Reimbursement for Female-Specific Compared With Male-Specific Procedures Over Time.

OBJECTIVE: To evaluate whether per-procedure work relative value units (RVUs) have changed over time and to compare time-based compensation for female-specific procedures compared with male-specific procedures. METHODS: Using the National Surgical Quality Improvement Program files for 2015-2018, we compared operative time and RVUs for 12 pairs of sex-specific procedures. Procedures were matched to be anatomically and technically similar. Procedure-assigned RVUs in 2015 were compared with 1997. Procedure compensation was determined using median dollars per RVU provided in SullivanCotter's 2018 Physician Compensation and Productivity Survey. This was compared with specialty-specific McGraw-Hill per-RVU data from 1994. Statistical analysis was performed with chi-square and Kruskal-Wallis tests. RESULTS: A total of 12,120 patients underwent 6,217 male-specific procedures and 5,903 female-specific procedures. Male-specific procedures had a median (interquartile range) RVU of 25.2 (21.4-25.2), compared with 7.5 (7.5-23.4) for female-specific procedures (P<.001). Male-specific procedures were 79 minutes longer (median [interquartile range] 136 minutes [98-186] vs 57 minutes [25-125], P<.001). Female-specific procedures were reimbursed at a higher hourly rate (10.6 RVU/hour [7.2-16.2] vs 9.7 RVU/hour [7.4-12.8], P<.001). However, male-specific procedures were better reimbursed ($599/h [$457-790] vs $555/h [$377-843], P<.001). Overall, per-procedure RVUs for male-specific surgeries have increased 13%, whereas, for female-specific surgeries, per-procedure RVUs have increased 26%. Reimbursement per RVU for male-specific procedures has decreased 8% ($67.30 to $61.65), whereas for female-specific procedures it has increased 14% ($44.50 to $52.02). CONCLUSION: Increases in RVUs and specialty-specific compensation have resulted in more equitable reimbursement for female-specific procedures. However, even with these changes, there is a lower relative value of work, driven by specialty-specific compensation rates, for procedures performed for women-only compared with equivalent men-only procedures.

Discrepancies between author- and industry-reported disclosures of financial relationships at an annual gynecologic oncology research meeting.

OBJECTIVE: Trillions of dollars pass to physicians from industry-related businesses annually, leading to many opportunities for financial conflicts of interest. The Open Payments Database (OPD) was created to ensure transparency. We describe the industry relationships as reported in the OPD for presenters at the 2019 Society of Gynecologic Oncology (SGO) Annual Meeting and evaluate concordance between author disclosures of their financial interests and information provided by the OPD. METHODS: This is an observational, cross-sectional study. Disclosure data were collected from authors with oral and featured abstract presentations in the 2019 SGO annual conference. These disclosures were compared to data available for each author in the 2018 OPD, which included the amount and nature of industry payments. RESULTS: We examined the disclosures of 301 authors who met inclusion criteria. Of 161 authors who had disclosure statements on their presentations,147 reported "no disclosures," and 14 disclosed industry relationships. The remaining 140 did not list any disclosure information. Sixty percent (184/301) of authors had industry relationships in the 2018 OPD, including 173 of 287 (60.3%) of authors who either reported no disclosures or did not have disclosure data available in their presentations. These transactions totaled over 43 million USD from 122 different companies, with most payments (46%) categorized as "Research or Associated Research." Accurate disclosure reporting was associated with receiving higher payments or research payments, and being a presenting author. CONCLUSIONS: Most authors at the SGO annual conference did not correctly disclose their industry relationships when compared with their entries in the OPD.

Economic Analysis of Neoadjuvant Chemotherapy Versus Primary Debulking Surgery for Advanced Epithelial Ovarian Cancer Using an Aggressive Surgical Paradigm.

