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Algorithm reduces CT use in pediatric appendicitis
CHICAGO – Use of a diagnostic algorithm for pediatric appendicitis significantly decreases computed tomography utilization without compromising high sensitivity and specificity, according to findings from a study of emergency cases.
Of 840 patients seen in an academic children’s hospital emergency department from Aug. 1, 2014 to July 31, 2015, after implementation of the diagnostic algorithm, 267 were diagnosed with appendicitis. CT utilization was 27.3% overall, and 24.2% in patients with appendicitis, compared with 75.4% among 557 patients with appendicitis seen from Jan. 1, 2011 to February 28, 2014, before implementation, Dr. Sohail R. Shah of Baylor College of Medicine/Texas Children’s Hospital, Houston reported at the annual meeting of the American Surgical Association
The work was completed at his prior position at Children’s Mercy Hospital Kansas City.
“Additionally, utilization of ultrasound prior to CT went from 24% up to 95%, surgical consultation prior to CT increased from 14.7% to 76.1% after implementation, and operative intervention without any imaging went from just under 2% to almost 10% after implementation of the diagnostic algorithm,” Dr. Shah said, adding that the pre- and postimplementation patient groups were similar with respect to demographics.
The diagnostic pathway had a sensitivity of 98.6% and specificity of 94.4%, he said.
Appendicitis is the most common abdominal condition leading to the hospitalization of children, and it accounts for about 70,000 children hospitalized annually in the United States, with an average related healthcare cost of $675 million each year, he said.
The diagnosis in children can be difficult, thus many centers rely heavily on CT scans. However, increasing use of CT in children could lead to an increased lifetime risk of radiation-induced malignancy.
“In fact, the American College of Radiology currently recommends that a CT scan not be done for the diagnosis of appendicitis until after ultrasound has been considered as an option. Our objective with this work was to decrease CT utilization for the diagnosis of appendicitis in children at our academic free-standing children’s hospital emergency department through the introduction of a diagnostic algorithm,” he said.
A multidisciplinary team at Children’s Mercy Hospital worked to develop an algorithm, which promoted earlier surgical consultation and prioritized ultrasound imaging over CT scans. The algorithm involved the use of the 10-point Pediatric Appendicitis Score for risk stratification. For a score of 1-3, with low probability of appendicitis, the patient was discharged home or received further work-up for an alternative diagnosis. For a score of 4-6, with intermediate probability of appendicitis, an ultrasound was ordered. If the ultrasound was negative, the patient was discharged home or received further work-up for an alternative diagnosis; if the ultrasound was positive, surgery was consulted; if the ultrasound was indeterminate, surgery was consulted prior to consideration of CT scan. For a score of 7-10, surgery was immediately consulted for further management.
“If this algorithm is followed appropriately for all patients, then no patient should have a CT scan without first having an ultrasound and surgical consultation,” Dr. Shah said.
He reported having no disclosures.
The complete manuscript of this presentation is anticipated to be published in the Annals of Surgery pending editorial review.
CHICAGO – Use of a diagnostic algorithm for pediatric appendicitis significantly decreases computed tomography utilization without compromising high sensitivity and specificity, according to findings from a study of emergency cases.
Of 840 patients seen in an academic children’s hospital emergency department from Aug. 1, 2014 to July 31, 2015, after implementation of the diagnostic algorithm, 267 were diagnosed with appendicitis. CT utilization was 27.3% overall, and 24.2% in patients with appendicitis, compared with 75.4% among 557 patients with appendicitis seen from Jan. 1, 2011 to February 28, 2014, before implementation, Dr. Sohail R. Shah of Baylor College of Medicine/Texas Children’s Hospital, Houston reported at the annual meeting of the American Surgical Association
The work was completed at his prior position at Children’s Mercy Hospital Kansas City.
“Additionally, utilization of ultrasound prior to CT went from 24% up to 95%, surgical consultation prior to CT increased from 14.7% to 76.1% after implementation, and operative intervention without any imaging went from just under 2% to almost 10% after implementation of the diagnostic algorithm,” Dr. Shah said, adding that the pre- and postimplementation patient groups were similar with respect to demographics.
The diagnostic pathway had a sensitivity of 98.6% and specificity of 94.4%, he said.
Appendicitis is the most common abdominal condition leading to the hospitalization of children, and it accounts for about 70,000 children hospitalized annually in the United States, with an average related healthcare cost of $675 million each year, he said.
The diagnosis in children can be difficult, thus many centers rely heavily on CT scans. However, increasing use of CT in children could lead to an increased lifetime risk of radiation-induced malignancy.
“In fact, the American College of Radiology currently recommends that a CT scan not be done for the diagnosis of appendicitis until after ultrasound has been considered as an option. Our objective with this work was to decrease CT utilization for the diagnosis of appendicitis in children at our academic free-standing children’s hospital emergency department through the introduction of a diagnostic algorithm,” he said.
A multidisciplinary team at Children’s Mercy Hospital worked to develop an algorithm, which promoted earlier surgical consultation and prioritized ultrasound imaging over CT scans. The algorithm involved the use of the 10-point Pediatric Appendicitis Score for risk stratification. For a score of 1-3, with low probability of appendicitis, the patient was discharged home or received further work-up for an alternative diagnosis. For a score of 4-6, with intermediate probability of appendicitis, an ultrasound was ordered. If the ultrasound was negative, the patient was discharged home or received further work-up for an alternative diagnosis; if the ultrasound was positive, surgery was consulted; if the ultrasound was indeterminate, surgery was consulted prior to consideration of CT scan. For a score of 7-10, surgery was immediately consulted for further management.
“If this algorithm is followed appropriately for all patients, then no patient should have a CT scan without first having an ultrasound and surgical consultation,” Dr. Shah said.
He reported having no disclosures.
The complete manuscript of this presentation is anticipated to be published in the Annals of Surgery pending editorial review.
CHICAGO – Use of a diagnostic algorithm for pediatric appendicitis significantly decreases computed tomography utilization without compromising high sensitivity and specificity, according to findings from a study of emergency cases.
Of 840 patients seen in an academic children’s hospital emergency department from Aug. 1, 2014 to July 31, 2015, after implementation of the diagnostic algorithm, 267 were diagnosed with appendicitis. CT utilization was 27.3% overall, and 24.2% in patients with appendicitis, compared with 75.4% among 557 patients with appendicitis seen from Jan. 1, 2011 to February 28, 2014, before implementation, Dr. Sohail R. Shah of Baylor College of Medicine/Texas Children’s Hospital, Houston reported at the annual meeting of the American Surgical Association
The work was completed at his prior position at Children’s Mercy Hospital Kansas City.
“Additionally, utilization of ultrasound prior to CT went from 24% up to 95%, surgical consultation prior to CT increased from 14.7% to 76.1% after implementation, and operative intervention without any imaging went from just under 2% to almost 10% after implementation of the diagnostic algorithm,” Dr. Shah said, adding that the pre- and postimplementation patient groups were similar with respect to demographics.
The diagnostic pathway had a sensitivity of 98.6% and specificity of 94.4%, he said.
Appendicitis is the most common abdominal condition leading to the hospitalization of children, and it accounts for about 70,000 children hospitalized annually in the United States, with an average related healthcare cost of $675 million each year, he said.
The diagnosis in children can be difficult, thus many centers rely heavily on CT scans. However, increasing use of CT in children could lead to an increased lifetime risk of radiation-induced malignancy.
“In fact, the American College of Radiology currently recommends that a CT scan not be done for the diagnosis of appendicitis until after ultrasound has been considered as an option. Our objective with this work was to decrease CT utilization for the diagnosis of appendicitis in children at our academic free-standing children’s hospital emergency department through the introduction of a diagnostic algorithm,” he said.
A multidisciplinary team at Children’s Mercy Hospital worked to develop an algorithm, which promoted earlier surgical consultation and prioritized ultrasound imaging over CT scans. The algorithm involved the use of the 10-point Pediatric Appendicitis Score for risk stratification. For a score of 1-3, with low probability of appendicitis, the patient was discharged home or received further work-up for an alternative diagnosis. For a score of 4-6, with intermediate probability of appendicitis, an ultrasound was ordered. If the ultrasound was negative, the patient was discharged home or received further work-up for an alternative diagnosis; if the ultrasound was positive, surgery was consulted; if the ultrasound was indeterminate, surgery was consulted prior to consideration of CT scan. For a score of 7-10, surgery was immediately consulted for further management.
“If this algorithm is followed appropriately for all patients, then no patient should have a CT scan without first having an ultrasound and surgical consultation,” Dr. Shah said.
He reported having no disclosures.
The complete manuscript of this presentation is anticipated to be published in the Annals of Surgery pending editorial review.
AT THE ASA ANNUAL MEETING
Key clinical point: Use of a diagnostic algorithm for pediatric appendicitis significantly decreases computed tomography utilization without compromising high sensitivity and specificity, according to findings from a study of nearly 1,400 cases.
Major finding: CT utilization in patients with appendicitis was 24.2% before, and 75.4% after, implementation of the algorithm.
Data source: A review of nearly 1,400 pediatric appendicitis cases.
Disclosures: Dr. Shah reported having no disclosures.
Why we should strive for a vaginal hysterectomy rate of 40%
One of the great honors of my professional career was being nominated to the presidency of the Society of Gynecologic Surgeons and being given the opportunity to deliver the presidential address at the Society’s 42nd annual scientific meeting in Palm Springs, Calif.
One of the core principles of the SGS mission statement is supporting excellence in gynecologic surgery and, to that end, the main focus of my term was to address the decline in vaginal hysterectomy rates. What follows is an excerpt from my speech explaining the rationale for vaginal hysterectomy (VH) and steps the SGS is taking to reverse the decline.
Unfortunately, what is happening in today’s practice environment is declining use of vaginal hysterectomy, with concomitant increases in endoscopic hysterectomy, mostly with the use of robotic assistance. Being the president of a society previously known as the Vaginal Surgeons Society, it would not be surprising to hear that I have been accused of being “anti-robot.”
Nothing could be further from the truth.
When we talk about the surgical treatment of patients with endometrial and cervical cancer, I do not need a randomized clinical trial to know that not making a laparotomy incision is probably a good thing when you’re treating these patients. There are benefits to using robotic techniques in this subpopulation; it is cost effective due to the reduced morbidity and straight stick laparoscopy for these patients is difficult to perform; therefore it’s not been as widely published or performed. I believe that robotic hysterectomy for these disorders should be the standard of care. In this regard, I am pro robot (Gynecologic Oncol. 2015;138[2]:457-71).
On the other hand, I also don’t need a randomized trial (even though randomized trials exist) to know that if you have a choice to make, or not make, extra incisions during surgery, it’s better to not make the extra incisions.
It’s certainly not rocket science to know that a Zeppelin or Heaney clamp is orders of magnitude cheaper than equipment required to perform an endoscopic hysterectomy – $22.25 USD for instrument and $3.19 USD to process per case (Am J Obstet Gynecol. 2016;214[4]:S461-2]).
Level I evidence demonstrates that when compared to other minimally invasive hysterectomy techniques, vaginal hysterectomy is cheaper, the convalescence is stable or reduced, and the complication rates are lower (Cochrane Database Syst Rev. 2015 Aug. 12;8:CD003677).
Moreover, if you don’t place a port, you can’t get a port site complication (these complications are rare, but potentially serious when they occur). You can’t perforate the common iliac vein. You can’t put a Veress needle through the small bowel. You can’t get a Richter’s hernia. And finally, while you can get cuff dehiscence with vaginal hysterectomy, I’ve never seen it, and this is a real issue with the endoscopic approaches (Cochrane Database Syst Rev. 2012 Feb. 15;2:CD006583 ).
This isn’t just my opinion. Every major surgical society has recommended vaginal hysterectomy when technically feasible.
Of course, “technical feasibility” is the kicker and it’s important to ask what this means.
First, we have to look at what I call the hysterectomy continuum. There are the young, sexually-active women with uterovaginal procidentia where an endoscopic approach for sacral colpopexy might be considered. Then you have patients who are vaginally parous, have a mobile uterus less than 12 weeks in size, and have a basic gynecologic condition such as dysfunctional uterine bleeding, cervical intraepithelial neoplasia, or painful menses (this is about 40%-50% of patients when I reviewed internal North Valley Permanente Group data in 2012); these patients are certainly excellent candidates for vaginal hysterectomy. Then there are patients with 30-week-size fibroid uterus, three prior C-sections, and known stage 4 endometriosis (where an open or robotic approach would be justified).
Second, we have to address the contradictory data presented in the literature regarding vaginal hysterectomy rates. On one hand, we have data from large case series and randomized, controlled trials which demonstrate that it’s feasible to perform a high percentage of vaginal hysterectomies (Obstet Gynecol. 2004;103[6]:1321-5and Arch Gynecol Obstet. 2014;290[3]:485-91). On the other hand, 40 years of population data show the opposite (Obstet Gynecol. 2009;114[5]:1041-8).
In the pre-endoscopic era, 80% and 20% of hysterectomies were performed via the abdominal and vaginal routes, respectively. During the laparoscopic era, 64%, 22%, and 14% of hysterectomies were performed via the abdominal, vaginal, and laparoscopic routes, respectively. And during the current robotic era, it is now 32%, 16%, 28%, and 25% performed via the abdominal, vaginal, laparoscopic, and robotic routes, respectively.
During this 40-year time frame, despite data and recommendations that support vaginal hysterectomy, there has never been an obvious incentive to perform this procedure (e.g. to my knowledge, no one has ever been paid more to do a vaginal hysterectomy, or been prominently featured on a hospital’s website regarding his or her ability to perform an “incision-less” hysterectomy (Am J Obstet Gynecol. 2012;207[3]:174.e1-174.e7). Why weren’t and why aren’t we outraged about this? I have always been under the impression that cheaper and safer is better!
The first thing I hear to explain this – mostly from robotic surgeons and from the robotic surgery device sales representatives – is that the decline in the proportion of vaginal hysterectomies is irrelevant in that it has taken the robot to meaningfully reduce open hysterectomy rates. The other argument I hear – mostly from the laparoscopic surgeons – is that vaginal hysterectomy rates have not changed because most gynecologists cannot and will never be able to perform the procedure. So, what is the point of even discussing solutions?
I disagree with the laparoscopic and robotic surgeons. We should be outraged and do something to effect change. Vaginal hysterectomy offers better value (for surgeons who aren’t thinking about value right now, I suggest that you start. Value-based reimbursement is coming soon) and we know that a high percentage of vaginal hysterectomies are feasible in general gynecologic populations. Surgeons who perform vaginal hysterectomy are not magicians or better surgeons, just differently trained. We have to recognize that many, or even most, patients are candidates for vaginal hysterectomy.
Finally, when we look at robotics for benign disease, we spend more money than on other minimally invasive hysterectomy techniques but we don’t get better outcomes (J Minim Invasive Gynecol. 2010;17[6]:730-8and Eur J Obstet Gynecol Reprod Biol. 150[1]:92-6). Yet surgeons currently use robotics for 25% or more of benign hysterectomies.
What are we thinking and how can we afford to continue this?
We need to counsel our patients (and ourselves) that a total hysterectomy requires an incision in the vagina, and there can be a need for additional abdominal incisions of varying size and number. Fully informed consent must include a discussion of all types of hysterectomy including both patient and surgeon factors associated with the recommended route. Ultimately, the route of hysterectomy should be based on the patient and not the surgeon (Obstet Gynecol. 2014;124[3]:585-8).
It is easy to say, and supported by the evidence, that we should do more vaginal hysterectomies. It is also easy to note that the rate of vaginal hysterectomy has been stable to declining over the last 4 decades and that there are significant issues with residency training in gynecologic surgery (serious issues, but beyond the scope of this editorial).
