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Socioeconomic disparities persist in hysterectomy access
Black women undergoing hysterectomies were significantly more likely to be treated by low-volume surgeons than high-volume surgeons, and to experience perioperative complications as a result, based on data from more than 300,000 patients.
“Outcomes for hysterectomy, for both benign and malignant disease, are improved when the procedure is performed at high-volume hospitals and by high-volume surgeons,” Anne Knisely, MD, of Columbia University, New York, and colleagues wrote.
Historically, Black patients have been less likely to be referred to high-volume hospitals, the researchers noted. Recent efforts to regionalize surgical procedures to high-volume hospitals aim to reduce disparities and improve care for all patients, but the data on disparities in care within high-volume hospitals are limited, they said.
In a study published in Obstetrics & Gynecology, the researchers identified 300,586 women who underwent hysterectomy in New York state between 2000 and 2014. The researchers divided surgeons at these hospitals into volume groups based on average annual hysterectomy volume.
The women were treated by 5,505 surgeons at 59 hospitals. Overall, Black women comprised significantly more of the patients treated by low-volume surgeons compared with high-volume surgeons (19.4% vs. 14.3%; adjusted odds ratio, 1.26), and more women treated by low-volume surgeons had Medicare insurance compared with those treated by high-volume surgeons (20.6% vs. 14.5%; aOR, 1.22).
A majority of the patients (262,005 patients) were treated by a total of 1,377 high-volume surgeons, while 2,105 low-volume surgeons treated 2,900 patients. Abdominal hysterectomies accounted for 57.5% of the procedures, followed by laparoscopic (23.9%), vaginal (13.2%), and robotic assisted (5.3%). Approximately two-thirds (64.4%) of the patients were aged 40-59 years; 63.7% were White, 15.1% were Black, and 8.5% were Hispanic.
The overall complication rate was significantly higher in patients treated by low-volume surgeons, compared with high-volume surgeons (31.0% vs. 10.3%), including intraoperative complications, surgical-site complications, medical complications, and transfusions. The perioperative mortality rate also was significantly higher for patients of low-volume surgeons compared with high-volume surgeons (2.2% vs. 0.2%).
Low-volume surgeons were more likely to perform urgent or emergent procedures, compared with high-volume surgeons (26.1% vs 6.4%), and to perform abdominal hysterectomy versus minimally invasive hysterectomy compared with high-volume surgeons (77.8% vs. 54.7%), the researchers added.
The study findings were limited by several factors, including the observational design and possible undercoding of outcomes, inclusion only of New York state patients, lack of data on clinical characteristics such as surgical history and complexity, lack of data on surgeon characteristics, and changing practice patterns over time, the researchers noted.
However, “this study demonstrates increased perioperative morbidity and mortality for patients who underwent hysterectomy by low-volume surgeons, in comparison with high-volume surgeons, at high-volume hospitals,” and that Black patients were more likely to be treated by low-volume surgeons, they said. “Although centralization of complex surgical care to higher-volume hospitals may have benefit, there are additional surgeon-level factors that must be considered to address disparities in access to high-quality care for patients undergoing hysterectomy.”
Explore range of issues to improve access
“It is always beneficial to review morbidity and mortality statistics,” Constance Bohon, MD, a gynecologist in private practice in Washington, D.C., said in an interview. “With a heightened awareness of equity and equality, now is a good time to review the data with that focus in mind. Hospital committees review the data on a regular basis, but they may not have looked closely at demographics in the past.
“It was always my understanding that for many procedures, including surgery, volume impacts outcome, so the finding that low-volume surgeons had worse outcomes than high-volume surgeons was not particularly surprising,” said Dr. Bohon. However, the question of how hospitals might address disparities in access to high-volume surgeons “is a difficult question, because there are a variety of issues that may not be caused by disparities,” she added. “It may be that the high-volume surgeons do not take Medicare. It may be that some of the emergent/urgent surgeries come from patients seen in the ED and the high-volume surgeons may not take call or see new patients in the ED. There may be a difference in the preop testing done that may be more extensive with the high-volume surgeons as compared with the low-volume surgeons. It may be that it is easier to get an appointment with a low-volume rather than a high-volume surgeon.
“Additional research is needed to determine whether there is an algorithm that can be created to determine risk for morbidity or mortality based on factors such as the number of years in practice, the number of hysterectomies per year, and the age of the physician,” Dr. Bohon explained. “The patient data could include preexisting risk factors such as weight, preexisting medical conditions, prior surgeries, and current medications, along with demographics. It would be interesting to determine whether low-risk patients have similar outcomes with low- as compared with high-volume surgeons while high-risk patients do not. The demographics could then be evaluated to determine if disparities exist for both low- and high-risk patients.”
The study received no outside funding. One coauthor disclosed serving as a consultant for Clovis Oncology, receiving research funding from Merck, and receiving royalties from UpToDate. Lead author Dr. Knisely had no financial conflicts to disclose. Dr. Bohon had no financial conflicts to disclose, but serves on the Ob.Gyn. News editorial advisory board.
Black women undergoing hysterectomies were significantly more likely to be treated by low-volume surgeons than high-volume surgeons, and to experience perioperative complications as a result, based on data from more than 300,000 patients.
“Outcomes for hysterectomy, for both benign and malignant disease, are improved when the procedure is performed at high-volume hospitals and by high-volume surgeons,” Anne Knisely, MD, of Columbia University, New York, and colleagues wrote.
Historically, Black patients have been less likely to be referred to high-volume hospitals, the researchers noted. Recent efforts to regionalize surgical procedures to high-volume hospitals aim to reduce disparities and improve care for all patients, but the data on disparities in care within high-volume hospitals are limited, they said.
In a study published in Obstetrics & Gynecology, the researchers identified 300,586 women who underwent hysterectomy in New York state between 2000 and 2014. The researchers divided surgeons at these hospitals into volume groups based on average annual hysterectomy volume.
The women were treated by 5,505 surgeons at 59 hospitals. Overall, Black women comprised significantly more of the patients treated by low-volume surgeons compared with high-volume surgeons (19.4% vs. 14.3%; adjusted odds ratio, 1.26), and more women treated by low-volume surgeons had Medicare insurance compared with those treated by high-volume surgeons (20.6% vs. 14.5%; aOR, 1.22).
A majority of the patients (262,005 patients) were treated by a total of 1,377 high-volume surgeons, while 2,105 low-volume surgeons treated 2,900 patients. Abdominal hysterectomies accounted for 57.5% of the procedures, followed by laparoscopic (23.9%), vaginal (13.2%), and robotic assisted (5.3%). Approximately two-thirds (64.4%) of the patients were aged 40-59 years; 63.7% were White, 15.1% were Black, and 8.5% were Hispanic.
The overall complication rate was significantly higher in patients treated by low-volume surgeons, compared with high-volume surgeons (31.0% vs. 10.3%), including intraoperative complications, surgical-site complications, medical complications, and transfusions. The perioperative mortality rate also was significantly higher for patients of low-volume surgeons compared with high-volume surgeons (2.2% vs. 0.2%).
Low-volume surgeons were more likely to perform urgent or emergent procedures, compared with high-volume surgeons (26.1% vs 6.4%), and to perform abdominal hysterectomy versus minimally invasive hysterectomy compared with high-volume surgeons (77.8% vs. 54.7%), the researchers added.
The study findings were limited by several factors, including the observational design and possible undercoding of outcomes, inclusion only of New York state patients, lack of data on clinical characteristics such as surgical history and complexity, lack of data on surgeon characteristics, and changing practice patterns over time, the researchers noted.
However, “this study demonstrates increased perioperative morbidity and mortality for patients who underwent hysterectomy by low-volume surgeons, in comparison with high-volume surgeons, at high-volume hospitals,” and that Black patients were more likely to be treated by low-volume surgeons, they said. “Although centralization of complex surgical care to higher-volume hospitals may have benefit, there are additional surgeon-level factors that must be considered to address disparities in access to high-quality care for patients undergoing hysterectomy.”
Explore range of issues to improve access
“It is always beneficial to review morbidity and mortality statistics,” Constance Bohon, MD, a gynecologist in private practice in Washington, D.C., said in an interview. “With a heightened awareness of equity and equality, now is a good time to review the data with that focus in mind. Hospital committees review the data on a regular basis, but they may not have looked closely at demographics in the past.
“It was always my understanding that for many procedures, including surgery, volume impacts outcome, so the finding that low-volume surgeons had worse outcomes than high-volume surgeons was not particularly surprising,” said Dr. Bohon. However, the question of how hospitals might address disparities in access to high-volume surgeons “is a difficult question, because there are a variety of issues that may not be caused by disparities,” she added. “It may be that the high-volume surgeons do not take Medicare. It may be that some of the emergent/urgent surgeries come from patients seen in the ED and the high-volume surgeons may not take call or see new patients in the ED. There may be a difference in the preop testing done that may be more extensive with the high-volume surgeons as compared with the low-volume surgeons. It may be that it is easier to get an appointment with a low-volume rather than a high-volume surgeon.
“Additional research is needed to determine whether there is an algorithm that can be created to determine risk for morbidity or mortality based on factors such as the number of years in practice, the number of hysterectomies per year, and the age of the physician,” Dr. Bohon explained. “The patient data could include preexisting risk factors such as weight, preexisting medical conditions, prior surgeries, and current medications, along with demographics. It would be interesting to determine whether low-risk patients have similar outcomes with low- as compared with high-volume surgeons while high-risk patients do not. The demographics could then be evaluated to determine if disparities exist for both low- and high-risk patients.”
The study received no outside funding. One coauthor disclosed serving as a consultant for Clovis Oncology, receiving research funding from Merck, and receiving royalties from UpToDate. Lead author Dr. Knisely had no financial conflicts to disclose. Dr. Bohon had no financial conflicts to disclose, but serves on the Ob.Gyn. News editorial advisory board.
Black women undergoing hysterectomies were significantly more likely to be treated by low-volume surgeons than high-volume surgeons, and to experience perioperative complications as a result, based on data from more than 300,000 patients.
“Outcomes for hysterectomy, for both benign and malignant disease, are improved when the procedure is performed at high-volume hospitals and by high-volume surgeons,” Anne Knisely, MD, of Columbia University, New York, and colleagues wrote.
Historically, Black patients have been less likely to be referred to high-volume hospitals, the researchers noted. Recent efforts to regionalize surgical procedures to high-volume hospitals aim to reduce disparities and improve care for all patients, but the data on disparities in care within high-volume hospitals are limited, they said.
In a study published in Obstetrics & Gynecology, the researchers identified 300,586 women who underwent hysterectomy in New York state between 2000 and 2014. The researchers divided surgeons at these hospitals into volume groups based on average annual hysterectomy volume.
The women were treated by 5,505 surgeons at 59 hospitals. Overall, Black women comprised significantly more of the patients treated by low-volume surgeons compared with high-volume surgeons (19.4% vs. 14.3%; adjusted odds ratio, 1.26), and more women treated by low-volume surgeons had Medicare insurance compared with those treated by high-volume surgeons (20.6% vs. 14.5%; aOR, 1.22).
A majority of the patients (262,005 patients) were treated by a total of 1,377 high-volume surgeons, while 2,105 low-volume surgeons treated 2,900 patients. Abdominal hysterectomies accounted for 57.5% of the procedures, followed by laparoscopic (23.9%), vaginal (13.2%), and robotic assisted (5.3%). Approximately two-thirds (64.4%) of the patients were aged 40-59 years; 63.7% were White, 15.1% were Black, and 8.5% were Hispanic.
The overall complication rate was significantly higher in patients treated by low-volume surgeons, compared with high-volume surgeons (31.0% vs. 10.3%), including intraoperative complications, surgical-site complications, medical complications, and transfusions. The perioperative mortality rate also was significantly higher for patients of low-volume surgeons compared with high-volume surgeons (2.2% vs. 0.2%).
Low-volume surgeons were more likely to perform urgent or emergent procedures, compared with high-volume surgeons (26.1% vs 6.4%), and to perform abdominal hysterectomy versus minimally invasive hysterectomy compared with high-volume surgeons (77.8% vs. 54.7%), the researchers added.
The study findings were limited by several factors, including the observational design and possible undercoding of outcomes, inclusion only of New York state patients, lack of data on clinical characteristics such as surgical history and complexity, lack of data on surgeon characteristics, and changing practice patterns over time, the researchers noted.
However, “this study demonstrates increased perioperative morbidity and mortality for patients who underwent hysterectomy by low-volume surgeons, in comparison with high-volume surgeons, at high-volume hospitals,” and that Black patients were more likely to be treated by low-volume surgeons, they said. “Although centralization of complex surgical care to higher-volume hospitals may have benefit, there are additional surgeon-level factors that must be considered to address disparities in access to high-quality care for patients undergoing hysterectomy.”
Explore range of issues to improve access
“It is always beneficial to review morbidity and mortality statistics,” Constance Bohon, MD, a gynecologist in private practice in Washington, D.C., said in an interview. “With a heightened awareness of equity and equality, now is a good time to review the data with that focus in mind. Hospital committees review the data on a regular basis, but they may not have looked closely at demographics in the past.
“It was always my understanding that for many procedures, including surgery, volume impacts outcome, so the finding that low-volume surgeons had worse outcomes than high-volume surgeons was not particularly surprising,” said Dr. Bohon. However, the question of how hospitals might address disparities in access to high-volume surgeons “is a difficult question, because there are a variety of issues that may not be caused by disparities,” she added. “It may be that the high-volume surgeons do not take Medicare. It may be that some of the emergent/urgent surgeries come from patients seen in the ED and the high-volume surgeons may not take call or see new patients in the ED. There may be a difference in the preop testing done that may be more extensive with the high-volume surgeons as compared with the low-volume surgeons. It may be that it is easier to get an appointment with a low-volume rather than a high-volume surgeon.
“Additional research is needed to determine whether there is an algorithm that can be created to determine risk for morbidity or mortality based on factors such as the number of years in practice, the number of hysterectomies per year, and the age of the physician,” Dr. Bohon explained. “The patient data could include preexisting risk factors such as weight, preexisting medical conditions, prior surgeries, and current medications, along with demographics. It would be interesting to determine whether low-risk patients have similar outcomes with low- as compared with high-volume surgeons while high-risk patients do not. The demographics could then be evaluated to determine if disparities exist for both low- and high-risk patients.”
The study received no outside funding. One coauthor disclosed serving as a consultant for Clovis Oncology, receiving research funding from Merck, and receiving royalties from UpToDate. Lead author Dr. Knisely had no financial conflicts to disclose. Dr. Bohon had no financial conflicts to disclose, but serves on the Ob.Gyn. News editorial advisory board.
FROM OBSTETRICS & GYNECOLOGY
Obstetric units place twice as many wrong-patient orders as medical-surgical units
Clinicians in obstetric units place nearly twice as many wrong-patient orders as their medical-surgical counterparts, based on a retrospective look at more than 1.3 million orders.
These findings suggest that obstetric patients are at particular risk for this type of medical error, and that steps are needed to address obstetric clinical culture, work flow, and electronic medical record interfaces, reported lead author Adina R. Kern-Goldberger, MD, of the department of obstetrics and gynecology at the University of Pennsylvania, Philadelphia, and colleagues.
The root of the issue may come from the very nature of obstetrics, and the homogeneity of the patient population, they wrote in Obstetrics & Gynecology.
“Obstetrics is a unique clinical environment because all patients are admitted with a common diagnosis – pregnancy – and have much more overlap in demographic characteristics than a typical inpatient unit given that they are all females of reproductive age,” the investigators wrote. “The labor and delivery environment also is distinct in the hospital given its dynamic tempo and unpredictable work flow. There also is the added risk of neonates typically being registered in the hospital record under the mother’s name after birth. This generates abundant opportunity for errors in order placement, both between obstetric patients and between postpartum patients and their newborns.”
To determine the relative magnitude of this risk, Dr. Kern-Goldberger and colleagues analyzed EMRs from 45,436 obstetric patients and 12,915 medical-surgical patients at “a large, urban, integrated health system in New York City,” including 1,329,463 order sessions placed between 2016 and 2018.
The primary outcome was near-miss wrong-patient orders, which were identified by the Wrong-Patient Retract-and-Reorder measure.
“The measure uses an electronic query to detect retract-and-reorder events, defined as one or more orders placed for patient A, canceled by the same clinician within 10 minutes, and reordered by the same clinician for patient B within the next 10 minutes,” the investigators wrote.In obstetric units, 79.5 wrong-patient orders were placed per 100,000 order sessions, which was 98% higher than the rate of 42.3 wrong-patient orders per 100,000 order sessions in medical-surgical units (odds ratio, 1.98; 95% confidence interval, 1.64-2.39), a disparity that was observed across clinician types and times of day.Advanced practice clinicians in obstetrics placed 47.3 wrong-patient orders per 100,000 order sessions, which was significantly lower than that of their colleagues: attending physicians (127.0 per 100,000) and house staff (119.9 per 100,000).
Wrong-patient orders in obstetrics most often involved medication (73.2 per 100,000), particularly nifedipine, antibiotics, tocolytics, and nonoxytocin uterotonics. The “other” category, including but not limited to lab studies and nursing orders, was associated with 51.0 wrong-patient orders per 100,000 order sessions, while errors in diagnostic imaging orders followed distantly behind, at a rate of 5.7 per 1000,000.
“Although the obstetric clinical environment – particularly labor and delivery – is vibrant and frequently chaotic, it is critical to establish a calm, orderly, and safe culture around order entry,” the investigators wrote. “This, combined with efforts to improve house staff work flow and to optimize EMR interfaces, is likely to help mitigate the threat of wrong order errors to patient care and ultimately improve maternal health and safety.”
According to Catherine D. Cansino, MD, associate clinical professor of obstetrics and gynecology at UC Davis (Calif.) Health, the findings highlight the value of medical informatics while revealing a need to improve EMR interfaces.
“Medical informatics is a growing field and expertise among ob.gyns. is very important,” Dr. Cansino said in an interview. “This study by Kern-Goldberger and colleagues highlights the vulnerability of our EMR systems (and our patients, indirectly) when medical informatics systems are not optimized. The investigators present a study that advocates for greater emphasis on optimizing such systems in obstetrics units, especially in the context of high acuity settings such as obstetrics, compared to medical-surgical units. Appropriately, the study highlights the avoided harm when correcting medical errors for obstetric patients since such errors potentially affect both the delivering patient and the newborn.”
The study was funded by AHRQ. One coauthor disclosed funding from the Icahn School of Medicine at Mount Sinai, Georgetown University, the National Institutes of Health – Office of Scientific Review, and the Social Science Research Council. Another reported funding from Roche.
