Rural disparities in surgical care from gynecologic oncologists among Midwestern ovarian cancer patients.

OBJECTIVE: Up to one-third of women with ovarian cancer in the United States do not receive surgical care from a gynecologic oncologist specialist despite guideline recommendations. We aim to investigate the impact of rurality on receiving surgical care from a specialist, referral to a specialist, and specialist surgery after referral, and the consequences of specialist care. METHODS: We utilized a retrospective cohort created through an extension of standard cancer surveillance in three Midwestern states. Multivariable adjusted logistic regression was utilized to assess gynecologic oncologist treatment of women 18-89 years old, who were diagnosed with primary, histologically confirmed, malignant ovarian cancer in 2010-2012 in Kansas, Missouri and Iowa by rurality. RESULTS: Rural women were significantly less likely to receive surgical care from a gynecologic oncologist specialist (adjusted odds ratio (OR) 0.37, 95% confidence interval (CI) 0.24-0.58) and referral to a specialist (OR 0.37, 95% CI 0.23-0.59) compared to urban women. There was no significant difference in specialist surgery after a referral (OR 0.56, 95% CI 0.26-1.20). Rural women treated surgically by a gynecologic oncologist versus non-specialist were more likely to receive cytoreduction and more complete tumor removal to ≤1 cm. CONCLUSION: There is a large rural-urban difference in receipt of ovarian cancer surgery from a gynecologic oncologist specialist (versus a non-specialist). Disparities in referral rates contribute to the rural-urban difference. Further research will help define the causes of referral disparities, as well as promising strategies to address them.

Canadian cost-effectiveness model of BRCA-driven surgical prevention of breast/ovarian cancers compared to treatment if cancer develops.

OBJECTIVES: To assess the cost effectiveness from a Canadian perspective of index patient germline BRCA testing and then, if positive, family members with subsequent risk-reducing surgery (RRS) in as yet unaffected mutation carriers compared with no testing and treatment of cancer when it develops. METHODS: A patient level simulation was developed comparing outcomes between two groups using Canadian data. Group 1: no mutation testing with treatment if cancer developed. Group 2: cascade testing (index patient BRCA tested and first-/second-degree relatives tested if index patient/first-degree relative is positive) with RRS in carriers. End points were the incremental cost-effectiveness ratio (ICER) and budget impact. RESULTS: There were 29,102 index patients: 2,786 ovarian cancer and 26,316 breast cancer (BC). Using the base-case assumption of 44 percent and 21 percent of women with a BRCA mutation receiving risk-reducing bilateral salpingo-oophorectomy and risk-reducing mastectomy, respectively, testing was cost effective versus no testing and treatment on cancer development, with an ICER of CAD 14,942 (USD 10,555) per quality-adjusted life-year (QALY), 127 and 104 fewer cases of ovarian and BC, respectively, and twenty-one fewer all-cause deaths. Testing remained cost effective versus no testing at the commonly accepted North American threshold of approximately CAD 100,000 (or USD 100,000) per QALY gained in all scenario analyses, and cost effectiveness improved as RRS uptake rates increased. CONCLUSIONS: Prevention via testing and RRS is cost effective at current RRS uptake rates; however, optimization of uptake rates and RRS will increase cost effectiveness and can provide cost savings.

Risk-reducing Bilateral Salpingo-oophorectomy: Assessing the Incidence of Occult Ovarian Cancer and Surgeon Adherence to Recommended Practices.

