Effect of information campaign by the mass media on hysterectomy rates

Using geographically weighted Poisson regression to examine the association between socioeconomic factors and hysterectomy incidence in Wallonia, Belgium

BACKGROUND

Various studies have investigated geographical variations in the incidence of hysterectomy in Western countries and analyzed socioeconomic factors to explain those variations. However, few studies have used spatial analysis to characterize them. Geographically weighted Poisson regression (GWPR) explores the spatially varying impacts of covariates across a study area and focuses attention on local variations. Given the potential of GWPR to guide decision-making, this study aimed to describe the geographical distribution of hysterectomy incidence for benign indications in women older than 15 years old (15+) at the municipal level in Wallonia (southern region of Belgium) and to analyze potential associations with socioeconomic factors ('Education/training', 'Income and purchasing power' and 'Health and care') influencing the use of this surgery.

METHODS

We carried out an ecological study on data for women aged 15+ living in one of the 262 Walloon municipalities who underwent hysterectomies for benign indications between 2012 and 2014. We linked standardized hysterectomy rates to three municipal-level socioeconomic factors ('Education/training', 'Income and purchasing power' and 'Health and care'). Then, a Poisson regression model and a GWPR were applied to study the relationships between hysterectomy incidence and socioeconomic covariates in Wallonia.

RESULTS

The hysterectomy rate varied across the region. The Poisson regression revealed a positive and significant association between the hysterectomy rate and 'Income and purchasing power', and a negative and significant association between hysterectomies and 'Health and care'. The same associations were seen in the GWPR model. The latter demonstrated that the association between hysterectomies and 'Education and training' ranged from negative to positive over the study area.

CONCLUSIONS

Hysterectomy incidence was shown to have nonstationary relationships with socioeconomic factors. These results support the development of targeted interventions for a more appropriate use of this surgery.

Regional variation of hysterectomy for benign uterine diseases in Switzerland

Background

Hysterectomy is the last treatment option for benign uterine diseases, and vaginal hysterectomy is preferred over more invasive techniques. We assessed the regional variation in hysterectomy rates for benign uterine diseases across Switzerland and explored potential determinants of variation.

Methods

We conducted a population-based analysis using patient discharge data from all Swiss hospitals between 2013 and 2016. Hospital service areas (HSAs) for hysterectomies were derived by analyzing patient flows. We calculated age-standardized mean procedure rates and measures of regional variation (extremal quotient [EQ], highest divided by lowest rate) and systematic component of variation [SCV]). We estimated the reduction in the variance of crude hysterectomy rates across HSAs in multilevel regression models, with incremental adjustment for procedure year, age, cultural/socioeconomic factors, burden of disease, and density of gynecologists.

Results

Overall, 40,211 hysterectomies from 54 HSAs were analyzed. The mean age-standardized hysterectomy rate was 298/100,000 women (range 186–456). While the variation in overall procedure rate was moderate (EQ 2.5, SCV 3.7), we found a very high procedure-specific variation (EQ vaginal 5.0, laparoscopic 6.3, abdominal 8.0; SCV vaginal 17.5, laparoscopic 11.2, abdominal 16.9). Adjusted for procedure year, demographic, cultural, and sociodemographic factors, a large share (64%) of the variance remained unexplained (vaginal 63%, laparoscopic 85%, abdominal 70%). The main determinants of variation were socioeconomic/cultural factors. Burden of disease and the density of gynecologists was not associated with procedure rates.

Conclusions

Switzerland has a very high regional variation in vaginal, laparoscopic, and abdominal hysterectomy for benign uterine disease. After adjustment for potential determinants of variation including demographic factors, socioeconomic and cultural factors, burden of disease, and the density of gynecologists, two thirds of the variation remain unexplained.

Medical practice variation: public reporting a first necessary step to spark change

From previous work, we know that medical practice varies widely, and that unwarranted variation signals low value for patients and society. We also know that public reporting helps to create awareness of the need for quality improvement. Despite the availability of rich data, most Western countries have no routine surveillance of the geographic distribution of utilization, costs, and outcomes of healthcare, including trends in variation over time. This paper highlights the role of transparent public reporting as a necessary first step to spark change and reduce unwarranted variation. Two recent examples of public reporting are presented to illustrate possible ways to reduce unwarranted variation and improve care. We conclude by introducing the Value Improvement Cycle, which underscores that reporting is only a necessary first step, and suggests a path toward developing a multi-stakeholder approach to change.

Rates and Routes of Hysterectomy for Benign Indications in Austria 2002 - 2014

INTRODUCTION

Rates and routes of hysterectomy have implications for quality, costs and training. This study analyzed rates of benign hysterectomy and surgical approaches for benign hysterectomy in Austria from 2002 to 2014.

MATERIAL AND METHODS

This was a population-based retrospective observational study of coding data from all acute care hospitals (public and private) in Austria. Main outcome measures were numbers of women undergoing hysterectomy for benign indications in Austria per year and the route of hysterectomy for benign indications.

