Moving the needle: Quality improvement strategies to achieve guideline-concordant care of obstetric patients with severe hypertension.

OBJECTIVES: To improve timely treatment and follow-up of birthing individuals with severe hypertension. STUDY DESIGN: A quality improvement (QI) initiative was implemented at an academic tertiary care center in the United States of America for individuals with obstetric hypertensive emergencies. Statistical process control charts were utilized to track process measures and interventions tested through plan-do-study-act cycles. Measures were disaggregated by race and ethnicity to identify and improve disparities. MAIN OUTCOME MEASURES: Treatment of hypertensive events within 60 min, receipt of blood pressure (BP) device at discharge and completed postpartum follow-up BP check within 7 days of discharge. RESULTS: All process measures showed statistically significant improvements. The primary process measure, timely treatment of hypertensive emergencies, improved from 29 % to 76 %. Receipt of BP device improved from 37 % to 91 % and follow-up BP checks from 58 % to 81 %. No racial or ethnic disparities were noted at baseline or after interventions. Readmission rates within 6 weeks of delivery increased from 2.3 % to 6.1 % for the cohort with no severe morbidity or mortality events after discharge. Strategies associated with improvement included project launch with establishment of the "why," telehealth, simulation, a video display of quality metrics on the birthing unit, promoting BP cuff access, and automated orders. CONCLUSIONS: This comprehensive QI initiative provides novel improvement strategies for the management of individuals with severe hypertensive disorders of pregnancy for the timely treatment of severe BP, attainment of home BP devices, and follow-up after discharge. Quality improvement methodology is practical and essential for achieving guideline-concordant care.

Long-Term Costs of Minimally Invasive Sacral Colpopexy Compared to Native Tissue Vaginal Repair With Concomitant Hysterectomy.

STUDY OBJECTIVE: To determine the long-term costs of hysterectomy with minimally invasive sacrocolpopexy (MISCP) versus uterosacral ligament suspension (USLS) for primary uterovaginal prolapse repair. DESIGN: A hospital-based decision analysis model was built using TreeAge Pro (TreeAge Software Inc, Williamstown, MA). Those with prolapse were modeled to undergo either vaginal hysterectomy with USLS or minimally invasive total hysterectomy with sacrocolpopexy (MISCP). We modeled the chance of complications of the index procedure, prolapse recurrence with the option for surgical retreatment, complications of the salvage procedure, and possible second prolapse recurrence. The primary outcome was cost of the surgical strategy. The proportion of patients living with prolapse after treatment was the secondary outcome. SETTING: Tertiary center for urogynecology. PATIENTS: Female patients undergoing surgical repair by the same team for primary uterovaginal prolapse. INTERVENTIONS: Comparison analysis of estimated long-term costs was performed. MEASUREMENTS AND MAIN RESULTS: Our primary outcome showed that a strategy of undergoing MISCP as the primary index procedure cost $19 935 and that undergoing USLS as the primary index procedure cost $15 457, a difference of $4478. Furthermore, 21.1% of women in the USLS group will be living with recurrent prolapse compared to 6.2% of MISCP patients. Switching from USLS to MISCP to minimize recurrence risk would cost $30 054 per case of prolapse prevented. Additionally, a surgeon would have to perform 6.7 cases by MISCP instead of USLS in order to prevent 1 patient from having recurrent prolapse. CONCLUSION: The higher initial costs of MISCP compared to USLS persist in the long term after factoring in recurrence and complication rates, though more patients who undergo USLS live with prolapse recurrence.

Urethral Bulking With Polyacrylamide Hydrogel Compared With Other Treatments for Stress Urinary Incontinence: A Cost-Effectiveness Analysis.

Our objective was to perform a cost-effectiveness analysis comparing polyacrylamide hydrogel urethral bulking with other surgical and nonsurgical treatments for stress urinary incontinence (SUI). We created a cost-effectiveness analysis using TreeAge Pro, modeling eight SUI treatments. Treatment with midurethral sling (MUS) had the highest effectiveness (1.86 quality-adjusted life-years [QALYs]), followed by polyacrylamide hydrogel (1.82 QALYs), with a difference (Δ 0.02/year) less than the minimally important difference for utilities of 0.03 annually. When the proportion of polyacrylamide hydrogel urethral bulking procedures performed in the office setting is greater than 58%, polyacrylamide hydrogel is a cost-effective treatment for SUI, along with pessary, pelvic floor physical therapy, and MUS. Although MUS is more effective and, therefore, the preferred SUI treatment, polyacrylamide hydrogel is a reasonable alternative depending on patient preferences and treatment goals.

