RESUMEN
INTRODUCTION AND HYPOTHESIS: We compared postoperative complications in elderly patients discharged on POD#0 versus POD#1 after prolapse repair. METHODS: Data were obtained from the National Surgical Quality Improvement database. A total of 20,984 women 65 years and older who underwent prolapse repair between 2014 and 2020 were analyzed. Patient demographics, comorbidities, readmission, reoperation, and 30-day postoperative complications were compared in patients discharged on POD#0 versus POD#1. A sensitivity analysis was completed to examine outcomes in patients who underwent an apical prolapse repair. Multivariate logistic regression was performed to evaluate for potential confounders. RESULTS: Age, race, ethnicity, American Society of Anesthesiologists class, prolapse repair type, and operative time were significantly different in patients discharged on POD#0 vs POD#1 (all p < 0.01). Patients discharged on POD#0 had significantly fewer postoperative complications (2.63% vs 3.44%) and readmissions (1.56% vs 2.18%, all p < 0.01). On multivariate regression modeling, postoperative discharge day was independently associated with complications, but not with readmissions or reoperation after. Patients who underwent an apical prolapse repair and were discharged on POD#0 had significantly more postoperative complications (3.5% vs 2.5%, p = 0.02) and readmissions (2.42% vs 10.08%, p < 0.01) than those discharged on POD#1. In this group, multivariate regression modeling demonstrated that postoperative discharge day was independently associated with any postoperative complication. CONCLUSIONS: For elderly women undergoing prolapse repair, the type of surgery should be considered when determining postoperative admission versus same-day discharge. Admission overnight does not seem to benefit women undergoing vaginal repairs but may decrease overall morbidity and risk of readmission in women undergoing an apical prolapse repair.
Asunto(s)
Alta del Paciente , Readmisión del Paciente , Prolapso de Órgano Pélvico , Complicaciones Posoperatorias , Humanos , Anciano , Femenino , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Alta del Paciente/estadística & datos numéricos , Prolapso de Órgano Pélvico/cirugía , Readmisión del Paciente/estadística & datos numéricos , Anciano de 80 o más Años , Reoperación/estadística & datos numéricos , Procedimientos Quirúrgicos Ginecológicos/estadística & datos numéricos , Procedimientos Quirúrgicos Ginecológicos/efectos adversos , Estudios RetrospectivosRESUMEN
INTRODUCTION AND HYPOTHESIS: There is a need for cost effective interventions that increase surgical preparedness in urogynecology. METHODS: We performed an ancillary prospective economic evaluation of the Telehealth Intervention to Increase Patient Preparedness for Surgery (TIPPS) Trial, a randomized multicenter trial that evaluated the impact of a preoperative telehealth call on surgical preparedness in women undergoing urogynecologic surgery. A within-trial analysis from the health care sector and societal perspective was performed. Cost-effectiveness was computed from health care sector and societal perspectives, with an 8-week time horizon. RESULTS: A total of 126 women were included in our analysis. QALYs gained were similar between groups (telehealth 0.1414 + 0.0249; usual care 0.1409 + 0.0179). The cumulative mean per-person costs at 8 weeks from the healthcare sector perspective were telehealth call: $8696 +/- 3341; usual care: $8473 +/- 3118 (p = 0.693) and from the societal perspective were telehealth call: $11,195 + 5191; usual care: $11,213 +/- 4869 (p = 0.944). The preoperative telehealth call intervention was not cost effective from the health care sector perspective with an ICER of $460,091/QALY (95%CI -$7,382,608/QALY, $7,673,961) using the generally accepted maximum willingness to pay threshold of $150,000/QALY (Neumann et al. N Engl J Med. 371(9):796-7, 2014). From the societal perspective, because incremental costs per QALY gained were negative $-35,925/QALY (95%CI, -$382,978/QALY, $317,226), results suggest that preoperative telehealth call dominated usual care. CONCLUSIONS: A preoperative telehealth call is cost effective from the society perspective. CLINICAL TRIAL REGISTRATION: Registered with http://ClinicalTrials.gov . Date of registration: March 26, 2019 Date of initial participant enrollment: June 5, 2019 URL: https://clinicaltrials.gov/ct2/show/record/NCT03890471 Clinical trial identification number: NCT03890471.
