Investigating disparities in compliance of nursing pain reassessment for obstetrics and gynecology patients.

BACKGROUND: Racial and socioeconomic disparities, exacerbated during the COVID-19 pandemic and surrounding socio-political polarization, affect access to, delivery of, and patient perception of healthcare. Perioperatively, the bedside nurse carries the greatest responsibility of direct care, which includes pain reassessment, a metric tracked for compliance. OBJECTIVE: This study aimed to critically assess disparities in obstetrics and gynecology perioperative care and how these have changed since March 2020 using nursing pain reassessment compliance within a quality improvement framework. STUDY DESIGN: A retrospective cohort of 76,984 pain reassessment encounters from 10,774 obstetrics and gynecology patients at a large, academic hospital from September 2017 to March 2021 was obtained from Tableau: Quality, Safety and Risk Prevention platform. Noncompliance proportions were analyzed by patient race across service lines; a sensitivity analysis was performed excluding patients who were of neither Black nor White race. Secondary outcomes included analysis by patient ethnicity, body mass index, age, language, procedure, and insurance. Additional analyses were performed by temporally stratifying patients into pre- and post-March 2020 cohorts to investigate potential pandemic and sociopolitical effects on healthcare disparities. Continuous variables were assessed with Wilcoxon rank test, categorical variables were assessed with chi-squared test, and multivariable logistic regression analyses were performed (P<.05). RESULTS: Noncompliance proportions of pain reassessment did not differ significantly between Black and White patients as an aggregate of all obstetrics and gynecology patients (8.1% vs 8.2%), but greater differences were found within the divisions of Benign Subspecialty Gynecologic Surgery (Minimally Invasive Gynecologic Surgery + Urogynecology) (14.9% vs 10.70%; P=.03) and Maternal Fetal Medicine (9.5% vs 8.3%; P=.04). Black patients admitted to Gynecologic Oncology experienced lower noncompliance proportions than White patients (5.6% vs 10.4%; P<.01). These differences persisted after adjustment for body mass index, age, insurance, timeline, procedure type, and number of nurses attending to each patient with multivariable analyses. Noncompliance proportions were higher for patients with body mass index ≥35 kg/m2 within Benign Subspecialty Gynecology (17.9% vs 10.4%; P<.01). Non-Hispanic/Latino patients (P=.03), those ≥65 years (P<.01), those with Medicare (P<.01), and those who underwent hysterectomy (P<.01) also experienced greater noncompliance proportions. Aggregate noncompliance proportions differed slightly pre- and post-March 2020; this trend was seen across all service lines except Midwifery and was significant for Benign Subspecialty Gynecology after multivariable analysis (odds ratio, 1.41; 95% confidence interval, 1.02-1.93; P=.04). Though increases in noncompliance proportions were seen for non-White patients after March 2020, this was not statistically significant. CONCLUSION: Significant race, ethnicity, age, procedure, and body mass index-based disparities were identified in the delivery of perioperative bedside care, especially for those admitted to Benign Subspecialty Gynecologic Services. Conversely, Black patients admitted to Gynecologic Oncology experienced lower levels of nursing noncompliance. This may be in part be related to the actions of a Gynecologic Oncology nurse practioner at our institution who helps coordinate care for the division's postoperative patients. Noncompliance proportions increased after March 2020 within Benign Subspecialty Gynecologic Services. Although this study was not designed to establish causation, possible contributing factors include implicit or explicit biases regarding pain experience across race, body mass index, age, or surgical indication, discrepancies in pain management across hospital units, and downstream effects of healthcare worker burnout, understaffing, increased use of travelers, or sociopolitical polarization since March 2020. This study demonstrates the need for ongoing investigation of healthcare disparities at all interfaces of patient care and provides a way forward for tangible improvement of patient-directed outcomes by utilizing an actionable metric within a quality improvement framework.

The prevalence of hyperglycemia and its association with perioperative outcomes in gynecologic surgery: a retrospective cohort study.

