Discordance between beliefs and recommendations of gynecologic oncologists in ovarian cancer management.

PURPOSE: The purpose of this study was to determine how physician experts make decisions for clinical scenarios in ovarian cancer and describe a profile of factors reported to influence treatment decisions. METHODS: A questionnaire was sent to Full Members of the Society of Gynecologic Oncologists regarding surgery and chemotherapy for scenarios of primary and recurrent ovarian cancer. RESULTS: In a scenario of primary presentation, 94% of respondents chose a treatment of tumor resection over chemotherapy. Despite the preference for surgery in a clinical scenario, 50% agreed with a statement that neoadjuvant chemotherapy is equivalent to primary surgery. In a scenario of recurrent disease, a comparable number of respondents chose a treatment of secondary cytoreductive surgery (45%) versus direct retreatment with chemotherapy (49%). Those choosing surgery responded that they believed in extensive surgery to achieve optimal cytoreduction. Most (62%) respondents described themselves as collaborative in treatment planning, yet only 24% reported that patient preference strongly influences their decision making. CONCLUSIONS: Although a plan for primary cytoreduction is favored, in specific scenarios, views were divided for the role of neoadjuvant chemotherapy. For a recurrent disease scenario, support was divided between secondary cytoreductive surgery and direct retreatment with chemotherapy. Further clinical research is necessary to minimize the discordance between physician beliefs and recommendations.

Procedure-related miscarriages and Down syndrome-affected births: implications for prenatal testing based on women's preferences.

OBJECTIVE: To determine how pregnant women of varying ages, races, ethnicities, and socioeconomic backgrounds value procedure-related miscarriage and Down-syndrome-affected birth. METHODS: We studied cross-sectionally 534 sociodemographically diverse pregnant women who sought care at obstetric clinics and practices throughout the San Francisco Bay area. Preferences for procedure-related miscarriage and the birth of an infant affected by Down syndrome were assessed using the time trade-off and standard gamble metrics. Because current guidelines assume that procedure-related miscarriage and Down syndrome-affected birth are valued equally, we calculated the difference in preference scores for those two outcomes. We also collected detailed information on demographics, attitudes, and beliefs. RESULTS: On average, procedure-related miscarriage was preferable to Down syndrome-affected birth, as evidenced by positive differences in preference scores for them (time trade-off difference: mean = 0.09, median = 0.06; standard gamble difference: mean = 0.11, median = 0.02; P <.001 for both, one-sample sign test). There was substantial subject-to-subject variation in preferences that correlated strongly with attitudes about miscarriage, Down syndrome, and diagnostic testing. CONCLUSION: Pregnant women tend to find the prospect of a Down syndrome-affected birth more burdensome than a procedure-related miscarriage, calling into question the equal risk threshold for prenatal diagnosis. Individual preferences for those outcomes varied profoundly. Current guidelines do not appropriately consider individual preferences in lower-risk women, and the process for developing prenatal testing guidelines should be reconsidered to better reflect individual values.

Neonatal circumcision: a dispassionate analysis.

PIP: This review provides a dispassionate analysis of the evidence on the benefits and risks of neonatal circumcision. The evidence is considered within a clinically relevant framework in which decision-making relies on three interrelated factors: 1) clinical experience, 2) scientific evidence, and 3) patient preference. The roles of patient preference and clinical experience are outlined; then health benefits, risks, and economic costs of circumcision are explored. The most commonly proposed benefits of circumcision are prevention of penile inflammatory disorders, urinary tract infections, penile cancer, and sexually transmitted diseases. Meanwhile, the short-term risks of circumcision include surgical complications and the infliction of pain and distress on the neonate. A potential long-term consequence of the procedure is sexual dysfunction. In considering the cost-effectiveness of circumcision, the following areas are taken into account: 1) economic data on the direct and indirect cost of the procedure and subsequent care, 2) valid estimates of the probability of events prevented and events cause by the intervention, and 3) an accurate estimate of the circumcision's impact on health status. Evidence of the technical aspects of circumcision, namely, the surgical and anesthetic techniques, are also reviewed.^ieng

Regional differences in operative obstetrics: a look to the South.

OBJECTIVE: To compare operative delivery rates across regions of the United States from 1987 to 1994 and to evaluate how the rates of severe obstetric lacerations changed during the same period. METHODS: I used diagnosis and procedure data from the National Hospital Discharge Survey and natality data from the National Center for Health Statistics to describe temporal and regional variations in the rates of cesarean, forceps, and vacuum delivery. I described temporal trends in the rates of cervical and severe perineal lacerations during the same period. I performed exploratory analyses of detailed 1990 data to test for regional differences in demographic risk factors that might explain differences in operative delivery rates. RESULTS: Between 1987 and 1994, cesarean delivery rates fell from approximately 25% to less than 22% in all regions except the South. Operative vaginal delivery rates were stable at 10-12% and were consistently lowest in the Northeast (8.2% in 1994) and highest in the South (12.9% in 1994). Vacuum surpassed forceps deliveries in all regions except the South. The rates of cervical and fourth-degree perineal lacerations declined by 57% and 40%, respectively, whereas the rate of third-degree lacerations did not decline. Demographic risk factors for cesarean delivery were no more prevalent in the South than in other regions. Age under 25 years was the only demographic risk factor for forceps delivery that was more prevalent in the South. CONCLUSION: In all but the southern United States, cesarean delivery rates declined and vacuum surpassed forceps delivery. These regional differences are not explained by differences in demographic risk factors.

