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.

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.

Laparoscopy versus laparotomy in the management of benign unilateral adnexal masses.

STUDY OBJECTIVE: To compare operative characteristics and charges of laparoscopy and laparotomy for women with a benign unilateral adnexal mass 7 cm or less in greatest diameter. DESIGN: Historical cohort study (Canadian Task Force classification II-2). SETTING: Clinic department of obstetrics and gynecology. PATIENTS: One hundred six women. INTERVENTION: Unilateral oophorectomy or unilateral salpingo-oophorectomy performed by laparoscopy or laparotomy. MEASUREMENTS AND MAIN RESULTS: When patients were compared on an intent to treat basis, no differences in greatest mass diameter (4.2 vs 4.5 cm), patient age (49.2 vs 46.4 yrs), or body mass index (26.0 vs 27.0 kg/m(2)) were found between 62 laparoscopies and 44 laparotomies. Laparoscopy was associated with longer operating times (94 vs 63 min, p <0.001), shorter hospital stay (1.6 vs 2.5 days, p <0.001), higher sterile supply charges ($1031 vs $40, p <0.001), and lower hospital room charges ($672 vs $1351, p <0.0001). No significant differences in total hospital charges, febrile morbidity, or transfusion rates were identified. CONCLUSION: Patient charges and early operative morbidity are similar for laparoscopy and laparotomy. Therefore, patient and surgeon preference should be a primary consideration when deciding on operative approach in carefully selected women with a unilateral adnexal mass.

Safe and cost-effective laparoscopic removal of adnexal masses.

STUDY OBJECTIVE: To evaluate laparoscopic removal of adnexal masses using a plastic bag to avoid peritoneal spillage. DESIGN: An observational study. SETTING: A university-affiliated private hospital. PATIENTS: Thirty-one women (mean age 48.7 yrs) with adnexal masses. INTERVENTIONS: Laparoscopic removal of adnexal masses ranging from 3 to 12 cm (18 complex, 5 septated cystic masses, 8 persistent simple cysts). The masses were placed in plastic sandwich bag and removed through the umbilical incision. Hospital costs, length of stay and operating times were compared with those of 24 patients undergoing the removal of similar masses by laparotomy. MEASUREMENTS AND MAIN RESULTS: Three masses were functional cysts, 4 were tubal cysts, 4 were endometriomas, and 20 were benign ovarian neoplasms. There were no malignancies. Peritoneal spillage occurred during one ovarian cystectomy. The only complication was bleeding from the cannula site. Comparing laparoscopy and laparotomy, average operating time was 73.45 minutes (range 34-148 min) and 81 minutes, average length of hospital stay was 17.4 hours (range 6-73 hrs) and 2.92 days, and average hospital cost was $2401 and $3539, respectively. CONCLUSION: Laparoscopic access provides a cost-effective method of removing adnexal masses with a very small risk of peritoneal spillage. When managed in this manner, rather than laparotomy, the cost reduction was significant.