Women physicians receive lower Press Ganey patient satisfaction scores in a multicenter study of outpatient gynecology care.

BACKGROUND: Emerging data suggest that patient satisfaction data are subject to inherent biases that negatively affect women physicians. OBJECTIVE: This study aimed to describe the association between the Press Ganey patient satisfaction survey and physician gender in a multi-institutional study of outpatient gynecologic care. STUDY DESIGN: This was a multisite, observational, population-based survey study using the results of Press Ganey patient satisfaction surveys from 5 unrelated community-based and academic medical institutions with outpatient gynecology visits between January 2020 and April 2022. The primary outcome variable was the likelihood to recommend a physician, and individual survey responses served as the unit of analysis. Patient demographic data were collected through the survey, including self-reported age, gender, and race and ethnicity (categorized as White, Asian, or Underrepresented in Medicine, which groups together Black, Hispanic or LatinX, American Indian or Alaskan Native, and Hawaiian or Pacific Islander). Bivariate comparisons between demographics (physician gender, patient and physician age quartile, patient and physician race) and likelihood to recommend were assessed using generalized estimating equation models clustered by physician. Odds ratios, 95% confidence intervals, and P values for these analyses are reported, and results were considered statistically significant at P<.05. Analysis was performed using SAS, version 9.4 (SAS Institute Inc., Cary, NC). RESULTS: Data were obtained from 15,184 surveys for 130 physicians. Most physicians were women (n=95 [73%]) and White (n=98 [75%]), and patients were also predominantly White (n=10,495 [69%]). A little over half of all visits were race-concordant, meaning that both patient and physician reported the same race (57%). Women physicians were less likely to receive a topbox survey score (74% vs 77%) and in the multivariate model had 19% lower odds of receiving a topbox score (95% confidence interval, 0.69-0.95). Patient age had a statistically significant relationship with score, with patients aged ≥63 years having >3-fold increase in odds of providing a topbox score (odds ratio, 3.10; 95% confidence interval, 2.12-4.52) compared with the youngest patients. After adjustment, patient and physician race and ethnicity showed similar effects on the odds of a topbox likelihood-to-recommend score, with Asian physicians and Asian patients having lower odds of a topbox likelihood-to-recommend score when compared with White physicians and patients (odds ratio: 0.89 [95% confidence interval, 0.81-0.98] and 0.62 [95% confidence interval, 0.48-0.79], respectively). Underrepresented in medicine physicians and patients showed significantly increased odds of a topbox likelihood-to-recommend score (odds ratio: 1.27 [95% confidence interval, 1.21-1.33] and 1.03 [95% confidence interval, 1.01-1.06], respectively). The physician age quartile was not significantly associated with odds of a topbox likelihood-to-recommend score. CONCLUSION: Women gynecologists were 18% less likely to receive top patient satisfaction scores compared with men in this multisite, population-based survey study using the results of Press Ganey patient satisfaction surveys. The results of these questionnaires should be adjusted for bias given that they provide data currently being used to understand patient-centered care.

Low-fat dietary pattern reduces urinary incontinence in postmenopausal women: post hoc analysis of the Women's Health Initiative Diet Modification Trial.

BACKGROUND: Urinary incontinence affects >40% of women in the United States, with an annual societal cost of >$12 billion and demonstrated associations with depressive symptoms, social isolation, and loss of work productivity. Weight has been established as an exposure that increases urinary incontinence risk and certain dietary components have been associated with urinary incontinence symptoms. We hypothesized that diet plays a key role in the association between weight and urinary incontinence in US women. OBJECTIVE: This study aimed to examine the effect of a low-fat diet on urinary incontinence in postmenopausal women as a post hoc analysis of a randomized controlled trial of diet modification. STUDY DESIGN: This was a post hoc analysis of the Women's Health Initiative Dietary Modification randomized controlled trial of 48,835 postmenopausal women from 40 US centers assigned to a dietary intervention (20% energy from fat, 5 fruits or vegetable servings, and 6 whole grain servings daily and an intensive behavioral modification program) or to the usual diet comparison group. The outcome was urinary incontinence at 1 year. RESULTS: Of the participants, 60% were randomized to the usual diet comparison group and 40% to the dietary modification intervention. After adjusting for weight change, women assigned to the dietary modification intervention were less likely to report urinary incontinence (odds ratio, 0.94; 95% confidence interval, 0.90-0.98; P=.003), more likely to report urinary incontinence resolution (odds ratio, 1.11; 95% confidence interval, 1.03-1.19; P=.01), and less likely to develop urinary incontinence (odds ratio, 0.92; 95% confidence interval, 0.87-0.98; P=.01) in adjusted models. CONCLUSION: Dietary modification may be a reasonable treatment for postmenopausal women with incontinence and also a urinary incontinence prevention strategy for continent women. Our results provide evidence to support a randomized clinical trial to determine whether a reduced fat-intake dietary modification is an effective intervention for the prevention and treatment of urinary incontinence. In addition to providing further insights into mechanisms of lower urinary tract symptoms, these findings may have a substantial impact on public health based on the evidence that diet seems to be a modifiable risk factor for urinary incontinence.