STUDY OBJECTIVE: This study aimed to determine the incidence of ovarian cancer diagnosed at the time of risk-reducing bilateral salpingo-oophorectomy in a large cohort of patients with a BRCA mutation. In addition, we aimed to determine the adherence to the recommended practices for performing a risk-reducing bilateral salpingo-oophorectomy as described by the American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncology. We sought to determine if adherence differed by the type of training (i.e., gynecologic oncologists vs benign gynecologists). DESIGN: Descriptive, retrospective analysis. SETTING: Academic medical center. PATIENTS: Two hundred sixty-nine patients with a known BRCA mutation. INTERVENTIONS: Prophylactic risk-reducing bilateral salpingo-oophorectomy performed either by a gynecologic oncologist or a benign gynecologist between July 2007 and September 2018. MEASUREMENTS AND MAIN RESULTS: Among 269 patients who underwent risk-reducing bilateral salpingo-oophorectomies, 220 procedures were performed by gynecologic oncologists, and 49 were performed by benign gynecologists. Washings were not performed in 5% of the procedures performed by gynecologic oncologists and 37% of the procedures performed by benign gynecologists (p <.001). Complete serial sectioning of the adnexa was not performed in 12% of the procedures performed by oncologists, and 13% of the procedures performed by benign gynecologists (p = .714). There were 8 cases (2.9%) of tubal or ovarian cancer diagnosed within this cohort. Of these cases, only 3 (1.1%) were diagnosed at the time of surgery and met the criteria for conversion to a staging procedure. CONCLUSION: Because the incidence of ovarian cancer diagnosis at the time of risk-reducing bilateral salpingo-oophorectomy is low and is often not diagnosed at the time of surgery owing to the presence of only microscopic disease, it may not be necessary for gynecologic oncologists to exclusively perform these procedures. However, this study also revealed that when this procedure is performed by benign gynecologic surgeons, some of the recommended practices are not routinely followed. If general gynecologic surgeons are to routinely perform risk-reducing bilateral salpingo-oophorectomies, it is important to promote better adherence to these practices.

Uterus at a price: Disability insurance and hysterectomy.

Taiwanese Labor, Government Employee, and Farmer Insurance programs provide 5 to 6 months of salary to enrollees who undergo hysterectomies or oophorectomies before their 45th birthday. These programs create incentives for more and earlier treatments, referred to as inducement and timing effects. Using National Health Insurance data between 1997 and 2011, we estimate these effects on surgery hazards by difference-in-difference and bunching-smoothing polynomial methods. For Government Employee and Labor Insurance, inducement is 11-12% of all hysterectomies, and timing 20% of inducement. For oophorectomies, both effects are insignificant. Enrollees' behaviors are consistent with rational choices. Each surgery qualifies an enrollee for the same benefit, but oophorectomy has more adverse health consequences than hysterectomy. Induced hysterectomies increase benefit payments and surgical costs, at about the cost of a mammogram and 5 pap smears per enrollee.

Inappropriate oophorectomy at time of benign premenopausal hysterectomy.

OBJECTIVE: We assessed rates of oophorectomy during benign hysterectomy around the release of the American College of Obstetricians and Gynecologists 2008 practice bulletin on prophylactic oophorectomy, and evaluated predictors of inappropriate premenopausal oophorectomy. METHODS: A cross-sectional administrative database analysis was performed utilizing the California Office of Statewide Health Planning Development Patient Discharge Database for years 2005 to 2011. After identifying all premenopausal women undergoing hysterectomy for benign conditions, International Classification of Diseases (ICD)-9 diagnosis codes were reviewed to create a master list of indications for oophorectomy. We defined appropriate oophorectomy as cases with concomitant coding for ovarian cyst, breast cancer susceptibility gene carrier status, and other diagnoses. Using patient demographics and hospital characteristics to predict inappropriate oophorectomy, a logistic regression model was created. RESULTS: We identified 57,776 benign premenopausal hysterectomies with oophorectomies during the period studied. Of the premenopausal oophorectomies, 37.7% (21,783) were deemed "inappropriate" with no documented reason for removal. The total number of premenopausal inpatient hysterectomies with oophorectomy decreased yearly (12,227/y in 2005 to 5,930/y in 2011). However, the percentage of inappropriate oophorectomies remained stable. In multivariate analysis, Hispanic and African American ethnicity/race associated with increased odds of inappropriate oophorectomy (P < 0.001). Urban and at low Medi-Cal utilization hospitals showed increased odds of inappropriate oophorectomy. CONCLUSIONS: In premenopausal women undergoing benign hysterectomy, over one-third undergo oophorectomy without an appropriate indication documented. The rate of inappropriate oophorectomy in California has not changed since the 2008 American College of Obstetricians and Gynecologists guidelines. Whereas the absolute number of inpatient hysterectomies for benign indications has decreased, our work suggests persistent utilization of oophorectomy in premenopausal women, despite well-documented long-term adverse health implications.