Asunto(s)
Análisis de Costo-Efectividad , Telemedicina , Femenino , Humanos , Análisis Costo-Beneficio , Estudios Prospectivos , Años de Vida Ajustados por Calidad de Vida , Teléfono , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
OBJECTIVE: To assess and compile the current level of evidence regarding successful surgical treatment of vesicovaginal fistulae and how these perioperative interventions affect anatomic, patient-centered, and adverse outcomes. DATA SOURCES: PubMed and EMBASE were searched from inception through September 9, 2022. METHODS OF STUDY SELECTION: This review included comparative studies (of any sample size) and single-group studies (1,000 or more participants) of primary or recurrent vesicovaginal fistula (ie, vesicovaginal fistula, urethrovaginal fistula, and bladder neck-vaginal fistula). We evaluated preintervention assessment or management, various techniques for intraoperative management, and postoperative management. Outcomes of interest included anatomic and objective outcomes (such as successful repair, fistula closure, urinary incontinence, recurrent fistula, perioperative complications) and subjective outcomes (such as voiding symptoms and quality of life). Abstracts and full-text articles were screened in duplicate, and study descriptions and findings were extracted into standardized extraction forms. Risk of bias was assessed independently by two investigators and adjudicated by a third. Study quality was summarized with standardized tools. We conducted random-effects model and restricted maximum-likelihood meta-analyses of relative risks when at least three studies compared similar interventions and reported similar outcome measures. TABULATION, INTEGRATION, AND RESULTS: Forty-six studies met the inclusion criteria. Studies were categorized into 11 domains: 1) preoperative assessment, 2) preoperative and postoperative physical therapy, 3) route of surgery, 4) incorporation of a flap, 5) trimming, 6) layered closure, 7) intraoperative antibiotics, 8) fibrin glue, 9) fascial sling, 10) postoperative Foley catheter duration, and 11) quality of life. Although the strength of the data is insufficient, preoperative phenazopyridine, physical therapy, layered closure, and intraoperative antibiotics seemed to improve the rate of successful fistula repair. Route of surgery (vaginal vs abdominal laparotomy) was determined primarily by surgeon preference and showed no difference in successful fistula repair. In addition, use of interpositional flaps, trimming fistula edges, fibrin glue, and fascial sling did not show significant improvement in rates of fistula cure. Overall, quality-of-life scores improved postoperatively regardless of route of repair and use of interpositional flaps. CONCLUSION: Our findings highlight the limited information available to guide evidence-based treatment of vesicovaginal fistula repair. Overall, high-quality evidence is lacking to provide guidelines; therefore, expert opinion remains the primary influence for fistula repair recommendations. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021214948.
Asunto(s)
Fístula Vesicovaginal , Femenino , Humanos , Antibacterianos , Adhesivo de Tejido de Fibrina , Calidad de Vida , Vejiga Urinaria , Fístula Vesicovaginal/cirugíaRESUMEN
Background: On June 24, 2022, the Supreme Court of the United States in the case of Dobbs v Jackson Women's Health Organization ended constitutional protection for abortion, thus severely restricting access to reproductive health care for millions of individuals. Concerns have arisen about the potential impact on medical students, residents, and fellows training in restricted areas and the effect on gynecologic training and the future provision of competent comprehensive women's health care in the United States. Objective: To qualitatively explore the anticipated impacts of the Dobbs ruling on training in obstetrics and gynecology (OB/GYN). Methods: A participatory action research approach employing methods of qualitative analysis was used. Trainees and leaders in national OB/GYN professional and academic organizations with missions related to clinical care and training of medical students, residents, and fellows in OB/GYN participated. Two focus groups were held via Zoom in July 2022. Using an iterative process, transcripts underwent coding by 2 independent researchers to identify categories and common themes. Themes were organized into categories and subcategories. An additional reviewer resolved discrepancies. Results: Twenty-six OB/GYN leaders/stakeholders representing 14 OB/GYN societies along with 4 trainees participated. Eight thematic categories were identified: competency, provision of reproductive health care, residency selection, inequity in training, alternative training, law-based vs evidence-based medicine, morality and ethics, and uncertainty about next steps. Conclusions: This qualitative study of leaders and learners in OB/GYN identified 8 themes of potential impacts of the Dobbs ruling on current and future training in OB/GYN.
Asunto(s)
Ginecología , Internado y Residencia , Obstetricia , Embarazo , Femenino , Humanos , Estados Unidos , Ginecología/educación , Obstetricia/educación , Salud de la Mujer , CurriculumRESUMEN
OBJECTIVE: This study aimed to evaluate the 3- to 5-year retreatment outcomes for conservatively and surgically treated urinary incontinence (UI) in a population of women 66 years and older. METHODS: This retrospective cohort study used 5% Medicare data to evaluate UI retreatment outcomes of women undergoing physical therapy (PT), pessary treatment, or sling surgery. The data set used inpatient, outpatient, and carrier claims from 2008 to 2016 in women 66 years and older with fee-for-service coverage. Treatment failure was defined as receiving another UI treatment (pessary, PT, sling, Burch urethropexy, or urethral bulking) or repeat sling. A secondary analysis was performed where additional treatment courses of PT or pessary were also considered a treatment failure. Survival analysis was used to evaluate the time from treatment initiation to retreatment. RESULTS: Between 2008 and 2013, 13,417 women were included with an index UI treatment, and follow-up continued through 2016. In this cohort, 41.4% received pessary treatment, 31.8% received PT, and 26.8% underwent sling surgery. In the primary analysis, pessaries had the lowest treatment failure rate compared with PT (P<0.001) and sling surgery (P<0.001; survival probability, 0.94 [pessary], 0.90 [PT], 0.88 [sling]). In the analysis where retreatment with PT or a pessary was considered a failure, sling surgery had the lowest retreatment rate (survival probability, 0.58 [pessary], 0.81 [PT], 0.88 [sling]; P<0.001 for all comparisons). CONCLUSIONS: In this administrative database analysis, there was a small but statistically significant difference in treatment failure among women undergoing sling surgery, PT, or pessary treatment, but pessary use was commonly associated with the need for repeat pessary fittings.
