Critical pathways intervention to reduce length of hospital stay

PURPOSE

Despite their popularity, critical pathways have been evaluated in only a few controlled studies. We evaluated the effectiveness of critical pathways in reducing length of hospital stay.

SUBJECTS AND METHODS

We compared postoperative lengths of stay of patients who underwent coronary artery bypass graft (CABG) surgery, total knee replacement, colectomy, thoracic surgery, or hysterectomy before and after pathway implementation at a university hospital. For three procedures, changes in lengths of stay at neighboring hospitals without pathway programs were assessed for comparison.

RESULTS

A total of 6,796 patients underwent one of the procedures during the study. The percentage of eligible patients managed on a critical pathway ranged from 94% for hysterectomy to 26% for colectomy. For most procedures, the postoperative length of stay was decreasing during the baseline period. After pathway implementation, the length of stay decreased 21% for total knee replacement, 9% for CABG surgery, 7% for thoracic surgery, 5% for hysterectomy, and 3% for colectomy (all P < 0.01). However, similar decreases were seen in the neighboring hospitals that did not have critical pathways or other specific efficiency initiatives.

CONCLUSIONS

Critical pathways were associated with a rapid reduction in postoperative length of stay after all five study procedures. Secular trends at nearby hospitals, however, produced comparable reductions for the three procedures available for comparison. These findings raise questions about the effectiveness of critical pathways in a competitive environment.

Comparison between personal learning curves for abdominal and laparoscopic hysterectomy

BACKGROUND

To compare personal learning curves for abdominal and laparoscopic hysterectomy.

METHODS

The first 200 patients scheduled for abdominal hysterectomy and the first 200 patients scheduled for laparoscopic hysterectomy by a single operator were compared using learning curves according to operation time, operative blood loss, and occurrence of complications.

RESULTS

Learning curves for both types of hysterectomy were rather similiar, but the learning of the laparoscopic procedure seemed to be quicker. With increasing experience the operating time decreased by 25% in abdominal and by 41% in laparoscopic hysterectomies. The mean operating time in abdominal hysterectomy was 74 min and 70 min in laparoscopic hysterectomy. Operative blood loss decreased by 50% and 44%, respectively. The mean operative blood loss was smaller (203 vs 295 ml, p<0.0001) in laparoscopic hysterectomy. Increased experience had no effect on complication rates in abdominal hysterectomies, but a decrease of 44% was seen in laparoscopic hysterectomies (p<0.05). The overall complication rate (26% vs 22%) were similar for the two techniques, and only a few patients (1.5% vs 1%) had major (bladder or ureteric) complications.

CONCLUSIONS

A trained gynecologist can learn the laparoscopic technique for hysterectomy at least as quickly as the abdominal technique.

Effect of surgeon's experience on the surgical outcome of laparoscopic surgery for women with endometrial cancer

OBJECTIVE

The purpose of this study was to assess the effect of increasing surgeon's experience in the laparoscopic management of women with endometrial cancer on the surgical outcome of these patients.

METHODS

Seventy-five consecutive women with clinical stage I endometrial cancer who underwent laparoscopically assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node sampling by the same surgeon using the same technique and instruments over a period of 2 years were divided into three equal groups based on the date of surgery. The three groups were compared in patient characteristics and surgical outcome using one-way analysis of variance and Pearson chi(2) tests.

RESULTS

The three groups were similar in patient characteristics. There was no significant difference in estimated amount of blood loss, rate of conversion to laparotomy, complications, and length of hospital stay among the three groups. There was a significant decrease in operating time (means: 231.0 min for group 1, 175.0 min for group 2, and 167.7 min for group 3, P < 0.001) and a significant increase in the number of pelvic lymph nodes harvested (7.8 for group 1, 10.6 for group 2, and 11.9 for group 3, P < 0.05) with increasing surgeon's experience.

CONCLUSIONS

A learning curve is demonstrated in the laparoscopic management of women with endometrial cancer. With increasing surgeon's experience, there is significant decrease in operating time and increase in the number of pelvic lymph nodes removed.

[Hysterectomy for benign lesions in Brittany: analysis of medical practices]

OBJECTIVES

By who, why and how are done hysterectomies for benign lesions.

MATERIAL

and methods. The 413 medical files of all the patients who underwent an hysterectomy for benign lesion during the last trimester of 1997 were recorded by the Medical Information Departments of the 53 health establishments of the Brittany Region. Surgical procedures, medical indications, pathological findings were analyzed according to the guidelines encountered in the medical literature.