Clinicians in obstetric units place nearly twice as many wrong-patient orders as their medical-surgical counterparts, based on a retrospective look at more than 1.3 million orders.
These findings suggest that obstetric patients are at particular risk for this type of medical error, and that steps are needed to address obstetric clinical culture, work flow, and electronic medical record interfaces, reported lead author Adina R. Kern-Goldberger, MD, of the department of obstetrics and gynecology at the University of Pennsylvania, Philadelphia, and colleagues.
The root of the issue may come from the very nature of obstetrics, and the homogeneity of the patient population, they wrote in Obstetrics & Gynecology.
“Obstetrics is a unique clinical environment because all patients are admitted with a common diagnosis – pregnancy – and have much more overlap in demographic characteristics than a typical inpatient unit given that they are all females of reproductive age,” the investigators wrote. “The labor and delivery environment also is distinct in the hospital given its dynamic tempo and unpredictable work flow. There also is the added risk of neonates typically being registered in the hospital record under the mother’s name after birth. This generates abundant opportunity for errors in order placement, both between obstetric patients and between postpartum patients and their newborns.”
To determine the relative magnitude of this risk, Dr. Kern-Goldberger and colleagues analyzed EMRs from 45,436 obstetric patients and 12,915 medical-surgical patients at “a large, urban, integrated health system in New York City,” including 1,329,463 order sessions placed between 2016 and 2018.
The primary outcome was near-miss wrong-patient orders, which were identified by the Wrong-Patient Retract-and-Reorder measure.
“The measure uses an electronic query to detect retract-and-reorder events, defined as one or more orders placed for patient A, canceled by the same clinician within 10 minutes, and reordered by the same clinician for patient B within the next 10 minutes,” the investigators wrote.In obstetric units, 79.5 wrong-patient orders were placed per 100,000 order sessions, which was 98% higher than the rate of 42.3 wrong-patient orders per 100,000 order sessions in medical-surgical units (odds ratio, 1.98; 95% confidence interval, 1.64-2.39), a disparity that was observed across clinician types and times of day.Advanced practice clinicians in obstetrics placed 47.3 wrong-patient orders per 100,000 order sessions, which was significantly lower than that of their colleagues: attending physicians (127.0 per 100,000) and house staff (119.9 per 100,000).
Wrong-patient orders in obstetrics most often involved medication (73.2 per 100,000), particularly nifedipine, antibiotics, tocolytics, and nonoxytocin uterotonics. The “other” category, including but not limited to lab studies and nursing orders, was associated with 51.0 wrong-patient orders per 100,000 order sessions, while errors in diagnostic imaging orders followed distantly behind, at a rate of 5.7 per 1000,000.
“Although the obstetric clinical environment – particularly labor and delivery – is vibrant and frequently chaotic, it is critical to establish a calm, orderly, and safe culture around order entry,” the investigators wrote. “This, combined with efforts to improve house staff work flow and to optimize EMR interfaces, is likely to help mitigate the threat of wrong order errors to patient care and ultimately improve maternal health and safety.”
According to Catherine D. Cansino, MD, associate clinical professor of obstetrics and gynecology at UC Davis (Calif.) Health, the findings highlight the value of medical informatics while revealing a need to improve EMR interfaces.
“Medical informatics is a growing field and expertise among ob.gyns. is very important,” Dr. Cansino said in an interview. “This study by Kern-Goldberger and colleagues highlights the vulnerability of our EMR systems (and our patients, indirectly) when medical informatics systems are not optimized. The investigators present a study that advocates for greater emphasis on optimizing such systems in obstetrics units, especially in the context of high acuity settings such as obstetrics, compared to medical-surgical units. Appropriately, the study highlights the avoided harm when correcting medical errors for obstetric patients since such errors potentially affect both the delivering patient and the newborn.”
The study was funded by AHRQ. One coauthor disclosed funding from the Icahn School of Medicine at Mount Sinai, Georgetown University, the National Institutes of Health – Office of Scientific Review, and the Social Science Research Council. Another reported funding from Roche.
Clinicians in obstetric units place nearly twice as many wrong-patient orders as their medical-surgical counterparts, based on a retrospective look at more than 1.3 million orders.
These findings suggest that obstetric patients are at particular risk for this type of medical error, and that steps are needed to address obstetric clinical culture, work flow, and electronic medical record interfaces, reported lead author Adina R. Kern-Goldberger, MD, of the department of obstetrics and gynecology at the University of Pennsylvania, Philadelphia, and colleagues.
The root of the issue may come from the very nature of obstetrics, and the homogeneity of the patient population, they wrote in Obstetrics & Gynecology.
“Obstetrics is a unique clinical environment because all patients are admitted with a common diagnosis – pregnancy – and have much more overlap in demographic characteristics than a typical inpatient unit given that they are all females of reproductive age,” the investigators wrote. “The labor and delivery environment also is distinct in the hospital given its dynamic tempo and unpredictable work flow. There also is the added risk of neonates typically being registered in the hospital record under the mother’s name after birth. This generates abundant opportunity for errors in order placement, both between obstetric patients and between postpartum patients and their newborns.”
To determine the relative magnitude of this risk, Dr. Kern-Goldberger and colleagues analyzed EMRs from 45,436 obstetric patients and 12,915 medical-surgical patients at “a large, urban, integrated health system in New York City,” including 1,329,463 order sessions placed between 2016 and 2018.
The primary outcome was near-miss wrong-patient orders, which were identified by the Wrong-Patient Retract-and-Reorder measure.
“The measure uses an electronic query to detect retract-and-reorder events, defined as one or more orders placed for patient A, canceled by the same clinician within 10 minutes, and reordered by the same clinician for patient B within the next 10 minutes,” the investigators wrote.In obstetric units, 79.5 wrong-patient orders were placed per 100,000 order sessions, which was 98% higher than the rate of 42.3 wrong-patient orders per 100,000 order sessions in medical-surgical units (odds ratio, 1.98; 95% confidence interval, 1.64-2.39), a disparity that was observed across clinician types and times of day.Advanced practice clinicians in obstetrics placed 47.3 wrong-patient orders per 100,000 order sessions, which was significantly lower than that of their colleagues: attending physicians (127.0 per 100,000) and house staff (119.9 per 100,000).
Wrong-patient orders in obstetrics most often involved medication (73.2 per 100,000), particularly nifedipine, antibiotics, tocolytics, and nonoxytocin uterotonics. The “other” category, including but not limited to lab studies and nursing orders, was associated with 51.0 wrong-patient orders per 100,000 order sessions, while errors in diagnostic imaging orders followed distantly behind, at a rate of 5.7 per 1000,000.
“Although the obstetric clinical environment – particularly labor and delivery – is vibrant and frequently chaotic, it is critical to establish a calm, orderly, and safe culture around order entry,” the investigators wrote. “This, combined with efforts to improve house staff work flow and to optimize EMR interfaces, is likely to help mitigate the threat of wrong order errors to patient care and ultimately improve maternal health and safety.”
According to Catherine D. Cansino, MD, associate clinical professor of obstetrics and gynecology at UC Davis (Calif.) Health, the findings highlight the value of medical informatics while revealing a need to improve EMR interfaces.
“Medical informatics is a growing field and expertise among ob.gyns. is very important,” Dr. Cansino said in an interview. “This study by Kern-Goldberger and colleagues highlights the vulnerability of our EMR systems (and our patients, indirectly) when medical informatics systems are not optimized. The investigators present a study that advocates for greater emphasis on optimizing such systems in obstetrics units, especially in the context of high acuity settings such as obstetrics, compared to medical-surgical units. Appropriately, the study highlights the avoided harm when correcting medical errors for obstetric patients since such errors potentially affect both the delivering patient and the newborn.”
The study was funded by AHRQ. One coauthor disclosed funding from the Icahn School of Medicine at Mount Sinai, Georgetown University, the National Institutes of Health – Office of Scientific Review, and the Social Science Research Council. Another reported funding from Roche.
FROM OBSTETRICS & GYNECOLOGY
Does optimal iron absorption include vitamin C?
Her blood work shows a hematocrit level of 32, a mean corpuscular volume of 77, a platelet count of 390,000, and a ferritin level of 5.
What would you recommend for iron replacement?
A. FeSO4 325 mg three times a day with vitamin C
B. FeSO4 325 mg daily with vitamin C
C. FeSO4 325 mg every other day
Recommendations and supporting research
I think I would start with choice C, FeSO4 every other day.
Treatment of iron deficiency with oral iron has traditionally been done by giving 150-200 mg of elemental iron (which is equal to three 325 mg tablets of iron sulfate).1 This dosing regimen has considerable gastrointestinal side effects. Recent evidence has shown that iron absorption is diminished the more frequently it is given.
Stoffel and colleagues found that fractional iron absorption was higher in iron-deficient women who were given iron every other day, compared with those who received daily iron.2 They also found that the more frequently iron was administered, the higher the hepcidin levels were, and the lower the iron absorption.
Karacok and colleagues studied every other day iron versus daily iron for the treatment of iron-deficiency anemia of pregnancy.3 A total of 217 women completed randomization and participated in the study, with all women receiving 100 mg of elemental iron, either daily (111) or every other day (106). There was no significant difference in increase in ferritin levels, or hemoglobin increase between the groups. The daily iron group had more gastrointestinal symptoms (41.4%) than the every other day iron group (15.1%) (P < .0057).
Düzen Oflas and colleagues looked at the same question in nonpregnant women with iron deficiency anemia.4 Study patients either received 80 mg iron sulfate twice a day, 80 mg once a day, or 80 mg every other day. There was no statistically significant difference in hemoglobin improvement between groups, but the group that received twice a day dosing of iron had statistically significantly higher ferritin levels than the daily or every other day iron groups. This improvement in ferritin levels came at a cost, though, as 68% of patients in the twice daily iron group had gastrointestinal symptoms, compared with only 10% in the every other day iron group (P < .01).
Vitamin C is often recommended to be taken with iron to promote absorption. The evidence for this practice is scant, and dates back almost 50 years.5,6
Cook and Reddy found there was no significant difference in mean iron absorption among the three dietary periods studied in 12 patients despite a range of mean daily intakes of dietary vitamin C of 51-247 mg/d.7
Hunt and colleagues studied 25 non pregnant, healthy women with low ferritin levels.8 The women’s meals were supplemented with vitamin C (500 mg, three times a day) for 5 of the 10 weeks, in a double-blind, crossover design. Vitamin C supplementation did not lead to a difference in iron absorption, lab indices of iron deficiency, or the biological half-life of iron.
Li and colleagues looked at the effect of vitamin C supplementation on iron levels in women with iron deficiency anemia.9 A total of 440 women were recruited, with 432 completing the trial. Women were randomized to receive iron supplements plus vitamin C or iron supplements only. Their findings were that oral iron supplements alone were equivalent to oral iron supplements plus vitamin C in improving hemoglobin recovery and iron absorption.
Bottom line
Less frequent administration of iron supplements (every other day) is as effective as more frequent administration, with less GI symptoms. Also, adding vitamin C does not appear to improve absorption of iron supplements.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at imnews@mdedge.com.
References
1. 1. Fairbanks VF and Beutler E. Iron deficiency, in “Williams Textbook of Hematology, 6th ed.” (New York: McGraw-Hill, 2001).
2. Stoffel N et al. Lancet Haematology. 2017;4: e524-33.
3. Karakoc G et al. J Matern Fetal Neonatal Med. 2021 Apr 18:1-5
4. Düzen Oflas N et al. Intern Med J. 2020 Jul;50(7):854-8
5. Cook JD and Monsen ER. Am J Clin Nutr. 1977;30:235-41.
6. Hallberg L etal. Hum Nutr Appl Nutr. 1986;40: 97-113.
7. Cook JD and Reddy M. Am J Clin Nutr. 2001;73:93-8.
8. Hunt JR et al. Am J Clin Nutr. 1994 Jun;59(6):1381-5.
9. Li N et al. JAMA Netw Open. 2020 Nov 2;3(11):e2023644.
Her blood work shows a hematocrit level of 32, a mean corpuscular volume of 77, a platelet count of 390,000, and a ferritin level of 5.
What would you recommend for iron replacement?
A. FeSO4 325 mg three times a day with vitamin C
B. FeSO4 325 mg daily with vitamin C
C. FeSO4 325 mg every other day
Recommendations and supporting research
I think I would start with choice C, FeSO4 every other day.
Treatment of iron deficiency with oral iron has traditionally been done by giving 150-200 mg of elemental iron (which is equal to three 325 mg tablets of iron sulfate).1 This dosing regimen has considerable gastrointestinal side effects. Recent evidence has shown that iron absorption is diminished the more frequently it is given.
Stoffel and colleagues found that fractional iron absorption was higher in iron-deficient women who were given iron every other day, compared with those who received daily iron.2 They also found that the more frequently iron was administered, the higher the hepcidin levels were, and the lower the iron absorption.
Karacok and colleagues studied every other day iron versus daily iron for the treatment of iron-deficiency anemia of pregnancy.3 A total of 217 women completed randomization and participated in the study, with all women receiving 100 mg of elemental iron, either daily (111) or every other day (106). There was no significant difference in increase in ferritin levels, or hemoglobin increase between the groups. The daily iron group had more gastrointestinal symptoms (41.4%) than the every other day iron group (15.1%) (P < .0057).
Düzen Oflas and colleagues looked at the same question in nonpregnant women with iron deficiency anemia.4 Study patients either received 80 mg iron sulfate twice a day, 80 mg once a day, or 80 mg every other day. There was no statistically significant difference in hemoglobin improvement between groups, but the group that received twice a day dosing of iron had statistically significantly higher ferritin levels than the daily or every other day iron groups. This improvement in ferritin levels came at a cost, though, as 68% of patients in the twice daily iron group had gastrointestinal symptoms, compared with only 10% in the every other day iron group (P < .01).
Vitamin C is often recommended to be taken with iron to promote absorption. The evidence for this practice is scant, and dates back almost 50 years.5,6
Cook and Reddy found there was no significant difference in mean iron absorption among the three dietary periods studied in 12 patients despite a range of mean daily intakes of dietary vitamin C of 51-247 mg/d.7
Hunt and colleagues studied 25 non pregnant, healthy women with low ferritin levels.8 The women’s meals were supplemented with vitamin C (500 mg, three times a day) for 5 of the 10 weeks, in a double-blind, crossover design. Vitamin C supplementation did not lead to a difference in iron absorption, lab indices of iron deficiency, or the biological half-life of iron.
Li and colleagues looked at the effect of vitamin C supplementation on iron levels in women with iron deficiency anemia.9 A total of 440 women were recruited, with 432 completing the trial. Women were randomized to receive iron supplements plus vitamin C or iron supplements only. Their findings were that oral iron supplements alone were equivalent to oral iron supplements plus vitamin C in improving hemoglobin recovery and iron absorption.
Bottom line
Less frequent administration of iron supplements (every other day) is as effective as more frequent administration, with less GI symptoms. Also, adding vitamin C does not appear to improve absorption of iron supplements.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at imnews@mdedge.com.
References
1. 1. Fairbanks VF and Beutler E. Iron deficiency, in “Williams Textbook of Hematology, 6th ed.” (New York: McGraw-Hill, 2001).
2. Stoffel N et al. Lancet Haematology. 2017;4: e524-33.
3. Karakoc G et al. J Matern Fetal Neonatal Med. 2021 Apr 18:1-5
4. Düzen Oflas N et al. Intern Med J. 2020 Jul;50(7):854-8
5. Cook JD and Monsen ER. Am J Clin Nutr. 1977;30:235-41.
6. Hallberg L etal. Hum Nutr Appl Nutr. 1986;40: 97-113.
7. Cook JD and Reddy M. Am J Clin Nutr. 2001;73:93-8.
8. Hunt JR et al. Am J Clin Nutr. 1994 Jun;59(6):1381-5.
9. Li N et al. JAMA Netw Open. 2020 Nov 2;3(11):e2023644.
Her blood work shows a hematocrit level of 32, a mean corpuscular volume of 77, a platelet count of 390,000, and a ferritin level of 5.
What would you recommend for iron replacement?
A. FeSO4 325 mg three times a day with vitamin C
B. FeSO4 325 mg daily with vitamin C
C. FeSO4 325 mg every other day
Recommendations and supporting research
I think I would start with choice C, FeSO4 every other day.
Treatment of iron deficiency with oral iron has traditionally been done by giving 150-200 mg of elemental iron (which is equal to three 325 mg tablets of iron sulfate).1 This dosing regimen has considerable gastrointestinal side effects. Recent evidence has shown that iron absorption is diminished the more frequently it is given.
Stoffel and colleagues found that fractional iron absorption was higher in iron-deficient women who were given iron every other day, compared with those who received daily iron.2 They also found that the more frequently iron was administered, the higher the hepcidin levels were, and the lower the iron absorption.
Karacok and colleagues studied every other day iron versus daily iron for the treatment of iron-deficiency anemia of pregnancy.3 A total of 217 women completed randomization and participated in the study, with all women receiving 100 mg of elemental iron, either daily (111) or every other day (106). There was no significant difference in increase in ferritin levels, or hemoglobin increase between the groups. The daily iron group had more gastrointestinal symptoms (41.4%) than the every other day iron group (15.1%) (P < .0057).
Düzen Oflas and colleagues looked at the same question in nonpregnant women with iron deficiency anemia.4 Study patients either received 80 mg iron sulfate twice a day, 80 mg once a day, or 80 mg every other day. There was no statistically significant difference in hemoglobin improvement between groups, but the group that received twice a day dosing of iron had statistically significantly higher ferritin levels than the daily or every other day iron groups. This improvement in ferritin levels came at a cost, though, as 68% of patients in the twice daily iron group had gastrointestinal symptoms, compared with only 10% in the every other day iron group (P < .01).
Vitamin C is often recommended to be taken with iron to promote absorption. The evidence for this practice is scant, and dates back almost 50 years.5,6
Cook and Reddy found there was no significant difference in mean iron absorption among the three dietary periods studied in 12 patients despite a range of mean daily intakes of dietary vitamin C of 51-247 mg/d.7
Hunt and colleagues studied 25 non pregnant, healthy women with low ferritin levels.8 The women’s meals were supplemented with vitamin C (500 mg, three times a day) for 5 of the 10 weeks, in a double-blind, crossover design. Vitamin C supplementation did not lead to a difference in iron absorption, lab indices of iron deficiency, or the biological half-life of iron.
Li and colleagues looked at the effect of vitamin C supplementation on iron levels in women with iron deficiency anemia.9 A total of 440 women were recruited, with 432 completing the trial. Women were randomized to receive iron supplements plus vitamin C or iron supplements only. Their findings were that oral iron supplements alone were equivalent to oral iron supplements plus vitamin C in improving hemoglobin recovery and iron absorption.