PREVALENCE AND TYPES OF GENDER-AFFIRMING SURGERY AMONG A SAMPLE OF TRANSGENDER ENDOCRINOLOGY PATIENTS PRIOR TO STATE EXPANSION OF INSURANCE COVERAGE.

OBJECTIVE: Transgender individuals now have many options for medical intervention, including gender-affirmation surgeries. However, it is unknown how common it is for transgender individuals to undergo these surgeries. The purpose of this cross-sectional study was to assess the prevalence of gender-affirming surgeries among transgender patients in 2015, which was immediately prior to insurance changes that made gender-affirming surgery more affordable for Massachusetts residents. METHODS: A retrospective chart review of 99 transgender patients was performed at the Endocrinology Clinic at Boston Medical Center, an urban safety net hospital. The records for 99 transgender subjects who received treatment between 2004-2015, including 28 transmen and 71 transwomen, were examined. The outcome measures were the types of medical interventions chosen by transgender patients, which included hormone therapy, chest surgery, gonadectomy, genital surgery, and facial surgery. RESULTS: Thirty-five percent of subjects had undergone at least one gender-affirming surgery. Transmen were more likely to have had surgery than transwomen (54% vs. 28%). Twenty-five percent of patients had chest surgery, 13% had genital surgery or gonadectomy, and 8% had facial surgery. CONCLUSION: In 2015, a majority of transgender endocrinology clinic patients had not undergone any type of gender-affirmation surgery. Among those who did elect to have a surgery, genital surgery or gonadectomy were uncommon. The low rate of surgery among this sample of transgender patients may be attributable to the financial cost, lack of interest in surgery, or that genital surgery is not a high priority for transgender individuals relative to surgery to change visible features such as face and chest. Abbreviation: HT = hormone therapy.

Associations of Premenopausal Hysterectomy and Oophorectomy With Breast Cancer Among Black and White Women: The Carolina Breast Cancer Study, 1993-2001.

Black women experience higher rates of hysterectomy than other women in the United States. Although research indicates that premenopausal hysterectomy with bilateral oophorectomy decreases the risk of breast cancer in black women, it remains unclear how hysterectomy without ovary removal affects risk, whether menopausal hormone therapy use attenuates inverse associations, and whether associations vary by cancer subtype. In the population-based, case-control Carolina Breast Cancer Study of invasive breast cancer in 1,391 black (725 cases, 666 controls) and 1,727 white (939 cases, 788 controls) women in North Carolina (1993-2001), we investigated the associations of premenopausal hysterectomy and oophorectomy with breast cancer risk. Compared with no history of premenopausal surgery, bilateral oophorectomy and hysterectomy without oophorectomy were associated with lower odds of breast cancer (for bilateral oophorectomy, multivariable-adjusted odds ratios = 0.60, 95% confidence interval: 0.47, 0.77; for hysterectomy without oophorectomy, multivariable-adjusted odds ratios = 0.68, 95% confidence interval: 0.55, 0.84). Estimates did not vary by race and were similar for hormone receptor-positive and hormone receptor-negative cancers. Use of estrogen-only menopausal hormone therapy did not attenuate the associations. Premenopausal hysterectomy, even without ovary removal, may reduce the long-term risk of hormone receptor-positive and hormone receptor-negative breast cancers. Varying rates of hysterectomy are a potentially important contributor to differences in breast cancer incidence among racial/ethnic groups.

Effect of Regional Hospital Competition and Hospital Financial Status on the Use of Robotic-Assisted Surgery.