RESULTS

Hysterectomies were done by many surgeons (112). Inaugural signs noted in the medical files were classical, but various and often associated without a main indication of hysterectomy. Histological diagnose were identical with those found usually in the literature. The abdominal route was mainly used, particularly when the operation was done by a generalist surgeon and in case of uterus weight superior to 250 g. The post operative outcome has revealed the same nature and frequency of complications as usually described.

CONCLUSION

In this study, it appears that efforts remain necessary to clarify the indications for hysterectomy in the medical files (in order to promote the alternative procedures to the hysterectomy), and that the proportion of hysterectomies performed by the abdominal route should be reduced in aid of the others surgical routes.

The appropriateness of recommendations for hysterectomy

OBJECTIVE

To evaluate the appropriateness of recommendations for hysterectomies done for nonemergency and non-oncologic indications.

METHODS

We assessed the appropriateness of recommendations for hysterectomy for 497 women who had the operation between August 1993 and July 1995 in one of nine capitated medical groups in Southern California. Appropriateness was assessed using two sets of criteria, the first developed by a multispecialty expert physician panel using the RAND/University of California-Los Angeles appropriateness method, and the second consisting of the ACOG criteria sets for hysterectomies. The main outcome measure was the appropriateness of recommendation for hysterectomy, based on expert panel ratings and ACOG criteria sets.

RESULTS

The most common indications for hysterectomy were leiomyomata (60% of hysterectomies), pelvic relaxation (11%), pain (9%), and bleeding (8%). Three hundred sixty-seven (70%) of the hysterectomies did not meet the level of care recommended by the expert panel and were judged to be recommended inappropriately. ACOG criteria sets were applicable to 71 women, and 54 (76%) did not meet ACOG criteria for hysterectomy. The most common reasons recommendations for hysterectomies considered inappropriate were lack of adequate diagnostic evaluation and failure to try alternative treatments before hysterectomy.

CONCLUSION

Hysterectomy is often recommended for indications judged inappropriate. Patients and physicians should work together to ensure that proper diagnostic evaluation has been done and appropriate treatments considered before hysterectomy is recommended.

Swiss consensus guidelines for hysterectomy. Swiss Society of Gynecology and Obstetrics, Switzerland

OBJECTIVE

The quality of the indication for hysterectomy is widely discussed at present. In early 1996, the committee for quality assurance of the Swiss Society of Gynecology and Obstetrics decided to set up nationally accepted guidelines for the indication of hysterectomy.

METHODS

A modified Delphi approach was used. In a first step, general guidelines and actions prior to hysterectomy were defined. An expert panel of 17 Swiss gynecologists rated 74 frequent indications, twice for appropriateness (more benefits than risks for the patient), once for necessity (n = 34; procedure has to be offered or discussed with the patient), and outlined suggestions to be performed prior to hysterectomy.

RESULTS

In a home rating round before the first panel met, there was an agreement rate of 48%. In 45% we observed neither agreement nor disagreement; in 7% we found disagreement. After the panel discussion 89% of experts agreed, 11% were indeterminate, and there was no disagreement. The necessity ratings showed agreement in 68% while 32% were indeterminate. The average median rating on a 1-9 point scale (1 = extremely inappropriate, 9 = extremely appropriate or necessary) was 5.4 over all single indications for appropriateness and 7.8 in single indications for necessity. After a second panel for consensus all panelists agreed on both appropriateness and necessity.

CONCLUSION

The results of the appropriateness and necessity consensus presented in this paper reflect the findings of a 17 member Swiss panel. This joint effort by a medical society may be a step towards the direction of a peer controlled healthcare system.

Outcomes in abdominal hysterectomy patients with benign disease. Use of physician-developed clinical protocols

OBJECTIVE

To develop a clinical protocol for standardizing preoperative and postoperative care in abdominal hysterectomy patients with benign disease while maintaining quality and increasing efficiency.

STUDY DESIGN

Protocol and nonprotocol groups of patients were compared with respect to key quality and efficiency outcomes in a non-randomized study. Patient group outcomes were compared using descriptive, Student's t, chi 2 and log-rank statistics. Statistical tests were performed at a .05 level of significance.