So, what are we at SGS doing to support increased rates of vaginal hysterectomy? Every December we sponsor a postgraduate course on vaginal hysterectomy techniques. This is an excellent learning opportunity. (Visit www.sgsonline.org for more information regarding dates and costs). We’re starting partnerships with the American College of Obstetricians and Gynecologists (ACOG), the Foundation for Exxcellence in Women’s Health and others, to begin a “train the trainer” program to teach junior faculty how to do and teach vaginal hysterectomy. We’ve developed CREOG (Council on Resident Education in Obstetrics and Gynecology) modules to educate residents about the procedure, and we are in the process of communicating with residency and fellowship program directors about what else we can do to assist them with vaginal hysterectomy teaching. Other goals are to work with ACOG to develop quality metrics for hysterectomy and to develop physician-focused alternative payment models that recognize the value of vaginal hysterectomy.
I believe that in this country we should train for, incentivize, and insist upon a vaginal hysterectomy rate of at least 40% (this albeit arbitrary percentage is based upon the majority of vaginally parous women with uteri less than 12 weeks in size and a minority of the more difficult patients getting a vaginal hysterectomy). And before you say “it’s never been 40%,” please consider the famous quotation by Dr. William Mayo: “The best interest of the patient is the only interest to be considered.” Clearly, the best interest of the patient, if she is a candidate, is to have a vaginal hysterectomy. Our mission at SGS is to facilitate surgical education to make more patients candidates for vaginal hysterectomy so that we can achieve the 40% goal.
Dr. Walter is director of urogynecology and pelvic pain at The Permanente Medical Group, Roseville, Calif. He is also the immediate past president of the Society of Gynecologic Surgeons. He reported having no financial disclosures.
One of the great honors of my professional career was being nominated to the presidency of the Society of Gynecologic Surgeons and being given the opportunity to deliver the presidential address at the Society’s 42nd annual scientific meeting in Palm Springs, Calif.
One of the core principles of the SGS mission statement is supporting excellence in gynecologic surgery and, to that end, the main focus of my term was to address the decline in vaginal hysterectomy rates. What follows is an excerpt from my speech explaining the rationale for vaginal hysterectomy (VH) and steps the SGS is taking to reverse the decline.
Unfortunately, what is happening in today’s practice environment is declining use of vaginal hysterectomy, with concomitant increases in endoscopic hysterectomy, mostly with the use of robotic assistance. Being the president of a society previously known as the Vaginal Surgeons Society, it would not be surprising to hear that I have been accused of being “anti-robot.”
Nothing could be further from the truth.
When we talk about the surgical treatment of patients with endometrial and cervical cancer, I do not need a randomized clinical trial to know that not making a laparotomy incision is probably a good thing when you’re treating these patients. There are benefits to using robotic techniques in this subpopulation; it is cost effective due to the reduced morbidity and straight stick laparoscopy for these patients is difficult to perform; therefore it’s not been as widely published or performed. I believe that robotic hysterectomy for these disorders should be the standard of care. In this regard, I am pro robot (Gynecologic Oncol. 2015;138[2]:457-71).
On the other hand, I also don’t need a randomized trial (even though randomized trials exist) to know that if you have a choice to make, or not make, extra incisions during surgery, it’s better to not make the extra incisions.
It’s certainly not rocket science to know that a Zeppelin or Heaney clamp is orders of magnitude cheaper than equipment required to perform an endoscopic hysterectomy – $22.25 USD for instrument and $3.19 USD to process per case (Am J Obstet Gynecol. 2016;214[4]:S461-2]).
Level I evidence demonstrates that when compared to other minimally invasive hysterectomy techniques, vaginal hysterectomy is cheaper, the convalescence is stable or reduced, and the complication rates are lower (Cochrane Database Syst Rev. 2015 Aug. 12;8:CD003677).
Moreover, if you don’t place a port, you can’t get a port site complication (these complications are rare, but potentially serious when they occur). You can’t perforate the common iliac vein. You can’t put a Veress needle through the small bowel. You can’t get a Richter’s hernia. And finally, while you can get cuff dehiscence with vaginal hysterectomy, I’ve never seen it, and this is a real issue with the endoscopic approaches (Cochrane Database Syst Rev. 2012 Feb. 15;2:CD006583 ).
This isn’t just my opinion. Every major surgical society has recommended vaginal hysterectomy when technically feasible.
Of course, “technical feasibility” is the kicker and it’s important to ask what this means.
First, we have to look at what I call the hysterectomy continuum. There are the young, sexually-active women with uterovaginal procidentia where an endoscopic approach for sacral colpopexy might be considered. Then you have patients who are vaginally parous, have a mobile uterus less than 12 weeks in size, and have a basic gynecologic condition such as dysfunctional uterine bleeding, cervical intraepithelial neoplasia, or painful menses (this is about 40%-50% of patients when I reviewed internal North Valley Permanente Group data in 2012); these patients are certainly excellent candidates for vaginal hysterectomy. Then there are patients with 30-week-size fibroid uterus, three prior C-sections, and known stage 4 endometriosis (where an open or robotic approach would be justified).
Second, we have to address the contradictory data presented in the literature regarding vaginal hysterectomy rates. On one hand, we have data from large case series and randomized, controlled trials which demonstrate that it’s feasible to perform a high percentage of vaginal hysterectomies (Obstet Gynecol. 2004;103[6]:1321-5and Arch Gynecol Obstet. 2014;290[3]:485-91). On the other hand, 40 years of population data show the opposite (Obstet Gynecol. 2009;114[5]:1041-8).
In the pre-endoscopic era, 80% and 20% of hysterectomies were performed via the abdominal and vaginal routes, respectively. During the laparoscopic era, 64%, 22%, and 14% of hysterectomies were performed via the abdominal, vaginal, and laparoscopic routes, respectively. And during the current robotic era, it is now 32%, 16%, 28%, and 25% performed via the abdominal, vaginal, laparoscopic, and robotic routes, respectively.
During this 40-year time frame, despite data and recommendations that support vaginal hysterectomy, there has never been an obvious incentive to perform this procedure (e.g. to my knowledge, no one has ever been paid more to do a vaginal hysterectomy, or been prominently featured on a hospital’s website regarding his or her ability to perform an “incision-less” hysterectomy (Am J Obstet Gynecol. 2012;207[3]:174.e1-174.e7). Why weren’t and why aren’t we outraged about this? I have always been under the impression that cheaper and safer is better!
The first thing I hear to explain this – mostly from robotic surgeons and from the robotic surgery device sales representatives – is that the decline in the proportion of vaginal hysterectomies is irrelevant in that it has taken the robot to meaningfully reduce open hysterectomy rates. The other argument I hear – mostly from the laparoscopic surgeons – is that vaginal hysterectomy rates have not changed because most gynecologists cannot and will never be able to perform the procedure. So, what is the point of even discussing solutions?
I disagree with the laparoscopic and robotic surgeons. We should be outraged and do something to effect change. Vaginal hysterectomy offers better value (for surgeons who aren’t thinking about value right now, I suggest that you start. Value-based reimbursement is coming soon) and we know that a high percentage of vaginal hysterectomies are feasible in general gynecologic populations. Surgeons who perform vaginal hysterectomy are not magicians or better surgeons, just differently trained. We have to recognize that many, or even most, patients are candidates for vaginal hysterectomy.
Finally, when we look at robotics for benign disease, we spend more money than on other minimally invasive hysterectomy techniques but we don’t get better outcomes (J Minim Invasive Gynecol. 2010;17[6]:730-8and Eur J Obstet Gynecol Reprod Biol. 150[1]:92-6). Yet surgeons currently use robotics for 25% or more of benign hysterectomies.
What are we thinking and how can we afford to continue this?
We need to counsel our patients (and ourselves) that a total hysterectomy requires an incision in the vagina, and there can be a need for additional abdominal incisions of varying size and number. Fully informed consent must include a discussion of all types of hysterectomy including both patient and surgeon factors associated with the recommended route. Ultimately, the route of hysterectomy should be based on the patient and not the surgeon (Obstet Gynecol. 2014;124[3]:585-8).
It is easy to say, and supported by the evidence, that we should do more vaginal hysterectomies. It is also easy to note that the rate of vaginal hysterectomy has been stable to declining over the last 4 decades and that there are significant issues with residency training in gynecologic surgery (serious issues, but beyond the scope of this editorial).
So, what are we at SGS doing to support increased rates of vaginal hysterectomy? Every December we sponsor a postgraduate course on vaginal hysterectomy techniques. This is an excellent learning opportunity. (Visit www.sgsonline.org for more information regarding dates and costs). We’re starting partnerships with the American College of Obstetricians and Gynecologists (ACOG), the Foundation for Exxcellence in Women’s Health and others, to begin a “train the trainer” program to teach junior faculty how to do and teach vaginal hysterectomy. We’ve developed CREOG (Council on Resident Education in Obstetrics and Gynecology) modules to educate residents about the procedure, and we are in the process of communicating with residency and fellowship program directors about what else we can do to assist them with vaginal hysterectomy teaching. Other goals are to work with ACOG to develop quality metrics for hysterectomy and to develop physician-focused alternative payment models that recognize the value of vaginal hysterectomy.
I believe that in this country we should train for, incentivize, and insist upon a vaginal hysterectomy rate of at least 40% (this albeit arbitrary percentage is based upon the majority of vaginally parous women with uteri less than 12 weeks in size and a minority of the more difficult patients getting a vaginal hysterectomy). And before you say “it’s never been 40%,” please consider the famous quotation by Dr. William Mayo: “The best interest of the patient is the only interest to be considered.” Clearly, the best interest of the patient, if she is a candidate, is to have a vaginal hysterectomy. Our mission at SGS is to facilitate surgical education to make more patients candidates for vaginal hysterectomy so that we can achieve the 40% goal.
Dr. Walter is director of urogynecology and pelvic pain at The Permanente Medical Group, Roseville, Calif. He is also the immediate past president of the Society of Gynecologic Surgeons. He reported having no financial disclosures.
One of the great honors of my professional career was being nominated to the presidency of the Society of Gynecologic Surgeons and being given the opportunity to deliver the presidential address at the Society’s 42nd annual scientific meeting in Palm Springs, Calif.
One of the core principles of the SGS mission statement is supporting excellence in gynecologic surgery and, to that end, the main focus of my term was to address the decline in vaginal hysterectomy rates. What follows is an excerpt from my speech explaining the rationale for vaginal hysterectomy (VH) and steps the SGS is taking to reverse the decline.
Unfortunately, what is happening in today’s practice environment is declining use of vaginal hysterectomy, with concomitant increases in endoscopic hysterectomy, mostly with the use of robotic assistance. Being the president of a society previously known as the Vaginal Surgeons Society, it would not be surprising to hear that I have been accused of being “anti-robot.”
Nothing could be further from the truth.
When we talk about the surgical treatment of patients with endometrial and cervical cancer, I do not need a randomized clinical trial to know that not making a laparotomy incision is probably a good thing when you’re treating these patients. There are benefits to using robotic techniques in this subpopulation; it is cost effective due to the reduced morbidity and straight stick laparoscopy for these patients is difficult to perform; therefore it’s not been as widely published or performed. I believe that robotic hysterectomy for these disorders should be the standard of care. In this regard, I am pro robot (Gynecologic Oncol. 2015;138[2]:457-71).
On the other hand, I also don’t need a randomized trial (even though randomized trials exist) to know that if you have a choice to make, or not make, extra incisions during surgery, it’s better to not make the extra incisions.
It’s certainly not rocket science to know that a Zeppelin or Heaney clamp is orders of magnitude cheaper than equipment required to perform an endoscopic hysterectomy – $22.25 USD for instrument and $3.19 USD to process per case (Am J Obstet Gynecol. 2016;214[4]:S461-2]).
Level I evidence demonstrates that when compared to other minimally invasive hysterectomy techniques, vaginal hysterectomy is cheaper, the convalescence is stable or reduced, and the complication rates are lower (Cochrane Database Syst Rev. 2015 Aug. 12;8:CD003677).
Moreover, if you don’t place a port, you can’t get a port site complication (these complications are rare, but potentially serious when they occur). You can’t perforate the common iliac vein. You can’t put a Veress needle through the small bowel. You can’t get a Richter’s hernia. And finally, while you can get cuff dehiscence with vaginal hysterectomy, I’ve never seen it, and this is a real issue with the endoscopic approaches (Cochrane Database Syst Rev. 2012 Feb. 15;2:CD006583 ).
This isn’t just my opinion. Every major surgical society has recommended vaginal hysterectomy when technically feasible.
Of course, “technical feasibility” is the kicker and it’s important to ask what this means.
First, we have to look at what I call the hysterectomy continuum. There are the young, sexually-active women with uterovaginal procidentia where an endoscopic approach for sacral colpopexy might be considered. Then you have patients who are vaginally parous, have a mobile uterus less than 12 weeks in size, and have a basic gynecologic condition such as dysfunctional uterine bleeding, cervical intraepithelial neoplasia, or painful menses (this is about 40%-50% of patients when I reviewed internal North Valley Permanente Group data in 2012); these patients are certainly excellent candidates for vaginal hysterectomy. Then there are patients with 30-week-size fibroid uterus, three prior C-sections, and known stage 4 endometriosis (where an open or robotic approach would be justified).
Second, we have to address the contradictory data presented in the literature regarding vaginal hysterectomy rates. On one hand, we have data from large case series and randomized, controlled trials which demonstrate that it’s feasible to perform a high percentage of vaginal hysterectomies (Obstet Gynecol. 2004;103[6]:1321-5and Arch Gynecol Obstet. 2014;290[3]:485-91). On the other hand, 40 years of population data show the opposite (Obstet Gynecol. 2009;114[5]:1041-8).
In the pre-endoscopic era, 80% and 20% of hysterectomies were performed via the abdominal and vaginal routes, respectively. During the laparoscopic era, 64%, 22%, and 14% of hysterectomies were performed via the abdominal, vaginal, and laparoscopic routes, respectively. And during the current robotic era, it is now 32%, 16%, 28%, and 25% performed via the abdominal, vaginal, laparoscopic, and robotic routes, respectively.
During this 40-year time frame, despite data and recommendations that support vaginal hysterectomy, there has never been an obvious incentive to perform this procedure (e.g. to my knowledge, no one has ever been paid more to do a vaginal hysterectomy, or been prominently featured on a hospital’s website regarding his or her ability to perform an “incision-less” hysterectomy (Am J Obstet Gynecol. 2012;207[3]:174.e1-174.e7). Why weren’t and why aren’t we outraged about this? I have always been under the impression that cheaper and safer is better!
The first thing I hear to explain this – mostly from robotic surgeons and from the robotic surgery device sales representatives – is that the decline in the proportion of vaginal hysterectomies is irrelevant in that it has taken the robot to meaningfully reduce open hysterectomy rates. The other argument I hear – mostly from the laparoscopic surgeons – is that vaginal hysterectomy rates have not changed because most gynecologists cannot and will never be able to perform the procedure. So, what is the point of even discussing solutions?
I disagree with the laparoscopic and robotic surgeons. We should be outraged and do something to effect change. Vaginal hysterectomy offers better value (for surgeons who aren’t thinking about value right now, I suggest that you start. Value-based reimbursement is coming soon) and we know that a high percentage of vaginal hysterectomies are feasible in general gynecologic populations. Surgeons who perform vaginal hysterectomy are not magicians or better surgeons, just differently trained. We have to recognize that many, or even most, patients are candidates for vaginal hysterectomy.
Finally, when we look at robotics for benign disease, we spend more money than on other minimally invasive hysterectomy techniques but we don’t get better outcomes (J Minim Invasive Gynecol. 2010;17[6]:730-8and Eur J Obstet Gynecol Reprod Biol. 150[1]:92-6). Yet surgeons currently use robotics for 25% or more of benign hysterectomies.
What are we thinking and how can we afford to continue this?