IMPORTANCE: Despite the lack of efficacy data, robotic-assisted surgery has diffused rapidly into practice. Marketing to physicians, hospitals, and patients has been widespread, but how this marketing has contributed to the diffusion of the technology remains unknown. OBJECTIVE: To examine the effect of regional hospital competition and hospital financial status on the use of robotic-assisted surgery for 5 commonly performed procedures. DESIGN, SETTING, AND PARTICIPANTS: A cohort study of 221 637 patients who underwent radical prostatectomy, total nephrectomy, partial nephrectomy, hysterectomy, or oophorectomy at 1370 hospitals in the United States from January 1, 2010, to December 31, 2011, was conducted. The association between hospital competition, hospital financial status, and performance of robotic-assisted surgery was examined. MAIN OUTCOMES AND MEASURES: The association between hospital competition was measured with the Herfindahl-Hirschman Index (HHI), hospital financial status was estimated as operating margin, and performance of robotic-assisted surgery was examined using multivariate mixed-effects regression models. RESULTS: We identified 221 637 patients who underwent one of the procedures of interest. The cohort included 30 345 patients who underwent radical prostatectomy; 20 802, total nephrectomy; 8060, partial nephrectomy; 134 985, hysterectomy; and 27 445, oophorectomy. Robotic-assisted operations were performed for 20 500 (67.6%) radical prostatectomies, 1405 (6.8%) total nephrectomies, 2759 (34.2%) partial nephrectomies, 14 047 (10.4%) hysterectomies, and 1782 (6.5%) oophorectomies. Use of robotic-assisted surgery increased for each procedure from January 2010 through December 2011. For all 5 operations, increased market competition (as measured by the HHI) was associated with increased use of robotic-assisted surgery. For prostatectomy, the risk ratios (95% CIs) for undergoing a robotic-assisted procedure were 2.20 (1.50-3.24) at hospitals in moderately competitive markets and 2.64 (1.84-3.78) for highly competitive markets compared with noncompetitive markets. For hysterectomy, patients at hospitals in moderately (3.75 [2.26-6.25]) and highly (5.30; [3.27-8.57]) competitive markets were more likely to undergo a robotic-assisted surgery. Increased hospital profitability was associated with use of robotic-assisted surgery only for partial nephrectomy in facilities with medium-high (1.67 [1.13-2.48]) and high (1.50 [0.98-2.29]) operating margins. With analysis limited to patients treated at a hospital that had performed robotic-assisted surgery, there was no longer an association between competition and use of robotic-assisted surgery. CONCLUSIONS AND RELEVANCE: Patients undergoing surgery in a hospital in a competitive regional market were more likely to undergo a robotic-assisted procedure. These data imply that regional competition may influence a hospital's decision to acquire a surgical robot.

Stopping ovarian cancer screening in BRCA1/2 mutation carriers: effects on risk management decisions & outcome of risk-reducing salpingo-oophorectomy specimens.

OBJECTIVE: Ovarian cancer screening (OCS) for BRCA1/2 mutation carriers was stopped in our family cancer clinic in 2009 because of its ineffectiveness. The study objective was to investigate the effect of stopping OCS on the timing and uptake of risk-reducing salpingo-oophorectomy (RRSO) and on the percentage of occult cancers in the specimens. METHODS: 419 BRCA1/2 mutation carriers were recruited between January 1999 and June 2013. Uptake, timing and the outcome of the RRSO specimens before stopping OCS (period I) were compared to those after stopping OCS (period II). RESULTS: The percentage of women undergoing RRSO within the recommended age range increased from 81% to 95%. Receiving DNA test results in period II independently predicted a shorter time interval to RRSO (hazard ratio: 2.48, 95% confidence interval: 1.81-3.39). The incidence of detecting occult cancers in RRSO specimens before and after stopping OCS was 1.3% and 1.8%, respectively, and was not statistically significantly different. CONCLUSIONS: The presentation of risk management options to women may influence their decision. The increased patient awareness of the ineffectiveness of OCS could have led to a higher percentage of women undergoing RRSO and doing so more often within the recommended age range.

Factors influencing same-day hospital discharge and risk factors for readmission after robotic surgery in the gynecologic oncology patient population.