RESULTS

Results from two separate protocol study periods conducted in 1996 and 1997 are reported. In both study periods statistical analyses and graphic presentations illustrate that protocol implementation improved quality of care by increasing the percentage of patients receiving appropriate antibiotic prophylaxis; maintained quality as monitored through 30-day readmission rates and a postdischarge patient survey; and improved efficiency, as evidenced by shorter times to incision and length of hospital stay.

CONCLUSION

At Toledo Hospital, the clinical practice protocol directed at abdominal hysterectomy patients has been an effective tool in efforts to improve quality and efficiency in patient care.

The impact of adjuvant radiotherapy on carcinosarcoma of the uterus

BACKGROUND

The role of adjuvant radiotherapy in the setting of uterine carcinosarcoma has not been clearly established.

METHODS

A retrospective review of 60 patients receiving definitive therapy for carcinosarcoma of the uterus was undertaken at a single institution. Twenty-nine of 60 patients were treated with adjuvant radiotherapy.

RESULTS

The addition of radiotherapy significantly reduced the local recurrence rate from 55% (17 patients) to 3% (1 patient). Adjuvant radiotherapy reduced the risk of distant failure and death in patients with disease confined to the uterus but did not impact distant recurrence or survival in stage III patients. Increasing stage and depth of myometrial tumor invasion were negatively associated with overall survival and disease-free survival but had no impact on local recurrence rates. The nuclear grade of the epithelial component was predictive of local recurrence (P = 0.0592), but epithelial architectural grade, grade of stromal component, and stromal versus epithelial predominance did not provide prognostic information. The relative risk of local recurrence of unirradiated patients versus irradiated patients was 17.54 (P = 0.0055) after adjusting for nuclear grade of the epithelial component.

CONCLUSIONS

Local failure represents a significant site of failure in the absence of adjuvant radiotherapy. The improvement in local failure rates with the addition of radiotherapy translates into an improvement in distant failure rates and survival only for patients with stage I/II disease. Epithelial nuclear grade, in addition to depth of myometrial invasion and stage, provides important prognostic information. Epithelial architectural grade, stromal grade, type of stromal component (homologous versus heterologous), and predominance of either stromal or epithelial component were not found to be significant prognostic factors.

Outcomes of hysterectomy

Recent randomized trials and prospective cohort studies have provided new information on the health outcomes of hysterectomy for nonmalignant conditions. These studies consistently have demonstrated a marked improvement in symptoms and quality of life during the early years after surgery. The long-term effects of premenopausal hysterectomy on ovarian function have not been established, but existing evidence suggests there is no adverse effect on risk for cardiovascular disease from hysterectomy alone. Epidemiologic studies have indicated that premenopausal hysterectomy with ovarian preservation is associated with a modest decrease in future risk for ovarian cancer and possibly breast cancer. There is no consistent evidence for adverse effects on bowel or bladder function. Hysterectomy does not cause long-term psychiatric morbidity, and psychological status generally improves. Studies of sexual function have shown varying results, with most suggesting improvement or no change in sexual function for the majority of women.

Uterine myomas and factors associated with hysterectomy in premenopausal women

OBJECTIVE

Our purpose was to describe clinical characteristics in premenopausal women with uterine myomas and to identify factors associated with hysterectomy.

STUDY DESIGN

Data were collected by chart abstraction in 421 premenopausal women with myomas and analyzed by univariate and multivariable regression.

RESULTS

Over a median follow-up period of 29 months, 86% of women had symptoms associated with myomas and 40% had an increase in uterine size of > 2 gestational weeks. By multivariable regression, bleeding symptoms at presentation and previous surgical history of cholecystectomy and adhesiolysis were significantly associated with greater odds of hysterectomy. There was a significant interaction between age and uterine size, so that as age increased, uterine size had a greater impact on the likelihood of hysterectomy.

CONCLUSIONS

In this cohort of premenopausal women myomas were associated with symptoms in almost all women over the follow-up period. Hysterectomy was performed in 22% of women overall.

Subtotal hysterectomy in modern gynecology: a decision analysis

OBJECTIVE

Our purpose was to compare the risks and benefits of subtotal (supracervical) hysterectomy with those of total hysterectomy in women at low risk for cervical cancer.

STUDY DESIGN

A decision analysis was performed. Baseline probabilities for operative and postoperative morbidity, mortality, and long-term quality of life were established for subtotal and total hysterectomy.

