Consent Practices for Assisted Vaginal Births (AVB) at Two Tertiary Care Hospitals: A Retrospective Review of Physician Documentation.

OBJECTIVE: To determine whether assisted vaginal birth (AVB) consent documentation, a surrogate for in vivo consent, aligns with Canadian practice guidelines at 2 Canadian tertiary-level obstetric centres. METHODS: This was a retrospective review of AVBs (vacuum and forceps) from July 2019 to December 2019 at 2 tertiary-level hospitals with template-based (Site 1) or dictation-based (Site 2) documentation. We extracted, from obstetric and neonatal charts, AVB type, physician and documenter types (resident/fellow/family doctor/generalist obstetrics and gynecology [OBGYN]/maternal-fetal medicine), and consent elements (present/absent) based on a predetermined checklist. Data were summarized and comparisons were made using chi-square test, Fisher exact test, and logistic regression, where appropriate. RESULTS: We identified 551 AVBs (156 forceps, 395 vacuum) with most documentation completed by generalist OBGYNs or residents (333/551, 60.5%). Most vacuum-assisted deliveries documented no specific maternal (366/395, 92.7%) or neonatal (364/395, 92.2%) risks, and 107/156 (68.6%) and 106/156 (67.9%) forceps-assisted deliveries lacked specific documentation of maternal and neonatal risk, respectively. At Site 2, postpartum hemorrhage risk at vacuum-assisted deliveries was more commonly documented (6/90 [6.7%] vs. 2/395 [0.7%], P = 0.002) as was at least 1 neonatal risk and risk of obstetrical anal sphincter injury at forceps-assisted deliveries (50/133 [37.6%] vs. 0/23 [0%], P < 0.001) and (43/133 [32.3%] vs. 0/23 [0%], P = 0.001), respectively. CONCLUSIONS: Opportunity to improve AVB consent documentation exists, warranting quality improvement initiatives.

Surgeon Gender and Performance Outcomes for Hysterectomies: Retrospective Cohort Study.

STUDY OBJECTIVE: To evaluate whether there are differences in several performance metrics between male and female surgeons for hysterectomies. DESIGN: Multicenter retrospective cohort study. We matched surgeries performed by female surgeons to those by male surgeons using a propensity score and compared outcomes by gender after adjusting for years in practice and fellowship training. SETTING: A total of 6 hospitals (3 academic, 3 community) in Ontario, Canada, between July 2016 and December 2019. PATIENTS: All consecutive patients. INTERVENTIONS: Hysterectomy. MEASUREMENTS AND MAIN RESULTS: Primary outcome was a composite of any complication or return to emergency room (ER) within 30 days. Secondary outcomes were grade II or greater complications, return to ER, and operative time. We included 2664 hysterectomies performed by 77 surgeons. After propensity matching, 963 surgeries performed by females were compared with 963 performed by males. There were no differences in the primary (relative risk [RR], 0.92; 95% confidence interval [CI], 0.71-1.20; p = .56) or secondary outcomes of grade II or greater complication (RR, 1.01; 95% CI, 0.71-1.45; p = .96) or return to ER (RR, 0.81; 95% CI, 0.55-1.20; p = .30). However, surgeries performed by males were 24.72 minutes shorter (95% CI, 18.09-31.34 minutes; p <.001). Entire cohort post hoc regression analysis confirmed these findings. E-value analysis indicated that it is unlikely for an unmeasured confounder to undo the observed difference. CONCLUSION: Although complication and readmission rates are similar, male surgeons may have a shorter operating time than female surgeons for hysterectomies, which may have implications for health systems and inequalities in surgeon renumeration.

Minimally Invasive Management of Second Trimester Placenta Percreta.