STUDY OBJECTIVE: To determine the factors that allow for a safe outpatient robotic-assisted minimally invasive gynecologic oncology surgery procedure. DESIGN: Retrospective chart review (Canadian Task Force classification II-1). SETTING: University hospital. PATIENTS: All patients (140) undergoing robotic-assisted minimally invasive surgery with the gynecologic oncology service from January 1, 2013, to December 31, 2013. INTERVENTIONS: Risk factors for unsuccessful discharge within 23 hours of surgery and same-day discharge were assessed using logistic regression models. MEASUREMENTS AND MAIN RESULTS: All patients were initially scheduled for same-day discharge. The outpatient surgery group was defined by discharge within 23 hours of the surgery end time, and a same-day surgery subgroup was defined by discharge before midnight on the day of surgery. One hundred fifteen (82.1%) were successfully discharged within 23 hours of surgery, and 90 (64.3%) were discharged the same day. The median hospital stay was 5.3 hours (range, 1-48 hours). Unsuccessful discharge within 23 hours was associated with a preoperative diagnosis of lung disease and intraoperative complications; unsuccessful same-day discharge was associated with older age and later surgery end time. Only 2 patients (1.4%) were readmitted to the hospital within 30 days of surgery. CONCLUSIONS: Outpatient robotic-assisted minimally invasive surgery is safe and feasible for most gynecologic oncology patients and appears to have a low readmission rate. Older age, preoperative lung disease, and later surgical end time were risk factors for prolonged hospital stay. These patients may benefit from preoperative measures to facilitate earlier discharge.

Comparative effectiveness of robotically assisted compared with laparoscopic adnexal surgery for benign gynecologic disease.

OBJECTIVE: To perform a population-based analysis to compare the complications and cost of laparoscopic and robotically assisted adnexal surgery. METHODS: A nationwide database was used to analyze the use and outcomes of robotically assisted adnexal surgery from 2009 to 2012. Multivariable mixed effects regression models were developed to examine predictors of use of robotic surgery. After propensity score matching, complications and cost were compared between robotically assisted and laparoscopic surgery. RESULTS: Eighty-seven thousand five hundred fourteen women were identified. From 2009 to 2012, performance of robotic-assisted oophorectomy increased from 3.5% (95% confidence interval [CI] 3.2-3.8%) to 15.0% (95% CI 14.4-15.6%), whereas robotically assisted cystectomy rose from 2.4% (95% CI 2.0-2.7%) to 12.9% (95% CI 12.2-13.5%). The overall complication rate was 7.1% (95% CI 4.0-10.2%) for robotically assisted compared with 6.0% (95% CI 2.9-9.1%) for laparoscopic oophorectomy (odds ratio [OR] 1.20, 95% CI 1.00-1.45; P=.052). Robotic-assisted oophorectomy was associated with a higher rate of intraoperative complications (3.4% compared with 2.1%, OR 1.60, 95% CI 1.21-2.13). The overall complication rate was 3.7% (95% CI -0.8 to 8.2%) after robotically assisted compared with 2.7% (95% CI -1.8 to 7.2%) for laparoscopic cystectomy (OR 1.38, 95% CI 0.95-1.99). The intraoperative complication rate was higher for robotically assisted cystectomy (2.0% compared with 0.9%, OR 2.40, 95% CI 1.31-4.38). Compared with laparoscopy, robotically assisted oophorectomy was associated with $2,504 (95% CI $2,356-2,652) increased total costs and robotically assisted cystectomy $3,310 (95% CI $3,082-3,581) higher costs. CONCLUSION: Use of robotically assisted adnexal surgery increased rapidly. Compared with laparoscopic surgery, robotically assisted adnexal surgery is associated with substantially greater costs and a small, but statistically significant, increase in intraoperative complications.

The effect of neighborhood-level socioeconomic status on racial differences in ovarian cancer treatment in a population-based analysis in Chicago.

