Racial disparities between measures of area deprivation and financial toxicity, and uterine volume in myomectomy patients.

BACKGROUND: At time of myomectomy, a surgical procedure to remove uterine fibroids, Black women tend to have larger uteri than White women. This makes Black patients less likely to undergo a minimally invasive myomectomy which has been shown to have less postoperative pain, less frequent postoperative fever and shorter length of stay compared to abdominal myomectomies. The associations between individual financial toxicity and community area deprivation and uterine volume at the time of myomectomy have not been investigated. METHODS: We conducted a secondary data analysis of patients with fibroids scheduled for myomectomy using data from a fibroid treatment registry in [location]. We used validated measures of individual-level Financial Toxicity (higher scores = better financial status) and community-level Area Deprivation (ADI, high scores = worse deprivation). To examine associations with log transformed uterine volume, we used linear regression clustered on race (Black vs. White). RESULTS: Black participants had worse financial toxicity, greater deprivation and larger uterine volumes compared with White participants. A greater Financial Toxicity score (better financial status) was associated with lower uterine volume. For every 10 unit increase in Financial Toxicity, the mean total uterine volume decreased by 9.95% (Confidence Interval [CI]: -9.95%, -3.99%). ADI was also associated with uterine volume. A single unit increase in ADI (worse deprivation) was associated with a 5.13% (CI: 2.02%, 7.25%) increase in mean uterine volume. CONCLUSION: Disproportionately worse Financial Toxicity and ADI among Black patients is likely due to structural racism - which now must be considered in gynecologic research and practice. TRIAL REGISTRATION: Not applicable.

Effects of Shared Decision Making on Opioid Prescribing After Hysterectomy.

OBJECTIVE: To evaluate the effects of shared decision making using a simple decision aid for opioid prescribing after hysterectomy. METHODS: We conducted a prospective quality initiative study including all patients undergoing hysterectomy for benign, nonobstetric indications between March 1, 2018, and July 31, 2018, at our academic institution. Using a visual decision aid, patients received uniform education regarding postoperative pain management. They were then educated on the department's guidelines regarding the maximum number of tablets recommended per prescription and the mean number of opioid tablets used by a similar cohort of patients in a previously published study at our institution. Patients were then asked to choose their desired number of tablets to receive on discharge. Structured telephone interviews were conducted 14 days after surgery. The primary outcome was total opioids prescribed before compared with after implementation of the decision aid. Secondary outcomes included opioid consumption, patient satisfaction, and refill requests after intervention implementation. RESULTS: Of 170 eligible patients, 159 (93.5%) used the decision aid (one patient who used the decision aid was subsequently excluded from the analysis owing to significant perioperative complications), including 110 (69.6%) laparoscopic, 40 (25.3%) vaginal, and eight (5.3%) abdominal hysterectomies. Telephone surveys were completed for 89.2% (n=141) of participants. Student's t-test showed that patients who participated in the decision aid (post-decision aid cohort) were discharged with significantly fewer oral morphine equivalents than patients who underwent hysterectomy before implementation of the decision aid (pre-decision aid cohort) (92±35 vs 160±81, P<.01), with no significant change in the number of requested refills (9.5% [n=15] vs 5.7% [n=14], P=.15). In the post-decision aid cohort, 76.6% of patients (n=121) chose fewer tablets than the guideline-allotted maximum. Approximately 76% of patients (n=102) reported having leftover tablets. CONCLUSION: This quality improvement initiative illustrates that a simple decision aid can result in a significant decrease in opioid prescribing without compromising patient satisfaction or postoperative pain management.

Comparison of Post-Cesarean Section Opioid Analgesic Requirements in Women With Opioid Use Disorder Treated With Methadone or Buprenorphine.