Supracervical Hysterectomy Is Protective against Mesh Complications after Minimally Invasive Abdominal Sacrocolpopexy: A Population-Based Cohort Study of 12,189 Patients.

PURPOSE: Although minimally invasive (robotic or laparoscopic) abdominal sacrocolpopexy (MISC) has become the new gold standard for durable pelvic organ prolapse repair after the vaginal mesh controversy, current literature is limited. Our objective was to study reoperation for mesh complications after MISC. MATERIALS AND METHODS: All women undergoing MISC in California from January 2012 to December 2018 were identified from Office of Statewide Health Planning and Development data sets using appropriate ICD-9/10 (International Classification of Diseases 9th/10th Revision) and CPT® (Current Procedural Terminology) codes. Univariate and multivariable analyses were performed to assess associations between patient demographics, surgical details and our primary outcomes: rates of reoperation for a mesh complication. RESULTS: Of 12,189 women undergoing MISC 8,398 (68.9%) had concomitant hysterectomy. Total hysterectomy (TH) and supracervical hysterectomy (SCH) were performed in 5,027 (41.2%) and 3,371 (27.6%) cases, respectively. Reoperation rates for mesh complications were lower after SCH vs TH (overall: 0.7%, mean followup time 1,111 days vs 3.1%, mean followup time 1,095 days, p <0.001; subcohort with at least 4 years of followup: 2.1% vs 8.9%, p <0.001). Additionally, mesh complication rates were higher even if TH was performed remotely, as compared to concomitant SCH (5.2% vs 0.7%, p <0.001). The increased risk for reoperation due to mesh complications after TH was preserved on multivariable analysis (OR 4.20, 95% CI 2.72‒6.50, p <0.001). CONCLUSIONS: Concomitant TH at time of MISC is associated with a significantly higher rate of mesh complication as compared to SCH. The increased risk of a mesh complication associated with TH is present even if the TH was performed prior to the MISC.

Racial Disparities in Outcomes of Women Undergoing Myomectomy.

OBJECTIVE: To assess the association of racial and socioeconomic factors with outcomes of abdominal myomectomies. METHODS: All women undergoing abdominal myomectomy in California from 2005 to 2012 were identified from the OSHPD (Office of Statewide Health Planning and Development) using appropriate International Classification of Diseases and Current Procedural Terminology codes. Demographics, comorbidities, surgical approaches, and complications occurring within 30 days of the procedure were identified. Multivariate associations were assessed with mixed effects logistic regression models. RESULTS: The cohort of 35,151 women was racially and ethnically diverse (White, 38.8%; Black, 19.9%; Hispanic, 20.3%; and Asian, 15.3%). Among all procedures, 33,906 were performed through an open abdominal approach, and 1,245 were performed using a minimally invasive approach. Proportionally, Black patients were more likely than White patients to have open procedures, and open approaches were associated with higher complication rates. Overall, 2,622 (7.5%) women suffered at least one complication. Although severe complications did not vary by race or ethnicity, Black (9.0%), Hispanic (7.9%), and Asian (7.5%) patients were more likely to suffer complications of any severity compared with White patients (6.7%, P<.001). As compared with patients with private insurance (6.4%), those with indigent payer status (Medicaid [12.1%] and self-pay [11.1%]) had higher complication rates (P<.001). Controlling for all factors, Black and Asian patients were more likely to suffer complications compared with White patients. CONCLUSION: The overall complication rate after abdominal myomectomy was 7.5%. Comorbidities, an open approach, and indigent payer status were associated with increased complication risk. Controlling for all factors, Black and Asian patients still had increased risks of complications.

