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

Quality of life and sexual function after abdominal versus laparoscopic hysterectomy: a prospective study

BACKGROUND

This study aimed to evaluate the quality of life (QoL) and sexual function of women who underwent total abdominal hysterectomy and total laparoscopic hysterectomy.

METHODS

In this prospective cohort study, a total of 121 patients who underwent total abdominal hysterectomy (N.=65) and total laparoscopic hysterectomy (N.=56) operations for benign indications were included. Sociodemographic features, obstetric histories, and clinical characteristics of the patients were noted. Quality of life assessment was conducted with the World Health Organization Quality of Life-BREF questionnaire, which has five domains: overall quality of life + health, physical health, psychological health, social relationships, and environment. Sexual function was assessed by the Golombok-Rust Inventory of Sexual Satisfaction Scale with subscales of infrequency, non-communication, avoidance, non-sensuality, dissatisfaction, vaginismus, and anorgasmia. The patients were asked to fill in both questionnaires before the operation and six months after the operation.

RESULTS

Of the 121 patients, 104 of them completed the postoperative surveys. In the total laparoscopic hysterectomy group, the individual improvements of the overall quality of life + health physical, and psychological health domains were statistically higher than the total abdominal hysterectomy group. In terms of sexual function, the total abdominal hysterectomy group had worse avoidance, non-sensuality, dissatisfaction, and vaginismus subscale scores and total score both in the preoperative and postoperative period compared to the total laparoscopic hysterectomy group. However, the individual differences and the number of patients exhibiting sexual dysfunction before and after surgery were not statistically significant in both groups.

CONCLUSIONS

Laparoscopic hysterectomy was superior to abdominal hysterectomy in improving the quality of life of the patients. Both abdominal and laparoscopic hysterectomies were not found to affect female sexuality.

The role of noninvasive diagnostic imaging in monitoring pregnancy and detecting patients at risk for preterm birth: a review of quantitative approaches

Preterm birth (PTB) is the leading cause of neonatal morbidity and mortality worldwide. The ability to predict patients at risk for preterm birth remains a major health challenge. The currently available clinical diagnostics such as cervical length and fetal fibronectin may detect only up to 30% of patients who eventually experience a spontaneous preterm birth. This paper reviews ongoing efforts to improve the ability to conduct a risk assessment for preterm birth. In particular, this work focuses on quantitative methods of imaging using ultrasound-based techniques, magnetic resonance imaging, and optical imaging modalities. While ultrasound imaging is the major modality for preterm birth risk assessment, a summary of efforts to adopt other imaging modalities is also discussed to identify the technical and diagnostic limits associated with adopting them in clinical settings. We conclude the review by proposing a new approach using combined photoacoustic, ultrasound, and elastography as a potential means to better assess cervical tissue remodeling, and thus improve the detection of patients at-risk of PTB.

Is Vaginal Hysterectomy Safe for an Enlarged Uterus?

Objective

The purpose of this study was to compare the surgical outcomes between two sets of women undergoing vaginal hysterectomy (VH) for benign gynecological conditions: those with moderately enlarged ( ≥12 weeks') uteruses and those with normal-sized uteruses.

Materials and Methods

The medical records of 84 women who underwent vaginal hysterectomies for benign gynecological conditions at Şişli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey between 2013 and 2015 were reviewed. Age, uterine sizes, indications, duration of hospitalization, operation time, hematocrit (HCT) levels, and complications were analyzed.

Results

The most common indications for VH were uterine descensus. However, most women had presented with more than one indication. The mean age of the patients who underwent VH was 56.12. The maximum volume of the uterus was found to be 1244.74 ml, and the smallest volume was found to be 18.83 ml. The mean volume of the uterus was found as 122.6629 ml. The mean duration of operation was 159.70 minutes, whereas the mean duration of hospital stay was 3.79 days. The mean preoperative HCT and hemoglobin (Hgb) values were 37.098 (±3.64) gr/dl and 12.365 (±1.35) gr/dl respectively. Postoperative HCT and Hgb values were 31.363 (±3.94) gr/dl and 10.52 (±1.38) respectively.

Conclusion

VH is usually a simple procedure with low morbidity. It is important to choose the appropriate patient when deciding on the operation. In addition, having experienced surgeons in the field of VH increases the success of surgery.

Impact of Laparoscopic Hysterectomy on Quality of Life

There is an ongoing debate regarding the benefits and drawbacks of the various routes of hysterectomy. A number of studies have examined overall quality of life outcomes as well as specific patient-reported outcomes including physical, psychosocial, and sexual functioning after hysterectomy. Existing studies have used varied methodologies with widely heterogeneous results, but patient satisfaction appears to be very high after laparoscopic hysterectomy, with many studies favoring the laparoscopic approach over other routes of hysterectomy. There are many opportunities for further investigation into the impact of laparoscopic hysterectomy on quality of life-an outcome measure that may be 1 of the most important in surgeries for benign indications.

Comparative Effectiveness of a Technology-Facilitated Depression Care Management Model in Safety-Net Primary Care Patients With Type 2 Diabetes: 6-Month Outcomes of a Large Clinical Trial

BACKGROUND

Comorbid depression is a significant challenge for safety-net primary care systems. Team-based collaborative depression care is effective, but complex system factors in safety-net organizations impede adoption and result in persistent disparities in outcomes. Diabetes-Depression Care-management Adoption Trial (DCAT) evaluated whether depression care could be significantly improved by harnessing information and communication technologies to automate routine screening and monitoring of patient symptoms and treatment adherence and allow timely communication with providers.

OBJECTIVE

The aim of this study was to compare 6-month outcomes of a technology-facilitated care model with a usual care model and a supported care model that involved team-based collaborative depression care for safety-net primary care adult patients with type 2 diabetes.

METHODS

DCAT is a translational study in collaboration with Los Angeles County Department of Health Services, the second largest safety-net care system in the United States. A comparative effectiveness study with quasi-experimental design was conducted in three groups of adult patients with type 2 diabetes to compare three delivery models: usual care, supported care, and technology-facilitated care. Six-month outcomes included depression and diabetes care measures and patient-reported outcomes. Comparative treatment effects were estimated by linear or logistic regression models that used generalized propensity scores to adjust for sampling bias inherent in the nonrandomized design.