BACKGROUND: Preoperative hyperglycemia has been associated with perioperative morbidity in general surgery patients. Additionally, preoperative hyperglycemia may indicate underlying impaired glucose metabolism. Thus, identification of preoperative hyperglycemia may provide an opportunity to mitigate both short-term surgical and long-term health risk. We aimed to study this phenomenon specifically in the gynecologic surgery population. Specifically, we aimed to evaluate the association between preoperative hyperglycemia and perioperative complications in gynecologic surgery patients and to characterize adherence to diabetes screening guidelines. METHODS: This retrospective cohort study included 913 women undergoing major gynecologic surgery on an enhanced recovery pathway from January 2018 to July 2019. The main exposure was day of surgery glucose ≥ 140 g/dL. Multivariate regression identified risk factors for hyperglycemia and composite and wound-specific complications. RESULTS: Sixty-seven (7.3%) patients were hyperglycemic. Diabetes (aOR 24.0, 95% CI 12.3-46.9, P < .001) and malignancy (aOR 2.3, 95% CI 1.2-4.5, P = .01) were associated with hyperglycemia. Hyperglycemia was not associated with increased odds of composite perioperative (aOR 1.3, 95% CI 0.7-2.4, P = 0.49) or wound-specific complications (aOR 1.1, 95% CI 0.7-1.5, P = 0.76). Of nondiabetic patients, 391/779 (50%) met the USPSTF criteria for diabetes screening; 117 (30%) had documented screening in the preceding 3 years. Of the 274 unscreened patients, 94 (34%) had day of surgery glucose levels suggestive of impaired glucose metabolism (glucose ≥ 100 g/dL). CONCLUSION: In our study cohort, the prevalence of hyperglycemia was low and was not associated with higher risk of composite or wound-specific complications. However, adherence to diabetes screening guidelines was poor. Future studies should aim to develop a preoperative blood glucose testing strategy that balances the low utility of universal glucose screening with the benefit of diagnosing impaired glucose metabolism in at-risk individuals.

Incidental urinary tract injury and the formation of vesicovaginal fistula at the time of hysterectomy for benign indications.

INTRODUCTION AND HYPOTHESIS: The association between hysterectomy type, laparoscopy use and vesicovaginal fistula (VVF) is currently unclear and would be useful to determine route of surgery and provide adequate patient counseling. The objective of this study was to evaluate the magnitude of association between the use of laparoscopic assistance, recognized intraoperative urinary tract injury and subsequent VVF repair and to quantify any differences in fistula repair and injury detection by hysterectomy type. Lastly, we sought to determine whether the type of hysterectomy is a risk factor for VVF repair independent of injury identification. METHODS: We performed a retrospective cohort study utilizing the Healthcare Cost and Utilization Project database examining benign hysterectomies performed in California, New York and Florida from 2005-2011. Multivariable logistic regression models were used to evaluate associations among hysterectomy type, reported injury and VVF. RESULTS: Of 581,395 eligible hysterectomies, urinary tract injuries occurred in 6702 patients (1.15%) and 640 patients developed VVF (0.11%). Patients with reported injury were 20-fold more likely to develop VVF than those without (OR = 20.6; 1.96% vs. 0.089% respectively). The association between reported injury and VVF development was stronger if laparoscopy was involved (OR = 30) than if it was not (OR = 17). Patients undergoing laparoscopic procedures were less likely to have injury reported (OR = 0.6) but more likely to undergo VVF repair (OR = 1.5). This association with VVF repair was independent of injury identification. Patients developing VVF were more likely to have undergone total abdominal hysterectomy compared to other hysterectomy types. CONCLUSIONS: Laparoscopy is an independent risk factor for the need for subsequent VVF repair, independent of hysterectomy type and presence of intraoperatively recognized urinary tract injury.

Assessment of practices in screening and treating women with bacteriuria.