Bottom line
Less frequent administration of iron supplements (every other day) is as effective as more frequent administration, with less GI symptoms. Also, adding vitamin C does not appear to improve absorption of iron supplements.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at imnews@mdedge.com.
References
1. 1. Fairbanks VF and Beutler E. Iron deficiency, in “Williams Textbook of Hematology, 6th ed.” (New York: McGraw-Hill, 2001).
2. Stoffel N et al. Lancet Haematology. 2017;4: e524-33.
3. Karakoc G et al. J Matern Fetal Neonatal Med. 2021 Apr 18:1-5
4. Düzen Oflas N et al. Intern Med J. 2020 Jul;50(7):854-8
5. Cook JD and Monsen ER. Am J Clin Nutr. 1977;30:235-41.
6. Hallberg L etal. Hum Nutr Appl Nutr. 1986;40: 97-113.
7. Cook JD and Reddy M. Am J Clin Nutr. 2001;73:93-8.
8. Hunt JR et al. Am J Clin Nutr. 1994 Jun;59(6):1381-5.
9. Li N et al. JAMA Netw Open. 2020 Nov 2;3(11):e2023644.
Cancer mortality continues to drop in females as breast cancer reversal looms
Overall cancer mortality in females continues to decrease in the United States, but “previous declining trends in death rates slowed” for breast cancer in recent years, according to an annual report by several national organizations.
The analysis of long-term trends in cancer death rates shows that a decline of 1.4% per year from 2001 to 2016 accelerated to 2.1% per year in 2016-2018, the American Cancer Society, Centers for Disease Control and Prevention, National Cancer Institute, and the North American Association of Central Cancer Registries said.
Decreases in overall cancer mortality were seen in females of all races and ethnic groups over the most recent 5-year period included in the report, 2014-2018, varying from –1.6% per year in both non-Hispanic Blacks and Whites to –0.9% for non-Hispanic American Indians/Alaska Natives (AI/ANs), Farhad Islami, MD, PhD, of the American Cancer Society, Atlanta, and associates said in the Journal of the National Cancer Institute.
Over those 5 years, death rates fell for 14 of the 20 most common cancers in females; increased for liver, uterus, brain, pancreas, and soft tissue including heart; and remained stable for cancers of the oral cavity/pharynx, they reported.
Breast cancer was among those that declined, but the rate of that decline has been slowing. Mortality declined by an average of 2.3% per year in 2003-2007, by 1.6% a year in 2007-2014, and by just 1.0% annually during 2014-2018, based on data from the National Center for Health Statistics’ National Vital Statistics System.
Mortality from all cancers in 2014-2018 was 133.5 deaths per 100,000 standard population, with the racial/ethnic gap ranging from 85.4 per 100,000 (non-Hispanic Asian/Pacific Islander) to 154.9 (non-Hispanic Black), Dr. Islami and associates said.
Melanoma had the largest decline in mortality over that period among the 20 most common cancers in females, falling by an average of 4.4% per year, with lung cancer next at 4.3%. Among those with increased death rates, uterine cancer saw the largest rise at 2.0% a year, the research team said.
The deaths caused by cancer of the uterus were most common in non-Hispanic Black females, 8.9 per 100,000 population, followed by non-Hispanic White (4.5), Hispanic (4.1), non-Hispanic AI/AN (4.0), and non-Hispanic Asian/Pacific Islander (3.3), they reported.
“Long-term increasing trends in uterine cancer death rates parallel trends in incidence, although death rates are increasing at a somewhat faster rate. Increasing uterine cancer incidence has been attributed to increasing obesity prevalence and decreased use of combined hormone replacement therapy,” Dr. Islami and associates pointed out.
Breast cancer deaths also were most common among Blacks in 2014-2018, occurring at a rate of 28.2 per 100,000, as were deaths from cancer of the cervix (3.4 per 100,000), while ovarian cancers deaths were highest in White females (7.1 per 100,000), the researchers noted.
The continuing racial and ethnic disparity “largely reflects a combination of multiple intertwined factors” of tumor biology, diagnosis, treatment, and systemic discrimination, they wrote, adding that Black persons “are more likely to have a higher exposure to some cancer risk factors and limited access to healthy food, safe places for physical activity, and evidence-based cancer preventive services.”
The report was funded by the four participating groups. Six of the 12 investigators are employees of the American Cancer Society whose salaries are solely paid by the society; the other authors had no conflicts of interest to disclose.
Overall cancer mortality in females continues to decrease in the United States, but “previous declining trends in death rates slowed” for breast cancer in recent years, according to an annual report by several national organizations.
The analysis of long-term trends in cancer death rates shows that a decline of 1.4% per year from 2001 to 2016 accelerated to 2.1% per year in 2016-2018, the American Cancer Society, Centers for Disease Control and Prevention, National Cancer Institute, and the North American Association of Central Cancer Registries said.
Decreases in overall cancer mortality were seen in females of all races and ethnic groups over the most recent 5-year period included in the report, 2014-2018, varying from –1.6% per year in both non-Hispanic Blacks and Whites to –0.9% for non-Hispanic American Indians/Alaska Natives (AI/ANs), Farhad Islami, MD, PhD, of the American Cancer Society, Atlanta, and associates said in the Journal of the National Cancer Institute.
Over those 5 years, death rates fell for 14 of the 20 most common cancers in females; increased for liver, uterus, brain, pancreas, and soft tissue including heart; and remained stable for cancers of the oral cavity/pharynx, they reported.
Breast cancer was among those that declined, but the rate of that decline has been slowing. Mortality declined by an average of 2.3% per year in 2003-2007, by 1.6% a year in 2007-2014, and by just 1.0% annually during 2014-2018, based on data from the National Center for Health Statistics’ National Vital Statistics System.
Mortality from all cancers in 2014-2018 was 133.5 deaths per 100,000 standard population, with the racial/ethnic gap ranging from 85.4 per 100,000 (non-Hispanic Asian/Pacific Islander) to 154.9 (non-Hispanic Black), Dr. Islami and associates said.
Melanoma had the largest decline in mortality over that period among the 20 most common cancers in females, falling by an average of 4.4% per year, with lung cancer next at 4.3%. Among those with increased death rates, uterine cancer saw the largest rise at 2.0% a year, the research team said.
The deaths caused by cancer of the uterus were most common in non-Hispanic Black females, 8.9 per 100,000 population, followed by non-Hispanic White (4.5), Hispanic (4.1), non-Hispanic AI/AN (4.0), and non-Hispanic Asian/Pacific Islander (3.3), they reported.
“Long-term increasing trends in uterine cancer death rates parallel trends in incidence, although death rates are increasing at a somewhat faster rate. Increasing uterine cancer incidence has been attributed to increasing obesity prevalence and decreased use of combined hormone replacement therapy,” Dr. Islami and associates pointed out.
Breast cancer deaths also were most common among Blacks in 2014-2018, occurring at a rate of 28.2 per 100,000, as were deaths from cancer of the cervix (3.4 per 100,000), while ovarian cancers deaths were highest in White females (7.1 per 100,000), the researchers noted.
The continuing racial and ethnic disparity “largely reflects a combination of multiple intertwined factors” of tumor biology, diagnosis, treatment, and systemic discrimination, they wrote, adding that Black persons “are more likely to have a higher exposure to some cancer risk factors and limited access to healthy food, safe places for physical activity, and evidence-based cancer preventive services.”
The report was funded by the four participating groups. Six of the 12 investigators are employees of the American Cancer Society whose salaries are solely paid by the society; the other authors had no conflicts of interest to disclose.
Overall cancer mortality in females continues to decrease in the United States, but “previous declining trends in death rates slowed” for breast cancer in recent years, according to an annual report by several national organizations.
The analysis of long-term trends in cancer death rates shows that a decline of 1.4% per year from 2001 to 2016 accelerated to 2.1% per year in 2016-2018, the American Cancer Society, Centers for Disease Control and Prevention, National Cancer Institute, and the North American Association of Central Cancer Registries said.
Decreases in overall cancer mortality were seen in females of all races and ethnic groups over the most recent 5-year period included in the report, 2014-2018, varying from –1.6% per year in both non-Hispanic Blacks and Whites to –0.9% for non-Hispanic American Indians/Alaska Natives (AI/ANs), Farhad Islami, MD, PhD, of the American Cancer Society, Atlanta, and associates said in the Journal of the National Cancer Institute.
Over those 5 years, death rates fell for 14 of the 20 most common cancers in females; increased for liver, uterus, brain, pancreas, and soft tissue including heart; and remained stable for cancers of the oral cavity/pharynx, they reported.
Breast cancer was among those that declined, but the rate of that decline has been slowing. Mortality declined by an average of 2.3% per year in 2003-2007, by 1.6% a year in 2007-2014, and by just 1.0% annually during 2014-2018, based on data from the National Center for Health Statistics’ National Vital Statistics System.
Mortality from all cancers in 2014-2018 was 133.5 deaths per 100,000 standard population, with the racial/ethnic gap ranging from 85.4 per 100,000 (non-Hispanic Asian/Pacific Islander) to 154.9 (non-Hispanic Black), Dr. Islami and associates said.
Melanoma had the largest decline in mortality over that period among the 20 most common cancers in females, falling by an average of 4.4% per year, with lung cancer next at 4.3%. Among those with increased death rates, uterine cancer saw the largest rise at 2.0% a year, the research team said.
The deaths caused by cancer of the uterus were most common in non-Hispanic Black females, 8.9 per 100,000 population, followed by non-Hispanic White (4.5), Hispanic (4.1), non-Hispanic AI/AN (4.0), and non-Hispanic Asian/Pacific Islander (3.3), they reported.
“Long-term increasing trends in uterine cancer death rates parallel trends in incidence, although death rates are increasing at a somewhat faster rate. Increasing uterine cancer incidence has been attributed to increasing obesity prevalence and decreased use of combined hormone replacement therapy,” Dr. Islami and associates pointed out.
Breast cancer deaths also were most common among Blacks in 2014-2018, occurring at a rate of 28.2 per 100,000, as were deaths from cancer of the cervix (3.4 per 100,000), while ovarian cancers deaths were highest in White females (7.1 per 100,000), the researchers noted.
The continuing racial and ethnic disparity “largely reflects a combination of multiple intertwined factors” of tumor biology, diagnosis, treatment, and systemic discrimination, they wrote, adding that Black persons “are more likely to have a higher exposure to some cancer risk factors and limited access to healthy food, safe places for physical activity, and evidence-based cancer preventive services.”
The report was funded by the four participating groups. Six of the 12 investigators are employees of the American Cancer Society whose salaries are solely paid by the society; the other authors had no conflicts of interest to disclose.
FROM THE JOURNAL OF THE NATIONAL CANCER INSTITUTE
Most U.S. adults age 50+ report good health: Survey
a nonprofit hospice/advanced illness care organization based in Virginia.
Among the respondents, 41% said their health was very good or excellent.
However, the ratings differed largely by race, employment status, and income.
Employment status was also associated with a significant difference in the way people viewed their health at the top tier and bottom tier.
The middle tier (“good” health) was reported similarly (from 33% to 37%) whether a person was employed, retired, or not employed. However, employed respondents were much more likely to report they had “excellent” or “very good” health (51% vs. 44% for retirees and 21% for the not employed).
Conversely, those who were not employed were far more likely to report “fair” or “poor” health (45%) than those who were employed (13%) or retired (20%).
Similarly, respondents with incomes of less than $50,000 were three times more likely to report their health as “fair” or “poor” than were those with incomes of more than $100,000 (36% vs. 12%).
WebMD/CCH surveyed 3,464 U.S. residents ages 50 and older between Aug. 13 and Nov. 9, 2020. WebMD.com readers were randomly invited to take a 10-minute online survey.
Aging at home a priority
The survey also highlighted a strong preference for aging in place, says Steve Cone, chief of communications and philanthropy at CCH.
“More now than ever before, thanks to the COVID experience, baby boomers and their children really believe that’s the holy grail,” he says.
Mr. Cone notes that the quick spread of COVID-19 through some nursing homes early in the pandemic likely has strengthened people’s resolve to live out their lives in their own homes.
The survey indicated that 85% of people aged 50+ who are living in their own home, a family member’s home, or a loved one’s home responded that it is “very important” or “important” to stay in their home as they age.
When asked what services they would need to continue their living situation, the most common responses were housekeeping, home repair services, and transportation (listed as needs by 35% to 45% of respondents). Regarding changes they would have to make to feel safe in their home as they age, installing grab bars and/or safety rails in the bath/shower was the most popular answer (50%).
Use of telemedicine
Respondents were also asked about their acceptance of telemedicine, and 62% said they would be likely or very likely to engage in virtual visits with a doctor it in the future.
However, the likelihood varied by income level. Specifically, respondents with incomes over $100,000 were significantly more likely to say they would use telemedicine in the future than were those with incomes below $50,000 (74% vs. 60%). They were also more likely to already have used telemedicine.
Although respondents generally embraced telemedicine, they are less confident about some types of monitoring, according to Mr. Cone.
Emergency response (64%) was the leading type of remote monitoring respondents ages 50 and older would allow. Only a minority of respondents would allow the other types of monitoring asked about in the survey.
Close to one-quarter of respondents would not allow any type of monitoring.
Fewer than one-third would allow tracking of medication compliance, refrigerator use, sleep habits, or bathroom use.
People see monitoring of some movements as “Orwellian,” Mr. Cone says.
Knowledge of hospice
The survey findings support the need for more widespread use of hospice so people can stay in their homes as they age, Mr. Cone says.
When illness gets severe, “There’s no reason you have to get rushed to the emergency room or wind up in a hospital,” Mr. Cone says.
He notes that hospice and palliative care can come to patients wherever they reside – in their home, an assisted living center, a nursing home, or even a hospital room.
“That doesn’t mean the physician isn’t involved,” he says. “But working as a team, we can keep them in their homes and their lifestyle intact.”
Patients whose doctors attest that they are likely to live a maximum 6 months are eligible for hospice. But most families wait too long to long to start hospice or palliative care for a patient, Mr. Cone says, and may not be aware of what these services typically cover, including meal preparation and pet care.
In the survey, nearly one-third of respondents said they did not know that palliative care is something that “can be given at any stage of a serious illness” or “provides non-medical services (e.g., patient/family communication, help with insurance issues, scheduling appointments, arranging transportation).”
He notes palliative care and hospice are covered by Medicare and Medicaid and also by most private insurance plans or by individual companies providing the service.
However, health care providers may have to overcome a general reluctance to discuss hospice when sharing options for those severely ill.
The survey showed that while 51% of those 50 and older are at least “slightly interested” in learning more about hospice, a nearly equal number say they are “not at all interested” (49%).
Most using hospice are White
More than 90% of those surveyed reported that aspects of hospice care, including “comfort and relief from pain at the end of patients’ lives,” providing a dedicated care team, and an alternative to other care settings, are “very important” or “important.”
However, national hospice use rates are extremely low for minorities and the LGBTQ community, according to Mr. Cone. Among Medicare hospice recipients, 82% were white, 8.2% Black, 6.7% Hispanic, and 1.8% Asian or Pacific Islander, according to the National Hospice and Palliative Care Organization.
Those numbers signal a need for outreach to those communities with information on what services are available and how to access them, he says.
Health costs top concern
The survey also asked about level of concern regarding matters including family, health, financials, and end-of-life directives and found adults aged 50 and older expressed the greatest amount of concern for health care costs that are not covered by insurance.
More than half (56%) said they were concerned or very concerned about those costs, which was higher than the percentage concerned about losing a spouse (49%).
Respondents were less concerned (“slightly concerned” or “not at all concerned”) about their children living far away, planning end-of life-directives, and falling or having reduced mobility.
A version of this article first appeared on WebMD.com.
a nonprofit hospice/advanced illness care organization based in Virginia.
Among the respondents, 41% said their health was very good or excellent.
However, the ratings differed largely by race, employment status, and income.
Employment status was also associated with a significant difference in the way people viewed their health at the top tier and bottom tier.
The middle tier (“good” health) was reported similarly (from 33% to 37%) whether a person was employed, retired, or not employed. However, employed respondents were much more likely to report they had “excellent” or “very good” health (51% vs. 44% for retirees and 21% for the not employed).
Conversely, those who were not employed were far more likely to report “fair” or “poor” health (45%) than those who were employed (13%) or retired (20%).
Similarly, respondents with incomes of less than $50,000 were three times more likely to report their health as “fair” or “poor” than were those with incomes of more than $100,000 (36% vs. 12%).
WebMD/CCH surveyed 3,464 U.S. residents ages 50 and older between Aug. 13 and Nov. 9, 2020. WebMD.com readers were randomly invited to take a 10-minute online survey.
Aging at home a priority
The survey also highlighted a strong preference for aging in place, says Steve Cone, chief of communications and philanthropy at CCH.
“More now than ever before, thanks to the COVID experience, baby boomers and their children really believe that’s the holy grail,” he says.
Mr. Cone notes that the quick spread of COVID-19 through some nursing homes early in the pandemic likely has strengthened people’s resolve to live out their lives in their own homes.
The survey indicated that 85% of people aged 50+ who are living in their own home, a family member’s home, or a loved one’s home responded that it is “very important” or “important” to stay in their home as they age.
When asked what services they would need to continue their living situation, the most common responses were housekeeping, home repair services, and transportation (listed as needs by 35% to 45% of respondents). Regarding changes they would have to make to feel safe in their home as they age, installing grab bars and/or safety rails in the bath/shower was the most popular answer (50%).
Use of telemedicine
Respondents were also asked about their acceptance of telemedicine, and 62% said they would be likely or very likely to engage in virtual visits with a doctor it in the future.
However, the likelihood varied by income level. Specifically, respondents with incomes over $100,000 were significantly more likely to say they would use telemedicine in the future than were those with incomes below $50,000 (74% vs. 60%). They were also more likely to already have used telemedicine.
Although respondents generally embraced telemedicine, they are less confident about some types of monitoring, according to Mr. Cone.
Emergency response (64%) was the leading type of remote monitoring respondents ages 50 and older would allow. Only a minority of respondents would allow the other types of monitoring asked about in the survey.
Close to one-quarter of respondents would not allow any type of monitoring.
Fewer than one-third would allow tracking of medication compliance, refrigerator use, sleep habits, or bathroom use.
People see monitoring of some movements as “Orwellian,” Mr. Cone says.
Knowledge of hospice
The survey findings support the need for more widespread use of hospice so people can stay in their homes as they age, Mr. Cone says.
When illness gets severe, “There’s no reason you have to get rushed to the emergency room or wind up in a hospital,” Mr. Cone says.