RESULTS

The number of benign hysterectomies performed per year declined from 10 675 in 2002 to 7747 in 2014, a decline of 27%. The use of vaginal hysterectomy was stable (53% and 47%, respectively). Use of laparoscopic techniques increased (5% in 2002, 32% in 2014) whereas use of abdominal hysterectomy decreased (41% and 20%, respectively).

CONCLUSIONS

Numbers of benign hysterectomies performed per year in Austria declined substantially between 2002 and 2014. Use of vaginal hysterectomy was stable at about 50%, whereas increased use of laparoscopic techniques was associated with lower rates of open hysterectomy.

Medical practice variations: changing the theoretical approach

Variations in medical practice are well documented, but there has been less progress in explaining these variations. This paper discusses the existing theories and hypotheses and concludes that a change in theoretical approach is required, to one that more directly highlights the social context influencing the behaviour of doctors in their daily practice. An initial alternative model for explaining variation in practice style is presented. The paper illustrates how (combinations of) important structural factors, such as the availability of hospital resources, the way the doctor is reimbursed, the availability of patients, professional uncertainty, and the way the hospital is financed, lead to hypotheses about when different local standards of medical care emerge. It is concluded that theoretical progress in research on variations in medical practice is possible and that empirical research needs to be driven by hypotheses that emphasize the role of social contexts in the doctor's decision behaviour. Some suggestions for future lines of research are outlined.

Impact of mass media on public behavior and physicians: an ecological study of the H1N1 influenza pandemic

BACKGROUND

The mass media plays an important role in public health behavior.

PURPOSE

The objective of the present study was to investigate the effect of mass media coverage of the H1N1 pandemic on the number of emergency department (ED) visits and hospital admission rates.

METHODS

An ecological study of ED visits to 8 general Israeli hospitals due to influenza-like illness during the period June-October 2009 was performed. Data on the number of visits per day for children and adults and daily hospitalization rates were analyzed. Associations with the estimated value of H1N1-related publications and weekly reports from nationwide sentinel clinics were assessed. The analysis was performed in 2012-2013.

RESULTS

There were 55,070 ED visits due to influenza-like illness during the study period. The overall number of media reports was 1,812 (14.3% radio broadcasts, 9.8% television broadcasts, 27.5% newspaper articles, and 48.5% major website reports). The overall estimated value of advertising of publications was $16,399,000, excluding the Internet. While H1N1 incidence recorded by Israeli sentinel clinics showed no association with mass media publications, peaks of media reports were followed by an increase in the number of ED visits, usually with a delay of 3 days (P = .005). This association was noted in children (P < .001) but not in adults (P > .1), with a corresponding decrease in hospital admission rates. Publications' framing had no association with ED visits.

CONCLUSIONS

During the 2009 H1N1 influenza outbreak in Israel, an increase in mass media coverage was associated with an increase in pediatric ED visits.

[Prevalence of hysterectomy in women 18 to 79 years old: results of the German Health Interview and Examination Survey for Adults (DEGS1)]

In many countries, hysterectomy is one of the most frequently performed surgical procedures in gynaecology. The aim of this study is to analyse the prevalence of hysterectomy in Germany by socio-demographic factors and factors of (reproductive) health. Analyses are based on data from the "German Health Interview and Examination Survey for Adults (DEGS1)", which is part of the health monitoring of the Robert Koch Institute (RKI). The prevalence of hysterectomy among participating women (18-79 years old) was 17.5% (n = 689). Most women (49.1%) were 40-49 years old when surgery was performed. 6.1% of hysterectomised women had cancer of the uterus or ovaries, and 19.7% underwent a simultaneous oophorectomy. There were significant differences in the prevalence of hysterectomy regarding social status, place of residence in 1988, number of live births, and body weight. DEGS1 is the first study showing the prevalence of hysterectomy in a representative sample of the German population. More detailed analyses of the DEGS data, among other data sources, are needed to evaluate the importance of the described associations and to assess trends. An English full-text version of this article is available at SpringerLink as supplemental.

Hysterectomy in Germany: a DRG-based nationwide analysis, 2005-2006

BACKGROUND

Hysterectomy is among the more common surgical procedures in gynecology. The aim of this study was to calculate population-wide rates of hysterectomy across Germany and to obtain information on the different modalities of hysterectomy currently performed in German hospitals. This was done on the basis of nationwide DRG statistics (DRG = diagnosis-related groups) covering the years 2005-2006.

METHODS

We analyzed the nationwide DRG statistics for 2005 and 2006, in which we found 305 015 hysterectomies. Based on these data we calculated hysterectomy rates for the female population. We determined the indications for each hysterectomy with an algorithm based on the ICD-10 codes, and we categorized the operations on the basis of their OPS codes (OPS = Operationen- und Prozedurenschlüssel [Classification of Operations and Procedures]).

