Assessment of treatment outcomes of interstitial cystitis with hydrodistention and bladder training by O'Leary-Sant Interstitial Cystitis Symptom and Problem Indices.

OBJECTIVE: To investigate whether the O'Leary-Sant Interstitial Cystitis Symptom Index (ICSI) and Interstitial Cystitis Problem Index (ICPI) is efficacy measure tool for interstitial Cystitis (IC) treatment with hydrodistention (HD) and bladder training (BT). MATERIALS AND METHODS: From January 2003 to March 2006, 108 consecutive IC patients were treated by HD and BT after HD. This study evaluated the efficacy of treatment with the specific questionnaire for IC, the ICSI and ICPI. Each patient filled out the questionnaire before HD and three months after HD and BT. The efficacy of the treatment was evaluated using the average scores of ICSI and ICPI. RESULTS: The mean ± margin of error, (95% confidence interval) of total scores of ICSI and ICPI were 13.89 ± 2.95, (13.33-14.45) and 12.51 ± 2.50, (12.04-12.98) before HD, respectively, and were 2.70 ± 1.16, (2.44-2.95) and 1.99 ± 1.27, (1.71-2.26) (all p < 0.005) three months after HD and BT, respectively. CONCLUSION: O'Leary-Sant ICSI and ICPI is not only a screening tool for IC but also a useful assessment tool for IC treatment outcomes.

Quality-initiated prophylactic antibiotic use in laparoscopic-assisted vaginal hysterectomy.

BACKGROUND: An evidence-based initiation of quality improvement activity for reducing the usage of prophylactic antibiotic in laparoscopic-assisted vaginal hysterectomy (LAVH) in a tertiary hospital. AIMS: The authors investigated whether single or multiple doses of cefazoline were more cost-effective in preventing postoperative infection associated with LAVH. METHODS: The study groups comprised of 310 patients who had undergone LAVH continuously in a medical centre. Patients were divided into two groups on the basis of whether they received a single dose or multiple doses (range: two to four doses) of cefazoline during the perioperative period. Postoperative infections such as pelvic cellulitis or abscess, vaginal cuff abscess, wound infection and urinary tract infection that occurred either during hospitalisation or within one month after discharge were observed and recorded. Incremental cost-effectiveness ratio (ICER) was calculated using the mean direct drug cost and the prophylactic effect of infection in both groups. RESULTS: The prophylactic effect of infection was similar in the single-dose group and the multiple-dose group (94.6% vs 93.9%, P = 0.986). The ICER was significantly lower in the single-dose group (153.3 vs 460.4, P < 0.001). CONCLUSIONS: The result revealed that a single dose of cefazoline is more cost-effective than multiple doses in the prevention of infection associated with LAVH. It fulfils the goal of cost minimisation and quality of care in today's environment of medical cost containment.

The physician as a factor in outpatient medical care after laparoscopically assisted vaginal hysterectomy: a multivariate analysis.

OBJECTIVE: To evaluate whether physician experience affects outpatient medical care utilization after laparoscopically assisted vaginal hysterectomy (LAVH). STUDY DESIGN: A total of 120 patients who underwent LAVH were included in the study; 84 underwent LAVH by 2 senior physicians, who had performed an average of 3 LAVHs per month for >6 years; 36 patients underwent LAVH by 3 junior physicians, who had performed an average of 1 case per month for < 3 years. Data were analyzed by the multiple linear regression model. The dependent variable was the number of outpatient visits within 3 months after discharge. The independent variables were patient age, parity, pelvic adhesions, chronic disease and physicians performing LAVH > 6 years. RESULTS: The patients in the 2 groups did not differ in age, parity, chronic disease or pelvic adhesions. The level of physician experience significantly influenced the mean number of outpatient visits after LAVH within 3 months. After controlling for patient characteristics, the mean number of outpatient visits after discharge within 3 months of LAVH performed by senior physicians with 6 years of experience was reduced (-1.98). CONCLUSION: LAVH performed by experienced physicians reduces the need for patients to seek postoperative outpatient medical care, thereby controlling medical costs incurred under the hospital global budget payment system. However, adding more variables to the multiple regression model, such as the socioeconomic status of patients, habits of seeking medical help, distance between home and hospital and relationship between patient and physician, may further explain the factors affecting outpatient medical care utilization.

Short course of prophylactic antibiotics in laparoscopically assisted vaginal hysterectomy.

