Title: Socioeconomic Factors Influence Surgical Wait Times for Non-emergent Gynecologic
Surgical Procedures: A Retrospective Analysis
Version: 3 Date: 25 Aug 2023
Reviewer's report:
Thank you for the opportunity to review this work. The paper addresses an important topic
regarding the factors that affect a patient’s surgical wait times for benign gynecologic procedures
in New York hospitals affiliated with a single institution. The retrospective data review was from
4 months prior to the COVID-19 pandemic, which likely underestimates the extent of current
wait times and disparities.
The paper is well written and fills in the missing gap in the surgical delay literature
for benign gynecology. The findings are mostly concordant with factors described in the
published literature. The authors found that longer wait times were associated with being seen
preoperatively at a federally qualified health center (regardless of insurance status) and with a
patient needing medical clearance. The authors should be commended for the amount of manual
chart review they conducted. Their patient population was also very diverse, with less than 1/3
identifying as white.
However, there are a few points that need further clarification:
1. The authors use findings from the gynecologic oncology literature of FHQC hospitals and
insurance status as guidance for their clinical hypothesis. Table 2 shows demographics divided
by insurance status. I do not feel that a general demographics table as in figure 1 adds much, but
rather should be separated into FQHC/Private clinic. I’m not sure why Medicaid and Medicare
were combined in the multivariate analysis and not separated as they were in their demographics
– especially since they later perform a univariate analysis.
2. While the authors do adjust for the presence or absence of block time, they do not explain
whether there are differences in the number of cases that can be booked during the block time
allocated to those practicing from a FQHC vs private. There is also no analysis controlling for
location of surgery – i.e. if one of the 3 NY hospitals is a public hospital, and if that is where
most of the FHQC patients obtain their procedure.
3. For preoperative indications for surgery, would consider describing in the text how the primary
diagnosis was determined, since it seems like the authors attributed one preoperative indication
per patient, but I imagine patients often would have more than one diagnosis. Also, was the
breakdown of diagnoses and surgical cases different between the locations, and by insurance
type? It may be helpful to dichotomize the cases into major and minor procedures, and consider
adding “major or minor” procedure as a covariate in your analysis as well.
4. Given that medical clearance is factor, it would be important to describe what that entails in
the different practice settings. Does the gynecologist ask the patient to see their primary care
provider, is there support staff to help schedule these appointments, is there a preoperative clinic
that patients would go to, etc.
a. Do the authors have information on how long medical clearances took for patients – and if
that differed based on patient clinic location.
5. The study is over a short period of 5 months, which includes the last 3 months of the year.
The authors mention briefly in the discussion about the factor of patient preference, but patients
with private insurance may try to have their procedures prior to the new year so to meet their
deductible and thus artificially skew the data. I wonder if there was any difference in wait times
from October to December, versus Jan and February.
Minor comments
- Legends in figures 1 and 2 need to explain the acronyms used. Also, would be clearer if the
bar graphs were listed in an ascending or descending frequency, and to include the counts.
- Tables 4-6 can be simplified into 1 table
- The authors should qualify their findings for being relevant in the United States, as many
countries do not have the same fractured healthcare system.