We need to counsel our patients (and ourselves) that a total hysterectomy requires an incision in the vagina, and there can be a need for additional abdominal incisions of varying size and number. Fully informed consent must include a discussion of all types of hysterectomy including both patient and surgeon factors associated with the recommended route. Ultimately, the route of hysterectomy should be based on the patient and not the surgeon (Obstet Gynecol. 2014;124[3]:585-8).
It is easy to say, and supported by the evidence, that we should do more vaginal hysterectomies. It is also easy to note that the rate of vaginal hysterectomy has been stable to declining over the last 4 decades and that there are significant issues with residency training in gynecologic surgery (serious issues, but beyond the scope of this editorial).
So, what are we at SGS doing to support increased rates of vaginal hysterectomy? Every December we sponsor a postgraduate course on vaginal hysterectomy techniques. This is an excellent learning opportunity. (Visit www.sgsonline.org for more information regarding dates and costs). We’re starting partnerships with the American College of Obstetricians and Gynecologists (ACOG), the Foundation for Exxcellence in Women’s Health and others, to begin a “train the trainer” program to teach junior faculty how to do and teach vaginal hysterectomy. We’ve developed CREOG (Council on Resident Education in Obstetrics and Gynecology) modules to educate residents about the procedure, and we are in the process of communicating with residency and fellowship program directors about what else we can do to assist them with vaginal hysterectomy teaching. Other goals are to work with ACOG to develop quality metrics for hysterectomy and to develop physician-focused alternative payment models that recognize the value of vaginal hysterectomy.
I believe that in this country we should train for, incentivize, and insist upon a vaginal hysterectomy rate of at least 40% (this albeit arbitrary percentage is based upon the majority of vaginally parous women with uteri less than 12 weeks in size and a minority of the more difficult patients getting a vaginal hysterectomy). And before you say “it’s never been 40%,” please consider the famous quotation by Dr. William Mayo: “The best interest of the patient is the only interest to be considered.” Clearly, the best interest of the patient, if she is a candidate, is to have a vaginal hysterectomy. Our mission at SGS is to facilitate surgical education to make more patients candidates for vaginal hysterectomy so that we can achieve the 40% goal.
Dr. Walter is director of urogynecology and pelvic pain at The Permanente Medical Group, Roseville, Calif. He is also the immediate past president of the Society of Gynecologic Surgeons. He reported having no financial disclosures.
Autism screening rises after process-based training
A 3- to 6-month learning program for pediatric and family medicine providers significantly improved their screening for autism spectrum disorders (ASD) at 18- and 24-month well child visits, based on data from 26 primary care practices that participated in the program and from 43 physicians who completed surveys before and after the program, according to findings published online May 5 in Pediatrics.
“Unlike traditional continuing medical education, the LC [learning collaborative] focused on improvement of processes of care at the practice level,” wrote Dr. Paul S. Carbone and his colleagues of the University of Utah, Salt Lake City. The first signs of ASD can be present as early as 2 years of age, but often remain undiagnosed for lack of screening at 18- and 24-month visits, they noted.
Rates of documented ASD screening among toddlers increased from 16% before starting the program to 91% during the last month of the program, and 70% of the practices sustained the 91% screening rate 4 years later.
Physician self-efficacy improved significantly from baseline to after the program on the nine autism conditions (such as sleep problems, constipation, and attention deficit/hyperactivity disorder [ADHD]) and seven autism needs (such as making referrals, addressing developmental concerns, and identifying community support services) included in the survey. On a scale of 1 to 10, the average physician’s progress rating was 6.5 after completing the program.
“A LC using the methods we describe is a successful approach to improving the early identification and ongoing care of children with ASD in primary care practices,” they researchers said.
Read the whole article at Pediatrics (2016 May. doi: 10.1542/peds.2015-1850).
A 3- to 6-month learning program for pediatric and family medicine providers significantly improved their screening for autism spectrum disorders (ASD) at 18- and 24-month well child visits, based on data from 26 primary care practices that participated in the program and from 43 physicians who completed surveys before and after the program, according to findings published online May 5 in Pediatrics.
“Unlike traditional continuing medical education, the LC [learning collaborative] focused on improvement of processes of care at the practice level,” wrote Dr. Paul S. Carbone and his colleagues of the University of Utah, Salt Lake City. The first signs of ASD can be present as early as 2 years of age, but often remain undiagnosed for lack of screening at 18- and 24-month visits, they noted.
Rates of documented ASD screening among toddlers increased from 16% before starting the program to 91% during the last month of the program, and 70% of the practices sustained the 91% screening rate 4 years later.
Physician self-efficacy improved significantly from baseline to after the program on the nine autism conditions (such as sleep problems, constipation, and attention deficit/hyperactivity disorder [ADHD]) and seven autism needs (such as making referrals, addressing developmental concerns, and identifying community support services) included in the survey. On a scale of 1 to 10, the average physician’s progress rating was 6.5 after completing the program.
“A LC using the methods we describe is a successful approach to improving the early identification and ongoing care of children with ASD in primary care practices,” they researchers said.
Read the whole article at Pediatrics (2016 May. doi: 10.1542/peds.2015-1850).
A 3- to 6-month learning program for pediatric and family medicine providers significantly improved their screening for autism spectrum disorders (ASD) at 18- and 24-month well child visits, based on data from 26 primary care practices that participated in the program and from 43 physicians who completed surveys before and after the program, according to findings published online May 5 in Pediatrics.
“Unlike traditional continuing medical education, the LC [learning collaborative] focused on improvement of processes of care at the practice level,” wrote Dr. Paul S. Carbone and his colleagues of the University of Utah, Salt Lake City. The first signs of ASD can be present as early as 2 years of age, but often remain undiagnosed for lack of screening at 18- and 24-month visits, they noted.
Rates of documented ASD screening among toddlers increased from 16% before starting the program to 91% during the last month of the program, and 70% of the practices sustained the 91% screening rate 4 years later.
Physician self-efficacy improved significantly from baseline to after the program on the nine autism conditions (such as sleep problems, constipation, and attention deficit/hyperactivity disorder [ADHD]) and seven autism needs (such as making referrals, addressing developmental concerns, and identifying community support services) included in the survey. On a scale of 1 to 10, the average physician’s progress rating was 6.5 after completing the program.
“A LC using the methods we describe is a successful approach to improving the early identification and ongoing care of children with ASD in primary care practices,” they researchers said.
Read the whole article at Pediatrics (2016 May. doi: 10.1542/peds.2015-1850).
FROM PEDIATRICS
Preeclampsia test cancelled: $5M settlement, and more
Preeclampsia test cancelled: $5M settlement
A 35-year-old woman was pregnant with her first child. Prior to and during her pregnancy, she took medication for chronic hypertension. Although another ObGyn had ordered a 24-hour urinalysis to test for preeclampsia, the ObGyn who saw the mother in early May for a third trimester visit cancelled the test.
The mother delivered the child by cesarean delivery when the fetal heart-rate monitor indicated fetal distress. After birth, the child received a diagnosis of cerebral palsy, spastic quadriplegia, and dystonia.
Parents' claim: The decision by the second ObGyn to cancel the 24-hour urinalysis eliminated the opportunity to diagnose preeclampsia superimposed on chronic hypertension. Over time, preeclampsia impaired blood flow to the placenta and fetus. If the mother had been assessed in early May, the injury could have been prevented.
Defendants' defense: The case was settled during trial.
Verdict: A $5,000,000 Illinois settlement was reached through mediation with the hospital physicians’ group and 2 ObGyns.
Umbilical cord damaged at delivery: $1.5M settlement
A mother at full term presented to the hospital in labor. During delivery, the umbilical cord was severed during maneuvers to address shoulder dystocia. The fetus was stillborn.
Parents' claim: The patient told the nurses that shoulder dystocia had been encountered during a previous delivery. Shoulder dystocia maneuvers were not performed correctly. Cesarean delivery was never offered.
Hospital's Defense: The nurses called the certified nurse midwife who was managing labor and delivery to alert her of the patient’s history. The midwife denied receiving such a call. The case was settled during trial.
Verdict: A $1.5 million Illinois settlement was reached.
What caused sepsis after oophorectomy?
A woman had a cyst on her left ovary. The ObGyn began surgery laparoscopically but converted to open salpingo-oophorectomy because of extensive adhesions. Four days after surgery, the patient received a diagnosis of peritonitis and sepsis due to spillage from the sigmoid colon. She required a second surgery to repair the damage, followed by a long recovery.
Patient's claim: The ObGyn should not have attempted laparoscopic surgery; he knew of her extensive surgical history and should have anticipated the presence of adhesions. If the laparoscopic entry site had been examined properly intraoperatively, the injury could have been repaired immediately.
Physician's defense: The ObGyn had no reason to believe the patient would have adhesions in the umbilical area; prior surgeries occurred in the upper abdomen. Laparoscopic surgery with Veress needle access is an accepted method used by obstetric surgeons. The ObGyn carefully irrigated and inspected the abdomen before closing. Injury to the sigmoid colon is a known complication of left oophorectomy.
At the time of surgery, the patient was likely suffering from diverticulosis, a long-term condition that can lead to a leak in the large colon. The weakness in the patient’s colon caused a postsurgical leak; signs and symptoms did not appear until 4 days after surgery.
Verdict: A California defense verdict was returned.
Ectopic pregnancy misdiagnosed
A 39-year-old woman reported abdominal pain to her ObGyn. After ultrasonography (US), she was given a diagnosis of ectopic pregnancy. The ObGyn administered methotrexate to terminate the pregnancy. Five days later, repeat US showed a viable uterine pregnancy. Based on the risks posed by methotrexate, the patient terminated the pregnancy.
Patient's claim: The ObGyn misdiagnosed the pregnancy as ectopic.
Hospital's Defense: The case was settled during trial.
Verdict: A $625,000 Illinois settlement was reached.
Infant dies. was it fetal hydrops?
A woman was admitted to the hospital in full-term labor. She was cared for by a team of residents and nurses supervised by an attending ObGyn. During labor, the staff documented late, variable decelerations with periods of minimal or undetectable variability on the fetal heart-rate monitor. The fetal heart rate, however, was reported as being reassuring overall.
After 90 minutes, fetal heart-rate tracings became non-reassuring. Because the baby's head was crowning, the ObGyn used vacuum extraction for delivery. The infant was born without signs of life. A neonatologist thought the infant appeared hydropic with generalized edema, ascites, and pleural effusion. Efforts at resuscitation were unsuccessful until the neonatologist performed thoracentesis. The infant died several hours later. Cause of death has charted as hypoxic ischemic encephalopathy and multisystem organ failure.
Estate's claim: The hospital staff deviated from the standard of care by failing to appropriately communicate, failing to recognize fetal distress, and failing to perform a cesarean delivery when tracings were nonreassuring. An expert neonatologist claimed that failure to react to fetal distress caused the fetus to develop severe intrauterine hypoxic ischemia causing death.
Defendants' defense: Overall, the fetal heart-rate tracings were reassuring. The team communicated appropriately and kept the attending ObGyn alerted to the status. Delivery was expedited when fetal distress was evident.
Fetal hydrops was the end result of a serious problem in utero that could not have developed during the hours of labor and delivery; it most likely arose days to weeks before delivery. Nothing that occurred during labor and delivery caused hypoxic ischemic encephalopathy.
Verdict: An Illinois defense verdict was returned.
Child has permanent shoulder injury: $1M verdict
A mother was admitted to a hospital in full-term labor. During delivery, anterior shoulder dystocia was encountered.
The child received a diagnosis of a left brachial plexus injury and extracranial and intracranial bleeding. She underwent 3 surgeries to reattach nerve roots and move muscles and tendons in her shoulder and forearm in an effort to improve function in her left arm, wrist, and hand. She has undergone extensive physical and occupational therapy. Her left arm is smaller than her right arm and she has minimal strength, dexterity, and only 20% functionality of her left arm.
Parent's claim: The ObGyn exerted excessive traction when delivering the child. Alternate methods should have been used to manage shoulder dystocia. The hospital nurses should not have used fundal pressure.
Defendants' defense: The suit was brought against the ObGyn, his practice, and the hospital. The ObGyn claimed that he used several maneuvers to manage shoulder dystocia. The child’s injuries were a result of the maternal forces of labor and were not caused by negligence on the part of the ObGyn or nurses. The nurses denied using fundal pressure; they were trained to use suprapubic pressure.
Verdict: A $1,012,00 Illinois verdict was returned, finding the ObGyn’s practice 100% liable.
Parvovirus exposure: Fetal death
When a woman first saw an ObGyn, ultrasonography (US) indicated that her fetus was at 8 to 9 weeks’ gestation. One month later, she told the same ObGyn that she had been exposed to Fifth disease. Because blood work was positive for parvovirus B19, the ObGyn ordered the patient to undergo US every 2 weeks for the next 10 weeks. Two weeks later, the patient saw a second ObGyn at the same clinic. Although the first ObGyn had ordered US, none was performed; the patient’s next appointment was scheduled in 4 weeks. At that time, the patient saw a third ObGyn, who ordered US. He noted in her chart that the fetus had a nuchal fold, indicating Down syndrome. He told the patient to return in 2 weeks for a follow-up US. The results of that US showed that the fetus had died. Fetal cord blood tested positive for parvovirus B19.
Parent's claim: All 3 ObGyns failed to react properly to indications of parvovirus infection. Regular US should have been performed, as suggested by the first ObGyn. The mother should have been referred to a perinatologist or other maternal-fetal specialist when blood work was positive for parvovirus B19. A specialist could have provided treatment for the virus.
Physician's defense: The ObGyns denied any breach in the standard of care. They claimed that results would have been the same if they had referred the patient to a specialist.
Verdict: An Alabama defense verdict was returned.
Preeclampsia test cancelled: $5M settlement
A 35-year-old woman was pregnant with her first child. Prior to and during her pregnancy, she took medication for chronic hypertension. Although another ObGyn had ordered a 24-hour urinalysis to test for preeclampsia, the ObGyn who saw the mother in early May for a third trimester visit cancelled the test.
The mother delivered the child by cesarean delivery when the fetal heart-rate monitor indicated fetal distress. After birth, the child received a diagnosis of cerebral palsy, spastic quadriplegia, and dystonia.
Parents' claim: The decision by the second ObGyn to cancel the 24-hour urinalysis eliminated the opportunity to diagnose preeclampsia superimposed on chronic hypertension. Over time, preeclampsia impaired blood flow to the placenta and fetus. If the mother had been assessed in early May, the injury could have been prevented.
Defendants' defense: The case was settled during trial.
Verdict: A $5,000,000 Illinois settlement was reached through mediation with the hospital physicians’ group and 2 ObGyns.
Umbilical cord damaged at delivery: $1.5M settlement
A mother at full term presented to the hospital in labor. During delivery, the umbilical cord was severed during maneuvers to address shoulder dystocia. The fetus was stillborn.
Parents' claim: The patient told the nurses that shoulder dystocia had been encountered during a previous delivery. Shoulder dystocia maneuvers were not performed correctly. Cesarean delivery was never offered.
Hospital's Defense: The nurses called the certified nurse midwife who was managing labor and delivery to alert her of the patient’s history. The midwife denied receiving such a call. The case was settled during trial.
Verdict: A $1.5 million Illinois settlement was reached.
What caused sepsis after oophorectomy?
A woman had a cyst on her left ovary. The ObGyn began surgery laparoscopically but converted to open salpingo-oophorectomy because of extensive adhesions. Four days after surgery, the patient received a diagnosis of peritonitis and sepsis due to spillage from the sigmoid colon. She required a second surgery to repair the damage, followed by a long recovery.
Patient's claim: The ObGyn should not have attempted laparoscopic surgery; he knew of her extensive surgical history and should have anticipated the presence of adhesions. If the laparoscopic entry site had been examined properly intraoperatively, the injury could have been repaired immediately.
Physician's defense: The ObGyn had no reason to believe the patient would have adhesions in the umbilical area; prior surgeries occurred in the upper abdomen. Laparoscopic surgery with Veress needle access is an accepted method used by obstetric surgeons. The ObGyn carefully irrigated and inspected the abdomen before closing. Injury to the sigmoid colon is a known complication of left oophorectomy.