RESULTS

DCAT enrolled 1406 patients (484 in usual care, 480 in supported care, and 442 in technology-facilitated care), most of whom were Hispanic or Latino and female. Compared with usual care, both the supported care and technology-facilitated care groups were associated with significant reduction in depressive symptoms measured by scores on the 9-item Patient Health Questionnaire (least squares estimate, LSE: usual care=6.35, supported care=5.05, technology-facilitated care=5.16; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.02); decreased prevalence of major depression (odds ratio, OR: supported care vs usual care=0.45, technology-facilitated care vs usual care=0.33; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.007); and reduced functional disability as measured by Sheehan Disability Scale scores (LSE: usual care=3.21, supported care=2.61, technology-facilitated care=2.59; P value: supported care vs usual care=.04, technology-facilitated care vs usual care=.03). Technology-facilitated care was significantly associated with depression remission (technology-facilitated care vs usual care: OR=2.98, P=.04); increased satisfaction with care for emotional problems among depressed patients (LSE: usual care=3.20, technology-facilitated care=3.70; P=.05); reduced total cholesterol level (LSE: usual care=176.40, technology-facilitated care=160.46; P=.01); improved satisfaction with diabetes care (LSE: usual care=4.01, technology-facilitated care=4.20; P=.05); and increased odds of taking an glycated hemoglobin test (technology-facilitated care vs usual care: OR=3.40, P<.001).

CONCLUSIONS

Both the technology-facilitated care and supported care delivery models showed potential to improve 6-month depression and functional disability outcomes. The technology-facilitated care model has a greater likelihood to improve depression remission, patient satisfaction, and diabetes care quality.

Temporal trend and nationwide utility for hysterectomies in Taiwan, 1997-2010

OBJECTIVE

This study investigates the nationwide utilization and temporal trend of hysterectomies in Taiwan.

MATERIALS AND METHODS

The present study used the National Health Insurance Research Database that included claims of nearly the entire population in Taiwan since the inception of the National Health Insurance program in 1995. We analyzed age-adjusted rates of hysterectomies in Taiwan from 1997 through to 2010 and compared with the rates in 16 countries of the Organization for Economic Co-operation and Development. We also examined the utilization of various types of hysterectomies in Taiwan during this period.

RESULTS

There was a cross-country variation in the age-standardized rate of hysterectomy: 105 per 100,000 females in Spain, 156 per 100,000 females in Taiwan, 179 per 100,000 females in 16 Organization for Economic Co-operation and Development countries, and 325 per 100,000 females in the United States in 2008. The trend of the age-standardized rate of hysterectomy in Taiwan declined from 222.3 per 100,000 women in 1998 to 145.2 per 100,000 women in 2010. The most common type of hysterectomy during this period was total abdominal hysterectomy (51.2%). Subtotal hysterectomies increased by 117% (r²=0.89; p<0.01), from 672 in 1997 to 1458 in 2010; however, total hysterectomies decreased by 3.5% (r²=0.43; p=0.01), from 20,966 in 1997 to 20,230 in 2010. Laparoscopically assisted procedures (laparoscopic supracervical hysterectomy and laparoscopic hysterectomy) increased 4.98-fold (r²=0.23; p=0.09), from 1453 in 1997 to 8684 in 2010. By contrast, the proportion of conventional open hysterectomies (total abdominal hysterectomy, and subtotal or supracervical abdominal hysterectomy) decreased by 36.5% (r²=0.59; p<0.01), from 17,327 in 1997 to 10,994 in 2010. The proportion of vaginal hysterectomies decreased by 29.7% (r²=0.72; p<0.01), from 2858 in 1997 to 2010 in 2010.

CONCLUSION

As in most Western countries, hysterectomy rates in Taiwan declined by year. There was a marked shift in the types of hysterectomies from 1997 through to 2010 in Taiwan. Minimally invasive surgeries and supracervical hysterectomies were more commonly adopted.

Acute kidney injury in major gynaecological surgery: an observational study

OBJECTIVE

To assess the prevalence, outcomes and cost associated with acute kidney injury (AKI) defined by consensus risk, injury, failure, loss, and end-stage kidney (RIFLE) criteria after gynaecologic surgery.

DESIGN

Retrospective single-centre cohort study.

SETTING

Academic medical centre.

SAMPLE

Two thousand three hundred and forty-one adult women undergoing major inpatient gynaecologic surgery between January 2000 and November 2010.

METHODS

AKI was defined by RIFLE criteria as an increase in serum creatinine greater than or equal to 50% from the reference creatinine. We used multivariable regression analyses to determine the association between perioperative factors, AKI, mortality and cost.

MAIN OUTCOME MEASURES

AKI, combined major adverse events (hospital mortality, sepsis or mechanical ventilation), 90-day mortality and hospital cost.

RESULTS

Overall prevalence of AKI was 13%. The prevalence of AKI was associated with the primary diagnosis. Of women with benign tumour surgeries, 5% (43/801) experienced AKI compared with 18% (211/1159) of women with malignant disease (P < 0.001). Only 1.3% of the whole cohort had evidence of urologic mechanical injury. In a multivariable logistic regression analysis, AKI patients had nine times the odds of a major adverse event compared to patients without AKI (adjusted odds ratio 8.95, 95% confidence interval 5.27-15.22). We have identified several readily available perioperative factors that can be used to identify patients at high risk for AKI after in-hospital gynaecologic surgery.

CONCLUSIONS

AKI is a common complication after major inpatient gynaecologic surgery associated with an increase in resource utilisation and hospital cost, morbidity and mortality.