RESULTS

The overall rate of hysterectomy in Germany was 362 per 100 000 person-years. 55% of hysterectomies for benign diseases of the female genital tract were performed transvaginally. Bilateral ovariectomy was performed concomitantly in 23% of all hysterectomies, while 4% of all hysterectomies were subtotal. Hysterectomy rates varied considerably across federal states: the rate for benign disease was lowest in Hamburg (213.8 per 100 000 women per year) and highest in Mecklenburg-West Pomerania (361.9 per 100 000 women per year).

CONCLUSION

Hysterectomy rates vary markedly from one region to another. Moreover, even though recent studies have shown that bilateral ovariectomy is harmful to women under 50 who undergo hysterectomy for benign disease, it is still performed in 4% of all hysterectomies for benign indications in Germany.

Media coverage and public reaction to a celebrity cancer diagnosis

BACKGROUND

Celebrity diagnoses can have important effects on public behaviour. UK television celebrity Jade Goody died from cervical cancer in 2009. We investigated the impact of her illness on media coverage of cervical cancer prevention, health information seeking behaviour and cervical screening coverage.

METHODS

National UK newspaper articles containing the words 'Jade Goody' and 'cancer' were examined for public health messages. Google Insights for Search was used to quantify Internet searches as a measure of public health information seeking. Cervical screening coverage data were examined for temporal associations with this story.

RESULTS

Of 1203 articles, 116 (9.6%) included a clear public health message. The majority highlighted screening (8.2%). Fewer articles provided advice about vaccination (3.0%), number of sexual partners (1.4%), smoking (0.6%) and condom use (0.4%). Key events were associated with increased Internet searches for 'cervical cancer' and 'smear test', although only weakly with searches for 'HPV'. Cervical screening coverage increased during this period.

CONCLUSION

Increased public interest in disease prevention can follow a celebrity diagnosis. Although media coverage sometimes included public health information, articles typically focused on secondary instead of primary prevention. There is further potential to maximize the public health benefit of future celebrity diagnoses.

Cytogenetic aberrations and the development of uterine leiomyomata

This study was conducted to define the cytogenetically critical regions of uterine leiomyomata, hoping to demonstrate the presence of possible genes involved in their evolution. It was carried out on 25 randomly selected uterine leiomyoma specimens obtained from 16 patients during hysterectomy or myomectomy operations. Successful tissue culture and karyotyping were performed in 19 specimens. There was no correlation between patient age, gravidity, or presenting symptom and the presence of chromosomal abnormality. A significant correlation was found between short culture turnaround time and the occurrence of chromosomal abnormality. Abnormal clonal karyotypes were present in 6 specimens, non-clonal abnormalities in 4 specimens and normal karyotypes were found in 9 specimens. Myomas with cross section >4 cm showed an increased incidence of abnormal karyotypes and a statistically significant higher incidence of clonal abnormalities. On the other hand, submucous myomas presented fewer clonal abnormalities than did intramural or subserosal myomas. Clonal chromosomal abnormalities involved 5 different chromosomes (2, 7, 8, 12, 22), which indicate genetic heterogeneity of such benign tumors and the need of molecular cytogenetic studies or molecular studies to characterize possible candidate genes at specific chromosomal breakpoints.

Average household exposure to newspaper coverage about the harmful effects of hormone therapy and population-based declines in hormone therapy use

BACKGROUND

The news media facilitated the rapid dissemination of the findings from the estrogen plus progestin therapy arm of the Women's Health Initiative (EPT-WHI).

OBJECTIVE

To examine the relationship between the potential exposure to newspaper coverage and subsequent hormone therapy (HT) use. DESIGN/POPULATION: Population-based cohort of women receiving mammography at 7 sites (327,144 postmenopausal women).

MEASUREMENTS

The outcome was the monthly prevalence of self-reported HT use. Circulation data for local, regional, and national newspapers was used to create zip-code level measures of the estimated average household exposure to newspaper coverage that reported the harmful effects of HT in July 2002.

RESULTS

Women had an average potential household exposure of 1.4 articles. There was substantial variation in the level of average household exposure to newspaper coverage; women from rural sites received less than women from urban sites. Use of HT declined for all average potential exposure groups after the publication of the EPT-WHI. HT prevalence among women who lived in areas where there was an average household exposure of at least 3 articles declined significantly more (45 to 27%) compared to women who lived in areas with <1 article (43 to 31%) during each of the subsequent 5 months (relative risks 0.86-0.92; p < .006 for all).

CONCLUSIONS

Greater average household exposure to newspaper coverage about the harms associated with HT was associated with a large population-based decline in HT use. Further studies should examine whether media coverage directly influences the health behavior of individual women.

Medical practice variations in hospital care; time trends of a spatial phenomenon

A persistent finding in health services research is that health care delivery and hospital utilisation in the Western world varies widely between areas, both within and between countries. Most studies have concentrated on cross-sectional variations in medical practice. The aim of this article is to investigate whether or not small area variation changed through time. We used hospital discharge rates in the Netherlands for 12 diagnostic or surgical categories to indicate medical practice patterns. The data cover a time span of almost two decades: 1980-1997. First, it was found that in most cases regions are consistently above or below the national trend in the study period. Second, the analysis revealed a statistically significant decline of regional variation in hospital discharges in general during the 1980s and the 1990s. In all but one medical category the results of the separate analyses point towards a downward trend. In one-third of the medical categories this downward trend was statistically significant. Potential parallel changes in regional disparities in need for care, e.g. morbidity or age composition of regional populations or changes in regional differences in care supply are discussed.

