Disparities in Benign Gynecologic Surgical Care.

A person's health is not only affected by their disease states, but also the quality of care and posttreatment sequelae. Research shows that disparities exist in benign gynecologic surgery access to care, techniques, and perioperative outcomes. Surgical education, pathways that emphasize minimally invasive approaches, and patient-centered care that recognizes historical influences on patient perspectives are critical to dampening these disparities.

Laparoscopic Major Vascular Injuries in Gynecologic Surgery for Benign Indications: A Systematic Review.

OBJECTIVE: To identify the incidence, location, etiology, and mortality of major vascular injuries in gynecologic laparoscopy for benign indications. DATA SOURCES: A systematic review of PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov, and MEDLINE was conducted. METHODS OF STUDY SELECTION: One thousand ninety-seven studies were screened for inclusion with 147 full-text articles reviewed. Sixty-six studies published between 1978 and 2016 met inclusion criteria, representing 197,062 surgeries. Articles that were included reported the incidence of major vascular injuries during gynecologic laparoscopy for benign indications. Exclusion criteria included surgery for gynecologic malignancy, duplicated data, case series and reports, manuscripts not in English, and studies published only as abstracts. TABULATION, INTEGRATION, AND RESULTS: Injuries to the aorta, inferior vena cava, iliac (common, external, or internal), and inferior epigastric vessels were recorded, as were injuries denoted as major but not otherwise specified. A total of 179 major vascular injuries were reported with an incidence of 0.09% (95% CI 0.08-0.10). The inferior epigastric vessels were the most commonly injured vessel (0.04%, 95% CI 0.03-0.05), comprising 48% (95% CI 40-55) of all injuries. The majority of injuries occurred during abdominal entry (82%, 95% CI 76-89), and the remainder occurred during surgical dissection (18%, 95% CI 11-24). Most injuries were recognized intraoperatively (93%, 95% CI 87-100), and approximately half (55%, 95% CI 46-63) required laparotomy for repair. Only two of the 179 major vascular injuries resulted in death, for an overall mortality rate from vascular injuries of 0.001% (95% CI 0.000-0.004). CONCLUSION: The incidence of major vascular injury during gynecologic laparoscopy found in this review is very low, and the vast majority of injuries did not result in death. Laparoscopy remains a safe surgical technique in relation to vascular injuries when performed for benign gynecologic disease.

Impact of Surgical Wait Time to Hysterectomy for Benign Gynecologic Disease.

STUDY OBJECTIVE: To determine the impact of surgical wait time on healthcare use and surgical outcomes for patients undergoing hysterectomy for benign gynecologic indications. DESIGN: Retrospective cohort study. SETTING: Urban, academic tertiary care center. PATIENTS: Patients who underwent hysterectomy for benign disease between 2012 and 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were categorized into 2 groups, dichotomized by surgical wait times >30 days or ≤30 days. Healthcare use was measured by the number of discrete patient interactions with the healthcare system through phone calls, secure electronic messaging, and office and emergency room visits. Univariate and multivariable logistic regression models were performed to assess the association between surgical wait time and healthcare use and perioperative outcomes while controlling for confounders. A total of 277 patients were included in our analysis: 106 (38.3%) had surgical wait times >30 days (median 47 days, range 24-68 days), and 171 (67.1%) had surgical wait times ≤30 days (median 19 days; range 12-26 days). The groups did not differ by age, insurance status, substance use, or comorbid conditions. Patients in the group with surgical wait times >30 days were more likely to have increased healthcare use (69 of 106, 65% vs 43 of 171, 25%; odds ratio 5.55; 95% confidence interval, 3.27-9.41). There were no differences in intraoperative complications (9 of 106, 8% vs 19 of 171, 11%; p = .482) or postoperative complications (28 of 106, 26% vs 32 of 171, 19%; p = .13) between the groups; however, after controlling for potential confounders, patients with surgical wait times >30 days were 3.22 times more likely to be readmitted than patients with surgical wait times ≤30 days (95% confidence interval, 1.27-8.19). CONCLUSION: A surgical wait time >30 days in patients undergoing a hysterectomy for benign disease is associated with increased healthcare use in the interim. Although patients who experience longer surgical wait times do not experience worse surgical outcomes, they may be at higher risk for readmission after surgery. Targeted interventions to optimize perioperative coordination of care for patients undergoing a hysterectomy for benign disease, especially those within vulnerable populations, are needed to improve quality of care, decrease any redundant or inefficient healthcare use, and reduce any unnecessary delays.

Patient and Hospital Characteristics Associated with Minimally Invasive Hysterectomy: Evidence from 143 Illinois Hospitals, 2016 to 2018.

