High-volume Surgeons and Reducing Racial Disparities in Route of Hysterectomy.

STUDY OBJECTIVE: To examine racial disparities in route of hysterectomy and perioperative outcomes before and after expansion of high-volume minimally invasive surgeons (>10 minimally invasive hysterectomies [MIHs]/year). DESIGN: Retrospective cohort study. SETTING: Multicenter academic teaching institution. PATIENTS: All patients who underwent a scheduled hysterectomy for benign indications during 2018 (preintervention) and 2022 (postintervention). INTERVENTIONS: Recruitment of fellowship in minimally invasive gynecologic surgery-trained faculty and increased surgical training for academic specialists in obstetrics and gynecology occurred in 2020. MEASUREMENTS AND MAIN RESULTS: Patients in the preintervention cohort (n = 171) were older (median age, 45 years vs 43 years; p = .003) whereas patients in the postintervention cohort (n = 234) had a higher burden of comorbidities (26% American Society of Anesthesiologists class III vs 19%; p = .03). Uterine weight was not significantly different between cohorts (p = .328). Between the pre- and postintervention cohorts, high-volume minimally invasive surgeons increased from 27% (n = 4) to 44% (n = 7) of those performing hysterectomies within the division and percentage of hysterectomies performed via minimally invasive route increased (63% vs 82%; p <.001). In the preintervention cohort, Black patients had a lower percentage of hysterectomies performed via minimally invasive route than White patients (Black = 56% MIH vs White = 76% MIH; p = .014). In the postintervention cohort, differences by race were no longer significant (Black = 78% MIH vs White = 87% MIH; p = .127). There was a significant increase (22%) in MIH for Black patients between cohorts (p <.001). After adjusting for age, body mass index, American Society of Anesthesiologists class, previous surgery, and uterine weight, disparities by race were no longer present in the postintervention cohort. Perioperative outcomes including length of stay (p <.001), infection rates (p = .002), and blood loss (p = .01) improved after intervention. CONCLUSION: Increasing fellowship in minimally invasive gynecologic surgery-trained gynecologic surgeons and providing more opportunities in robotic/laparoscopic training for academic specialists may improve access to MIH for Black patients and reduce disparities.

Patient Consent for Medical Student Pelvic Exams under Anesthesia: An Exploratory Retrospective Chart Review.

AbstractObjective: We performed this study to examine patients' choices to permit or refuse medical student pelvic examinations under anesthesia (EUAs) during planned gynecologic procedures. DESIGN: We conducted an exploratory retrospective chart review of electronic consent forms at a single academic medical center using contingency tables, logistic regression, and nonparametric tests to explore relationships between patient and physician characteristics and consent. RESULTS: We identified and downloaded electronic consent forms for a census of 4,000 patients undergoing gynecologic surgery from September 2020 through calendar year 2022. Forms were linked to anonymized medical record information. Of the 4,000 patients, 142 (3.6%) were removed from analysis because consent forms were incomplete. Of 3,858 patients, 308 (8.0%) were asked for EUA consent more than once, 46 of whom were not consistent. Overall, 3,308 (85.7%) patients consented every time asked, and 550 (14.2%) refused or limited EUA consent at least once. Nine patients limited their consent to female students, and two patients refused medical student participation at all. We performed exploratory multiple logistic regression analyses exploring differences in rates of consent across patient and physician demographic groups. CONCLUSIONS: We find that some patients are more likely than others to refuse a pelvic EUA, magnifying the dignitary harm from a nonconsensual invasion of intimate bodily integrity and perpetuating historic wrongs visited upon vulnerable people of color and religious minorities. Patients' rights to respect and control over their bodies require that physicians take seriously the ethical obligation to inform their patients and ask them for permission.

Prior authorization in gynecologic oncology: An analysis of clinical impact.