STUDY OBJECTIVE: To describe the diagnostic and surgical challenges in the management of second trimester placenta percreta. DESIGN: Stepwise demonstration of the surgical technique with the use of an educational video. SETTING: Second trimester placenta percreta is a rare entity, with very few case reports in the literature. Our video demonstrates the challenges of a minimally invasive approach toward definitive surgical management with hysterectomy. A 39-year-old G7P3 (3 previous cesarean deliveries) female at 17 weeks and 2 days gestation presented with acute abdominal pain to a community hospital. This was a spontaneously conceived pregnancy. Her hemoglobin level on admission was 92 g/L. An ultrasound showed a normal uterus, and the appendix was not visualized. One unit of packed red blood cells was transfused, and she underwent exploratory laparoscopy for a possible retrocecal hematoma/mass seen on computerized tomography. In the operating room, acute hemoperitoneum was visualized with placenta-like tissue invading through the anterior lower uterine segment (Figures 2 & 3). A hemostatic agent (Floseal, Baxter) was placed over the bleeding, and she was then transferred to a tertiary academic center for further management. INTERVENTIONS: Magnetic resonance imaging was performed on the following day after transfer to our facility, which confirmed placenta percreta at the level of the bladder (Figure 1). Following counseling with a multidisciplinary team and given that there was ongoing bleeding from the invading placental tissue, pregnancy continuation and uterine conservation were not possible. The patient was offered preprocedure termination of pregnancy with intra-cardiac injection of potassium chloride and 350 cc of amniotic fluid was drained at that time. This was done to facilitate visualization for a minimally invasive approach. We describe 5 main challenges of minimally invasive hysterectomy for placental percreta and provide a stepwise approach to mitigating them: visibility, vascular control, bladder dissection, colpotomy, and specimen retrieval. We adapted the previously described laparotomy techniques of progressive uterine devascularization and approach to bladder dissection and colpotomy to laparoscopy [1,2]. In addition, we performed dilatation and evacuation to allow for vaginal specimen removal. The patient's postoperative course was uncomplicated, and she was discharged home in a stable condition. CONCLUSION: Midtrimester placenta percreta poses significant challenges in diagnosis and surgical management. Total laparoscopic hysterectomy for this condition poses unique challenges but is feasible and safe.

Accuracy of Surgeon Self-Reflection on Hysterectomy Quality Metrics.

OBJECTIVE: To evaluate the accuracy of gynecologic surgeons' self-reflection across hysterectomy case volume, proportion of cases performed using a minimally invasive approach (minimally invasive rate), and complication rate and to assess whether accuracy is associated with specific surgeon or practice characteristics. METHODS: This was a cross-sectional cohort study of gynecologic surgeons at eight Canadian hospitals between 2016 and 2019. Surgeons estimated case volume, minimally invasive rate, and complication rate for hysterectomies for a 6-month period using an online survey. Kendall's tau-beta correlation coefficient (τ) measured association between estimated and actual performance. Differences (delta) between each surgeon's estimated and actual performance were calculated. The central tendency of differences among the cohort was represented by a median (median delta) and compared with 0 (perfect accuracy) using the Wilcoxon signed rank test. Differences in characteristics between surgeons classified as underestimators, accurate estimators, and overestimators by tertile of delta were evaluated using analysis of variance and χ2 tests. RESULTS: Eighty-four surgeons across eight hospitals were included. Association between estimated and actual performance was moderate for case volume (τ=0.46, P<.001) and minimally invasive rate (τ=0.52, P<.001) and weak for complication rate (τ=0.14, P=.080). Surgeons underestimated their complication rate (median delta -7.0%, 95% CI -11.0% to -3.5%, P<.001) but accurately estimated case volume (median delta 1.0, 95% CI 0.0-2.5, P=.082) and minimally invasive rate (median delta 4.0%, 95% CI -4.5% to 10.0%, P=.337). Surgeons who underestimated their complication rates had higher average complication rates (33.7%) than those who estimated accurately (12.1%, P<.001) or overestimated (7.7%, P<.001) and were more likely to be fellowship-trained (P<.001). CONCLUSION: Attending gynecologic surgeons inaccurately reflect on their complication rates, and those who most underestimate their complication rates have higher rates than their peers.