Interrupted time series designs in health technology assessment: lessons from two systematic reviews of behavior change strategies

OBJECTIVES

In an interrupted time series (ITS) design, data are collected at multiple instances over time before and after an intervention to detect whether the intervention has an effect significantly greater than the underlying secular trend. We critically reviewed the methodological quality of ITS designs using studies included in two systematic reviews (a review of mass media interventions and a review of guideline dissemination and implementation strategies).

METHODS

Quality criteria were developed, and data were abstracted from each study. If the primary study analyzed the ITS design inappropriately, we reanalyzed the results by using time series regression.

RESULTS

Twenty mass media studies and thirty-eight guideline studies were included. A total of 66% of ITS studies did not rule out the threat that another event could have occurred at the point of intervention. Thirty-three studies were reanalyzed, of which eight had significant preintervention trends. All of the studies were considered "effective" in the original report, but approximately half of the reanalyzed studies showed no statistically significant differences.

CONCLUSIONS

We demonstrated that ITS designs are often analyzed inappropriately, underpowered, and poorly reported in implementation research. We have illustrated a framework for appraising ITS designs, and more widespread adoption of this framework would strengthen reviews that use ITS designs.

Improving care of the critically ill: institutional and health-care system approaches

Institutional and health-care system approaches complement bedside strategies to improve care of the critically ill. Focusing on the USA and the UK, we discuss seven approaches: education (especially of non-clinical managers, policy-makers, and the public), organisational guidelines, performance reporting, financial and sociobehavioural incentives to health-care professionals and institutions, regulation, legal requirements, and health-care system reorganisation. No single action is likely to have sustained effect and we recommend a combination of approaches. Several recent initiatives that hold promise tie performance reporting to financial incentives. Though performance reporting has been hampered by concerns over cost and accuracy, it remains an essential component and we recommend continued effort in this area. We also recommend more public education and use of organisational guidelines, such as admission criteria and staffing levels in intensive care units. Even if these endeavours are successful, with rising demand for services and continuing pressure to control costs, optimum care of the critically ill will not be realised without a fundamental reorganisation of services. In both the USA and UK, we recommend exploration of regionalised care, akin to US state trauma systems, and greater use of physician-extenders, such as nurse practitioners, to provide enhanced access to specialist care for critical illness.

[Risk factors for hysterectomy among Brazilian women]

A case-control study was conducted to investigate risk factors for hysterectomy among women using the public health system in Northeast Brazil. The cases were 373 women aged 30-54 years that had undergone elective hysterectomy for benign pelvic conditions. Controls were 742 women with preserved uterus selected from public health clinics. Data were collected through a review of medical records and a personal interview using a structured, pre-tested questionnaire. Unconditional multiple logistic regression was applied in the analysis. Women at greater risk for hysterectomy were those with a higher per capita family income, zero to three children, a history of medical consultation for menstrual problems, hospitalization for gynecological problems, or tubal ligation before age 30 years. Menopause and a history of stillbirth appeared as protective factors in the statistical analysis.

Current knowledge of risks and benefits of prophylactic oophorectomy at hysterectomy for benign disease in United Kingdom and Republic of Ireland

OBJECTIVE

To estimate current practice of prophylactic oophorectomy at hysterectomy for benign disease and also define the role of the variables considered prior to making the decision of prophylactic oophorectomy among consultant obstetricians and gynaecologists in UK and Republic of Ireland.

DESIGN

A postal questionnaire was sent to all 1536 practising consultant gynaecologists in UK and Republic of Ireland. METHODS AND MAIN OUTCOMES MEASURED: Of the 809 replies received, 21% of the respondents routinely performed prophylactic oophorectomy. There was a wide regional variation; 40% consultants in Wales considered prophylactic oophorectomy compared to 16% in the Northern and Yorkshire regions. Consultants with a special interest with a more surgical bias were more likely to consider performing prophylactic oophorectomy. The majority of respondents estimated that prophylactic oophorectomy would reduce risk of ovarian cancer by up to 5%, and that following hysterectomy and ovarian conservation there was an increased risk of premature menopause.

CONCLUSION

There is a large variation and uncertainty in the practice of prophylactic oophorectomy in UK and Ireland.

Consumer health information: the role of breast cancer associations

BACKGROUND

Providing information for patients is currently a growth need for health professionals, medical journals, and consumer associations. Despite several patients or consumers associations being active in Italy, scarce evidence is available on the volume and type of activities carried out. A national survey was carried out to investigate the volume and the nature of phone requests for information addressed to associations belonging to the Italian Forum of EUROPA DONNA, an European movement active in 28 countries, working to raise public awareness of breast cancer.

