Variation in telemedicine usage in gynecologic cancer: Are we widening or narrowing disparities?

INTRODUCTION: Telemedicine rapidly increased with the COVID-19 pandemic and could reduce cancer care disparities. Our objective was to evaluate sociodemographic (race, insurance), patient, health system, and cancer factors associated with telemedicine use in gynecologic cancers. METHODS: We conducted a retrospective cohort study of patients with endometrial cancer and epithelial ovarian cancer with at least one visit from March 2020 to October 2021, using a real-world electronic health record-derived database, representing approximately 800 sites in US academic (14%) and community practices (86%). We used multivariable Poisson regression modeling to analyze the association of ever using telemedicine with patient, sociodemographic, health system, and cancer factors. RESULTS: Of 3950 patients with ovarian cancer, 1119 (28.3%) had at least one telemedicine visit. Of 2510 patients with endometrial cancer, 720 (28.7%) had at least one telemedicine visit. At community cancer practices, patients who identified as Black were less likely to have a telemedicine visit than patients who identified as white in both ovarian and endometrial cancer (Ovarian: RR 0.62, 95% CI 0.42-0.9; Endometrial: RR 0.56, 95% CI 0.38-0.83). Patients in the Southeast, Midwest, West, and Puerto Rico were less likely to have telemedicine visits than patients in the Northeast. Uninsured patients were less likely, and patients with Medicare were more likely, to have one or more telemedicine visit than patients with private insurance. CONCLUSIONS: In this national cohort study, <30% of patients ever used telemedicine, and significant racial and regional disparities existed in utilization. Telemedicine expansion efforts should include programs to improve equity in access to telemedicine.

Telehealth utilization in gynecologic oncology clinical trials.

OBJECTIVE: Prior to the COVID-19 pandemic, telehealth visits and remote clinical trial operations (such as local collection of laboratory tests or imaging studies) were underutilized in gynecologic oncology clinical trials. Current literature on these operational changes provides anecdotal experience and expert opinion with few studies describing patient-level safety data. We aimed to evaluate the safety and feasibility of telehealth and remote clinical trial operations during the COVID-19 Pandemic. METHODS: Gynecologic oncology patients enrolled and actively receiving treatment on a clinical trial at a single, academic institution during the designated pre-Telehealth and Telehealth periods were identified. Patients with at least 1 provider or research coordinator telehealth visit were included. Patient demographics, health system encounters, adverse events, and protocol deviations were collected. Pairwise comparisons were performed between the pre-Telehealth and Telehealth period with each patient serving as their own control. RESULTS: Thirty-one patients met inclusion criteria. Virtual provider visits and off-site laboratory testing increased during the Telehealth period. Delays in provider visits, imaging, and laboratory testing did not differ between time periods. Total and minor protocol deviations increased in incidence during the Telehealth period and were due to documentation of telehealth and deferment of non-therapeutic testing. Major protocol deviations, emergency department visits, admissions, and severe adverse events were of low incidence and did not differ between time periods. CONCLUSIONS: Telehealth and remote clinical trial operations appeared safe and did not compromise clinical trial protocols in a small, single institutional study. Larger scale evaluations of such trial adaptations should be performed to determine continued utility following the Pandemic.

Minimally Invasive Surgery Survey: A Survey of Surgical Team Members' Perceptions for Successful Minimally Invasive Surgery.