The Xenopus homeobox gene pitx3 impinges upon somitogenesis and laterality

Pitx3 has been identified as the causative locus in a developmental eye mutation associated with mammalian anterior segment dysgenesis, congenital cataracts, and aphakia. In recent studies of frog eye development we discovered that pitx3 expresses symmetrically in the somites and lateral plate mesoderm and asymmetrically during cardiac and gut looping. We report that disruption of pitx3 activity on one side of an embryo relative to the other, either by over- or underexpression of pitx3, elicits a crooked dorsal axis in embryos that is a consequence of a retarded progression through somitogenesis. Unlike in amniotes, Xenopus somites form as cohorts of presomitic cells that rotate perpendicular to the dorsal axis. Since no vertebral anomalies have been reported in mouse and human Pitx3 mutants, we attempt to distinguish whether the segmentation clock is uniquely affected in frog or if the pitx3 perturbation inhibits the cellular changes that are necessary to rotation of presomitic cells. In Xenopus, pitx3 appears to inhibit the rotation of presomitic cell cohorts and to be necessary to the bilaterally symmetric expression of pitx2 in somites.

Which parameters may influence the duration of hospitalization after vaginal hysterectomy?

OBJECTIVE

To estimate the variables that may affect the duration of hospitalization after vaginal hysterectomy.

MATERIAL AND METHODS

An 11-year retrospective analysis was performed on data derived from 197 patients who underwent vaginal hysterectomy due to non-malignant pathology at a tertiary care center between January 2000 to November 2011.

RESULTS

The average age of the patients in our series was 60.9±11.1 with a duration of hospitalization of 11.6±6.1 days after vaginal hysterectomy. The grouping variables consisted of age, number of pregnancies, abortions, parities and the presence of intra or postoperative complications. Advanced age (>60), increased number of pregnancies (>5) and parities (>5) and occurrence of intra or postoperative complications were found to be correlated with the duration of hospitalization after vaginal hysterectomy. Categorical variables were analyzed by Pearson's chi square or the Fisher exact test. The Mann Whitney U test was used to compare groups, while the correlation of variables was assessed with the Spearman Correlation Analysis.

CONCLUSION

Vaginal hysterectomy is a safe and effective procedure. Advanced age, increased number of pregnancies and parities and occurrence of intra or postoperative complications may prolong the duration of hospitalization after surgery. Increased experience, careful surgical technique and adherence to aseptic principles may improve the cost-effectivity and decrease the duration of hospitalization.

Hysterectomy…..Which route?

OBJECTIVE

We designed this study to focus on women with mobile uteri benign no larger than 14 weeks, who would ordinarily be considered candidates for vaginal hysterectomy and compare the outcomes when abdominal routes were chosen. We also compared the intra and post operative complications, requirement for blood transfusion, length of hospital stay, between abdominal and vaginal route of hysterectomy.

METHOD

In a simple randomized prospective comparative study 200 consecutive patients requiring hysterectomy for benign uterine conditions were analysed over a period of 2 years. (June 2006-May 2008). Group A (n = 100) underwent vaginal hysterectomy (non descent vaginal hysterectomy, NDVH) which was compared with group B (n = 100) who had abdominal hysterectomy.

RESULTS

As far as duration of operation, duration of i.v. drip, mobilization in post operative ward, duration of hospital stay, P value was significant. Regarding blood loss P value was insignificant.

CONCLUSION

The accessibility of the vaginal passage, disease confined to the uterus and the surgeons experience are the major determining factors for the choice of the route of hysterectomy.

Multidisciplinary convalescence recommendations after gynaecological surgery: a modified Delphi method among experts

OBJECTIVE

To generate structured detailed uniform convalescence recommendations after gynaecological surgery by a modified Delphi method amongst experts and a representative group of physicians.

DESIGN

Modified Delphi study.

SETTING

Expert physicians recruited by their respective medical boards and employed at different hospitals, doctor's surgeries and healthcare services.

POPULATION

Twelve experts (five gynaecologists, two general practitioners [GPs] and five occupational physicians [OPs]) and a representative sample of 63 medical doctors.

METHODS

Multidisciplinary detailed recommendations for graded resumption of relevant activities after uncomplicated hysterectomy (laparoscopic supracervical, total laparoscopic/laparoscopic-assisted, vaginal and abdominal hysterectomies) and laparoscopic adnexal surgery were developed. Recommendations were based on a literature review and a modified Delphi procedure among 12 experts, recruited in collaboration with the participating medical boards of gynaecologists, GPs and OPs.

MAIN OUTCOME MEASURES

A multidisciplinary consensus of at least 67% on the relevant detailed convalescence recommendations in relation to hysterectomy and laparoscopic adnexal surgery.

RESULTS

Out of initially 65 activities, the expert panel judged 38 activities relevant for convalescence recommendations. Consensus for all activities was achieved after four Delphi rounds and two group discussions. The recommendations were judged as feasible by a representative sample of 26 gynaecologists, 19 GPs and 18 OPs.

CONCLUSIONS

Consensus between gynaecologists, GPs and OPs was achieved on all relevant convalescence recommendations regarding hysterectomy (abdominal, vaginal and laparoscopic) and laparoscopic adnexal surgery.

Cost effectiveness of laparoscopy versus laparotomy in early stage endometrial cancer: a randomised trial

OBJECTIVE

To determine the cost effectiveness of total laparoscopic hysterectomy (TLH) versus total abdominal hysterectomy (TAH) in early stage endometrial cancer alongside a multicenter randomised controlled trial (RCT).

METHODS

An economic analysis was conducted in 279 patients (TLH n=185; TAH n=94) with early stage endometrial cancer from a societal perspective, including all relevant costs over a three month time horizon. Health outcomes were expressed in terms of major complication-free rate and in terms of utility based on women's response to the EQ-5D. Comparisons of costs per major complication-free patient gained and costs with utility gain and costs were made, using incremental cost effectiveness ratios.

RESULTS

The mean major complication-free rate and median utility scores were comparable between TLH and TAH at three months. TLH is more costly intraoperatively (Δ$1.129) and less costly postoperatively in-hospital (Δ$-1.350) compared to TAH. Incremental costs per major complication-free patient were $-52. Higher cost ($249) were generated while no gains in utility (-0.02) were observed for TLH compared to TAH. Analysing utility at six weeks, incremental costs per additional point on the EQ-5D scale were $1.617.

