Quality Initiative to Improve Compliance With Perioperative Anticoagulation.

PURPOSE: Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in gynecologic oncology surgical patients. Many centers use neuraxial analgesia (NA), which affects the timing of prophylactic anticoagulation. In 2012, we determined that the rate of VTE in patients undergoing laparotomy with NA was higher than in those who received alternative pain control. In addition, compliance with preoperative anticoagulation guidelines was only 40%. We undertook a quality initiative (QI) project to increase compliance to 80% in NA cases and maintain 90% in non-NA cases. METHODS: A multidisciplinary working group designed and deployed a QI intervention bundle. Compliance was defined as the receipt of a prophylactic dose of anticoagulant within 1 hour after NA or before skin incision regardless of anesthesia type. Data were abstracted from the medical record after the study period. Cases from the year before QI were used for comparison. Primary outcome was compliance and secondary outcome was the rate of VTE. RESULTS: One hundred women were treated under the QI project and 182 historical cases (HCs) were used for comparison. Overall compliance improved (96% QI v 73% HC; P < .001). This difference was marked in cases with NA (95% QI v 40% HC; P < .001) and remained stable in non-NA cases (97% QI v 91% HC; P = .29). The overall rate of VTE, independent of anesthesia type, remained unchanged (2.1% HC v 0% QI; P = .3). CONCLUSION: Relatively simple and inexpensive initiatives to improve routine processes within the surgical pathway are feasible and attract staff participation. Such efforts are likely to translate into greater levels of patient safety.

Prospective screening with the validated Opioid Risk Tool demonstrates gynecologic oncology patients are at low risk for opioid misuse.

OBJECTIVE: To characterize risk for opioid misuse among gynecologic oncology patients. METHODS: The Opioid Risk Tool (ORT), a validated screen for opioid misuse risk, was administered to a convenience sample of patients with gynecologic cancer receiving opioid prescriptions in gynecologic oncology or palliative care clinics from January 2012-June 2016. Demographic and clinical information was abstracted on chart review. The primary outcome was ORT risk level (low vs. moderate or high). Chi-square tests were performed for categorical variables. RESULTS: A total of 118 women were screened. Most women were Caucasian (79%) with a median age of 57years. Ovarian cancer patients comprised 46% of the cohort with fewer endometrial (25%), cervical (23%), vulvar (4%), and vaginal (2%) cancer patients. The median ORT score was 1.0 (range, 0-10) out of a possible 26. Overall, 87% of patients were categorized as low-risk for opioid misuse, 7% as moderate-risk, and 6% as high-risk. Patients who were at moderate or high-risk of opioid misuse were significantly younger (47 vs. 58years, p=0.02), more likely to have cervical cancer (p=0.02), be smokers (p=0.01) and be uninsured or on Medicare (p=0.03). CONCLUSIONS: Most gynecologic oncology patients in our cohort were low-risk for opioid misuse (87%). Cervical cancer patients were more likely to be moderate to high-risk for misuse. Future screening efforts for opioid misuse may have the highest utility in this subset of patients.

Rates of human papillomavirus vaccine uptake amongst girls five years after introduction of statewide mandate in Virginia.

BACKGROUND: The Commonwealth of Virginia enacted statewide school-entry human papillomavirus vaccine mandate in 2008 requiring all girls to receive the vaccine before starting the 6th grade. The mandate, one of very few in the country, has been in effect for 5 years. This study assesses the impact that it has had on the rates of human papillomavirus uptake. OBJECTIVE: The purpose of this study was to evaluate the uptake of the human papillomavirus vaccine among girls seeking well-child care 5 years after the introduction of a statewide mandate in Virginia in October 2008. STUDY DESIGN: This prospective cohort study used the Clinical Data Repository at the University of Virginia to identify girls 11-12 years old who was seen for well-child care from January to December 2014. Billing and diagnosis codes were used to establish human papillomavirus vaccine administration. Those girls who were identified through the Clinical Data Repository were then contacted by advance letter followed by a representative from the University of Virginia Center for Survey Research who invited the responsible parent or guardian to complete a 50-item telephone questionnaire. Questionnaire results were used to inform objective findings and to assess parental attitudes that were related to human papillomavirus vaccination. Findings were compared against those of Pierce et al (2013), who evaluated human papillomavirus vaccination levels in a similar cohort of patients in 2008, before mandate enactment, to assess relative change attributable to vaccine mandate. RESULTS: Nine hundred eight girls were identified through the Clinical Data Repository; 50.9% of the girls received at least 1 dose of human papillomavirus vaccine. White race and private insurance coverage were found to be associated negatively with human papillomavirus vaccine uptake (relative risk, 0.74 and 0.71; 95% confidence interval, 0.64-0.85 and 0.62-0.81, respectively). Black race and public insurance coverage were found to be associated positively with vaccine uptake (relative risk, 1.35 and 1.39; 95% confidence interval, 1.17-1.55 and 1.22-1.58, respectively). In comparison with the previous study, there has been no change in human papillomavirus vaccine uptake or distribution of uptake after the introduction of the statewide mandate for human papillomavirus vaccination. CONCLUSION: The statewide human papillomavirus vaccine mandate has had no impact on the overall rate of human papillomavirus vaccination, nor has it diminished the previously described racial or payer disparities in vaccine uptake in school-aged girls being seen for well-child care in the state of Virginia.