Asunto(s)
Cabestrillo Suburetral , Incontinencia Urinaria de Esfuerzo , Incontinencia Urinaria , Femenino , Anciano , Humanos , Estados Unidos , Incontinencia Urinaria de Esfuerzo/cirugía , Estudios Retrospectivos , Medicare , Incontinencia Urinaria/cirugíaRESUMEN
OBJECTIVE: To describe the psychometric properties of existing patient-reported outcome measures for women with prolapse using the COSMIN (Consensus-Based Standards for the Selection of Health Measurement Instruments) framework. Additional objectives were to describe the patient-reported outcome scoring method or interpretation, methods of administration, and to compile a list of the non-English languages in which the patient-reported outcomes are reportedly validated. DATA SOURCES: PubMed and EMBASE was searched through September 2021. Study characteristics, patient-reported outcome details, and psychometric testing data were extracted. Methodologic quality was assessed with COSMIN guidelines. METHODS OF STUDY SELECTION: Studies reporting the validation of a patient-reported outcome in women with prolapse (or women with pelvic floor disorders that included a prolapse assessment) and reporting psychometric testing data on English-language patient-reported outcome for at least one measurement property per COSMIN and the U.S. Department of Health and Human Services definitions were included, as well as studies reporting the translation of an existing patient-reported outcome into another language, a new method of patient-reported outcome administration, or a scoring interpretation. Studies reporting only pretreatment and posttreatment scores, only content or face validity, or only findings for nonprolapse domains of the patient-reported outcome were excluded. TABULATION, INTEGRATION, AND RESULTS: Fifty-four studies covering 32 patient-reported outcomes were included; 106 studies assessing translation into a non-English language were excluded from the formal review. The number of validation studies per patient-reported outcome (one version of one questionnaire) ranged from 1 to 11. Reliability was the most reported measurement property, and most measurement properties received an average rating of sufficient. The condition-specific patient-reported outcomes had on average more studies and reported data across more measurement properties compared with adapted and generic patient-reported outcomes. CONCLUSION: Although measurement property data vary on patient-reported outcomes for women with prolapse, most data were of good quality. Overall, condition-specific patient-reported outcomes had more studies and reported data across more measurement properties. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021278796.
Asunto(s)
Prolapso de Órgano Pélvico , Calidad de Vida , Medición de Resultados Informados por el Paciente , Prolapso de Órgano Pélvico/terapia , Humanos , Femenino , Psicometría , Reproducibilidad de los Resultados , Encuestas y CuestionariosRESUMEN
IMPORTANCE: Overactive bladder (OAB) syndrome and urinary incontinence, age, and comorbid burden are strong risk factors for falls in women. Less is known about their cumulative effects on fall risk in a urogynecologic population. OBJECTIVE: The purpose of this study was to investigate the effects of coexisting OAB, older age, and comorbidities on risk of falling among treatment seeking women with pelvic floor disorders. STUDY DESIGN: We conducted a retrospective medical records review of 348 consecutive women presenting to a urogynecology clinic over 6 months. Fall risk was determined by the Centers for Disease Control and Prevention's, Stopping Elderly Accidents, Deaths, and Injuries screening tool. Clinical and sociodemographic measures were abstracted from the electronic medical record. Odds of screening positive for high fall risk based on different patient profiles were calculated. We then used a classification and regression tree analysis to determine the relative importance of the different variables on fall risk within the homogeneous subgroups. RESULTS: Of the 348 women (mean age, 58.7 ± 15.8 years) who completed the fall risk screen, 124 (36%) screened positive for increased fall risk. Overactive bladder symptoms increased the likelihood of a positive fall risk screen across all combinations of age and comorbid burden. The patient profile of ≥3 OAB symptoms, ≥4 comorbid conditions, and age 65 years or older increased the odds of screening positive for high fall risk more than 6-fold (odds ratio, 6.4; 95% confidence interval, 3.1-12.9). In the following order of importance, the combination of high comorbid burden, OAB, and older age identified approximately 3 in 4 patients (73.3%) at high risk of falling. CONCLUSION: The presence of 3 easily identifiable patient characteristics is strongly associated with a risk of falls in women seeking care for pelvic floor disorders.