OBJECTIVE: To evaluate whether a short course of prophylactic antibiotics is as efficacious as a longer course in laparoscopically assisted vaginal hysterectomy (LAVH). STUDY DESIGN: A total of 156 patients who underwent LAVH were included in the study; 82 received a long course of combined prophylactic antibiotics, and 74 received a short course, administered for < 24 hours during the perioperative period. The subjects were randomly assigned using a computer-generated schedule. Data regarding resource consumption were collected from the hospital's electronic database. Patient characteristics and medical care process data were collected from the patient charts. Student's t test was used to determine the statistical significance of the differences between continuous variables in the 2 groups of patients. The chi2 test was used to measure the statistical significance of differences between nominal variables in the 2 groups. RESULTS: The short course significantly influenced the number of injected vials of antibiotics, the antibiotic fee and the total admission fee. The average total admission fee decreased by 2.3% (p = 0.034), and the average antibiotic-fee dropped by 68.4% (p < 0.01). The average injected vials of cephalothin decreased by 4.3, and the vials of gentamycin decreased by 3.3 (p < 0.01). As for the rate of operative site infection and urinary tract infection during hospitalization and within 7 days of discharge, no statistical differences were found between the 2 groups (p = 0.735; p = 0.917). CONCLUSION: This pilot study revealed that a short course of prophylactic antibiotics was as efficacious as a longer course in preventing postoperative infection. It was also cost-effective.

The effect of physician experience on costs and clinical outcomes of laparoscopic-assisted vaginal hysterectomy: a multivariate analysis.

STUDY OBJECTIVE: To evaluate whether or not a physician's experience has an effect on costs and clinical outcomes of an implemented clinical pathway for laparoscopic-assisted vaginal hysterectomy (LAVH). DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: One hundred twenty women. INTERVENTION: LAVHs, 84 performed by senior physicians and 36 by junior physicians. MEASUREMENTS AND MAIN RESULTS: According to results of multiple linear regression analysis, after controlling for other independent variables, senior attending physicians, each with over 6 years of experience, managed to reduce all costs related to LAVH, operating time, and length of stay. Logistic regression analysis revealed no differences in the occurrence of intravenous fluid injection, antibiotic injection more than 2 days after surgery, and complications between physicians with and those without experience. Neither group had blood transfusions, patient mortality, or readmissions within 2 weeks of discharge. CONCLUSION: Physician experience reduces medical costs and maintains the quality of care in LAVH. We suggest regular training courses for less-experienced physicians in order to contain costs and maintain quality of care under the quota case-payment system.

Laparoscopy-assisted vaginal hysterectomy clinical pathway. A multivariate analysis of impact on costs and quality of care.

Numerous studies have demonstrated that a well-designed clinical pathway is an effective means of sustaining quality while controlling costs in the management of certain disease entities. We evaluated the impact that cost and medical quality have on the implementation of a clinical pathway for laparoscopy-assisted vaginal hysterectomy (LAVH). This retrospective study involved a sample of 124 patients who underwent LAVH in a medical center in central Taiwan. Patients were divided into two groups on the basis of whether they received treatment before or after implementation of the LAVH clinical pathway. The preclinical pathway group was comprised of 40 patients who underwent LAVH before clinical pathway implementation (May-December 1997). The clinical pathway group included 84 patients who underwent LAVH after implementation of the clinical pathway (January 1998-March 1999). In order to study the impact of the LAVH clinical pathway, patient characteristics were controlled by multiple linear regression. The results showed a significant reduction in cost, average length of hospital stay, and average duration of surgery and anesthesia (p < 0.01). Dependent nominal variables for clinical indicators like postoperative intravenous fluid and injection of antibiotics 48 h after surgery, and complications were analyzed by a logistic regression model. The results noted better control of antibiotic intravenous injection 48 h after surgery in the clinical pathway group (p = 0.03). The other indicators included delay of operation day, blood transfusion, patient mortality, and patients readmitted within 2 weeks. There was one operation day delay and one readmission within 2 weeks of discharge in the preclinical pathway group. Based on our results, the implementation of a clinical pathway for LAVH contains cost while maintaining quality of care, especially when the medical fees are paid under the case payment system.

A clinical pathway for laparoscopically assisted vaginal hysterectomy. Impact on costs and clinical outcome.

OBJECTIVE: To evaluate the cost of and clinical outcome of implementing a clinical pathway for laparoscopically assisted vaginal hysterectomy. STUDY DESIGN: A retrospective study of the case records of patients who underwent laparoscopically assisted vaginal hysterectomy before (May-December 1997) and after (January 1998-March 1999) implementation of a clinical pathway. Data regarding resource consumption and clinical outcome represented by 10 clinical indicators were collected. Student's t test and the chi 2 test were used, as appropriate. Statistical significance was set at P = .05. RESULTS: After implementation of the laparoscopically assisted vaginal hysterectomy clinical pathway, the average total fee decreased significantly, by 8.1% (P = .03), the average inpatient drug fee decreased by 50.6% (P < .01), and the laboratory fee dropped by 56.2% (P < .01). Furthermore, the length of hospital stay significantly decreased, from 6.90 to 4.08 days (P < .01); the average operation time decreased by 24.8% (P < .01); and the average anesthesia time decreased by 21.6% (P < .01). The pre-clinical pathway and post-clinical pathway complication rate did not differ statistically, but the rate of initiating intravenous antibiotic injections > 48 hours following surgery decreased by 76.2% in the clinical pathway group (P = .02). CONCLUSION: Implementation of a clinical pathway for laparoscopically assisted vaginal hysterectomy can improve health care outcomes by decreasing length of hospital stay and admission fees and by maintaining quality of care. The clinical pathway is a good policy for maintaining cost containment and high-quality patient care.