METHODS

A structured questionnaire was sent to all EUROPA DONNA breast cancer associations to be filled in by the persons in charge for delivering the telephone information.

RESULTS

Of the 87 breast cancer associations contacted, 41 (47%) participated to the survey, completing a total of 2383 questionnaires for 4251 kinds of information. Most of the people who called were women and about 57% were breast cancer patients. A wide range of information were required: 29% on prevention, 22% on practical problems of daily life, 23% on services actually offered by breast cancer associations, 10% on psychological counselling, and finally 14% for advice on primary therapy and follow-up. In more than one-third of phone calls, people were looking for opinion from women who personally experienced a breast cancer.

CONCLUSION

This survey shows that breast cancer associations receive daily requests of information and convey a wide range of information. The findings underline the need to create meaningful partnership between health professionals and patient's associations in the complex field of information and communication.

Randomised trial of an integrated educational strategy to reduce investigation rates in young women with dysfunctional uterine bleeding

OBJECTIVES

To assess the effectiveness of an integrated educational strategy to change clinician behaviour and reduce the number of hysteroscopies and/or dilatation and curettages for women 40 years or less with dysfunctional uterine bleeding (DUB).

DESIGN

Randomised controlled trial with six-month follow-up.

SETTING

Public teaching hospital gynaecology units with 12,000-13,000 relevant procedures per year.

PARTICIPANTS

Six public gynaecology units made up of 62 gynaecologists or trainees allocated at random to intervention group - three, or control group - 3. Intervention An educational strategy that included dissemination of evidence-based guidelines via a problem-based interactive workshop facilitated by an opinion leader and a laminated algorithm and guidelines.

MAIN OUTCOME MEASURES

The number of hysteroscopies and/or dilatation and curettages performed for DUB on women 40 years or less, clinician behaviour change and perceived booking rates of the procedure.

RESULTS

At six months, there was no significant effect on the number of hysteroscopies and/or dilatation and curettages performed but there was an increase in evidence-based behaviour.

CONCLUSIONS

While the evidence-based educational strategy for the appropriate investigation of young women with DUB resulted in clinician behaviour change when applied to theoretical cases, it did not result in a reduction in hysteroscopy/D&C rates at six months.

[Has the time arrived for the management of waiting lists?]

Individuals on the waiting list frequently suffer an additional risk caused by the mean time until they receive treatment; however, other individuals do not need the treatment for which they are waiting.Both arguments, which can be contrasted with empirical evidence, would be sufficient to affirm that waiting list management should be implemented, leaving aside policies that are more of less opportunistic. Opportunistic policies are understood as those providing misinformation on waiting lists or their "manipulation", and using programs of auto-coordination with the sole aim of reaching the end of the year without a waiting list of not more than six months, etc. The panorama is not completely bleak. Some management initiatives (and even Politics with a capital P) are opening the way forward and may enter the Agenda in the next few years. In this context, the application of guaranteed times of medical care or the prioritization of waiting lists according to explicit criteria should be highlighted. It is worth remembering that, except for the queues in the waiting rooms of health centers and emergency departments, waiting lists are mediated by the decision of the physician. Therefore, an essential strategy for managing waiting lists consists of attenuating the problems caused by uncertainty (or ignorance) of the patient's diagnosis or prognosis.

Hysterectomy and socioeconomic position in Rome, Italy

STUDY OBJECTIVE

There exists conflicting evidence regarding the higher risk of hysterectomy among women of a lower educational and economic level. This study aims to assess whether in Italy socioeconomic level is related to hysterectomy undertaken for different medical reasons.

DESIGN

An area based index was used to assign socieconomic status (SES; four levels defined) to 3141 women (aged 35 years or older) who underwent a hysterectomy in 1997 and were residing in Rome. Data were taken from hospital discharge records. Direct age standardised hospitalisation rates by SES level were calculated for overall hysterectomies and for those performed for either malignant or non-malignant causes. Statistical differences were detected using the ratios of standardised rates and the test for linear trend.

MAIN RESULTS

The hysterectomy rate was 36.7 per 10 000 women aged 35 years or more. Hysterectomy for uterine leiomyoma accounted for 41% of all operations and was more frequent among women aged 35-49 years than for those aged 50 years or more (crude rates: 28.6 and 7.7 per 10 000, respectively). The risk of hysterectomy was 35% higher for the lowest SES group, compared with the highest group. No association was found between SES and hysterectomy rates for malignant causes, although less affluent women in age group 35-49 years had 87% higher risk of hysterectomy compared with most affluent women. The inverse association between SES and hysterectomy rates attributable to non-malignant causes was statistically significant for women aged 35-49 years but not for those aged 50 years or more.

CONCLUSIONS

The inverse relation between hysterectomy and SES is largely attributable to benign disorders of the uterus, namely leiomyoma and prolapse. More affluent women may have a greater uptake of less invasive techniques for removing uterine leiomyoma compared with less affluent women, who are more likely to undergo unnecessary hysterectomies irrespective of their reproductive age.