Impact of a 12-minute educational video prior to initial consultation in a Mature Women's Health and Menopause Clinic.

OBJECTIVES: Assess acceptability of a 12-minute educational video before menopause clinic consultation and evaluate its impact on knowledge and treatment certainty. METHODS: This was a pre-post intervention study among new patients with vasomotor symptoms (VMS) referred to a menopause clinic in Toronto, Canada. Participants completed electronic questionnaires before and after viewing a 12-minute online video covering menopause facts and VMS treatments. Participants' demographic information and referring provider type were recorded. A 19-item true/false knowledge quiz and validated Decision Conflict Scale (DCS) were administered before and after viewing the video along with a validated Acceptability questionnaire after the video. Demographic information and acceptability were summarized descriptively and independent samples t tests compared knowledge and DCS total and subscores before and after viewing the education module. Multivariable analysis was used to identify factors associated with achieving treatment certainty. RESULTS: Seventy-one participants completed pre- and postintervention questionnaires. Mean age was 51.4 ± 6.0 years and most were White (58/71, 81.7%), had a university degree (24/71, 63.3%) and household income >$90,000 (53/71, 74.6%). After the video, there was significant increase in knowledge score (12.7 ± 2.1 vs. 16.9 ± 1.8, P < 0.001) and decrease in all DCS scores (total and five subscores) compared with preintervention scores (P < 0.001). Acceptability was high with 62/71 (87.3%) respondents indicating the tool was useful. Findings were independent of level of education, household income, and referring physician type. CONCLUSION: In a study of predominantly university-educated White women, a 12-minute education module on menopause and VMS treatment was acceptable, there was improved knowledge and decision certainty about VMS treatment.

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.

Individualized Assessment of Risk of Complications after Benign Hysterectomy.

STUDY OBJECTIVES: The primary objective of this study is to identify patient characteristics associated with postoperative complications or readmissions after hysterectomy for a benign indication. DESIGN: Retrospective cohort. SETTING: The Surgical Gynecologic Scorecard Database includes performance metrics and patient outcomes for hysterectomies across 7 sites in Ontario, Canada. PARTICIPANTS: Individuals who underwent hysterectomy for benign gynecologic indication and were recorded in the Surgical Gynecologic Scorecard Database between July 2016 and June 2019 were included in this study. MEASUREMENTS AND MAIN RESULTS: Two outcomes of interest were considered: (1) complications grade II or greater on the Clavien-Dindo classification scale and (2) emergency room visits or hospital readmissions within 6 weeks after operation. Logistic models were generated to determine the associations between outcome of interest and potential predictors using a mixed-step AIC selection algorithm. A total of 2792 patients underwent hysterectomy for a benign indication during the study period, with a mean age of 52.6 ± 11.7 years and mean body mass index of 29.0 ± 0.7 kg/m2. The most common indications for surgery were abnormal uterine bleeding (33.3%) and myomas (33.6%). Previous cesarean delivery (adjusted odds ratio [aOR], 1.22; 95% confidence interval [CI], 1.04-1.42), American Society of Anesthesiologists class ≥3 (aOR, 2.31; 95% CI, 1.42-3.99), preoperative anemia (aOR, 1.51; 95% CI, 1.12-2.02), and laparotomic approach (aOR, 1.73; 95% CI, 1.30-2.29) were associated with increased odds of complication. Perioperative complications (aOR, 2.95; 95% CI, 2.12-4.08), preoperative anemia (aOR, 1.43; 95% CI, 1.03-1.98), and vaginal (aOR, 1.94; 95% CI, 1.26-2.96) or laparotomic (aOR, 1.64; 95% CI, 1.10-2.43) approach were associated with increased odds of emergency room visit or readmission to hospital. CONCLUSION: This study identified several important risk factors for complications after hysterectomy. The utility of these data is important to help improve counseling for patients undergoing a hysterectomy and potentially optimize modifiable risk factors when identified preoperatively.