Projecting future prolapse outcomes with induction of labor at 39 weeks: a decision analysis.

INTRODUCTION AND HYPOTHESIS: In 2018, the ARRIVE trial (A Randomized Trial of Induction Versus Expectant Management) concluded that routine induction of labor (IOL) at 39 weeks gestation decreases cesarean delivery risk, with slightly lighter birthweight infants. We debated whether routine IOL would improve, worsen, or not change POP risk compared with expectant management (EM). METHODS: We constructed a decision analysis model with a lifetime horizon where nulliparous women reaching 39 weeks underwent IOL or EM. Subsequent vaginal versus cesarean delivery varied based on prior deliveries for up to four births. Subsequent delivery prior to 39 weeks and distribution of gestational age, birthweight, and delivery mode between 24 and 39 weeks was modeled from national data. We modeled increased POP risk with increasing vaginal parity, forceps delivery, and weight of largest infant delivered vaginally, accounting for differential infant weights in each strategy. RESULTS: IOL and EM have similar population-wide POP risk (15.9% and 15.7% respectively). Among women with only spontaneous vaginal deliveries that reached 39 weeks or beyond, the prevalence of POP was 20% after one delivery and 29% after four deliveries, with no difference between groups. The cesarean rate was lower with IOL (27.8% versus 29.8%). Sensitivity analysis revealed no meaningful thresholds among the variables, supporting model robustness. CONCLUSION: While routine induction of labor at 39 weeks results in a meaningfully higher vaginal delivery rate, there was no increase in POP, possibly due to the protective effect of lower birthweight.

Cost-Utility Analysis of Midurethral Sling Timing Among Women Undergoing Prolapse Surgery.

IMPORTANCE: There are no guidelines regarding the ideal timing of midurethral sling (MUS) placement following prolapse repair. OBJECTIVE: The objective of this study was to estimate the cost-utility of concomitant MUS versus staged MUS among women undergoing apical suspension surgery for pelvic organ prolapse. STUDY DESIGN: Cost-utility modeling using a decision analysis tree compared concomitant MUS with staged MUS over a 1-year time horizon. The primary outcome was the incremental cost-effectiveness ratio (ICER). Six scenarios were modeled to estimate cost-utilities for women with preoperative overt, occult, or no stress urinary incontinence (SUI) who underwent either minimally invasive sacrocolpopexy or vaginal native tissue apical suspension. Possible complications of de novo overactive bladder, urinary retention requiring sling lysis, mesh exposure, and persistent SUI were included. Costs from a third-party payer perspective were derived from Medicare 2022 reimbursements. One-way sensitivity analyses were performed. RESULTS: Among women without preoperative SUI, staged MUS was the dominant strategy for both surgical routes with higher utility and lower costs. For women with either occult or overt SUI undergoing sacrocolpopexy or vaginal repair, concomitant MUS was cost-effective (ICER = $21,114-$96,536 per quality-adjusted life-year). Therefore, concomitant MUS is preferred for patients with preoperative SUI as higher costs were offset by higher effectiveness. One-way sensitivity analyses demonstrated that ICERs were most affected by probability of cure following MUS. CONCLUSIONS: A staged MUS procedure is the dominant strategy for women undergoing apical prolapse repair without preoperative SUI. In women with either overt or occult SUI, the ICER was below the willingness-to-pay threshold of $100,000 per quality-adjusted life-year, suggesting that concomitant MUS surgery is cost-effective.

Hemoglobin A1c and Reoperation After Surgery for Stress Incontinence or Prolapse.

IMPORTANCE: Few studies compare the link between hemogobin A1c (HbA1c) and urogynecologic surgical complications. OBJECTIVE: The objective of this study was to determine the association between HbA1c and reoperation in women undergoing surgery for stress urinary incontinence (SUI) or pelvic organ prolapse (POP). STUDY DESIGN: We performed 2 separate retrospective cohort analyses using Cerner's HealthFacts Database (750 hospitals; 519,000,000 patient encounters from January 1, 2010, to November 30, 2018). We included women undergoing surgery for (1) SUI or (2) apical POP by International Classification of Diseases coding who had HbA1c at the initial procedure. Each analysis compared those undergoing reoperation for complications or recurrence and those who did not. Multivariable logistic regression assessed the association between reoperation and HbA1c both as a continuous variable and comparing the commonly accepted cutoff ≥8. RESULTS: Of 30,180 SUI surgical procedures and 26,389 POP surgical procedures, 1,625 (5.4%) and 805 (3.1%) had HbA1c. Median (interquartile range) HbA1c in grams per deciliter was similar by reoperation status (SUI: 6.0 [5.6-6.8] vs 6.1 [5.6-6.9], P = 0.35; POP: 6.2 [5.6-6.6] vs 6.1 [5.7-6.8], P = 0.60). Reoperation was also similar using the HbA1c ≥8% cutoff (SUI: 6.9% vs 7.4%, P = 0.79; POP: 6.3% vs 5.4%, P = 0.77). On multivariate analysis, HbA1c value was not a significant predictor of reoperation either as a continuous (SUI: odds ratio [OR] = 0.966, 95% CI = 0.833-1.119; POP: OR = 1.040, 95% CI = 0.801-1.350) or dichotomous variable ≥8 (SUI: OR = 0.767, 95% CI = 0.407-1.446; POP: OR = 0.988, 95% CI = 0.331-2.951). Mean follow-up was 4.28-5.13 years. CONCLUSION: Although other studies have shown a link between diabetes and complications, we were unable to show an association between HbA1c values and rates of reoperation.