Cervical Cancer in Women Aged 35 Years and Younger.

PURPOSE: Age has been evaluated as a prognostic factor in cervical cancer in both hospital- and population-based studies. Results regarding the relation of age and cervical cancer prognosis are conflicting. This study pursued a contemporary assessment of the association of extreme young age at the time of a cervical cancer diagnosis on survival. METHODS: Institutional review board approval was obtained, and retrospective data collection at 2 academic institutions was performed. Inclusion criteria involved women ≤ 35 years diagnosed with cervical cancer between 1990 and 2012. Data included demographic and prognostic information pertinent to survival and progression. Characteristics of very young (≤ 25 years) and young (>25-35 years) women were compared. Kaplan-Meier estimates, the log-rank test, and Cox proportional hazards modeling were used to assess the association of age, tumor histology, grade, stage, and parametrial involvement with progression-free survival (PFS) and overall survival (OS). FINDINGS: Incident cases (n = 126) of cervical cancer in patients ≤ 35 years of age were identified of which complete clinical information was available for 114 women. Fifteen percent (17 of 114) were ≤ 25 years, with the remaining 85% (97 of 114) being 26 to 35 years of age. Race, smoking status, and marital status were comparable between the 2 groups. Squamous histology dominated overall (77 of 114; 68%) with adenocarcinoma contributing ~25% (30 of 114; 26%) of cases. The majority (96 of 114, 84%) had either stage 1A (31 of 114, 27%) or 1B (65 of 114, 57%) disease. A log-rank test revealed no evidence to infer a difference in either PFS or OS among the age groups (P = 0.511 and P = 0.340). In a univariate analysis, grade and stage significantly affected OS (P < 0.0001, P = 0.045), and stage significantly affected PFS (P < 0.0001). In multivariate modeling, presence of parametrial involvement and histologic cancer type significantly affected both PFS (P = 0.002, P = 0.001) and OS (P = 0.001, P = 0.001). IMPLICATIONS: Tumor histology, parametrial involvement, and stage continue to be strong prognosticators for PFS and OS. Progression and survival outcomes are age independent in women with cervical cancer ≤ 35 years of age. Further study of a larger young cohort may potentially yield different outcomes.

Lean methodology improves efficiency in outpatient academic Gynecologic Oncology clinics.

OBJECTIVES: Patient satisfaction scores may be used as a measure of quality of care, but outpatient scores are significantly and negatively affected by long clinic wait times. Patients in academic Gynecologic Oncology clinic at UVA for chemotherapy visits experience multiple wait times during a complex multipurpose visit. The purpose of this study was to utilize Lean methodology to identify variability in patient flow in order to guide solutions for improvement. METHODS: A value stream map of our clinic process was created. Patient surveys and clinical timestamps were used to identify which visit components were contributing to delays and to identify process variability. After results were analyzed, a process change was instituted, with the patient surveys then repeated. RESULTS: In the first phase, women experienced short wait times for the first appointment, but the average wait time between appointments gradually increased, with a peak mean wait time of 65 min (range 38-108) just prior to drug infusion. The total mean wait time (including all visits) was 119 min (range 81-154). After instituting process intervention, the overall wait time decreased significantly (82 vs 119 min, p=0.001), but was still affected by aspects of the process that were outside of the investigators' control. CONCLUSIONS: Analyzing patient flow through an academic Gynecologic Oncology clinic can elucidate inefficiencies and guide improvements. Change in process can meaningfully affect overall waiting time. Next steps include instituting a more global change in process, as well as linking results to patient satisfaction scores.

Preoperative imaging of uterine malignancy: A low-value service.

