensive Cancer Center (Drs Tergas, Hou, Corresponding author: Jason D. Wright, MD.
for Assisted Reproductive Technology Writing Burke, Hershman, and Wright), Columbia University jw2459@columbia.edu

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