STUDY OBJECTIVE: To identify patient and hospital characteristics associated with minimally invasive hysterectomy. DESIGN: Retrospective population-based analysis of administrative data. SETTING: Data from the Illinois Hospital Association Comparative Health Care and Hospital Data Reporting Services Database. PATIENTS: Women undergoing hysterectomy for benign gynecologic indications in Illinois, 2016 to 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We determined the significance of the proportion of minimally invasive surgery (MIS) versus abdominal hysterectomies by patient and hospital characteristics. Multivariable logistic regression was used to determine the association between patient and hospital characteristics and the likelihood of MIS versus abdominal hysterectomy controlling for the simultaneous effects of all patient and hospital characteristics and year of surgery. There were 42 945 hysterectomies for benign indications at 143 nonfederal Illinois hospitals from 2016 to 2018. More than three-fourths (32 387, 75.4%) of hysterectomies were MIS. Non-Hispanic black patients had the lowest percentage of MIS (54.7%) compared with 82.1% among whites (p <.001). Being non-Hispanic black (odds ratio [OR] = 0.53, 95% confidence interval [CI], 0.47-0.60), other or unknown race and ethnicity (OR 0.76, 95% CI, 0.52-0.85), or having a diagnosis of myomas (OR 0.54, 95% CI, 0.49-0.60) were associated with a lower likelihood of MIS. Patients treated at hospitals with >80% MIS had almost 6 times the likelihood of MIS (OR 5.89, 95% CI, 4.51-7.68). CONCLUSION: Black race and a myoma diagnosis were independently associated with decreased odds of undergoing an MIS hysterectomy, whereas the strongest predictor of undergoing an MIS hysterectomy was hospital proportion of minimally invasive procedures.

Factors that Influence Applicants Pursuing a Fellowship in Minimally Invasive Gynecologic Surgery.

STUDY OBJECTIVE: The Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS) has been the most competitive fellowship in Obstetrics and Gynecology since 2015. Since its inception, it has served to provide advanced endoscopic training and addresses the need for additional proficiency beyond residency. We sought to identify factors that influence applicants in choosing to pursue minimally invasive gynecologic surgery training. DESIGN: Cross-sectional study. SETTING: 2018 FMIGS application cycle. PATIENTS: Not applicable. INTERVENTIONS: A novel, 32-item Web-based survey was distributed to all FMIGS applicants during the 2018 application cycle. MEASUREMENTS AND MAIN RESULTS: Descriptive statistics were used to characterize the applicant sample and responses. Our survey response rate was 47.4% (37/78). Interest in the subject area of minimally invasive gynecologic surgery was the single most influential factor driving applicants to pursue FMIGS, followed by an interest in an academic career. Income level was the least important factor in their decision, with 37.8% rating this as not important. There were no differences in motivational factors between male and female applicants. Few applicants felt "very comfortable" performing laparoscopic hysterectomy (16.2%) or laparoscopic myomectomy (3.0%) on completion of residency training. CONCLUSION: FMIGS applicants are motivated by their interest in minimally invasive gynecologic surgery, academia and research, and the opportunity to increase their proficiency with advanced endoscopic procedures.

Patient-reported outcome measures in benign gynecologic surgery: updates and selected tools.

PURPOSE OF REVIEW: Use of patient-reported outcome measures in clinical practice and research is becoming more prevalent and reflects initiatives to center the patient in healthcare delivery and outcomes assessment. The purpose of this review is to provide a summary description of selected, validated tools used to assess outcomes related to several benign gynecologic conditions: abnormal uterine bleeding, fibroids and endometriosis. RECENT FINDINGS: Given the availability of several validated instruments to assess patient outcomes in benign gynecology, there is still significant heterogeneity in tools used in trials. SUMMARY: Patient outcomes assessment should be an integral part of clinical practice and research in order to treat the whole patient and address any health-related impacts on quality of life. More attention is needed to increase standardization of tools used in research to facilitate assessment of comparative efficacy between treatments.

Risk perception of future cardiovascular disease in women diagnosed with a hypertensive disorder of pregnancy.

OBJECTIVE: The objective of this study is to evaluate a woman's risk perception for future cardiovascular disease (CVD) after being diagnosed with a hypertensive disorder of pregnancy. METHODS: A prospective cohort of women diagnosed with a hypertensive disorder of pregnancy (HDP) was studied. Each woman completed two surveys, one prior to hospital discharge and one 2 weeks later, designed to assess knowledge of and risk perception for future CVD based on their recent diagnosis of a HDP. Rates of postpartum depression were also assessed. RESULTS: Of the 146 subjects included, 28% were diagnosed with preeclampsia with severe features, 52.1% with preeclampsia with mild features, and 19.9% had chronic hypertension. Women with severe features and those delivering preterm were more likely to report a perception of increased risk of both recurrent HDP in a future pregnancy (p = 0.004 and 0.005, respectively) and hypertension later in life (p = 0.01 and 0.03, respectively). Women delivering preterm were more likely to report an accurate perception of increased risk of myocardial infarction and stroke compared to those delivering at term (p = 0.006 and 0.002, respectively). CONCLUSIONS: Disease severity and preterm delivery were associated with a higher likelihood of the perception of an increased risk for both recurrent HDP and hypertension in the future. Only preterm delivery was associated with a higher risk perception for stroke and myocardial infarction. Interventions targeted at improved health awareness in women diagnosed with HDP are warranted.