BACKGROUND: Prior authorization was designed to minimize unnecessary care and reduce spending but has been associated with delays in necessary care. Our objective was to estimate the occurrence of prior authorization, and impact on cancer care, in gynecologic oncology. METHODS: We performed a retrospective cross-sectional study of patients seen in University of Pennsylvania gynecologic oncology practices (January-March 2021). Using electronic medical records, we measured the incidence of prior authorization during the 3-month period and prior experience of prior authorization for cancer care overall and by type of order (chemotherapy, imaging, surgery, prescription drugs). We assessed the impact of prior authorization occurrence on clinical outcomes (time to service, changes in care). RESULTS: Of the 2112 clinic visits of 1406 unique patients, 5% experienced prior authorization during the 3-month study period. An additional 20% faced prior authorization requests earlier in cancer care. Of the 83 prior authorization requests, imaging accounted for the majority (54%) followed by supportive medications (29%) and chemotherapy (17%). After appeal, 79% of cases were approved. For patients whose prior authorizations were approved, there was a mean of 16 days from order placement to care delivery (95% CI 11-20, range 0-98 days). Of the 17 denials, 3 (18%) led to a substantial change in care (i.e., not receiving planned treatment). CONCLUSION: 25% of gynecologic oncology patients experienced prior authorization during their cancer care. While 80% of claims were ultimately approved, patients experienced over a 2-week delay in care when prior authorization occurred. Reform is needed to reduce the burden of prior authorization in oncology.

Oncologic outcomes of uterine preservation for pre-menopausal patients with stage II epithelial ovarian carcinoma.

OBJECTIVE: Fertility-sparing surgery is rarely offered for patients with stage II epithelial ovarian carcinoma. The aim of the present study was to evaluate the overall survival of pre-menopausal patients with stage II epithelial ovarian carcinoma who did not undergo hysterectomy. METHODS: The National Cancer Database was accessed, and patients aged ≤40 years without a history of another tumor diagnosed between 2004 and 2015 with a pathological stage II epithelial ovarian carcinoma, who underwent lymphadenectomy and received multi-agent chemotherapy, were identified. Overall survival was compared with the log-rank test after generation of Kaplan-Meier curves. A Cox model was constructed to control for tumor histology. RESULTS: A total of 185 patients met the inclusion criteria. The rate of uterine preservation was 24.3% (45 patients). Patients who did not undergo hysterectomy were younger (median 32 vs 37 years, p<0.001) and less likely to have high-grade tumors compared with those who underwent hysterectomy. The two groups were comparable in terms of presence of co-morbidities and performance of adequate lymphadenectomy (p>0.05). Median follow-up of the present cohort was 62.3 months (95% CI 53.6 to 71.0) and a total of 22 deaths occurred. There was no difference in overall survival between patients who did and did not undergo hysterectomy (p=0.50; 5-year overall survival rates 87.5% and 91.4%, respectively). After controlling for tumor histology, grade and substage, omission of hysterectomy was not associated with worse survival (HR 0.69, 95% CI 0.22 to 2.12). CONCLUSIONS: Uterine preservation was not associated with worse survival in this cohort of pre-menopausal patients with stage II epithelial ovarian carcinoma.

Fertility sparing surgery for patients with FIGO stage I clear cell ovarian carcinoma: a database analysis and systematic review of the literature.

OBJECTIVE: Fertility sparing surgery for patients with early stage ovarian clear cell carcinoma is controversial. We aimed to investigate the impact of fertility sparing surgery on the oncologic outcomes of young patients with stage I ovarian clear cell carcinoma. METHODS: The National Cancer Database was accessed and patients with pathological stage IA or IC ovarian clear cell carcinoma, aged <45 years, were selected. Based on site specific surgery codes, patients who underwent fertility sparing or radical surgery were identified. Overall survival was evaluated following generation of Kaplan-Meier curves, and compared with the log rank test. Multivariate Cox analysis was performed to control for possible confounders. A systematic review of literature of the Pubmed, EMBASE and Web of Science databases was also performed to summarize all reported cases. RESULTS: A total of 57 (35.8%) and 102 (64.2%) patients underwent fertility sparing and radical surgery. There was no difference in overall survival between patients who had fertility sparing and radical surgery (p=0.92); 5 year overall survival rates were 89% and 87.9%, respectively. After controlling for the performance of lymphadenectomy and disease substage, fertility sparing surgery was not associated with worse survival (hazard ratio 0.83, 95% confidence interval 0.30 to 2.32). A systematic review of the literature identified 132 patients with stage I disease who underwent fertility sparing surgery; a total of 20 patients (15.2%) experienced a relapse at a median of 18 months from surgery. CONCLUSIONS: In a large cohort of young patients with stage I ovarian clear cell carcinoma, fertility sparing surgery was not associated with worse survival.

Perioperative Considerations for Hysterectomy in Second-Trimester Molar Pregnancy.