Asunto(s)
Trastornos del Suelo Pélvico , Vejiga Urinaria Hiperactiva , Incontinencia Urinaria , Humanos , Femenino , Anciano , Adulto , Persona de Mediana Edad , Vejiga Urinaria Hiperactiva/epidemiología , Estudios Retrospectivos , Trastornos del Suelo Pélvico/epidemiología , Registros Electrónicos de SaludRESUMEN
IMPORTANCE: The impact of language discordance on care for Spanish-speaking patients with pelvic floor disorders is unknown. OBJECTIVE: The aim of this study was to compare the impact of language concordance with the impact of language discordance on the patient experience and trust in their provider. METHODS: This cross-sectional cohort study enrolled English- and Spanish-speaking patients during initial evaluation in a urogynecology clinic. English- and Spanish-speaking patients seen by native English- or Spanish-speaking providers were recruited to the language-concordant group. The language-discordant group included Spanish-speaking patients seen with a translator or by nonnative Spanish-speaking providers. Patients completed the Trust in Physician Scale and the Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey (CG-CAHPS). Patients and providers rated the provider's Spanish proficiency on a 10-point scale from 0 (low) to 10 (high). Symptom bother questionnaires were completed 4-6 months after enrollment. RESULTS: Eighty women were recruited, with 40 in each group. Mean age was 55.4 ± 12.9 years. The majority identified as White (75%) and Hispanic (77.5%). Trust in Physician Scale scores were similar between groups (46.2 ± 8.5 vs 44.4 ± 7.5, P > 0.05). The provider communication, provider rating, and recommendation domains of the CG-CAHPS did not differ between groups (all P > 0.05). Provider self-rating of Spanish proficiency was lower than patient ratings (7.5 ± 1.8 vs 9.8 ± 0.5, P < 0.001). There was no difference between groups in symptom bother at 4-6 months (all P > 0.05). CONCLUSIONS: Patient-provider language discordance does not affect patient trust in the provider or perception of the encounter as measured by the Trust in Physician Scale and CG-CAHPS questionnaires.
Asunto(s)
Barreras de Comunicación , Trastornos del Suelo Pélvico , Confianza , Adulto , Anciano , Femenino , Humanos , Persona de Mediana Edad , Estudios Transversales , Hispánicos o Latinos , Lenguaje , Percepción , BlancoRESUMEN
INTRODUCTION AND HYPOTHESIS: We sought to further develop and validate the Surgical Preparedness Assessment (SPA) scale to evaluate patient preparedness for urogynecological surgery. METHODS: This was a planned ancillary analysis of a randomized controlled trial (RCT) evaluating the impact of a preoperative telehealth call on patient preparedness for urogynecological surgery. Patients completed the Preoperative Preparedness Questionnaire (PPQ), the modified Preparedness for Colorectal Cancer Surgery Questionnaire (PCSQ), the Pelvic Floor Distress Inventory (PFDI-20), the Satisfaction Decision Scale (SDS), and the Decision Regret Scale (DRS). Content validity was established through expert opinion and patient cognitive interviews. Factor analysis identified item grouping into domains. Cronbach's alpha reported internal consistency. Known group validity was assessed by comparing intervention arms. External validity was evaluated by comparing intervention arms and correlations with SDS and DRS. RESULTS: Eleven items and 3 domains met the criteria (information needs, satisfaction and pain, and catheterization). Cronbach's alpha values were acceptable for domains and ranged from 0.74 to 0.93. SPA scores did not correlate with other patient-reported outcomes. Mean SPA scores were lower among women who received a telehealth call vs those who did not (1.30 ± 0.31 vs 1.51 ± 0.44; p = 0.002). CONCLUSIONS: The content-valid SPA demonstrates high internal consistency and known group validity.