OBJECTIVES: Neoadjuvant chemotherapy (NACT) versus primary debulking surgery (PDS) for advanced epithelial ovarian cancer (AEOC) remains controversial in the United States. Generalizability of existing trial results has been criticized because of less aggressive debulking procedures than commonly used in the United States. As a result, economic evaluations using input data from these trials may not accurately reflect costs and outcomes associated with more aggressive primary surgery. Using data from an ongoing trial performing aggressive debulking, we investigated the cost-effectiveness and cost-utility of NACT versus PDS for AEOC. METHODS: A decision tree model was constructed to estimate differences in short-term outcomes and costs for a hypothetical cohort of 15,000 AEOC patients (US annual incidence of AEOC) treated with NACT versus PDS over a 1-year time horizon from a Medicare payer perspective. Outcomes included costs per cancer-related death averted, life-years and quality-adjusted life-years (QALYs) gained. Base-case probabilities, costs, and utilities were based on the Surgical Complications Related to Primary or Interval Debulking in Ovarian Neoplasms trial. Base-case analyses assumed equivalent survival; threshold analysis estimated the maximum survival difference that would result in NACT being cost-effective at $50,000/QALY and $100,000/QALY willingness-to-pay thresholds. Probabilistic sensitivity analysis was used to characterize model uncertainty. RESULTS: Compared with PDS, NACT was associated with $142 million in cost savings, 1098 fewer cancer-related deaths, and 1355 life-years and 1715 QALYs gained, making it the dominant treatment strategy for all outcomes. In sensitivity analysis, NACT remained dominant in 99.3% of simulations. Neoadjuvant chemotherapy remained cost-effective at $50,000/QALY and $100,000/QALY willingness-to-pay thresholds if survival differences were less than 2.7 and 1.4 months, respectively. CONCLUSIONS: In the short term, NACT is cost-saving with improved outcomes. However, if PDS provides a longer-term survival advantage, it may be cost-effective. Research is needed on the role of patient preferences in tradeoffs between survival and quality of life.

Cost effectiveness of neoadjuvant chemotherapy followed by interval cytoreductive surgery versus primary cytoreductive surgery for patients with advanced stage ovarian cancer during the initial treatment phase.

OBJECTIVE: Advanced stage epithelial ovarian cancer (AEOC) can be treated with either neoadjuvant chemotherapy (NACT) or primary cytoreductive surgery (PCS). Although randomized controlled trials show that NACT is non-inferior in overall survival compared to PCS, there may be improvement in short-term morbidity. We sought to investigate the cost-effectiveness of NACT relative to PCS for AEOC from the US Medicare perspective. METHODS: A cost-effectiveness analysis using a Markov model with a 7-month time horizon comparing (1) 3cycles of NACT with carboplatin and paclitaxel (CT), followed by interval cytoreductive surgery, then 3 additional cycles of CT, or (2) PCS followed by 6cycles of CT. Input parameters included probability of chemotherapy complications, surgical complications, treatment completion, treatment costs, and utilities. Model outcomes included costs, life-years gained, quality-adjusted life-years (QALYs) gained, and incremental cost-effectiveness ratios (ICER), in terms of cost per life-year gained and cost per QALY gained. We accounted for differences in surgical complexity by incorporating the cost of additional procedures and the probability of undergoing those procedures. Probabilistic sensitivity analysis (PSA) was performed via Monte Carlo simulations. RESULTS: NACT resulted in a savings of $7034 per patient with a 0.035 QALY increase compared to PCS; therefore, NACT dominated PCS in the base case analysis. With PSA, NACT was the dominant strategy more than 99% of the time. CONCLUSIONS: In the short-term, NACT is a cost-effective alternative compared to PCS in women with AEOC. These results may translate to longer term cost-effectiveness; however, data from randomized control trials continues to mature.

Risks and benefits of opportunistic salpingectomy during vaginal hysterectomy: a decision analysis.

BACKGROUND: Fallopian tubes are commonly removed during laparoscopic and open hysterectomy to prevent ovarian and tubal cancer but are not routinely removed during vaginal hysterectomy because of perceptions of increased morbidity, difficulty, or inadequate surgical training. OBJECTIVE: We sought to quantify complications and costs associated with a strategy of planned salpingectomy during vaginal hysterectomy. STUDY DESIGN: We created a decision analysis model using TreeAgePro. Effectiveness outcomes included ovarian cancer incidence and mortality as well as major surgical complications. Modeled complications included transfusion, conversion to laparotomy or laparoscopy, abscess/hematoma requiring intervention, ileus, readmission, and reoperation within 30 days. We also modeled subsequent benign adnexal surgery beyond the postoperative window. Those whose procedures were converted from a vaginal route were assumed to undergo bilateral salpingectomy, regardless of treatment group, following American College of Obstetricians and Gynecologists guidelines. Costs were gathered from published literature and Medicare reimbursement data, with internal cost data from 892 hysterectomies at a single institution used to estimate costs when necessary. Complication rates were determined from published literature and from 13,397 vaginal hysterectomies recorded in the National Surgical Quality Improvement Program database from 2008 through 2013. RESULTS: Switching from a policy of vaginal hysterectomy alone to a policy of routine planned salpingectomy prevents a diagnosis of ovarian cancer in 1 of every 225 women having surgery and prevents death from ovarian cancer in 1 of every 450 women having surgery. Overall, salpingectomy was a less expensive strategy than not performing salpingectomy ($7350.62 vs $8113.45). Sensitivity analysis demonstrated the driving force behind increased costs was the increased risk of subsequent benign adnexal surgery among women retaining their tubes. Planned opportunistic salpingectomy had more major complications than hysterectomy alone (7.95% vs 7.68%). Major complications included transfusion, conversion to laparotomy or laparoscopy, abscess/hematoma requiring intervention, ileus, readmission, and reoperation within 30 days. Therefore, routine salpingectomy results in 0.61 additional complications per case of cancer prevented and 1.21 additional complications per death prevented. A surgeon therefore must withstand an additional ∼3 complications to prevent 5 cancer diagnoses and ∼6 additional complications to prevent 5 cancer deaths. CONCLUSION: Salpingectomy should routinely be performed with vaginal hysterectomy because it was the dominant and therefore cost-effective strategy. Complications are minimally increased, but the trade-off with cancer prevention is highly favorable.