At the time of surgery, the patient was likely suffering from diverticulosis, a long-term condition that can lead to a leak in the large colon. The weakness in the patient’s colon caused a postsurgical leak; signs and symptoms did not appear until 4 days after surgery.
Verdict: A California defense verdict was returned.
Ectopic pregnancy misdiagnosed
A 39-year-old woman reported abdominal pain to her ObGyn. After ultrasonography (US), she was given a diagnosis of ectopic pregnancy. The ObGyn administered methotrexate to terminate the pregnancy. Five days later, repeat US showed a viable uterine pregnancy. Based on the risks posed by methotrexate, the patient terminated the pregnancy.
Patient's claim: The ObGyn misdiagnosed the pregnancy as ectopic.
Hospital's Defense: The case was settled during trial.
Verdict: A $625,000 Illinois settlement was reached.
Infant dies. was it fetal hydrops?
A woman was admitted to the hospital in full-term labor. She was cared for by a team of residents and nurses supervised by an attending ObGyn. During labor, the staff documented late, variable decelerations with periods of minimal or undetectable variability on the fetal heart-rate monitor. The fetal heart rate, however, was reported as being reassuring overall.
After 90 minutes, fetal heart-rate tracings became non-reassuring. Because the baby's head was crowning, the ObGyn used vacuum extraction for delivery. The infant was born without signs of life. A neonatologist thought the infant appeared hydropic with generalized edema, ascites, and pleural effusion. Efforts at resuscitation were unsuccessful until the neonatologist performed thoracentesis. The infant died several hours later. Cause of death has charted as hypoxic ischemic encephalopathy and multisystem organ failure.
Estate's claim: The hospital staff deviated from the standard of care by failing to appropriately communicate, failing to recognize fetal distress, and failing to perform a cesarean delivery when tracings were nonreassuring. An expert neonatologist claimed that failure to react to fetal distress caused the fetus to develop severe intrauterine hypoxic ischemia causing death.
Defendants' defense: Overall, the fetal heart-rate tracings were reassuring. The team communicated appropriately and kept the attending ObGyn alerted to the status. Delivery was expedited when fetal distress was evident.
Fetal hydrops was the end result of a serious problem in utero that could not have developed during the hours of labor and delivery; it most likely arose days to weeks before delivery. Nothing that occurred during labor and delivery caused hypoxic ischemic encephalopathy.
Verdict: An Illinois defense verdict was returned.
Child has permanent shoulder injury: $1M verdict
A mother was admitted to a hospital in full-term labor. During delivery, anterior shoulder dystocia was encountered.
The child received a diagnosis of a left brachial plexus injury and extracranial and intracranial bleeding. She underwent 3 surgeries to reattach nerve roots and move muscles and tendons in her shoulder and forearm in an effort to improve function in her left arm, wrist, and hand. She has undergone extensive physical and occupational therapy. Her left arm is smaller than her right arm and she has minimal strength, dexterity, and only 20% functionality of her left arm.
Parent's claim: The ObGyn exerted excessive traction when delivering the child. Alternate methods should have been used to manage shoulder dystocia. The hospital nurses should not have used fundal pressure.
Defendants' defense: The suit was brought against the ObGyn, his practice, and the hospital. The ObGyn claimed that he used several maneuvers to manage shoulder dystocia. The child’s injuries were a result of the maternal forces of labor and were not caused by negligence on the part of the ObGyn or nurses. The nurses denied using fundal pressure; they were trained to use suprapubic pressure.
Verdict: A $1,012,00 Illinois verdict was returned, finding the ObGyn’s practice 100% liable.
Parvovirus exposure: Fetal death
When a woman first saw an ObGyn, ultrasonography (US) indicated that her fetus was at 8 to 9 weeks’ gestation. One month later, she told the same ObGyn that she had been exposed to Fifth disease. Because blood work was positive for parvovirus B19, the ObGyn ordered the patient to undergo US every 2 weeks for the next 10 weeks. Two weeks later, the patient saw a second ObGyn at the same clinic. Although the first ObGyn had ordered US, none was performed; the patient’s next appointment was scheduled in 4 weeks. At that time, the patient saw a third ObGyn, who ordered US. He noted in her chart that the fetus had a nuchal fold, indicating Down syndrome. He told the patient to return in 2 weeks for a follow-up US. The results of that US showed that the fetus had died. Fetal cord blood tested positive for parvovirus B19.
Parent's claim: All 3 ObGyns failed to react properly to indications of parvovirus infection. Regular US should have been performed, as suggested by the first ObGyn. The mother should have been referred to a perinatologist or other maternal-fetal specialist when blood work was positive for parvovirus B19. A specialist could have provided treatment for the virus.
Physician's defense: The ObGyns denied any breach in the standard of care. They claimed that results would have been the same if they had referred the patient to a specialist.
Verdict: An Alabama defense verdict was returned.
Preeclampsia test cancelled: $5M settlement
A 35-year-old woman was pregnant with her first child. Prior to and during her pregnancy, she took medication for chronic hypertension. Although another ObGyn had ordered a 24-hour urinalysis to test for preeclampsia, the ObGyn who saw the mother in early May for a third trimester visit cancelled the test.
The mother delivered the child by cesarean delivery when the fetal heart-rate monitor indicated fetal distress. After birth, the child received a diagnosis of cerebral palsy, spastic quadriplegia, and dystonia.
Parents' claim: The decision by the second ObGyn to cancel the 24-hour urinalysis eliminated the opportunity to diagnose preeclampsia superimposed on chronic hypertension. Over time, preeclampsia impaired blood flow to the placenta and fetus. If the mother had been assessed in early May, the injury could have been prevented.
Defendants' defense: The case was settled during trial.
Verdict: A $5,000,000 Illinois settlement was reached through mediation with the hospital physicians’ group and 2 ObGyns.
Umbilical cord damaged at delivery: $1.5M settlement
A mother at full term presented to the hospital in labor. During delivery, the umbilical cord was severed during maneuvers to address shoulder dystocia. The fetus was stillborn.
Parents' claim: The patient told the nurses that shoulder dystocia had been encountered during a previous delivery. Shoulder dystocia maneuvers were not performed correctly. Cesarean delivery was never offered.
Hospital's Defense: The nurses called the certified nurse midwife who was managing labor and delivery to alert her of the patient’s history. The midwife denied receiving such a call. The case was settled during trial.
Verdict: A $1.5 million Illinois settlement was reached.
What caused sepsis after oophorectomy?
A woman had a cyst on her left ovary. The ObGyn began surgery laparoscopically but converted to open salpingo-oophorectomy because of extensive adhesions. Four days after surgery, the patient received a diagnosis of peritonitis and sepsis due to spillage from the sigmoid colon. She required a second surgery to repair the damage, followed by a long recovery.
Patient's claim: The ObGyn should not have attempted laparoscopic surgery; he knew of her extensive surgical history and should have anticipated the presence of adhesions. If the laparoscopic entry site had been examined properly intraoperatively, the injury could have been repaired immediately.
Physician's defense: The ObGyn had no reason to believe the patient would have adhesions in the umbilical area; prior surgeries occurred in the upper abdomen. Laparoscopic surgery with Veress needle access is an accepted method used by obstetric surgeons. The ObGyn carefully irrigated and inspected the abdomen before closing. Injury to the sigmoid colon is a known complication of left oophorectomy.
At the time of surgery, the patient was likely suffering from diverticulosis, a long-term condition that can lead to a leak in the large colon. The weakness in the patient’s colon caused a postsurgical leak; signs and symptoms did not appear until 4 days after surgery.
Verdict: A California defense verdict was returned.
Ectopic pregnancy misdiagnosed
A 39-year-old woman reported abdominal pain to her ObGyn. After ultrasonography (US), she was given a diagnosis of ectopic pregnancy. The ObGyn administered methotrexate to terminate the pregnancy. Five days later, repeat US showed a viable uterine pregnancy. Based on the risks posed by methotrexate, the patient terminated the pregnancy.
Patient's claim: The ObGyn misdiagnosed the pregnancy as ectopic.
Hospital's Defense: The case was settled during trial.
Verdict: A $625,000 Illinois settlement was reached.
Infant dies. was it fetal hydrops?
A woman was admitted to the hospital in full-term labor. She was cared for by a team of residents and nurses supervised by an attending ObGyn. During labor, the staff documented late, variable decelerations with periods of minimal or undetectable variability on the fetal heart-rate monitor. The fetal heart rate, however, was reported as being reassuring overall.
After 90 minutes, fetal heart-rate tracings became non-reassuring. Because the baby's head was crowning, the ObGyn used vacuum extraction for delivery. The infant was born without signs of life. A neonatologist thought the infant appeared hydropic with generalized edema, ascites, and pleural effusion. Efforts at resuscitation were unsuccessful until the neonatologist performed thoracentesis. The infant died several hours later. Cause of death has charted as hypoxic ischemic encephalopathy and multisystem organ failure.
Estate's claim: The hospital staff deviated from the standard of care by failing to appropriately communicate, failing to recognize fetal distress, and failing to perform a cesarean delivery when tracings were nonreassuring. An expert neonatologist claimed that failure to react to fetal distress caused the fetus to develop severe intrauterine hypoxic ischemia causing death.
Defendants' defense: Overall, the fetal heart-rate tracings were reassuring. The team communicated appropriately and kept the attending ObGyn alerted to the status. Delivery was expedited when fetal distress was evident.
Fetal hydrops was the end result of a serious problem in utero that could not have developed during the hours of labor and delivery; it most likely arose days to weeks before delivery. Nothing that occurred during labor and delivery caused hypoxic ischemic encephalopathy.
Verdict: An Illinois defense verdict was returned.
Child has permanent shoulder injury: $1M verdict
A mother was admitted to a hospital in full-term labor. During delivery, anterior shoulder dystocia was encountered.
The child received a diagnosis of a left brachial plexus injury and extracranial and intracranial bleeding. She underwent 3 surgeries to reattach nerve roots and move muscles and tendons in her shoulder and forearm in an effort to improve function in her left arm, wrist, and hand. She has undergone extensive physical and occupational therapy. Her left arm is smaller than her right arm and she has minimal strength, dexterity, and only 20% functionality of her left arm.
Parent's claim: The ObGyn exerted excessive traction when delivering the child. Alternate methods should have been used to manage shoulder dystocia. The hospital nurses should not have used fundal pressure.
Defendants' defense: The suit was brought against the ObGyn, his practice, and the hospital. The ObGyn claimed that he used several maneuvers to manage shoulder dystocia. The child’s injuries were a result of the maternal forces of labor and were not caused by negligence on the part of the ObGyn or nurses. The nurses denied using fundal pressure; they were trained to use suprapubic pressure.
Verdict: A $1,012,00 Illinois verdict was returned, finding the ObGyn’s practice 100% liable.
Parvovirus exposure: Fetal death
When a woman first saw an ObGyn, ultrasonography (US) indicated that her fetus was at 8 to 9 weeks’ gestation. One month later, she told the same ObGyn that she had been exposed to Fifth disease. Because blood work was positive for parvovirus B19, the ObGyn ordered the patient to undergo US every 2 weeks for the next 10 weeks. Two weeks later, the patient saw a second ObGyn at the same clinic. Although the first ObGyn had ordered US, none was performed; the patient’s next appointment was scheduled in 4 weeks. At that time, the patient saw a third ObGyn, who ordered US. He noted in her chart that the fetus had a nuchal fold, indicating Down syndrome. He told the patient to return in 2 weeks for a follow-up US. The results of that US showed that the fetus had died. Fetal cord blood tested positive for parvovirus B19.
Parent's claim: All 3 ObGyns failed to react properly to indications of parvovirus infection. Regular US should have been performed, as suggested by the first ObGyn. The mother should have been referred to a perinatologist or other maternal-fetal specialist when blood work was positive for parvovirus B19. A specialist could have provided treatment for the virus.
Physician's defense: The ObGyns denied any breach in the standard of care. They claimed that results would have been the same if they had referred the patient to a specialist.
Verdict: An Alabama defense verdict was returned.
Additional Medical Verdicts
• Umbilical cord damaged at delivery: $1.5M settlement
• What caused sepsis after oophorectomy?
• Ectopic pregnancy misdiagnosed
• Infant dies. Was it fetal hydrops?
• Child has permanent shoulder injury: $1M verdict
• Parvovirus exposure: fetal death
Training impacted performance of surgical quality measures
INDIAN WELLS, CALIF. – Surgeons with fellowship training in female pelvic medicine and reconstructive surgery were significantly more likely to perform proposed quality measures at the time of hysterectomy for pelvic organ prolapse, compared with those who lack such training, a single-center study showed.
“The Physician Quality Reporting System was instituted as part of recent health care reform, with the aim of improving the reporting of quality measures, with the overall goal of improving the quality of care provided to patients throughout all areas of medicine,” Dr. Emily Adams-Piper said at the annual scientific meeting of the Society of Gynecologic Surgeons. “While there are many types of quality measures, including outcome measures and patient satisfaction measures, process measures may be the most directly applicable for the practicing clinician, because they provide recommended actions during specific patient encounters that can guide practice.”
Dr. Adams-Piper, a resident physician in the division of urogynecology at the University of California, Irvine, and her associates set out to investigate the use of proposed quality measures at the time of hysterectomy for pelvic organ prolapse (POP) among women receiving care from Southern California Permanente Medical Group, a large HMO.
They wanted to know if training background affected the rate of performance of four different quality measures related to hysterectomy for POP: offering conservative treatment prior to the surgical treatment of POP, quantitative assessment of POP with either a Baden-Walker or a POP-Q exam, apical support procedure performed at the time of hysterectomy for prolapse, and performance of intraoperative cystoscopy.
Patients who underwent hysterectomy for POP in 2008 were eligible for the study. The researchers reviewed electronic medical records for clinical and demographic data and categorized surgeons by their level of training.
“They were considered fellowship trained if they had pursued additional formal subspecialty training in female pelvic medicine and reconstructive surgery,” Dr. Adams-Piper explained. “Surgeons were considered grandfathered if they subsequently took the FPMRS [Female Pelvic Medicine and Reconstructive Surgery] boards when they became available in 2013. Surgeons were considered generalist if they fit into neither of these two categories and completed a residency in ob.gyn.”
Chi-squared tests were used to compare demographics and performance of the proposed quality measures. Of the 662 hysterectomies performed in 2008, 328 were included in the final analysis. The mean patient age was 60 years, the mean parity was 2.9, and the mean body mass index was 27.9 kg/m2.
Overall performance of the four proposed quality measures was high, ranging from 82%-87%. More than half of quality assessments (58%) were performed with the POP-Q exam, while the majority of apical support procedures were uterosacral ligament vault suspensions (67%), followed by sacrocolpopexy (18%), McCall culdoplasty (12%), and sacrospinous ligament fixation (3%).
When categorized by training, fellowship-trained surgeons performed 133 hysterectomies, “grandfathered” surgeons performed 55, and generalist gynecologic surgeons performed 140. Fellowship-trained surgeons performed each of the four proposed quality measures more often than did grandfathered surgeons, who performed them more often than generalist gynecologic surgeons did.
Specifically, conservative treatment was offered by 94% of fellowship-trained surgeons, 87% of grandfathered surgeons, and 76% of generalist gynecologic surgeons (P = .0002). Qualitative preoperative assessment of POP was performed by 99% of fellowship-trained surgeons, 93% of grandfathered surgeons, and 73% of generalist gynecologic surgeons (three-way comparison reached statistical significance, with a P less than .0001).
Apical repair was performed by 96% of fellowship-trained surgeons, 82% of grandfathered surgeons, and 69% of generalist gynecologic surgeons (P less than .0001). Finally, cystoscopy was performed by 98% of fellowship-trained surgeons, 91% of grandfathered surgeons, and 72% of generalist gynecologic surgeons (P less than .0001).
