The Effect of Diagnosis-Related Group Payment System on Quality of Care in the Field of Obstetrics and Gynecology among Korean Tertiary Hospitals.

PURPOSE: To examine changes in clinical practice patterns following the introduction of diagnosis-related groups (DRGs) under the fee-for-service payment system in July 2013 among Korean tertiary hospitals and to evaluate its effect on the quality of hospital care. MATERIALS AND METHODS: Using the 2012-2014 administrative database from National Health Insurance Service claim data, we reviewed medical information for 160400 patients who underwent cesarean sections (C-secs), hysterectomies, or adnexectomies at 43 tertiary hospitals. We compared changes in several variables, including length of stay, spillover, readmission rate, and the number of simultaneous and emergency operations, from before to after introduction of the DRGs. RESULTS: DRGs significantly reduced the length of stay of patients undergoing C-secs, hysterectomies, and adnexectomies (8.0±6.9 vs. 6.0±2.3 days, 7.4±3.5 vs. 6.4±2.7 days, 6.3±3.6 vs. 6.2±4.0 days, respectively, all p<0.001). Readmission rates decreased after introduction of DRGs (2.13% vs. 1.19% for C-secs, 4.51% vs. 3.05% for hysterectomies, 4.77% vs. 2.65% for adnexectomies, all p<0.001). Spillover rates did not change. Simultaneous surgeries, such as colpopexy and transobturator-tape procedures, during hysterectomies decreased, while colporrhaphy during hysterectomies and adnexectomies or myomectomies during C-secs did not change. The number of emergency operations for hysterectomies and adnexectomies decreased. CONCLUSION: Implementation of DRGs in the field of obstetrics and gynecology among Korean tertiary hospitals led to reductions in the length of stay without increasing outpatient visits and readmission rates. The number of simultaneous surgeries requiring expensive operative instruments and emergency operations decreased after introduction of the DRGs.

Large-Scale Implementation of Structured Reporting of Adnexal Masses on Ultrasound.

PURPOSE: The aim of this article is to describe the development and implementation of structured reporting of adnexal mass findings on pelvic ultrasound in a large integrated health care delivery system. METHODS: A structured reporting system that includes standardized terminology for describing adnexal masses on ultrasound was developed by a multidisciplinary team of radiologists, gynecologists, and gynecologic oncologists on the basis of literature review and internal data. The system uses a reporting template that requires radiologists to assign abnormal adnexal masses to one of five possible categories on the basis of standardized criteria: category 0, 1, 2, or 3 for masses <10 cm, to reflect increasing concern for malignancy, and category X for masses >10 cm. Unique predefined hashtags were linked to each category to enable electronic data extraction, and a hard stop feature was installed that prevents reports from being finalized without a category designation. In 2014, after a 3-month pilot study, large-scale implementation was supported by an educational campaign consisting of web-based conferences, e-mail announcements, and local presentations. Clinical management recommendations on the basis of category and other clinical factors were provided in a separate practice resource for clinicians. RESULTS: Analysis of adherence revealed that 93% of the approximately 12,000 reports describing abnormal adnexal masses in 2016 included category designations. Feedback from referring providers via an anonymous survey indicated high levels of satisfaction with reports. CONCLUSIONS: Multidisciplinary collaboration and leveraging of technology enabled large-scale implementation of structured reporting with high levels of adherence among radiologists and improved satisfaction among referring providers.

Diagnostic accuracy and cost-effectiveness of different strategies to triage women with adnexal masses: a prospective study.