OBJECTIVE: The aim of this study is to examine the value of computed tomography (CT) or magnetic resonance imaging (MRI) before surgical treatment of uterine malignancy. METHODS: Retrospective chart review was undertaken of women who underwent hysterectomy for uterine cancer at the University of Virginia. Radiologic reports were examined for evidence of cervical or extrauterine disease or incidental findings and correlated with detection of extrauterine disease at surgery. RESULTS: Overall, 204 of 448 patients (45%) had preoperative imaging. Scans were ordered nearly evenly by referring clinicians and gynecologic oncologists (GO) (95 vs. 122, 44% vs. 56%). Imaging was most common among patients with grade 3 endometrioid or non-endometrioid histology (86 of 101, 85%). Women referred with low grade disease had more false positive (4 of 112, 4%) than true positive scans (2 of 113, 2%). Overall, 23 of 190 (12%) reviewed preoperative scans indicated suspected extrauterine disease. Two of these 23 women were low risk by intra-operative "Mayo criteria" and had stage 1A disease; 14 of 23 (61%) had stage II or greater disease. CONCLUSIONS: Preoperative CT or MRI is of low value in predicting extra-uterine disease among uterine cancer patients with low grade disease. Women with low grade disease had false positive results more frequently than true detection of extrauterine disease. Abnormal imaging findings are more common and predictive of extrauterine disease in women with grade 3 or non-endometrioid histology but the value of these scans remains unclear.

Continuous epidural infusion anesthesia and analgesia in gynecologic oncology patients: less pain, more gain?

OBJECTIVE: There is a lack of consistent data regarding gynecologic oncology (GO) patients and the use of neuraxial anesthesia for post-operative pain management. Our objective was to compare the use of continuous epidural infusion (CEI) as part of post-operative pain management to more traditional management schemes. METHODS: GO patients undergoing laparotomy from July 1st, 2011 through July 31st, 2012 were identified. Patient demographic data and peri-operative details were abstracted from the medical record. The primary outcome was a mean patient visual analog pain score. Secondary outcomes included length of stay, post-operative urinary tract infection (UTI) and venous thromboembolic (VTE) events. RESULTS: There were 237 laparotomies during the study time period. Fifty-six women had CEI for post-operative pain management and 181 did not. Patients with CEI had lower pain scores on POD #0 (3.8 vs 5.3, p < 0.01), #1 (2.6 vs 4.0, p < 0.01) and #2 (2.5 vs 3.5, p < 0.01) compared to women without CEI. There was no difference in the length of stay between those with and without CEI (103 vs 94 h, p = 0.32). Women with CEI did have a longer length of urinary catheterization (56 vs 26 h, p = 0.01) but not an increased rate of UTI (5.5% vs 1.8%, p = 0.24). There was a higher rate of post-operative VTE events among women with CEI (8.9% vs 1.7%, p = 0.02). CONCLUSIONS: In this small series, GO patients undergoing laparotomy had improved post-operative pain control when their analgesia regimen included CEI. However, the higher rate of VTE events among CEI users is concerning and merits further investigation.

The Patient Protection and Affordable Care Act: impact on the care of gynecologic oncology patients in the absence of Medicaid expansion in central Virginia.

OBJECTIVE: Many gynecologic oncology (GO) patients in Virginia are low income and their care is supplemented by Disproportionate Share Hospital (DSH) funds. Our objective is to estimate how many new GO patients may lose access to care if the state forgoes Medicaid expansion. METHODS: New patients referred to the GO service between July 1, 2010 and July 1, 2012 were identified. Data were collected regarding age, race, referral diagnosis, payor, and state pay scale. Pay scale 1 (PS1) is equal to the federal poverty level (FPL). Assumptions included the following: (1) pay scale is a surrogate for income, (2) PS1 patients will be ineligible for discounted insurance through the exchanges, and (3) decreasing DSH funds will result in a reduction of the free-care pool. RESULTS: There were 1623 referrals to the GO service and the majority (83%) was Caucasian. The payor distribution was 44% commercial insurance, 5.6% Medicaid, 31% Medicare, and 10.4% uninsured. Among the 361 women who were PS1, 32% were uninsured. Thirty percent of PS1 patients were minorities and 47.4% had a malignancy. Of note, 52% of new patients with cervical cancer were PS1. CONCLUSION: Seven percent of new GO patients are PS1 and uninsured. This population contains a disproportionate number of minorities and women with cancer. These women will have difficulty affording care as DSH funding decreases, particularly in states with lean Medicaid that opt out of Medicaid expansion. The burden of lack of access to care will be shouldered by an unfortunate few.