When the researchers evaluated the cumulative performance of all measures in the same patient, fellowship-trained surgeons had the highest rates (89%, compared with 62% of grandfathered surgeons, and 39% of generalist gynecologic surgeons; P less than .0001).
“When we looked at the patient characteristics and their distribution across the surgeon training backgrounds, we found no significant differences in the age, BMI, gravidity, or parity of the subjects that underwent surgeries with the three groups,” Dr. Adams-Piper said.
She acknowledged certain limitations of the study, including the fact that it reflects clinical practice in a single health care delivery system, it relied on prior documentation, and it evaluated data from 2008.
“From this study we can conclude that perioperative practice patterns differ by surgeon training background,” she said. “However, in order for the proposed quality measures to be clinically meaningful, they must be correlated with patient-centered outcomes.”
Dr. Adams-Piper reported having no financial disclosures. The meeting was jointly sponsored by the American College of Surgeons.
INDIAN WELLS, CALIF. – Surgeons with fellowship training in female pelvic medicine and reconstructive surgery were significantly more likely to perform proposed quality measures at the time of hysterectomy for pelvic organ prolapse, compared with those who lack such training, a single-center study showed.
“The Physician Quality Reporting System was instituted as part of recent health care reform, with the aim of improving the reporting of quality measures, with the overall goal of improving the quality of care provided to patients throughout all areas of medicine,” Dr. Emily Adams-Piper said at the annual scientific meeting of the Society of Gynecologic Surgeons. “While there are many types of quality measures, including outcome measures and patient satisfaction measures, process measures may be the most directly applicable for the practicing clinician, because they provide recommended actions during specific patient encounters that can guide practice.”
Dr. Adams-Piper, a resident physician in the division of urogynecology at the University of California, Irvine, and her associates set out to investigate the use of proposed quality measures at the time of hysterectomy for pelvic organ prolapse (POP) among women receiving care from Southern California Permanente Medical Group, a large HMO.
They wanted to know if training background affected the rate of performance of four different quality measures related to hysterectomy for POP: offering conservative treatment prior to the surgical treatment of POP, quantitative assessment of POP with either a Baden-Walker or a POP-Q exam, apical support procedure performed at the time of hysterectomy for prolapse, and performance of intraoperative cystoscopy.
Patients who underwent hysterectomy for POP in 2008 were eligible for the study. The researchers reviewed electronic medical records for clinical and demographic data and categorized surgeons by their level of training.
“They were considered fellowship trained if they had pursued additional formal subspecialty training in female pelvic medicine and reconstructive surgery,” Dr. Adams-Piper explained. “Surgeons were considered grandfathered if they subsequently took the FPMRS [Female Pelvic Medicine and Reconstructive Surgery] boards when they became available in 2013. Surgeons were considered generalist if they fit into neither of these two categories and completed a residency in ob.gyn.”
Chi-squared tests were used to compare demographics and performance of the proposed quality measures. Of the 662 hysterectomies performed in 2008, 328 were included in the final analysis. The mean patient age was 60 years, the mean parity was 2.9, and the mean body mass index was 27.9 kg/m2.
Overall performance of the four proposed quality measures was high, ranging from 82%-87%. More than half of quality assessments (58%) were performed with the POP-Q exam, while the majority of apical support procedures were uterosacral ligament vault suspensions (67%), followed by sacrocolpopexy (18%), McCall culdoplasty (12%), and sacrospinous ligament fixation (3%).
When categorized by training, fellowship-trained surgeons performed 133 hysterectomies, “grandfathered” surgeons performed 55, and generalist gynecologic surgeons performed 140. Fellowship-trained surgeons performed each of the four proposed quality measures more often than did grandfathered surgeons, who performed them more often than generalist gynecologic surgeons did.
Specifically, conservative treatment was offered by 94% of fellowship-trained surgeons, 87% of grandfathered surgeons, and 76% of generalist gynecologic surgeons (P = .0002). Qualitative preoperative assessment of POP was performed by 99% of fellowship-trained surgeons, 93% of grandfathered surgeons, and 73% of generalist gynecologic surgeons (three-way comparison reached statistical significance, with a P less than .0001).
Apical repair was performed by 96% of fellowship-trained surgeons, 82% of grandfathered surgeons, and 69% of generalist gynecologic surgeons (P less than .0001). Finally, cystoscopy was performed by 98% of fellowship-trained surgeons, 91% of grandfathered surgeons, and 72% of generalist gynecologic surgeons (P less than .0001).
When the researchers evaluated the cumulative performance of all measures in the same patient, fellowship-trained surgeons had the highest rates (89%, compared with 62% of grandfathered surgeons, and 39% of generalist gynecologic surgeons; P less than .0001).
“When we looked at the patient characteristics and their distribution across the surgeon training backgrounds, we found no significant differences in the age, BMI, gravidity, or parity of the subjects that underwent surgeries with the three groups,” Dr. Adams-Piper said.
She acknowledged certain limitations of the study, including the fact that it reflects clinical practice in a single health care delivery system, it relied on prior documentation, and it evaluated data from 2008.
“From this study we can conclude that perioperative practice patterns differ by surgeon training background,” she said. “However, in order for the proposed quality measures to be clinically meaningful, they must be correlated with patient-centered outcomes.”
Dr. Adams-Piper reported having no financial disclosures. The meeting was jointly sponsored by the American College of Surgeons.
INDIAN WELLS, CALIF. – Surgeons with fellowship training in female pelvic medicine and reconstructive surgery were significantly more likely to perform proposed quality measures at the time of hysterectomy for pelvic organ prolapse, compared with those who lack such training, a single-center study showed.
“The Physician Quality Reporting System was instituted as part of recent health care reform, with the aim of improving the reporting of quality measures, with the overall goal of improving the quality of care provided to patients throughout all areas of medicine,” Dr. Emily Adams-Piper said at the annual scientific meeting of the Society of Gynecologic Surgeons. “While there are many types of quality measures, including outcome measures and patient satisfaction measures, process measures may be the most directly applicable for the practicing clinician, because they provide recommended actions during specific patient encounters that can guide practice.”
Dr. Adams-Piper, a resident physician in the division of urogynecology at the University of California, Irvine, and her associates set out to investigate the use of proposed quality measures at the time of hysterectomy for pelvic organ prolapse (POP) among women receiving care from Southern California Permanente Medical Group, a large HMO.
They wanted to know if training background affected the rate of performance of four different quality measures related to hysterectomy for POP: offering conservative treatment prior to the surgical treatment of POP, quantitative assessment of POP with either a Baden-Walker or a POP-Q exam, apical support procedure performed at the time of hysterectomy for prolapse, and performance of intraoperative cystoscopy.
Patients who underwent hysterectomy for POP in 2008 were eligible for the study. The researchers reviewed electronic medical records for clinical and demographic data and categorized surgeons by their level of training.
“They were considered fellowship trained if they had pursued additional formal subspecialty training in female pelvic medicine and reconstructive surgery,” Dr. Adams-Piper explained. “Surgeons were considered grandfathered if they subsequently took the FPMRS [Female Pelvic Medicine and Reconstructive Surgery] boards when they became available in 2013. Surgeons were considered generalist if they fit into neither of these two categories and completed a residency in ob.gyn.”
Chi-squared tests were used to compare demographics and performance of the proposed quality measures. Of the 662 hysterectomies performed in 2008, 328 were included in the final analysis. The mean patient age was 60 years, the mean parity was 2.9, and the mean body mass index was 27.9 kg/m2.
Overall performance of the four proposed quality measures was high, ranging from 82%-87%. More than half of quality assessments (58%) were performed with the POP-Q exam, while the majority of apical support procedures were uterosacral ligament vault suspensions (67%), followed by sacrocolpopexy (18%), McCall culdoplasty (12%), and sacrospinous ligament fixation (3%).
When categorized by training, fellowship-trained surgeons performed 133 hysterectomies, “grandfathered” surgeons performed 55, and generalist gynecologic surgeons performed 140. Fellowship-trained surgeons performed each of the four proposed quality measures more often than did grandfathered surgeons, who performed them more often than generalist gynecologic surgeons did.
Specifically, conservative treatment was offered by 94% of fellowship-trained surgeons, 87% of grandfathered surgeons, and 76% of generalist gynecologic surgeons (P = .0002). Qualitative preoperative assessment of POP was performed by 99% of fellowship-trained surgeons, 93% of grandfathered surgeons, and 73% of generalist gynecologic surgeons (three-way comparison reached statistical significance, with a P less than .0001).
Apical repair was performed by 96% of fellowship-trained surgeons, 82% of grandfathered surgeons, and 69% of generalist gynecologic surgeons (P less than .0001). Finally, cystoscopy was performed by 98% of fellowship-trained surgeons, 91% of grandfathered surgeons, and 72% of generalist gynecologic surgeons (P less than .0001).
When the researchers evaluated the cumulative performance of all measures in the same patient, fellowship-trained surgeons had the highest rates (89%, compared with 62% of grandfathered surgeons, and 39% of generalist gynecologic surgeons; P less than .0001).
“When we looked at the patient characteristics and their distribution across the surgeon training backgrounds, we found no significant differences in the age, BMI, gravidity, or parity of the subjects that underwent surgeries with the three groups,” Dr. Adams-Piper said.
She acknowledged certain limitations of the study, including the fact that it reflects clinical practice in a single health care delivery system, it relied on prior documentation, and it evaluated data from 2008.
“From this study we can conclude that perioperative practice patterns differ by surgeon training background,” she said. “However, in order for the proposed quality measures to be clinically meaningful, they must be correlated with patient-centered outcomes.”
Dr. Adams-Piper reported having no financial disclosures. The meeting was jointly sponsored by the American College of Surgeons.
AT SGS 2016
Key clinical point: The level of surgical training impacted performance of proposed quality measures at the time of hysterectomy for pelvic organ prolapse.
Major finding: Fellowship-trained surgeons in female pelvic medicine and reconstructive surgery were significantly more likely to perform proposed quality measures relating to hysterectomy for pelvic organ prolapse at 89%, compared with 39% of generalist gynecologic surgeons.
Data source: A review 328 hysterectomies performed in 2008 by surgeons in a Southern California HMO.
Disclosures: Dr. Adams-Piper reported having no financial disclosures.
Surgery, pessary are both good options for treating prolapse
INDIAN WELLS, CALIF. – Both surgery and pessary are effective at helping women with pelvic organ prolapse attain pre-treatment goals, improvements in quality of life, and improvements in patient-reported outcome scores, results from a prospective cohort study demonstrated.
“Women seeking care for pelvic organ prolapse have a wide range of severity in symptoms and they often have highly individual goals for treatment,” Dr. Kyle J. Wohlrab said at the annual scientific meeting of the Society of Gynecologic Surgeons. “We know that when we attain those goals, we help their quality of life.”
Dr. Wohlrab, of the Division of Female Pelvic Medicine and Reconstructive Surgery at Women and Infants Hospital, Providence, R.I., and his associates set out to compare goal attainment between women who chose surgery versus pessary for treatment of their pelvic organ prolapse. Their secondary aim was to evaluate the association between improvements in symptoms and quality of life scores with goal attainment.
Women were eligible if they had symptomatic bulge symptoms and stage 2 or greater pelvic organ prolapse. They were enrolled when they chose either surgery or pessary for treatment and had a successful pessary fitting. The study participants were asked what their 10 most important goals for treatment were, and the researchers categorized them as functional goals (physical, social, emotional, and sexual) or symptom goals (prolapse, urinary, bowel, and pain/discomfort).
The secondary study outcomes were patient-reported outcomes based on the Pelvic Floor Distress Inventory-20 (PFDI-20), the Pelvic Floor Impact Questionnaire-short form 7 (PFIQ-7), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), and the Body Image Scale (BIS), which were administered at baseline, 6 months, and 12 months.
A total of 160 women were studied, 80 in each treatment group. Compared with those in the pessary group, women in the surgical group were younger at baseline (a mean of 59 years vs. 64 years), and had less severe prolapse (Pelvic Organ Prolapse Quantification System stage 2 vs. 3), but they had worse PFDI-20 scores (a mean of 126 vs. 104) and BIS scores (a mean of 32 vs. 22).
Dr. Wohlrab and his associates found that 75% of patients in the surgery group achieved all of their functional goals, compared with 58% of those in the pessary group, a difference that did not reach statistical significance except in the category of physical function, which favored patients in the surgery group (87% of goals attained, vs. 62% of those in the pessary group; P = .03).
At the same time, 74% of patients in the surgery group achieved all of their symptom goals, compared with 70% of those in the pessary group, a difference that did not reach statistical significance (P = .7).
Both surgery and pessary groups had significant improvements in the PFDI-20, PFIQ-7, and the BIS scores from baseline (P less than .05 for all). Mean scores on the PISQ-12 also improved from baseline in the surgery group (P less than .05), but not in the pessary group.
Dr. Wohlrab reported having no financial disclosures. The meeting was jointly sponsored by the American College of Surgeons.
INDIAN WELLS, CALIF. – Both surgery and pessary are effective at helping women with pelvic organ prolapse attain pre-treatment goals, improvements in quality of life, and improvements in patient-reported outcome scores, results from a prospective cohort study demonstrated.
“Women seeking care for pelvic organ prolapse have a wide range of severity in symptoms and they often have highly individual goals for treatment,” Dr. Kyle J. Wohlrab said at the annual scientific meeting of the Society of Gynecologic Surgeons. “We know that when we attain those goals, we help their quality of life.”
Dr. Wohlrab, of the Division of Female Pelvic Medicine and Reconstructive Surgery at Women and Infants Hospital, Providence, R.I., and his associates set out to compare goal attainment between women who chose surgery versus pessary for treatment of their pelvic organ prolapse. Their secondary aim was to evaluate the association between improvements in symptoms and quality of life scores with goal attainment.
Women were eligible if they had symptomatic bulge symptoms and stage 2 or greater pelvic organ prolapse. They were enrolled when they chose either surgery or pessary for treatment and had a successful pessary fitting. The study participants were asked what their 10 most important goals for treatment were, and the researchers categorized them as functional goals (physical, social, emotional, and sexual) or symptom goals (prolapse, urinary, bowel, and pain/discomfort).
The secondary study outcomes were patient-reported outcomes based on the Pelvic Floor Distress Inventory-20 (PFDI-20), the Pelvic Floor Impact Questionnaire-short form 7 (PFIQ-7), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), and the Body Image Scale (BIS), which were administered at baseline, 6 months, and 12 months.
A total of 160 women were studied, 80 in each treatment group. Compared with those in the pessary group, women in the surgical group were younger at baseline (a mean of 59 years vs. 64 years), and had less severe prolapse (Pelvic Organ Prolapse Quantification System stage 2 vs. 3), but they had worse PFDI-20 scores (a mean of 126 vs. 104) and BIS scores (a mean of 32 vs. 22).
Dr. Wohlrab and his associates found that 75% of patients in the surgery group achieved all of their functional goals, compared with 58% of those in the pessary group, a difference that did not reach statistical significance except in the category of physical function, which favored patients in the surgery group (87% of goals attained, vs. 62% of those in the pessary group; P = .03).
At the same time, 74% of patients in the surgery group achieved all of their symptom goals, compared with 70% of those in the pessary group, a difference that did not reach statistical significance (P = .7).
Both surgery and pessary groups had significant improvements in the PFDI-20, PFIQ-7, and the BIS scores from baseline (P less than .05 for all). Mean scores on the PISQ-12 also improved from baseline in the surgery group (P less than .05), but not in the pessary group.
Dr. Wohlrab reported having no financial disclosures. The meeting was jointly sponsored by the American College of Surgeons.
INDIAN WELLS, CALIF. – Both surgery and pessary are effective at helping women with pelvic organ prolapse attain pre-treatment goals, improvements in quality of life, and improvements in patient-reported outcome scores, results from a prospective cohort study demonstrated.