Postoperative complications and recurrence rates after rectal prolapse surgery versus combined rectal prolapse and pelvic organ prolapse surgery.

INTRODUCTION AND HYPOTHESIS: Our primary objectives were to compare < 30-day postoperative complications and RP recurrence rates after RP-only surgery and combined surgery. Our secondary objectives were to determine preoperative predictors of < 30-day complications and RP recurrence. METHODS: A prospective IRB-approved cohort study was performed at a single tertiary care center from 2017 to 2020. Female patients with symptomatic RP underwent either RP-only surgery or combined surgery based on the discretion of the colorectal and FPMRS surgeons. Primary outcome measures were < 30-day complications separated into Clavien-Dindo (CD) classes and rectal prolapse on physical examination. RESULTS: Seventy women had RP-only surgery and 45 had combined surgery with a mean follow-up time of 208 days. Sixty-eight percent underwent abdominal RP repair, and 32% underwent perineal RP repair. Twenty percent had one or more complications, 14% in the RP-only group and 29% in the combined surgery group (p = 0.06). On multivariate analysis, combined surgery patients had a 30% increased risk of complications compared to RP-only surgery patients (RR = 1.3). Most of these complications were minor (14/17, 82.4%) and categorized as CD I or II, including urinary retention and UTI. Twelve percent of this cohort had RP recurrence, 11% in the RP-only group and 13% in the combined surgery group (p = 0.76). Preoperative risk factors for RP recurrence included a primary complaint of rectal bleeding (RR 5.5) and reporting stools consistent with Bristol Stool Scale of 1 (RR 2.1). CONCLUSION: Patients undergoing combined RP + POP surgery had a higher risk of complications and equivalent RP recurrence rates compared to patients undergoing RP-only surgery.

Does Rectocele on Defecography Equate to Rectocele on Physical Examination in Patients With Defecatory Symptoms?

OBJECTIVES: Our primary objective was to determine the association between rectocele size on defecography and physical examination in symptomatic patients. Our secondary objective was to describe the associations between both defecography and physical examination findings with defecatory symptoms and progression to surgical repair of rectocele. METHODS: We performed a retrospective review of all patients referred to a female pelvic medicine and reconstructive surgery clinic with a diagnosis of rectocele based on defecography and/or physical examination at a single institution from 2003 to 2017. Patients who did not have defecatory symptoms, did not undergo defecography imaging, or did not have a physical examination in a female pelvic medicine and reconstructive surgery clinic within 12 months of defecography imaging were excluded. RESULTS: Of 200 patients, 181 (90.5%) had a rectocele diagnosed on defecography and 170 (85%) had a rectocele diagnosed on physical examination. Pearson and Spearman tests of correlation both showed a positive relationship between the rectocele size on defecography and rectocele stage on physical examination; however, one was not reliable to predict the results of the other (Pearson correlation = 0.25; Spearman ρ = 0.29). The strongest predictor of surgery was rectocele stage on physical examination (P < 0.001). Size of rectocele on defecography was not a strong independent predictor for surgery (P = 0.01), although its significance improved with the addition of splinting (P = 0.004). CONCLUSIONS: Our results suggest that rectocele on defecography does not necessarily equate to rectocele on physical examination in patients with defecatory symptoms. Rectocele on physical examination was more predictive for surgery than rectocele on defecography.

Predictors of Colpocleisis Outcomes in an Older Population Based Cohort.

