Endometriosis Diagnosis and Social Vulnerability Score

INTRODUCTION: Endometriosis is a chronic inflammatory condition that profoundly affects those who suffer from pelvic pain and abnormal bleeding, resulting in negative impacts on quality of life and associated socioeconomic burdens. The estimated prevalence of 10% may be underreported due to challenges in diagnosis. According to prior retrospective studies and recent meta-analyses, White patients and those with commercial insurance are more likely to be diagnosed with endometriosis. Assuming these sociodemographic differences in the diagnosis of endometriosis are artifacts of diagnostic biases and other factors like access to care drive this difference, the main goal of this study was to evaluate social and demographic variables that may impact the diagnosis of endometriosis. OBJECTIVE: To determine if individuals with higher vulnerability scores will have a lower prevalence of endometriosis diagnosis. METHODS: We performed a retrospective review of a national quality database, Vizient ® Clinical Data Base, to determine if the Vizient® Vulnerability IndexTM (VVI) was associated with the diagnosis of endometriosis. To better understand health care disparities and equitable health care delivery, the VVI incorporates community-level demographic and socioeconomic variables. The VVI domains include public safety, access to public transportation, social cohesion, clean environment, housing stability, neighborhood safety net, overall health care access, education, and income levels. A vulnerability score is assigned to geographic regions or populations based on the aggregated data where a higher score indicates greater vulnerability. The database collects information from >1000 academic and community hospitals across the country. Data was abstracted with complete coverage, which consisted of markets where 95% of providers were included. Among all reproductive-aged individuals, those who had a hysterectomy were identified using Current Procedural Terminology (CPT) codes. International Classification of Disease (ICD) diagnosis codes were used to confirm endometriosis diagnosis. The prevalence of endometriosis was calculated among those undergoing hysterectomy for all indications. Linear regression models estimated the likelihood of endometriosis diagnosis, and multivariable adjusted models accounted for potential confounding factors. RESULTS: The hysterectomy cohort consisted of 466,425 reproductive-aged individuals, aged 18–50 years, who resided in a zip code with complete Vizient coverage from October 2010 through November 2023. Among this population, about 14% were diagnosed with endometriosis per year. Individuals with higher vulnerability scores were increasingly less likely to be diagnosed with endometriosis. The group with the highest VVI was 24% less likely to be diagnosed with endometriosis. Additionally, Black race, Hispanic ethnicity, and public insurance were associated with a decreased likelihood of endometriosis diagnosis. Among those with endometriosis, likelihood of an emergency room visit for pelvic pain was more likely as vulnerability increased (Figure 1). CONCLUSIONS: As the vulnerability score increases, the likelihood of endometriosis diagnosis decreases. This study demonstrates that endometriosis diagnosis may be linked with social determinants of health access and access to care, and provides further confirmation that health disparities and diagnostic biases exist in the care of patients with endometriosis symptoms. Although a multi-pronged approach is warranted to improve equitable care, clinician awareness of the preexisting sociodemographic variables that preclude proper diagnosis may improve care (Tables 1 and 2).