STUDY OBJECTIVE: To develop a valid and reliable survey to measure surgical team members' perceptions regarding their institution's requirements for successful minimally invasive surgery (MIS). DESIGN: Questionnaire development and validation study (Canadian Task Force classification II-2). SETTING: Three hospital types: rural, urban/academic, and community/academic. PARTICIPANTS: Minimally invasive staff (team members). INTERVENTION: Development and validation of a minimally invasive surgery survey (MISS). MEASUREMENT AND MAIN RESULTS: Using the Safety Attitudes questionnaire as a guide, we developed questions assessing study participants' attitudes regarding the requirements for successful MIS. The questions were closed-ended and responses based on a 5-point Likert scale. The large pool of questions was then given to 4 focus groups made up of 3 to 6 individuals. Each focus group consisted of individuals from a specific profession (e.g., surgeons, anesthesiologists, nurses, and surgical technicians). Questions were revised based on focus group recommendations, resulting in a final 52-question set. The question set was then distributed to MIS team members. Individuals were included if they had participated in >10 MIS cases and worked in the MIS setting in the past 3 months. Participants in the trial population were asked to repeat the questionnaire 4 weeks later to evaluate internal consistency. Participants' demographics, including age, gender, specialty, profession, and years of experience, were captured in the questionnaire. Factor analysis with varimax rotation was performed to determine domains (questions evaluating similar themes). For internal consistency and reliability, domains were tested using interitem correlations and Cronbach's α. Cronbach's α > .6 was considered internally consistent. Kendall's correlation coefficient τ closer to 1 and with p < .05 was considered significant for the test-retest reliability. Two hundred fifty participants answered the initial question set. Of those, 53 were eliminated because they did not meet inclusion criteria or failed to answer all questions, leaving 197 participants. Most participants were women (68% vs 32%), and 42% were between the ages 30 and 39 years. Factor analysis identified 6 domains: collaboration, error reporting, job proficiency/efficiency, problem-solving, job satisfaction, and situational awareness. Interitem correlations testing for redundancy for each domain ranged from .2 to .7, suggesting similar themed questions while avoiding redundancy. Cronbach's α, testing internal consistency, was .87. Sixty-two participants from the original cohort repeated the question set at 4 weeks. Forty-three were analyzed for test-retest reliability after excluding those who did not meet inclusion criteria. The final questions showed high test-retest reliability (τ = .3-.7, p < .05). The final questionnaire was made up of 29 questions from the original 52 question set. CONCLUSION: The MISS is a reliable and valid tool that can be used to measure how surgical team members conceptualize the requirements for successful MIS. The MISS revealed that participants identified 6 important domains of a successful workenvironment: collaboration, error reporting, job proficiency/efficiency, problem-solving, job satisfaction, and situational awareness. The questionnaire can be used to understand and align various surgical team members' goals and expectations and may help improve quality of care in the MIS setting.

Predictive value of 5-Factor modified frailty index in Oncologic and benign hysterectomies.

Background: The 5-factor modified frailty index (mFI-5) has been validated against the original 11-factor modified frailty index in gynecologic surgery, however its utility has not been evaluated between benign versus gynecologic oncology patient populations. Objective: To evaluate the predictive value of the mFI-5 in identifying women at increased risk for major postoperative complications, readmission, or death within 30 days of hysterectomy for benign and oncologic indications. Methods: Patients who underwent hysterectomy between 2015 and 2017 were identified from the NSQIP database and stratified into benign or malignant indications. Demographic and mFI-5 variables were extracted. The mFI-5 was calculated by dividing the sum of all affirmative variables by the total number of input variables in the database. Logistic regression modeling was performed adjusting for confounders. C-statistic with 95% CI was obtained post-regression. Results: 80,293 hysterectomies (59,078 benign and 21,215 oncologic) were identified. The benign group was more likely to have an mFI-5 score of 0 (70 % vs 50 %, p = 0.001) and had shorter operative times (p = 0.001). In the benign group, mFI-5 was a strong predictor of mortality (c = 0.819, CI 0.704-0.933). Within the oncology group, the mFI-5 was a strong predictor of mortality (c = 0.801, CI 0.750-0.851), particularly for uterine and cervical cancers. It was moderately predictive of readmission (c = 0.671, CI 0.656-0.686) and strongly predictive of Clavien-Dindo class III and IV complications (c = 0.732, CI 0.713-0.750). Conclusion: The mFI-5 is a strong predictor of 30-day mortality and serious postoperative complications. These findings have the potential to improve identification of high-risk patients in the preoperative setting.

Therapeutic Suggestion in Postoperative Pain Control: A Randomized Controlled Trial.

OBJECTIVES: There is conflicting research on the effect of therapeutic suggestion in the perioperative period. This study systematically compared subjective and objective measures of postoperative pain, nausea and vomiting, urinary and bowel function, and global perception of symptomatic improvement between participants receiving perioperative therapeutic suggestion versus routine perioperative care during minimally invasive pelvic reconstructive surgery. METHODS: This was a single-blinded, randomized controlled trial of participants undergoing vaginal hysterectomy with minimally invasive sacrocolpopexy and concomitant prolapse repairs. The intervention group received perioperative therapeutic suggestion, whereas the control group did not. Primary outcomes included postoperative pain scores and analgesic use. Secondary outcomes included a postoperative nausea and vomiting scale, the Pelvic Floor Distress Inventory Questionnaire-Short Form 20, the Patient Global Impression of Improvement scale, and time to return of bowel and bladder function. RESULTS: Sixteen participants were randomized to each group. Final analysis included 15 intervention and 14 control participants. Overall measures of postoperative pain and analgesic use were low across all participants without a significant difference between intervention and control groups (opioid: 52.5; interquartile range [IQR], 25.5-58.9 vs 66 IQR, 7.3-125.8; morphine milligram equivalents; P = 0.64; acetaminophen: 2225 mg; IQR, 500-2600 mg vs 2800 mg; IQR, 650-4775 mg; P = 0.38). There were no statistically significant differences in secondary outcomes of urinary symptoms, bowel function, and subjective improvement of prolapse symptoms. CONCLUSIONS: No differences in postoperative pain, analgesic use, return of bowel and bladder function, or pelvic organ prolapse symptoms were noted in participants receiving perioperative therapeutic suggestion versus routine perioperative care.

