Quality of life, health care utilization, and costs among women undergoing hysterectomy in a managed-care setting

Multimodal strategies to improve surgical outcome

OBJECTIVE

To evaluate the effect of modifying perioperative care in noncardiac surgical patients on morbidity, mortality, and other outcome measures.

BACKGROUND

New approaches in pain control, introduction of techniques that reduce the perioperative stress response, and the more frequent use of minimal invasive surgical access have been introduced over the past decade. The impact of these interventions, either alone or in combination, on perioperative outcome was evaluated.

METHODS

We searched Medline for the period of 1980 to the present using the key terms fast track surgery, accelerated care programs, postoperative complications and preoperative patient preparation; and we examined and discussed the articles that were identified to include in this review. This information was supplemented with our own research on the mediators of the stress response in surgical patients, the use of epidural anesthesia in elective operations, and pilot studies of fast track surgical procedures using the multimodality approach.

RESULTS

The introduction of newer approaches to perioperative care has reduced both morbidity and mortality in surgical patients. In the future, most elective operations will become day surgical procedures or require only 1 to 2 days of postoperative hospitalization. Reorganization of the perioperative team (anesthesiologists, surgeons, nurses, and physical therapists) will be essential to achieve successful fast track surgical programs.

CONCLUSIONS

Understanding perioperative pathophysiology and implementation of care regimes to reduce the stress of an operation, will continue to accelerate rehabilitation associated with decreased hospitalization and increased satisfaction and safety after discharge. Developments and improvements of multimodal interventions within the context of "fast track" surgery programs represents the major challenge for the medical professionals working to achieve a "pain and risk free" perioperative course.

Symptom experience in women after hysterectomy

OBJECTIVE

To review the literature addressing the symptom experience of women after hysterectomy.

DATA SOURCES

Computerized searches in MEDLINE and CINAHL, as well as texts and references cited in articles. Key concepts in the searches included hysterectomy, sleep disturbance and pain, hysterectomy and fatigue, hysterectomy, depression, and depressed mood.

STUDY SELECTION

Articles and comprehensive works relevant to key concepts and published after 1970, with an emphasis on new findings from 1990 to 2000. Sixty-four citations were identified as useful to this review.

DATA EXTRACTION

Data were organized under the following headings: women and hysterectomy, biopsychosocial perspectives, common symptoms after hysterectomy (pain, disturbed sleep, fatigue, depressed mood, anxiety), and significance of review (implications).

DATA SYNTHESIS

Literature suggests that after a hysterectomy, women experience complications during the postoperative recovery period that may vary with the type of surgical procedure. During this period, the quantity and quality of sleep as well as other symptoms (pain, fatigue, anxiety, and depression) are influenced by various physiologic, psychologic, and social factors. Despite limited evidence that sleep problems may occur frequently during the recovery period, only a few researchers have systematically examined sleep patterns in women after hysterectomy. None of these studies, however, used objective sleep measures or examined multiple dimensions of these women's lives.

CONCLUSIONS

This review conceptualized the women's symptom experience as the experience of specific symptoms (pain, sleep disturbance, fatigue, depressed mood, and anxiety) that were influenced by biopsychosocial factors.

Fast track hysterectomy

OBJECTIVE

To identify factors limiting early discharge after laparoscopically assisted vaginal hysterectomy (LAVH) and abdominal hysterectomy, in a fast track setting with emphasis on information, treatment of pain, early mobilization, and early food intake.

STUDY DESIGN

A prospective, descriptive study of 32 unselected women allocated to either abdominal hysterectomy (n=16) or LAVH (n=16). The patients received the same information, care, and advice for the perioperative period except for an assumed 1-day hospital stay in the LAVH-group and 2 days in the abdominal group.

RESULTS

Patients were discharged median 1 day (1-3) after LAVH and 2 days (2-4) after abdominal hysterectomy. Work was resumed median 23 days after abdominal hysterectomy and 28 days after LAVH (P > 0.05).

CONCLUSIONS

The study questions the previously proposed advantages of shortened hospitalization and convalescence after LAVH compared with abdominal hysterectomy. Further studies with active rehabilitation are needed to demonstrate real differences between laparoscopic and open hysterectomy.

Reduced disability at five years with early treatment of inflammatory polyarthritis: results from a large observational cohort, using propensity models to adjust for disease severity

OBJECTIVE

To determine the effect of treatment with disease-modifying antirheumatic drugs (DMARDs) and/or steroids on 5-year disability outcome in patients with inflammatory polyarthritis.

METHODS

Three hundred eighty-four patients registered by the Norfolk Arthritis Register (a primary care-based observational cohort) were followed up for 5 years. Treatment details and Health Assessment Questionnaire (HAQ) scores were recorded annually. Logistic regression was used to model differences in baseline factors associated with the start of DMARDs and/or steroids within 12 months of baseline. Based on this model, each subject was given a probability of starting treatment ("propensity score"). A second model compared the odds of disability (HAQ score > or =1.00) in treated and untreated patients, adjusting for differences in disease severity using the propensity score.