PURPOSE: Colpocleisis is an obliterative surgical option for women with pelvic organ prolapse that is often performed in a frail population. However, because outcomes remain largely unknown we aimed to assess the durability and perioperative safety of colpocleisis in a large population based cohort. MATERIALS AND METHODS: All women undergoing colpocleisis and other pelvic organ prolapse repairs in California (2005-2011) were identified using the Office of Statewide Health Planning and Development data sets. Durability was defined as the absence of future pelvic organ prolapse repair after index repair for the duration of the data sets. Thirty-day morbidity was assessed by identifying readmissions, repeat surgeries and complications. A metric to assess frailty in large administrative databases was applied to assess the impact of frailty on outcomes. Colpocleisis outcomes were compared to other types of pelvic organ prolapse repairs by developing propensity score matched groups. RESULTS: Among the 2,707 women undergoing colpocleisis, reoperation for prolapse occurred in 47 (1.8%). At least 1 complication occurred in 11.1% of the cohort, with serious complications occurring in 2%. Frail patients were more likely to experience any complication (23.3% vs 10.3%, p <0.01) and a serious complication (5.0% vs 1.8%, p=0.02) and was the best predictor of morbidity. Colpocleisis was associated with a more durable repair (overall failure 1.8% vs 3.5%, p <0.01) with no difference in complication rates as compared to the matched cohort. CONCLUSIONS: Colpocleisis provides a more durable outcome than reconstructive pelvic organ prolapse repairs without increased perioperative morbidity. Frailty is a better predictor than age for perioperative complications after colpocleisis.

Incidence of Pelvic Floor Disorders in US Army Female Soldiers.

OBJECTIVE: To determine the incidence of pelvic floor disorders (PFD) among active-duty US Army female soldiers. MATERIALS AND METHODS: We studied 102,015 women for incident PFD using the Stanford Military Data Repository, which comprises medical, demographic and service-related information on all soldiers on active duty in the US Army during 2011-2014. Cox proportional hazards estimated adjusted associations with PFD diagnoses. In the adjusted models, military-specific characteristics and fitness were evaluated alongside known PFD predictors. RESULTS: Among 102,015 subjects at risk there was a cumulative incidence of 6.4% over a mean of 27 months (median 29, range 1-42). In adjusted models, obese soldiers were more likely to have a PFD compared to those of normal weight (hazard ratio [HR] 1.23, confidence interval [CI] 1.14-1.34, P <0.001) and those with recent weight gain were more likely to have a PFD compared to those without (HR 1.32, CI 1.24-1.40, P <0.05). Women with the lowest physical fitness scores were more likely to have a PFD (HR 1.14, CI 1.04-1.25) compared to those with the highest scores. CONCLUSION: Over a median follow-up time of 29 months, 1 in 15 women in this active-duty cohort was diagnosed with a PFD. Optimizing risk factors including body mass index and physical fitness may benefit the pelvic health of female soldiers, independent of age, children, and years of service.

Balancing the possibility of needing a future incontinence procedure versus a future urethral sling revision surgery: a tradeoff analysis for continent women undergoing pelvic organ prolapse surgery.

INTRODUCTION AND HYPOTHESIS: Although urinary incontinence surgery has potential benefits such as preventing de novo stress urinary incontinence in women undergoing pelvic organ prolapse (POP) surgery, it comes with the potential cost of overtreatment and complications. We compared future surgery rates in a population cohort of women undergoing vaginal pelvic organ prolapse surgery. METHODS: All women undergoing POP repair in California from 2005 to 2011 were identified from the Office of Statewide Health Planning and Development databases. Rates of repeat surgery in those with and without concomitant urethral sling procedures were compared. To control for confounding effects, multivariate mixed effects logistic regression models were constructed to compare each woman's individualized risk of undergoing either sling revision surgery or future incontinence surgery. RESULTS: In the cohort, 38,456 underwent a sling procedure at the time of POP repair and 42,858 did not. The future surgery rate was higher for sling-related complications in the POP + sling cohort compared with future incontinence surgery in the POP alone cohort (3.5% versus 3.0% respectively, p < 0.001). The difference persisted in multivariate modeling, where most women (60%) are at a higher risk of requiring sling revision surgery compared with needing a future primary incontinence procedure (40%). CONCLUSIONS: Women who undergo vaginal prolapse repair without an incontinence procedure are at a low risk of future incontinence surgery. Women without urinary incontinence who are considering vaginal POP surgery should be informed of the risks and benefits of including a sling procedure.

Reoperation rates for pelvic organ prolapse repairs with biologic and synthetic grafts in a large population-based cohort.