Surgical correction of the genital hiatus at the time of sacrocolpopexy - a 7-year Markov analysis: a cost-effectiveness analysis.

INTRODUCTION AND HYPOTHESIS: To perform a cost-effectiveness analysis of concurrent posterior repair performed at the time of laparoscopic hysterectomy with sacrocolpopexy over a 7-year time period. We hypothesize it is not cost-effective to perform a posterior colporrhaphy. METHODS: We used TreeAge Pro® to construct a decision model with Markov modeling to compare sacrocolpopexy with and without concurrent posterior repair (SCP and SCP+PR) over a time horizon of 7 years. Outcomes included probability and costs associated with prolapse recurrence, prolapse retreatment, and complications including rectal injury, rectovaginal hematoma requiring reoperation, and postoperative dyspareunia. Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) calculated as ∆ costs /∆ effectiveness and the willingness to pay (WTP) was set at $100,000/QALY. RESULTS: Our model showed that SCP was the dominant strategy, with lower costs (-$ 2681.06) and higher effectiveness (+0.10) compared to SCP+PR over the 7-year period. In two-way sensitivity analyses, we varied the probability of prolapse recurrence after both strategies. Our conclusions would only change if the probability of recurrence after SCP was at least 29.7% higher than after SCP+PR. When varying the probabilities of dyspareunia for both strategies, SCP+PR only became the dominant strategy if the probability of dyspareunia for SCP+PR was lower than the rate of SCP alone. CONCLUSIONS: In this 7-year Markov cost-effectiveness analysis, SCP without concurrent PR was the dominant strategy. SCP+PR costs more with lower effectiveness than SCP alone, due to higher surgical cost of SCP+PR and higher probability of dyspareunia after SCP+PR.

Differences in Sexual and Physical Abuse History by Presenting Chief Complaint in an Outpatient Urogynecology Population.

IMPORTANCE: One in 3 women experience sexual or physical violence in their lifetimes. Health consequences for survivors are numerous, including urogynecologic symptoms. OBJECTIVES: We aimed to determine prevalence and factors that predict a history of sexual or physical abuse (SA/PA) in outpatient urogynecology, specifically whether the chief complaint (CC) predicts a history of SA/PA. STUDY DESIGN: This cross-sectional study analyzed 1,000 newly presenting patients to 1 of 7 urogynecology offices in western Pennsylvania from November 2014 to November 2015. All sociodemographic/medical data were retrospectively abstracted. Univariable and multivariable logistic regression analyzed risk factors based on known associated variables. RESULTS: One thousand new patients had a mean age of 58.4 ± 15.8 years with a body mass index (BMI) of 28.8 ± 6.5. Nearly 12% reported a history of SA/PA. Patients with CC of pelvic pain were more than twice as likely to report abuse compared with all other CCs (odds ratio [OR], 2.690; 95% confidence interval [CI], 1.576-4.592). Prolapse was the most common CC (36.2%) but had the lowest prevalence of abuse (6.1%). Nocturia was an additional urogynecologic variable predictive of abuse (OR, 1.162 per nightly episode; 95% CI, 1.033-1.308). Increasing BMI and decreasing age both increased the risk of SA/PA. Smoking conferred the highest likelihood of abuse history (OR, 3.676; 95% CI, 2.252-5.988). CONCLUSIONS: Although those with a CC of prolapse were less likely to report abuse history, we recommend routine screening for all women. Pelvic pain was the most common CC among women reporting abuse. Special efforts should be made to screen those at higher risk with complaints of pelvic pain who are younger, smokers, with higher BMI, and with increased nocturia.