CONCLUSION

TLH is cost effective compared to TAH, based on major complication-free rate as measure of effect. Along with future cost saving strategies in laparoscopy, TLH is assumed to be cost effective for both effect measures. Therefore and due to comparable safety, TLH should be recommended as a standard-of-care surgical procedure in early endometrial cancer.

Costs and effects of abdominal versus laparoscopic hysterectomy: systematic review of controlled trials

Objective

Comparative evaluation of costs and effects of laparoscopic hysterectomy (LH) and abdominal hysterectomy (AH).

Data sources

Controlled trials from Cochrane Central register of controlled trials, Medline, Embase and prospective trial registers.

Selection of studies

Twelve (randomized) controlled studies including the search terms costs, laparoscopy, laparotomy and hysterectomy were identified.

Methods

The type of cost analysis, perspective of cost analyses and separate cost components were assessed. The direct and indirect costs were extracted from the original studies. For the cost estimation, hospital stay and procedure costs were selected as most important cost drivers. As main outcome the major complication rate was taken.

Findings

Analysis was performed on 2226 patients, of which 1013 (45.5%) in the LH group and 1213 (54.5%) in the AH group. Five studies scored ≥10 points (out of 19) for methodological quality. The reported total direct costs in the LH group ($63,997) were 6.1% higher than the AH group ($60,114). The reported total indirect costs of the LH group ($1,609) were half of the total indirect in the AH group ($3,139). The estimated mean major complication rate in the LH group (14.3%) was lower than in the AH group (15.9%). The estimated total costs in the LH group were $3,884 versus $3,312 in the AH group. The incremental costs for reducing one patient with major complication(s) in the LH group compared to the AH group was $35,750.

Conclusions

The shorter hospital stay in the LH group compensates for the increased procedure costs, with less morbidity. LH points in the direction of cost effectiveness, however further research is warranted with a broader costs perspective including long term effects as societal benefit, quality of life and survival.

Evaluation of closure versus non-closure of vaginal vault after vaginal hysterectomy

This randomised prospective study in 53 women having vaginal hysterectomy for benign conditions compared a closed vault technique with an open technique. Twenty-seven had the vault closed (group A) whereas 26 patients had an open vault (group B). The primary outcomes include, vault haematoma (as detected by ultrasound on day 3) and fever. Secondary outcomes are haemorrhage, urinary tract infection, urinary retention and vault granulation tissue. The study did not show any statistical difference between either group. Prolapse of the fallopian tube was recorded in one case in the open vault group. A randomised controlled study on a larger scale is recommended.

Vaginal hysterectomy: dispelling the myths

Despite advances in minimally invasive surgery, most hysterectomies are still performed by laparotomy. The ratio of abdominal to vaginal hysterectomies ranges from 1:1 to 6:1 across North America, and in Canada is approximately 3:1. The SOGC clinical practice guideline on hysterectomy states that the vaginal route should be considered for every hysterectomy; if it is assumed that most surgeons would try to follow accepted guidelines, vaginal hysterectomy is presumably being considered and excluded. The evidence is compelling that vaginal hysterectomy is the approach of choice for benign pathology. The cited contraindications to vaginal hysterectomy are often unsubstantiated. In this commentary we examine the four reasons most often cited for avoiding a vaginal hysterectomy: (1) uterine size, (2) nulliparity and uterine descent, (3) need for oophorectomy, and (4) previous abdominopelvic surgery and extrauterine disease. More research is necessary to evaluate and demystify the barriers to performing minimally invasive hysterectomy. We recommend that preceptorship programs be developed for gynaecologic surgeons in an attempt to decrease the ratio of abdominal to vaginal hysterectomies.

Ten-year results of a prospective study on the prognostic role of ploidy in endometrial carcinoma

BACKGROUND

To improve the outcome of endometrial cancer patients, a more accurate prognostic assessment is mandatory. The aims of the study were to evaluate the role of flow cytometric DNA ploidy as an independent prognostic factor in patients with endometrial cancer and to verify if ploidy was able to distinguish patients with different prognosis into homogeneous subgroups for grade of differentiation and stage.

METHODS

In a prospective study, DNA ploidy was evaluated from fresh tumor samples in 174 endometrial cancer patients who underwent surgery as the first treatment. Ploidy, as well as classical parameters, were analyzed in relation to the length of disease-free survival and disease-specific survival.

RESULTS

DNA aneuploidy was found in 49 patients (28.2%). Patients with DNA-aneuploid tumors had a significantly reduced disease-free interval and disease-specific survival (P < .0001). The 10-year survival probability was 53.2% for DNA-aneuploid patients and 91.0% for patients with DNA-diploid tumors. By multivariate analysis DNA-aneuploid type was the strongest independent predictor of poor outcome, followed by age and stage. Patients with DNA-aneuploid tumor had a significantly higher risk ratio for recurrence (5.03) and death due to disease (6.50) than patients with DNA-diploid tumors. Stratification by DNA-ploidy within each group by grade of differentiation allowed identification of patients with significantly different outcome. In grade 2 tumors, 10-year survival was 45.0% in aneuploid cases and 91.9% in diploid cases (P < .0001). Patients with advanced-stage (>I) diploid tumor did significantly better than patients with stage I aneuploid tumor (P = .04).

CONCLUSIONS

The presence of DNA-aneuploid type in endometrial cancer identifies high-risk cases among the patients considered 'low risk' according to stage and grade of differentiation.

A review of the application of propensity score methods yielded increasing use, advantages in specific settings, but not substantially different estimates compared with conventional multivariable methods

OBJECTIVE

Propensity score (PS) analyses attempt to control for confounding in nonexperimental studies by adjusting for the likelihood that a given patient is exposed. Such analyses have been proposed to address confounding by indication, but there is little empirical evidence that they achieve better control than conventional multivariate outcome modeling.

STUDY DESIGN AND METHODS

Using PubMed and Science Citation Index, we assessed the use of propensity scores over time and critically evaluated studies published through 2003.