“Women seeking care for pelvic organ prolapse have a wide range of severity in symptoms and they often have highly individual goals for treatment,” Dr. Kyle J. Wohlrab said at the annual scientific meeting of the Society of Gynecologic Surgeons. “We know that when we attain those goals, we help their quality of life.”
Dr. Wohlrab, of the Division of Female Pelvic Medicine and Reconstructive Surgery at Women and Infants Hospital, Providence, R.I., and his associates set out to compare goal attainment between women who chose surgery versus pessary for treatment of their pelvic organ prolapse. Their secondary aim was to evaluate the association between improvements in symptoms and quality of life scores with goal attainment.
Women were eligible if they had symptomatic bulge symptoms and stage 2 or greater pelvic organ prolapse. They were enrolled when they chose either surgery or pessary for treatment and had a successful pessary fitting. The study participants were asked what their 10 most important goals for treatment were, and the researchers categorized them as functional goals (physical, social, emotional, and sexual) or symptom goals (prolapse, urinary, bowel, and pain/discomfort).
The secondary study outcomes were patient-reported outcomes based on the Pelvic Floor Distress Inventory-20 (PFDI-20), the Pelvic Floor Impact Questionnaire-short form 7 (PFIQ-7), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), and the Body Image Scale (BIS), which were administered at baseline, 6 months, and 12 months.
A total of 160 women were studied, 80 in each treatment group. Compared with those in the pessary group, women in the surgical group were younger at baseline (a mean of 59 years vs. 64 years), and had less severe prolapse (Pelvic Organ Prolapse Quantification System stage 2 vs. 3), but they had worse PFDI-20 scores (a mean of 126 vs. 104) and BIS scores (a mean of 32 vs. 22).
Dr. Wohlrab and his associates found that 75% of patients in the surgery group achieved all of their functional goals, compared with 58% of those in the pessary group, a difference that did not reach statistical significance except in the category of physical function, which favored patients in the surgery group (87% of goals attained, vs. 62% of those in the pessary group; P = .03).
At the same time, 74% of patients in the surgery group achieved all of their symptom goals, compared with 70% of those in the pessary group, a difference that did not reach statistical significance (P = .7).
Both surgery and pessary groups had significant improvements in the PFDI-20, PFIQ-7, and the BIS scores from baseline (P less than .05 for all). Mean scores on the PISQ-12 also improved from baseline in the surgery group (P less than .05), but not in the pessary group.
Dr. Wohlrab reported having no financial disclosures. The meeting was jointly sponsored by the American College of Surgeons.
AT SGS 2016
Key clinical point: Both surgery and pessary were effective in helping women with pelvic organ prolapse reach pre-treatment functional and symptom goals.
Major finding: Seventy-five percent of patients in the surgery group achieved all of their pre-treatment functional goals, compared with 58% of those in the pessary group, a difference that did not reach statistical significance.
Data source: A prospective cohort study of 180 women who chose either surgery or pessary for treatment of pelvic organ prolapse.
Disclosures: Dr. Wohlrab reported having no financial disclosures.
Premenopausal age linked to lower sexual function after gynecologic cancer surgery
INDIAN WELLS, CALIF. – Premenopausal age was associated with a greater temporary decline in sexual desire 1 month after undergoing surgery for suspected gynecologic malignancies, results from an ancillary analysis showed.
“Sexual health is an important dimension of quality of life for women with gynecologic cancer,” Dr. C. Emi Bretschneider, lead study author, said at the annual scientific meeting of the Society of Gynecologic Surgeons. “Limited data exists on the impact of surgery for treatment of gynecologic cancer on patient-reported sexual desire and interest.”
In an effort to evaluate the impact on sexual function in women undergoing surgery for presumed or known gynecologic malignancies, the researchers performed an ancillary analysis of a cohort study analyzing quality-of-life and operative outcomes in 185 women who underwent gynecologic oncology procedures at the University of North Carolina, Chapel Hill, between October 2013 and October 2014.
Study participants completed the Patient-Reported Outcomes Measurement Information System Sexual Function and Satisfaction Questionnaire (PROMIS-SFQ) at baseline and at 1, 3, and 6 months postoperatively. The questionnaire evaluates four subdomains of sexual function: global satisfaction with sex life, interest in sexual activity, lubrication, and vaginal discomfort. The researchers used student t-test and linear regression to compare mean score changes between cancer types, surgical route, menopausal status, and postoperative complications, said Dr. Bretschneider of the university’s department of obstetrics and gynecology.
Of the 281 patients initially enrolled, 185 (66%) completed the PROMIS-SFQ at baseline and at 1 month postoperatively, forming the primary cohort from which the researchers performed the analysis. Of these 185 patients, 170 (92%) completed the PROMIS-SFQ at 3 months and 174 (94%) completed the survey at 6 months postoperatively.
The average age of patients at baseline was 56 years: most (77%) were white, mean body mass index was 32.9 kg/m2, 62% were partnered, and 63% underwent minimally invasive procedures. Following surgery, 131 of the patients (71%) were diagnosed with a malignancy, most commonly uterine cancer (84%), followed by ovarian (23%), cervical (17%), and vulvar cancer (3%).
Dr. Bretschneider reported that the mean baseline sexual interest score among all study participants was 44.8. At 1 month postoperatively, the mean scores decreased a mean of 3.8 points from baseline to 41. By 3 and 6 months postoperatively, the mean sexual interest scores increased from baseline by 1.9 and 2.7 points, respectively, to 46.7 and 47.5.
Women younger than age 55 years had a greater decrease in sexual interest between baseline and 1 month postoperatively, compared with their counterparts aged 55 and older (a mean of –5.5 vs. –2.3 points, respectively; P = .02).
On multivariate analysis adjusted for cancer diagnosis, minimally invasive surgery, and cancer site, women younger than age 55 continued to have a greater decrease in sexual interest between baseline and 1 month postoperatively, compared with their counterparts aged 55 and older (a mean of –4.59 points). Additionally, women who had cancer had a greater drop in sexual desire, compared with those with benign disease (a mean of –5.6 points).
“This study offers new information on the impact of surgery on sexual function for women with gynecologic cancer,” Dr. Bretschneider said at the meeting, which was jointly sponsored by the American College of Surgeons. “The study was further strengthened by its prospective design and well-characterized, large cohort of women.” Weaknesses, she continued, include its generalizability, “which may be limited, as the study cohort was recruited from a single academic institution. Also, the small sample size for some cancer sites reduced our ability to sense cancer site as a causal agent for sexual dysfunction.”
Dr. Bretschneider reported having no financial disclosures.
INDIAN WELLS, CALIF. – Premenopausal age was associated with a greater temporary decline in sexual desire 1 month after undergoing surgery for suspected gynecologic malignancies, results from an ancillary analysis showed.
“Sexual health is an important dimension of quality of life for women with gynecologic cancer,” Dr. C. Emi Bretschneider, lead study author, said at the annual scientific meeting of the Society of Gynecologic Surgeons. “Limited data exists on the impact of surgery for treatment of gynecologic cancer on patient-reported sexual desire and interest.”
In an effort to evaluate the impact on sexual function in women undergoing surgery for presumed or known gynecologic malignancies, the researchers performed an ancillary analysis of a cohort study analyzing quality-of-life and operative outcomes in 185 women who underwent gynecologic oncology procedures at the University of North Carolina, Chapel Hill, between October 2013 and October 2014.
Study participants completed the Patient-Reported Outcomes Measurement Information System Sexual Function and Satisfaction Questionnaire (PROMIS-SFQ) at baseline and at 1, 3, and 6 months postoperatively. The questionnaire evaluates four subdomains of sexual function: global satisfaction with sex life, interest in sexual activity, lubrication, and vaginal discomfort. The researchers used student t-test and linear regression to compare mean score changes between cancer types, surgical route, menopausal status, and postoperative complications, said Dr. Bretschneider of the university’s department of obstetrics and gynecology.
Of the 281 patients initially enrolled, 185 (66%) completed the PROMIS-SFQ at baseline and at 1 month postoperatively, forming the primary cohort from which the researchers performed the analysis. Of these 185 patients, 170 (92%) completed the PROMIS-SFQ at 3 months and 174 (94%) completed the survey at 6 months postoperatively.
The average age of patients at baseline was 56 years: most (77%) were white, mean body mass index was 32.9 kg/m2, 62% were partnered, and 63% underwent minimally invasive procedures. Following surgery, 131 of the patients (71%) were diagnosed with a malignancy, most commonly uterine cancer (84%), followed by ovarian (23%), cervical (17%), and vulvar cancer (3%).
Dr. Bretschneider reported that the mean baseline sexual interest score among all study participants was 44.8. At 1 month postoperatively, the mean scores decreased a mean of 3.8 points from baseline to 41. By 3 and 6 months postoperatively, the mean sexual interest scores increased from baseline by 1.9 and 2.7 points, respectively, to 46.7 and 47.5.
Women younger than age 55 years had a greater decrease in sexual interest between baseline and 1 month postoperatively, compared with their counterparts aged 55 and older (a mean of –5.5 vs. –2.3 points, respectively; P = .02).
On multivariate analysis adjusted for cancer diagnosis, minimally invasive surgery, and cancer site, women younger than age 55 continued to have a greater decrease in sexual interest between baseline and 1 month postoperatively, compared with their counterparts aged 55 and older (a mean of –4.59 points). Additionally, women who had cancer had a greater drop in sexual desire, compared with those with benign disease (a mean of –5.6 points).
“This study offers new information on the impact of surgery on sexual function for women with gynecologic cancer,” Dr. Bretschneider said at the meeting, which was jointly sponsored by the American College of Surgeons. “The study was further strengthened by its prospective design and well-characterized, large cohort of women.” Weaknesses, she continued, include its generalizability, “which may be limited, as the study cohort was recruited from a single academic institution. Also, the small sample size for some cancer sites reduced our ability to sense cancer site as a causal agent for sexual dysfunction.”
Dr. Bretschneider reported having no financial disclosures.
INDIAN WELLS, CALIF. – Premenopausal age was associated with a greater temporary decline in sexual desire 1 month after undergoing surgery for suspected gynecologic malignancies, results from an ancillary analysis showed.
“Sexual health is an important dimension of quality of life for women with gynecologic cancer,” Dr. C. Emi Bretschneider, lead study author, said at the annual scientific meeting of the Society of Gynecologic Surgeons. “Limited data exists on the impact of surgery for treatment of gynecologic cancer on patient-reported sexual desire and interest.”
In an effort to evaluate the impact on sexual function in women undergoing surgery for presumed or known gynecologic malignancies, the researchers performed an ancillary analysis of a cohort study analyzing quality-of-life and operative outcomes in 185 women who underwent gynecologic oncology procedures at the University of North Carolina, Chapel Hill, between October 2013 and October 2014.
Study participants completed the Patient-Reported Outcomes Measurement Information System Sexual Function and Satisfaction Questionnaire (PROMIS-SFQ) at baseline and at 1, 3, and 6 months postoperatively. The questionnaire evaluates four subdomains of sexual function: global satisfaction with sex life, interest in sexual activity, lubrication, and vaginal discomfort. The researchers used student t-test and linear regression to compare mean score changes between cancer types, surgical route, menopausal status, and postoperative complications, said Dr. Bretschneider of the university’s department of obstetrics and gynecology.
Of the 281 patients initially enrolled, 185 (66%) completed the PROMIS-SFQ at baseline and at 1 month postoperatively, forming the primary cohort from which the researchers performed the analysis. Of these 185 patients, 170 (92%) completed the PROMIS-SFQ at 3 months and 174 (94%) completed the survey at 6 months postoperatively.
The average age of patients at baseline was 56 years: most (77%) were white, mean body mass index was 32.9 kg/m2, 62% were partnered, and 63% underwent minimally invasive procedures. Following surgery, 131 of the patients (71%) were diagnosed with a malignancy, most commonly uterine cancer (84%), followed by ovarian (23%), cervical (17%), and vulvar cancer (3%).
Dr. Bretschneider reported that the mean baseline sexual interest score among all study participants was 44.8. At 1 month postoperatively, the mean scores decreased a mean of 3.8 points from baseline to 41. By 3 and 6 months postoperatively, the mean sexual interest scores increased from baseline by 1.9 and 2.7 points, respectively, to 46.7 and 47.5.
Women younger than age 55 years had a greater decrease in sexual interest between baseline and 1 month postoperatively, compared with their counterparts aged 55 and older (a mean of –5.5 vs. –2.3 points, respectively; P = .02).
On multivariate analysis adjusted for cancer diagnosis, minimally invasive surgery, and cancer site, women younger than age 55 continued to have a greater decrease in sexual interest between baseline and 1 month postoperatively, compared with their counterparts aged 55 and older (a mean of –4.59 points). Additionally, women who had cancer had a greater drop in sexual desire, compared with those with benign disease (a mean of –5.6 points).
“This study offers new information on the impact of surgery on sexual function for women with gynecologic cancer,” Dr. Bretschneider said at the meeting, which was jointly sponsored by the American College of Surgeons. “The study was further strengthened by its prospective design and well-characterized, large cohort of women.” Weaknesses, she continued, include its generalizability, “which may be limited, as the study cohort was recruited from a single academic institution. Also, the small sample size for some cancer sites reduced our ability to sense cancer site as a causal agent for sexual dysfunction.”
Dr. Bretschneider reported having no financial disclosures.
AT SGS 2016
Key clinical point: Premenopausal age was associated with a greater temporary decline in sexual function following gynecologic oncology procedures.
Major finding: Women younger than age 55 years had a greater decrease in sexual interest between baseline and 1 month postoperatively, compared with their counterparts aged 55 and older (a mean of –5.5 vs. –2.3 points on the PROMIS-SFQ, respectively; P = .02).
Data source: An ancillary analysis of a cohort study analyzing quality-of-life and operative outcomes in 185 women who underwent gynecologic oncology procedures between October 2013 and October 2014.
Disclosures: Dr. Bretschneider reported having no financial disclosures.
Perioperative bundle implementation reduced SSIs after hysterectomy
INDIAN WELLS, CALIF. – Implementation of a gynecologic perioperative infection prevention bundle for patients undergoing hysterectomy in a large academic hospital led to a 53% decrease in surgical site infections (SSIs) and a 50% drop in deep and organ space infections, a retrospective study found.
“There are approximately 600,000 hysterectomies performed each year in the United States, and the infection rate is widely reported as 1%-4%,” Dr. Sarah E. Andiman said at the annual scientific meeting of the Society of Gynecologic Surgeons. “SSIs lead to increased morbidity, negative patient experiences, prolonged hospital stays, additional procedures, and increased costs. The exact costs of SSIs related to hysterectomy are not known. However, the Centers for Medicare & Medicaid Services has required public reporting of SSIs after hysterectomy since 2013.”
An interdisciplinary team at Yale–New Haven Hospital designed a perioperative gynecology-specific bundle aimed at reducing the SSI rate in hysterectomies. Dr. Andiman of the department of obstetrics, gynecology, and reproductive sciences at Yale University, New Haven, Conn., and her associates examined the efficacy of the infection prevention bundle. The primary outcome was SSI rate change, while the secondary outcome was hospital cost of admission for the initial care episode.
The bundle consists of a preoperative phase that includes chlorhexidine wipes, patient-controlled warming, and a standard antibiotic regimen consisting of 2 g of cefazolin within 1 hour of incision and 500 mg of metronidazole administered when there is a potential for bowel involvement.
The intraoperative phase of the bundle includes a standardized method of vaginal preparation with chlorhexidine and an abdominal prep with ChloraPrep. “Staff and trainees underwent training with an educational video that is available over our intranet,” Dr. Andiman said. “Also included was antibiotic redosing at 3 hours and intraoperative maintenance of temperature above 36° C.” The postoperative phase includes maintenance of a surgical dressing for 24-48 hours.