OBJECTIVE: Transvaginal sonography (TVS) and serum biomarkers are used widely in clinical practice to triage women with adnexal masses, but the effectiveness of current biomarkers is weak. The aim of this study was to determine the best method of diagnosing patients with adnexal masses, in terms of diagnostic accuracy and economic costs, among four triage strategies: (1) the International Ovarian Tumor Analysis group's simple rules (SR) for interpretation of TVS with subjective assessment (SA) by an experienced ultrasound operator when TVS results are inconclusive (referred to hereafter as SR ± SA), (2) SR ± SA and cancer antigen 125 (CA 125), (3) SR ± SA and human epididymis protein 4 (HE4) and (4) SR ± SA and the risk of malignancy algorithm (ROMA). Our main hypothesis was that the addition of the biomarkers to SR ± SA could improve triaging of these patients in terms of diagnostic accuracy (i.e. malignant vs benign). As secondary analyses, we estimated the cost effectiveness of the four strategies and the diagnostic accuracy of SR ± SA at the study hospitals. METHODS: Between February 2013 and January 2015, 447 consecutive patients who were scheduled for surgery for an adnexal mass at the S. Anna and Mauriziano Hospitals in Turin were enrolled in this multicenter prospective cohort study. Preoperative TVS was performed and preoperative CA 125 and HE4 levels were measured. Pathology reports were used to assess the diagnostic accuracy of the four triage strategies and the cost of each strategy was calculated. RESULTS: A total of 391 patients were included in the analysis: 57% (n = 221) were premenopausal and 43% (n = 170) were postmenopausal. The overall prevalence of malignancy was 21%. SR were conclusive in 89% of patients and thus did not require SA; the overall performance of SR ± SA showed a sensitivity of 82%, specificity of 92% and positive and negative predictive values and positive and negative likelihood ratios of 74%, 95%, 10.5 and 0.19, respectively. In premenopausal women, mean cost among the four triage strategies varied from €36.41 for SR ± SA to €70.12 for SR ± SA + ROMA. The addition of biomarkers to SR ± SA showed no diagnostic advantage compared with SR ± SA alone and was more costly. Among postmenopausal women, mean cost among the four triage strategies varied from €39.52 for SR ± SA to €73.23 for SR ± SA + ROMA. Among these women, SR ± SA + CA 125 and SR ± SA + ROMA had a higher sensitivity (both 92% (95% CI, 85-99%)) than SR ± SA (81% (95% CI, 71-91%)), but SR ± SA had a higher specificity (84% (95% CI, 77-91%)). SR ± SA + CA 125 and SR ± SA + ROMA improved diagnostic accuracy, each diagnosing a third more malignant adnexal masses. In postmenopausal women, compared with SR ± SA alone, SR ± SA + CA 125 showed a net reclassification improvement (NRI) of 28.8% at an extra cost of €13.00, while the extra cost for SR ± SA + ROMA was €33.71, with a comparable gain, in terms of NRI, as that of SR ± SA + CA 125. CONCLUSIONS: In our study sample, SR ± SA seems to be the best strategy to triage women with adnexal masses for surgical management. Among postmenopausal women, SR ± SA + CA 125 increased the NRI at a reasonable extra cost. Our data do not justify the use of HE4 and ROMA in the initial triage of women with adnexal masses. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Port site infiltration of local anesthetic after laparoendoscopic single site surgery for benign adnexal disease

OBJECTIVE: To determine whether local bupivacaine injection into the incision site after gynecologic laparoendoscopic single site surgery (LESS) improves postoperative pain. METHODS: This prospective cohort study included consecutive 158 patients who had LESS for benign adnexal disease from March 2013 to December 2015. Chronologically, 82 patients (March 2013 to August 2014) received no bupivacaine (group 1) and 76 (August 2014 to December 2015) received a bupivacaine block (group 2). For group 2, 10 mL 0.25% bupivacaine was injected into the 20 mm-incision site through all preperitoneal layers after LESS completion. Primary outcome is postoperative pain score using the visual analog scale (VAS). RESULTS: There was no difference in clinicopathological characteristics between the groups. Operating time (expressed as median [range], 92 [55–222] vs. 100 [50–185] minutes, P=0.137) and estimated blood loss (50 [30–1,500] vs. 125 [30–1,000] mL, P=0.482) were similar between the groups. Post-surgical VAS pain scores after 3 hours (3.5 [2–6] vs. 3.5 [2–5], P=0.478), 6 to 8 hours (3.5 [2–6] vs. 3 [1–8], P=0.478), and 16 to 24 hours (3 [2–4] vs. 3 [1–7], P=0.664) did not differ between groups. CONCLUSION: Bupivacaine injection into the trocar site did not improve postoperative pain after LESS. Randomized trials are needed to evaluate the benefits of local bupivacaine anesthetic for postoperative pain reduction.

Pregnancy outcomes after emergent laparoscopic surgery for acute adnexal disorders at less than 10 weeks of gestation.

AIM: To report our experience with pregnancy outcomes after emergent laparoscopic surgery for acute adnexal disorders at less than 10 weeks of gestation when surgical intervention could be more invasive to intrauterine pregnancy. METHODS: Gasless multiport laparoscopic surgery or transumbilical laparoendoscopic single-site surgery was performed with securing of the surgical view by the abdominal wall-lift method. Intraoperative autologous blood salvage and donation was performed in cases associated with significant hemoperitoneum. RESULTS: Six cases of ovarian bleeding with ruptured corpus luteal cyst, three cases of adnexal torsion with corpus luteal cyst, and one case each of ruptured heterotopic ampullary pregnancy and heterotopic tubal stump isthmic pregnancy after salpingectomy were managed. For ruptured corpus luteal cyst, hemostasis was achieved by removal of hematoma followed by suturing. For adnexal torsion, detorsion with cyst aspiration was performed in two cases and detorsion alone was performed in one case. For ruptured heterotopic ampullary pregnancy, unilateral salpingectomy was performed. For ruptured heterotopic tubal stump isthmic pregnancy after salpingectomy, removal of the expelled villous tissue followed by hemostatic coagulation was performed. In five cases associated with massive hemoperitoneum, intraoperative autologous blood salvage and donation were performed to avoid homologous blood transfusion. After surgery, seven live births were achieved, while two cases of biochemical pregnancy loss and a case of complete miscarriage were noted. CONCLUSION: Although miscarriage could be a significant concern in the perioperative period, gasless laparoscopic surgery appeared to be feasible for management of acute adnexal disorders at less than 10 weeks of gestation.

Disappearance of an adnexal mass with Saam acupuncture: a case report.