Universal Urogynecologic Consultation and Screening for Fecal Incontinence in Pregnant Women With a History of Obstetric Anal Sphincter Injury: A Cost-Effectiveness Analysis.

IMPORTANCE: Obstetric anal sphincter injuries (OASIS) predispose for the development of fecal incontinence (FI), but management of subsequent pregnancy after OASIS is controversial. OBJECTIVE: We aimed to determine if universal urogynecologic consultation (UUC) for pregnant women with prior OASIS is cost-effective. STUDY DESIGN: We performed a cost-effectiveness analysis of pregnant women with a history of OASIS modeling UUC compared with no referral (usual care). We modeled the route of delivery, peripartum complications, and subsequent treatment options for FI. Probabilities and utilities were obtained from published literature. Costs using a third-party payer perspective were gathered from the Medicare physician fee schedule reimbursement data or published literature converted to 2019 U.S. dollars. Cost-effectiveness was determined using incremental cost-effectiveness ratios). RESULTS: Our model demonstrated that UUC for pregnant patients with prior OASIS was cost-effective. Compared with usual care, the incremental cost-effectiveness ratio for this strategy was $19,858.32 per quality-adjusted life-year, below the willingness to pay a threshold of $50,000/quality-adjusted life-year. Universal urogynecologic consultation reduced the ultimate rate of FI from 25.33% to 22.67% and reduced patients living with untreated FI from 17.36% to 1.49%. Universal urogynecologic consultation increased the use of physical therapy by 14.14%, whereas rates of sacral neuromodulation and sphincteroplasty increased by only 2.48% and 0.58%, respectively. Universal urogynecologic consultation reduced the rate of vaginal delivery from 97.26% to 72.42%, which in turn led to a 1.15% increase in peripartum maternal complications. CONCLUSIONS: Universal urogynecologic consultation in women with a history of OASIS is a cost-effective strategy that decreases the overall incidence of FI, increases treatment utilization for FI, and only marginally increases the risk of maternal morbidity.

Financial analysis of minimally invasive sacrocolpopexy compared with native tissue vaginal repair with concomitant hysterectomy.

INTRODUCTION: Minimally invasive sacrocolpopexy (MISCP) is increasingly used for uterovaginal prolapse, but comparative cost data of MISCP versus native tissue vaginal repair (NTR) are lacking. The objective was to determine the cost difference, from a hospital perspective, between MISCP and NTR performed with hysterectomy for uterovaginal prolapse. METHODS: This was a retrospective cohort study at a tertiary care center of women who underwent NTR or MISCP with concomitant hysterectomy in 2021. Hospital charges, direct and indirect costs, and operating margin (revenue minus costs) were obtained from Strata Jazz and compared using SPSS. RESULTS: A total of 82 women were included, 33 MISCP (25 robotic, 8 laparoscopic) versus 49 NTR. Demographic and surgical data were similar, except that MISCP had younger age (50.5 vs 61.1 years, p<0.01). Same-day discharge and estimated blood loss were similar, but operative time was longer for MISCP (204 vs 161 min, p<0.01). MISCP total costs were higher (US$17,422 vs US$13,001, p<0.01). MISCP had higher direct costs (US$12,354 vs US$9,305, p<0.01) and indirect costs (US$5,068 vs US$3,696, p<0.01). Consumable supply costs were higher with MISCP (US$4,429 vs US$2,089, p<0.01), but the cost of operating room time and staff was similar (US$7,926 vs US$7,216, p=0.07). Controlling for same-day discharge, anti-incontinence procedures and smoking, total costs were higher for MISCP (adjusted beta = US$4,262, p<0.01). Mean charges (US$102,060 vs US$97,185, p=0.379), revenue (US$22,214 vs US$22,491, p=0.929), and operating margin (US$8,719 vs US$3,966, p=0.134) were not statistically different. CONCLUSION: Minimally invasive sacrocolpopexy had higher costs than NTR; however, charges, reimbursement, and operating margins were not statistically significantly different between the groups.