RESULTS

Use of propensity scores increased from a total of 8 reports before 1998 to 71 in 2003. Most of the 177 published studies abstracted assessed medications (N=60) or surgical interventions (N=51), mainly in cardiology and cardiac surgery (N=90). Whether PS methods or conventional outcome models were used to control for confounding had little effect on results in those studies in which such comparison was possible. Only 9 of 69 studies (13%) had an effect estimate that differed by more than 20% from that obtained with a conventional outcome model in all PS analyses presented.

CONCLUSIONS

Publication of results based on propensity score methods has increased dramatically, but there is little evidence that these methods yield substantially different estimates compared with conventional multivariable methods.

Factors Associated With Increased Charges for Hysterectomy

OBJECTIVE

To evaluate factors associated with increased hospital charges for hysterectomy with specific attention to differences based on surgical approach.

METHODS

We performed a retrospective cohort study of 686 patients who underwent hysterectomy between January 1997 and September 1997 using medical chart review and hospital financial information. Demographic information, surgical approach (abdominal, vaginal, or laparoscopic), and surgical and postoperative factors were extracted from the medical record. Hospital charges were obtained from the hospital billing database. Relationships between charges and various clinical and demographic variables were examined using chi(2), Fisher exact test, t tests, or analysis of variance, where appropriate. Logistic regression was used to estimate odds ratios while controlling for important confounding variables.

RESULTS

In our logistic regression model, blood loss greater than 1,000 mL (odds ratio [OR] 11.8, 95% confidence interval [CI] 4.2-33.2) and operative time 105 minutes or more (OR 14.2, CI 5.8-34.5) were strongly associated with higher charges for hysterectomy. Other factors associated with higher charges included: postoperative fever (OR 2.2, CI 1.1-4.5), increasing length of hospitalization (OR 5.3, CI 3.7-7.7), the use of prophylactic antibiotics (OR 3.0, CI 1.3-6.6), and the laparoscopic surgical approach compared with vaginal hysterectomy (OR 2.7, CI 1.0-7.0).

CONCLUSION

Surgical factors such as operative time and blood loss were strongly associated with increased hospital charges for hysterectomy.

Mid- and Long-Term Quality-of-Life Assessment in Patients Undergoing Uterine Fibroid Embolization

OBJECTIVE

Our objective was to assess the mid- and long-term outcomes concerning fibroid-specific and fibroid-associated quality of life in patients treated by uterine fibroid embolization.

MATERIALS AND METHODS

A retrospective cohort study was performed, including consecutive patients with a minimum follow-up of 1 year. Analysis was performed by a questionnaire consisting of 49 questions about six topics: baseline characteristics, preinterventional status, diagnostic workup and treatment planning, periinterventional period and procedure-related quality of life, follow-up, and general satisfaction.

RESULTS

The analysis was performed based on questionnaires from 53 (85.5%) of 62 patients. The mean follow-up was 3.0 +/- 1.0 (SD) years (range, 1.0-5.0 years). Uterine fibroid embolization led to a reduction of bleeding symptoms in 79.2% of patients (n = 48 before uterine fibroid embolization; n = 10 after uterine fibroid embolization), pain in 81.5% (n = 27; n = five, respectively), bulk-related symptoms in 78.6% (n = 14; n = three, respectively), urinary dysfunction in 60% (n = 10; n = four, respectively), sexual dysfunction in 71.4% (n = seven; n = two, respectively), fatigue in 62.5% (n = 24; n = nine, respectively), limitations in social life in 88.2% (n = 17; n = two, respectively), and a depressed mood in 89.5% (n = 19; n = two, respectively). The median impairment score for bleeding and pain decreased significantly from 6 to 0 and from 4 to 0, respectively (both p < 0.001). The general quality-of-life index increased significantly from 6 to 9 (p < 0.001). Forty-two (79.2%) patients judged the result as very satisfactory and would highly recommend uterine fibroid embolization to other patients.

CONCLUSION

Uterine fibroid embolization leads to an impressive mid- and long-term improvement of all investigated physical and psychological fibroid-related and fibroid-associated symptoms and significantly improves women's health-related quality of life.

Minimally invasive: minimally reimbursed? An examination of six laparoscopic surgical procedures

It is generally believed that minimally invasive surgery (MIS) results in less postoperative pain, fewer complications, and shorter recovery periods compared with open procedures. Yet despite these benefits, the level of reimbursement assigned to the surgeon by United States health-care payers is often lower than that for open procedures. Furthermore, the cost of performing a MIS may be higher vs an open procedure because specialized equipment, increased surgical time, or both may be required. In this report, we examine the issue by comparing reimbursements for MIS with open procedures, summarizing the medical literature on MIS vs open surgical procedures, and offering recommendations for payers who establish reimbursement policies. The review is focused on six MIS procedures where outcomes data exist: laparoscopic cholecystectomy (lap chole), laparoscopic colectomy (LC), laparoscopic fundoplication (LF), laparoscopic hysterectomy (LH), laparoscopic ventral hernia repair (LVHR), and laparoscopic appendectomy (LA). Outcomes summarized were length of hospital stay (LOS), operating room time, operating room costs, complications, and return to work or normal activities. The level of scientific evidence was assigned to each study using predetermined criteria. A total of 112 articles were reviewed: 14 for lap chole, 26 for LC, 7 for LF, 19 for LH, 9 for LVHR, and 37 for LA. The data demonstrate that these procedures result in reduced hospital stay, reduced hospital costs, and faster return to work or normal activities. Yet, the operating room time and costs are frequently higher for MIS. These findings suggest that as both the outcomes value and level of operating room resources are greater, MIS warrants reimbursement that meets or exceeds that of open procedures.

Abdominal vs vaginal hysterectomy: a comparative study of the postoperative quality of life and satisfaction

OBJECTIVE

To compare the short-term results of the quality of life and satisfaction of patients submitted to total abdominal hysterectomy (TAH) and vaginal hysterectomy (VH) for benign uterine disease.

METHODS

Women referred for hysterectomy for uterine myoma were randomized to TAH (n=30) or VH (n=30). The exclusion criteria were uterine prolapse, indication associated surgical procedures and uterine size > or =300 cm3. After a month, follow-up questionnaires had a response rate of 100%, and consisted of an interview with application of SF-36 questionnaire (functional capacity, physical aspect and pain) and evaluation of satisfaction rate.