INTRODUCTION AND HYPOTHESIS: As the long-term complications of synthetic mesh become increasingly apparent, re-evaluation of alternative graft options for pelvic organ prolapse (POP) repairs is critical. We sought to compare the long-term reoperation rates of biologic and synthetic grafts in POP repair. METHODS: Using the California Office of Statewide Health Planning and Development database, we identified all women who underwent index inpatient POP repair with either a synthetic or biologic graft between 2005 and 2011 in the state of California. ICD-9 and CPT codes were used to identify subsequent surgeries in these patients for either recurrent POP or a graft complication. RESULTS: A total of 14,192 women underwent POP repair with a biologic (14%) or synthetic graft (86%) during the study period. Women with biologic grafts had increased rates of surgery for recurrent pelvic organ prolapse (3.6% vs 2.5%, p = 0.01), whereas women with synthetic grafts had higher rates of repeat surgery for a graft complication (3.0 vs 2.0%, p = 0.02). There were no significant differences between the overall risk of repeat surgery between the groups (5.7% vs 5.6%, p = 0.79). These effects persisted in multivariate modeling. CONCLUSIONS: We demonstrate in a large population-based cohort that biologic grafts are associated with an increased rate of repeat surgery for POP recurrence whereas synthetic mesh is associated with an increased rate of repeat surgery for a graft complication. These competing risks result in an equivalent overall any-cause repeat surgery rate between the groups. These data suggest that neither type of graft should be excluded from use and encourage a personalized risk assessment.

Urologic Injury and Fistula After Hysterectomy for Benign Indications.

OBJECTIVE: To explore the rates and risk factors for sustaining a genitourinary injury during hysterectomy for benign indications. METHODS: In this population-based cohort study, all women who underwent hysterectomy for benign indications were identified from the Office of Statewide Health Planning and Development databases in California (2005-2011). Genitourinary injuries were further classified as identified at the time of hysterectomy, identified after the date of hysterectomy; or unidentified until a fistula developed. RESULTS: Of the 296,130 women undergoing hysterectomy for benign indications, there were 2,817 (1.0%) ureteral injuries, 2,058 (0.7%) bladder injuries and 834 (0.3%) genitourinary fistulas (80/834 of which developed after an injury repair). Diagnosis was delayed in 18.6% and 5.5% of ureteral and bladder injuries, respectively. Subsequent genitourinary fistula development was lower if the injury was identified immediately (compared with delayed) for both ureteral (0.7% vs 3.4% odds ratio [OR] 0.28; 95% CI 0.14-0.57) and bladder injuries (2.5% vs 6.5% OR 0.37; 95% CI 0.16-0.83). Indwelling ureteral stent placement alone was more successful in decreasing the risk of a second ureteral repair for immediately recognized ureteral injuries (99.0% vs 39.8% for delayed injuries). With multivariate adjustment, prolapse repair (OR 1.44, 95% CI 1.30-1.58), an incontinence procedure (OR 1.40, 95% CI 1.21-1.61), mesh augmented prolapse repair (OR 1.55, 95% CI 1.31-1.83), diagnosis of endometriosis (OR 1.46, 95% CI 1.36-1.56), and surgery at a facility in the bottom quartile of hysterectomy volume (OR 1.37, 95% CI 1.01-1.89) were all associated with an increased likelihood of a genitourinary injury. An exclusively vaginal (OR 0.56, 95% CI 0.53-0.64) or laparoscopic (OR 0.80, 95% CI 0.75-0.86) approach was associated with lower risk of a genitourinary injury as compared with an abdominal approach. CONCLUSION: Genitourinary injury occurs in 1.8% of hysterectomies for benign indications; immediate identification and repair is associated with a reduced risk of subsequent genitourinary fistula formation.

Rates and Risk Factors for Future Stress Urinary Incontinence Surgery after Pelvic Organ Prolapse Repair in a Large Population-based Cohort in California.

OBJECTIVES: To determine the rate and risk factors for future stress urinary incontinence (SUI) surgery in a large population-based cohort of previously continent women following pelvic organ prolapse (POP) repair without concomitant SUI treatment. METHODS: Data from the Office of Statewide Health Planning and Development were used to identify all women who underwent anterior, apical, or combined anteroapical POP repair without concomitant SUI procedures in the state of California between 2005 and 2011 with at least 1-year follow-up. Patient and surgical characteristics were explored for associations with subsequent SUI procedures. RESULTS: Of 41,689 women undergoing anterior or apical POP surgery, 1,504 (3.6%) underwent subsequent SUI surgery with a mean follow-up time of 4.1 years. Age (odds ratio [OR] 1.01), obesity (OR 1.98), use of mesh at the time of POP repair (OR 2.04), diabetes mellitus (OR 1.19), white race, and combined anteroapical repair (OR 1.30) were associated with increased odds of future SUI surgery. CONCLUSION: The rate of subsequent surgery for de novo SUI following POP repair on a population level is low. Patient and surgical characteristics may alter a woman's individual risk and should be considered in surgical planning.