BACKGROUND: Less than half of women with ovarian cancer and blacks specifically receive therapy adherent to National Comprehensive Cancer Network (NCCN) guidelines. The purpose is to assess the effect of neighborhood-level socioeconomic status (SES) on black-white treatment differences in a population-based analysis in a highly-segregated community. METHODS: Illinois State Cancer Registry data for invasive epithelial ovarian cancer cases diagnosed in Cook County, IL in non-Hispanic white (NHW) or black (NHB) women from 1998 to 2009 was analyzed. As few women receive NCCN-adherent care, variables were constructed to assess extent of treatment, including receipt of: 1) debulking surgery; 2) any surgery; 3) multi-agent chemotherapy; and 4) any chemotherapy. Two measures (concentrated affluence and disadvantage) were used to estimate neighborhood-level SES. Multivariable logistic regression was used to compute odds ratios (OR) and 95% confidence intervals (95% CI), with generalized linear mixed models to account for hierarchical data. RESULTS: 2766 (81.0%) NHW and 647 (19.0%) NHB women were diagnosed. Adjusting for covariates, NHB were less likely to receive debulking surgery (OR: 0.39; 95% CI: 0.30-0.50), any surgery (OR: 0.38; 95%CI: 0.29-0.49), multi-agent chemotherapy (OR: 0.56; 95% CI: 0.45-0.71) and any chemotherapy (OR: 0.58; 95% CI: 0.45-0.74). Concentrated affluence but not disadvantage was significant in final models for multi-agent and any chemotherapy, but not debulking or any surgery. CONCLUSIONS: Results identify black-white differences consistent across treatments that persist despite adjustment for neighborhood-level SES. IMPACT: Results advance inequality awareness beyond "ideal" NCCN-adherent care, indicating inequality exists in delivery of even the most basic oncologic care.

Adapting the coping in deliberation (CODE) framework: a multi-method approach in the context of familial ovarian cancer risk management.

OBJECTIVE: To test whether the coping in deliberation (CODE) framework can be adapted to a specific preference-sensitive medical decision: risk-reducing bilateral salpingo-oophorectomy (RRSO) in women at increased risk of ovarian cancer. METHODS: We performed a systematic literature search to identify issues important to women during deliberations about RRSO. Three focus groups with patients (most were pre-menopausal and untested for genetic mutations) and 11 interviews with health professionals were conducted to determine which issues mattered in the UK context. Data were used to adapt the generic CODE framework. RESULTS: The literature search yielded 49 relevant studies, which highlighted various issues and coping options important during deliberations, including mutation status, risks of surgery, family obligations, physician recommendation, peer support and reliable information sources. Consultations with UK stakeholders confirmed most of these factors as pertinent influences on deliberations. Questions in the generic framework were adapted to reflect the issues and coping options identified. CONCLUSIONS: The generic CODE framework was readily adapted to a specific preference-sensitive medical decision, showing that deliberations and coping are linked during deliberations about RRSO. PRACTICE IMPLICATIONS: Adapted versions of the CODE framework may be used to develop tailored decision support methods and materials in order to improve patient-centred care.

Factors influencing uptake and timing of risk reducing salpingo-oophorectomy in women at risk of familial ovarian cancer: a competing risk time to event analysis.

OBJECTIVE: To evaluate factors affecting uptake of risk-reducing salpingo-oophorectomy (RRSO) over time in women at high-risk of familial ovarian cancer. DESIGN: Prospective observational cohort. SETTING: Tertiary high-risk familial gynaecological cancer clinic. POPULATION/SAMPLE: New clinic attendees between March 2004 and November 2009, fulfilling the high-risk criteria for the UK Familial Ovarian Cancer Screening Study. METHODS: Risk management options discussed included RRSO and ovarian surveillance. Outcome data were analysed from a bespoke database. The competing risk method was used to model the cumulative incidence function (CIF) of RRSO over time, and the sub-hazard ratio (SHR) was used to assess the strength of the association of variables of interest with RRSO. Gray's test was used to evaluate the difference in CIF between two groups and multivariable competing risk regression analysis was used to model the cumulative probabilities of covariates on the CIF. RESULTS: Of 1133 eligible women, 265 (21.4%) opted for RRSO and 868 (69.9%) chose screening. Women undergoing RRSO were older (49 years, interquartile range 12.2 years) than those preferring screening (43.4 years, interquartile range 11.9 years) (P < 0.0005). The CIF for RRSO at 5 years was 0.55 (95% CI 0.45-0.64) for BRCA1/2 carriers and 0.22 (95% CI 0.19-0.26) for women of unknown mutation status (P < 0.0001); 0.42 (95% CI 0.36-0.47) for postmenopausal women (P < 0.0001); 0.29 (95% CI 0.25-0.33) for parity ≥1 (P = 0.009) and 0.47 (95% CI 0.39-0.55) for a personal history of breast cancer (P < 0.0001). Variables of significance from the regression analysis were: a BRCA1/2 mutation (SHR 2.31, 95% CI 1.7-3.14), postmenopausal status (SHR 2.16, 95% CI 1.62-2.87)) and a personal history of breast cancer (SHR 1.5, 95% CI 1.09-2.06). CONCLUSIONS: Decision-making is a complex process and women opt for surgery many years after initial risk assessment. BRCA carriers, postmenopausal women and women who had breast cancer are significantly more likely to opt for preventative surgery.

