Patient Characteristics Associated with Delays to Benign Gynecologic Surgery: Impact of the COVID-19 Pandemic

Study Objective

To examine how demographic and socioeconomic characteristics impact timing of minimally invasive gynecologic surgery (MIGS) before and during the COVID-19 pandemic.

Design

Retrospective cohort study using electronic medical record data. Primary outcome was interval between referral to MIGS and date of surgery.

Setting

Tertiary-level MIGS division in the southeast US.

Patients or Participants

Historical cohort undergoing surgery with MIGS 2014-2016 (n=377) and cohort in 2020 referred during the pandemic (n=191).

Interventions

Laparoscopic hysterectomy, myomectomy, adnexal surgery, or excision of endometriosis.

Measurements and Main Results

Patient demographics (race, age, marital status, language, insurance, and socioeconomic factors) were evaluated for significant associations with surgical delay. Patients with fibroids and abnormal uterine bleeding had a shorter interval to surgery (median 95 days, range 66-133) compared to patients with chronic pelvic pain (median 127 days, range 73-274). Our model adjusting for surgical indication revealed that single patients were 2.13 times as likely to wait >90 days (95% CI 1.35-3.36) compared to partnered patients prior to the pandemic. Additionally, those in the lowest quartile of median household income (<$42,572 vs > $75,020; OR 2.42, 95% CI 1.32, 4.46) and those from zip codes with the highest proportion of population in poverty (≥ 0.20 vs <0.07; OR 1.93, 95% CI 1.04, 3.6) were more likely to wait > 90 days. However, all of these differences disappeared during the pandemic. There were no differences in time to surgery by race, ethnicity, language, population density, markers of education by zip code, or insurance before or during the pandemic.

Conclusion

Historically, race and socioeconomic factors are associated with decreased access to MIGS and vulnerable populations were disproportionately affected by the COVID-19 pandemic. Despite this, we found decreased time to surgery at our institution, and previous socioeconomic disparities associated with scheduling delays were improved during the pandemic, suggesting improved equitable access to tertiary-level MIGS.

Risk factors for repeat hernia repair in women of childbearing age

PURPOSE

Herniorrhaphy is a source of substantial cost and morbidity. Although women are a substantial proportion of patients seeking repair, gender-specific data, including the influence of childbirth on hernia recurrence, are lacking. Our objective was to estimate the rate and identify risk factors for repeat herniorrhaphy in reproductive-aged women.

METHODS

Retrospective cohort study of women who underwent herniorrhaphy during June 2000-December 2014 in the United States. Women aged 18-50 who underwent umbilical, incisional/ventral, or inguinal/femoral herniorrhaphy in the Truven Health Analytics MarketScan^® Commercial Claims and Encounters database were included. Women without a hernia diagnosis or multiple/concurrent index herniorrhaphy types were excluded. Primary outcome of interest was second herniorrhaphy.

RESULTS

Of 123,674 women, 13% had a second herniorrhaphy within 10 years; increasing age, comorbidities, childbirth, smoking, obesity, and inpatient procedure were independently associated with increased risk. Cesarean delivery before umbilical herniorrhaphy (HR 1.61, 95% CI 1.34, 1.92) and both vaginal (HR 2.57, 95% CI 1.98, 3.34) and cesarean delivery (HR 2.95, 95% CI 2.25, 3.87) after umbilical herniorrhaphy were associated with increased risk of second herniorrhaphy. Both vaginal (HR 1.66, 95% CI 1.13, 2.43) and cesarean delivery (HR 2.72, 95% CI 2.09, 3.53) after incisional/ventral herniorrhaphy and vaginal delivery after inguinal/femoral herniorrhaphy (HR 1.75, 95% CI 1.22, 2.51) were associated with increased risk of second herniorrhaphy.

CONCLUSIONS

Among reproductive-aged women, childbirth, increasing age, comorbidities, smoking, and obesity increase risk of subsequent herniorrhaphy. Risk of second herniorrhaphy is higher with cesarean delivery compared to vaginal delivery, and higher for delivery occurring after initial hernia repair compared to before.

Prevalence of menopausal symptoms among mid-life women: findings from electronic medical records

BACKGROUND

To assess the prevalence of menopausal symptoms among women prescribed hormone therapy (HT) using electronic medical record data from a regional healthcare organization.

METHODS

Retrospective data from the Reliant Medical Group from 1/1/2006-12/31/2011 were assessed for 102 randomly-selected patients. Study eligibility criteria included: females aged 45 to 65; prescribed oral or transdermal HT; no history of breast cancer, venous thromboembolism, stroke, gynecological cancer, or hysterectomy; continuously enrolled in the health plan for 1 year before and after the first observed HT prescription. Prevalence of menopause-related symptoms was analyzed descriptively at both the patient and visit levels.