Asunto(s)
Trastornos del Suelo Pélvico , Femenino , Humanos , Trastornos del Suelo Pélvico/cirugía , Trastornos del Suelo Pélvico/psicología , Reproducibilidad de los Resultados , Encuestas y Cuestionarios , Diafragma Pélvico , DolorRESUMEN
INTRODUCTION AND HYPOTHESIS: Patient-reported outcome measure instruments include patient-reported outcomes (PROs) and patient-reported goals (PRGs), which allow practitioners to measure symptoms and determine outcomes of treatment that matter to patients. METHODS: This is a structured review completed by the International Urogynecology Consultation (IUC), sponsored by the International Urogynecological Association (IUGA). The aim of this working group was to evaluate and synthesize the existing evidence for PROs and PRGs in the initial clinical work-up/evaluation and research arena for patients with pelvic organ prolapse (POP). RESULTS: The initial search generated 3589 non-duplicated studies. After abstract review by 4 authors, 211 full texts were assessed for eligibility by 2 writing group members, and 199 studies were reviewed in detail. Any disagreements on abstract or full-text articles were resolved by a third reviewer or during video meetings as a group. The list of POP PROs and information on PRGs was developed from these articles. Tables were generated to describe the validation of each PRO and to provide currently available, validated translations. CONCLUSIONS: All patients presenting for POP should be evaluated for vaginal, bladder, bowel and sexual symptoms including their goals for symptom treatment. This screening can be facilitated by a validated PRO; however, most PROs provide more information than needed to provide clinical care and were designed for research purposes.
Asunto(s)
Prolapso de Órgano Pélvico , Femenino , Humanos , Medición de Resultados Informados por el Paciente , Prolapso de Órgano Pélvico/terapia , Derivación y Consulta , TraduccionesRESUMEN
IMPORTANCE: Understanding postoperative opioid consumption is key to reducing opioid misuse. OBJECTIVE: The aim of the study was to quantify the amount of outpatient opioids consumed after urogynecologic surgery. STUDY DESIGN: This is a prospective multicenter cohort study sponsored by the American Urogynecologic Society Fellow's Pelvic Research Network. Women undergoing pelvic organ prolapse or urinary incontinence surgery between May 2019 and January 2021 were included. Patients used text messaging to report daily opioid consumption, pain levels, and nonopioid analgesic consumption 2 weeks postoperatively. Demographic and perioperative factors associated with high opioid use (>75th percentile) were identified. RESULTS: Two hundred sixty-one patients were included from 9 academic centers. The median (interquartile range) morphine milligram equivalents (MME) consumed were 28 (0-65) and prescribed were 75 (50-113). The median ibuprofen and acetaminophen tablets consumed were 19 (10-34) and 12 (4-26). The median pain level was 2.7 of 10 (1.7-4.4). Factors associated with high MME use (>65 MME) included body mass index greater than 30 ( P < 0.01), chronic pain ( P < 0.01), elevated baseline pain score ( P < 0.01), elevated blood loss ( P < 0.01), longer operating time ( P < 0.01), and southern region ( P < 0.01). High MME consumers more frequently underwent perineorrhaphy ( P = 0.03), although this was not significant on multivariate analysis. CONCLUSIONS: Urogynecology patients consume a median of 28 MME (3-4 oxycodone 5-mg tablets) after surgery, and surgeons prescribe 3 times this amount (75 MME, 10 oxycodone tablets). In addition, there are several factors that can be used to identify patients who will require greater numbers of opioids. These data may be used to enhance existing prescribing guidelines.
Asunto(s)
Analgésicos no Narcóticos , Trastornos Relacionados con Opioides , Envío de Mensajes de Texto , Humanos , Femenino , Analgésicos Opioides/uso terapéutico , Oxicodona/uso terapéutico , Analgésicos no Narcóticos/uso terapéutico , Acetaminofén/uso terapéutico , Dolor Postoperatorio/tratamiento farmacológico , Ibuprofeno , Estudios Prospectivos , Estudios de Cohortes , Trastornos Relacionados con Opioides/tratamiento farmacológicoRESUMEN
INTRODUCTION AND HYPOTHESIS: Evidence-based care pathways improve care standardization and patient outcomes. We created pelvic organ prolapse (POP) and stress urinary incontinence (SUI) care pathways as decision aids for our multidisciplinary team to use when counseling patients. METHODS: Using a modified Delphi process, an expert team reviewed existing guidelines and literature to reach consensus on pathway definitions and components. RESULTS: Entry to the care pathways occurs via an advanced practice provider visit. Symptom and quality-of-life questionnaires as well as open-ended patient goals are used to guide patient-provider shared decision making. All treatment choices, including surgical and nonsurgical management, are presented to patients by advanced practice providers. Patients electing nonsurgical management follow-up by telehealth (preferred) or in-person visits as determined by the care pathway. Surgeon consultations are scheduled for patients desiring surgery. Surgical patients undergo urodynamics, simple cystometrics or deferred bladder testing according to the urodynamics clinical pathway. Postoperative follow-up includes telehealth visits and minimizes in-person visits for women with uncomplicated postoperative courses. Patients with resolution of symptoms are graduated from clinic and return to their referring physician. The pathways are revised following publication of new compelling evidence. CONCLUSIONS: We developed POP and SUI care pathways to standardize care across a diverse provider group. Advanced practice providers use care pathways with patients as shared decision-making tools for initial evaluation of patients with prolapse and incontinence. These pathways serve as components of value-based care and encourage team members to function independently while utilizing the full scope of their training.