He notes that hospice and palliative care can come to patients wherever they reside – in their home, an assisted living center, a nursing home, or even a hospital room.
“That doesn’t mean the physician isn’t involved,” he says. “But working as a team, we can keep them in their homes and their lifestyle intact.”
Patients whose doctors attest that they are likely to live a maximum 6 months are eligible for hospice. But most families wait too long to long to start hospice or palliative care for a patient, Mr. Cone says, and may not be aware of what these services typically cover, including meal preparation and pet care.
In the survey, nearly one-third of respondents said they did not know that palliative care is something that “can be given at any stage of a serious illness” or “provides non-medical services (e.g., patient/family communication, help with insurance issues, scheduling appointments, arranging transportation).”
He notes palliative care and hospice are covered by Medicare and Medicaid and also by most private insurance plans or by individual companies providing the service.
However, health care providers may have to overcome a general reluctance to discuss hospice when sharing options for those severely ill.
The survey showed that while 51% of those 50 and older are at least “slightly interested” in learning more about hospice, a nearly equal number say they are “not at all interested” (49%).
Most using hospice are White
More than 90% of those surveyed reported that aspects of hospice care, including “comfort and relief from pain at the end of patients’ lives,” providing a dedicated care team, and an alternative to other care settings, are “very important” or “important.”
However, national hospice use rates are extremely low for minorities and the LGBTQ community, according to Mr. Cone. Among Medicare hospice recipients, 82% were white, 8.2% Black, 6.7% Hispanic, and 1.8% Asian or Pacific Islander, according to the National Hospice and Palliative Care Organization.
Those numbers signal a need for outreach to those communities with information on what services are available and how to access them, he says.
Health costs top concern
The survey also asked about level of concern regarding matters including family, health, financials, and end-of-life directives and found adults aged 50 and older expressed the greatest amount of concern for health care costs that are not covered by insurance.
More than half (56%) said they were concerned or very concerned about those costs, which was higher than the percentage concerned about losing a spouse (49%).
Respondents were less concerned (“slightly concerned” or “not at all concerned”) about their children living far away, planning end-of life-directives, and falling or having reduced mobility.
A version of this article first appeared on WebMD.com.
a nonprofit hospice/advanced illness care organization based in Virginia.
Among the respondents, 41% said their health was very good or excellent.
However, the ratings differed largely by race, employment status, and income.
Employment status was also associated with a significant difference in the way people viewed their health at the top tier and bottom tier.
The middle tier (“good” health) was reported similarly (from 33% to 37%) whether a person was employed, retired, or not employed. However, employed respondents were much more likely to report they had “excellent” or “very good” health (51% vs. 44% for retirees and 21% for the not employed).
Conversely, those who were not employed were far more likely to report “fair” or “poor” health (45%) than those who were employed (13%) or retired (20%).
Similarly, respondents with incomes of less than $50,000 were three times more likely to report their health as “fair” or “poor” than were those with incomes of more than $100,000 (36% vs. 12%).
WebMD/CCH surveyed 3,464 U.S. residents ages 50 and older between Aug. 13 and Nov. 9, 2020. WebMD.com readers were randomly invited to take a 10-minute online survey.
Aging at home a priority
The survey also highlighted a strong preference for aging in place, says Steve Cone, chief of communications and philanthropy at CCH.
“More now than ever before, thanks to the COVID experience, baby boomers and their children really believe that’s the holy grail,” he says.
Mr. Cone notes that the quick spread of COVID-19 through some nursing homes early in the pandemic likely has strengthened people’s resolve to live out their lives in their own homes.
The survey indicated that 85% of people aged 50+ who are living in their own home, a family member’s home, or a loved one’s home responded that it is “very important” or “important” to stay in their home as they age.
When asked what services they would need to continue their living situation, the most common responses were housekeeping, home repair services, and transportation (listed as needs by 35% to 45% of respondents). Regarding changes they would have to make to feel safe in their home as they age, installing grab bars and/or safety rails in the bath/shower was the most popular answer (50%).
Use of telemedicine
Respondents were also asked about their acceptance of telemedicine, and 62% said they would be likely or very likely to engage in virtual visits with a doctor it in the future.
However, the likelihood varied by income level. Specifically, respondents with incomes over $100,000 were significantly more likely to say they would use telemedicine in the future than were those with incomes below $50,000 (74% vs. 60%). They were also more likely to already have used telemedicine.
Although respondents generally embraced telemedicine, they are less confident about some types of monitoring, according to Mr. Cone.
Emergency response (64%) was the leading type of remote monitoring respondents ages 50 and older would allow. Only a minority of respondents would allow the other types of monitoring asked about in the survey.
Close to one-quarter of respondents would not allow any type of monitoring.
Fewer than one-third would allow tracking of medication compliance, refrigerator use, sleep habits, or bathroom use.
People see monitoring of some movements as “Orwellian,” Mr. Cone says.
Knowledge of hospice
The survey findings support the need for more widespread use of hospice so people can stay in their homes as they age, Mr. Cone says.
When illness gets severe, “There’s no reason you have to get rushed to the emergency room or wind up in a hospital,” Mr. Cone says.
He notes that hospice and palliative care can come to patients wherever they reside – in their home, an assisted living center, a nursing home, or even a hospital room.
“That doesn’t mean the physician isn’t involved,” he says. “But working as a team, we can keep them in their homes and their lifestyle intact.”
Patients whose doctors attest that they are likely to live a maximum 6 months are eligible for hospice. But most families wait too long to long to start hospice or palliative care for a patient, Mr. Cone says, and may not be aware of what these services typically cover, including meal preparation and pet care.
In the survey, nearly one-third of respondents said they did not know that palliative care is something that “can be given at any stage of a serious illness” or “provides non-medical services (e.g., patient/family communication, help with insurance issues, scheduling appointments, arranging transportation).”
He notes palliative care and hospice are covered by Medicare and Medicaid and also by most private insurance plans or by individual companies providing the service.
However, health care providers may have to overcome a general reluctance to discuss hospice when sharing options for those severely ill.
The survey showed that while 51% of those 50 and older are at least “slightly interested” in learning more about hospice, a nearly equal number say they are “not at all interested” (49%).
Most using hospice are White
More than 90% of those surveyed reported that aspects of hospice care, including “comfort and relief from pain at the end of patients’ lives,” providing a dedicated care team, and an alternative to other care settings, are “very important” or “important.”
However, national hospice use rates are extremely low for minorities and the LGBTQ community, according to Mr. Cone. Among Medicare hospice recipients, 82% were white, 8.2% Black, 6.7% Hispanic, and 1.8% Asian or Pacific Islander, according to the National Hospice and Palliative Care Organization.
Those numbers signal a need for outreach to those communities with information on what services are available and how to access them, he says.
Health costs top concern
The survey also asked about level of concern regarding matters including family, health, financials, and end-of-life directives and found adults aged 50 and older expressed the greatest amount of concern for health care costs that are not covered by insurance.
More than half (56%) said they were concerned or very concerned about those costs, which was higher than the percentage concerned about losing a spouse (49%).
Respondents were less concerned (“slightly concerned” or “not at all concerned”) about their children living far away, planning end-of life-directives, and falling or having reduced mobility.
A version of this article first appeared on WebMD.com.
Twenty Years of Breast Reduction Surgery at a Veterans Affairs Medical Center
Women make up an estimated 10% of the veteran population.1 The US Department of Veterans Affairs (VA) projected that there would be an increase of 18,000 female veterans per year for 10 years based on 2015 data. The number of women veterans enrolled in the VA health care increased from 397,024 to 729,989 (83.9%) between 2005 and 2015.2 This rise in the number of enrolled women veterans also increased the demand for female-specific health care services, such as breast reduction surgery, a reconstructive procedure provided at the Malcom Randall VA Medical Center (MRVAMC) federal teaching hospital in Gainesville, Florida.
Patients who experience symptomatic macromastia will report a history of neck and shoulder pain, shoulder grooving from bra straps, inframammary intertrigo, difficulty finding clothes that fit, and discomfort participating in sports. For the treatment of symptomatic macromastia, patients report a high satisfaction rate after breast reduction surgery.3-5 Unfortunately, the complications from the surgery can significantly disrupt a woman’s life due to previously unplanned hospital admissions, clinic appointments, wound care, time off work, and poor aesthetic outcome. Faculty awareness of a large number of complications for patients after breast reduction surgery prompted the MRVAMC Plastic Surgery Service to establish a stricter surgical screening protocol using body mass index (BMI) values and negative nicotine status to help patients be healthier and reduce the potential risk before offering surgery. A medical literature search did not find an existing study on veteran-specific breast reduction surgery.
Methods
The University of Florida and North Florida/South Georgia Veterans Health System Institutional Review Board approved a retrospective chart review of all breast reduction surgeries performed at MRVAMC over a 20-year period (July 1, 2000-June 30, 2020). Electronic health records were queried for all primary bilateral breast reduction surgeries performed for symptomatic macromastia using Current Procedural Terminology code 19318. Potentially modifiable or predictable risk factors for wound complications were recorded: nicotine status, BMI, diabetes mellitus (DM) status, skin incision pattern, and pedicle location. Skin incision patterns were either vertical (periareolar plus a vertical scar from the areola to the inframammary fold) or traditional Wise pattern (also known as anchor pattern: periareolar scar, vertical scar to inframammary fold, plus a horizontal scar along the inframammary fold) as seen in Figures 1 and 2. The pedicle is the source of blood supply to the nipple, which was documented as either from the inferior aspect or the superior or superior/medial aspect.
For this study, the blood supply from the superior and superior/medial was logged in the same category. Records were reviewed 3 months after surgery for documentation of local wound complications, such as hematoma, infection, wound breakdown, skin necrosis, and nipple necrosis. Major complications were defined as requiring an unplanned hospital admission or urgent return to the operating room. A χ2 test using a P value of < .05 was used to determine statistical significance between the incidence of wound complications and the individually identifiable variables.
Results
One hundred fifteen bilateral breast reduction surgeries were performed at MRVAMC over a 20-year period. Patient median age was 43 years. Median combined specimen weight was 1272 g. Forty-eight (41.7%) wound complications were documented, including 8 (7%) major complications. Most complications were identified in the first 7 years of the study before the new protocol and consult template became active. The new template resulted in the local complication rate dropping from 62% (July 2000-June 2007) to 26% (July 2007-June 2020). BMI > 32 (P = .03) and active nicotine use (P = .004) were found to be statistically significant independent risk factors for wound complications. Median BMI for all patients was 30. DM status (P = .22), skin incision pattern (P = .25), and pedicle location (P = .13) were not found to be predictors of wound complications (Table). There was no significant change in the incidence of major complications before and after the new protocols were enforced.
Discussion
Breast reduction surgery is an elective reconstructive option to treat symptomatic macromastia. There are several accepted ways to do the reduction surgical procedure where the blood supply (pedicle) to the nipple can vary and the visible scars can be in a horizontal, vertical, or Wise pattern. Technique is usually based on surgeon training, comfort, and preference. There are several known complications specific to this operation that include asymmetry, changes in nipple sensation, unattractive scars, diminished ability to breastfeed, and wound complications.5-7 Wound complications include seroma, hematoma, dehiscence, infection, wound breakdown, skin necrosis, and nipple necrosis.
This study focused on wound complications with the objective of identifying and modifying risk factors. Two known risk factors documented in the literature, nicotine use and obesity, already had been addressed by our service, and results were known anecdotally but had not been previously verified. This study also looked at other potential risk factors, including the pedicle location, skin incision, and DM status.
Residents or fellows participated in all the surgeries. An outcome analysis from The American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2011 found that resident participation was associated with morbidity, including wound complications.8 This study was performed at a federal hospital with a complexity level 1a rating, which is designated based on the highest level of patient volume, risk, teaching, research, intensive care unit beds, and specialty services.9 The hospital is closely affiliated with a level 1 trauma center and teaching hospital; therefore, resident and fellow participation is not a modifiable risk factor.
This study did not find an increased risk of wound complications in patients with DM, which has been found to be an independent risk factor in a prior study.10 DM status was indicated in only 3 histories, and they all had perioperative hemoglobin A1c levels < 8%. There is documentation of patients receiving perioperative antibiotics in 99 out of 116 of the surgical records; however, we did not include this in the analysis because the operative reports from the first year of the study were incomplete.
Smoking is a known risk factor for local wound complications in breast reduction surgery.10-15 The VA has a smoking cessation program through its mental health service that provides counseling and medication treatment options, including nicotine replacement, bupropion, and varenicline. We require patients to be at least 4 weeks nicotine free before surgery, which has been previously recommended in the literature.16
Existing studies that compare the traditional Wise pattern/inferior pedicle with vertical pattern/superior medial pedicle did not find an increased risk of wound complications.17-19 Our study separated the different incisions from the pedicle because the surgical technique among the different surgeons in the study varied, where sometimes the traditional Wise pattern was combined with the less traditional superior-medial pedicle. We did not find a statistical difference when comparing the incisions and pedicle location, which suggests that the incision type and source of blood supply to the nipple are not the determining factors for wound complications in the early postoperative period.
Obesity is a known risk factor for local wound complications.12,13,15,20-22 Studies have shown that patients who are obese benefit from breast reduction surgery; authors have argued against restricting surgery to these higher risk patients.4,23-25 Patients usually report decades of macromastia symptoms at consultation; so, we believe delaying the surgical procedure to get patients to a safer risk profile is in their best interest. We chose a cutoff BMI of 32 as a realistic value rather than 30, which is considered the definition of obesity. Patients at MRVAMC have access to MOVE!, a weight loss management program through primary care. We believe in being reasonable; so if a patient makes a significant improvement in her health but falls short of the required cutoff, we will still consider offering the surgical procedure after a full explanation of the surgical risks.
Wound complications, especially those that require admission or frequent appointments can seriously disrupt a patient’s life, creating unnecessary hardships and expense in time lost from work, travel, and child care. MRVAMC has a catchment area the size of North Carolina; so many of our patients travel hours for their appointments. The added scars and deformity from wound dehiscence and debridement can lead to asymmetry, widened scars, and future revision operations. Multiple clinic appointments for wound care not only impact that individual patient, but also has the effect of limiting access for all patients in a health care environment with high patient volume and limited providers, operating room time, and clinic appointments. As a result, minimizing predictable wound complications benefits the entire system.
Limitations and Strengths
This retrospective review comprised multiple different surgeons, including faculty and trainees, who were involved in the consultation, surgery, and postoperative care of the patients over a 20-year period; therefore, consistency in documentation is lacking. In addition, we were limited to only the information available on the charts. For example, wound size and laterality were not consistently documented. The MRVAMC complication rate was consistent with the current literature (range, 14-52%).12,18,20,24
The major strength of the study is that the veterans tend to stay within the VA, which makes complications easier to identify and follow. Patients who do not present initially to their surgeon due to travel limitations will typically contact their primary care provider or present to their local VA urgent care or emergency department provider, who will route the patient back to the surgical specialty service through the electronic health record.
Conclusions
Breast reduction surgery has a high wound complication rate, which can be predicted and improved on so that patients can receive their indicated surgical procedure with minimal inconvenience and downtime. This review confirms that preoperative weight loss and nicotine cessation were the appropriate focus of the MRVAMC plastic surgery service’s efforts to achieve a safer surgical experience. We will continue to enforce our protocol and encourage patients who are interested in breast reduction surgery and fall outside the requirements to work with their primary care provider on smoking cessation and weight loss through better nutrition and physical activity.
Acknowledgment
This manuscript is the result of work supported with resources and the use of facilities at the North Florida/South Georgia Veterans Health System in Gainesville, Florida.