Association Between Concomitant Hysterectomy and Repeat Surgery for Pelvic Organ Prolapse Repair in a Cohort of Nearly 100,000 Women.

OBJECTIVE: To evaluate the association of hysterectomy at the time of pelvic organ prolapse (POP) repair with the risk of undergoing subsequent POP surgery in a large population-based cohort. METHODS: Data from the California Office of Statewide Health Planning and Development were used in this retrospective cohort study to identify all women who underwent an anterior, apical, posterior or multiple compartment POP repair at nonfederal hospitals between January 1, 2005, and December 31, 2011, using Current Procedural Terminology and International Classification of Diseases, 9th Revision procedure codes. Women with a diagnosis code indicating prior hysterectomy were excluded, and the first prolapse surgery during the study period was considered the index repair. Demographic and surgical characteristics were explored for associations with the primary outcome of a repeat POP surgery. We compared reoperation rates for recurrent POP between patients who did compared with those who did not have a hysterectomy at the time of their index POP repair. RESULTS: Of the 93,831 women meeting inclusion criteria, 42,340 (45.1%) underwent hysterectomy with index POP repair. Forty-eight percent of index repairs involved multiple compartments, 14.0% included mesh, and 48.9% included an incontinence procedure. Mean follow-up was 1,485 days (median 1,500 days). The repeat POP surgery rate was lower in those patients in whom hysterectomy was performed at the time of index POP repair, 3.0% vs 4.4% (relative risk [RR] 0.67, 95% CI 0.62-0.71). Multivariate modeling revealed that hysterectomy was associated with a decreased risk of future surgery for anterior (odds ratio [OR] 0.71, 95% CI 0.64-0.78), apical (OR 0.76, 95% CI 0.70-0.84), and posterior (OR 0.69, 95% CI 0.65-0.75) POP recurrence. The hysterectomy group had increased lengths of hospital stay (mean 2.2 days vs 1.8 days, mean difference 0.40, 95% CI 0.38-0.43), rates of blood transfusion (2.5% vs 1.5, RR 1.62, 95% CI 1.47-1.78), rates of perioperative hemorrhage (1.5% vs 1.1%, RR 1.32, 95% CI 1.18-1.49), rates of urologic injury or fistula (0.9% vs 0.6%, RR 1.66, 95% CI 1.42-1.93), rates of infection or sepsis (0.9% vs 0.4%, RR 2.12, 95% CI 1.79-2.52), and rate of readmission for an infectious etiology (0.7% vs 0.3%, RR 2.54, 95% CI 2.08-3.10) as compared with those who did not undergo hysterectomy. CONCLUSION: We demonstrate in a large population-based cohort that hysterectomy at the time of prolapse repair is associated with a decreased risk of future POP surgery by 1-3% and is independently associated with higher perioperative morbidity. Individualized risks and benefits should be included in the discussion of POP surgery.

Care Seeking Patterns for Women Requiring a Repeat Pelvic Organ Prolapse Surgery Due to Native Tissue Repair Failure Compared to a Mesh Complication.

OBJECTIVE: To explore patient migration patterns in patients requiring repeat surgery after Pelvic Organ Prolapse (POP) repair as there is a limited understanding of care seeking patterns for repeat surgery after POP repair. We hypothesized that undergoing repeat surgery for a prolapse mesh complication would be associated with an increased incidence of migration to a new facility for care compared to those undergoing repeat surgery for recurrent POP. METHODS: In this retrospective population based study, all females who underwent an index POP repair procedure (with or without mesh) at nonfederal facilities who subsequently underwent a repeat surgery (recurrent prolapse repair or mesh complication) were identified from the Office of Statewide Health Planning and Development for the state of California (2005-2011). The location of index repair and repeat surgery were identified and factors associated with migration were explored. RESULTS: Of the 3,930 women who underwent repeat surgery for either POP recurrence or a mesh complication, 1,331 (33.9%) had surgery at a new facility. Multivariate analysis revealed that mesh complications (odds ratio [OR] 1.28, P = 0.004) or native tissue same compartment recurrence (OR 1.19, P = 0.02) were both associated with increased odds of undergoing surgery at a new facility. Having surgery in a county with multiple centers increased the odds of migration to a new facility for care (OR = 1.33, P < 0.001), unless the initial repair was at a high volume institution (OR = 0.32, P < 0.001). Overall across indications, women changing locations for their second surgery tended to migrate toward select centers in urban areas. CONCLUSION: Women who undergo repeat surgery after POP repair have similar patterns of migration to a new facility irrespective of the indication for surgery.