Women's sexual behavior, body image and satisfaction with surgical outcomes after hysterectomy: a comparison of vaginal and abdominal surgery

The aim of this study was to investigate the impact of vaginal and abdominal hysterectomy on women's sexual behavior, sexual dysfunction, body image and satisfaction with surgery. A prospective study was conducted on 90 women to evaluate the outcomes of hysterectomy. Data were collected prior to surgery, three months and two years after surgery, using self-report questionnaires. The results showed significant differences in women's sexual behavior and sexual dysfunction before and after hysterectomy, independent of the surgical procedure performed. Women in both groups reported improvements in sexual desire, sexual activity and sexual intercourse three months and two years after surgery. Sexual dysfunction such as dyspareunia, vaginismus, lack of orgasm and loss of sexual interest diminished significantly after surgery. Regression analyses revealed that postmenopausal status, severity of gynecological complaints and frequency of sexual intercourse were the most important factors for improved sexual outcomes. Women in the abdominal group were dissatisfied with their body image because of the abdominal scar, experienced more pain and had a longer period of recovery from surgery compared to women in the vaginal group. According to the results, sexual behavior alone is not an important factor in choosing vaginal or abdominal hysterectomy. However, sexual behavior was important in both groups when evaluating outcomes after hysterectomy.

Mass media interventions: effects on health services utilisation

BACKGROUND

The mass media frequently cover health related topics, are the leading source of information about important health issues, and are targeted by those who aim to influence the behaviour of health professionals and patients.

OBJECTIVES

To assess the effects of mass media on the utilisation of health services.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register (1996 to 1999), MEDLINE, EMBASE, Eric, PsycLit (to 1999), and reference lists of articles. We hand searched the journals Communication Research (February 1987 to August 1996), European Journal of Communication (1986 to 1994), Journal of Communication (winter 1986 to summer 1996), Communication Theory (February 1991 to August 1996), Critical Studies in Mass Communication (March 1984 to March 1995) and Journalism Quarterly (1986 to summer 1996).

SELECTION CRITERIA

Randomised trials, controlled clinical trials, controlled before-and-after studies and interrupted time series analyses of mass media interventions. The participants were health care professionals, patients and the general public.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Twenty studies were included. All used interrupted time series designs. Fifteen evaluated the impact of formal mass media campaigns, and five of media coverage of health-related issues. The overall methodological quality was variable. Six studies did not perform any statistical analysis, and nine used inappropriate statistical tests (ie not taking into account the effect of time trend). All of the studies apart from one concluded that mass media was effective. These positive findings were confirmed by our re-analysis in seven studies. The direction of effect was consistent across studies towards the expected change.

REVIEWER'S CONCLUSIONS

Despite the limited information about key aspects of mass media interventions and the poor quality of the available primary research there is evidence that these channels of communication may have an important role in influencing the use of health care interventions. Although the findings of this review may be affected by publication bias, those engaged in promoting better uptake of research information in clinical practice should consider mass media as one of the tools that may encourage the use of effective services and discourage those of unproven effectiveness.

Declining trend in major gynaecological surgery in The Netherlands during 1991-1998. Is there an impact on surgical skills and innovative ability?

OBJECTIVES

To assess the number of major surgical procedures in gynaecology over a period of eight years in The Netherlands and to detect possible trends. Relevance of the trends and the possible impact on surgical skills and on innovative ability are discussed.

DESIGN

Observational study.

SETTING

Hospital care in The Netherlands.

SAMPLE

Data from a national hospital discharge database, from all 119 hospitals in The Netherlands.

METHODS

When a patient is discharged from the hospital. data on the diagnosis and treatment are registered by local medical officers and administrators. Registration of surgical procedures is based on the International Classification of Procedures in Medicine (ICPM, WHO 1978), the so-called WCC-standard. All hospitals but one (a cancer centre) in The Netherlands participate in this registration, resulting in 99.3% of all admissions. Data on gynaccological manpower were obtained from the Dutch College of Obstetricians and Gynaecologists. In order to standardise the frequency numbers per 1,000 women, yearly data of the female population according to age were obtained from the Central Office for Population Statistics.

RESULTS

The female population aged 20 years of age and older increased 3% between 1991 and 1998, from 5.8 million to 6.0 million. In the same period the number of gynaecologists grew from 604 to 625, also an increase of 3%. The total number of hysterectomies dropped from 21,433 in 1991 to 16,320 (-24 %) in 1998 (chi2 for trend 1,245.1. P < 0.001) Surgery of the uterine cavity, either performed hysteroscopically or blind, increased from 311 to 1,958 (+ 625%) cases per year (chi2 for trend 2,459.2, P < 0.001). No trend has been detected in the numbers of adnexal operations, including surgical treatment of tubal pregnancy (tubotomy or tubectomy). In 1998, 12% of all ovarian surgery and 28% of all surgery for ectopic pregnancies was performed laparoscopically. Surgery for female urinary incontinence experienced a strong decline of 46% in the studied period. The frequency of vaginal repair decreased with 1354 (-16%) cases. The abdominal prolapse surgery (abdominal sacral colpopexy, obliteration of the Douglas pouch) is steadily increasing, although the absolute numbers are small. In 1998 seven hundred and forty-three women underwent an abdominal approach of their prolapse repair, compared with 7239 that had the vaginal repair.