The fistula crisis in sub-Saharan Africa: an ongoing struggle in education and awareness.

This article examines the social and physical causes of obstetric fistulas, as well as resulting social and psychological consequences. Preventative strategies are addressed using Niger as a microcosm for this devastating condition that affects two million women worldwide.

Safety and Feasibility of Discharge Without an Opioid Prescription for Patients Undergoing Gynecologic Surgery.

OBJECTIVE: To implement a quality-improvement intervention aimed at reducing unnecessary opioid prescriptions for patients who are undergoing gynecologic surgery. METHODS: This was a retrospective cohort study that included data from the pre- and post-quality-improvement initiative cohorts. Patients at an urban, tertiary academic medical center who were undergoing scheduled minimally invasive surgery and open abdominal surgery by a gynecologic oncologist were included. Patients underwent preoperative counseling, standardization of perioperative analgesia, and a postoperative opioid prescribing algorithm. Descriptive statistics were calculated for demographic and perioperative characteristics, process measures, and outcome measures. RESULTS: A total of 532 abdominal surgeries were analyzed. The total percentage of patients discharged with an opioid prescription decreased from 82.7% (n=229/276) to 23.1% (n=59/256) (P<.001) and was significantly reduced for all routes of surgery. The mean number of opioid tablets prescribed for all patients was significantly reduced from 7.2 tablets (SD=5.7) to 1.8 tablets (SD=4.3) (P<.001). Eighty-three percent of patients (n=97/117) who underwent minimally invasive hysterectomy and were discharged on postoperative day 0 or day 1 were not provided an opioid prescription. Fifty-one percent of patients who underwent laparotomy were discharged without an opioid prescription. The percentage of patients who required an opioid refill or new prescription in the preintervention and postintervention cohorts remained constant (6.5%, n=18/276 vs 5.9%, n=15/256, P=.75), as did postoperative calls for pain (8.3%, n=23/276 vs 10.9%, n=33/256). CONCLUSION: Patients who are undergoing scheduled abdominal gynecologic surgery can be safely discharged without opioid prescriptions with appropriate education and perioperative analgesia prescribing practices. These protocols and prescribing practices profoundly limit opioid prescriptions, which is an important factor in combating the ongoing opioid crisis.

Diminished ovarian reserve as measured by means of baseline follicle-stimulating hormone and antral follicle count is not associated with pregnancy loss in younger in vitro fertilization patients.

OBJECTIVE: To assess the relationship between diminished ovarian reserve and pregnancy outcomes in a large cohort of women achieving pregnancy through in vitro fertilization (IVF). We evaluated antral follicle count (AFC) and baseline FSH as a measure of ovarian reserve. Secondarily, we assessed whether diminished ovarian reserve was associated with aneuploidy among spontaneous abortions. DESIGN: Retrospective cohort study. SETTING: Multicenter private practice. PATIENT(S): All patients aged 21-44 years undergoing fresh autologous IVF cycles during 2009-2013 that resulted in positive serum hCG with recorded baseline FSH levels. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Live births per early pregnancy, biochemical pregnancies, clinical pregnancy losses, and aneuploidy rates in products of conception among pregnancy losses. RESULT(S): A total of 9,489 cycles among 8,214 patients were analyzed. There was no association between live birth and ovarian reserve among pregnant IVF patients under the age of 35 years. Among patients 35 years of age and older, elevated baseline FSH was associated with a higher risk of pregnancy loss, which increased with increasing age. AFC was not significantly associated with pregnancy loss at any age. No associations were found between ovarian reserve measures and aneuploidy in products of conception in age-adjusted analyses, although the power to effectively evaluate this was limited. CONCLUSION(S): Diminished ovarian reserve is not associated with an increase in miscarriage among younger women achieving pregnancy through IVF. Elevated FSH is associated with a higher risk of IVF pregnancy loss among older patients. We found no evidence to confirm that diminished ovarian reserve is associated with increased aneuploidy among spontaneous abortions.