What Impacts the All Cause Risk of Reoperation after Pelvic Organ Prolapse Repair? A Comparison of Mesh and Native Tissue Approaches in 110,329 Women.

PURPOSE: Several factors are hypothesized to impact the risks of mesh augmented pelvic organ prolapse repair, including 1) the characteristics of the material, 2) surgical experience and 3) patient selection. We present a large, population based approach to explore the impact of these factors on outcomes and describe an ideal mesh use strategy. MATERIALS AND METHODS: Data from the Office of Statewide Health Planning and Development were accessed to identify all women who underwent pelvic organ prolapse repair in California from 2005 to 2011. Multivariate mixed effects logistic regression models were constructed to explore which patient, surgical and facility factors were associated with repeat surgery for a complication due to mesh or recurrent pelvic organ prolapse. RESULTS: A total of 110,329 women underwent pelvic organ prolapse repair during the study period and mesh was used in 16.2% of the repairs. The overall repeat surgery rate was higher in women who underwent mesh repair (5.4% vs 4.3%, p <0.001). However, multivariate modeling revealed that mesh itself was not independently associated with repeat surgery. Rather, repair at a facility where there was a greater propensity to use mesh was independently associated with repeat surgery (highest vs lowest mesh use quartile OR 1.55, p <0.01). Further modeling revealed that the lowest risk occurred when mesh was used in 5% of anterior and 10% of anterior apical repairs. CONCLUSIONS: Our findings demonstrate that mesh is not independently associated with an increase in the rate of complications of pelvic organ prolapse repair on a large scale. We present a model that supports judicious use of the product on the population level which balances the risk of complications against that of recurrent pelvic organ prolapse.

Physician Gender Is Associated with Press Ganey Patient Satisfaction Scores in Outpatient Gynecology.

BACKGROUND: Patient satisfaction is gaining increasing attention as a quality measure in health care, but the methods used to assess it may negatively impact women physicians. OBJECTIVE: Our objective was to examine the relationship between physician gender and patient satisfaction with outpatient gynecology care as measured by the Press Ganey patient satisfaction survey. STUDY DESIGN: This cross-sectional study analyzed 909 Press Ganey patient satisfaction surveys linked to outpatient gynecology visits at a single academic institution (March 2013-August 2014), including self-reported demographics and satisfaction. Surveys are delivered in a standardized fashion electronically and by mail. Surveys were completed by 821 unique patients and 13,780 gynecology visits occurred during the study period. The primary outcome variable was likelihood to recommend (LTR) a physician. We used χ2 tests of independence to assess the effect of demographic concordance on LTR and two generalized estimating equations models were run clustered by physician, with topbox physician LTR as the outcome variable. Analysis was performed in SAS Enterprise Guide 7.1 (SAS, Inc., Cary, NC). RESULTS: Nine hundred nine surveys with complete demographic data were completed by women during the study period (mean age, 49.3 years). Age- and race-concordant patient-physician pairs received significantly higher proportions of top LTR score than discordant pairs (p = .014 and p < .0001, respectively). In contrast, gender-concordant pairs received a significantly lower proportion of top scores than discordant pairs (p = .027). In the generalized estimating equations model adjusting for health care environment, only gender remained statistically significant. Women physicians had significantly lower odds (47%) of receiving a top score (odds ratio, 0.53; 95% CI, 0.37-0.78; p = .001). CONCLUSIONS: Women gynecologists are 47% less likely to receive top patient satisfaction scores compared with their male counterparts owing to their gender alone, suggesting that gender bias may impact the results of patient satisfaction questionnaires. Therefore, the results of this and similar questionnaires should be interpreted with great caution until the impact on women physicians is better understood.