[Rating the quality of care offered to women who underwent hysterectomy]. / Valoración de la calidad de la atención ofrecida a mujeres a quienes se realizó histerectomía.

BACKGROUND: In recent years emerged as a primary need, the evaluation of the services offered to get better quality in them. Health systems are subject to these assessments. OBJECTIVE: To assess the quality of care provided to patients who underwent hysterectomy, since the reference of the family physician, until discharge by the gynecologist. We analyzed the diagnostic results in the short and long-term, patient satisfaction and gynecologist satisfaction, regarding the conditions for offering services. PATIENTS AND METHOD: Retrospective study including 118 patients who underwent hysterectomy and were analyzed the following aspects: history, diagnoses and outcomes. Cross-sectional surveys were also conducted to obtain the satisfaction of patients and the physicians who performed the surgeries. RESULTS: The satisfaction of patients was confirmed, in contrast to the opinion of gynecologists who expressed dissatisfaction with the resources they have. There was discrepancy between diagnosis, planned surgery and the procedure performed, however, the clinical results were adequate. CONCLUSIONS: At present, any institution should periodically evaluate the services it provides to implement measures and procedures commensurate with their population and resources and invite users to participate in internal decision making and provide the opportunity to become an evaluator to generate a culture of self-improvement and continuous improvement in all involved.

Hysterectomy in Germany: a DRG-based nationwide analysis, 2005-2006.

BACKGROUND: Hysterectomy is among the more common surgical procedures in gynecology. The aim of this study was to calculate population-wide rates of hysterectomy across Germany and to obtain information on the different modalities of hysterectomy currently performed in German hospitals. This was done on the basis of nationwide DRG statistics (DRG = diagnosis-related groups) covering the years 2005-2006. METHODS: We analyzed the nationwide DRG statistics for 2005 and 2006, in which we found 305 015 hysterectomies. Based on these data we calculated hysterectomy rates for the female population. We determined the indications for each hysterectomy with an algorithm based on the ICD-10 codes, and we categorized the operations on the basis of their OPS codes (OPS = Operationen- und Prozedurenschlüssel [Classification of Operations and Procedures]). RESULTS: The overall rate of hysterectomy in Germany was 362 per 100 000 person-years. 55% of hysterectomies for benign diseases of the female genital tract were performed transvaginally. Bilateral ovariectomy was performed concomitantly in 23% of all hysterectomies, while 4% of all hysterectomies were subtotal. Hysterectomy rates varied considerably across federal states: the rate for benign disease was lowest in Hamburg (213.8 per 100 000 women per year) and highest in Mecklenburg-West Pomerania (361.9 per 100 000 women per year). CONCLUSION: Hysterectomy rates vary markedly from one region to another. Moreover, even though recent studies have shown that bilateral ovariectomy is harmful to women under 50 who undergo hysterectomy for benign disease, it is still performed in 4% of all hysterectomies for benign indications in Germany.

[Genetic predisposition to breast and ovarian cancer: importance of test results]. / Prédisposition génétique aux cancers du sein et de l'ovaire: importance des résultats des tests.