CONCLUSIONS

The declining trend of major gynaecological surgery in combination with the increasing number of gynaecologists will result in more difficulty for gynaecologists to acquire and maintain surgical skills and may therefore affect their ability to innovate within the surgical profession.

Fibroid embolisation: a technique not without significant complications

Uterine artery embolisation is a new minimally invasive technique used for the treatment of fibroids. Twenty-one women underwent bilateral uterine artery embolisation at our unit, and we assessed the efficacy, morbidity and patient satisfaction with the procedure. Mixed outcomes were found. Reduction in fibroid volume measured by magnetic resonance imaging was impressive, and the majority of women felt their symptoms had improved. One woman achieved a full term pregnancy following the procedure. However, the procedure involved a significant inpatient stay, analgesia requirement, and a slower recovery time than anticipated. One woman died following overwhelming sepsis occurring 10 days after the procedure. Further studies are required to assess the role this technique may play in the management of uterine fibroids.

Biosocial determinants of hysterectomy in New Zealand

OBJECTIVES

This study examined the prevalence and biosocial correlates of hysterectomy.

METHODS

Data were from a 1995 national survey of women aged 20 to 59 years. We applied piecewise nonparametric exponential hazards models to a subsample aged 25 to 59 to estimate the effects of biosocial correlates on hysterectomy likelihood.

RESULTS

Risks of hysterectomy for 1991 through 1995 were lower than those before 1981. University-educated and professional women were less likely to undergo hysterectomy. Higher parity and intrauterine device side effects increased the risk.

CONCLUSIONS

This study confirms international results, especially those on education and occupation, but also points to ethnicity's mediating role. Education and occupation covary independently with hysterectomy. Analysis of time variance and periodicity showed declines in likelihood from 1981.

Prevalence of hysterectomy in Ireland

OBJECTIVES

To assess factors influencing the prevalence of hysterectomy in Ireland.

METHODS

Analysis of results of a questionnaire completed by a population-based cohort of 17735 women aged 50-65 years attending for breast screening.

RESULTS

Prevalence of hysterectomy was 22.2%, was increased in proportion to parity and was higher in younger women, those who had previously used oral contraception and those who had private health insurance; peak age at operation was 45-49 years.

CONCLUSION

The relatively high prevalence parity reflects contraceptive practices and utilization of health service resources.

Does provision of an evidence-based information change public willingness to accept screening tests?

OBJECTIVE: To investigate whether the willingness of the general population to undergo a screening test of questionable effectiveness for pancreatic cancer is influenced by the quality and the extent of the information provided. DESIGN: Randomised study. SETTING: Switzerland. PARTICIPANTS: Representative sample (N=1000) of the general population aged over 20. INTERVENTIONS: Participants were randomly allocated into two groups (N=500 each), with one group to receive basic and the other extended quality of information. The information was presented in two hypothetical scenarios about implicit and explicit benefits and adverse events of the screening test. Response rates were, respectively, 80.2% (N=401) and 93.2% (N=466). MAIN OUTCOME MEASURES: Stated willingness to undergo the screening test. RESULTS: Out of the 401 participants receiving the basic information scenario, 241 (60%) stated their willingness to accept the test, as compared to the 63/466 (13.5%) exposed to the extended one (P < 0.001). After adjusting for respondent characteristics through a logistic regression model, the 'information effect', expressed in terms of odds-ratio (OR), shows that provision of additional information was related to a 91% (OR 0.09; 95CI: 0.07 - 0.13) relative reduction in the likelihood of accepting the screening test. CONCLUSION: The quality and the extent of the information provided about the implicit and explicit benefits and adverse events on hypothetical scenarios of a screening test may dramatically change the willingness of people to participate in the testing. This study suggests that provision of full information on the yield of health care interventions plays an important role in protecting the public from being exposed to procedures of questionable effectiveness.

Promoting consumers' demand for evidence-based medicine

The widespread implementation of rationing and priority-setting policies in health care opposes the stochastic practice of medicine induced by professional uncertainty and professional vested interests in market-oriented clinical environments. It also clashes with consumers' overly optimistic and "mythical" view of the effectiveness of medicine, which is bound to support a potentially unlimited provision of health services. Thus, for consumers and society at large, it is necessary to create conditions favorable for a more conscious demand of evidence-based health care. In pursuit of this goal, we suggest the adoption of a community-oriented strategy based upon delivery of information to the public in order a) to generate greater awareness ("healthy skepticism") among consumers, through disclosure of data on the true effectiveness of health care interventions and on the existing variation in their utilization, and b) to provide tools to empower consumers in dealing better with both the uncertainty in their own individual patient-physician relationships and with the health policy issues to be faced in the future. Such a community-oriented strategy could also reinforce and support, through the generation of a "bottom-up" pressure from consumers toward physicians, a wider adoption of evidence-based interventions by health care professionals. This paper, using data from surveys on public opinions and attitudes toward the practice of medicine, focuses on how consumer demand for more evidence-based medical practice can be promoted.