Longitudinal urinary microbiome characteristics in women with urgency urinary incontinence undergoing sacral neuromodulation.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate the stability of the urinary microbiome communities in women undergoing sacral neuromodulation (SNM) for urgency urinary incontinence (UUI). We hypothesized that clinical response to SNM therapy would be associated with changes in the urinary microbiome. METHODS: Women completed the Overactive Bladder Questionnaire Short-Form, the International Consultation on Incontinence Questionnaire Short Form, and the Female Sexual Function Index at baseline and 3 months post-SNM implantation. Transurethral urinary specimens were obtained for microbiome analysis at baseline and 3 months postoperatively. The V4 region of the 16S rRNA gene (515F-806R) was amplified with region-specific primers, and Amplicon Sequence Variants (ASVs) were identified with a closed-reference approach of taxonomic classification. Alpha-diversity was calculated using the phylogenetic (i.e., Faith's phylogenetic diversity) and nonphylogenetic metrics (i.e., Shannon diversity, and Pielou's evenness) using the QIIME2 plugin. Longitudinal paired volatility analysis was performed using the DEICODE and Gemelli plugin to account for host specificity across both time and space. RESULTS: Nineteen women who underwent SNM and provided both baseline and 3-month urine samples were included in this analysis. Women reported improvement in objective (number of UUI episodes) and subjective (symptom severity and health-related quality of life) measures. Ninety percent of the bacteria were classified as Bacteroidetes, Firmicutes, Proteobacteria, and Actinobacteria. No significant differences were observed in each subject's beta-diversity at 3 months compared with their baseline microbiome. CONCLUSIONS: Our descriptive pilot study of a cohort of women who had achieved objective and subjective improvements in UUI following SNM therapy demonstrates that the urinary microbiome remains relatively stable, despite variability amongst the cohort.

Characterization of the GU microbiome in women with self-perceived bladder health over the life course.

BACKGROUND: A variety of factors influence bladder health, including environmental factors, life experiences, biologic foundations, and coexistent medical conditions. A biologically diverse microbial community exists in the urine that is likely influenced by the microbial inhabitants of the vagina. The relationship between the genitourinary (GU) microbiome and self-perceived bladder health is unknown. OBJECTIVE: To longitudinally define the GU microbiome in women with self-percieved bladder health sampled across multiple time points over a year. STUDY DESIGN: Women with no reported lower urinary tract dysfunction or symptoms (LUTS) were recruited from six clinical sites and assessed every 6 weeks for 1 year. Voided urine and vaginal samples were longitudinally collected. Self-perceived bladder health was assessed with select items from the LURN comprehensive assessment of self-reported urinary symptoms (CASUS) tool. We defined four life phases as follows: young (18-34 years, nulliparous), midlife (35-45 years, menstruating), transitional (46-60 years, perimenopausal), mature (>60 years, not using vaginal and/or systemic hormone replacement therapy). DNA was extracted from samples, and the V4 region of the 16S rRNA gene was amplified with region-specific primers. The 16S rRNA sequencing on an Illumina NovaSeq. Microbial beta-diversity was calculated using DEICODE to identify microbial taxa that cluster in the samples. Longitudinal volatility analysis was performed using the gemelli plugin. Log-abundance ratios of microbial features were explored and visualized in Qurro. RESULTS: Fifty-four (N = 16 young, N = 16 midlife, N = 15 transitional, N = 7 mature) women were enrolled and provided baseline data. Most women in each life phase (93%-98%) continued to report self-perceived bladder health throughout the 1-year follow-up as assessed by CASUS items. Temporal-based microbial diversity of urinary and vaginal microbiome remained relatively stable over 1 year in all subjects. The GU microbiomes of mature women were distinct and microbially diverse from that of young, midlife, and transitional women, with genera of Gardnerella, Cupriavidus, and Dialister contributory to the microbial features of the mature microbiome. The mature GU microbiome was statistically different (p < 0.0001) from the midlife, transitional, and young microbiome for the log ratio of Gardnerella and Cupriavidus (in the numerator) and Lactobacillus (in the denominator) for voided samples and Gardnerella and Dialister (in the numerator) and Lactobacillus (in the denominator) for vaginal samples. Differences in the GU microbiome were also demonstrated via longitudinal beta-diversity between women developing urinary frequency as reported by CASUS responses or objectively on bladder diary compared to women without urinary frequency. CONCLUSION: In women with a self-perceived healthy bladder, the GU microbiome remained stable in all age groups over a 1 year period. Differences were seen with respect to life phase, where mature women were distinct from all other groups, and with respect to self-reported LUTS.

Surgical cost of robotic-assisted sacrocolpopexy: a comparison of two robotic platforms.