Clinical Benefits Associated With Medicaid Coverage Before Diagnosis of Gynecologic Cancers.

PURPOSE: Many low-income patients enroll in Medicaid at the time of cancer diagnosis, which improves survival outcomes. Medicaid enrollment before cancer diagnosis may confer additional benefits. Our objective was to compare stage at diagnosis and overall mortality between women with and without Medicaid enrollment before gynecologic cancer diagnosis. METHODS AND MATERIALS: Women younger than 65 years with a gynecologic cancer (2003 to 2008) were identified through the North Carolina Central Cancer Registry and linked to state Medicaid enrollment files. Those with and without Medicaid enrollment within 6 months before diagnosis were identified. Propensity matching was used to balance the exposure groups. Stage at diagnosis was evaluated by using logistic regression, and all-cause mortality was assessed with Cox proportional hazard models. RESULTS: Of 564 women, one half (n = 282) had prediagnosis Medicaid enrollment. Disease sites included the cervix (44%), uterus (25%), ovary (26%), and vulva/vagina (5%). More than one half (51%) of cancers were advanced stage. Women without prediagnosis Medicaid had an increased odds of advanced-stage disease (hazard ratio, 1.46; 95% CI, 1.03 to 2.05). Crude survival outcomes differed significantly between the groups; however, when adjusted for stage at diagnosis, lack of prediagnosis Medicaid coverage had a hazard ratio of 1.19 (95% CI, 0.92 to 1.53). CONCLUSION: Medicaid enrollment before gynecologic cancer diagnosis is associated with an earlier stage at presentation. Given the existence of a cervical cancer screening program in North Carolina and lack of Medicaid expansion, these data suggest that screening programs alone are not sufficient to counteract the delay in diagnosis that is common for uninsured individuals.

The limited utility of currently available venous thromboembolism risk assessment tools in gynecological oncology patients.

BACKGROUND: Use of risk assessment tools, such as the Caprini score or Rogers score, is recommended by national societies to stratify surgical patients by venous thromboembolism risk and guide prophylaxis. However, these tools were not developed in a gynecological oncology patient population, and their utility in this population is unknown. OBJECTIVE: The objective of the study was to examine the ability of both the Caprini and Rogers scores to stratify gynecological oncology patients by the risk of venous thromboembolism. STUDY DESIGN: Patients undergoing surgery for cervical, ovarian, uterine, vaginal, and vulvar cancers between 2008 and 2013 were identified from the National Surgical Quality Improvement Program Database using International Classification of Diseases, ninth revision, codes. The Caprini and Rogers scores were calculated for each patient based on the recorded demographic and procedure data. Venous thromboembolism events were recorded for 30 days postoperatively. Patients were categorized into risk groups based on the calculated Caprini and Rogers scores and the incidence of venous thromboembolism, and the 95% confidence interval was estimated for each of these groups. The relationship between the risk score and venous thromboembolism incidence was examined with Pearson's correlation coefficient. RESULTS: Of 17,713 patients, 1.8% developed a venous thromboembolism. No patients were classified by the Caprini score as low risk, 0.1% were moderate risk, 3.0% were higher risk (score 4), and 96.9% were highest risk (score ≥5). The Caprini score groupings did not correlate with venous thromboembolism. The high-risk group had a paradoxically higher incidence of venous thromboembolism of 2.5% compared with the highest-risk group, 1.7% (P = .40). However, when the highest-risk group of the Caprini score was substratified, it was highly correlated with venous thromboembolism (R(2) = 0.93). For the Rogers score, only 0.2% of patients were low risk (score <7), 36.9% were medium risk (score 7-10), and 63.0% were high risk (score >10). When the highest risk group of the Rogers score was substratified, it was also highly correlated with venous thromboembolism (R(2) = 0.99). CONCLUSION: Gynecological oncology patients score very high on current venous thromboembolism risk assessment models. The Caprini score is limited in its ability to discriminate relative venous thromboembolism risk among gynecological oncology patients because 97% are in the highest-risk category. Substratification of the highest-risk groups allows for relative venous thromboembolism risk stratification among gynecological oncology patients, suggesting that further evaluation of risk stratification is needed in gynecological oncology surgery.