We report the case of a 30-year-old woman with a right adnexal mass resembling an ovarian cyst who declined diagnostic laparoscopy and requested treatment with acupuncture. The patient was treated with Saam acupuncture for 14 weeks. After treatment, transvaginal sonography revealed disappearance of the right adnexal mass. No adverse effects of the Saam acupuncture treatment were reported.

[Spectrum of ocular and adnexal disease treated with acupuncture].

Data studies are adopted to do systematic analysis on diseases described in theses on effect observation of acupuncture in Chinese Bio-Medical Literature and Retrieval System during 1978 to 2005. Numbers (frequency) of the disease mentioned are counted so as to analyze the acupuncture spectrum of ocular and adnexal diseases. The result indicates that the number of acupuncture spectrum of ocular and adnexal diseases is 31, which includes 22 diseases and 5 symptoms defined with western medicine as well as 4 syndromes of TCM. Thus, it can be concluded that ocular and adnexal disease is the one of the major component of acupuncture spectrums, and it is worth to popularize and apply that acupuncture for illness of this kind in clinic.

Spectrum of ocular and adnexal disease treated with acupuncture / 中国针灸

Data studies are adopted to do systematic analysis on diseases described in theses on effect observation of acupuncture in Chinese Bio-Medical Literature and Retrieval System during 1978 to 2005. Numbers (frequency) of the disease mentioned are counted so as to analyze the acupuncture spectrum of ocular and adnexal diseases. The result indicates that the number of acupuncture spectrum of ocular and adnexal diseases is 31, which includes 22 diseases and 5 symptoms defined with western medicine as well as 4 syndromes of TCM. Thus, it can be concluded that ocular and adnexal disease is the one of the major component of acupuncture spectrums, and it is worth to popularize and apply that acupuncture for illness of this kind in clinic.

Selenium supplementation reduced oxidative DNA damage in adnexectomized BRCA1 mutations carriers.

Some experimental evidence suggests that BRCA1 plays a role in repair of oxidative DNA damage. Selenium has anticancer properties that are linked with protection against oxidative stress. To assess whether supplementation of BRCA1 mutation carriers with selenium have a beneficial effect concerning oxidative stress/DNA damage in the present double-blinded placebo control study, we determined 8-oxodG level in cellular DNA and urinary excretion of 8-oxodG and 8-oxoGua in the mutation carriers. We found that 8-oxodG level in leukocytes DNA is significantly higher in BRCA1 mutation carriers. In the distinct subpopulation of BRCA1 mutation carriers without symptoms of cancer who underwent adnexectomy and were supplemented with selenium, the level of 8-oxodG in DNA decreased significantly in comparison with the subgroup without supplementation. Simultaneously in the same group, an increase of urinary 8-oxoGua, the product of base excision repair (hOGG1 glycosylase), was observed. Therefore, it is likely that the selenium supplementation of the patients is responsible for the increase of BER enzymes activities, which in turn may result in reduction of oxidative DNA damage. Importantly, in a double-blinded placebo control prospective study, it was shown that in the same patient groups, reduction in cancer incidents was observed. Altogether, these results suggest that BRCA1 deficiency contributes to 8-oxodG accumulation in cellular DNA, which in turn may be a factor responsible for cancer development in women with mutations, and that the risk to developed breast cancer in BRCA1 mutation carriers may be reduced in selenium-supplemented patients who underwent adnexectomy.

Laparoscopic sterilization under local anesthesia.

Fifty-two women were sterilized through laparoscope under local anesthesia with Filshieclips. The majority (94%) were satisfied with the method. During the operation three patients were submitted to general anesthesia due to adhesions (two) and inadequate relaxation (one). Admission period and sick leave were reduced to a minimum.

PIP: Between January, 1991, and May, 1992, gynecologists at Glostrup County Hospital in Denmark performed laparoscopic sterilization (Filshie clips) under local anesthesia on 52 women 25-42 years old. 11 of the women had previously undergone an abdominal operation, especially appendectomy or cesarean section. At the same time of laparoscopic sterilization, 9 women and 2 underwent curettage and legal abortion, respectively. The physicians had to resort to general anesthesia in 3 cases due to discomfort in 1 patient and pelvic adhesions in the other 2 cases. As of 12 months after laparoscopic sterilization, none of the women had conceived. 44 (94%) of the 46 women who responded to the questionnaire were very satisfied with the operation. 96% of those satisfied with the operation would recommend it to others. 40 women were discharged from the hospital on the same day as the laparoscopic sterilization. The others were discharged the day after the operation. Sick leave after discharge ranged from 0-8 days, with the mean being 2-3 days. The 2 women who had undergone simultaneous legal abortion had the most severe discomfort. The physicians recommend that simultaneous legal abortion should not be conducted under local anesthesia. Local anesthesia for sterilization would likely benefit patients with cardial or pulmonary symptoms and those who fear general anesthesia. Based on the high acceptance rate of laparoscopic sterilization under local anesthesia and the need to cut back on costs when possible, the physicians recommend that this method be used more often.