1. US Department of Veterans Affairs. Statistics at a glance. Published February 2020. Accessed June 18, 2021. https://www.va.gov/vetdata/docs/Quickfacts/Homepage_slideshow_4_6_20.PDF
2. US Department of Veterans Affairs, National Center for Veterans Analysis and Statistics. Women veterans report: the past, present, and future of women veterans. Published February 2017. Accessed June 18, 2020. https://www.va.gov/vetdata/docs/specialreports/women_veterans_2015_final.pdf
3. Crittenden TA, Watson DI, Ratcliffe J, Griffin PA, Dean NR. Outcomes of breast reduction surgery using the breast-q: a prospective study and comparison with normative data. Plast Reconstr Surg. 2019;144(5):1034-1044. doi:10.1097/PRS.0000000000006114
4. Thoma A, Sprague S, Veltri K, Duku E, Furlong W. A prospective study of patients undergoing breast reduction surgery: health-related quality of life and clinical outcomes. Plast Reconstr Surg. 2007;120(1):13-26. doi:10.1097/01.prs.0000263370.94191.90
5. Nuzzi LC, Firriolo JM, Pike CM, DiVasta AD, Labow BI. Complications and quality of life following reduction mammaplasty in adolescents and young women.Plast Reconstr Surg. 2019;144(3):572-581. doi:10.1097/PRS.0000000000005907
6. Hall-Findlay EJ, Shestak KC. Breast reduction. Plast Reconstr Surg. 2015;136(4):531e-544e. doi:10.1097/PRS.0000000000001622
7. Kraut RY, Brown E, Korownyk C, et al. The impact of breast reduction surgery on breastfeeding: systematic review of observational studies. PLoS One. 2017;12(10):e0186591. doi:10.1371/journal.pone.0186591
8. Fischer JP, Wes AM, Kovach SJ. The impact of surgical resident participation in breast reduction surgery--outcome analysis from the 2005-2011 ACS-NSQIP datasets. J Plast Surg Hand Surg. 2014;48(5):315-321. doi:10.3109/2000656X.2014.882345
9. Site Facility Name and Complexity Summary of VHA Facility. Accessed June 18, 2021. https://www.vendorportal.ecms.va.gov/FBODocumentServer/DocumentServer.aspx?DocumentId=2793591&FileName=VA118-16-R-1059-A00002002.docx
10. Lewin R, Göransson M, Elander A, Thorarinsson A, Lundberg J, Lidén M. Risk factors for complications after breast reduction surgery. J Plast Surg Hand Surg. 2014;48(1):10-14. doi:10.3109/2000656X.2013.791625
11. Cunningham BL, Gear AJ, Kerrigan CL, Collins ED. Analysis of breast reduction complications derived from the BRAVO study. Plast Reconstr Surg. 2005;115(6):1597-1604. doi:10.1097/01.prs.0000160695.33457.db
12. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Ann Plast Surg. 2015;75(4):383-387. doi:10.1097/SAP.0000000000000192
13. Manahan MA, Buretta KJ, Chang D, Mithani SK, Mallalieu J, Shermak MA. An outcomes analysis of 2142 breast reduction procedures. Ann Plast Surg. 2015;74(3):289-292. doi:10.1097/SAP.0b013e31829d2261
14. Hillam JS, Borsting EA, Chim JH, Thaller SR. Smoking as a risk factor for breast reduction: an analysis of 13,503 cases. J Plast Reconstr Aesthet Surg. 2017;70(6):734-740. doi:10.1016/j.bjps.2016.12.012
15. Zhang MX, Chen CY, Fang QQ, et al. Risk factors for complications after reduction mammoplasty: a meta-analysis. PLoS One. 2016;11(12):e0167746. doi:10.1371/journal.pone.0167746
16. Sørensen LT. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Ann Surg. 2012;255(6):1069-1079.doi:10.1097/SLA.0b013e31824f632d
17. Antony AK, Yegiyants SS, Danielson KK, et al. A matched cohort study of superomedial pedicle vertical scar breast reduction (100 breasts) and traditional inferior pedicle Wise-pattern reduction (100 breasts): an outcomes study over 3 years. Plast Reconstr Surg. 2013;132(5):1068-1076. doi:10.1097/PRS.0b013e3182a48b2d
18. Hunter-Smith DJ, Smoll NR, Marne B, Maung H, Findlay MW. Comparing breast-reduction techniques: time-to-event analysis and recommendations. Aesthetic Plast Surg. 2012;36(3):600-606. doi:10.1007/s00266-011-9860-3
19. Ogunleye AA, Leroux O, Morrison N, Preminger AB. Complications after reduction mammaplasty: a comparison of wise pattern/inferior pedicle and vertical scar/superomedial pedicle. Ann Plast Surg. 2017;79(1):13-16. doi:10.1097/SAP.0000000000001059
20. Bauermeister AJ, Gill K, Zuriarrain A, Earle SA, Newman MI. Reduction mammaplasty with superomedial pedicle technique: a literature review and retrospective analysis of 938 consecutive breast reductions. J Plast Reconstr Aesthet Surg. 2019;72(3):410-418. doi:10.1016/j.bjps.2018.12.004
21. Nelson JA, Fischer JP, Chung CU, et al. Obesity and early complications following reduction mammaplasty: an analysis of 4545 patients from the 2005-2011 NSQIP datasets. J Plast Surg Hand Surg. 2014;48(5):334-339. doi:10.3109/2000656X.2014.886582
22. Kreithen J, Caffee H, Rosenberg J, et al. A comparison of the LeJour and Wise pattern methods of breast reduction. Ann Plast Surg. 2005;54(3):236-241. doi:10.3109/2000656X.2014.886582
23. Güemes A, Pérez E, Sousa R, et al. Quality of life and alleviation of symptoms after breast reduction for macromastia in obese patients: is surgery worth it? Aesthetic Plast Surg. 2016;40(1):62-70. doi:10.1007/s00266-015-0601-x
24. Setälä L, Papp A, Joukainen S, et al. Obesity and complications in breast reduction surgery: are restrictions justified? J Plast Reconstr Aesthet Surg. 2009;62(2):195-199. doi:10.1016/j.bjps.2007.10.043
25. Shah R, Al-Ajam Y, Stott D, Kang N. Obesity in mammaplasty: a study of complications following breast reduction. J Plast Reconstr Aesthet Surg. 2011;64(4):508-514. doi:10.1016/j.bjps.2007.10.043
Women make up an estimated 10% of the veteran population.1 The US Department of Veterans Affairs (VA) projected that there would be an increase of 18,000 female veterans per year for 10 years based on 2015 data. The number of women veterans enrolled in the VA health care increased from 397,024 to 729,989 (83.9%) between 2005 and 2015.2 This rise in the number of enrolled women veterans also increased the demand for female-specific health care services, such as breast reduction surgery, a reconstructive procedure provided at the Malcom Randall VA Medical Center (MRVAMC) federal teaching hospital in Gainesville, Florida.
Patients who experience symptomatic macromastia will report a history of neck and shoulder pain, shoulder grooving from bra straps, inframammary intertrigo, difficulty finding clothes that fit, and discomfort participating in sports. For the treatment of symptomatic macromastia, patients report a high satisfaction rate after breast reduction surgery.3-5 Unfortunately, the complications from the surgery can significantly disrupt a woman’s life due to previously unplanned hospital admissions, clinic appointments, wound care, time off work, and poor aesthetic outcome. Faculty awareness of a large number of complications for patients after breast reduction surgery prompted the MRVAMC Plastic Surgery Service to establish a stricter surgical screening protocol using body mass index (BMI) values and negative nicotine status to help patients be healthier and reduce the potential risk before offering surgery. A medical literature search did not find an existing study on veteran-specific breast reduction surgery.
Methods
The University of Florida and North Florida/South Georgia Veterans Health System Institutional Review Board approved a retrospective chart review of all breast reduction surgeries performed at MRVAMC over a 20-year period (July 1, 2000-June 30, 2020). Electronic health records were queried for all primary bilateral breast reduction surgeries performed for symptomatic macromastia using Current Procedural Terminology code 19318. Potentially modifiable or predictable risk factors for wound complications were recorded: nicotine status, BMI, diabetes mellitus (DM) status, skin incision pattern, and pedicle location. Skin incision patterns were either vertical (periareolar plus a vertical scar from the areola to the inframammary fold) or traditional Wise pattern (also known as anchor pattern: periareolar scar, vertical scar to inframammary fold, plus a horizontal scar along the inframammary fold) as seen in Figures 1 and 2. The pedicle is the source of blood supply to the nipple, which was documented as either from the inferior aspect or the superior or superior/medial aspect.
For this study, the blood supply from the superior and superior/medial was logged in the same category. Records were reviewed 3 months after surgery for documentation of local wound complications, such as hematoma, infection, wound breakdown, skin necrosis, and nipple necrosis. Major complications were defined as requiring an unplanned hospital admission or urgent return to the operating room. A χ2 test using a P value of < .05 was used to determine statistical significance between the incidence of wound complications and the individually identifiable variables.
Results
One hundred fifteen bilateral breast reduction surgeries were performed at MRVAMC over a 20-year period. Patient median age was 43 years. Median combined specimen weight was 1272 g. Forty-eight (41.7%) wound complications were documented, including 8 (7%) major complications. Most complications were identified in the first 7 years of the study before the new protocol and consult template became active. The new template resulted in the local complication rate dropping from 62% (July 2000-June 2007) to 26% (July 2007-June 2020). BMI > 32 (P = .03) and active nicotine use (P = .004) were found to be statistically significant independent risk factors for wound complications. Median BMI for all patients was 30. DM status (P = .22), skin incision pattern (P = .25), and pedicle location (P = .13) were not found to be predictors of wound complications (Table). There was no significant change in the incidence of major complications before and after the new protocols were enforced.
Discussion
Breast reduction surgery is an elective reconstructive option to treat symptomatic macromastia. There are several accepted ways to do the reduction surgical procedure where the blood supply (pedicle) to the nipple can vary and the visible scars can be in a horizontal, vertical, or Wise pattern. Technique is usually based on surgeon training, comfort, and preference. There are several known complications specific to this operation that include asymmetry, changes in nipple sensation, unattractive scars, diminished ability to breastfeed, and wound complications.5-7 Wound complications include seroma, hematoma, dehiscence, infection, wound breakdown, skin necrosis, and nipple necrosis.
This study focused on wound complications with the objective of identifying and modifying risk factors. Two known risk factors documented in the literature, nicotine use and obesity, already had been addressed by our service, and results were known anecdotally but had not been previously verified. This study also looked at other potential risk factors, including the pedicle location, skin incision, and DM status.
Residents or fellows participated in all the surgeries. An outcome analysis from The American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2011 found that resident participation was associated with morbidity, including wound complications.8 This study was performed at a federal hospital with a complexity level 1a rating, which is designated based on the highest level of patient volume, risk, teaching, research, intensive care unit beds, and specialty services.9 The hospital is closely affiliated with a level 1 trauma center and teaching hospital; therefore, resident and fellow participation is not a modifiable risk factor.
This study did not find an increased risk of wound complications in patients with DM, which has been found to be an independent risk factor in a prior study.10 DM status was indicated in only 3 histories, and they all had perioperative hemoglobin A1c levels < 8%. There is documentation of patients receiving perioperative antibiotics in 99 out of 116 of the surgical records; however, we did not include this in the analysis because the operative reports from the first year of the study were incomplete.
Smoking is a known risk factor for local wound complications in breast reduction surgery.10-15 The VA has a smoking cessation program through its mental health service that provides counseling and medication treatment options, including nicotine replacement, bupropion, and varenicline. We require patients to be at least 4 weeks nicotine free before surgery, which has been previously recommended in the literature.16
Existing studies that compare the traditional Wise pattern/inferior pedicle with vertical pattern/superior medial pedicle did not find an increased risk of wound complications.17-19 Our study separated the different incisions from the pedicle because the surgical technique among the different surgeons in the study varied, where sometimes the traditional Wise pattern was combined with the less traditional superior-medial pedicle. We did not find a statistical difference when comparing the incisions and pedicle location, which suggests that the incision type and source of blood supply to the nipple are not the determining factors for wound complications in the early postoperative period.
Obesity is a known risk factor for local wound complications.12,13,15,20-22 Studies have shown that patients who are obese benefit from breast reduction surgery; authors have argued against restricting surgery to these higher risk patients.4,23-25 Patients usually report decades of macromastia symptoms at consultation; so, we believe delaying the surgical procedure to get patients to a safer risk profile is in their best interest. We chose a cutoff BMI of 32 as a realistic value rather than 30, which is considered the definition of obesity. Patients at MRVAMC have access to MOVE!, a weight loss management program through primary care. We believe in being reasonable; so if a patient makes a significant improvement in her health but falls short of the required cutoff, we will still consider offering the surgical procedure after a full explanation of the surgical risks.
Wound complications, especially those that require admission or frequent appointments can seriously disrupt a patient’s life, creating unnecessary hardships and expense in time lost from work, travel, and child care. MRVAMC has a catchment area the size of North Carolina; so many of our patients travel hours for their appointments. The added scars and deformity from wound dehiscence and debridement can lead to asymmetry, widened scars, and future revision operations. Multiple clinic appointments for wound care not only impact that individual patient, but also has the effect of limiting access for all patients in a health care environment with high patient volume and limited providers, operating room time, and clinic appointments. As a result, minimizing predictable wound complications benefits the entire system.
Limitations and Strengths
This retrospective review comprised multiple different surgeons, including faculty and trainees, who were involved in the consultation, surgery, and postoperative care of the patients over a 20-year period; therefore, consistency in documentation is lacking. In addition, we were limited to only the information available on the charts. For example, wound size and laterality were not consistently documented. The MRVAMC complication rate was consistent with the current literature (range, 14-52%).12,18,20,24
The major strength of the study is that the veterans tend to stay within the VA, which makes complications easier to identify and follow. Patients who do not present initially to their surgeon due to travel limitations will typically contact their primary care provider or present to their local VA urgent care or emergency department provider, who will route the patient back to the surgical specialty service through the electronic health record.
Conclusions
Breast reduction surgery has a high wound complication rate, which can be predicted and improved on so that patients can receive their indicated surgical procedure with minimal inconvenience and downtime. This review confirms that preoperative weight loss and nicotine cessation were the appropriate focus of the MRVAMC plastic surgery service’s efforts to achieve a safer surgical experience. We will continue to enforce our protocol and encourage patients who are interested in breast reduction surgery and fall outside the requirements to work with their primary care provider on smoking cessation and weight loss through better nutrition and physical activity.
Acknowledgment
This manuscript is the result of work supported with resources and the use of facilities at the North Florida/South Georgia Veterans Health System in Gainesville, Florida.
Women make up an estimated 10% of the veteran population.1 The US Department of Veterans Affairs (VA) projected that there would be an increase of 18,000 female veterans per year for 10 years based on 2015 data. The number of women veterans enrolled in the VA health care increased from 397,024 to 729,989 (83.9%) between 2005 and 2015.2 This rise in the number of enrolled women veterans also increased the demand for female-specific health care services, such as breast reduction surgery, a reconstructive procedure provided at the Malcom Randall VA Medical Center (MRVAMC) federal teaching hospital in Gainesville, Florida.
Patients who experience symptomatic macromastia will report a history of neck and shoulder pain, shoulder grooving from bra straps, inframammary intertrigo, difficulty finding clothes that fit, and discomfort participating in sports. For the treatment of symptomatic macromastia, patients report a high satisfaction rate after breast reduction surgery.3-5 Unfortunately, the complications from the surgery can significantly disrupt a woman’s life due to previously unplanned hospital admissions, clinic appointments, wound care, time off work, and poor aesthetic outcome. Faculty awareness of a large number of complications for patients after breast reduction surgery prompted the MRVAMC Plastic Surgery Service to establish a stricter surgical screening protocol using body mass index (BMI) values and negative nicotine status to help patients be healthier and reduce the potential risk before offering surgery. A medical literature search did not find an existing study on veteran-specific breast reduction surgery.
Methods
The University of Florida and North Florida/South Georgia Veterans Health System Institutional Review Board approved a retrospective chart review of all breast reduction surgeries performed at MRVAMC over a 20-year period (July 1, 2000-June 30, 2020). Electronic health records were queried for all primary bilateral breast reduction surgeries performed for symptomatic macromastia using Current Procedural Terminology code 19318. Potentially modifiable or predictable risk factors for wound complications were recorded: nicotine status, BMI, diabetes mellitus (DM) status, skin incision pattern, and pedicle location. Skin incision patterns were either vertical (periareolar plus a vertical scar from the areola to the inframammary fold) or traditional Wise pattern (also known as anchor pattern: periareolar scar, vertical scar to inframammary fold, plus a horizontal scar along the inframammary fold) as seen in Figures 1 and 2. The pedicle is the source of blood supply to the nipple, which was documented as either from the inferior aspect or the superior or superior/medial aspect.
For this study, the blood supply from the superior and superior/medial was logged in the same category. Records were reviewed 3 months after surgery for documentation of local wound complications, such as hematoma, infection, wound breakdown, skin necrosis, and nipple necrosis. Major complications were defined as requiring an unplanned hospital admission or urgent return to the operating room. A χ2 test using a P value of < .05 was used to determine statistical significance between the incidence of wound complications and the individually identifiable variables.
Results
One hundred fifteen bilateral breast reduction surgeries were performed at MRVAMC over a 20-year period. Patient median age was 43 years. Median combined specimen weight was 1272 g. Forty-eight (41.7%) wound complications were documented, including 8 (7%) major complications. Most complications were identified in the first 7 years of the study before the new protocol and consult template became active. The new template resulted in the local complication rate dropping from 62% (July 2000-June 2007) to 26% (July 2007-June 2020). BMI > 32 (P = .03) and active nicotine use (P = .004) were found to be statistically significant independent risk factors for wound complications. Median BMI for all patients was 30. DM status (P = .22), skin incision pattern (P = .25), and pedicle location (P = .13) were not found to be predictors of wound complications (Table). There was no significant change in the incidence of major complications before and after the new protocols were enforced.
Discussion
Breast reduction surgery is an elective reconstructive option to treat symptomatic macromastia. There are several accepted ways to do the reduction surgical procedure where the blood supply (pedicle) to the nipple can vary and the visible scars can be in a horizontal, vertical, or Wise pattern. Technique is usually based on surgeon training, comfort, and preference. There are several known complications specific to this operation that include asymmetry, changes in nipple sensation, unattractive scars, diminished ability to breastfeed, and wound complications.5-7 Wound complications include seroma, hematoma, dehiscence, infection, wound breakdown, skin necrosis, and nipple necrosis.
This study focused on wound complications with the objective of identifying and modifying risk factors. Two known risk factors documented in the literature, nicotine use and obesity, already had been addressed by our service, and results were known anecdotally but had not been previously verified. This study also looked at other potential risk factors, including the pedicle location, skin incision, and DM status.
Residents or fellows participated in all the surgeries. An outcome analysis from The American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2011 found that resident participation was associated with morbidity, including wound complications.8 This study was performed at a federal hospital with a complexity level 1a rating, which is designated based on the highest level of patient volume, risk, teaching, research, intensive care unit beds, and specialty services.9 The hospital is closely affiliated with a level 1 trauma center and teaching hospital; therefore, resident and fellow participation is not a modifiable risk factor.
This study did not find an increased risk of wound complications in patients with DM, which has been found to be an independent risk factor in a prior study.10 DM status was indicated in only 3 histories, and they all had perioperative hemoglobin A1c levels < 8%. There is documentation of patients receiving perioperative antibiotics in 99 out of 116 of the surgical records; however, we did not include this in the analysis because the operative reports from the first year of the study were incomplete.
Smoking is a known risk factor for local wound complications in breast reduction surgery.10-15 The VA has a smoking cessation program through its mental health service that provides counseling and medication treatment options, including nicotine replacement, bupropion, and varenicline. We require patients to be at least 4 weeks nicotine free before surgery, which has been previously recommended in the literature.16
Existing studies that compare the traditional Wise pattern/inferior pedicle with vertical pattern/superior medial pedicle did not find an increased risk of wound complications.17-19 Our study separated the different incisions from the pedicle because the surgical technique among the different surgeons in the study varied, where sometimes the traditional Wise pattern was combined with the less traditional superior-medial pedicle. We did not find a statistical difference when comparing the incisions and pedicle location, which suggests that the incision type and source of blood supply to the nipple are not the determining factors for wound complications in the early postoperative period.
Obesity is a known risk factor for local wound complications.12,13,15,20-22 Studies have shown that patients who are obese benefit from breast reduction surgery; authors have argued against restricting surgery to these higher risk patients.4,23-25 Patients usually report decades of macromastia symptoms at consultation; so, we believe delaying the surgical procedure to get patients to a safer risk profile is in their best interest. We chose a cutoff BMI of 32 as a realistic value rather than 30, which is considered the definition of obesity. Patients at MRVAMC have access to MOVE!, a weight loss management program through primary care. We believe in being reasonable; so if a patient makes a significant improvement in her health but falls short of the required cutoff, we will still consider offering the surgical procedure after a full explanation of the surgical risks.
Wound complications, especially those that require admission or frequent appointments can seriously disrupt a patient’s life, creating unnecessary hardships and expense in time lost from work, travel, and child care. MRVAMC has a catchment area the size of North Carolina; so many of our patients travel hours for their appointments. The added scars and deformity from wound dehiscence and debridement can lead to asymmetry, widened scars, and future revision operations. Multiple clinic appointments for wound care not only impact that individual patient, but also has the effect of limiting access for all patients in a health care environment with high patient volume and limited providers, operating room time, and clinic appointments. As a result, minimizing predictable wound complications benefits the entire system.