IMPORTANCE: Robotic assistance in pelvic organ prolapse surgery can improve surgeon ergonomics and instrument dexterity compared with traditional laparoscopy but at increased costs. OBJECTIVE: To compare total costs for robotic-assisted sacrocolpopexy (RSC) between two robotic platforms at an academic medical center. METHODS: Retrospective cohort of Senhance (Ascensus) RSC between 1/1/2019 and 6/30/21 who were matched 2:1 with DaVinci (Intuitive) RSC. Primary outcome was total costs to hospital system; secondarily we evaluated cost sub-categories. Purchase costs of the robotic systems were not included. T-test, chi-square, and Fisher's exact tests were used. A multivariable linear regression was performed to model total costs adjusting for potential confounders. RESULTS: The matched cohort included 75 subjects. The 25 Senhance and 50 DaVinci cases were similar overall, with mean age 60.5 ± 9.7, BMI 27.9 ± 4.7, and parity 2.5 ± 1.0. Majority were white (97.3%) and postmenopausal (86.5%) with predominantly stage III prolapse (64.9%). Senhance cases had longer OR times (Δ = 32.1 min, p = 0.01). There were no differences in concomitant procedures, intraoperative complications, or short-term postoperative complications between platforms (all p > 0.05). On univariable analysis, costs were similar (Senhance $5368.31 ± 1486.89, DaVinci $5741.76 ± 1197.20, p = 0.29). Cost subcategories (medications, supplies, etc.) were also similar (all p > 0.05). On multivariable linear regression, total cost was $908.33 lower for Senhance (p = 0.01) when adjusting for operative time, estimated blood loss, concomitant mid-urethral sling, and use of the GelPoint mini port system. CONCLUSIONS: Despite longer operating times, total cost of robotic-assisted sacrocolpopexy was significantly lower when using the Senhance compared to the DaVinci system.

Reoperation rates of stress incontinence surgery in rural vs urban hospitals.

BACKGROUND: XXX. OBJECTIVE: This study aimed to determine the impact of a rural vs urban hospital location on the risk of undergoing a second surgery for stress urinary incontinence. STUDY DESIGN: Using the Cerner Health Facts nationwide electronic medical record database, we identified patients who underwent surgeries for stress incontinence between January 1, 2010 and November 30, 2018. Stress incontinence surgeries included synthetic midurethral slings, fascial slings, retropubic urethral suspension, and other surgeries for stress urinary incontinence, such as the laparoscopic sling or the Pereyra procedure. Patients were divided into 2 cohorts, namely those who had a single operation and those who had a reoperation, defined as any second stress incontinence surgery or revision after initial incontinence surgery. Logistic regression analysis was performed to determine whether urban vs rural hospital location impacted reoperation rates. We adjusted for significant sociodemographic variables identified in the univariate analysis with a P value <.1. RESULTS: Of the 25,085 women who underwent stress incontinence procedures, 669 (2.7%) underwent a second surgery. Of these, 346 (51.7%) patients underwent were a second stress incontinence procedure, 307 (45.9%) underwent revisions of the index case, and 16 (2.4%) underwent both. Women in the single surgery cohort were older (median age, 54 vs 53 years; P=.029). In the total sample, 85.5% identified as White and 4.5% identified as Black. Of the study cohort, 7720 (30.8%) had obesity and 2660 (10.6%) had diabetes. There was a higher rate of reoperation among patients with obesity (3.0% vs 2.5%; P=.017). Among patients who underwent a concomitant prolapse surgery with their index surgery, there were fewer reoperations (2.2% vs 2.8%; P=.012). In the univariate analysis, we did not detect a difference between women who lived in rural vs urban areas (3.0% vs 2.6%; P=.16). After adjusting for confounders, we still did not see a significant association between rural hospital location and the risk for repeat surgery (odds ratio, 1.00; 95% confidence interval, 0.76-1.31). In this multivariable regression, obesity increased the risk for having a reoperation (odds ratio, 1.20; 95% confidence interval, 1.02-1.41), whereas patients who had concomitant prolapse procedures with their index surgery had a reduced risk for having a reoperation (odds ratio, 0.80; 95% confidence interval, 0.66-0.98). CONCLUSION: We did not detect an association between hospital location (rural vs urban) and the risk for reoperation among women undergoing stress incontinence surgery. With low reoperation rates, patients can be reassured that they are receiving excellent care in either setting.

Risk factors for the development of acute pyelonephritis in women with a positive urine culture.

INTRODUCTION: In treating lower urinary tract symptoms (LUTS), the risk of overtreatment with antibiotics must be reconciled with the risk of an untreated urinary tract infection (UTI) progressing to acute pyelonephritis (APN). Using Cerner HealthFacts, a longitudinal clinical informatics database, we aimed to determine risk factors associated with the development of APN from UTI in an effort to guide the initiation of empiric antibiotics. METHODS: We queried the Cerner HealthFacts database for women over age 18 with a positive urine culture. Any patient with an International Classification of Disease (ICD) code indicating chronic pyelonephritis was excluded. Development of APN within 30 days of the positive culture, specified by ICD coding, was our primary outcome. Patient and facility factors were assessed as potential risk factors for the development of APN using multivariable regression. RESULTS: Out of 58 344 women with a positive urine culture, 3.9% (2296) developed APN. Mean patient age was 54.4 ± 25.3 years. Overall, 12 variables were predictive for APN and 11 variables were protective against APN. Presence of obstructive and reflux uropathies (OR 4.58), presentation to an acute care facility (OR 3.19), urinary retention (OR 2.30), history of UTI (OR 2.19), and renal comorbidities (OR 2.07) conferred the highest odds of APN development. The most protective variable against APN development was cognitive impairment (OR 0.49). CONCLUSIONS: Identified risk factors associated with APN development may aid decisions regarding empiric antibiotic initiation for patients presenting with LUTS while awaiting urine culture results. The relationship between cognitive impairment and progression to APN deserves further study.

