Minimally Invasive Surgery Presented at the Academic Surgical Congress 2016| Volume 161, ISSUE 5, P1341-1347, May 2017

Disparities in receipt of a laparoscopic operation for ectopic pregnancy among TRICARE beneficiaries

Published:November 11, 2016DOI:


      Racial disparities in receipt of a laparoscopic operation for ectopic pregnancy are attributed to inequalities in access to care. This study sought to determine if racial disparities in laparoscopic operation for ectopic pregnancy exist among a universally insured population.


      Using 2006–2010 TRICARE (insurance for members of the United States Armed Services and their dependents) data, patients who received a laparoscopic operation or laparotomy for ectopic pregnancy were stratified into direct/military or purchased/civilian system of care. Odds of receipt of a laparoscopic operation in each racial group were compared adjusting for patient demographics, system of care, and severity of ectopic pregnancy.


      Among 3,041 patients in the study sample, 1,878 (61.7%) received laparotomy and 1,163 (38.2%) received a laparoscopic operation within 30 days of diagnosis. Overall, 42.4% of white women received a laparoscopic operation compared with 33.1% of Asian women and 34.9% of black women (P < .001). On multivariable analysis, black women had a 33% lesser odds of receiving a laparoscopic operation (odds ratio: 0.67; confidence interval: 0.55–0.83) compared with white women. These disparities were absent within direct care (odds ratio: 0.93; confidence interval: 0.71–1.21) but were present within purchased care (odds ratio: 0.54; confidence interval: 0.40–0.73).


      Racial minority patients are less likely to receive a laparoscopic operation for ectopic pregnancy despite universal insurance coverage within civilian/purchased care. Further work is warranted to better understand the factors other than insurance access that may contribute to racial disparities in selection of operative approach.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Hoover K.W.
        • Tao G.
        • Kent C.K.
        Trends in the diagnosis and treatment of ectopic pregnancy in the United States.
        Obstet Gynecol. 2010; 115: 495-502
        • Hajenius P.J.
        • Mol F.
        • Mol B.W.
        • Bossuyt P.M.
        • Ankum W.M.
        • van der Veen F.
        Interventions for tubal ectopic pregnancy.
        Cochrane Database Syst Rev. 2007; : CD000324
        • Cohen A.
        • Almog B.
        • Satel A.
        • Lessing J.B.
        • Tsafrir Z.
        • Levin I.
        Laparoscopy versus laparotomy in the management of ectopic pregnancy with massive hemoperitoneum.
        Int J Gynaecol Obstet. 2013; 123: 139-141
        • Barnhart K.T.
        Clinical practice. Ectopic pregnancy.
        N Engl J Med. 2009; 361: 379-387
        • Takeda A.
        • Manabe S.
        • Mitsui T.
        • Nakamura H.
        Management of patients with ectopic pregnancy with massive hemoperitoneum by laparoscopic surgery with intraoperative autologous blood transfusion.
        J Minim Invasive Gynecol. 2006; 13: 43-48
        • Stulberg D.B.
        • Cain L.R.
        • Dahlquist I.
        • Lauderdale D.S.
        Ectopic pregnancy rates in the Medicaid population.
        Am J Obstet Gynecol. 2013; 208: 274.e1-274.e7
        • Stulberg D.B.
        • Cain L.R.
        • Dahlquist I.
        • Lauderdale D.S.
        Ectopic pregnancy rates and racial disparities in the Medicaid population, 2004-2008.
        Fertil Steril. 2014; 102: 1671-1676
        • Creanga A.A.
        • Shapiro-Mendoza C.K.
        • Bish C.L.
        • Zane S.
        • Berg C.J.
        • Callaghan W.M.
        Trends in ectopic pregnancy mortality in the United States: 1980-2007.
        Obstet Gynecol. 2011; 117: 837-843
        • Cohen S.L.
        • Vitonis A.F.
        • Einarsson J.I.
        Updated hysterectomy surveillance and factors associated with minimally invasive hysterectomy.
        JSLS. 2014; 18
        • Lee J.
        • Jennings K.
        • Borahay M.A.
        • Rodriguez A.M.
        • Kilic G.S.
        • Snyder R.R.
        • et al.
        Trends in the national distribution of laparoscopic hysterectomies from 2003 to 2010.
        J Minim Invasive Gynecol. 2014; 21: 656-661
        • Van Hove C.
        • Hardiman K.
        • Diggs B.
        • Deveney C.
        • Sheppard B.
        Demographic and socioeconomic trends in the use of laparoscopic appendectomy from 1997 to 2003.
        Am J Surg. 2008; 195: 580-584
        • Duke C.M.
        • Dun E.C.
        • Sood A.
        • Pal L.
        • Dabaja A.A.
        Predictors of salpingostomy versus salpingectomy for surgical management of tubal ectopic pregnancy: do racial disparities exist?.
        Fertil Steril. 2015; 104: e82
        • Bagchi A.D.
        • Schone E.
        • Higgins P.
        • Granger E.
        • Casscells S.W.
        • Croghan T.
        Racial and ethnic health disparities in TRICARE.
        J Natl Med Assoc. 2009; 101: 663-670
        • Bagchi A.D.
        • Stewart K.
        • McLaughlin C.
        • Higgins P.
        • Croghan T.
        Treatment and outcomes for congestive heart failure by race/ethnicity in TRICARE.
        Med Care. 2011; 49: 489-495
        • Chow W.H.
        • Daling J.R.
        • Cates W.J.
        • Greenberg R.S.
        Epidemiology of ectopic pregnancy.
        Epidemiol Rev. 1987; 9: 70-94
        • Brown D.S.
        • Kurlantzick V.G.
        • McCall N.T.
        • Williams T.V.
        • Gantt C.J.
        • Granger E.
        Use of six clinical preventive services in TRICARE Prime compared to insured, managed care, and all U.S. populations and Healthy People 2010.
        Prev Med. 2009; 48: 389-391
        • Henry A.J.
        • Hevelone N.D.
        • Lipsitz S.
        • Nguyen L.L.
        Comparative methods for handling missing data in large databases.
        J Vasc Surg. 2013; 58: 1353-1359.e6
      1. Department of Defense Financial Management Regulation Volume 11a: Reimbursable Operations, Policy and Procedures Under Secretary of Defense (Comptroller). 11. Available from:

        • Esselen K.M.
        • Vitonis A.
        • Einarsson J.
        • Muto M.G.
        • Cohen S.
        Health care disparities in hysterectomy for gynecologic cancers: data from the 2012 National Inpatient Sample.
        Obstet Gynecol. 2015; 126: 1029-1039
        • Abenhaim H.A.
        • Azziz R.
        • Hu J.
        • Bartolucci A.
        • Tulandi T.
        Socioeconomic and racial predictors of undergoing laparoscopic hysterectomy for selected benign diseases: analysis of 341487 hysterectomies.
        J Minim Invasive Gynecol. 2008; 15: 11-15
        • Haider A.H.
        • Schneider E.B.
        • Sriram N.
        • Dossick D.S.
        • Scott V.K.
        • Swoboda S.M.
        • et al.
        Unconscious race and social class bias among acute care surgical clinicians and clinical treatment decisions.
        JAMA Surg. 2015; 150: 457-464
        • Wang Y.
        • Beydoun M.A.
        The obesity epidemic in the United States—gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis.
        Epidemiol Rev. 2007; 29: 6-28
        • Fuchs Weizman N.
        • Maurer R.
        • Einarsson J.I.
        • Vitonis A.F.
        • Cohen S.L.
        Survey on barriers to adoption of laparoscopic surgery.
        J Surg Educ. 2015; 72: 985-994
        • Odejinmi F.
        • Rizzuto I.
        • Oliver R.
        • Alalade A.
        • Agarwal N.
        • Olowu O.
        Beyond guidelines: effectiveness of a programme in achieving operative laparoscopy for all women requiring surgical management of ectopic pregnancy.
        Gynecol Obstet Invest. 2015; 80: 46-53
        • Vu K.
        • Gehlbach D.L.
        • Rosa C.
        Operative laparoscopy for the treatment of ectopic pregnancy in a residency program.
        J Reprod Med. 1996; 41: 602-604