RESULTS

Unadjusted analysis suggested that patients who received treatment had an increased odds of a worse outcome compared with those who did not receive treatment. When adjusted for differences in disease severity, using the propensity score, early treatment (within 6 months of symptom onset) was associated with a similar odds of disability at 5 years compared with those not treated (odds ratio 0.71; 95% confidence interval 0.34, 1.44). In contrast, starting treatment later (> or =6 months) was associated with a 2-fold increased odds of having a HAQ score > or =1.00 at 5 years.

CONCLUSION

The propensity score was a useful method of adjusting for "confounding by indication" in observational studies. Furthermore, this study showed that early treatment with DMARDs/steroids (within 6 months of symptom onset) reduced the odds of disability 5 years later to a level comparable with that of patients judged clinically as not requiring treatment.

Saline contrast sonohysterography in the preoperative assessment of benign intrauterine disorders

OBJECTIVES

To assess the value of saline contrast sonohysterography (SCSH) in the preoperative evaluation of benign intrauterine lesions.

DESIGN

Patients presenting with abnormal bleeding related to benign uterine pathologies and scheduled for surgical treatment were prospectively enrolled in a study conducted between 1 January 1996 and 31 December 1997. SCSH was first carried out with the intention of establishing further surgical management (hysterectomy or hysteroscopy). The end point of the study was to compare the surgical option ultimately carried out with the one decided after SCSH. In addition, size and location of intrauterine lesions determined by SCSH were compared with those issued from surgical records. Similarly, pathologic results were juxtaposed to SCSH diagnosis. Statistical analysis used non-parametric and correlation tests.

RESULTS

Two hundred and thirty-three patients were included in the study, 39.5% of whom were postmenopausal. SCSH was consistently effective in the choice of the best surgical method, because no hysterectomy was required when an operative hysteroscopy was indicated on SCSH data. Similarly, only one patient treated by hysterectomy (5.8%) could have undergone a more conservative approach. But this patient had a genital prolapse, and thus hysterectomy was a part of the treatment. SCSH correlated well with surgery for the location and size of intrauterine lesions (P < 0.001). SCSH was accurate in the diagnosis of polyps and submucous myomas (sensitivity 85.7%, specificity 95.4%).

CONCLUSIONS

SCSH appears an important tool for preoperative assessment of benign intrauterine pathologies. It should be used in the selection of patients that should be scheduled for an operative hysteroscopy.

Decision-directed hysterectomy: a possible approach to improve medical and economic outcomes

OBJECTIVE

This study was undertaken to determine if the use of formal guidelines in selecting the route of hysterectomy would improve medical and economic outcomes.

METHOD

Data from 4595 hysterectomies performed at a single center in women whose primary diagnosis were unrelated to invasive cancer or pregnancy were analyzed in terms of mean, uterine weight, costs, length of stay, and complications.

RESULTS

When formal guidelines were used to determine the route of hysterectomy, vaginal hysterectomy was performed in 90% of the patients treated and in 100% of the patients in whom the pathology was confined to the uterus. In comparison, when formal guidelines were not incorporated in the decision-making process, vaginal hysterectomy was performed in 42% of the patients treated and in 64% of the patients in whom the pathology was confined to the uterus.

CONCLUSIONS

Using these or similar guidelines to assist in clinical decision making would have resulted in a potential savings of US$1184000 for every 1000 hysterectomies performed at the institution where this study was undertaken and would have freed up 1020 patient-bed days and reduced complications by approximately 20%.

Cost and quality-of-life issues associated with different surgical therapies for the treatment of abnormal uterine bleeding

Abnormal uterine bleeding is a common problem among women of reproductive age and can be treated medically or surgically. When medical therapy fails to cure menorrhagia, many women undergo hysterectomy. Over the past 15 years, operative laparoscopy and hysteroscopy increasingly have replaced traditional surgery (i.e., abdominal and vaginal hysterectomy). An endoscopic approach such as LAVH has been added to the therapeutic choices of patient and physician. Additionally, hysterectomy alternatives such as endometrial resection and ablation and myomectomy have been offered to women with significant menorrhagia. This article reviewed the cost and quality-of-life issues of endoscopic treatment versus traditional surgical methods. Vaginal hysterectomy is the least costly of all hysterectomy techniques. Studies have shown that for LAVH, direct costs are higher that abdominal hysterectomy. However, this difference decreases with additional operator experience and with the use of nondisposable instrumentation. The indirect cost of LAVH is significantly less than abdominal hysterectomy because of the more rapid convalescence. With endometrial resection and ablation, direct and indirect costs are significantly less than those of hysterectomy even when high failure rates are factored. Women choose this procedure over hysterectomy because it avoids major surgery, allows for a fast return to normal functioning, and entails short hospitalization. Hysterectomy can lead to many psychologic and physical changes for a woman. It continues to provide a high satisfaction rate because it is a guaranteed cure for abnormal bleeding.