Asunto(s)
Trastornos del Suelo Pélvico , Prolapso de Órgano Pélvico , Cirujanos , Incontinencia Urinaria de Esfuerzo , Vías Clínicas , Toma de Decisiones Conjunta , Femenino , Humanos , Trastornos del Suelo Pélvico/complicaciones , Prolapso de Órgano Pélvico/complicaciones , Prolapso de Órgano Pélvico/cirugía , Incontinencia Urinaria de Esfuerzo/etiología , Incontinencia Urinaria de Esfuerzo/cirugíaRESUMEN
INTRODUCTION AND HYPOTHESIS: Methods to increase surgical preparedness in urogynecology are lacking. Our objective was to evaluate the impact of a preoperative provider-initiated telehealth call on surgical preparedness. METHODS: This was a multicenter randomized controlled trial. Women undergoing surgery for pelvic organ prolapse and/or stress urinary incontinence were randomized to either a telehealth call 3 (± 2) days before surgery plus usual preoperative counseling versus usual preoperative counseling alone. Our primary outcome was surgical preparedness, as measured by the Preoperative Prepardeness Questionnaire. The Modified Surgical Pain Scale, Pelvic Floor Distress Inventory-20, Patient Global Impressions of Improvement, Patient Global Impressions of Severity, Satisfaction with Decision Scale, Decision Regret Scale, and Clavien-Dindo scores were obtained at 4-8 weeks postoperatively and comparisons were made between groups. RESULTS: Mean telehealth call time was 11.1 ± 4.11 min. Women who received a preoperative telehealth call (n = 63) were significantly more prepared for surgery than those who received usual preoperative counseling alone (n = 69); 82.5 vs 59.4%, p < 0.01). A preoperative telehealth call was associated with greater understanding of surgical alternatives (77.8 vs 59.4%, p = 0.03), complications (69.8 vs 47.8%, p = 0.01), hospital-based catheter care (54 vs 34.8%, p = 0.04) and patient perception that nurses and doctors had spent enough time preparing them for their upcoming surgery (84.1 vs 60.9%, p < 0.01). At 4-8 weeks, no differences in postoperative and patient reported outcomes were observed between groups (all p > 0.05). CONCLUSIONS: A short preoperative telehealth call improves patient preparedness for urogynecological surgery.
Asunto(s)
Prolapso de Órgano Pélvico , Telemedicina , Incontinencia Urinaria de Esfuerzo , Femenino , Humanos , Diafragma Pélvico , Prolapso de Órgano Pélvico/cirugía , Cuidados Preoperatorios/métodos , Incontinencia Urinaria de Esfuerzo/cirugíaRESUMEN
OBJECTIVE: To describe the timing, quality and patient concerns regarding the first sexual encounter after surgery for pelvic organ prolapse (POP) or urinary incontinence (UI). METHODS: Women scheduled to undergo POP or UI surgery who self-identified as sexually active were recruited to this qualitative study. Routine counseling regarding the return to sexual activity was provided 4-6 weeks postoperatively. Participants completed interviews 2-4 months after their surgery. Interviews were tape recorded, de-identified, and transcribed. Transcriptions were coded for major themes by two independent researchers; disagreements were arbitrated by the research team. Analysis was performed using Dedoose software. RESULTS: Twenty patients with an average age of 52.4 years participated. Most identified themselves as White (85%), one quarter had a history of hysterectomy, and 15% had previously undergone pelvic reconstructive surgery. Nineteen (95%) patients resumed intercourse 2-4 months after surgery. Thematic saturation was reached with major themes of Outside Influences, Conflicting Emotions, Uncertainty, Sexual Changes and Stability, Normalization, and Self-Image. First sexual encounter timing was strongly influenced by partners' desires and fears and physician counseling. Fear of damage to repairs affected patients' comfort with return to sexual activity. Although uncertain of how anatomical changes or presence of mesh would affect function, women hoped that changes would be positive, regardless of preoperative sexual function. Some women found their experience unchanged, whereas others reported need for change in sexual position, use of lubrication, and sensation of foreign body. Positive changes included increase in desire, pleasure, and improvement in orgasm. Self-image generally improved after surgery, which increased women's sexual confidence. CONCLUSION: The return to sexual activity after surgery for POP or UI represents a great unknown for many women. Reports of initial sexual activity after surgery are often positive, and physicians strongly influence initial postoperative sexual encounter timing. Frank counseling about patient and partners' fears regarding the effect of repair on sexual activity would likely improve patients' outcomes.