Prevalence of sexual assault history among women with common gynecologic symptoms.

OBJECTIVE: The purpose of this study was to evaluate the prevalence of a sexual assault history among women with and without 3 common gynecologic complaints: dysmenorrhea, menorrhagia, and sexual dysfunction. STUDY DESIGN: Data came from 3 surveys of women randomly selected from general populations: 2 United States regional samples (n = 1428 and n = 1703) and 1 national sample (n = 963). Prevalence rates and adjusted odds ratios were calculated and combined across the 3 samples with a meta-analysis. RESULTS: The prevalence of an assault history ranged from 6% to 26% among women with 1 symptom to 13% to 40% among women with 3 symptoms. Symptoms were associated with increased odds of an assault history for women 18 to 34 years old (odds ratio 1.90, 95% confidence interval 1.56 to 2.32), 35 to 44 years old (odds ratio 1.99, 95% confidence interval 1.57 to 2.53), and >54 years old (odds ratio 1.37, 95% confidence interval 1.04 to 1.80). Symptoms were unrelated to sexual assault history for women in the perimenopausal (45 to 54 years) age group (odds ratio 0.94, 95% confidence interval 0.71 to 1.24). Symptom level was unrelated to having disclosed assaults to a physician (odds ratio 1.17, 95% confidence interval 0.85 to 1.62). CONCLUSIONS: Women in the general population with common gynecologic complaints are at a substantially increased risk of having a history of sexual assault.

Teaching critical appraisal to medical students in obstetrics and gynecology.

Critical appraisal might be the most important skill to acquire in medical school. Despite its importance, this issue has received little attention in obstetrics and gynecology training. This article describes the approach used at San Francisco General Hospital. We teach critical appraisal in several ways. We provide a series of student seminars that foster critical reading of the literature. Topics range from technology assessment to contraception to sexually transmitted diseases. Evidence-based ward rounds complement the experience. During the rotation, each student formally reviews one topic in women's health using the US Preventive Services Task Force rating system. Although we lack a quantitative assessment of this approach, student feedback has been enthusiastic. Critical appraisal skills enable students to continue their medical education after completion of their formal training.

Human immunodeficiency virus test refusal in pregnancy: a challenge to voluntary testing.

OBJECTIVE: To determine if awareness of methods to reduce vertical transmission of human immunodeficiency virus (HIV) is associated with HIV test acceptance and to clarify patients' attitudes toward routine versus elective prenatal HIV testing. METHODS: In a cross-sectional study, 247 antenatal patients were surveyed regarding HIV knowledge, self-perceived HIV risk, and willingness to learn a positive test result. This information, along with demographic and risk factor data, was related to HIV test acceptance. Patients also indicated their attitudes toward routine versus elective prenatal testing for HIV and other common prenatal screening tests. RESULTS: Seventy-two percent of antenatal patients accepted HIV testing. Test acceptance was not associated with the presence of risk factors, self-perceived HIV risk, or demographic factors, including race and ethnicity. Test acceptance was associated positively with patients' knowledge of a medical intervention to reduce vertical transmission and their willingness to learn a positive HIV test result. Only 24% of patients knew that the risk of vertical transmission could be reduced using medication. Sixty-nine percent of patients said that prenatal HIV testing should be routine, whereas 27% said that it should be done only after specific written consent. As a group, our patients viewed HIV screening no differently from screening for other infections in pregnancy. CONCLUSION: Interventions aimed at increasing HIV testing rates among pregnant women should focus on educating patients about vertical transmission reduction and promising new therapies for HIV infection. Proponents of elective testing should re-evaluate the assumption that patients view HIV testing differently from other prenatal tests for which separate written consent is not required.

Rapid hospital discharge following laparoscopy for ectopic pregnancy. A promise unfulfilled?

This study was done to determine whether laparoscopy for ectopic pregnancy in the United States is associated with rapid postoperative discharge, defined as 2 days or less, and to estimate how often ambulatory treatment of ectopic pregnancy occurs without subsequent hospital admission. We used the National Hospital Discharge Survey to estimate the frequency of ectopic pregnancy admissions, operations, and length of hospital stays in 1990. We used the National Ambulatory Medical Care Survey to estimate the number, type, and disposition of office visits for ectopic pregnancy in 1990. According to National Hospital Discharge Survey data, tubal pregnancy led to an estimated 57,000 hospital admissions in 1990. Most (70%) of the 26,000 patients treated with laparoscopy were in the hospital 3 days or more, and most (73%) underwent salpingectomy. The number of ambulatory visits for ectopic pregnancy was too low to estimate reliably according to the standards of the National Center for Health Statistics. We found that laparoscopy was used frequently for the treatment of ectopic pregnancy but was not associated with rapid postoperative discharge. Further research is needed to determine whether these findings persist and whether reimbursement incentives, patient preference, or problems with the diffusion of technology are responsible.

