Use of Obstetric and Gynecologic Hospitalists Is Associated With Decreased Severe Maternal Morbidity in the United States.

OBJECTIVES: This study aimed to evaluate the prevalence of obstetric and gynecologic (Ob/Gyn) hospitalists and determine if an association exists between the presence of Ob/Gyn hospitalists and severe maternal morbidity (SMM). METHODS: This observational study included data from hospitals listed in the USA TODAY 's 2019 article titled, "Deadly deliveries: Childbirth complication rates at maternity hospitals." Telephone and email surveys of staff in these hospitals identified the presence or absence of continuous providers in the hospital 24 hours, 7 days a week (24/7 coverage) and the types of providers who are employed, then compared these responses with the SMM cited by USA TODAY . RESULTS: Eight hundred ten hospitals were contacted, with participation from 614 labor and delivery units for a response rate of 75.8%. Fifty-seven percent of units were staffed with 24/7 coverage, with 46% of hospitals' coverage primarily provided by an Ob/Gyn hospitalist and 54% primarily by a nonhospitalist OB/Gyn provider. The SMM and presence of 24/7 coverage increased with the level of neonatal care and delivery volume. Of hospitals with 24/7 coverage, those that primarily used Ob/Gyn hospitalists had a lower SMM for all mothers (1.7 versus 2.0, P = 0.014) and for low-income mothers (1.9 versus 2.30, P = 0.007) than those who primarily used nonhospitalist OB/Gyn providers. CONCLUSIONS: Severe maternal morbidity increases with delivery volume, level of neonatal care, and 24/7 coverage. Of hospitals with 24/7 coverage, units that staff with Ob/Gyn hospitalists have lower levels of SMM than those that use nonhospitalist Ob/Gyn providers.

A curriculum for Burch colposuspension and diagnostic cystoscopy evaluated by an objective structured assessment of technical skills.

OBJECTIVE: The purpose of this study was to develop an effective curriculum for teaching colposuspension and diagnostic cystoscopy. STUDY DESIGN: Fifty-five residents underwent an Objective Structured Assessment of Technical Skills that was composed of a task-specific checklist and validated global assessment. Thirty of the residents had been exposed to a training curriculum, and 25 residents served as untrained control subjects. RESULTS: For the colposuspension and cystoscopy checklists, the reliability coefficient was 0.85 and 0.72, and the interrater reliability was 0.92 and 0.68, respectively. Although residents who were provided the curriculum performed better on both task-specific checklists, the differences did not reach statistical significance. Senior residents performed consistently better than junior residents for both tasks. When a comparison was made of the junior residents separately to account for previous experience, trained residents performed significantly better on the cystoscopy checklist (P = .029). CONCLUSION: This curriculum is an effective way to teach diagnostic cystoscopy to junior residents. The checklist for this Objective Structured Assessment of Technical Skills has good reliability and construct validity.

Comparison of objective, structured assessment of technical skills with a virtual reality hysteroscopy trainer and standard latex hysteroscopy model.

OBJECTIVE: To evaluate a virtual reality (VR) hysteroscopy device and a standard latex hysteroscopy model for assessment of residents' surgical skills. STUDY DESIGN: As part of a 7-station, objective, structured assessment of technical skills (OSATS), 13 obstetrics and gynecology residents performed myoma resection with the Immersion Hysteroscopy VR Trainer (Gaithersburg, Maryland) and dissection of a polyp with a model from Limbs and Things, Inc. (LT) (Bristol, England). OSATS were scored by both blinded (to the residents' levels) and unblinded examiners using a task-specific checklist, global rating scale and pass/fail assessment. RESULTS: Reliability indices for the VR model were 0.70 (checklist) and 0.98 (global), with an interrater reliability of 0.87 and 0.92, respectively. Correlation of scores between blinded and unblinded examiners was 0.78 for the checklist and 0.88 for the global (p < 0.001). Examination of construct validity revealed improved scores with-increasing postgraduate year. Comparison of VR scores to LT scores revealed VR scores to be significantly higher than LT scores (p < 0.001). Correlations of VR and LT scores were low for both the global (0.478, p = 0.12) and checklist (0.362, p = 0.24). CONCLUSION: The VR Hysteroscopy Trainer is not superior to standard models for evaluating surgical skills.

A new curriculum for hysteroscopy training as demonstrated by an objective structured assessment of technical skills (OSATS).