Asunto(s)
Prolapso de Órgano Pélvico/cirugía , Conducta Sexual , Incontinencia Urinaria/cirugía , Femenino , Humanos , Entrevistas como Asunto , Persona de Mediana Edad , Periodo Posoperatorio , Encuestas y CuestionariosRESUMEN
OBJECTIVES: Colocated services in a team-based integrated practice unit (IPU) optimize care of pelvic floor disorders. Our goal was to compare ancillary service utilization in a multidisciplinary IPU between patients covered by a bundled payment model (BPM) versus a traditional fee-for-service model (FFSM). METHODS: Medical records of women attending an IPU for pelvic floor disorders with colocated services, including nutrition, social work, psychiatry, physical therapy, and subspecialty care between October 2017 and December 2018, were included in this retrospective chart review. All patients were offered treatment with ancillary services according to standardized care pathways. Data extracted included patient demographics, pelvic floor disorder diagnoses, baseline severity measures, payment model, and ancillary services used. Univariate and multivariate logistic regression identified variables predicting higher uptake of ancillary services. RESULTS: A total of 575 women with pelvic floor disorders presented for care during the study period, of which 35.14% attended at least 1 appointment with any ancillary services provider. Ancillary service utilization did not differ between patients in the BPM group and those in the FFSM group (36.22 vs 33.47%; P = 0.489). Social work services were more likely to be used by the BPM compared with the FFSM group (15.95 vs 6.28%; P < 0.001). The diagnosis of fecal incontinence was associated with a higher chance of using any ancillary service (odds ratio, 4.91; 95% confidence interval, 1.81-13.33; P = 0.002). CONCLUSIONS: One third of patients with pelvic floor disorders receiving care in an IPU used colocated ancillary services. Utilization does not differ between payment models.
Asunto(s)
Servicios Técnicos en Hospital/estadística & datos numéricos , Planes de Aranceles por Servicios/estadística & datos numéricos , Paquetes de Atención al Paciente/estadística & datos numéricos , Femenino , Humanos , Persona de Mediana Edad , Trastornos del Suelo Pélvico/epidemiología , Trastornos del Suelo Pélvico/terapia , Estudios Retrospectivos , Estados UnidosRESUMEN
OBJECTIVES: To evaluate if age and medical comorbidities are associated with progression to implantation of sacral neuromodulation devices in women with symptomatic chronic urinary retention. METHODS: This multisite retrospective cohort included women with symptomatic chronic urinary retention who had a trial phase of sacral neuromodulation. The primary outcome was progression to implantation. Post-implantation outcomes were assessed as stable response versus decreased efficacy. A sub-analysis of catheter-reliant (intermittent-self catheterization or indwelling) patients was performed. Age was analyzed by 10-year units (decades of age). Multivariate logistic regression determined odds ratios for outcomes of implantation and for post-implantation stable response. RESULTS: Implantation occurred in 86% (243/284) women across six academic institutions. Most patients (160/243, 66%) were catheter reliant at the time of trial phase. Increased decade of age was associated with reduced implantation in all women [OR 0.54 (95% CI 0.42, 0.70)] and in the subgroup of catheter-reliant women [OR 0.52 (95% CI 0.37, 0.73)]. Post-implantation stable response occurred in 68% (193/243) of women at median follow-up of 2 years (range 0.3-15 years). Medical comorbidities present at the time of trials did not impact progression to implantation or post-implantation success. CONCLUSIONS: Increasing decade of age is associated with reduced implantation in women with symptomatic chronic urinary retention. There is no age cutoff at which outcomes change. Post-implantation stable response was not associated with age or medical comorbidities.
Asunto(s)
Terapia por Estimulación Eléctrica , Retención Urinaria , Femenino , Humanos , Estudios Retrospectivos , Sacro , Resultado del Tratamiento , Retención Urinaria/terapiaRESUMEN
INTRODUCTION AND HYPOTHESIS: Fecal incontinence treatment goals are understudied and are not described for women presenting to care. Our objective was to explore patient-reported goals for fecal incontinence management among women presenting for care at a pelvic floor disorders clinic and develop a conceptual framework that captures the range of desired treatment outcomes. METHODS: A qualitative analysis of patient-reported goals for women with fecal incontinence attending a pelvic floor disorders clinic from October 2017-November 2019 was conducted. A team-based approach was used to identify themes and emerging concepts and develop a conceptual framework. RESULTS: One hundred patients met the inclusion criteria. Mean age was 58 ± 14 years; 67% were White and 46% non-Hispanic. Seventy-nine percent of women had diagnosis(es) of prolapse, urinary complaints, or another pelvic floor disorder. From 230 unique goals identified, five thematic categories emerged: Emotional Status, Functional Status, Concurrent Pelvic Floor Disorders, Care Seeking, and Treatment Aspirations. Thematic domains not previously represented in other qualitative work include patients' focus on treatment for global pelvic health rather than solely on fecal incontinence and treatment aspirations ranging from improvement to cure. Our model captures the close relationship between all pelvic floor disorders and emotion, which in return affects all facets of care. CONCLUSIONS: Women with fecal incontinence report a range of treatment goals from improvement to complete resolution of symptoms. Focusing treatment on patient goals by addressing global pelvic health and negotiating realistic treatment outcomes may improve care in this population.