RESULTS

Mean age of patients was 54 years. The most common menopausal symptoms were: hot flushes (40%), night sweats (17%), insomnia (16%), vaginal dryness (13%), mood disorders (12%), and weight gain (12%). Among the 102 patients, 163 individual visits listing menopausal symptoms were identified, of which hot flushes (71 visits) were the most common symptom identified.

CONCLUSION

Our findings provide recent data on the types of menopausal symptoms experienced by mid-life women prescribed HT. Electronic medical records may be a rich source of data for future studies of menopausal symptoms in this population.

Numerical model for intraosseous infusion of the human calvarium for hydrocephalus shunting

Hydrocephaly is the defective absorption of cerebrospinal fluid (CSF) into the blood stream. This work is an experimental and computational fluid dynamic modelling study to determine the permeability of the diploë as a potential receptor for CSF. Human calvariae were studied by micro-CT to measure their porosity, the area of flow and develop model geometry. Pressure-flow measurements were conducted on specimens to determine their permeability in the physiological and transverse flow directions to compare with numerical results. The overall porosity and permeability of the calvaria were spatially variable. Results suggest an order of magnitude increase in permeability for a 14% increase in overall porosity based on a small number of samples. Numerical results fell within the experimental infusion tests results. Due to the difficulty and ethical considerations in obtaining adolescent skull samples to perform large-scale testing, the developed model will be invaluable.

Prevalence of Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) in food samples associated with foodborne illness in Alberta, Canada from 2007 to 2010

Consumption of foods containing Staphylococcus aureus can cause severe gastro-intestinal illness. Given the fact that over the past decade, Canada has seen increasing rates of methicillin-resistant S. aureus (MRSA) carriage and infection, the objective of this study was to investigate the impact of methicillin-susceptible S. aureus (MSSA) and MRSA on foodborne illness in Alberta, Canada. Between January 2007 and December 2010, there were 693 food samples associated with foodborne investigations submitted to the Alberta Provincial Laboratory for Public Health (ProvLab). These foods were screened for: Bacillus cereus, Clostridium perfringens, S. aureus, Aeromonas spp., Campylobacter spp., Escherichia coli O157:H7, Salmonella, Shigella spp., and Yersinia spp. S. aureus was identified in 10.5% (73/693) of samples, and of these, 59% (43/73) were co-contaminated with at least one other organism on the screening panel. The S. aureus positive samples included 29 meat, 20 prepared foods containing meat, 11 prepared foods not containing meat, 10 dairy, and three produce. Methicillin-resistance was not detected in any isolates tested. These findings indicate that the presence of S. aureus in food associated with foodborne investigations is a cause for concern, and although MRSA was not found, the potential for outbreaks exists, and ongoing surveillance should be sustained.

Surveillance of autopsy cases for D222G substitutions in haemagglutinin of the pandemic (H1N1) 2009 virus in Alberta, Canada

Pandemic (H1N1) 2009 virus-positive specimens were collected from autopsy patients and matched to pandemic (H1N1) 2009 virus-positive nasopharyngeal specimens from community control patients and pandemic (H1N1) 2009 virus-positive specimens from intensive-care unit (ICU) patients. Specimens were analysed for polymorphisms at amino acid 222 of the haemagglutinin (HA) glycoprotein. Whereas some specimens from autopsy patients were positive for D222N, none was positive for D222G. All control patient specimens were wild-type D222. D222G polymorphisms were also identified in a subset of ICU patients with admixtures of D222G and D222 and of D222N, D222G and D222 present. The relevance of D222N and D222G to influenza pathogenesis and transmissibility currently remains unclear.

A microsimulation of the cost-effectiveness of maraviroc for antiretroviral treatment-experienced HIV-infected individuals

PURPOSE

Maraviroc (MVC) is the first approved CCR5 antagonist. The aim of this study was to explore the cost-effectiveness of MVC in treatment-experienced or treatment-resistant HIV-infected adults.

METHODS

The validated HIV microsimulation model ARAMIS was used to predict clinical and economic outcomes of treating patients with optimized background therapy (OBT) alone, as compared to a strategy of testing for the patient's viral tropism and treating with OBT with or without (+/-) MVC in a cohort corresponding to the MOTIVATE screening cohort.

RESULTS

Compared to treatment with OBT alone, a treatment strategy of OBT +/- MVC (twice daily) according to tropism test result was predicted to increase CD4+ cell count after 5 years (from mean 249 to 360 cells/microL), undiscounted life expectancy (7.6 to 8.9 years), and quality-adjusted life years (QALYs; from 4.99 to 5.71) for an additional $40,500, giving an incremental cost-effectiveness ratio of $56,400 per QALY gained. The result was relatively insensitive to alternative clinical and cost assumptions within reasonable ranges, but for individuals with HIV susceptible to only two or fewer components of OBT, the ICER decreased to $52,000 per QALY gained.

CONCLUSION

MVC is cost-effective, especially among individuals with few remaining options for active antiretroviral therapy.