OBJECTIVE: The purpose of this study was to develop an effective curriculum to teach hysteroscopy, as well as to develop an objective assessment instrument (OSATS). STUDY DESIGN: All 24 residents in our training program attended a 3-hour hysteroscopy curriculum in each of 3 years. Each year after the curriculum, an OSATS was administered consisting of an assembly and operative task. Each task was evaluated with a task-specific checklist and a previously validated global assessment form. Twenty-four residents from an outside institution served as controls. All residents were examined by blinded and unblinded examiners. RESULTS: The reliability coefficient was .7857 for the checklist and .9763 for the global scale. Interrater reliability for the checklist was .7478 and ranged from .4222 to .9329 for the global instruments. Evaluation of construct validity revealed that the junior residents at both locations did significantly worse on the checklist and global scale than the senior residents for all 3 years of the study (P < .001). Those residents provided the curriculum did significantly better on both the checklist and the global scale than the resident controls with a mean of 45% versus 63% for the checklist and 18.3 versus 24.9 for the global score. (P = .001 checklist, P = .007 global scale). CONCLUSION: This curriculum is an effective way to impart knowledge and skill in the assembly and use of the operative hysteroscope. The checklist developed for this OSATS has excellent reliability and construct validity.

Assessment of resident surgical skills: is testing feasible?

OBJECTIVE: We have previously shown that in a single residency program objective structured assessment of technical skills (OSATS) is a reliable and valid method of assessing surgical competency. Our goal was to establish feasibility of this evaluation instrument when administered at multiple residency programs throughout the US, and assess the impact of a laboratory-based surgical curriculum on results. STUDY DESIGN: An OSATS exam was administered to 116 residents from 5 residency programs. One of the residency programs had participated in a comprehensive surgical curriculum over a 4-year period of time. The exam consisted of 3 open and 3 laparoscopic tasks. Residents were graded by both a blinded and unblinded examiner with task-specific checklist, global rating scale, pass/fail assessment, and tasks were timed. All tasks were performed on life-like models. RESULTS: Examinations were successfully completed at all sites. Each exam required 90 minutes of resident time. Reliability indices calculated with Cronbach's alpha were .97 for overall global rating and .95 for checklists. Interrater reliability between blinded and unblinded examiners ranged from .71 to .97 for individual tasks and was .95 overall. Assessment of construct validity (the ability to distinguish among residency levels) found significant differences among the residents for both blinded and unblinded examiners for all evaluation outcomes except time. For the test overall, the global rating scale showed significant differences among all 4 residency levels. The checklist showed significant differences at three levels (PGY3-4 >PGY2 >PGY1). Approximate cost for replaceable items was 40 US dollars to 150 per resident depending on which tasks were chosen. Comparison of scores between residents who received a laboratory-based curriculum and those who did not revealed significantly higher scores and shorter time to complete tasks for the group who received additional training. CONCLUSION: Large-scale testing has confirmed that OSATS is an objective, reliable, and valid method to assess surgical skills, and can easily be administered in most residency programs. A laboratory-based surgical curriculum improved test results and reduced time to complete tasks.

Evaluation of p27 in preinvasive and invasive malignancies of the cervix.

OBJECTIVE: p27 is a cell cycle inhibitor whose loss is commonly found in epithelial tumors. Low levels have been associated with poor prognosis. Our goal was to determine if p27 expression could be used to screen for dysplasia and if it is a prognostic factor for cervical malignancies. METHODS: Ten normal cervices, 51 consecutive cone biopsies for preinvasive disease, and 128 consecutive hysterectomies for invasive cervical cancer (1994-1999) were stained for p27 using standard immunocytochemical techniques. All of the cervical cancer patients were managed with radical hysterectomy and lymph node dissection, except for 14 women who underwent adjuvant hysterectomy and lymph node sampling after chemoradiation. RESULTS: There was no significant difference in p27 staining between normal cervices (all stained 4+) and preinvasive lesions (46/51 stained 4+ and 5/51 stained 3+). For the invasive lesions, 47 women had no residual disease in the hysterectomy specimen, due to prior cone biopsy (41) or radiation (6). All had 4+ p27 staining in the residual cervix. None of these women recurred. Eighty-one women had residual disease in the hysterectomy specimen; 25/81 (31%) had p27 staining of <50%. Loss of p27 was not significantly associated with invasion >50% (32 vs 27%), size >4 cm (20 vs 13%), or use of postoperative radiation (36 vs 20%). Loss of p27 was associated with lymphvascular space invasion (LVSI) (44 vs 20%, P = 0.04). Only 4 women had nodal metastasis; all 4 had p27 staining less than 50%; 6/81 (7%) women with residual disease developed recurrences and died. Of the women who died, 3/6 had p27 staining less than 50%. CONCLUSION: p27 is not lost in preinvasive cervical lesions and, therefore, cannot be used to screen for dysplasia. In cervical cancers p27 staining was <50% in 31% of cases, and is associated with increased risk of LVSI. Perhaps, because of the excellent overall survival of this group of women with Stage I cervical cancer, loss of p27 staining was not associated with poor prognosis.