Estimated National Cost of Pelvic Organ Prolapse Surgery in the United States

OBJECTIVE

To estimate the national cost of pelvic organ prolapse (POP) surgery in the United States.

METHODS

In this cross-sectional, population-based study, we used the 2016-2018 Healthcare Cost and Utilization Project National Inpatient Samples and National Ambulatory Surgery Samples to identify patients undergoing POP surgery using International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes, ICD-10 procedural codes, and Current Procedural Terminology codes. Cost-to-charge ratios and weighted estimates were used to calculate nationwide costs. Descriptive analysis was used to identify the sociodemographic, clinical, and surgical characteristics of the population undergoing POP surgery.

RESULTS

Between 2016 and 2018, there were 140,762 POP surgical cases annually with an annual national cost estimated at $1.523 billion per year. The median cost per procedure increased slightly from $8,837 in 2016 to $8,958 in 2018. Overall, 82.5% of the total surgeries and 78% of the total national costs associated with POP surgery came from the ambulatory setting over this time period. Of these surgeries, 44.7% included an apical repair, and 42.3% included a concomitant hysterectomy. The average age of the population was 62 years, and 20% of the total population receiving prolapse surgery were younger than age 50 years.

CONCLUSION

The annual national cost associated with surgical correction of POP is substantial, and the majority of cases occur in an ambulatory setting. These findings will contribute to enhancing cost-effectiveness analyses and decision-making processes for both health care professionals and policymakers as the national population continues to age.

The effect of 12-month postoperative weight change on outcomes following midurethral sling for stress urinary incontinence: a secondary analysis of the ESTEEM and TOMUS randomized trials

INTRODUCTION AND HYPOTHESIS

Prior studies demonstrate mixed results on the impact of obesity on the success of midurethral slings (MUS), with little known about how postoperative weight change affects outcomes. We aimed to examine the effect of postoperative weight change on outcomes 12 months after MUS for stress urinary incontinence (SUI).

METHODS

This secondary analysis utilized data from two multicenter randomized trials of women undergoing MUS placement. Subjects were categorized into cohorts based on change in body weight at 12 months postoperatively: weight gain (≥5% increase); weight loss (≥5% decrease), and weight stable (<5% change). The primary outcome was SUI cure (no SUI episodes in a 3-day bladder diary). Patients with mixed urinary incontinence (MUI) were analyzed for changes in daily average urge incontinence (UUI) episodes in a 3-day diary. Penalized logistic regression assessed the impact of demographic and perioperative variables on the primary outcome.

RESULTS

Of the 918 women included, 635 (70%) were weight stable, 144 (15%) had weight gain, and 139 (15%) had weight loss. Patients in the weight loss cohort had a higher smoking rate and a higher baseline body mass index (SD 0.29, 2.7 respectively). All cohorts experienced high SUI cure rates ranging from 77 to 81%, with no significant difference in SUI cure between cohorts (p = 0.607). Of 372 subjects with MUI, the weight loss cohort had significantly greater improvement in UUI episodes.

CONCLUSIONS

Weight change at 12 months postoperatively did not significantly alter efficacy of MUS for treatment of SUI. Patients with MUI who lost ≥5% body weight had significantly greater improvement in UUI episodes.

Exploring Patient Perspectives Surrounding Telemedicine Versus In-Person Preoperative Visits

IMPORTANCE

Telemedicine was increasingly used to provide patients with an alternative to in-office visits during the COVID-19 pandemic. While previous studies have described the role of telemedicine for preoperative visits for other surgical specialties, the role of this modality in preoperative visits for gynecologic surgery has not been thoroughly explored.

OBJECTIVES

The aims of the study are to explore and compare patient experience, decision making, and satisfaction among women undergoing telemedicine or in-person preoperative visits.

STUDY DESIGN

This was a qualitative study of women who underwent a preoperative appointment with a urogynecologic surgeon or minimally invasive gynecologic surgeon at a single academic institution from April to May of 2021. Data were collected using semistructured phone interviews, which focused on visit content, visit type decision making, surgical preparedness/confidence, and past surgical experiences. Interviews were thematically analyzed until theoretical saturation was achieved in accordance with grounded theory.

RESULTS

Theoretical saturation occurred with 20 interviews. Participants were evenly divided between in-person and telemedicine visits. Major themes included visit content, experience/quality, surgeon perception, and surgical preparedness. Advantages of telemedicine visits were convenience and safety. Advantages of in-person visits were social factors, perceived medical or surgical severity, and preoperative physical examination. Disadvantages for telemedicine visits included technology concerns and difficulty accessing preoperative materials. The disadvantage of an in-person visit was the inability to have family present because of COVID hospital policy restrictions. Participants in both groups felt prepared for surgery and reported high satisfaction with their care.

CONCLUSIONS

Decision making for selecting an in-person or telemedicine visit is complex and involves balancing multiple advantages and disadvantages. Participant experience was similar for both visit types with high satisfaction.