Effect of Time of Year on Surgical Outcomes in Patients Undergoing Minimally Invasive Sacral Colpopexy or Uterosacral Ligament Suspension.

IMPORTANCE: Academic urogynecologists incorporating fellows/residents into operative cases must ensure safety and quality outcomes throughout the learning curve of the academic year. OBJECTIVES: We evaluated if the month of year relative to fellow/resident promotions in July affects operating time, complications, and prolapse recurrence for minimally invasive sacral colpopexy (MISC) or uterosacral ligament suspension (USLS). STUDY DESIGN: This was a retrospective study comprising MISC and USLS from January 2009 to August 2015. Patient demographics, clinical, and surgical data were compared between months with July as month 1. Linear regression assessed operating time. Logistic regression assessed prolapse recurrence (composite of any POP-Q point beyond the hymen, pessary use, or reoperation) and complications. RESULTS: One thousand seven participants had a mean age of 59.9 ± 9.4, body mass index of 27.6 ± 4.2, gravity of 3.0 ± 1.5, and parity of 2.6 ± 1.1. Most had stage III (67.7%) or II prolapse (25.6%). Minimally invasive sacral colpopexy represented 81.0% (58.8% laparoscopic, 41.2% robotic). Uterosacral ligament suspensions were 68.1% vaginal versus laparoscopic/robotic. Median follow-up was 34 weeks (interquartile range, 11-82). Mean operating time was 199.8 ± 66.4 minutes with no impact by month ( P = 0.26). Minimally invasive sacral colpopexy (vs USLS, ß = 36.4 minutes), conversion to laparotomy (ß = 112.9 minutes), and concomitant hysterectomy (ß = 33.4 minutes) increased operating time ( P < 0.001). Complications ranged 7.9% (January) to 23.8% (March) with mean of 17.1%. Complications were unaffected by month (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.95-1.04), but USLS had more complications than MISC (OR, 1.55; 95% CI, 1.05-2.28). Prolapse recurred in 9.4% with no impact by month (OR, 0.95; 95% CI, 0.88-1.02). Minimally invasive sacral colpopexy had less recurrence than USLS (OR, 0.33; 95% CI, 0.18-0.60). CONCLUSIONS: Month of year relative to resident/fellow promotion did not affect operating time, complications, or recurrence, debunking the myth of worse outcomes earlier in the academic year.

Salpingo-oophorectomy or surveillance for ovarian endometrioma in asymptomatic premenopausal women: a cost-effectiveness analysis.