The effect of distance traveled on disease outcomes in gestational trophoblastic neoplasia.

BACKGROUND: Gestational trophoblastic neoplasia is a rare gynecological malignancy often treated at tertiary referral centers. Patients frequently travel long distances to obtain care for gestational trophoblastic neoplasia, which may affect cancer outcomes in these patients. OBJECTIVE: We examined the association between distance traveled to obtain care and disease burden at time of presentation as well as recurrence. STUDY DESIGN: We performed a retrospective cohort analysis of all patients diagnosed with gestational trophoblastic neoplasia from January 1995 to June 2015 at a high-volume tertiary referral center. Patients were included if they met International Federation of Gynecology and Obstetrics 2000 criteria for postmolar gestational trophoblastic neoplasia or had choriocarcinoma, placental-site trophoblastic tumor, or epithelioid trophoblastic tumor. Sixty patients were identified. Disease burden at presentation was examined using both the World Health Organization prognostic score and International Federation of Gynecology and Obstetrics. Patients who traveled more than 50 miles were considered long-distance travelers based on previous literature on the effect of distance traveled on cancer outcomes. Demographic, clinical, and pathological data were obtained by chart review. Bivariable comparisons were performed using the χ(2) test or Fisher exact test for categorical variables. The t test or Wilcoxon rank-sum test was used to compare continuous variables when normally or not normally distributed. RESULTS: Most patients presented at stage I (61%) with low-risk gestational trophoblastic neoplasia (70%). Median distance to care was 40 miles (range, 4-384). Eighteen patients (30%) had no insurance and 42 (70%) had either private or public insurance. Patients traveling more than 50 miles for care were more likely to have high-risk gestational trophoblastic neoplasia (46% vs 19%, P = .03), but there was no difference in recurrence (13% vs 11%, P = .89). Patients with high-risk gestational trophoblastic neoplasia lived 63 miles farther (92 vs 28 miles, P < .001) than patients with low-risk gestational trophoblastic neoplasia. Long-distance travelers had a longer period between antecedent pregnancy and gestational trophoblastic neoplasia diagnosis (10 weeks vs 4.5 weeks, P = .009) and were more likely to receive multiagent chemotherapy (86% vs 61%, P = .03). CONCLUSION: In this cohort, long distance traveled to obtain care for gestational trophoblastic neoplasia was associated with an increased risk of presenting with high-risk disease and requiring multiagent chemotherapy for treatment. Patients with high-risk gestational trophoblastic neoplasia traveled nearly 100 miles to obtain care. There may be a delay in diagnosis in women traveling more than 50 miles to obtain care; however, we found no difference in recurrence risk for long-distance travelers.

Trainee participation and perioperative complications in benign hysterectomy: the effect of route of surgery.