Temporal trends of postpartum haemorrhage in Switzerland: a 22-year retrospective population-based cohort study

AIM

Postpartum haemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality. Studies have reported an increase in incidence of postpartum haemorrhage in recent years. Our goal was to investigate changes in the incidence of postpartum haemorrhage (PPH) and its risk factors in Switzerland from 1993 to 2014.

METHODS

This population-based retrospective cohort study used data from the national Swiss Hospital in-patient database for obstetric and gynaecological hospital admissions - "Arbeitsgemeinschaft Schweizer Frauenkliniken" (ASF Statistik). All patients with deliveries between January 1993 and December 2014 were included. We used the database codes to identify patients with PPH, maternal factors, pregnancy-related and delivery-related factors. Significant changes in temporal trends were determined using Mantel-Haenszel test for trend. Multivariable logistic regression analyses were conducted to assess PPH and risk factors.

RESULTS

Births complicated by PPH in Switzerland increased from 2.5% in 1993 to 4.5% in 2014 (p <0.001), paralleled by an increase in uterine atony. Failure to progress during the second stage of labour (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.5-1.6), oxytocin augmentation (OR 1.2, 95% CI 1.2-1.3), vacuum extraction (OR 1.1, 95% CI 1.1-1.2), and especially abnormally invasive placenta (OR 10.4, 95% CI 9.5-11.5) and placenta praevia (OR 4.9, 95% CI 432-5.6) were factors with the highest risk for postpartum haemorrhage.

CONCLUSIONS

Postpartum haemorrhage is a relatively common and potentially dangerous obstetric complication with increasing incidence over the last two decades in Switzerland. Its increase over time has been paralleled by an increase in uterine atony.

Multiple target deep brain stimulation for multiple sclerosis related and poststroke Holmes' tremor

BACKGROUND

The results from thalamic deep brain stimulation (DBS) for atypical tremor syndromes including tremor from multiple sclerosis (MS) and stroke are often disappointing. Three recent case reports have suggested that simultaneous stimulation of multiple thalamic targets can result in sustained improvement in such cases.

METHODS

We analyzed the effectiveness of multiple target DBS in one patient with MS-related tremor and another with poststroke Holmes' tremor.

RESULTS

In the patient with MS tremor, we implanted bilateral ventralis intermedius (V.im.) and ventralis oralis anterior (V.o.a.) thalamic electrodes; this patient had significant tremor improvement with stimulation of either V.im. or V.o.a. targets; however, we did not observe additive effects with simultaneous stimulation. In our patient with a poststroke Holmes' tremor, we implanted DBS electrodes in unilateral V.im., V.o.a., and the globus pallidus internus (Gpi); this patient had moderate tremor reduction with Gpi stimulation alone; neither V.im. nor V.o.a. stimulation provided additional benefit.

CONCLUSION

In one patient with MS tremor, simultaneous V.im. and V.o.a. stimulation was not superior to V.im. or V.o.a. stimulation alone. In one case of Holmes' tremor, Gpi stimulation was a useful alternative to thalamic stimulation.

The relationship among three measures of social functioning in outpatients with schizophrenia

Deficits in social functioning are a defining characteristic of schizophrenia. Several instruments have been developed to measure social functioning in this population, but there has been little study of the correlation among different instruments. We used the Social Functioning Scale (SFS), the Multnomah Community Ability Scale (MCAS), and the Quality of Life Interview (QOLI) to evaluate 72 stable outpatients with schizophrenia. Results of canonical analyses indicate a significant but limited relationship between each set of measures. The largest overlap was between the QOLI and the SFS (R2c = .597) with less shared variance found between the SFS and the MCAS (R2c = .520) and between the MCAS and the QOLI (R2c = .335). Although the instruments share some common content. the instruments measure different aspects of social functioning. A consensus is needed about how to define and measure social functioning in this population.

Social functioning and neurocognitive deficits in outpatients with schizophrenia: a 2-year follow-up

Neurocognitive deficits have been associated with the social functioning impairments of patients with schizophrenia. More information is needed about how cognitive status and other variables predict social functioning over defined periods of time. In this study, 72 relatively stable outpatients with schizophrenia were compared between baseline and a 2-year follow-up on measures of social functioning. Patients were also assessed with a battery of neurocognitive tests and the Positive and Negative Syndrome Scale. Results were compared by univariate and multivariate analyses. A total of four out of seven subscales of the Social Functioning Scale (SFS) and the total SFS score did not show a significant change over the 2-year period. On the three SFS subscales that did show a significant change, residual change scores were correlated with better neurocognitive performance at baseline, younger age, and shorter illness duration. For the Multnomah Community Ability Scale, 48.9% of the total score at follow-up was predicted by initial negative symptoms and scores on the Aphasia Screening Test. These results document the independent contribution of demographic variables, negative symptoms, and neurocognitive deficits to the social functioning impairments of individuals with schizophrenia.

Predictors of residential independence among outpatients with schizophrenia

OBJECTIVE

Many outpatients with schizophrenia receive support or supervision in their place of residence, but the predictors of residential independence are not clearly understood. The purpose of this study was to identify factors that predict the degree of residential independence among outpatients with schizophrenia.