RESULTS

There were no differences in the patients' mean age, parity, body mass index, preoperative hemoglobin levels and uterine size between groups. Lower postoperative quality-of-life scores were found in the TAH group when compared to the VH group in functional capacity (P=0.002), physical aspect (P=0.008) and pain (P=0.002). The general satisfaction rate with the surgery was similar in the two groups of patients (P=0.147). However, a higher rate of patients submitted to VH would choose the same therapeutic modality (65.5 vs 90%; P=0.021).

CONCLUSIONS

A better postoperative quality of life (functional capacity, physical aspect and pain) and higher satisfaction rate was found in the VH when compared to TAH.

A randomized comparison of post-operative pain, quality of life, and physical performance during the first 6 weeks after abdominal or vaginal surgical correction of descensus uteri

AIMS

With respect to urogenital function, vaginal hysterectomy combined with anterior and/or posterior colporraphy has been shown to be superior to abdominal sacrocolpopexy with preservation of the uterus. We performed a randomized trial to compare the effects of both procedures on pain, quality of life and physical performance during the first six weeks after surgery.

METHODS

Eighty-two patients were randomized to have surgery either by vaginal or abdominal approach. All patients were asked to complete the RAND-36 before surgery and 6 weeks after surgery and to keep a diary for the first 6 weeks after surgery. This diary assessed the pain perception and use of pain medication, bother of limitations due to the surgery and performance of daily activities after surgery. These outcomes were compared.

RESULTS

All patients completed the RAND-36 and 68 patients completed the diary. Patients who had undergone abdominal surgery had a statistically lower score on the health change domain (56 vs 68), bodily pain domain (63 vs 80) and mental health domain (74 vs 81) of the RAND-36, as compared to patients who had undergone vaginal prolapse surgery. During hospital stay, the abdominal group experienced on average more days of pain (4.5 vs 3.0) and impaired mobility (3.7 vs 2.9) as compared to the vaginal group. Patients received more pain medication following abdominal surgery as compared to vaginal surgery.

CONCLUSIONS

The vaginal operation to correct a descensus uteri is associated with less pain, better quality of life and better mobility during the first 6 weeks of the recovery period as compared to the abdominal approach.

Health economics of hysterectomy

Health resources are finite, and it is increasingly necessary to practise medicine within defined budgets. Hysterectomy is recognized as one of the most frequently performed of all major surgical operations and is of great economic as well as medical and social importance. A full assessment of the value of an intervention requires consideration of both economic and clinical outcomes. New alternative therapies to uterine excision have been introduced, and new ways of performing hysterectomy have been developed. Cost-effectiveness analysis enables each of these approaches to be meaningfully compared. Using such analytic techniques, hysterectomy can be shown to be an effective and cost-effective intervention across a variety of indications. The vaginal route is the most cost-effective approach. There seems to be no obvious advantage in conserving or retaining the cervix, but there is as yet no evidence about the cost-effectiveness of concomitant oophorectomy.

Offering patients the opportunity to choose their hospital for total knee replacement: Impact on satisfaction with the surgery

OBJECTIVE

To describe the extent to which patients were offered a choice between 2 or more hospitals for total knee replacement (TKR); to examine the association between having a choice of hospital for TKR and satisfaction with the surgery; and to identify population groups less likely to be offered a choice.

METHODS

We studied a population-based sample of 932 Medicare beneficiaries who underwent elective TKR in 2000. We surveyed patients about their participation in choosing a hospital and their satisfaction with surgery. We examined whether lack of hospital choice influenced satisfaction with surgery after adjusting for age, sex, preoperative function, and socioeconomic status.

RESULTS

Among 932 TKR recipients (mean age 74 years, 67% women), more than half (53%) reported having a lack of hospital choice. After adjusting for socioeconomic status, patients reporting lack of choice were approximately twice as likely to be dissatisfied with the results of surgery as patients who reported choosing among 2 or more hospitals for TKR (odds ratio [OR] 2.09, 95% confidence interval [95% CI] 1.13-3.87). Results of logistic regression revealed that patients reporting lack of choice were more likely to be women (OR 1.52, 95% CI 1.14-2.04), >80 years of age (as compared with 65-70 years; OR 1.63, 95% CI 1.03-2.57), living in suburban areas (OR 1.68, 95% CI 1.23-2.30), nonwhite (OR 1.57, 95% CI 0.86-2.87), and were less likely to have TKR performed by a high-volume surgeon (OR 0.71, 95% CI 0.53-0.96).

CONCLUSION

More than half of the patients did not have a choice in selecting the hospital where they had TKR. Patients reporting lack of choice were more likely to be dissatisfied with surgery. Interventions to address preferences for hospital may improve satisfaction with care for patients with advanced knee arthritis.

The scope of vaginal hysterectomy

OBJECTIVE

The study was designed to check the feasibility of the vaginal route as the primary route for hysterectomy.

STUDY DESIGN

All patients in whom hysterectomy was indicated were first considered for vaginal hysterectomy unless this route was contraindicated. Vaginal hysterectomy (VH) was performed in 5655 patients, and in 90.4% of these no uterine prolapse was present. The operative intervention required, preconditions and any complications were carefully studied.

RESULTS

Of the 6945 cases considered, vaginal hysterectomy was possible in 5655 (81%). Successful simultaneous prophylactic oophorectomy or salpingo-oophorectomy was possible, in 1510 of 1572 cases without laparoscopic assistance. The indications are carefully discussed, with a strong emphasis on examination under anaesthesia, preoperative total uterine volume and, if required, laparoscopic evaluation and surgeons' readiness to reduce the frequency of recourse to laparotomy or laparoscopic assistance.

CONCLUSION

The vaginal route is the least invasive and most economical route for hysterectomy and should be the gynaecological surgeon's first choice. A uterus with a volume up to 300 cm3 or uterine size up to 12 weeks should be dealt with vaginally, and as surgeons become more experienced larger uteri and also the adnexa can be approached in the same manner, at least as trial vaginal hysterectomy.