INTRODUCTION: Evidence-based screening and treatment for bacteriuria is crucial to prevent increasing antibiotic resistance. The Infectious Disease Society of America (IDSA) previously released guidelines on the management of asymptomatic bacteriuria (ASB) and uncomplicated urinary tract infections (UTIs) in women. The study's objective was to assess physicians' practices in managing women with bacteriuria relative to these guideline recommendations. MATERIALS AND METHODS: Cross-sectional data from physicians were collected using an anonymous questionnaire. Multivariable logistic regression analyses identified independent predictors of adherence to guidelines. RESULTS: Data were collected from 260 physicians. Over half of physicians surveyed were unfamiliar with IDSA guidelines and overtreat ASB. Variables independently associated with overtreatment of ASB included a non-academic practice and practicing as an OBGYN. Nearly one third (30.1%) of physicians reported prescribing an antibiotic other than a recommended first-line agent for uncomplicated cystitis. Relative to internists, OBGYNs and urologists were more likely to prescribe a recommended first-line agent to women with uncomplicated cystitis. Of those who correctly selected a first-line agent, 29.8% prescribed a longer than recommended duration of therapy. IDSA guideline awareness was not associated with physicians' practices in managing women with bacteriuria. CONCLUSIONS: Most physicians surveyed were unfamiliar with guidelines related to managing ASB and uncomplicated UTIs in women, likely contributing to overscreening and overtreatment of ASB and the use of inappropriate antibiotic regimens in treating uncomplicated cystitis. However, optimal antibiotic prescribing was not associated with knowledge of IDSA guidelines, suggesting that guideline dissemination alone may not alter practice patterns among physicians managing women with bacteriuria.

Costs associated with instrument sterilization in gynecologic surgery.

BACKGROUND: With rising health care expenditures, hospitals must contain costs in ways that maintain high-quality patient care. A significant portion of perioperative costs are associated with materials and supplies; many reusable instruments on surgical trays go unused, which may account for significant annual excess processing costs. Reorganizing gynecologic trays to contain fewer instruments can result in significant cost savings. In the field of operative gynecology, there has been considerable attention to the various costs and surgical outcomes that are associated with hysterectomy performed in the abdominal, vaginal, and laparoscopic approaches; however, little research has been done on the cost differences that are associated with the reusable instruments that are used in these approaches. OBJECTIVES: This study aimed to identify the percent usage of instruments within gynecologic surgery and to identify differences by surgical approach. We further aimed to estimate the costs of sterilizing surgical instruments and estimate the excess costs that are associated with processing unused instruments. STUDY DESIGN: This was a single site observational study. Specific instruments that were used from incision to closure were recorded on operating room count sheets via direct observation of surgeries that were performed in the gynecologic operating rooms by a trained investigator. Cost data on instrument transportation, employee wages, and instrument replacement was obtained from institutional supply chain management. RESULTS: In total, 28 surgical cases (5 abdominal, 11 laparoscopic, and 12 vaginal) were analyzed, with an average of 2 hours 37 minutes operating room time and 5.4 instrument trays for each case. One hundred fifty trays were observed. Trays had an average of 38 instruments per tray (range, 1-141). Surgeons used an average of 36.7 instruments of 184 available instruments per case, for a usage rate of 20.5±2.8%. A significant difference was noted between usage rates in abdominal cases (26.3±6.5%) and vaginal cases (13.6±3.3%) but not between laparoscopic (19.4±4.2%) vs other approaches. Instrument use was correlated inversely with the number of instruments, with an average usage rate of 18.7% for trays that contained ≥10 instruments. Total annual institutional cost associated with instrument processing was estimated at $3.19 per instrument. CONCLUSION: Instrument usage in the gynecologic operating room is low, and the cost of processing instruments is significant. Availability of certain instruments is necessary for patient safety in the event of rare unexpected events. However, given that less than one quarter of the instruments pulled for surgery are used and that total processing cost per instrument exceeds $3.00, careful review of what instruments are included in each tray is warranted. Clearly, significant cost-savings are possible while concurrently balancing safety concerns.

Pelvic Floor Disorders Registry: Study Design and Outcome Measures.

