Summative Evaluation of Vaginal Surgery Skills: Setting A Pass-Fail Score.

INTRODUCTION AND HYPOTHESIS: We developed a summative assessment tool to evaluate competent performance on three procedure-specific low fidelity simulation models for vaginal surgery. Our purpose was to determine a pass-fail score for each model. METHODS: We enrolled participants (2011-2023, three Canadian academic centers) and grouped them according to operative competency in vaginal procedures. Novice operators were medical students recruited through targeted advertisement to clerkship level medical students. Proficient operators consisted of gynecology residents from the intervention arm of a randomized controlled trial, trained to competence in the use of the models; urogynecology fellows and attending gynecologic surgeons recruited through departmental rounds. All participants were asked to perform the three procedures on the models, were videotaped, and their performance assessed by evaluators familiar with the procedure and the scoring system, blinded to operator identity. A total performance score (range 0-400) assessed timing and errors. Basic skill deductions were set a priori. We calculated sensitivity and specificity scores and obtained an optimal cutoff based on Youden's J statistic. RESULTS: For anterior repair, we rated 46 novice and 16 proficient videos. The pass-fail score was 170/400. For posterior repair, we rated 54 novice and 14 proficient videos. The pass-fail score was 140/400. For vaginal hysterectomy, we rated 47 novice and 12 proficient videos. The pass-fail score was 180/400. Scores of proficient operators were significantly better than those of novice participants (p < 0.001 for all). CONCLUSIONS: A pass-fail score can distinguish between novice and proficient operators and can be used for summative assessment of surgical skill.

Assessing the impact of obesity on surgical quality outcomes among patients undergoing hysterectomy for benign, non-urgent indications.

OBJECTIVE: To evaluate the impact of body mass index (BMI) on surgical quality metrics for patients undergoing benign, non-urgent hysterectomy. STUDY DESIGN: A multicentre, retrospective review at 7 hospitals in Ontario, Canada (4 academic, 3 community) was conducted. Patients undergoing hysterectomy from July 2016 to June 2019 were included. Hysterectomies for premalignant, malignant and emergency indications were excluded. The primary outcome was a composite of any complication or readmission. Secondary outcomes were grade 2 or greater complication, postoperative emergency department (ED) visit, hospital readmission, operative time (ORT) and estimated blood loss (EBL). Patient characteristics (age, ASA class, preoperative diagnoses, preoperative anemia, prior surgeries), surgical factors (endometriosis, adhesions, hysterectomy route, uterine weight, concomitant procedures, ORT, EBL) and surgeon characteristics (volume, fellowship/generalist training, academic/community hospital) were recorded along with complications, hospital readmissions and ED visits. Outcomes were evaluated using logistic regression and log-regression linear analysis grouping patients by BMI category (normal, overweight, obesity class 1, 2, and 3) and by hysterectomy route (abdominal, laparoscopic, and vaginal). RESULTS: 2528 hysterectomies were performed by 67 surgeons. 828 (33%) patients had a normal BMI, 889 (35%) were overweight. 500 (20%) patients had a BMI corresponding to obesity class 1, 205 (8%) class 2 and 106 (4%) class 3. Obese patients had higher ASA class (p <.001) and more prior surgeries (p <.001) compared to patients with normal BMI. Those with class 2 and 3 obesity were younger (p <.001), had greater uterine weight (p <.001) and more intra-operative adhesions (p <.001). After controlling for covariates, there were no differences in the odds of the primary or secondary outcomes, with the exception of patients with class 2 obesity who underwent vaginal hysterectomy. They had 9.1% (11 min) significantly longer ORT (0.091, 95% CI 0.002-0.18, p <.05) and patients with an overweight BMI who underwent vaginal hysterectomy had 28 ml significantly less EBL (-0.154, 95% CI -0.26 to -0.05, p <.01) compared to patients with normal BMI. CONCLUSION: BMI was not independently associated with surgical quality outcomes in patients undergoing hysterectomy for benign, non-urgent indications. Abdominal, laparoscopic, and vaginal hysterectomy can be performed safely in overweight and obese patients.

Oncology training and education initiatives in low and middle income countries: a scoping review.