METHODS

Seventy-two outpatients with schizophrenia were assigned to three groups based on their degree of residential independence. The three groups were compared on three measures of social functioning, on the Positive and Negative Syndrome Scale, and on a battery of neuropsychological tests.

RESULTS

Patients' degree of residential independence was related to their frequency of family contact, hygiene skills, relative absence of negative symptoms, and participation in social activities. In a discriminant function analysis, the residential status of 78 percent of the patients was correctly classified.

CONCLUSIONS

Aspects of social functioning are significantly associated with patients' independent living status. Future research is needed to determine how family contact, social activities, and hygiene skills may increase patients' degree of residential independence.

Lack of insight among outpatients with schizophrenia

OBJECTIVE

This study investigated the prevalence of lack of insight among outpatients with schizophrenia and the relationship between lack of insight and other variables, including whether patients received professional residential supervision.

METHODS

A total of 87 stable outpatients with schizophrenia were drawn from community programs in a public-private mental health system. Subjects' clinical symptoms and insight about their illness were assessed using the Positive and Negative Syndrome Scale, a battery of neuropsychological tests, and the Social Functioning Scale.

RESULTS

The illness insight of 43 subjects, or 49.5 percent, was at least moderately impaired. Twenty-one subjects, or 25 percent, had severe insight deficits. In a multiple regression analysis, 40 percent of the variance in lack of insight was predicted by ratings of the severity of delusions, difficulty with abstract thinking, lack of social activities, and absence of anxiety. Patients who received professional residential supervision had more impaired insight than those living independently or with family.

CONCLUSIONS

Insight deficits are common among stable outpatients engaged in community-based care. These deficits have implications for patients' use of limited services such as residential supervision.

Neurocognitive deficits and social functioning in outpatients with schizophrenia

Previous studies suggest that neurocognitive factors may contribute to the reduced social functioning of patients with schizophrenia. To assess this relationship, we administered a battery of neurocognitive tests and independently assessed symptoms (PANSS) and social functioning (SFS) in 88 stable outpatients with schizophrenia. We found a significant correlation between neurocognitive and social functioning variables. Patients' performance on aphasia, spatial organization and visual spatial tasks was correlated with their competence at activities of daily living, frequency of social activities and total social functioning. Regression analyses of each social functioning scale revealed different symptom and neurocognitive predictors. Patients' overall social functioning was best predicted by a combination of negative symptoms and aphasia. The results support the potential use of interventions to reduce patients' cognitive deficits as a means to improve their social outcomes.

ROUNDS, a new time-sampling methodology for the quantitative behavioral assessment of schizophrenic withdrawal. Reliability and validity

Negative symptoms in schizophrenia have been the subject of much research interest. However, there has been a need for a way to measure withdrawal behavior quantitatively over time. We have developed a behavioral time-sampling methodology performed by nursing staff on a schizophrenia inpatient unit. Called ROUNDS, it gathers reliable and valid quantitative data about specific withdrawal behaviors such as posture, daytime sleep and levels of social interaction and activity. This paper describes the development of the method, its implementation, the statistical analysis of its reliability and validity, and the degree to which the data can be replicated with different sampling frequencies. We contend that this method can be applied to the analysis of a wide variety of questions about the nature and treatment response of schizophrenic withdrawal in an inpatient setting.

Expressive vocal behavior and the severity of coronary artery disease

This study sought to ascertain the relationship of expressive vocal behavior in a structured interview and the severity of coronary artery disease in a group of 79 patients referred for coronary angiography. One half of the structured interview was administered in a nonchallenging manner, the other half in a moderately challenging manner. In patients age 60 and younger, two speech measures derived from the nonchallenging interview, a computer-scored index of the frequency of simultaneous speech and judged loudness level, accounted for 38% of the variance in the patients' severity of stenosis scores, when the latter was indexed by the Gensini method. The same speech indices derived from the challenging interview segment accounted for only 18% of the variance on the patients' Gensini scores. In the older patient group, only one speech variable, speech rate in the nonchallenging interview segment, contributed to the patients' Gensini scores. The findings suggest a) that in younger patients objective, computer-scorable, speech variables correlate significantly with severity of coronary occlusion, and b) that is not essential that these speech indices be derived from a structured interview that is administered in a challenging and provocative manner. In the present study, there were no significant correlations between the participants' global TABP scores and their occlusion scores.

Components of hostility and the severity of coronary artery disease

Previous research has linked various measures of hostility to the prevalence and incidence of coronary heart disease (CHD). The present study sought to determine whether some dimensions of hostility are differentially related to angiographically documented severity of coronary artery disease (CAD). Specifically, a hostility measure that correlates with indices of neuroticism was compared with a hostility measure unrelated to neurotic tendencies. For patients 60 years and younger, results were significant, revealing that neurotic hostility was inversely associated with severity of CAD whereas nonneurotic hostility scores were positively related to extent of disease. Overall hostility scores derived from the combination of the two kinds of hostility measures were unrelated to CAD severity. Results suggest that the multidimensional nature of the hostility construct should be appreciated in attempts to associate measures of hostility with manifestations of CHD.