Title: The Carolina Hysterectomy Cohort (CHC): A novel case series of reproductive- aged
hysterectomy patients across 10 hospitals in the US South
Version: 0 Date: 21 Sep 2023
Reviewer's report:
Thank you for the opportunity to review this work. This paper presents the creation of a
comprehensive and diverse patient cohort of hysterectomy patients in a southern US healthcare
system from 2014-2017, with a description of the patient population. It describes how the authors
obtain and populate their data bank, including how they link various data sources. Their main
conclusion from preliminary perusal of the data is that the uninsured patients were different
than those who were publicly or privately insured. This endeavor is important for a nuanced
understanding of how we can improve our patient care and ensure equitable healthcare for
diverse patient populations – especially a population not captured by claims data – but there are
a few points that need clarifying and expanding prior to publication:
Abstract: The background in the abstract does not represent the paper. It focuses on symptom
burden differences, which is barely touched upon in the text. Was this copied from a different
paper?
Introduction: Please describe the healthcare system that this cohort arises from a little more –
does it include a safety net hospital, is it academic, how big is the patient population catchment
area and what is the SES of the area, etc.
Methods:
- Would summarize the abstraction process that is currently cited in 4 different citations (page
8). Since half of this paper describes how this cohort was formed and where the data comes
from, this abstraction process is relevant for reader comprehension.
- For physician data, the text describes “surgical signature” and “high surgical propensity.” I
am confused about what “high surgical propensity” means and how it was defined -  “>18%
of patients who had a hysterectomy were below the median of all three symptom scores” does
not make sense in this context. There are no discussions on “symptom scores” in the methods
or results.
Results:
- Why are these labeled ‘preliminary’? Is there something ‘final’ coming, and if so, that should
be clearly explained.
- The main analytical objective (per the Introduction paragraph) seems to be comparing patients
by payor type – specifically highlighting the uninsured group. The authors make multiple
comparative statements within this uninsured group, but do not provide any statistical analysis
to back up their statements. It would strengthen the paper to do a few comparative statistics of
differences in patient characteristics within the uninsured group, while also providing the results
in a dedicated table.
- Page 14: In the description of abstracted pre-op EMR notes, the authors note ‘the patterns
differed for uninsured patients’ by describing the ‘second most common with abnormal uterine
bleeding, with menorrhagia only noted…’. However, this may not be true as the diagnoses of
AUB and menorrhagia overlap – all menorrhagia is AUB but not all AUB is menorrhagia. Would
recommend having a gynecologist review how best to present these findings.
- Could the surgeon results be provided in a table, perhaps as supplementary data? How were
practice specializations determined? I’m surprised only 80% of the practices were OB/GYN –
what were the other 20%?
Discussion:
- New data is presented in the discussion that had not been in the Results section – and also do
not have statistical support. I.E. page 15 “…Hispanic and Black patients were disproportionally
likely to be uninsured”; page 16 “…lower median household income”
- There is no discussion on the physician data results. The authors mention in the last paragraph
that they “linked the patient data to their primary surgeons…enabling us to gain some insight…”
but do not provide this insight. Could this be expanded upon?
Minor:
- Page 2: the population has been referred to as ‘reproductive aged’ throughout the paper, but is
“non-elderly” here. Would change to reproductive-aged.
- Page 4: Would be clearer if this was new paragraph: “In this study, we…”
- Page 5: specify that this is a southeastern US state
- Page 6/Figure 1: Define NC. Under the first exclusion callout, can the last bullet be folded into
the other pregnancy/cancer diagnoses exclusions, or are those patients different?
- Page 9: Extra parathesis in “((e.g. gender, race …”
- Page 15: Please provide ranges when describing provider volume
- Page 19: Extraneous citations at the end
- There are some awkward sentence structures using colons: i.e. Page 16: “The primary
operational hurdles we faced were: reconciling…”
- The United States is abbreviated differently throughout: “US”, “U.S.”, “U.S.A”