Total laparoscopic hysterectomy and laparoscopic supracervical hysterectomy

Laparoscopic hysterectomy was first performed in 1989 and has become one of the procedures that may be offered to women with significant gynecologic symptoms. This article describes alternatives to hysterectomy, indications for laparoscopic hysterectomy, and outcomes and complications of laparoscopic hysterectomy as compared with vaginal and abdominal hysterectomy. Surgical technique for both total and supracervical hysterectomy are described as well as the learning curve, training, and credentialing for these procedures.

Transvaginal hysterectomy: rationale and surgical approach

Abdominal hysterectomy is performed in the United States at a 3:1 ratio over vaginal hysterectomy, despite evidence that vaginal hysterectomy offers advantages over abdominal hysterectomy with regard to operative time, complication rates, recovery, return to daily activities, and overall costs of treatment. In fact, the predominance of the abdominal approach may be based on factors other than clinical considerations, including resident training, use of limited or obsolete guidelines, greater third-party compensation for abdominal procedures, a presumption rather than a confirmation that pathology exists that contraindicates a vaginal approach, and misconceptions about the safety and cost of vaginal hysterectomy. A number of studies spanning several years demonstrate that the use of more systematic guidelines for selecting the route of hysterectomy results in a major shift toward the vaginal approach. Evidence also shows that transvaginal hysterectomy is both feasible and optimum for types of patients who have long been considered inappropriate candidates for the vaginal route. New instrumentation facilitates the vaginal approach and contributes to improved hemostasis and decreased operative time. Included here is a step-by-step approach to determining appropriate candidates for the vaginal approach via assessment of access, uterus size, and extent of pathology.

Comparison between bisection/morcellation and myometrial coring for reducing large uteri during vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy: results of a randomized prospective study

BACKGROUND

Vaginal hysterectomy (VH) is being performed increasingly by gynecologic surgeons. Thus, enlarged uteri are more frequently removed vaginally, requiring reducing techniques to allow vaginal extraction.

MATERIAL AND METHODS

We designed a randomized prospective study to compare bisection-morcellation and myometrial coring. Patients scheduled for VH or laparoscopically assisted vaginal hysterectomy (LAVH) were offered entry into the study. Endometrial cancer was an exclusion criterion. Uterine size was not a contraindication for vaginal surgery. We compared data from preoperative workup as well as from the operative and the postoperative course. Data were recorded prospectively. Results were analyzed with nonparametric tests and logistic regression models.

RESULTS

Thirty patients were included in the study. Patients were similar in both groups. No severe peroperative complication occurred in this series. Operating time was comparable in both groups. Uteri weighed more than 280 g in more than 70% of patients in both groups. Myometrial coring failed more often than bisection-morcellation (25% vs. 0%, p = 0.06). Patients and uteri characteristics had no influence on the risk of failure, except for narrow uteri, which were associated with an increased risk of failure in the myometrial coring group only (68.3 vs. 83.9 mm, p = 0.01). Postoperative courses were similar for the two techniques, except for an increased rate of fever in the myometrial coring group (28%, p = 0.03).

CONCLUSION

Both techniques appeared safe in this trial. Myometrial coring failed more frequently than bisection-morcellation, especially in the case of a narrow uterus. Postoperative fever was significantly more common after myometrial coring. Both techniques should be taught to resident surgeons.

Hysterectomy and sexual wellbeing: prospective observational study of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy

OBJECTIVES

To compare the effects of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy on sexual wellbeing.

DESIGN

Prospective observational study over six months.

SETTING

13 teaching and non-teaching hospitals in the Netherlands.

PARTICIPANTS

413 women who underwent hysterectomy for benign disease other than symptomatic prolapse of the uterus and endometriosis.

MAIN OUTCOME MEASURES

Reported sexual pleasure, sexual activity, and bothersome sexual problems.

RESULTS

Sexual pleasure significantly improved in all patients, independent of the type of hysterectomy. The prevalence of one or more bothersome sexual problems six months after vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy was 43% (38/89), 41% (31/76), and 39% (57/145), respectively (chi2 test, P = 0.88).

CONCLUSION

Sexual pleasure improves after vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy. The persistence and development of bothersome problems during sexual activity were similar for all three techniques.

Tolerance, Hospital Stay, and Recovery after Uterine Artery Embolization for Fibroids: The Ontario Uterine Fibroid Embolization Trial

PURPOSE

Uterine artery embolization (UAE) is gaining popularity as an alternative to hysterectomy for the treatment of fibroids. Although minimally invasive treatments such as UAE offer the potential of fewer complications, shorter hospital stay, and quicker recovery than surgery, there have been few published data on tolerance and recovery in patients undergoing UAE.

MATERIALS AND METHODS

This was a multicenter prospective single-arm clinical treatment trial involving the practices of 11 interventional radiologists in eight Ontario university-affiliated and community hospitals. Between November 1998 and November 2000, 555 women underwent UAE for symptomatic uterine fibroids. Follow-up included ultrasound examinations and telephone interviews. UAE was performed under conscious sedation. Polyvinyl alcohol particles (355-500 micro m) were the primary embolic agent, and the procedural endpoint involved stasis in the uterine arteries. Pain protocols included antiinflammatory medications and narcotics and a planned overnight hospital admission. Tolerance and recovery were measured by patient-reported pain intensity (10-point numeric rating and five-point descriptor scale), hospital length of stay (LOS), and time until return to work.

RESULTS

Intraprocedural pain was reported by 30% of patients and postprocedural pain was reported by 92% of patients (mean pain rating +/- SD, 7.0 +/- 2.47). The mean hospital LOS was 1.3 nights. Postprocedural pain was the most common indication for an LOS greater than 1 night (18%) or 2 nights (5%). Return visits to the hospital (10%) and readmissions (3%) were primarily for pain. The overall postprocedural complication rate was 8.0% (95% CI: 5.9%-10.6%). Of the 44 complications, 32 (73%) were pain-related. The mean recovery time after UAE was 13.1 days (median, 10.0 d).

CONCLUSION

The majority of patients had a 1-night LOS after UAE and recovered within 2 weeks. Postprocedural pain varied considerably and was the major indication for extended hospital stay and recovery.