Pelvic floor disorders affect up to 24% of adult women in the United States, and many patients with pelvic organ prolapse (POP) choose to undergo surgical repair to improve their quality of life. While a variety of surgical repair approaches and techniques are utilized, including mesh augmentation, there is limited comparative effectiveness and safety outcome data guiding best practice. In conjunction with device manufacturers, federal regulatory organizations, and professional societies, the American Urogynecologic Society developed the Pelvic Floor Disorders Registry (PFDR) designed to improve the quality of POP surgery by facilitating quality improvement and research on POP treatments. The PFDR will serve as a resource for surgeons interested in benchmarking and outcomes data and as a data repository for Food and Drug Administration-mandated POP surgical device studies. Provider-reported clinical data and patient-reported outcomes will be collected prospectively at baseline and for up to 3 years after treatment. All data elements including measures of success, adverse events, and surgeon characteristics were identified and defined within the context of the anticipated multifunctionality of the registry, and with collaboration from multiple stakeholders. The PFDR will provide a platform to collect high-quality, standardized patient-level data from a variety of nonsurgical (pessary) and surgical treatments of POP and other pelvic floor disorders. Data from this registry may be used to evaluate short- and longer-term treatment outcomes, patient-reported outcomes, and complications, as well as to identify factors associated with treatment success and failure with the overall goal of improving the quality of care for women with these conditions.

Differences in Patterns of Preoperative Assessment Between High, Intermediate, and Low Volume Surgeons When Performing Hysterectomy for Uterovaginal Prolapse.

OBJECTIVE: The aim of the study was to determine whether surgeon case volume is associated with preoperative evaluation of pelvic organ prolapse before a hysterectomy for uterovaginal prolapse including a complete objective evaluation of prolapse (Baden-Walker or Pelvic Organ Prolapse Quantification), an offer of nonsurgical options for therapy (pessary), and a preoperative assessment of urinary incontinence METHODS: We performed a multicenter retrospective review of hysterectomies done for uterovaginal prolapse at 4 hospital systems between January 1, 2008 and December 31, 2011. The number of hysterectomies per surgeon for 4 years was evaluated to establish low-volume (≤10 cases), intermediate-volume (11-49 cases), and high-volume (≥50 cases) groups. Rates of preoperative standardized prolapse evaluations, offer of pessary, and evaluation of stress urinary incontinence were determined by chart review of 15% of the hysterectomy cases. Adjustment was made in a logistic regression model for age, race, insurance status, and prolapse size. RESULTS: Three hundred one surgeons performed 4238 hysterectomies for prolapse during the study period. Rates of preoperative assessment by standardized pelvic examination differed between high-, intermediate-, and low-volume surgeons (91.2% vs. 61.3% vs. 48.8%, respectively), as did offer of a pessary (86.5% vs. 71.9% vs. 69.9%, respectively) and preoperative stress test for urinary incontinence (93.5% vs. 72.8% vs. 63.5%, respectively). Regression analysis revealed that high-volume surgeons were more likely than intermediate- or low-volume surgeons to perform a standardized pelvic examination, offer a pessary, or perform preoperative evaluation for urinary incontinence. CONCLUSIONS: High-volume surgeons were more likely than low-volume surgeons to perform a standardized preoperative pelvic examination, offer a pessary, and evaluate stress urinary incontinence.

Analysis of High-, Intermediate-, and Low-Volume Surgeons When Performing Hysterectomy for Uterovaginal Prolapse.

OBJECTIVES: To determine if surgeon volume is associated with differences in the use of apical colpopexy and cystoscopy and in the rate of intraoperative complications during hysterectomy for prolapse. METHODS: We performed a multicenter retrospective review of hysterectomies done for uterovaginal prolapse at 4 hospital systems between January 1, 2008, and December 31, 2011. Low (≤10 cases)-, intermediate (11-49 cases)-, and high (≥50 cases)-volume surgeon groups for the 4-year period were established a priori. Rates of concomitant colpopexy, cystoscopy, and intraoperative complications were determined by chart review for 15% of the cases. Multivariate logistic regression models adjusted for site and other clinical and patient variables were used to estimate associations between surgeon case volume and the use of apical colpopexy and cystoscopy and the rate of intraoperative complications. RESULTS: Three hundred one surgeons performed 4238 hysterectomies for prolapse during the study period. Six hundred thirty-eight patients were selected for chart review. The rates among high-, intermediate-, and low-volume surgeons for performing colpopexy were 85.2% versus 77.8% versus 61.1% (P < 0.001) and for cystoscopy were 96.8% versus 78.3% versus 74.7% (P < 0.001), respectively. Rates of intraoperative complications among the 3 groups were 4.4%, 11.6%, and 6.3% (P = 0.011), respectively. With adjustment, high-volume surgeons were more likely to do a colpopexy than low-volume surgeons (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1-3.1); however, the likelihood of colpopexy did not differ between high- and intermediate-volume surgeons (OR, 1.9; 95% CI, 0.84-4.3) or between intermediate- and low-volume surgeons (OR, 0.99; 95% CI, 0.50-2.0). High-volume surgeons were more likely than intermediate-volume (OR, 4.4; 95% CI, 1.7-11.0) and low-volume (OR, 4.5; 95% CI, 2.6-8.0) surgeons to do a cystoscopy. High-volume (OR, 0.42; 95% CI, 0.30-0.61) and low-volume (OR, 0.32; 95% CI, 0.15-0.66) surgeons were less likely than intermediate-volume surgeons to have intraoperative complications. The difference between high- and low-volume surgeons was not statistically significant (OR, 0.77; 95% CI, 0.5-1.2). CONCLUSIONS: Practice patterns with respect to hysterectomy for prolapse are complex when the use of colpopexy and cystoscopy and rates of intraoperative complications are analyzed by surgeon volume. The finding that intermediate-volume surgeons have the highest rates of intraoperative complications suggests a nonlinear relationship between surgeon volume and avoidance of injury.