BACKGROUND: Second-trimester complete molar pregnancies are rare. Due to a later presentation, means to reduce surgical and long-term morbidity from hemorrhage, hyperthyroidism, and gestational trophoblastic neoplasia risk should be considered. CASE: A 48-year-old woman presented at 17 6/7 weeks of gestation with vaginal bleeding, with a human chorionic gonadotropin (hCG) level of 483,906 milli-international units/mL, biochemical hyperthyroidism, and ultrasonographic suspicion for complete molar pregnancy. The patient received preoperative uterine artery embolization and antithyroid medication before undergoing total abdominal hysterectomy. Her thyroid function and hCG level normalized by 1 week and 69 days postoperatively, respectively. CONCLUSION: Uterine artery embolization and hysterectomy may reduce surgical blood loss and lower the risk of malignancy for patients at high risk for gestational trophoblastic neoplasia. Preoperative treatment of hyperthyroidism with gestational trophoblastic disease can reduce morbidity from thyrotoxicosis.

Insurance and racial disparities in prior authorization in gynecologic oncology.

While prior authorization aims to reduce unnecessary care, it may limit or delay medically necessary care. Delays in cancer care can impact survival and are more common in historically-marginalized populations. Our objective was to examine to what extent disparities occurred in prior authorizations for gynecologic oncology. Using electronic medical records, we performed a retrospective review of prior authorization occurrence during gynecologic oncology care and analyzed the association with patient race and insurance in a multivariate regression model. In this cohort of 1,406 patients treated at an academic gynecologic oncology practice, patients with Medicare Advantage and patients of Asian descent were more likely to experience prior authorization. Addressing insurance-mediate disparities, such as in the occurrence of prior authorization, may help reduce disparities in gynecologic cancer care.

Early hemodynamic assessment using NICOM in patients at risk of developing Sepsis immediately after emergency department triage.

BACKGROUND: One factor leading to the high mortality rate seen in sepsis is the subtle, dynamic nature of the disease, which can lead to delayed detection and under-resuscitation. This study investigated whether serial hemodynamic parameters obtained from a non-invasive cardiac output monitor (NICOM) predicts disease severity in patients at risk for sepsis. METHODS: Prospective clinical trial of the NICOM device in a convenience sample of adult ED patients at risk for sepsis who did not have obvious organ dysfunction at the time of triage. Hemodynamic data were collected immediately following triage and 2 hours after initial measurement and compared in two outcome groupings: (1) admitted vs. dehydrated, febrile, hypovolemicdischarged patients; (2) infectious vs. non-infectious sources. Receiver operator characteristic (ROC) curves were calculated to determine whether the NICOM values predict hospital admission better than a serum lactate. RESULTS: 50 patients were enrolled, 32 (64 %) were admitted to the hospital. Mean age was 49.5 (± 16.5) years and 62 % were female. There were no significant associations between changes in hemodynamic variables and patient disposition from the ED or diagnosis of infection. Lactate was significantly higher in admitted patients and those with infection (p = 0.01, p = 0.01 respectively). The area under the ROC [95 % Confidence Intervals] for lactate was 0.83 [0.64-0.92] compared to 0.59 [0.41-0.73] for cardiac output (CO), 0.68 [0.49-0.80] for cardiac index (CI), and 0.63 [0.36-0.80] for heart rate (HR) for predicting hospital admission. CONCLUSIONS: CO and CI, obtained at two separate time points, do not help with early disease severity differentiation of patients at risk for severe sepsis. Although mean HR was higher in those patients who were admitted, a serum lactate still served as a better predictor of patient admission from the ED.

Tuberculous peritonitis in children: Two case reports highlighting the important role of imaging.

Tuberculous peritonitis is an uncommon extrapulmonary form of Mycobacterium tuberculosis infection, frequently presenting with nonspecific and insidious symptoms. Diagnosis is therefore difficult, unsuspected, and often delayed, especially in the pediatric patient without an obvious history of exposure to the pathogen. This report presents a 9-year-old Hispanic girl and a 3-year-old African American boy presenting with nonspecific and insidious symptoms, such as abdominal pain, distention, and fever in whom computed tomography findings of peritoneal thickening and enhancement, high density ascites, lymphadenopathy, and bowel wall thickening acted as key components in establishing a final diagnosis of the condition. Computed tomography is an important clinical adjuvant in making this difficult diagnosis.