Oncogenetic consultations and predictive BRCA1/2 testing are intertwined processes and the specific impact of these genetic tests if performed alone through direct-to-consumer offers remains unknown. Noteworthy, the expectations of patients vary with their own status, whether they are affected or not by breast cancer at the time genetic testing is performed. The prescription of genetic tests for BCRA mutations has doubled in France between 2003 and 2009. There is a consensus on the fact that genetic results disclosure led to a significant increase in the knowledge and understanding that the patients have of the genetic risk and also changed the medical follow-up of these patients. Evaluating the psychological burden of tests disclosure did not reveal any major distress in patients who are followed by high-quality multidisciplinary teams. Longitudinal cohorts studies have now evaluated the perception and behaviour of these patients, and observed sociodemographic as well as geographic and psychosocial differences both in the acceptation of prophylactic strategies such as surgery, and time to surgery.

Analysis of contemporary trends in access to high-volume ovarian cancer surgical care.

BACKGROUND: Positive volume-outcome relationships exist for cancers treated with technically complex surgery, including ovarian cancer. However, contemporary patterns of primary surgical care for ovarian cancer according to hospital and surgeon case volume remain poorly defined. METHODS: The Maryland Health Service Cost Review Commission database was accessed for annual hospital and surgeon primary ovarian cancer surgical case volume for 2001-2008 and evaluated for statistically significant trends in access to high-volume surgical care compared with the earlier period for 1990-2000. chi(2) and logistic regression analyses were used to evaluate for significant trends in case volume distribution over time as well as factors associated with access to high-volume care. RESULTS: Overall, 2,475 primary ovarian cancer operations were performed by 472 surgeons at 43 hospitals. There was a statistically significant increase in the proportion of cases performed at high-volume centers from 22.8% in 1990-2000 to 61.1% in 2001-2008 (odds ratio = 5.30, 95% confidence interval = 4.68-6.00, P < .0001), while low-volume hospital case distribution decreased from 49.6 to 31.3%. Access to high-volume surgeons increased from 34.5% in 1990-2000 to 64.5% in 2001-2008 (odds ratio = 3.44, 95% confidence interval = 3.06-3.87, P < .0001), while the proportion of cases performed by low-volume surgeons decreased from 56.3 to 28.9%. After controlling for other variables, high-volume surgeons were significantly more likely to perform ovarian cancer surgery that included hysterectomy and staging/cytoreductive surgical procedures. CONCLUSIONS: The proportions of ovarian cancer patients undergoing primary surgery at high volume centers and by high-volume surgeons increased statistically significantly from 1990-2000 to 2001-2008. Further investigation is necessary to determine factors contributing to this favorable trend.

Factors associated with undergoing bilateral salpingo-oophorectomy at the time of hysterectomy for benign conditions.

OBJECTIVE: To identify possible factors associated with undergoing bilateral salpingo-oophorectomy (BSO) at the time of hysterectomy among women with benign conditions. METHODS: This was a cross-sectional analysis using the 2005 Nationwide Inpatient Sample. Women aged 18 years or older who underwent hysterectomy with BSO or hysterectomy only for a benign condition were included. We examined a broad range of factors associated with undergoing BSO in multivariable analyses. RESULTS: Fifty-two percent of 461,321 hysterectomies included BSO, with a mean age of 49 years compared with 43 years in the hysterectomy-only group (P<.001). The odds of BSO were two times higher in the Midwest and South and 1.67 times higher in the West as compared with the Northeast (P<.001). Women who were uninsured or had Medicaid were more likely to undergo BSO compared with those with private insurance (odds ratio 1.86, 95% confidence interval 1.14-3.04 for "no charge/charity," odds ratio 1.21, 95% confidence interval 1.08-1.35 for Medicaid) Although BSO was more common among white women than African-American, Latina, and Asian women (P<.001), lower income was associated with BSO among African-American and white women only, not among Asian and Latina women (P=.007 for test for interaction). BSO was eight times as likely with a laparoscopic hysterectomy and 12 times as likely with an abdominal hysterectomy compared with a vaginal approach (P<.001). Women who had endometriosis, pelvic infection, or an ovarian cyst were more likely to undergo BSO (P<.001) compared with women who did not have these diagnoses. CONCLUSION: There is significant nationwide variation in the practice of BSO. Age, route of hysterectomy, and diagnosis at surgery affect BSO rates. Nonclinical factors such as race or ethnicity, insurance status, income, and geographic location are also associated with BSO practice. LEVEL OF EVIDENCE: II.