Unexpected malignancy at the time of hysterectomy performed for a benign indication: A retrospective review.

OBJECTIVE: To determine the proportion of patients undergoing hysterectomy for a benign indication who have unexpected malignancy (UM) on postoperative pathology and characterize the nature of UMs. METHODS: This was a multi-center, retrospective study of patients undergoing hysterectomy for a benign indication from July 2016 to December 2019 at 7 Ontario, Canada hospitals (4 academic, 3 community). Hysterectomies for invasive placentation, malignant, and premalignant indications were excluded. Primary outcome was rate of unexpected malignancy as defined by the number of patients with malignancy on final pathology divided by the total number of hysterectomy cases. Data was extracted from health records and electronic charts. Patient, surgical, and surgeon characteristics were compared between benign and UM groups using bivariate methods. Associations between UM status and perioperative variables were assessed using bivariate logistic regression. RESULTS: In the study period, 2779 hysterectomies were performed. UM incidence was 1.8% (51 malignancies/2779 cases), with one patient having two malignancies (total UMs = 52). The most common UM types were endometrial (27/52, 51.9%) and sarcoma (13/52, 25%). Patients with UM were older (57.2 ± 11.4 years vs. 52.8 ± 12.5 years, p = .015), had more previous laparotomies (2 (1.25, 2.0) vs. 1 (1.0, 1.0), p < .001), and higher BMI (29.7 ± 7.2 kg/m2 vs. 28.0 ± 5.9 kg/m2, p = .049) and ASA class (p < .028). Regarding surgical factors, patients with UM had more adhesions (p = .001), transfusions (p = .020), and blood loss (p = .006) compared to those with benign pathology. Patient characteristics most strongly associated with UM were age (OR 2.57, 95% CI 1.78-3.72, p < .001) and preoperative diagnosis of pelvic mass (OR 2.76, 95% CI 1.11-6.20, p = .019). CONCLUSION: Incidence of UM at hysterectomy for benign indication was 1.8%. Several perioperative variables are associated with an increased chance of UM.

Avoidable bilateral salpingo-oophorectomy at hysterectomy: a large retrospective study.

OBJECTIVES: Evaluate the proportion of justified bilateral salpingo-oophorectomy (BSO) at hysterectomy, based on pathologic diagnosis, and determine prevalence of avoidable BSO based on pre- and intraoperative considerations and pathologic diagnosis. METHODS: Retrospective review of hysterectomies at seven Ontario, Canada hospitals from 2016 to 2019. Surgeries completed by oncologists or for invasive placentation were excluded. Patient, case, and surgeon characteristics were recorded along with pathologic diagnoses. Avoidable BSO criteria were: preoperative diagnosis of cervical dysplasia or benign diagnosis other than endometriosis, gender dysphoria, risk reduction or premenstrual dysphoric disorder; age < 51 years; absence of intraoperative endometriosis and adhesions; unjustified pathology (where "justified" pathology was endometriosis or (pre)malignant diagnosis except for cervical dysplasia). Patients with avoidable BSO were compared to those having at least one criterion for BSO. Binary logistic regression identified factors most strongly associated with avoidable BSO. RESULTS: Four thousand one hundred ninety-one hysterectomies were completed with 1,422 (33.9%) patients having concomitant BSO. Pathologic diagnosis justified BSO in most patients (1,035/1,422, 72.8%) with endometrial cancer being most common (439/1,422, 30.9%). When preoperative characteristics, intraoperative findings, and pathologic diagnoses were considered, 79 of 1,422 (5.6%) BSOs were avoidable. Compared to cases with at least one criterion for BSO, avoidable BSOs were more frequently completed by generalists (OR 1.80, 95% CI 1.10-2.99, P  = 0.021), for preoperative diagnoses of abnormal uterine bleeding/menorrhagia (OR 3.82, 95% CI 2.35-6.30, P  = 0.001) and fibroids (OR 4.25, 95% CI 2.63-6.92, P  < 0.001). CONCLUSION: Pathologic diagnosis justified most BSOs at hysterectomy. BSO was avoidable in 5.6% of patients, underscoring the need to standardize practice of BSO.