OBJECTIVE: Buprenorphine is a highly effective treatment for opioid use disorders, but its continuation in the perioperative setting remains controversial, unlike the accepted practice of perioperative methadone continuation. METHODS: We conducted a retrospective cohort study from 2006 to 2014 comparing post-cesarean section opioid analgesic requirements of women with opioid use disorders treated with methadone or buprenorphine. Preoperative, intraoperative, and postoperative opioid requirements (morphine equivalent dose [MED]), postoperative complications, and length of stay were compared between the methadone and buprenorphine groups. RESULTS: During the 9-year study period, there were 185 women treated with methadone (mean dose 93.7 mg, SD 2.6) and 88 women treated with buprenorphine (mean dose 16.1 mg, SD 7.8). There were no statistically significant differences in MED requirements in the methadone versus buprenorphine groups: preoperative MED (11.4 mg [SD 31.5] vs 20.0 mg [SD 15.1]; mean difference [MD] 8.6, 95% confidence interval [CI] -1.9, 19.1), intraoperative MED (3.5 mg [SD 6.6] vs 5.2 mg [SD 13.7]; MD 1.8, 95% CI -1.1, 4.6), and postoperative MED during hospitalization (97.7 mg [SD 65.6] vs 85.1 mg [SD 73.0]; MD -12.6, 95% CI -31.1, 5.8). There were no statistically significant differences in postoperative complications or length of stay. CONCLUSIONS: Our study suggests that buprenorphine treatment will not interfere more than methadone with pain management after a cesarean section with no significant differences in opioid analgesic requirements, postoperative complications, or length of hospital stay. Future studies should investigate the generalizability to other surgeries.

Determining a Learning Curve for Contained Hand Tissue Extraction: Perioperative Outcomes and Operative Time.

STUDY OBJECTIVE: To compare the operative time of contained hand tissue extraction with power morcellation and to quantify the learning curve required to develop this skill. DESIGN: A retrospective cohort study (Canadian Task Force classification II-3). SETTING: Lahey Hospital and Medical Center, a suburban academic tertiary care center serving a broad base of patients. PATIENTS: Eighty-eight women undergoing laparoscopic hysterectomy requiring morcellation or tissue extraction from 2012 through 2015. INTERVENTIONS: Power morcellation before the institution's ban on power morcellation and contained hand tissue extraction instituted in a response to the ban. MEASUREMENTS AND MAIN RESULTS: Data were collected to compare the operative time and perioperative outcomes of morcellation before discontinuation of the power morcellator and after adaptation of a contained hand tissue extraction protocol. The data were then used to determine a learning curve for the new procedure. Eighty-eight consecutive cases of laparoscopic hysterectomy requiring morcellation were identified during the study duration, with 46 patients undergoing power morcellation and 42 undergoing hand tissue extraction. The 2 groups were similar overall in body mass index (28.9 vs 29.5, p = .70), prior laparoscopy (28% vs 21%, p = .46) or laparotomy (39% vs 21%, p = .07), removal of the cervix (56% vs 86%, p < .01), and uterine weight (581 vs 628 g, p = .56). The hand tissue extraction group had an average operating room time of 170 minutes compared with 154 minutes (p = .08) for the power morcellation group. The 2 surgeons performed 32 and 10 hand tissue extractions, respectively, with a decrease in 0.7 and 3 minutes per case, respectively, over the course of 7 months (p = .3 and .6, respectively). CONCLUSION: Contained hand tissue extraction was similar to power morcellation in the total operative time. The learning curve of surgeons performing contained hand tissue extraction showed a nonsignificant trend toward improvement in the operative time with an increasing number of cases.

Caring for Pregnant Women with Opioid Use Disorder in the USA: Expanding and Improving Treatment.

PURPOSE OF THE REVIEW: Opioid use disorder in the USA is rising at an alarming rate, particularly among women of childbearing age. Pregnant women with opioid use disorder face numerous barriers to care, including limited access to treatment, stigma, and fear of legal consequences. This review of opioid use disorder in pregnancy is designed to assist health care providers caring for pregnant and postpartum women with the goal of expanding evidence-based treatment practices for this vulnerable population. RECENT FINDINGS: We review current literature on opioid use disorder among US women, existing legislation surrounding substance use in pregnancy, and available treatment options for pregnant women with opioid use disorder. Opioid agonist treatment (OAT) remains the standard of care for treating opioid use disorder in pregnancy. Medically assisted opioid withdrawal ("detoxification") is not recommended in pregnancy and is associated with high maternal relapse rates. Extended release naltrexone may confer benefit for carefully selected patients. Histories of trauma and mental health disorders are prevalent in this population; and best practice recommendations incorporate gender-specific, trauma-informed, mental health services. Breastfeeding with OAT is safe and beneficial for the mother-infant dyad. SUMMARY: Further research investigating options of OAT and the efficacy of opioid antagonists in pregnancy is needed. The US health care system can adapt to provide quality care for these mother-infant dyads by expanding comprehensive treatment services and improving access to care.