The Women's Health Curriculum by a problem-based learning method for medical students at the University of California, San Francisco.

OBJECTIVES: Our objectives were to (1) expand and strengthen the women's health curriculum at the University of California, San Francisco, and (2) evaluate the responses of both medical students and faculty to this curriculum. STUDY DESIGN: A written evaluation of the curriculum in women's health was completed by both students and faculty. Variables studied included mean scores of cases, the overall course score, and the preferences of medical students for faculty specialty in teaching the small groups. RESULTS: The overall course evaluation score was 7.81 (range 1 to 10). For those students who had both faculty from internal medicine or family medicine and obstetrics and gynecology, there was a strong preference that obstetrician-gynecologists teach the majority of the cases. CONCLUSIONS: The new case-based curriculum in women's health was enthusiastically received by both medical students and faculty.

Operations for stress urinary incontinence in the United States, 1988-1992.

OBJECTIVES: To determine the frequency and cost of operations for stress urinary incontinence in the United States. METHODS: We reviewed data from the 1988-1992 National Hospital Discharge Surveys and the 1991 California Office of Statewide Health Planning Survey. We determined the frequency and type of surgical procedures performed for stress urinary incontinence and estimated the total direct costs of these operations in the United States. RESULTS: From 1988 to 1992, the total number of operations for stress incontinence increased from 78,000 to over 100,000. The rate of operations increased most in women older than 65 years of age. The total direct cost for treatment of stress urinary incontinence in the United States in 1991 was about $0.5 billion. CONCLUSIONS: Operations for treatment of stress urinary incontinence are increasing in frequency in the United States. They are both more commonly performed and more costly than have been previously reported.

Predictors of repeat cesarean delivery after trial of labor: do any exist?

BACKGROUND: We evaluated the predictive value of risk factors for repeat cesarean delivery identified in retrospective studies. STUDY DESIGN: We identified 175 consecutive patients who underwent trial of labor (TOL) and compared detailed admission, intrapartum, and postpartum characteristics of those who required repeat cesarean delivery with those who had vaginal births. We calculated relative risks, positive predictive values, and sensitivities for potentially predictive admission characteristics. We also performed multiple logistic regression and classification analyses. RESULTS: Ninety-five percent of eligible patients underwent a TOL, and 85 percent of them delivered vaginally. Patients who had labor induced and patients with high fetal station on admission were significantly more likely to require repeat cesarean section (relative risk [RR]=2.9 and 2.1; 95 percent confidence interval [CI]=1.5 to 5.3, 1.1 to 4.2, respectively), but even these patients had high rates of vaginal birth (67 percent and 75 percent, respectively). A subgroup of patients who underwent labor induction and had large fetuses (estimated weight 3,800 g or more) had a 75 percent risk of cesarean delivery (RR=2.5, 95 percent CI=0.9 to 7.5). Multivariate models using different combinations of admission characteristics could not correctly identify which patients would require repeat cesarean delivery. CONCLUSIONS: Admission characteristics with statistically significant risk ratios have low predictive values because of the extremely low rate of repeat cesarean delivery in this population. A larger series is needed to study TOL outcomes in patients with large fetuses who are being induced. We conclude that until risk factors with high predictive value for repeat cesarean delivery are identified, all eligible patients should be encouraged to undergo a TOL.

Pygmalion in the nursing home. The effects of caregiver expectations on patient outcomes.

Several characteristics of nursing home care can diminish rather than enhance the clinical status of older residents. In view of evidence from other settings that "interpersonal expectancy effects" can influence outcomes in a variety of relations, we conducted a randomized controlled trial to test the effects of caregiver expectations on the clinical status of nursing home residents. Within 2 weeks of admission, 63 older residents at six nursing homes were given a comprehensive assessment of cognitive, functional, and emotional status. Residents were then randomly assigned to a "high-expectancy" or "average-expectancy" condition. Nurses and aides were told that, in comparison with other residents having similar problems, residents in the high-expectancy group were predicted to perform above average in their rehabilitation. The assessment was repeated 3 months later; information on the health and psychosocial status of residents was drawn from their medical records covering the same period. Aides reported having higher expectations for treatment group residents. When assessed by a blinded research assistant, residents in the high-expectancy group experienced greater relief of depressive symptoms but showed greater decrements in functional independence in comparison with control residents. Treatment group residents were admitted significantly less frequently to hospitals despite a comparable number of emergency ward visits, suggesting a lower incidence of severe illness despite comparable medical surveillance. There was also a trend toward improved performance in mental status testing among the high-expectancy residents compared with controls (P = .08). Additional research is needed to define further the magnitude and mechanisms of expectancy effects in relations between nursing home caregivers and residents.