The researchers collected data prospectively according to institutional guidelines for tracking SSIs using definitions from the Centers for Disease Control and Prevention. All cases of SSIs were reviewed by a committee. In instances where the protocol was not followed, direct feedback was given to appropriate team members within 2 weeks.
The preintervention period was defined as the beginning of data collection through full bundle implementation, which was April 2013 through November 2014. The postbundle implementation period was December 2014 through June 2015. The analysis was limited to total abdominal, total laparoscopic, robotic-assisted total laparoscopic, and laparoscopic-assisted vaginal hysterectomies. Transvaginal and obstetric hysterectomies were excluded from the study, leaving a total of 1,763 procedures for inclusion.
Between the prebundle and postbundle period, the researchers observed a 53% decrease in SSIs and a 50% decrease in deep and organ space infections (P = .04). The difference was primarily driven by the decrease in the infection rate for total abdominal hysterectomies, Dr. Andiman said at the meeting, which was jointly sponsored by the American College of Surgeons.
The researchers also found that the cost of hospital admissions decreased 17.6% between the prebundle and postbundle period, from $7,452 per case to $6,142 per case (P = .002).
Dr. Andiman acknowledged certain limitations of the analysis, including the staggered implementation of the bundle components. “However, in the next stage of our study, we will be looking at comprehensive compliance data to examine this further,” she said. “Finally, we currently only have cost data for the cost of the hospital admission for the index surgery. We are also analyzing cost data for patients who were readmitted up to 30 days postoperatively to assess how this factors into overall costs.”
In an interview, Dr. Linda Fan, a gynecologic surgeon at Yale and the senior study author, said that a perioperative care bundle “by itself is not enough” to decrease SSI rates following hysterectomy.
“Education of staff is really important in terms of the uptake of these sorts of interventions,” she said. “As we move forward and everyone is looking at value, we have to teach people how to implement the different elements of the bundle.”
The researchers reported having no relevant financial disclosures.
INDIAN WELLS, CALIF. – Implementation of a gynecologic perioperative infection prevention bundle for patients undergoing hysterectomy in a large academic hospital led to a 53% decrease in surgical site infections (SSIs) and a 50% drop in deep and organ space infections, a retrospective study found.
“There are approximately 600,000 hysterectomies performed each year in the United States, and the infection rate is widely reported as 1%-4%,” Dr. Sarah E. Andiman said at the annual scientific meeting of the Society of Gynecologic Surgeons. “SSIs lead to increased morbidity, negative patient experiences, prolonged hospital stays, additional procedures, and increased costs. The exact costs of SSIs related to hysterectomy are not known. However, the Centers for Medicare & Medicaid Services has required public reporting of SSIs after hysterectomy since 2013.”
An interdisciplinary team at Yale–New Haven Hospital designed a perioperative gynecology-specific bundle aimed at reducing the SSI rate in hysterectomies. Dr. Andiman of the department of obstetrics, gynecology, and reproductive sciences at Yale University, New Haven, Conn., and her associates examined the efficacy of the infection prevention bundle. The primary outcome was SSI rate change, while the secondary outcome was hospital cost of admission for the initial care episode.
The bundle consists of a preoperative phase that includes chlorhexidine wipes, patient-controlled warming, and a standard antibiotic regimen consisting of 2 g of cefazolin within 1 hour of incision and 500 mg of metronidazole administered when there is a potential for bowel involvement.
The intraoperative phase of the bundle includes a standardized method of vaginal preparation with chlorhexidine and an abdominal prep with ChloraPrep. “Staff and trainees underwent training with an educational video that is available over our intranet,” Dr. Andiman said. “Also included was antibiotic redosing at 3 hours and intraoperative maintenance of temperature above 36° C.” The postoperative phase includes maintenance of a surgical dressing for 24-48 hours.
The researchers collected data prospectively according to institutional guidelines for tracking SSIs using definitions from the Centers for Disease Control and Prevention. All cases of SSIs were reviewed by a committee. In instances where the protocol was not followed, direct feedback was given to appropriate team members within 2 weeks.
The preintervention period was defined as the beginning of data collection through full bundle implementation, which was April 2013 through November 2014. The postbundle implementation period was December 2014 through June 2015. The analysis was limited to total abdominal, total laparoscopic, robotic-assisted total laparoscopic, and laparoscopic-assisted vaginal hysterectomies. Transvaginal and obstetric hysterectomies were excluded from the study, leaving a total of 1,763 procedures for inclusion.
Between the prebundle and postbundle period, the researchers observed a 53% decrease in SSIs and a 50% decrease in deep and organ space infections (P = .04). The difference was primarily driven by the decrease in the infection rate for total abdominal hysterectomies, Dr. Andiman said at the meeting, which was jointly sponsored by the American College of Surgeons.
The researchers also found that the cost of hospital admissions decreased 17.6% between the prebundle and postbundle period, from $7,452 per case to $6,142 per case (P = .002).
Dr. Andiman acknowledged certain limitations of the analysis, including the staggered implementation of the bundle components. “However, in the next stage of our study, we will be looking at comprehensive compliance data to examine this further,” she said. “Finally, we currently only have cost data for the cost of the hospital admission for the index surgery. We are also analyzing cost data for patients who were readmitted up to 30 days postoperatively to assess how this factors into overall costs.”
In an interview, Dr. Linda Fan, a gynecologic surgeon at Yale and the senior study author, said that a perioperative care bundle “by itself is not enough” to decrease SSI rates following hysterectomy.
“Education of staff is really important in terms of the uptake of these sorts of interventions,” she said. “As we move forward and everyone is looking at value, we have to teach people how to implement the different elements of the bundle.”
The researchers reported having no relevant financial disclosures.
INDIAN WELLS, CALIF. – Implementation of a gynecologic perioperative infection prevention bundle for patients undergoing hysterectomy in a large academic hospital led to a 53% decrease in surgical site infections (SSIs) and a 50% drop in deep and organ space infections, a retrospective study found.
“There are approximately 600,000 hysterectomies performed each year in the United States, and the infection rate is widely reported as 1%-4%,” Dr. Sarah E. Andiman said at the annual scientific meeting of the Society of Gynecologic Surgeons. “SSIs lead to increased morbidity, negative patient experiences, prolonged hospital stays, additional procedures, and increased costs. The exact costs of SSIs related to hysterectomy are not known. However, the Centers for Medicare & Medicaid Services has required public reporting of SSIs after hysterectomy since 2013.”
An interdisciplinary team at Yale–New Haven Hospital designed a perioperative gynecology-specific bundle aimed at reducing the SSI rate in hysterectomies. Dr. Andiman of the department of obstetrics, gynecology, and reproductive sciences at Yale University, New Haven, Conn., and her associates examined the efficacy of the infection prevention bundle. The primary outcome was SSI rate change, while the secondary outcome was hospital cost of admission for the initial care episode.
The bundle consists of a preoperative phase that includes chlorhexidine wipes, patient-controlled warming, and a standard antibiotic regimen consisting of 2 g of cefazolin within 1 hour of incision and 500 mg of metronidazole administered when there is a potential for bowel involvement.
The intraoperative phase of the bundle includes a standardized method of vaginal preparation with chlorhexidine and an abdominal prep with ChloraPrep. “Staff and trainees underwent training with an educational video that is available over our intranet,” Dr. Andiman said. “Also included was antibiotic redosing at 3 hours and intraoperative maintenance of temperature above 36° C.” The postoperative phase includes maintenance of a surgical dressing for 24-48 hours.
The researchers collected data prospectively according to institutional guidelines for tracking SSIs using definitions from the Centers for Disease Control and Prevention. All cases of SSIs were reviewed by a committee. In instances where the protocol was not followed, direct feedback was given to appropriate team members within 2 weeks.
The preintervention period was defined as the beginning of data collection through full bundle implementation, which was April 2013 through November 2014. The postbundle implementation period was December 2014 through June 2015. The analysis was limited to total abdominal, total laparoscopic, robotic-assisted total laparoscopic, and laparoscopic-assisted vaginal hysterectomies. Transvaginal and obstetric hysterectomies were excluded from the study, leaving a total of 1,763 procedures for inclusion.
Between the prebundle and postbundle period, the researchers observed a 53% decrease in SSIs and a 50% decrease in deep and organ space infections (P = .04). The difference was primarily driven by the decrease in the infection rate for total abdominal hysterectomies, Dr. Andiman said at the meeting, which was jointly sponsored by the American College of Surgeons.
The researchers also found that the cost of hospital admissions decreased 17.6% between the prebundle and postbundle period, from $7,452 per case to $6,142 per case (P = .002).
Dr. Andiman acknowledged certain limitations of the analysis, including the staggered implementation of the bundle components. “However, in the next stage of our study, we will be looking at comprehensive compliance data to examine this further,” she said. “Finally, we currently only have cost data for the cost of the hospital admission for the index surgery. We are also analyzing cost data for patients who were readmitted up to 30 days postoperatively to assess how this factors into overall costs.”
In an interview, Dr. Linda Fan, a gynecologic surgeon at Yale and the senior study author, said that a perioperative care bundle “by itself is not enough” to decrease SSI rates following hysterectomy.
“Education of staff is really important in terms of the uptake of these sorts of interventions,” she said. “As we move forward and everyone is looking at value, we have to teach people how to implement the different elements of the bundle.”
The researchers reported having no relevant financial disclosures.
AT SGS 2016
Key clinical point: Implementation of a gynecologic perioperative bundle helped reduce surgical site infections following hysterectomy.
Major finding: Between the prebundle and postbundle period, the researchers observed a 53% decrease in surgical site infections and a 50% decrease in deep and organ space infections (P = .04).
Data source: A retrospective cohort study of 1,763 hysterectomies performed before and after implementation of a gynecologic perioperative bundle designed to prevent surgical site infections.
Disclosures: The researchers reported having no relevant financial disclosures.
Chlorhexidine-alcohol skin prep reduced SSIs after abdominal hysterectomy
INDIAN WELLS, CALIF. – Using chlorhexidine-alcohol preoperative skin antisepsis at the time of abdominal hysterectomy is associated with a lower incidence of surgical site infections (SSIs), compared with using povidone-iodine antiseptic solution, a large retrospective study showed.
“Surgical site infections have been linked to longer hospital stays, higher readmission rates, and overall increased healthcare costs,” Ali Bazzi, the lead study author, said at the annual scientific meeting of the Society of Gynecologic Surgeons. “Preoperative topical skin antiseptics have decreased the rate of SSIs over the years and have led to improved patient outcomes. Current published guidelines for skin preparations, specifically abdominal hysterectomies, do not routinely specify a choice of antiseptic. With greater than 500,000 hysterectomies performed each year in the United States, and about half done via laparotomy, this can have significant clinical implications.”
In an effort to determine whether the choice of preoperative topical antisepsis independently affects SSIs, Mr. Bazzi, a fourth-year medical student at the University of Michigan, Ann Arbor, and his associates in the university’s department of gynecologic oncology evaluated chlorhexidine-gluconate in alcohol versus povidone-iodine in aqueous solution. The second objective focused on determining certain patient factors and operative predictors of SSIs.
The researchers used the Michigan Surgical Quality Collaborative database to perform a retrospective cohort analysis of patients who underwent abdominal hysterectomy from July 2012 to February 2015. The primary outcome was diagnosis of a superficial, deep, or organ space SSI within 30 days of surgery, while the primary predictor was whether the individual cases received either the chlorhexidine-alcohol or the povidone-iodine antiseptic solution.
The researchers excluded cases with missing data, preoperative sepsis or emergent operative cases, and patients on chronic steroids due to immunosuppression, since these cases were associated with a higher than baseline risk of developing SSIs. Other types of skin preparation agents did not meet a large enough sample size and thus were underpowered. These cases were not included in the final analysis. Multivariate logistic regression models estimated the independent effect of skin antiseptic choice on the rate of SSI.
Mr. Bazzi reported results from 5,074 abdominal hysterectomies. Compared with patients in the povidone-iodine group, those in the chlorhexidine-alcohol group had several medical comorbidities, demographic and perioperative factors associated with the development of SSIs, including being more likely to have a BMI of 30 kg/m2 or greater; American Society of Anesthesiology Class of 3 or greater; dependent functional status; malignancy as a preoperative indication for surgery; estimated blood loss of greater than 250 cc; and surgery lasting longer than 3 hours.
The overall rate of any SSI was 3.6%. The unadjusted SSI rates based on antiseptic choice were 3.5% in the chlorhexidine-alcohol group and 3.8% in the povidone-iodine group. After using multivariate logistic regression adjusted for population differences, the researchers determined that chlorhexidine-alcohol was associated with a 30% lower odds of developing SSIs, compared with those in the povidone-iodine group (odds ratio, 0.71; 95% confidence interval, 0.51-0.98; P = .037).
Mr. Bazzi, who begins an ob.gyn. residency at St. John Hospital and Medical Center in Detroit in July 2016, acknowledged that other qualitative factors not included in the analysis could affect the incidence of SSIs, such as operative experience, surgical technique, resident exposure, type of ligature used, and excessive use of electrosurgical devices.
He noted that future randomized, controlled trials of skin antiseptic preparations given prior to abdominal hysterectomy would be helpful. For now, “we believe that future guidelines should specify the choice of antisepsis prior to abdominal hysterectomy,” he said at the meeting, which is jointly sponsored by the American College of Surgeons.
Mr. Bazzi reported having no financial disclosures.
INDIAN WELLS, CALIF. – Using chlorhexidine-alcohol preoperative skin antisepsis at the time of abdominal hysterectomy is associated with a lower incidence of surgical site infections (SSIs), compared with using povidone-iodine antiseptic solution, a large retrospective study showed.
“Surgical site infections have been linked to longer hospital stays, higher readmission rates, and overall increased healthcare costs,” Ali Bazzi, the lead study author, said at the annual scientific meeting of the Society of Gynecologic Surgeons. “Preoperative topical skin antiseptics have decreased the rate of SSIs over the years and have led to improved patient outcomes. Current published guidelines for skin preparations, specifically abdominal hysterectomies, do not routinely specify a choice of antiseptic. With greater than 500,000 hysterectomies performed each year in the United States, and about half done via laparotomy, this can have significant clinical implications.”
In an effort to determine whether the choice of preoperative topical antisepsis independently affects SSIs, Mr. Bazzi, a fourth-year medical student at the University of Michigan, Ann Arbor, and his associates in the university’s department of gynecologic oncology evaluated chlorhexidine-gluconate in alcohol versus povidone-iodine in aqueous solution. The second objective focused on determining certain patient factors and operative predictors of SSIs.
The researchers used the Michigan Surgical Quality Collaborative database to perform a retrospective cohort analysis of patients who underwent abdominal hysterectomy from July 2012 to February 2015. The primary outcome was diagnosis of a superficial, deep, or organ space SSI within 30 days of surgery, while the primary predictor was whether the individual cases received either the chlorhexidine-alcohol or the povidone-iodine antiseptic solution.
The researchers excluded cases with missing data, preoperative sepsis or emergent operative cases, and patients on chronic steroids due to immunosuppression, since these cases were associated with a higher than baseline risk of developing SSIs. Other types of skin preparation agents did not meet a large enough sample size and thus were underpowered. These cases were not included in the final analysis. Multivariate logistic regression models estimated the independent effect of skin antiseptic choice on the rate of SSI.
Mr. Bazzi reported results from 5,074 abdominal hysterectomies. Compared with patients in the povidone-iodine group, those in the chlorhexidine-alcohol group had several medical comorbidities, demographic and perioperative factors associated with the development of SSIs, including being more likely to have a BMI of 30 kg/m2 or greater; American Society of Anesthesiology Class of 3 or greater; dependent functional status; malignancy as a preoperative indication for surgery; estimated blood loss of greater than 250 cc; and surgery lasting longer than 3 hours.