Limitations and Strengths
This retrospective review comprised multiple different surgeons, including faculty and trainees, who were involved in the consultation, surgery, and postoperative care of the patients over a 20-year period; therefore, consistency in documentation is lacking. In addition, we were limited to only the information available on the charts. For example, wound size and laterality were not consistently documented. The MRVAMC complication rate was consistent with the current literature (range, 14-52%).12,18,20,24
The major strength of the study is that the veterans tend to stay within the VA, which makes complications easier to identify and follow. Patients who do not present initially to their surgeon due to travel limitations will typically contact their primary care provider or present to their local VA urgent care or emergency department provider, who will route the patient back to the surgical specialty service through the electronic health record.
Conclusions
Breast reduction surgery has a high wound complication rate, which can be predicted and improved on so that patients can receive their indicated surgical procedure with minimal inconvenience and downtime. This review confirms that preoperative weight loss and nicotine cessation were the appropriate focus of the MRVAMC plastic surgery service’s efforts to achieve a safer surgical experience. We will continue to enforce our protocol and encourage patients who are interested in breast reduction surgery and fall outside the requirements to work with their primary care provider on smoking cessation and weight loss through better nutrition and physical activity.
Acknowledgment
This manuscript is the result of work supported with resources and the use of facilities at the North Florida/South Georgia Veterans Health System in Gainesville, Florida.
1. US Department of Veterans Affairs. Statistics at a glance. Published February 2020. Accessed June 18, 2021. https://www.va.gov/vetdata/docs/Quickfacts/Homepage_slideshow_4_6_20.PDF
2. US Department of Veterans Affairs, National Center for Veterans Analysis and Statistics. Women veterans report: the past, present, and future of women veterans. Published February 2017. Accessed June 18, 2020. https://www.va.gov/vetdata/docs/specialreports/women_veterans_2015_final.pdf
3. Crittenden TA, Watson DI, Ratcliffe J, Griffin PA, Dean NR. Outcomes of breast reduction surgery using the breast-q: a prospective study and comparison with normative data. Plast Reconstr Surg. 2019;144(5):1034-1044. doi:10.1097/PRS.0000000000006114
4. Thoma A, Sprague S, Veltri K, Duku E, Furlong W. A prospective study of patients undergoing breast reduction surgery: health-related quality of life and clinical outcomes. Plast Reconstr Surg. 2007;120(1):13-26. doi:10.1097/01.prs.0000263370.94191.90
5. Nuzzi LC, Firriolo JM, Pike CM, DiVasta AD, Labow BI. Complications and quality of life following reduction mammaplasty in adolescents and young women.Plast Reconstr Surg. 2019;144(3):572-581. doi:10.1097/PRS.0000000000005907
6. Hall-Findlay EJ, Shestak KC. Breast reduction. Plast Reconstr Surg. 2015;136(4):531e-544e. doi:10.1097/PRS.0000000000001622
7. Kraut RY, Brown E, Korownyk C, et al. The impact of breast reduction surgery on breastfeeding: systematic review of observational studies. PLoS One. 2017;12(10):e0186591. doi:10.1371/journal.pone.0186591
8. Fischer JP, Wes AM, Kovach SJ. The impact of surgical resident participation in breast reduction surgery--outcome analysis from the 2005-2011 ACS-NSQIP datasets. J Plast Surg Hand Surg. 2014;48(5):315-321. doi:10.3109/2000656X.2014.882345
9. Site Facility Name and Complexity Summary of VHA Facility. Accessed June 18, 2021. https://www.vendorportal.ecms.va.gov/FBODocumentServer/DocumentServer.aspx?DocumentId=2793591&FileName=VA118-16-R-1059-A00002002.docx
10. Lewin R, Göransson M, Elander A, Thorarinsson A, Lundberg J, Lidén M. Risk factors for complications after breast reduction surgery. J Plast Surg Hand Surg. 2014;48(1):10-14. doi:10.3109/2000656X.2013.791625
11. Cunningham BL, Gear AJ, Kerrigan CL, Collins ED. Analysis of breast reduction complications derived from the BRAVO study. Plast Reconstr Surg. 2005;115(6):1597-1604. doi:10.1097/01.prs.0000160695.33457.db
12. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Ann Plast Surg. 2015;75(4):383-387. doi:10.1097/SAP.0000000000000192
13. Manahan MA, Buretta KJ, Chang D, Mithani SK, Mallalieu J, Shermak MA. An outcomes analysis of 2142 breast reduction procedures. Ann Plast Surg. 2015;74(3):289-292. doi:10.1097/SAP.0b013e31829d2261
14. Hillam JS, Borsting EA, Chim JH, Thaller SR. Smoking as a risk factor for breast reduction: an analysis of 13,503 cases. J Plast Reconstr Aesthet Surg. 2017;70(6):734-740. doi:10.1016/j.bjps.2016.12.012
15. Zhang MX, Chen CY, Fang QQ, et al. Risk factors for complications after reduction mammoplasty: a meta-analysis. PLoS One. 2016;11(12):e0167746. doi:10.1371/journal.pone.0167746
16. Sørensen LT. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Ann Surg. 2012;255(6):1069-1079.doi:10.1097/SLA.0b013e31824f632d
17. Antony AK, Yegiyants SS, Danielson KK, et al. A matched cohort study of superomedial pedicle vertical scar breast reduction (100 breasts) and traditional inferior pedicle Wise-pattern reduction (100 breasts): an outcomes study over 3 years. Plast Reconstr Surg. 2013;132(5):1068-1076. doi:10.1097/PRS.0b013e3182a48b2d
18. Hunter-Smith DJ, Smoll NR, Marne B, Maung H, Findlay MW. Comparing breast-reduction techniques: time-to-event analysis and recommendations. Aesthetic Plast Surg. 2012;36(3):600-606. doi:10.1007/s00266-011-9860-3
19. Ogunleye AA, Leroux O, Morrison N, Preminger AB. Complications after reduction mammaplasty: a comparison of wise pattern/inferior pedicle and vertical scar/superomedial pedicle. Ann Plast Surg. 2017;79(1):13-16. doi:10.1097/SAP.0000000000001059
20. Bauermeister AJ, Gill K, Zuriarrain A, Earle SA, Newman MI. Reduction mammaplasty with superomedial pedicle technique: a literature review and retrospective analysis of 938 consecutive breast reductions. J Plast Reconstr Aesthet Surg. 2019;72(3):410-418. doi:10.1016/j.bjps.2018.12.004
21. Nelson JA, Fischer JP, Chung CU, et al. Obesity and early complications following reduction mammaplasty: an analysis of 4545 patients from the 2005-2011 NSQIP datasets. J Plast Surg Hand Surg. 2014;48(5):334-339. doi:10.3109/2000656X.2014.886582
22. Kreithen J, Caffee H, Rosenberg J, et al. A comparison of the LeJour and Wise pattern methods of breast reduction. Ann Plast Surg. 2005;54(3):236-241. doi:10.3109/2000656X.2014.886582
23. Güemes A, Pérez E, Sousa R, et al. Quality of life and alleviation of symptoms after breast reduction for macromastia in obese patients: is surgery worth it? Aesthetic Plast Surg. 2016;40(1):62-70. doi:10.1007/s00266-015-0601-x
24. Setälä L, Papp A, Joukainen S, et al. Obesity and complications in breast reduction surgery: are restrictions justified? J Plast Reconstr Aesthet Surg. 2009;62(2):195-199. doi:10.1016/j.bjps.2007.10.043
25. Shah R, Al-Ajam Y, Stott D, Kang N. Obesity in mammaplasty: a study of complications following breast reduction. J Plast Reconstr Aesthet Surg. 2011;64(4):508-514. doi:10.1016/j.bjps.2007.10.043
1. US Department of Veterans Affairs. Statistics at a glance. Published February 2020. Accessed June 18, 2021. https://www.va.gov/vetdata/docs/Quickfacts/Homepage_slideshow_4_6_20.PDF
2. US Department of Veterans Affairs, National Center for Veterans Analysis and Statistics. Women veterans report: the past, present, and future of women veterans. Published February 2017. Accessed June 18, 2020. https://www.va.gov/vetdata/docs/specialreports/women_veterans_2015_final.pdf
3. Crittenden TA, Watson DI, Ratcliffe J, Griffin PA, Dean NR. Outcomes of breast reduction surgery using the breast-q: a prospective study and comparison with normative data. Plast Reconstr Surg. 2019;144(5):1034-1044. doi:10.1097/PRS.0000000000006114
4. Thoma A, Sprague S, Veltri K, Duku E, Furlong W. A prospective study of patients undergoing breast reduction surgery: health-related quality of life and clinical outcomes. Plast Reconstr Surg. 2007;120(1):13-26. doi:10.1097/01.prs.0000263370.94191.90
5. Nuzzi LC, Firriolo JM, Pike CM, DiVasta AD, Labow BI. Complications and quality of life following reduction mammaplasty in adolescents and young women.Plast Reconstr Surg. 2019;144(3):572-581. doi:10.1097/PRS.0000000000005907
6. Hall-Findlay EJ, Shestak KC. Breast reduction. Plast Reconstr Surg. 2015;136(4):531e-544e. doi:10.1097/PRS.0000000000001622
7. Kraut RY, Brown E, Korownyk C, et al. The impact of breast reduction surgery on breastfeeding: systematic review of observational studies. PLoS One. 2017;12(10):e0186591. doi:10.1371/journal.pone.0186591
8. Fischer JP, Wes AM, Kovach SJ. The impact of surgical resident participation in breast reduction surgery--outcome analysis from the 2005-2011 ACS-NSQIP datasets. J Plast Surg Hand Surg. 2014;48(5):315-321. doi:10.3109/2000656X.2014.882345
9. Site Facility Name and Complexity Summary of VHA Facility. Accessed June 18, 2021. https://www.vendorportal.ecms.va.gov/FBODocumentServer/DocumentServer.aspx?DocumentId=2793591&FileName=VA118-16-R-1059-A00002002.docx
10. Lewin R, Göransson M, Elander A, Thorarinsson A, Lundberg J, Lidén M. Risk factors for complications after breast reduction surgery. J Plast Surg Hand Surg. 2014;48(1):10-14. doi:10.3109/2000656X.2013.791625
11. Cunningham BL, Gear AJ, Kerrigan CL, Collins ED. Analysis of breast reduction complications derived from the BRAVO study. Plast Reconstr Surg. 2005;115(6):1597-1604. doi:10.1097/01.prs.0000160695.33457.db
12. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Ann Plast Surg. 2015;75(4):383-387. doi:10.1097/SAP.0000000000000192
13. Manahan MA, Buretta KJ, Chang D, Mithani SK, Mallalieu J, Shermak MA. An outcomes analysis of 2142 breast reduction procedures. Ann Plast Surg. 2015;74(3):289-292. doi:10.1097/SAP.0b013e31829d2261
14. Hillam JS, Borsting EA, Chim JH, Thaller SR. Smoking as a risk factor for breast reduction: an analysis of 13,503 cases. J Plast Reconstr Aesthet Surg. 2017;70(6):734-740. doi:10.1016/j.bjps.2016.12.012
15. Zhang MX, Chen CY, Fang QQ, et al. Risk factors for complications after reduction mammoplasty: a meta-analysis. PLoS One. 2016;11(12):e0167746. doi:10.1371/journal.pone.0167746
16. Sørensen LT. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Ann Surg. 2012;255(6):1069-1079.doi:10.1097/SLA.0b013e31824f632d
17. Antony AK, Yegiyants SS, Danielson KK, et al. A matched cohort study of superomedial pedicle vertical scar breast reduction (100 breasts) and traditional inferior pedicle Wise-pattern reduction (100 breasts): an outcomes study over 3 years. Plast Reconstr Surg. 2013;132(5):1068-1076. doi:10.1097/PRS.0b013e3182a48b2d
18. Hunter-Smith DJ, Smoll NR, Marne B, Maung H, Findlay MW. Comparing breast-reduction techniques: time-to-event analysis and recommendations. Aesthetic Plast Surg. 2012;36(3):600-606. doi:10.1007/s00266-011-9860-3
19. Ogunleye AA, Leroux O, Morrison N, Preminger AB. Complications after reduction mammaplasty: a comparison of wise pattern/inferior pedicle and vertical scar/superomedial pedicle. Ann Plast Surg. 2017;79(1):13-16. doi:10.1097/SAP.0000000000001059
20. Bauermeister AJ, Gill K, Zuriarrain A, Earle SA, Newman MI. Reduction mammaplasty with superomedial pedicle technique: a literature review and retrospective analysis of 938 consecutive breast reductions. J Plast Reconstr Aesthet Surg. 2019;72(3):410-418. doi:10.1016/j.bjps.2018.12.004
21. Nelson JA, Fischer JP, Chung CU, et al. Obesity and early complications following reduction mammaplasty: an analysis of 4545 patients from the 2005-2011 NSQIP datasets. J Plast Surg Hand Surg. 2014;48(5):334-339. doi:10.3109/2000656X.2014.886582
22. Kreithen J, Caffee H, Rosenberg J, et al. A comparison of the LeJour and Wise pattern methods of breast reduction. Ann Plast Surg. 2005;54(3):236-241. doi:10.3109/2000656X.2014.886582
23. Güemes A, Pérez E, Sousa R, et al. Quality of life and alleviation of symptoms after breast reduction for macromastia in obese patients: is surgery worth it? Aesthetic Plast Surg. 2016;40(1):62-70. doi:10.1007/s00266-015-0601-x
24. Setälä L, Papp A, Joukainen S, et al. Obesity and complications in breast reduction surgery: are restrictions justified? J Plast Reconstr Aesthet Surg. 2009;62(2):195-199. doi:10.1016/j.bjps.2007.10.043
25. Shah R, Al-Ajam Y, Stott D, Kang N. Obesity in mammaplasty: a study of complications following breast reduction. J Plast Reconstr Aesthet Surg. 2011;64(4):508-514. doi:10.1016/j.bjps.2007.10.043
Pregnant women no longer detained by ICE
Immigration and Customs Enforcement will no longer detain most migrant women who are pregnant, postpartum, or nursing for deportation. This reverses the policy previously put in place by the Trump administration.
Under the new directive, ICE officials generally will not detain or arrest women who are pregnant or nursing, or who have given birth within the previous year. In a July 1 memo signed by ICE Acting Director Tae Johnson, ICE officers are directed to house women in “an appropriate facility to manage their care.”
The memo goes on to state that “generally ICE should not detain, arrest, or take into custody for an administrative violation of the immigration laws individuals known to be pregnant, post partum, or nursing unless release is prohibited by law or exceptional circumstances exist.”
In addition, ICE is also required to evaluate those individuals who are already in custody “to determine if continued detention is appropriate.”
During the Obama administration, pregnant women were generally not detained except under extraordinary circumstances. However, these policies were reversed after Donald Trump took office, and there was an 80% increase in the number of times ICE detained pregnant women in the year that followed implementation of the new directive – from 1,160 in 2017 to 2,097 in 2018.
The new guidance now goes even further than the directive issued under President Obama as it also includes women who are nursing and the 1-year postpartum period.
This policy stems from the Biden-Harris administration’s plan to reform the immigration system, part of which was to create a more humane asylum system. In a statement released early in February 2021, the White House stated that the “Trump administration’s policies at the border have caused chaos, cruelty, and confusion,” and that they will now “begin to roll back the most damaging policies adopted by the prior administration, while taking effective action to manage migration across the region.” After migrant women are taken into custody, pregnancy tests are administered as part of regular health screenings. If women are found to be pregnant, the new ICE policy states that they “generally” should be released from detention.
However, there will still be circumstances when pregnant and postpartum women may be detained, such as when there is a high risk that the individual is violent or a national security concern. In these cases, a field office director must approve the arrest and detention as well as making sure that the women receive appropriate medical care.
“The harmful consequences of immigration detention have been documented for years,” said Rebekah Wolf, JD, staff attorney with the American Immigration Council. “Our 2017 joint complaint urging a thorough investigation into the increasing numbers of pregnant women facing harm in detention, illustrated the disturbing practice of detaining pregnant women and the lack of quality medical care provided to these women.”
She added that the “federal government should not be in the business of detaining pregnant or nursing individuals, and it’s good to see the Biden administration directing ICE to finally take meaningful steps to limit enforcement activities in this manner. We are hopeful that this announcement is an indication of a broader shift on detention policy.”
There are currently 13 pregnant women in ICE custody, and they are being considered for release under the new policy.
Immigration and Customs Enforcement will no longer detain most migrant women who are pregnant, postpartum, or nursing for deportation. This reverses the policy previously put in place by the Trump administration.
Under the new directive, ICE officials generally will not detain or arrest women who are pregnant or nursing, or who have given birth within the previous year. In a July 1 memo signed by ICE Acting Director Tae Johnson, ICE officers are directed to house women in “an appropriate facility to manage their care.”
The memo goes on to state that “generally ICE should not detain, arrest, or take into custody for an administrative violation of the immigration laws individuals known to be pregnant, post partum, or nursing unless release is prohibited by law or exceptional circumstances exist.”
In addition, ICE is also required to evaluate those individuals who are already in custody “to determine if continued detention is appropriate.”
During the Obama administration, pregnant women were generally not detained except under extraordinary circumstances. However, these policies were reversed after Donald Trump took office, and there was an 80% increase in the number of times ICE detained pregnant women in the year that followed implementation of the new directive – from 1,160 in 2017 to 2,097 in 2018.
The new guidance now goes even further than the directive issued under President Obama as it also includes women who are nursing and the 1-year postpartum period.
This policy stems from the Biden-Harris administration’s plan to reform the immigration system, part of which was to create a more humane asylum system. In a statement released early in February 2021, the White House stated that the “Trump administration’s policies at the border have caused chaos, cruelty, and confusion,” and that they will now “begin to roll back the most damaging policies adopted by the prior administration, while taking effective action to manage migration across the region.” After migrant women are taken into custody, pregnancy tests are administered as part of regular health screenings. If women are found to be pregnant, the new ICE policy states that they “generally” should be released from detention.
However, there will still be circumstances when pregnant and postpartum women may be detained, such as when there is a high risk that the individual is violent or a national security concern. In these cases, a field office director must approve the arrest and detention as well as making sure that the women receive appropriate medical care.
“The harmful consequences of immigration detention have been documented for years,” said Rebekah Wolf, JD, staff attorney with the American Immigration Council. “Our 2017 joint complaint urging a thorough investigation into the increasing numbers of pregnant women facing harm in detention, illustrated the disturbing practice of detaining pregnant women and the lack of quality medical care provided to these women.”