Cost-effectiveness of the use of transvaginal sonography in the evaluation of postmenopausal bleeding

OBJECTIVES

To assess the cost-effectiveness of transvaginal sonography (TVS) in the diagnostic work-up of women with postmenopausal bleeding.

METHODS

We performed a decision analysis in which we estimated life expectancy and cost of four strategies for the evaluation of postmenopausal bleeding: TVS (I), TVS and office endometrial biopsy (II), TVS and hysteroscopy (III), and endometrial biopsy (IV). In strategies incorporating TVS, calculations were performed for three different cut-off values between 3 and 9 mm double layer. Expectant management, i.e. no diagnosis or treatment was considered to be the reference strategy to which the other four strategies were compared. Data were obtained from the published literature. In extensive sensitivity analyses, we varied patient's age, discount rate, prevalence of endometrial carcinoma and atypical hyperplasia, and costs.

RESULTS

The strategy with endometrial biopsy and the strategy with TVS followed by endometrial biopsy in case of an increased endometrial thickness were the most cost-effective strategies. The strategy starting with endometrial biopsy was the most cost-effective when the prevalence of endometrial carcinoma was > or =15.3%, whereas the strategy with TVS and endometrial biopsy was the most cost-effective for women in which the prevalence of endometrial carcinoma was lower. In these strategies, a cut-off level for abnormality of 9 mm resulted in lowest cost per life-year gained.

CONCLUSIONS

TVS is of use in women with postmenopausal bleeding and a probability of endometrial carcinoma below 15%.

Short- and long-term clinical results of laparoscopic-assisted vaginal hysterectomy and total abdominal hysterectomy

STUDY OBJECTIVE

To compare short- and long-term clinical results of laparoscopic-assisted vaginal hysterectomy (LAVH) and total abdominal hysterectomy (TAH).

DESIGN

Retrospective cohort study (Canadian Task Force classification II-1).

SETTING

University-affiliated hospital.

PATIENTS

One hundred fifty women who underwent LAVH and 146 who underwent TAH.

INTERVENTION

Hysterectomy.

MEASUREMENTS AND MAIN RESULTS

Blood loss during surgery, narcotic analgesic consumption, duration of hospital stay, and convalescence time were significantly higher for women who underwent TAH than for those who underwent LAVH (p <0.05). Operating time was significantly longer for LAVH than for TAH (152.2 +/- 32.4 vs 96.5 +/- 29.6 min, p = 0.014). Eight-year follow-up showed no statistically significant differences in vaginal vault prolapse, cystocele, rectocele, enterocele, postcoital spotting, and cuff granulation between procedures (p >0.05).

CONCLUSIONS

Although short-term clinical results revealed some statistically significant differences between LAVH and TAH, long-term follow-up recorded similar frequencies of surgical sequelae.

Guidelines for the selection of the route of hysterectomy: application in a resident clinic population

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of the Society of Pelvic Reconstructive Surgeons guidelines for the determination of the route of hysterectomy in a resident clinic population.

STUDY DESIGN

A total of 407 consecutive women from the resident clinic population at Wright State University between October 1, 1994, and December 31, 1999, were assigned prospectively to abdominal or vaginal hysterectomy groups according to Society of Pelvic Reconstructive Surgeons guidelines. The women's age, race, and preoperative and postoperative uterine weights, length of stay, laparoscopic scores, operative time, and complications were compared.

RESULTS

Vaginal hysterectomy was completed successfully in 91.8% of the women. As expected, vaginal hysterectomy required the shortest operative time and length of stay and was associated with fewer complications than the abdominal approach (P <.01). Laparoscopic assistance was necessary in 25.8% of patients to assess extrauterine disease.

CONCLUSION

Resident physicians who followed the practice guidelines reduced the ratio of abdominal-to-vaginal hysterectomy from 3:1 to 1:11. The application of practice guidelines for the selection of the route of hysterectomy can increase the ratio of vaginal hysterectomies that are performed in residency programs and can help eradicate inconsistencies in health care delivery that exist currently.

Satisfaction with hysterectomy: low-income underinsured teaching hospital patients versus insured patients at a private hospital

OBJECTIVE

The purpose of this study was to measure patient health-related quality of life/satisfaction with the results of hysterectomy in 2 distinct groups of women.

STUDY DESIGN

A health-related outcomes questionnaire was completed 3 months after hysterectomy by 50 low-income women who underwent operation at a state-supported teaching hospital and by 50 women who underwent operation at a private hospital.

RESULTS

The women at the teaching hospital had a significantly worse outcome satisfaction score than the women at a private hospital. However, 98% of the patients at the teaching hospital and 100% of patients at the private hospital noted their symptoms to be improved. Factors such as race, age, preoperative indications, route of hysterectomy, oophorectomy, and hormone replacement therapy did not affect outcome scores.

CONCLUSION

Low-income women who undergo operation at a university teaching hospital experience lower satisfaction after hysterectomy than do other women.

Health-related quality of life measurement in women with common benign gynecologic conditions: a systematic review

Endometriosis, menorrhagia, chronic pelvic pain, and polycystic ovary syndrome are major sources of psychologic morbidity and can negatively affect quality of life. Although comparative studies have been published on the measurement of health-related quality of life for gynecologic malignancies, a similar review for these benign gynecologic conditions has not been conducted. Consequently, we searched the literature systematically to identify the impact of symptoms and treatments for these conditions on health status and to report on the types and psychometric properties of the instruments used. Papers were retrieved by systematically searching 6 electronic databases and hand-searching relevant reference lists and bibliographies. Forty-six studies used a questionnaire to measure health status: 34 studies (74%) used standardized instruments; of these, 23 studies (68%) used generic tools. Although a meta analysis was not possible, it appears that women with chronic pelvic pain and conditions that are associated with pelvic pain (such as endometriosis) report worse health-related quality of life. Despite the development of disease-specific questionnaires, only 2 questionnaires were generated from interviews of patients with the condition of interest, and few questionnaires are being used to evaluate the outcomes of treatment on subjective health status.