BACKGROUND: The global cancer burden falls disproportionately on low and middle-income countries (LMICs). One significant barrier to adequate cancer control in these countries is the lack of an adequately trained oncology workforce. Oncology education and training initiatives are a critical component of building the workforce. We performed a scoping review of published training and education initiatives for health professionals in LMICs to understand the strategies used to train the global oncology workforce. METHODS: We searched Ovid MEDLINE and Embase from database inception (1947) to 4 March 2020. Articles were eligible if they described an oncology medical education initiative (with a clear intervention and outcome) within an LMIC. Articles were classified based on the target population, the level of medical education, degree of collaboration with another institution and if there was an e-learning component to the intervention. FINDINGS: Of the 806 articles screened, 25 met criteria and were eligible for analysis. The majority of initiatives were targeted towards physicians and focused on continuing medical education. Almost all the initiatives were done in partnership with a collaborating organisation from a high-income country. Only one article described the impact of the initiative on patient outcomes. Less than half of the initiatives involved e-learning. CONCLUSIONS: There is a paucity of oncology training and education initiatives in LMICs published in English. Initiatives for non-physicians, efforts to foster collaboration within and between LMICs, knowledge sharing initiatives and studies that measure the impact of these initiatives on developing an effective workforce are highly recommended.

Impact of Minimally Invasive Gynaecology Fellowship Training on Quality Performance Metrics for Hysterectomy.

OBJECTIVE: To evaluate differences in quality metrics between hysterectomies performed by fellowship-trained surgeons and those performed by generalists. METHODS: Retrospective review of 2845 consecutive hysterectomies by 75 surgeons (23 fellowship-trained, 52 generalists) at 7 hospitals in Ontario, Canada. The primary outcome was a composite of any complication or return to the emergency department (ED) within 30 days of hysterectomy. Secondary outcomes were 2 quality outcome measures (grade of complication and return to ED within 30 days) and 4 quality process measures (minimally invasive hysterectomy rate, rate of preoperative anemia, same-day discharge for laparoscopic hysterectomy [LH], and performing cystoscopy at LH). RESULTS: Fellowship-trained surgeons were more likely to perform concurrent resection of endometriosis, bilateral ureterolysis, lysis of adhesions, uterine/internal iliac artery ligation, and morcellation (all P < 0.001). Generalists performed more vaginal procedures, including vaginal repair, vault suspension, and insertion of mid-urethral sling (all P < 0.001). After controlling for patient and surgical factors, there was no difference in the primary outcome (adjusted odds ratio [aOR] 1.07; 95% CI 0.79-1.45, P = 0.667). Fellowship-trained surgeons were more likely to perform minimally invasive hysterectomy (aOR 2.38; 95% CI 1.15-4.93, P = 0.020), had higher rates of same-day discharge for LH (aOR 2.23; 95% CI 1.31-3.81, P = 0.003), and were more likely to perform cystoscopy (unadjusted OR 2.94; 95% CI 2.30-3.85, P < 0.001). There were no differences in the rates of preoperative anemia, surgical complications, and ED visits. CONCLUSION: Differences exist between fellowship-trained surgeons and generalists regarding case mix and process quality metrics. Postoperative complications and readmissions were comparable for both groups of surgeons.

Unnecessary bilateral salpingo-oophorectomy at the time of hysterectomy and potential for ovarian preservation.

OBJECTIVE: To evaluate predictors of bilateral salpingo-oophorectomy at hysterectomy and determine rate of unnecessary bilateral salpingo-oophorectomy. METHODS: Retrospective review of hysterectomies at six Ontario, Canada hospitals from July 2016 to June 2018. Data was extracted from health records coding and electronic medical records. Of patients with concurrent bilateral salpingo-oophorectomy, age, preoperative diagnoses, surgical factors (presence of endometriosis/adhesions), and surgeon training (fellowship/no fellowship) were recorded. Chi-square tests compared indicated and nonindicated bilateral salpingo-oophorectomy cases based on preoperative diagnosis. Criteria for unnecessary bilateral salpingo-oophorectomy were: age under 51 years, benign preoperative diagnosis, and absence of intraoperative endometriosis and adhesions. RESULTS: Concurrent bilateral salpingo-oophorectomy occurred in 749/2,656 (28%) cases with 509/749 (68%) indicated based on preoperative diagnosis. There was interhospital variation in rate of indicated bilateral salpingo-oophorectomy based on preoperative diagnosis (45.3%-76.9%, χ2P < 0.001). Concurrent bilateral salpingo-oophorectomy at academic centers was more likely to have preoperative indications versus those at community hospitals (70% vs 63%, OR 1.42, 95% CI 1.02-1.97, P = 0.04). BSO performed by fellowship-trained surgeons were more likely to be indicated than those performed by generalists (75% vs 63%, OR 1.76, 95% CI 1.26-2.44, P = 0.001). Of patients without preoperative indications for bilateral salpingo-oophorectomy, 105/239 (44%) were under 51 years of age, of which 59 (58%) had no intraoperative endometriosis/adhesions. Ovarian preservation may have been reasonable in 8% (59/749). CONCLUSIONS: Concurrent bilateral salpingo-oophorectomy performed by generalists and at community hospitals was less likely to have preoperative indications. Ovarian preservation was potentially possible for 8%.