She added that the “federal government should not be in the business of detaining pregnant or nursing individuals, and it’s good to see the Biden administration directing ICE to finally take meaningful steps to limit enforcement activities in this manner. We are hopeful that this announcement is an indication of a broader shift on detention policy.”
There are currently 13 pregnant women in ICE custody, and they are being considered for release under the new policy.
Immigration and Customs Enforcement will no longer detain most migrant women who are pregnant, postpartum, or nursing for deportation. This reverses the policy previously put in place by the Trump administration.
Under the new directive, ICE officials generally will not detain or arrest women who are pregnant or nursing, or who have given birth within the previous year. In a July 1 memo signed by ICE Acting Director Tae Johnson, ICE officers are directed to house women in “an appropriate facility to manage their care.”
The memo goes on to state that “generally ICE should not detain, arrest, or take into custody for an administrative violation of the immigration laws individuals known to be pregnant, post partum, or nursing unless release is prohibited by law or exceptional circumstances exist.”
In addition, ICE is also required to evaluate those individuals who are already in custody “to determine if continued detention is appropriate.”
During the Obama administration, pregnant women were generally not detained except under extraordinary circumstances. However, these policies were reversed after Donald Trump took office, and there was an 80% increase in the number of times ICE detained pregnant women in the year that followed implementation of the new directive – from 1,160 in 2017 to 2,097 in 2018.
The new guidance now goes even further than the directive issued under President Obama as it also includes women who are nursing and the 1-year postpartum period.
This policy stems from the Biden-Harris administration’s plan to reform the immigration system, part of which was to create a more humane asylum system. In a statement released early in February 2021, the White House stated that the “Trump administration’s policies at the border have caused chaos, cruelty, and confusion,” and that they will now “begin to roll back the most damaging policies adopted by the prior administration, while taking effective action to manage migration across the region.” After migrant women are taken into custody, pregnancy tests are administered as part of regular health screenings. If women are found to be pregnant, the new ICE policy states that they “generally” should be released from detention.
However, there will still be circumstances when pregnant and postpartum women may be detained, such as when there is a high risk that the individual is violent or a national security concern. In these cases, a field office director must approve the arrest and detention as well as making sure that the women receive appropriate medical care.
“The harmful consequences of immigration detention have been documented for years,” said Rebekah Wolf, JD, staff attorney with the American Immigration Council. “Our 2017 joint complaint urging a thorough investigation into the increasing numbers of pregnant women facing harm in detention, illustrated the disturbing practice of detaining pregnant women and the lack of quality medical care provided to these women.”
She added that the “federal government should not be in the business of detaining pregnant or nursing individuals, and it’s good to see the Biden administration directing ICE to finally take meaningful steps to limit enforcement activities in this manner. We are hopeful that this announcement is an indication of a broader shift on detention policy.”
There are currently 13 pregnant women in ICE custody, and they are being considered for release under the new policy.
Healthy weight gain in pregnancy: What the USPSTF recommends
REFERENCES
- US Preventive Services Task Force. Behavioral counseling interventions for healthy weight and weight gain in pregnancy: US Preventive Services Task Force recommendation statement. JAMA. 2021;325:2087-2092. doi:10.1001/jama.2021.6949
- Rasmussen KM, Yaktine AL, eds. Weight Gain During Pregnancy: Reexamining the Guidelines. National Academies Press; 2009. doi: 10.17226/12584
REFERENCES
- US Preventive Services Task Force. Behavioral counseling interventions for healthy weight and weight gain in pregnancy: US Preventive Services Task Force recommendation statement. JAMA. 2021;325:2087-2092. doi:10.1001/jama.2021.6949
- Rasmussen KM, Yaktine AL, eds. Weight Gain During Pregnancy: Reexamining the Guidelines. National Academies Press; 2009. doi: 10.17226/12584
REFERENCES
- US Preventive Services Task Force. Behavioral counseling interventions for healthy weight and weight gain in pregnancy: US Preventive Services Task Force recommendation statement. JAMA. 2021;325:2087-2092. doi:10.1001/jama.2021.6949
- Rasmussen KM, Yaktine AL, eds. Weight Gain During Pregnancy: Reexamining the Guidelines. National Academies Press; 2009. doi: 10.17226/12584
California to pay victims of forced, coerced sterilizations
SACRAMENTO (AP) – California is poised to approve reparations of up to $25,000 to some of the thousands of people – some as young as 13 – who were sterilized decades ago because the government deemed them unfit to have children.
The payments will make California at least the third state – following Virginia and North Carolina – to compensate victims of the so-called eugenics movement that peaked in the 1930s. Supporters of the movement believed sterilizing people with mental illnesses, physical disabilities, and other traits they deemed undesirable would improve the human race.
While California sterilized more than 20,000 people before its law was repealed in 1979, only a few hundred are still alive. The state has set aside $7.5 million for the reparations program, part of its $262.6 billion operating budget that is awaiting Gov. Gavin Newsom’s signature.
California’s proposal is unique because it also would pay women the state coerced to get sterilized while they were in prison, some as recently as 2010. First exposed by the Center for Investigative Reporting in 2013, a subsequent audit found California sterilized 144 women between 2005 and 2013 with little or no evidence that officials counseled them or offered alternative treatment.
While all of the women signed consent forms, officials in 39 cases did not do everything that was legally required to obtain their permission.
“We must address and face our horrific history,” said Lorena Garcia Zermeño, policy and communications coordinator for the advocacy group California Latinas for Reproductive Justice. “This isn’t something that just happened in the past.”
California’s forced sterilization program started in 1909, following similar laws in Indiana and Washington. It was by far the largest program, accounting for about a third of everyone sterilized in the United States under those laws.
California’s law was so prominent that it inspired similar practices in Nazi Germany, according to Paul Lombardo, a law professor at Georgia State University, Atlanta, and an expert on the eugenics movement.
“The promise of eugenics at the very earliest is: ‘We could do away with all the state institutions – prisons, hospitals, asylums, orphanages,’” Mr. Lombardo said. “People who were in them just wouldn’t be born after awhile if you sterilized all of their parents.”
In California, victims include Mary Franco, who was sterilized in 1934 when she was just 13. Paperwork described her as “feeble minded” because of “sexual deviance,” according to her niece, Stacy Cordova, who has researched her case.
Ms. Cordova said Franco actually was molested by a neighbor. She said her family put Ms. Franco in an institution to protect the family’s reputation.
Ms. Cordova said her late aunt loved children and wanted to have a family. She married briefly when she was about 17, but Ms. Cordova said the marriage was annulled when the man discovered Ms. Franco couldn’t have children. She lived a lonely life in a Mexican culture that revered big families, Ms. Cordova said.
“I don’t know if it is justice. Money doesn’t pay for what happened to them. But it’s great to know that this is being recognized,” said Ms. Cordova, who has advocated for the state to pay survivors. “For me, this is not about the money. This is about the memory.”
Relatives like Ms. Cordova aren’t eligible for the payments, only direct victims are.
Sterilizations in California prisons appear to date to 1999, when the state changed its policy for unknown reasons to include a sterilization procedure known as “tubal ligation” as part of inmates’ medical care. Over the next decade, women reported they were coerced into this procedure, with some not fully understanding the ramifications.
A state law passed in 2014 bans sterilizations for the purpose of birth control at state prisons and local jails. The law permits sterilizations that are “medically necessary,” such as removing cancer, and requires facilities to report each year how many people were sterilized and for what reason.
Questionable sterilizations also occurred in facilities run by local governments. In 2018, the Los Angeles County Board of Supervisors apologized after more than 200 women were sterilized at the Los Angeles–University of Southern California Medical Center between 1968 and 1974.
Those people are not eligible for reparations under California’s program. But advocates say they hope to include them in the future.
“It’s only the beginning,” said state Assemblywoman Wendy Carrillo, a Democrat from Los Angeles who has been advocating for reparations. “I can’t imagine the trauma, the depression, the stress of being incarcerated, being rehabilitated and trying to start your life again in society, wanting to start a family, only to find out that that choice was taken away from you.”
Of the people California sterilized under its old eugenics law, just a few hundred are still alive, according to research conducted by the Sterilization and Social Justice Lab. Including the inmates who were sterilized most recently, advocates estimate more than 600 people would be eligible for reparations.
But finding them will be difficult, with advocates predicting only about 25% of eligible people will ultimately apply for reparations and be paid.
California’s Victim Compensation Board will run the program, with $2 million used to find victims by advertising and poring through state records. The state also set aside $1 million for plaques to honor the victims, leaving $4.5 million for reparations.
A version of this article appeared on Medscape.com.
Associated Press © 2021
SACRAMENTO (AP) – California is poised to approve reparations of up to $25,000 to some of the thousands of people – some as young as 13 – who were sterilized decades ago because the government deemed them unfit to have children.
The payments will make California at least the third state – following Virginia and North Carolina – to compensate victims of the so-called eugenics movement that peaked in the 1930s. Supporters of the movement believed sterilizing people with mental illnesses, physical disabilities, and other traits they deemed undesirable would improve the human race.
While California sterilized more than 20,000 people before its law was repealed in 1979, only a few hundred are still alive. The state has set aside $7.5 million for the reparations program, part of its $262.6 billion operating budget that is awaiting Gov. Gavin Newsom’s signature.
California’s proposal is unique because it also would pay women the state coerced to get sterilized while they were in prison, some as recently as 2010. First exposed by the Center for Investigative Reporting in 2013, a subsequent audit found California sterilized 144 women between 2005 and 2013 with little or no evidence that officials counseled them or offered alternative treatment.
While all of the women signed consent forms, officials in 39 cases did not do everything that was legally required to obtain their permission.
“We must address and face our horrific history,” said Lorena Garcia Zermeño, policy and communications coordinator for the advocacy group California Latinas for Reproductive Justice. “This isn’t something that just happened in the past.”
California’s forced sterilization program started in 1909, following similar laws in Indiana and Washington. It was by far the largest program, accounting for about a third of everyone sterilized in the United States under those laws.
California’s law was so prominent that it inspired similar practices in Nazi Germany, according to Paul Lombardo, a law professor at Georgia State University, Atlanta, and an expert on the eugenics movement.
“The promise of eugenics at the very earliest is: ‘We could do away with all the state institutions – prisons, hospitals, asylums, orphanages,’” Mr. Lombardo said. “People who were in them just wouldn’t be born after awhile if you sterilized all of their parents.”
In California, victims include Mary Franco, who was sterilized in 1934 when she was just 13. Paperwork described her as “feeble minded” because of “sexual deviance,” according to her niece, Stacy Cordova, who has researched her case.
Ms. Cordova said Franco actually was molested by a neighbor. She said her family put Ms. Franco in an institution to protect the family’s reputation.
Ms. Cordova said her late aunt loved children and wanted to have a family. She married briefly when she was about 17, but Ms. Cordova said the marriage was annulled when the man discovered Ms. Franco couldn’t have children. She lived a lonely life in a Mexican culture that revered big families, Ms. Cordova said.
“I don’t know if it is justice. Money doesn’t pay for what happened to them. But it’s great to know that this is being recognized,” said Ms. Cordova, who has advocated for the state to pay survivors. “For me, this is not about the money. This is about the memory.”
Relatives like Ms. Cordova aren’t eligible for the payments, only direct victims are.
Sterilizations in California prisons appear to date to 1999, when the state changed its policy for unknown reasons to include a sterilization procedure known as “tubal ligation” as part of inmates’ medical care. Over the next decade, women reported they were coerced into this procedure, with some not fully understanding the ramifications.
A state law passed in 2014 bans sterilizations for the purpose of birth control at state prisons and local jails. The law permits sterilizations that are “medically necessary,” such as removing cancer, and requires facilities to report each year how many people were sterilized and for what reason.
Questionable sterilizations also occurred in facilities run by local governments. In 2018, the Los Angeles County Board of Supervisors apologized after more than 200 women were sterilized at the Los Angeles–University of Southern California Medical Center between 1968 and 1974.
Those people are not eligible for reparations under California’s program. But advocates say they hope to include them in the future.
“It’s only the beginning,” said state Assemblywoman Wendy Carrillo, a Democrat from Los Angeles who has been advocating for reparations. “I can’t imagine the trauma, the depression, the stress of being incarcerated, being rehabilitated and trying to start your life again in society, wanting to start a family, only to find out that that choice was taken away from you.”
Of the people California sterilized under its old eugenics law, just a few hundred are still alive, according to research conducted by the Sterilization and Social Justice Lab. Including the inmates who were sterilized most recently, advocates estimate more than 600 people would be eligible for reparations.
But finding them will be difficult, with advocates predicting only about 25% of eligible people will ultimately apply for reparations and be paid.
California’s Victim Compensation Board will run the program, with $2 million used to find victims by advertising and poring through state records. The state also set aside $1 million for plaques to honor the victims, leaving $4.5 million for reparations.
A version of this article appeared on Medscape.com.
Associated Press © 2021
SACRAMENTO (AP) – California is poised to approve reparations of up to $25,000 to some of the thousands of people – some as young as 13 – who were sterilized decades ago because the government deemed them unfit to have children.
The payments will make California at least the third state – following Virginia and North Carolina – to compensate victims of the so-called eugenics movement that peaked in the 1930s. Supporters of the movement believed sterilizing people with mental illnesses, physical disabilities, and other traits they deemed undesirable would improve the human race.
While California sterilized more than 20,000 people before its law was repealed in 1979, only a few hundred are still alive. The state has set aside $7.5 million for the reparations program, part of its $262.6 billion operating budget that is awaiting Gov. Gavin Newsom’s signature.
California’s proposal is unique because it also would pay women the state coerced to get sterilized while they were in prison, some as recently as 2010. First exposed by the Center for Investigative Reporting in 2013, a subsequent audit found California sterilized 144 women between 2005 and 2013 with little or no evidence that officials counseled them or offered alternative treatment.
While all of the women signed consent forms, officials in 39 cases did not do everything that was legally required to obtain their permission.
“We must address and face our horrific history,” said Lorena Garcia Zermeño, policy and communications coordinator for the advocacy group California Latinas for Reproductive Justice. “This isn’t something that just happened in the past.”
California’s forced sterilization program started in 1909, following similar laws in Indiana and Washington. It was by far the largest program, accounting for about a third of everyone sterilized in the United States under those laws.
California’s law was so prominent that it inspired similar practices in Nazi Germany, according to Paul Lombardo, a law professor at Georgia State University, Atlanta, and an expert on the eugenics movement.
“The promise of eugenics at the very earliest is: ‘We could do away with all the state institutions – prisons, hospitals, asylums, orphanages,’” Mr. Lombardo said. “People who were in them just wouldn’t be born after awhile if you sterilized all of their parents.”
In California, victims include Mary Franco, who was sterilized in 1934 when she was just 13. Paperwork described her as “feeble minded” because of “sexual deviance,” according to her niece, Stacy Cordova, who has researched her case.
Ms. Cordova said Franco actually was molested by a neighbor. She said her family put Ms. Franco in an institution to protect the family’s reputation.
Ms. Cordova said her late aunt loved children and wanted to have a family. She married briefly when she was about 17, but Ms. Cordova said the marriage was annulled when the man discovered Ms. Franco couldn’t have children. She lived a lonely life in a Mexican culture that revered big families, Ms. Cordova said.
“I don’t know if it is justice. Money doesn’t pay for what happened to them. But it’s great to know that this is being recognized,” said Ms. Cordova, who has advocated for the state to pay survivors. “For me, this is not about the money. This is about the memory.”
Relatives like Ms. Cordova aren’t eligible for the payments, only direct victims are.
Sterilizations in California prisons appear to date to 1999, when the state changed its policy for unknown reasons to include a sterilization procedure known as “tubal ligation” as part of inmates’ medical care. Over the next decade, women reported they were coerced into this procedure, with some not fully understanding the ramifications.
A state law passed in 2014 bans sterilizations for the purpose of birth control at state prisons and local jails. The law permits sterilizations that are “medically necessary,” such as removing cancer, and requires facilities to report each year how many people were sterilized and for what reason.
Questionable sterilizations also occurred in facilities run by local governments. In 2018, the Los Angeles County Board of Supervisors apologized after more than 200 women were sterilized at the Los Angeles–University of Southern California Medical Center between 1968 and 1974.
Those people are not eligible for reparations under California’s program. But advocates say they hope to include them in the future.
“It’s only the beginning,” said state Assemblywoman Wendy Carrillo, a Democrat from Los Angeles who has been advocating for reparations. “I can’t imagine the trauma, the depression, the stress of being incarcerated, being rehabilitated and trying to start your life again in society, wanting to start a family, only to find out that that choice was taken away from you.”
Of the people California sterilized under its old eugenics law, just a few hundred are still alive, according to research conducted by the Sterilization and Social Justice Lab. Including the inmates who were sterilized most recently, advocates estimate more than 600 people would be eligible for reparations.
But finding them will be difficult, with advocates predicting only about 25% of eligible people will ultimately apply for reparations and be paid.
California’s Victim Compensation Board will run the program, with $2 million used to find victims by advertising and poring through state records. The state also set aside $1 million for plaques to honor the victims, leaving $4.5 million for reparations.
A version of this article appeared on Medscape.com.
Associated Press © 2021
Greater travel distance reduces rates of abortion
Travel distance is an important determinant of access to abortion care in the United States, new findings show.
Increases in median travel distance to the nearest abortion care facility were associated with significant reductions in median abortion rate.
The abortion rate was 21.1 per 1,000 female residents of reproductive age among those who lived less than 5 miles from a facility, but that number dropped to 3.9/1,000 for those living 120 miles or further away.
Overall, in a model of 3,107 U.S. counties that included 62.5 million women of reproductive age, there were an estimated 696,760 abortions (at a mean rate of 11.1/1,000). The authors estimate that if abortion services were integrated into primary care, an additional 18,190 abortions would be performed (mean rate, 11.4/1,000).
Similarly, if telemedicine became widely available in this setting, this would allow approximately 70,920 abortions (mean rate 12.3/1,000). The study was published online in JAMA Open Network.
Reducing travel distances to abortion facilities would increase access, but additional clinics and providers would be needed to meet the demand. But as the population density of many counties with poor access is low, innovative strategies are also needed.
Integrating abortion into primary care or making medication abortion care available by telemedicine may decrease this unmet need, and lead author Kirsten Thompson, MPH, noted that there is growing evidence that both solutions are quite feasible to implement.
“A study published in 2018 has led primary care providers to adopt the same regimen for miscarriage care, showing that they are interested and capable, despite the barriers posed by the mifepristone [Risk Evaluation and Mitigation Strategy] program for these patients,” said Ms. Thompson, who is program and communications director, Bixby Center for Global Reproductive Health, University of California, San Francisco. “Medical education programs designed specifically for primary care providers have trained family medicine and other clinicians in abortion care for over a decade.”