Where do Women go for Revision Surgeries? Geographic Migration Patterns after Urethral Sling Placement in California.

INTRODUCTION: Although long-term rates of sling revision after urethral sling placement have been well studied, details of these revisions have not been addressed. In this study we explore the timing, location and migration of patients from one facility to another for revision procedures. METHODS: Using data from the Office of Statewide Health Planning and Development (OSHPD) for the state of California (2005 to 2011), all females who underwent index outpatient urethral sling procedures at nonfederal facilities were identified (CPT 57288). Cases requiring eventual sling revision or urethrolysis were subsequently identified. Location, distance traveled and factors associated with seeking a new facility for revision were explored. RESULTS: Of the 44,605 patients undergoing urethral sling surgery 842 (1.9%) underwent sling revision, with 178 (22.5%) at a new facility. Facilities in the top 10% of surgical volume placed 41% of the slings and performed more than 50% of revisions. Patient proximity to multiple facilities and increased time between procedures were associated with an increased odds of changing facilities for revision (OR 2.11, p <0.0001 and OR 1.05 per month, p <0.0001, respectively). Placement at a high volume center was associated with decreased odds of changing facilities for revision (OR 0.32, p <0.0001). Patients migrated toward larger centers in urban areas for revision. CONCLUSIONS: Overall 78% of sling revisions are performed at the facility where the initial placement was performed. This suggests that the majority of facilities where urethral slings are placed also have the capability of sling revision surgery.

Racial and Socioeconomic Disparities in Short-term Urethral Sling Surgical Outcomes.

OBJECTIVE: To evaluate the association of racial and socioeconomic factors with the risk of adverse events in the first 30 days following urethral sling placement. METHODS: We accessed nonpublic data from the Office of Statewide Health Planning and Development in California from 2005 to 2011. All female patients who underwent an ambulatory urethral sling procedure in the entire state of California over the study period were identified (Current Procedural Terminology 57288). Our main outcome was any unplanned hospital visits within 30 days of the patient's surgery in the form of an inpatient admission, revision surgery, or emergency department visit. RESULTS: A total of 28,635 women who underwent outpatient urethral sling placement were identified. Within 30 days, 1628 women (5.7%) had at least 1 unplanned hospital visit. In the adjusted multivariate model, black race and Medicaid insurance status were both independently associated with increased odds of having an unplanned hospital visit (odds ratio 1.80, P < .01 and odds ratio 1.53, P < .01, respectively). This significance persisted even when controlling for patient comorbidities, demographics, and facility characteristics. CONCLUSION: We found that, similar to what has been reported in other fields, disparities in outcomes exist between socioeconomic and racial groups in the field of urogynecology.

Impact of Distance to Treatment Center on Care Seeking for Pelvic Floor Disorders.

OBJECTIVE: The aim of this study was to evaluate the impact of distance from residence to treatment center on access to care for female pelvic floor disorders at an academic institution. METHODS: A retrospective cross-sectional study was conducted of women seen for pelvic floor disorders at an academic institution from 2008 to 2014. Patient characteristics were extracted from charts. Geographical and US census data was obtained from public records and used to calculate distance from patient residence to physician office. Statistical analysis was performed using R Software (Version 0.98.1102) and Microsoft Excel (Version 14.4.7). Statistical significance was defined as a 2-sided P value of less than 0.05, and the χ test was used to determine associations of categorical variables. RESULTS: A total of 3015 patients were included in the analysis. The mean distance traveled was 93 miles. Thirty percent of patients traveled more than 50 miles. Many patients (43%) reported having the symptoms for more than 2 years. Patients who traveled farther were significantly more likely to be white, English-speaking, and with pelvic organ prolapse as primary complaint. These patients were more likely to plan surgery at the first visit than patients who traveled less far (29% vs 14%). Patients who traveled farther were also more likely to live in counties with a low percentage of persons older than 65 years and low percentage of female inhabitants. CONCLUSIONS: Women who travel the farthest for treatment of pelvic floor disorders have experienced the symptoms for longer duration and are more willing to plan surgery at presentation. These women also come from counties with fewer elderly women, suggesting future outreach care should focus on similar geographic areas.