BACKGROUND: Intraoperative trainee involvement in hysterectomy is common. However, the effect of intraoperative trainee involvement on perioperative complications depending on surgical approach is unknown. OBJECTIVE: To estimate the effect of intraoperative trainee involvement on perioperative complication after vaginal, laparoscopic, and abdominal hysterectomy for benign disease. METHODS: Patients undergoing laparoscopic, vaginal, or abdominal hysterectomy for benign disease from 2010 to 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Patients with and without trainee involvement were compared with regard to perioperative complications. Complications that occurred from the start of surgery to 30-days postoperatively were included. Perioperative complications were defined via the use of the validated Clavien-Dindo scale with ≥grade 3 complications defined as major and ≤grade 2 complications defined as minor. Major complications included myocardial infarction, pneumonia, venous thromboembolism, deep or organ space surgical-site infection, stroke, fascial dehiscence, unplanned return to the operating room, renal failure, cardiopulmonary arrest, sepsis, intubation greater than 48 hours, and death. Minor complications included urinary tract infection, blood transfusion, and superficial wound infection. To estimate the effect of trainee involvement depending on route of surgery, a stratified analysis was performed. Bivariable analysis and adjusted multivariable logistic regression were used. RESULTS: We identified 22,499 patients, of whom 42.1% had trainee participation. Surgical approaches were vaginal (22.7%), abdominal (47.1%), and laparoscopic (30.2%). The rate of major complication was 3.2%, and minor complication was 7.2%. In bivariable analysis, trainee involvement was associated with major complications in vaginal hysterectomy (3.3% vs 2.3%, P = .03), but not laparoscopic (3.0% vs 2.9%, P = .78) or abdominal hysterectomy (4.4% vs 3.6%, P = .07). Trainee involvement was also associated with minor complication in vaginal (7.3% vs 5.4%, P = .007), laparoscopic (5.9% vs 4.3%, P < .001), and abdominal hysterectomy (14.1% vs 9.2%, P < .001). In a multivariable analysis in which we adjusted for age, body mass index, medical comorbidity, American Society of Anesthesiologists score, and surgical complexity, the association between trainee involvement in vaginal hysterectomy and major complication persisted (adjusted odds ratio 1.45, 95% confidence interval 1.03-2.04); however, when operative time was added to the model, there was no longer an association between trainee involvement and major complication (adjusted odds ratio 1.26, 95% confidence interval 0.89-1.80). CONCLUSION: Surgical approach influences the relationship between trainee involvement and perioperative complication. Operative time is a key mediator of the relationship between trainee involvement and complication, and may be a modifiable risk factor.

Enhanced Recovery Pathways in Gynecology and Gynecologic Oncology.

IMPORTANCE: Enhanced recovery programs (ERPs) are considered standard of care across a variety of surgical disciplines, but ERPs have not been widely adopted in gynecology. OBJECTIVE: The aim of this study was to describe ERP principles and the role of ERPs in gynecology and gynecologic oncology. EVIDENCE ACQUISITION: Comprehensive literature search was performed using MEDLINE, the Cochrane Collaboration Database, and PubMed. RESULTS: Meta-analyses of a substantial number of randomized controlled trials have shown that implementation of ERP protocols is associated with decreased length of hospital stay, a decrease in rates of postoperative complication, decreased morbidity, and cost savings while preserving patient satisfaction and quality of life. CONCLUSIONS AND RELEVANCE: High-quality evidence exists for improved outcomes among patients in ERPs. Enhanced recovery programs save resources and costs across the health care system. As quality metrics and bundled payments increase in health care, ERPs will have increasing prominence.

A preoperative personalized risk assessment calculator for elderly ovarian cancer patients undergoing primary cytoreductive surgery.

OBJECTIVE: Cytoreductive surgery for ovarian cancer has higher rates of postoperative complication than neoadjuvant chemotherapy followed by surgery. If patients at high risk of postoperative complication were identified preoperatively, primary therapy could be tailored. Our objective was to develop a predictive model to estimate the risk of major postoperative complication after primary cytoreductive surgery among elderly ovarian cancer patients. METHODS: Patients who underwent primary surgery for ovarian cancer between 2005 and 2013 were identified from the National Surgical Quality Improvement Project. Patients were selected using primary procedure CPT codes. Major complications were defined as grade 3 or higher complications on the validated Claviden-Dindo scale. Using logistic regression, we identified demographic and clinical characteristics predictive of postoperative complication. RESULTS: We identified 2101 ovarian cancer patients of whom 35.9% were older than 65. Among women older than 65, the rate of major postoperative complication was 16.4%. Complications were directly associated with preoperative laboratory values (serum creatinine, platelets, white blood cell count, hematocrit), ascites, white race, and smoking status, and indirectly associated with albumin. Our predictive model had an area under receiver operating characteristic curve of 0.725. In order to not deny patients necessary surgery, we chose a 50% population rate of postoperative complication which produced model sensitivity of 9.8% and specificity of 98%. DISCUSSION: Our predictive model uses easily and routinely obtained objective preoperative factors to estimate the risk of postoperative complication among elderly ovarian cancer patients. This information can be used to assess risk, manage postoperative expectations, and make decisions regarding initial treatment.