As for telemedicine, Ms. Thompson explained that, during the pandemic, a preliminary injunction in a federal court case and then the Food and Drug Administration suspended enforcement of the in-person requirements of the mifepristone REMS. “In states that allow medical abortion care by telemedicine, providers have been able to offer remote care when medically appropriate, including mailing medical abortion pills to patients at home,” she said. “Researchers have already published evidence on the safety of and patient satisfaction with this approach.”
However, there are two main barriers to the widespread adoption of medical abortion by telemedicine in the United States. “One is the potentially temporary nature of the FDA’s enforcement discretion and second, are the 19 states with laws that ban it, singling out medical abortion as somehow different from other forms of care by telemedicine,” she said.
Study details
About one in four women in the United States will terminate a pregnancy during their lifetime, but the issue is highly contentious and many states have implemented policies that restrict access to abortion care. The authors pointed out that studies have documented clinic closures and women being unable to obtain abortion care, with low-income women and non-White women being disproportionately affected. Increased travel to a provider has also been associated with delays in care as well as increased costs and stress.
Prior research has shown that the further a woman lives from a facility, the less likely she is to obtain abortion care. In this study, Ms. Thompson and colleagues examined the association between travel distance to the nearest abortion care facility and the abortion rate, and then modeled the effect of reduced travel distance on rates.
They first conducted a cross-sectional geographic analysis using the American Community Survey and the U.S. Census to calculate county-level abortion rates per 1,000 women aged between 15 and 44 years. The 2015 data covered 1,948 counties in 27 states.
Abortion rates were then estimated for 3,107 counties in 48 states and the effect of different travel distance scenarios on the abortion rate was also estimated by multivariable model. Data were collected from April 2018 to October 2019.
There were 37.3 million women of reproductive age residing in the 27 states, and a total of 428,720 reported abortions (mean rate, 11.5/1,000; median rate, 9.9/1,000 women).
When looking at all 48 states, the population-weighted mean travel distance to the nearest facility was 25.6 miles, with a median travel distance of 8.2 miles.
A multivariable model showed that a greater travel distance was associated with lower abortion rates. When compared with traveling less than 5 miles, the abortion rate declined by 0.05/1,000 for women traveling between 5 to less than 15 miles for care, 0.22 for those traveling 15 to less than 30 miles, 0.34 for 30 to less than 60 miles, 0.43 for 60 to less than 120 miles, and 0.73 for those traveling 120 miles or more.
They estimated that, if all travel was under 30 miles, there would be a 2.6% increase or 18,190 additional abortions. A simulation also showed that there would be a 10.2% increase (70,920 additional abortions) using medication via telemedicine.
Solutions are feasible
Approached for an independent comment, Sarah W. Prager, MD, MAS, professor of obstetrics and gynecology and division chief, complex family planning, at the University of Washington, Seattle, agreed that the solutions proposed by the authors were feasible.
“More than a third of abortions that are eligible are now done with medication,” she said, “And 89% of abortions are done in the first trimester.”
What this means is that early first-trimester abortions can conceivably be performed in the primary care setting. “Any primary care clinician – whether it’s a family practice or internal medicine physician, or nurse practitioner or nurse midwife – can all be trained to do aspiration or prescribe medication in the first trimester,” said Dr. Prager. “So it could easily be integrated into primary care settings if there was motivation for that to happen.”
However, she emphasized that more is involved than just training the provider. “The whole clinic has to buy into it,” Dr. Prager explained. “The nurses have to be willing to assist, you need the medical assistants, the scheduler or person who works the front desk – the whole clinic system has to buy into it and that’s where it becomes more challenging.”
The individual provider may be willing, but the system may still not be allowing that to happen. “This is also where telemedicine can come in, where the medication can be mailed so it can circumvent the problem to a certain extent,” Dr. Prager added. “You don’t have to have the infrastructure in the same way.”
But many states already have laws in place to make that illegal, especially for abortion care even if they allow it for similar types of care.
Another expert also weighed in and agreed that these two solutions can potentially be implemented.
“The concept of decreased rates of abortion associated with greater distances traveled is not new, but what is unique to this manuscript is the estimations that the authors conducted in understanding the impact of expanding access to abortion among primary care and telehealth providers,” said Catherine Cansino, MD, MPH, associate clinical professor in the department of obstetrics and gynecology, University of California, Davis.
“The study provides convincing evidence regarding the need to strengthen infrastructures that support expansion of these services in primary care settings, among physicians and advanced care practitioners,” she said. “Training to provide medical abortion and first-trimester surgical abortion is simple. Many primary care providers are already doing gynecologic procedures – IUD insertions, colposcopies, endometrial biopsies.”
Thus, she noted, adding abortion care “to their toolkit isn’t too far of a stretch.”
As for telemedicine, Dr. Cansino pointed out how the COVID-19 pandemic has also expanded what both patients and providers think are safe options for providing and receiving good care. “Consultations through telemedicine coupled with access to medications for medical abortion through local pharmacies or express mail is definitely safe and feasible.”
The study was supported by the William and Flora Hewlett Foundation and by an anonymous foundation for general operating support (Ms Thompson). Ms. Thompson reported receiving personal fees from GenBioPro outside the submitted work. Dr. Cansino and Dr. Prager have no disclosures.
Travel distance is an important determinant of access to abortion care in the United States, new findings show.
Increases in median travel distance to the nearest abortion care facility were associated with significant reductions in median abortion rate.
The abortion rate was 21.1 per 1,000 female residents of reproductive age among those who lived less than 5 miles from a facility, but that number dropped to 3.9/1,000 for those living 120 miles or further away.
Overall, in a model of 3,107 U.S. counties that included 62.5 million women of reproductive age, there were an estimated 696,760 abortions (at a mean rate of 11.1/1,000). The authors estimate that if abortion services were integrated into primary care, an additional 18,190 abortions would be performed (mean rate, 11.4/1,000).
Similarly, if telemedicine became widely available in this setting, this would allow approximately 70,920 abortions (mean rate 12.3/1,000). The study was published online in JAMA Open Network.
Reducing travel distances to abortion facilities would increase access, but additional clinics and providers would be needed to meet the demand. But as the population density of many counties with poor access is low, innovative strategies are also needed.
Integrating abortion into primary care or making medication abortion care available by telemedicine may decrease this unmet need, and lead author Kirsten Thompson, MPH, noted that there is growing evidence that both solutions are quite feasible to implement.
“A study published in 2018 has led primary care providers to adopt the same regimen for miscarriage care, showing that they are interested and capable, despite the barriers posed by the mifepristone [Risk Evaluation and Mitigation Strategy] program for these patients,” said Ms. Thompson, who is program and communications director, Bixby Center for Global Reproductive Health, University of California, San Francisco. “Medical education programs designed specifically for primary care providers have trained family medicine and other clinicians in abortion care for over a decade.”
As for telemedicine, Ms. Thompson explained that, during the pandemic, a preliminary injunction in a federal court case and then the Food and Drug Administration suspended enforcement of the in-person requirements of the mifepristone REMS. “In states that allow medical abortion care by telemedicine, providers have been able to offer remote care when medically appropriate, including mailing medical abortion pills to patients at home,” she said. “Researchers have already published evidence on the safety of and patient satisfaction with this approach.”
However, there are two main barriers to the widespread adoption of medical abortion by telemedicine in the United States. “One is the potentially temporary nature of the FDA’s enforcement discretion and second, are the 19 states with laws that ban it, singling out medical abortion as somehow different from other forms of care by telemedicine,” she said.
Study details
About one in four women in the United States will terminate a pregnancy during their lifetime, but the issue is highly contentious and many states have implemented policies that restrict access to abortion care. The authors pointed out that studies have documented clinic closures and women being unable to obtain abortion care, with low-income women and non-White women being disproportionately affected. Increased travel to a provider has also been associated with delays in care as well as increased costs and stress.
Prior research has shown that the further a woman lives from a facility, the less likely she is to obtain abortion care. In this study, Ms. Thompson and colleagues examined the association between travel distance to the nearest abortion care facility and the abortion rate, and then modeled the effect of reduced travel distance on rates.
They first conducted a cross-sectional geographic analysis using the American Community Survey and the U.S. Census to calculate county-level abortion rates per 1,000 women aged between 15 and 44 years. The 2015 data covered 1,948 counties in 27 states.
Abortion rates were then estimated for 3,107 counties in 48 states and the effect of different travel distance scenarios on the abortion rate was also estimated by multivariable model. Data were collected from April 2018 to October 2019.
There were 37.3 million women of reproductive age residing in the 27 states, and a total of 428,720 reported abortions (mean rate, 11.5/1,000; median rate, 9.9/1,000 women).
When looking at all 48 states, the population-weighted mean travel distance to the nearest facility was 25.6 miles, with a median travel distance of 8.2 miles.
A multivariable model showed that a greater travel distance was associated with lower abortion rates. When compared with traveling less than 5 miles, the abortion rate declined by 0.05/1,000 for women traveling between 5 to less than 15 miles for care, 0.22 for those traveling 15 to less than 30 miles, 0.34 for 30 to less than 60 miles, 0.43 for 60 to less than 120 miles, and 0.73 for those traveling 120 miles or more.
They estimated that, if all travel was under 30 miles, there would be a 2.6% increase or 18,190 additional abortions. A simulation also showed that there would be a 10.2% increase (70,920 additional abortions) using medication via telemedicine.
Solutions are feasible
Approached for an independent comment, Sarah W. Prager, MD, MAS, professor of obstetrics and gynecology and division chief, complex family planning, at the University of Washington, Seattle, agreed that the solutions proposed by the authors were feasible.
“More than a third of abortions that are eligible are now done with medication,” she said, “And 89% of abortions are done in the first trimester.”
What this means is that early first-trimester abortions can conceivably be performed in the primary care setting. “Any primary care clinician – whether it’s a family practice or internal medicine physician, or nurse practitioner or nurse midwife – can all be trained to do aspiration or prescribe medication in the first trimester,” said Dr. Prager. “So it could easily be integrated into primary care settings if there was motivation for that to happen.”
However, she emphasized that more is involved than just training the provider. “The whole clinic has to buy into it,” Dr. Prager explained. “The nurses have to be willing to assist, you need the medical assistants, the scheduler or person who works the front desk – the whole clinic system has to buy into it and that’s where it becomes more challenging.”
The individual provider may be willing, but the system may still not be allowing that to happen. “This is also where telemedicine can come in, where the medication can be mailed so it can circumvent the problem to a certain extent,” Dr. Prager added. “You don’t have to have the infrastructure in the same way.”
But many states already have laws in place to make that illegal, especially for abortion care even if they allow it for similar types of care.
Another expert also weighed in and agreed that these two solutions can potentially be implemented.
“The concept of decreased rates of abortion associated with greater distances traveled is not new, but what is unique to this manuscript is the estimations that the authors conducted in understanding the impact of expanding access to abortion among primary care and telehealth providers,” said Catherine Cansino, MD, MPH, associate clinical professor in the department of obstetrics and gynecology, University of California, Davis.
“The study provides convincing evidence regarding the need to strengthen infrastructures that support expansion of these services in primary care settings, among physicians and advanced care practitioners,” she said. “Training to provide medical abortion and first-trimester surgical abortion is simple. Many primary care providers are already doing gynecologic procedures – IUD insertions, colposcopies, endometrial biopsies.”
Thus, she noted, adding abortion care “to their toolkit isn’t too far of a stretch.”
As for telemedicine, Dr. Cansino pointed out how the COVID-19 pandemic has also expanded what both patients and providers think are safe options for providing and receiving good care. “Consultations through telemedicine coupled with access to medications for medical abortion through local pharmacies or express mail is definitely safe and feasible.”
The study was supported by the William and Flora Hewlett Foundation and by an anonymous foundation for general operating support (Ms Thompson). Ms. Thompson reported receiving personal fees from GenBioPro outside the submitted work. Dr. Cansino and Dr. Prager have no disclosures.
Travel distance is an important determinant of access to abortion care in the United States, new findings show.
Increases in median travel distance to the nearest abortion care facility were associated with significant reductions in median abortion rate.
The abortion rate was 21.1 per 1,000 female residents of reproductive age among those who lived less than 5 miles from a facility, but that number dropped to 3.9/1,000 for those living 120 miles or further away.
Overall, in a model of 3,107 U.S. counties that included 62.5 million women of reproductive age, there were an estimated 696,760 abortions (at a mean rate of 11.1/1,000). The authors estimate that if abortion services were integrated into primary care, an additional 18,190 abortions would be performed (mean rate, 11.4/1,000).
Similarly, if telemedicine became widely available in this setting, this would allow approximately 70,920 abortions (mean rate 12.3/1,000). The study was published online in JAMA Open Network.
Reducing travel distances to abortion facilities would increase access, but additional clinics and providers would be needed to meet the demand. But as the population density of many counties with poor access is low, innovative strategies are also needed.
Integrating abortion into primary care or making medication abortion care available by telemedicine may decrease this unmet need, and lead author Kirsten Thompson, MPH, noted that there is growing evidence that both solutions are quite feasible to implement.
“A study published in 2018 has led primary care providers to adopt the same regimen for miscarriage care, showing that they are interested and capable, despite the barriers posed by the mifepristone [Risk Evaluation and Mitigation Strategy] program for these patients,” said Ms. Thompson, who is program and communications director, Bixby Center for Global Reproductive Health, University of California, San Francisco. “Medical education programs designed specifically for primary care providers have trained family medicine and other clinicians in abortion care for over a decade.”
As for telemedicine, Ms. Thompson explained that, during the pandemic, a preliminary injunction in a federal court case and then the Food and Drug Administration suspended enforcement of the in-person requirements of the mifepristone REMS. “In states that allow medical abortion care by telemedicine, providers have been able to offer remote care when medically appropriate, including mailing medical abortion pills to patients at home,” she said. “Researchers have already published evidence on the safety of and patient satisfaction with this approach.”
However, there are two main barriers to the widespread adoption of medical abortion by telemedicine in the United States. “One is the potentially temporary nature of the FDA’s enforcement discretion and second, are the 19 states with laws that ban it, singling out medical abortion as somehow different from other forms of care by telemedicine,” she said.
Study details
About one in four women in the United States will terminate a pregnancy during their lifetime, but the issue is highly contentious and many states have implemented policies that restrict access to abortion care. The authors pointed out that studies have documented clinic closures and women being unable to obtain abortion care, with low-income women and non-White women being disproportionately affected. Increased travel to a provider has also been associated with delays in care as well as increased costs and stress.
Prior research has shown that the further a woman lives from a facility, the less likely she is to obtain abortion care. In this study, Ms. Thompson and colleagues examined the association between travel distance to the nearest abortion care facility and the abortion rate, and then modeled the effect of reduced travel distance on rates.
They first conducted a cross-sectional geographic analysis using the American Community Survey and the U.S. Census to calculate county-level abortion rates per 1,000 women aged between 15 and 44 years. The 2015 data covered 1,948 counties in 27 states.
Abortion rates were then estimated for 3,107 counties in 48 states and the effect of different travel distance scenarios on the abortion rate was also estimated by multivariable model. Data were collected from April 2018 to October 2019.
There were 37.3 million women of reproductive age residing in the 27 states, and a total of 428,720 reported abortions (mean rate, 11.5/1,000; median rate, 9.9/1,000 women).
When looking at all 48 states, the population-weighted mean travel distance to the nearest facility was 25.6 miles, with a median travel distance of 8.2 miles.
A multivariable model showed that a greater travel distance was associated with lower abortion rates. When compared with traveling less than 5 miles, the abortion rate declined by 0.05/1,000 for women traveling between 5 to less than 15 miles for care, 0.22 for those traveling 15 to less than 30 miles, 0.34 for 30 to less than 60 miles, 0.43 for 60 to less than 120 miles, and 0.73 for those traveling 120 miles or more.
They estimated that, if all travel was under 30 miles, there would be a 2.6% increase or 18,190 additional abortions. A simulation also showed that there would be a 10.2% increase (70,920 additional abortions) using medication via telemedicine.
Solutions are feasible
Approached for an independent comment, Sarah W. Prager, MD, MAS, professor of obstetrics and gynecology and division chief, complex family planning, at the University of Washington, Seattle, agreed that the solutions proposed by the authors were feasible.
“More than a third of abortions that are eligible are now done with medication,” she said, “And 89% of abortions are done in the first trimester.”
What this means is that early first-trimester abortions can conceivably be performed in the primary care setting. “Any primary care clinician – whether it’s a family practice or internal medicine physician, or nurse practitioner or nurse midwife – can all be trained to do aspiration or prescribe medication in the first trimester,” said Dr. Prager. “So it could easily be integrated into primary care settings if there was motivation for that to happen.”
However, she emphasized that more is involved than just training the provider. “The whole clinic has to buy into it,” Dr. Prager explained. “The nurses have to be willing to assist, you need the medical assistants, the scheduler or person who works the front desk – the whole clinic system has to buy into it and that’s where it becomes more challenging.”
The individual provider may be willing, but the system may still not be allowing that to happen. “This is also where telemedicine can come in, where the medication can be mailed so it can circumvent the problem to a certain extent,” Dr. Prager added. “You don’t have to have the infrastructure in the same way.”
But many states already have laws in place to make that illegal, especially for abortion care even if they allow it for similar types of care.
Another expert also weighed in and agreed that these two solutions can potentially be implemented.
“The concept of decreased rates of abortion associated with greater distances traveled is not new, but what is unique to this manuscript is the estimations that the authors conducted in understanding the impact of expanding access to abortion among primary care and telehealth providers,” said Catherine Cansino, MD, MPH, associate clinical professor in the department of obstetrics and gynecology, University of California, Davis.
“The study provides convincing evidence regarding the need to strengthen infrastructures that support expansion of these services in primary care settings, among physicians and advanced care practitioners,” she said. “Training to provide medical abortion and first-trimester surgical abortion is simple. Many primary care providers are already doing gynecologic procedures – IUD insertions, colposcopies, endometrial biopsies.”
Thus, she noted, adding abortion care “to their toolkit isn’t too far of a stretch.”
As for telemedicine, Dr. Cansino pointed out how the COVID-19 pandemic has also expanded what both patients and providers think are safe options for providing and receiving good care. “Consultations through telemedicine coupled with access to medications for medical abortion through local pharmacies or express mail is definitely safe and feasible.”
The study was supported by the William and Flora Hewlett Foundation and by an anonymous foundation for general operating support (Ms Thompson). Ms. Thompson reported receiving personal fees from GenBioPro outside the submitted work. Dr. Cansino and Dr. Prager have no disclosures.
FROM JAMA NETWORK OPEN