Quality and readability of online health information on menopausal hormone therapy in Canada: what are our patients reading?

OBJECTIVE: To assess the quality and readability of 24 of the most accessed menopause hormone therapy (MHT) websites by Canadian women. METHODS: The top 24 websites from Google, Bing, and Yahoo were identified using the search term "hormone replacement therapy." Five menopause specialists assessed website content quality using the DISCERN Instrument, Journal of the American Medical Association (JAMA) benchmarks, and Abbott's Scale. Two reviewers assessed website credibility using the Health on the Net Foundation Code of Conduct certification, and website readability using the Simple Measure of Gobbledygook, Flesch-Kincaid Grade Level, and Flesch-Kincaid Read Ease formulae. RESULTS: Scores for quality of information varied. The mean JAMA score was low at 2.3 ±â€Š1.1 (out of 4). Only one website met all benchmarks. Fourteen websites (58%) had a good/excellent DISCERN score, while four (17%) had a poor/very poor score. For Abbott's Scale, both the mean authorship score at 2.2 ±â€Š1.0 (out of 4) and mean content score at 45.9 ±â€Š9.8 (out of 100) were low. Inter-rater reliability was high for all tools. Fifteen websites (63%) were Health on the Net Foundation Code of Conduct certified. The mean Flesch-Kincaid Read Ease was 42.7 ±â€Š10.3, mean Flesch-Kincaid Grade Level was 12.3 ±â€Š1.9, and mean Simple Measure of Gobbledygook grade level was 11.3 ±â€Š1.5. Only one website presented content at a reading level recommended for the public. Websites meeting more JAMA benchmarks were significantly less readable (P < 0.05). CONCLUSION: Although good quality MHT information exists online, several resources are inaccurate or incomplete. Overall, these resources are not considered comprehensible by the public. There is a need to disseminate accurate, comprehensive, and understandable MHT information online.

Delivery of menopause care during a pandemic: an evaluation of patient satisfaction with telephone visits.

OBJECTIVE: We aimed to evaluate patient satisfaction with telephone appointments during the first wave of the COVID-19 pandemic, determine visit type preference (in-person vs telephone), and predictors of those preferences. METHODS: In this cross-sectional study, patient visits during the first wave of COVID-19 (March 20 to July 15, 2020) were characterized (in-person vs telephone) in a single provider's weekly menopause clinic in Toronto, Canada. Patients attending telephone appointments were asked to complete a modified Telemedicine Satisfaction Questionnaire with 5-point Likert-scale responses. Demographic information was collected along with the patient-reported cost to attend an in-person appointment (monetary, travel time, and time away from work). Of those who experienced both visit types, preference was evaluated and bivariate analysis was performed identifying factors associated with visit type preference and included in a multivariable binary logistic regression model. RESULTS: During the first wave of the COVID-19 pandemic, 214 women had 246 visits, attending mostly by telephone (221/246, 90%). Mean Telemedicine Satisfaction Questionnaire composite score was 4.23 ±â€Š0.72. Of those who attended a prepandemic in-person appointment (118/139, 85%), a minority (24/118, 20%) preferred in-person visits. Those favoring in-person were more likely to commute less than 30 minutes (OR 3.78, 95% CI 1.16-12.29, P = 0.027), require less than 2 hours away from work (OR 4.05, 95% CI 1.07-15.4, P = 0.04), and spend less than $10 to attend (OR 3.67, 95% CI 1.1-12.26, P = 0.035). CONCLUSIONS: Menopause clinic telephone appointments had high patient satisfaction, with most preferring this visit type, although in-person visits are preferred among a minority of women.