Evidence into practice, experimentation and quasi experimentation: are the methods up to the task?

OBJECTIVE

Methodological review of evaluations of interventions intended to help health professionals provide more effective and efficient health care, motivated by the current experience of NHS Research and Development in England. Emphasis upon the forms of research appropriate to different stages in the development and evaluation of interventions, the use of experimental and quasi experimental designs, the methods used in systematic reviews and meta analyses.

METHOD

A proposed development process is derived from that used in the development of drugs. The strengths and weaknesses of different experimental and quasi experimental designs are derived from published methodological literature and first principles. Examples are drawn from the literature.

RESULTS

Like pharmaceuticals, implementation interventions need to go through several stages of development before they are evaluated in designed experiments. Where there are practical reasons that make random allocation impossible in quantitative evaluations, quasi experimental methods may provide useful information, although these studies are open to bias. It is rare for a single study to provide a complete answer to important questions, and systematic reviews of all available studies should be undertaken. Meta analytic techniques go some way towards countering the low power of many existing studies, reduce the risk of bias, and avoid the subjective approaches that may be found in narrative reviews.

CONCLUSIONS

The initiative taken by NHS Research and Development in examining methods to promote the uptake of research findings is welcome, but will only prove helpful if careful attention is paid to the different stages of the development process, and different research approaches are used appropriately at different stages.

Changes in reimbursement policy for antibiotics and prescribing patterns in general practice

OBJECTIVE: To study the effect of a reduction in reimbursement of the cost of antibiotics on the prescribing pattern in primary care in Denmark. METHOD: We analyzed the general practitioners' prescriptions of antibiotics during 1993--96 in relation to a reduction in reimbursement on the basis of national health service data in the county of North Jutland (population 488 000). On 1 January 1996 the reimbursement for tetracyclines was withdrawn, and for other antibiotics reimbursement was reduced from 75% to 50%. RESULTS: The total consumption of all antibiotic groups increased steadily in the county until 1995, and in 1996 a decrease of 13% was seen. A very marked reduction was noticed immediately after 1 January 1996 for the more expensive broad-spectrum antibiotics. The use of tetracyclines dropped by 42% during the first 3 months of 1996 after withdrawal of reimbursement. CONCLUSIONS: It is reasonable to assume that the new reimbursement policy has initiated a reduction and caused a shift in general practitioners' prescribing of antibiotics. Thus a differential reimbursement policy might influence general practitioners' prescribing behavior towards antibiotics, with desirable ecological consequences.

Hysterectomy for benign gynecologic disorders: when and why?

Controversy continues to swirl around hysterectomy-particularly about when and why it is appropriate for benign disorders. In the United States, one woman in three undergoes hysterectomy by age 65. The rate in the European Union nations ranges from 6% to 20%. In this review, the most recent epidemiologic data on hysterectomy are summarized, and the generally accepted indications for this procedure for benign gynecologic diseases are presented and discussed.

Central dimensions of clinical practice evaluation: efficiency, appropriateness and effectiveness--II

That a treatment selected for a given condition works, or that it works better than alternative treatments, or that it was selected because it works as well as but is cheaper than alternative treatments, should be of pivotal concern to clinicians and is of central concern to patients and to health care managers. Attempts to address these concerns have resulted in what is now widely termed the 'effectiveness movement'. The protagonists of the movement have been concerned to create a culture of evaluation and inquiry within which the formulation of evidence-based clinical guidelines and their introduction into routine practice have played a prominent part. The need to ensure cost effectiveness of clinical intervention has been at least as emphasized as the need to ensure the clinical effectiveness of health care interventions. Although cost-effectiveness analyses are now an indispensable feature of practice guideline formulation and treatment evaluation, few studies have examined any deterioration in patient outcome associated with successful cost containment. An adequate understanding of the concept of clinical effectiveness and the associated aims of the 'effectiveness movement' is central to an understanding of the future nature and extent of health service provision, not simply in the UK but also internationally. Having examined the concepts of efficiency and appropriateness previously (O'Neill, Miles & Polychronis 1996, Journal of Evaluation in Clinical Practice 2, 13-27) we move in this second of two articles to a detailed explanation of the concept of effectiveness, and to an examination of the derivation and use of clinical practice guideline, concluding with a consideration of the role of practice guidelines in ensuring the cost effectiveness of health care intervention. The reservation is expressed that a 'guidelines culture', when established, will be manipulated by health care commissioners for largely political purposes, creating a systematic bias in the purchasing process that will actively disadvantage a range of patient groups.