Risk factors for the development of vesicovaginal fistula after incidental cystotomy at the time of a benign hysterectomy.

OBJECTIVE: We sought to evaluate risk factors for vesicovaginal fistula (VVF) after incidental cystotomy during benign hysterectomies. STUDY DESIGN: All benign hysterectomies between January 2000 and May 2004 were reviewed. Demographic and operative data were abstracted. Cystotomies were graded using the American Association for the Surgery of Trauma (AAST) system. Patients developing VVF after cystotomy were compared to those who did not. Categorical variables were analyzed with Fisher exact test while Student t test was used for continuous data. RESULTS: A total of 1317 benign hysterectomies were reviewed (46% abdominal, 48% vaginal, and 6% laparoscopically assisted vaginal). In all, 34 cystotomies occurred with 4 (11.7%) developing a VVF. Patients developing VVF were more likely to have an AAST grade V cystotomy (75% vs 7%; P = .004). Patients developing VVF trended toward greater tobacco use, larger uterine size, and more operative blood loss. CONCLUSION: Patients with an AAST grade V cystotomy are at increased risk for VVF formation.

Urinary retention following tension-free vaginal tape successfully treated by sacral neuromodulation.

Postoperative urinary retention following anti-incontinence surgery has traditionally been thought to be due to overcorrection. There is increasing evidence, however, that a neurogenic component may also play a significant role. This is a case report of a 72-year-old woman who developed delayed partial urinary retention following a tension-free vaginal tape which resolved with initial sacral neuromodulation.

Predicting uterine weight before hysterectomy: ultrasound measurements versus clinical assessment.

OBJECTIVE: The purpose of this study was to determine the most accurate method in estimating the preoperative uterine weight of enlarged nongravid uteri. STUDY DESIGN: We performed a retrospective review of 1238 patients who were premenopausal and underwent hysterectomy for benign indications between January 1993 and July 1999. Eight hundred and sixty-four patients were selected to include only those that had both a reported bimanual assessment of preoperative uterine size and an ultrasonography report with all 3 estimated uterine dimensions. Reported uterine sizes on bimanual examination were converted to clinical weight (CWT). Two different calculations were used to estimate uterine weight from ultrasound measurements (UWT 1 and 2). Actual uterine weights (AWT) in pathology reports were then compared with the findings of bimanual assessment and the calculated weights to determine which method is the best predictor of AWT. Simple linear regression analysis was used to measure and compare how closely the estimated weights predicted the actual weight. Predictive residuals sum of squares (PRESS) was then used to determine the best predictor of actual weight. RESULTS: After exploring the data using linear modeling, all 3 estimated weights were significantly correlated to the actual weight when compared, but PRESS scores showed that the clinical weight estimate was superior by far compared with the other 2. CONCLUSION: In this study, bimanual assessment was shown to be the most accurate method of preoperative uterine weight estimation. Ultrasound examination may not be routinely needed when deciding the route of hysterectomy based on estimated weight.