Asunto(s)
Incontinencia Fecal , Trastornos del Suelo Pélvico , Adulto , Anciano , Femenino , Objetivos , Humanos , Persona de Mediana Edad , ProlapsoRESUMEN
OBJECTIVE: To evaluate if age and comorbidities are associated with progression from trial phase to implantation of an implantable pulse generator in women with overactive bladder. METHODS: This multisite retrospective cohort included women with overactive bladder with or without urinary incontinence who had a trial phase for sacral neuromodulation. The primary outcome was progression to implantation. A sub-analysis of implanted patients was performed for the outcome of additional therapies or "implant only" for the duration of follow-up. Multivariate logistic regression models including potential predictors of implantation and post-implantation addition of therapies were performed. RESULTS: At six academic institutions, 91% (785/864) of patients progressed to implantation. Post-implantation success was achieved by 69% (536/782) of patients at median follow-up of 2 (range 0.3 to 15) years. Odds of implantation [OR 0.73 (CI 0.61, 0.88)] and post-implantation success [OR 0.78 (CI 0.98, 0.97)] were lower with increasing decades of age. Medical comorbidities evaluated did not affect implantation rates or post-implant success. CONCLUSIONS: Most women have successful sacral neuromodulation trials despite older age and comorbidities. Higher decade of age has a negative effect on odds of implantation and is associated with addition of therapies post-implantation. Comorbidities assessed in this study did not affect implantation or addition of therapies post-implantation. Most women add therapies to improve efficacy post-implantation, and explantation rates are low.
Asunto(s)
Terapia por Estimulación Eléctrica , Vejiga Urinaria Hiperactiva , Anciano , Femenino , Humanos , Plexo Lumbosacro , Estudios Retrospectivos , Sacro , Resultado del Tratamiento , Vejiga Urinaria Hiperactiva/terapiaRESUMEN
Ineffective healthcare delivery and expenditures associated with the traditional fee for service in-person models have turned attention toward alternative payment models as a means of enhancing healthcare quality in the United States. Bundled care payment models are a form of alternate payment models that provide a single reimbursement for all services rendered for an episode of care and have been developed extensively in primary care settings with limited literature in urogynecology. We describe the process used to create a bundled care payment model for women seeking care in a subspecialty clinic for pelvic floor disorders in partnership with our safety net insurer. The process included estimation of prior average spend, the design of an integrated practice unit, creation of pelvic floor pathways, approximation of utilization rates, and estimation of reimbursement and expenses.
Asunto(s)
Costos de la Atención en Salud , Paquetes de Atención al Paciente , Trastornos del Suelo Pélvico/terapia , Calidad de la Atención de Salud , Mecanismo de Reembolso , Técnicas de Diagnóstico Obstétrico y Ginecológico , Técnicas de Diagnóstico Urológico , Femenino , Procedimientos Quirúrgicos Ginecológicos , Humanos , Visita a Consultorio Médico , Trastornos del Suelo Pélvico/diagnóstico , Telemedicina , Estados Unidos , Procedimientos Quirúrgicos UrológicosRESUMEN
INTRODUCTION AND HYPOTHESIS: The COVID-19 pandemic and the desire to "flatten the curve" of transmission have significantly affected the way providers care for patients. Female Pelvic Medicine and Reconstructive Surgeons (FPMRS) must provide high quality of care through remote access such as telemedicine. No clear guidelines exist on the use of telemedicine in FPMRS. Using expedited literature review methodology, we provide guidance regarding management of common outpatient urogynecology scenarios during the pandemic. METHODS: We grouped FPMRS conditions into those in which virtual management differs from direct in-person visits and conditions in which treatment would emphasize behavioral and conservative counseling but not deviate from current management paradigms. We conducted expedited literature review on four topics (telemedicine in FPMRS, pessary management, urinary tract infections, urinary retention) and addressed four other topics (urinary incontinence, prolapse, fecal incontinence, defecatory dysfunction) based on existing systematic reviews and guidelines. We further compiled expert consensus regarding management of FPMRS patients in the virtual setting, scenarios when in-person visits are necessary, symptoms that should alert providers, and specific considerations for FPMRS patients with suspected or confirmed COVID-19. RESULTS: Behavioral, medical, and conservative management will be valuable as first-line virtual treatments. Certain situations will require different treatments in the virtual setting while others will require an in-person visit despite the risks of COVID-19 transmission. CONCLUSIONS: We have presented guidance for treating FPMRS conditions via telemedicine based on rapid literature review and expert consensus and presented it in a format that can be actively referenced.