BACKGROUND: The lifetime risk of ovarian cancer is 1.9% among women with endometriosis compared with 1.3% among the general population. When an asymptomatic endometrioma is incidentally discovered on imaging, gynecologists must weigh the procedural complications and the potential for subsequent surgical menopause against future ovarian pathology or cancer. OBJECTIVE: We aimed to determine if performing unilateral salpingo-oophorectomy is a more cost-effective strategy for the prevention of death than surveillance for asymptomatic endometriomas. STUDY DESIGN: We created a cost-effectiveness model using TreeAge Pro (TreeAge Software Inc; Williamstown, MA) with a lifetime horizon. Our hypothetical cohort included premenopausal patients with 2 ovaries who did not desire fertility. Those diagnosed with asymptomatic endometrioma underwent either unilateral salpingo-oophorectomy or surveillance (ultrasound 6-12 weeks after diagnosis, then annually). Our primary effectiveness outcome was mortality, including death from ovarian cancer or surgery and all-cause mortality related to surgical menopause (± hormone replacement therapy) if the contralateral ovary is removed. We modeled the probabilities of surgical complications, occult malignancy, development of contralateral adnexal pathology, surgical menopause, use of hormone replacement therapy, and development of ovarian cancer. The costs included surgical procedures, complications, ultrasound surveillance, hormone therapy, and treatment of ovarian cancer, with information gathered from Medicare reimbursement data and published literature. Cost-effectiveness was determined using the incremental cost-effectiveness ratio of Δ costs / Δ deaths with a willingness-to-pay threshold of $11.6 million as the value of a statistical life. Multiple 1-way sensitivity analyses were performed to evaluate model robustness. RESULTS: Our model demonstrated that unilateral salpingo-oophorectomy is associated with improved outcomes compared with surveillance, with fewer deaths (0.28% vs 1.50%) and fewer cases of ovarian cancer (0.42% vs 2.96%). However, it costs more than sonographic surveillance at $6403.43 vs $5381.39 per case of incidental endometrioma. The incremental cost-effectiveness ratio showed that unilateral salpingo-oophorectomy costs $83,773.77 per death prevented and $40,237.80 per case of ovarian cancer prevented. As both values were well below the willingness-to-pay threshold, unilateral salpingo-oophorectomy is cost-effective and is the preferred strategy. If unilateral salpingo-oophorectomy were chosen over surveillance for premenopausal patients with incidental endometriomas, 1 diagnosis of ovarian cancer would be prevented in every 40 patients and 1 death averted in every 82 patients. We performed 1-way sensitivity analyses for all input variables and determined that there were no reasonable inputs that would alter our conclusions. CONCLUSION: Unilateral salpingo-oophorectomy is cost-effective and is the preferred strategy compared with surveillance for the management of incidental endometrioma in a premenopausal patient not desiring fertility. It incurs fewer deaths and fewer cases of ovarian cancer with costs below the national willingness-to-pay thresholds.

Assault-related injuries reported to police and treated by healthcare providers in the United States.

Research suggests that assault-related injuries known by the police significantly differ from those known by healthcare providers, but the magnitude and nature of these differences are poorly understood. To address this gap, our study examined the empirical differences between assault-related injuries reported to police and treated by healthcare providers. In June of 2021, we analyzed the National Crime Victimization Survey (1993-2019) to estimate the prevalence of police reporting and healthcare use among 5093 nonfatal victimizations that caused injury and were either reported to the police or treated by healthcare in the United States. Quasi-Poisson models identified the factors associated with whether people who sustained the injuries used healthcare (v. only reported to police) and reported to police (v. only used healthcare). Among victimizations that caused only minor injuries, 43% involved only a police report, 11% involved only healthcare, and 46% involved both services. Among victimizations that caused serious injuries, 14% involved only a police report, 13% involved only healthcare, and 73% involved both services. Whether people with violent injuries used healthcare (v. only reported to police) and reported to police (v. only used healthcare) was significantly associated with 13 different person- and incident-level factors. The number and nature of assault-related injuries reported to law enforcement significantly differ from those treated by healthcare providers. Therefore, public health efforts to link police and healthcare data are warranted and recommended.

Surgical Correction of the Genital Hiatus at the Time of Sacrocolpopexy-Are Concurrent Posterior Repairs Cost-Effective?

OBJECTIVE: The objective was to perform a cost-effectiveness analysis of posterior repair performed at the time of sacrocolpopexy (SCP). METHODS: We used TreeAge Pro to construct a decision model comparing laparoscopic hysterectomy with SCP with and without concurrent posterior repair (SCP and SCP + PR). Using a time horizon of 1 year, we modeled prolapse recurrence, prolapse retreatment, and complications, including rectal injury, rectovaginal hematoma requiring surgical take-back, and postoperative dyspareunia. Costs included index surgery, surgical retreatment, and complications. We modeled effectiveness as quality-adjusted life years (QALYs). Cost-effectiveness was defined using the incremental cost-effectiveness ratio and willingness to pay of $100,000/QALY. Sensitivity analyses were performed. RESULTS: Sacrocolpopexy was the dominant strategy with a cost of $65,714 and an effectiveness of 0.84. It was cost-effective at willingness to pay threshold less than $100,000/QALY. The SCP + PR costs more ($75,063) with lower effectiveness (0.83). The effectiveness of the 2 strategies was similar, differing only by 0.01 QALY, which is less than the minimally important difference for utilities. Tornado plots showed CEA results were most influenced by the cost of SCP, cost of SCP + PR, and probability of dyspareunia after SCP. In 1-way sensitivity analyses, the model outcome would change only if the cost of SCP was increased by 12.8% or if the cost of SCP + PR decreased by 14.5%. For dyspareunia, our model would only change if the probability of dyspareunia after SCP alone was 75.9% (base case, 18.6%), whereas the probability of dyspareunia after SCP + PR was 26.8%. CONCLUSION: In this cost-effectiveness analysis, SCP without concurrent PR was the dominant strategy.