The overall rate of any SSI was 3.6%. The unadjusted SSI rates based on antiseptic choice were 3.5% in the chlorhexidine-alcohol group and 3.8% in the povidone-iodine group. After using multivariate logistic regression adjusted for population differences, the researchers determined that chlorhexidine-alcohol was associated with a 30% lower odds of developing SSIs, compared with those in the povidone-iodine group (odds ratio, 0.71; 95% confidence interval, 0.51-0.98; P = .037).
Mr. Bazzi, who begins an ob.gyn. residency at St. John Hospital and Medical Center in Detroit in July 2016, acknowledged that other qualitative factors not included in the analysis could affect the incidence of SSIs, such as operative experience, surgical technique, resident exposure, type of ligature used, and excessive use of electrosurgical devices.
He noted that future randomized, controlled trials of skin antiseptic preparations given prior to abdominal hysterectomy would be helpful. For now, “we believe that future guidelines should specify the choice of antisepsis prior to abdominal hysterectomy,” he said at the meeting, which is jointly sponsored by the American College of Surgeons.
Mr. Bazzi reported having no financial disclosures.
INDIAN WELLS, CALIF. – Using chlorhexidine-alcohol preoperative skin antisepsis at the time of abdominal hysterectomy is associated with a lower incidence of surgical site infections (SSIs), compared with using povidone-iodine antiseptic solution, a large retrospective study showed.
“Surgical site infections have been linked to longer hospital stays, higher readmission rates, and overall increased healthcare costs,” Ali Bazzi, the lead study author, said at the annual scientific meeting of the Society of Gynecologic Surgeons. “Preoperative topical skin antiseptics have decreased the rate of SSIs over the years and have led to improved patient outcomes. Current published guidelines for skin preparations, specifically abdominal hysterectomies, do not routinely specify a choice of antiseptic. With greater than 500,000 hysterectomies performed each year in the United States, and about half done via laparotomy, this can have significant clinical implications.”
In an effort to determine whether the choice of preoperative topical antisepsis independently affects SSIs, Mr. Bazzi, a fourth-year medical student at the University of Michigan, Ann Arbor, and his associates in the university’s department of gynecologic oncology evaluated chlorhexidine-gluconate in alcohol versus povidone-iodine in aqueous solution. The second objective focused on determining certain patient factors and operative predictors of SSIs.
The researchers used the Michigan Surgical Quality Collaborative database to perform a retrospective cohort analysis of patients who underwent abdominal hysterectomy from July 2012 to February 2015. The primary outcome was diagnosis of a superficial, deep, or organ space SSI within 30 days of surgery, while the primary predictor was whether the individual cases received either the chlorhexidine-alcohol or the povidone-iodine antiseptic solution.
The researchers excluded cases with missing data, preoperative sepsis or emergent operative cases, and patients on chronic steroids due to immunosuppression, since these cases were associated with a higher than baseline risk of developing SSIs. Other types of skin preparation agents did not meet a large enough sample size and thus were underpowered. These cases were not included in the final analysis. Multivariate logistic regression models estimated the independent effect of skin antiseptic choice on the rate of SSI.
Mr. Bazzi reported results from 5,074 abdominal hysterectomies. Compared with patients in the povidone-iodine group, those in the chlorhexidine-alcohol group had several medical comorbidities, demographic and perioperative factors associated with the development of SSIs, including being more likely to have a BMI of 30 kg/m2 or greater; American Society of Anesthesiology Class of 3 or greater; dependent functional status; malignancy as a preoperative indication for surgery; estimated blood loss of greater than 250 cc; and surgery lasting longer than 3 hours.
The overall rate of any SSI was 3.6%. The unadjusted SSI rates based on antiseptic choice were 3.5% in the chlorhexidine-alcohol group and 3.8% in the povidone-iodine group. After using multivariate logistic regression adjusted for population differences, the researchers determined that chlorhexidine-alcohol was associated with a 30% lower odds of developing SSIs, compared with those in the povidone-iodine group (odds ratio, 0.71; 95% confidence interval, 0.51-0.98; P = .037).
Mr. Bazzi, who begins an ob.gyn. residency at St. John Hospital and Medical Center in Detroit in July 2016, acknowledged that other qualitative factors not included in the analysis could affect the incidence of SSIs, such as operative experience, surgical technique, resident exposure, type of ligature used, and excessive use of electrosurgical devices.
He noted that future randomized, controlled trials of skin antiseptic preparations given prior to abdominal hysterectomy would be helpful. For now, “we believe that future guidelines should specify the choice of antisepsis prior to abdominal hysterectomy,” he said at the meeting, which is jointly sponsored by the American College of Surgeons.
Mr. Bazzi reported having no financial disclosures.
AT SGS 2016
Key clinical point: Chlorhexidine-alcohol preoperative skin antisepsis at the time of abdominal hysterectomy was superior to povidone-iodine antiseptic solution in reducing SSIs.
Major finding: The use of chlorhexidine-alcohol preoperative skin antisepsis at the time of abdominal hysterectomy was associated with about a 30% lower odds of developing SSIs, compared with using povidone-iodine antiseptic solution (odds ratio, 0.71).
Data source: A retrospective cohort analysis of 5,074 patients who underwent abdominal hysterectomy from July 2012 to February 2015.
Disclosures: Mr. Bazzi reported having no financial disclosures.
Study identifies cognitive impairment in elderly urogynecologic patients
INDIAN WELLS, CALIF. – A rapid screening tool found that about 5% of urogynecologic patients aged 65-74 years showed signs of cognitive impairment, with that figure rising to more than 30% for patients age 85 and older, according to the results of a single-center study.
“As our gynecologic patients continue to age, it’s increasingly important that we continue to identify and manage the risk factors for cognitive decline that occur in the ambulatory and the perioperative care settings,” Dr. Elisa R. Trowbridge, lead study author, said at the annual scientific meeting of the Society of Gynecologic Surgeons. “However, data are lacking to describe the prevalence of cognitive impairment in this very specific population.”
In 2013, the Centers for Disease Control and Prevention estimated that one in eight patients older than 60 years of age deal with memory loss and confusion. However, fewer than 20% of these patients report this to their health care providers, said Dr. Trowbridge, division director of the University of Virginia Women’s Center for Continence and Pelvic Surgery in Charlottesville.
“For this reason the aim of our study was to evaluate the prevalence of cognitive impairment in a urogynecologic ambulatory population, and to evaluate the feasibility of using a standardized, validated screening questionnaire in the tertiary care setting,” she said.
The researchers invited 371 English-speaking patients aged 65 and older to participate and used two cognitive screening tools: the Mini-Cog and the AD8 (8-item Interview to Differentiate Aging and Dementia). They also used the Geriatric Depression Scale, as there is an association between depression and cognition in the elderly.
“Advantages of the Mini-Cog are that it’s administered in less than 3 minutes, it requires no special equipment, and it is not influenced by level of education, or any language variations,” Dr. Trowbridge said.
Of the 371 patients, 39 were excluded due to pre-existing cognitive impairment/dementia, active psychotic disorders, acute/unstable medical conditions, neurologic injury/disorders, alcohol/drug abuse, severe visual/hearing impairment, and illiteracy. An additional 37 patients declined to participate because they “were frustrated that we had asked to evaluate their memory,” she said. This left a total of 295 patients with a mean age of 75 years. Most (97%) were Caucasian, 62% were married, and each had an average of four major medical conditions, including hypertension, hyperlipidemia, and depression. The researchers stratified patients into three age groups: 65-74, 75-84, and 85 and older.
Cognitive impairment as measured by the Mini-Cog was identified in 5.3% of patients aged 65-74 years, 13.7% of those aged 75-84 years, and 31% of those aged 85 and older. The difference in impairment between those aged 65-74 years and those aged 75 years and older reached significance, with a P value of less than .001.
Cognitive impairment as measured by the AD8 found that all three age groups perceived themselves to have early cognitive changes: 25.9% of patients aged 65-74 years, 31.9% of those aged 75-84 years, and 40% of those aged 85 and older. There were no significant between-group differences in these results (P = .4). The most commonly identified areas of impairment were problems with thinking and memory (62%), judgment (52%), and trouble learning new tools or gadgets (44%).
Dr. Trowbridge also reported that 6.4% of the study population screened positive for depression on the Geriatric Depression Scale, with no significant differences between the age groups.
“In our study population, cognitive impairment as measured by a validated questionnaire is prevalent among women greater than 75 years of age,” she said at the meeting, which was jointly sponsored by the American College of Surgeons. “The Mini-Cog is a feasible screening tool for routine use in clinical practice that can be integrated easily into the urogynecologic evaluation. However, remember these are screening tools that effectively screen for previously unrecognized impairment, but a definitive diagnosis requires additional evaluation.”
Dr. Trowbridge reported having no financial disclosures.
INDIAN WELLS, CALIF. – A rapid screening tool found that about 5% of urogynecologic patients aged 65-74 years showed signs of cognitive impairment, with that figure rising to more than 30% for patients age 85 and older, according to the results of a single-center study.
“As our gynecologic patients continue to age, it’s increasingly important that we continue to identify and manage the risk factors for cognitive decline that occur in the ambulatory and the perioperative care settings,” Dr. Elisa R. Trowbridge, lead study author, said at the annual scientific meeting of the Society of Gynecologic Surgeons. “However, data are lacking to describe the prevalence of cognitive impairment in this very specific population.”
In 2013, the Centers for Disease Control and Prevention estimated that one in eight patients older than 60 years of age deal with memory loss and confusion. However, fewer than 20% of these patients report this to their health care providers, said Dr. Trowbridge, division director of the University of Virginia Women’s Center for Continence and Pelvic Surgery in Charlottesville.
“For this reason the aim of our study was to evaluate the prevalence of cognitive impairment in a urogynecologic ambulatory population, and to evaluate the feasibility of using a standardized, validated screening questionnaire in the tertiary care setting,” she said.
The researchers invited 371 English-speaking patients aged 65 and older to participate and used two cognitive screening tools: the Mini-Cog and the AD8 (8-item Interview to Differentiate Aging and Dementia). They also used the Geriatric Depression Scale, as there is an association between depression and cognition in the elderly.
“Advantages of the Mini-Cog are that it’s administered in less than 3 minutes, it requires no special equipment, and it is not influenced by level of education, or any language variations,” Dr. Trowbridge said.
Of the 371 patients, 39 were excluded due to pre-existing cognitive impairment/dementia, active psychotic disorders, acute/unstable medical conditions, neurologic injury/disorders, alcohol/drug abuse, severe visual/hearing impairment, and illiteracy. An additional 37 patients declined to participate because they “were frustrated that we had asked to evaluate their memory,” she said. This left a total of 295 patients with a mean age of 75 years. Most (97%) were Caucasian, 62% were married, and each had an average of four major medical conditions, including hypertension, hyperlipidemia, and depression. The researchers stratified patients into three age groups: 65-74, 75-84, and 85 and older.
Cognitive impairment as measured by the Mini-Cog was identified in 5.3% of patients aged 65-74 years, 13.7% of those aged 75-84 years, and 31% of those aged 85 and older. The difference in impairment between those aged 65-74 years and those aged 75 years and older reached significance, with a P value of less than .001.
Cognitive impairment as measured by the AD8 found that all three age groups perceived themselves to have early cognitive changes: 25.9% of patients aged 65-74 years, 31.9% of those aged 75-84 years, and 40% of those aged 85 and older. There were no significant between-group differences in these results (P = .4). The most commonly identified areas of impairment were problems with thinking and memory (62%), judgment (52%), and trouble learning new tools or gadgets (44%).
Dr. Trowbridge also reported that 6.4% of the study population screened positive for depression on the Geriatric Depression Scale, with no significant differences between the age groups.
“In our study population, cognitive impairment as measured by a validated questionnaire is prevalent among women greater than 75 years of age,” she said at the meeting, which was jointly sponsored by the American College of Surgeons. “The Mini-Cog is a feasible screening tool for routine use in clinical practice that can be integrated easily into the urogynecologic evaluation. However, remember these are screening tools that effectively screen for previously unrecognized impairment, but a definitive diagnosis requires additional evaluation.”
Dr. Trowbridge reported having no financial disclosures.
INDIAN WELLS, CALIF. – A rapid screening tool found that about 5% of urogynecologic patients aged 65-74 years showed signs of cognitive impairment, with that figure rising to more than 30% for patients age 85 and older, according to the results of a single-center study.
“As our gynecologic patients continue to age, it’s increasingly important that we continue to identify and manage the risk factors for cognitive decline that occur in the ambulatory and the perioperative care settings,” Dr. Elisa R. Trowbridge, lead study author, said at the annual scientific meeting of the Society of Gynecologic Surgeons. “However, data are lacking to describe the prevalence of cognitive impairment in this very specific population.”
In 2013, the Centers for Disease Control and Prevention estimated that one in eight patients older than 60 years of age deal with memory loss and confusion. However, fewer than 20% of these patients report this to their health care providers, said Dr. Trowbridge, division director of the University of Virginia Women’s Center for Continence and Pelvic Surgery in Charlottesville.
“For this reason the aim of our study was to evaluate the prevalence of cognitive impairment in a urogynecologic ambulatory population, and to evaluate the feasibility of using a standardized, validated screening questionnaire in the tertiary care setting,” she said.
The researchers invited 371 English-speaking patients aged 65 and older to participate and used two cognitive screening tools: the Mini-Cog and the AD8 (8-item Interview to Differentiate Aging and Dementia). They also used the Geriatric Depression Scale, as there is an association between depression and cognition in the elderly.
“Advantages of the Mini-Cog are that it’s administered in less than 3 minutes, it requires no special equipment, and it is not influenced by level of education, or any language variations,” Dr. Trowbridge said.
Of the 371 patients, 39 were excluded due to pre-existing cognitive impairment/dementia, active psychotic disorders, acute/unstable medical conditions, neurologic injury/disorders, alcohol/drug abuse, severe visual/hearing impairment, and illiteracy. An additional 37 patients declined to participate because they “were frustrated that we had asked to evaluate their memory,” she said. This left a total of 295 patients with a mean age of 75 years. Most (97%) were Caucasian, 62% were married, and each had an average of four major medical conditions, including hypertension, hyperlipidemia, and depression. The researchers stratified patients into three age groups: 65-74, 75-84, and 85 and older.
Cognitive impairment as measured by the Mini-Cog was identified in 5.3% of patients aged 65-74 years, 13.7% of those aged 75-84 years, and 31% of those aged 85 and older. The difference in impairment between those aged 65-74 years and those aged 75 years and older reached significance, with a P value of less than .001.
Cognitive impairment as measured by the AD8 found that all three age groups perceived themselves to have early cognitive changes: 25.9% of patients aged 65-74 years, 31.9% of those aged 75-84 years, and 40% of those aged 85 and older. There were no significant between-group differences in these results (P = .4). The most commonly identified areas of impairment were problems with thinking and memory (62%), judgment (52%), and trouble learning new tools or gadgets (44%).
Dr. Trowbridge also reported that 6.4% of the study population screened positive for depression on the Geriatric Depression Scale, with no significant differences between the age groups.
“In our study population, cognitive impairment as measured by a validated questionnaire is prevalent among women greater than 75 years of age,” she said at the meeting, which was jointly sponsored by the American College of Surgeons. “The Mini-Cog is a feasible screening tool for routine use in clinical practice that can be integrated easily into the urogynecologic evaluation. However, remember these are screening tools that effectively screen for previously unrecognized impairment, but a definitive diagnosis requires additional evaluation.”
Dr. Trowbridge reported having no financial disclosures.
AT SGS 2016
Key clinical point: The Mini-Cog is a feasible screening tool for routine use in clinical practice that can be integrated easily into the urogynecologic evaluation.
Major finding: Cognitive impairment as measured by the Mini-Cog was identified in 5.3% of patients aged 65-74 years, 13.7% of those aged 75-84 years, and 31% of those aged 85 and older.
Data source: A single-center study of 295 urogynecologic patients aged 65 and older.
Disclosures: Dr. Trowbridge reported having no financial disclosures.