Preoperative evaluation of tumor ploidy in endometrial carcinoma: An accurate tool to identify patients at risk for extrauterine disease and recurrence

BACKGROUND

Tumor ploidy is a strong prognostic factor in patients with endometrial carcinoma, but generally is evaluated only after surgery. The availability of a simple and reliable method to determine tumor ploidy before any treatment is initiated could be helpful in the selection of patients at high risk for advanced primary disease and subsequent recurrence, with several possible benefits. The objectives of the current study were: 1) to test the accuracy of flow cytometric determination of tumor ploidy from preoperative outpatient endometrial biopsies compared with standard postoperative evaluation from the surgical specimen and 2) to correlate this preoperative parameter with the local recurrence and extrauterine tumor spread.

METHODS

Tumor ploidy from both preoperative biopsy material and the macroscopic surgical specimens was evaluated prospectively in 50 consecutive patients with endometrial carcinoma. DNA analyses were performed in a blind fashion. Patients were followed for a median of 26 months (range, 16-46 months).

RESULTS

In 9 of 50 cases (18%) an aneuploid tumor was found by the standard postoperative analysis. All 9 aneuploid tumors (100%) also were identified correctly by the preoperative test on biopsy material. Occult extrauterine tumor spread was found in 10 patients (20%). The incidence rate of aneuploidy among these tumors was 50% compared with 10% in surgical International Federation of Gynecology and Obstetrics Stage I tumors (P = 0.01). The recurrence rate was 55.5% (5 of 9 tumors) in the aneuploid group and 2.4% (1 of 41 tumors) in the diploid group (P < 0.001). The disease free survival rates of patients with diploid and aneuploid tumors were 97.5% and 44.4%, respectively (P < 0.0001).

CONCLUSIONS

Preoperative tumor ploidy determination based on outpatient endometrial biopsy is as accurate as the standard postoperative evaluation in patients with endometrial carcinoma. Tumor aneuploidy confirms the usefulness of this method in selecting patients at risk for occult extrauterine tumor diffusion and recurrence.

Instrumentation for the diagnosis of term and preterm labour

The problems associated with labor during pregnancy are among the most important health issues facing physicians. Understanding the role of the uterus and cervix in labor and developing methods to control their function is essential to solving problems relating to labor. At the moment, only crude, inaccurate and subjective methods are used to assess changes in the uterus and cervix that occur in preparation for or during labor. In the past several years, we have developed noninvasive methods to quantitatively evaluate the uterus and cervix based respectively on recording of uterine electrical signals from the abdominal surface (uterine EMG) and measurement of light-induced cervical collagen fluorescence (LIF) with an optical device (Collascope). The methods are rapid and allow assessment of uterine contractility and cervical ripening. Studies in rats and humans indicate that uterine and cervical function can be successfully monitored during pregnancy using these approaches and that these techniques might be used in a variety of conditions associated with labor to better define management. The potential benefits of the proposed instrumentation and methods include a reducing the rate of preterm delivery, improving maternal and perinatal outcome, monitoring treatment, decreasing cesarean section rate and improving research methods to understand uterine and cervical function.

Prospective randomized clinical trial of laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy

OBJECTIVE

We compared operative time, length of hospital stay, postoperative recovery, return to work, and costs for women undergoing laparoscopically assisted vaginal hysterectomy or abdominal hysterectomy.

STUDY DESIGN

A prospective randomized clinical trial of laparoscopically assisted vaginal hysterectomy (n = 24) versus abdominal hysterectomy (n = 24) was carried out in a tertiary care setting. The main outcome variables were operative time, length of hospital stay, and return to work. Secondary outcomes were postoperative pain and return to normal activity as determined by weekly visual analog scales and daily diary. Hospital costs were calculated.

RESULTS

The laparoscopically assisted vaginal hysterectomy group had longer operative times (median and quartiles, laparoscopically assisted vaginal hysterectomy 180 [139, 225] minutes vs abdominal hysterectomy 130 [97, 155] minutes), lower requirements for postoperative intravenous analgesia (patient-controlled analgesia pump, median and quartiles: laparoscopically assisted vaginal hysterectomy 22.1 [15.9, 23.5] hours, abdominal hysterectomy 36.7 [26.2, 45.0] hours), shorter length of hospital stay (median and quartiles, laparoscopically assisted vaginal hysterectomy 1.5 [1.0, 2.3] days, abdominal hysterectomy 2.5 [1.5, 2.5] days), and quicker return to work (Kaplan-Meier analysis, P =.03). Both procedures had similar hospital costs (P =.21).

CONCLUSION

Laparoscopically assisted vaginal hysterectomy appears to allow patients a more rapid postoperative recovery and an earlier return to work with hospital costs similar to those of abdominal hysterectomy.

Laparoscopically assisted vaginal hysterectomy

The LAVH revolution beginning in the late 1980s is far from over. The overwhelming growth and, at times, overuse of the laparoscopic approach have waned somewhat as physicians reevaluate LAVH, adopt new techniques such as arterial embolization and myolysis, and rediscover old techniques such as uterine morcellation at vaginal hysterectomy. In addition, the cost of new procedures and instrumentation has come under intense scrutiny. As analysis of patient care moves from cost containment to improved outcomes, there will be renewed interest in minimally invasive approaches. The challenge to accumulate data, critically analyze each approach, and select the most appropriate procedure for each patient holds the greatest promise for improved patient satisfaction and outcomes.