RESULTS

Operative complication rates and ranges for total abdominal hysterectomy were infection 3.0% (3.0% to 20.0%), hemorrhage 2.0% (2.0% to 15.4%), and adjacent organ injury 1.0% (0.7% to 2.0%). Those for subtotal hysterectomy were infection 1.4% (1.0% to 5.0%), hemorrhage 2.0% (0.7% to 4.0%), and adjacent organ injury 0.7% (0.6% to 1.0%). Operative mortality, the risk for development of cervicovaginal cancer, and long-term adverse effects on sexual or vesicourethral function were low in both groups.

CONCLUSIONS

Recently proposed benefits from subtotal hysterectomy are not well proven. Total hysterectomy remains the procedure of choice for most women.

Hysterectomy debate focuses on cost efficiency, quality

Watch that high-tech device: it might be more costly than you think. Recent studies find surgeons performing hysterectomies using laparoscopic devices are actually racking up higher costs, despite marketers' claims to the contrary. Greater Baltimore Medical Center found this high-tech procedure costs $1,000 to $2,000 more than traditional hysterectomy techniques, and a watchdog group offers guidelines to lower costs without sacrificing quality.

Hysterectomy: indications, alternatives and predictors

Hysterectomy, the most common major nonobstetric operation, is performed in more than 570,000 women in the United States each year. Although the number of hysterectomies has decreased in recent years, many authorities believe that hysterectomy is often unnecessary and unjustified. There is no universally accepted set of criteria regarding the appropriate indications for hysterectomy. The main indications for hysterectomy include the following conditions: uterine leiomyomas, dysfunctional uterine bleeding, endometriosis/adenomyosis, chronic pelvic pain and genital prolapse. Current literature, however, routinely recommends conservative management of most nonmalignant gynecologic conditions, with hysterectomy reserved for refractory cases. Several nonmedical factors, such as patient race, age, geographic location, medical history and background, as well as health care provider characteristics, such as time since completion of training, gender, and affiliation with teaching hospitals, are also associated with hysterectomy rates.

Posthysterectomy fallopian tube herniation. A report of two cases

BACKGROUND

Tubal herniation as a complication of hysterectomy is a rare phenomenon, markedly more frequent after vaginal hysterectomy. With the increasing use of the vaginal route, the ratio between tubal herniation after vaginal versus abdominal hysterectomy may exceed 3:1.

CASE

We report two cases of tubal herniation into the vagina, one after vaginal hysterectomy and the other after total abdominal hysterectomy, in two patients, aged 36 and 37 years.

CONCLUSION

A tubal prolapse in the vagina may be considered a hernia and occurs only if a communication exists between the peritoneal cavity and vaginal canal. It can be an early or late prolapse. Symptoms consist almost exclusively of persistent blood loss and/or leukorrhea, dyspareunia and chronic pelvic pain. Whether the abdominal or vaginal approach should be used in surgical correction of prolapsed tubes must be decided in each case according to the patient's individual characteristics. Both histologic pictures described merit careful attention, distinguishing between the terminal tubal segment and the more cranial tract (above the vaginal strangulation).

An audit of hysterectomies in young women at the Queen Victoria Hospital, 1984-1994

A retrospective audit of hysterectomies in young women (age 30 years and under) was conducted. Forty-one hysterectomies, representing 4% of all hysterectomies at the hospital, were performed in women of this age group. The main clinical indications were abnormal uterine bleeding (44%), pelvic pain (20%) and endometriosis (15%). None were performed for invasive malignant conditions. Most women had some prior therapy for their symptoms. Thirty-seven of the operations were total abdominal hysterectomies and 4 women had a unilateral oophorectomy. Complications were found in 17 women. Causal pathology, though not always what was predicted clinically or on the basis of operative findings, was identified. Further studies would be worthwhile to document the experience from other institutions and to provide long-term follow-up.

Vaginal radical hysterectomy versus abdominal radical hysterectomy in the treatment of early-stage cervical cancer

The purpose of this study is to compare the safety, efficacy, and potential benefits of vaginal radical hysterectomy (VRH) versus abdominal radical hysterectomy (ARH) in the treatment of early-stage cervical cancer. We reviewed the charts of our first 52 patients with cervical cancer. We reviewed the charts of our first 52 patients with cervical cancer who underwent a laparoscopic pelvic lymphadenectomy (LPL), followed either by a VRH (Schauta) in 25 cases or ARH in 27 cases. For the 52 patients, the mean lymph nodes count obtained by LPL was 27 (range 8-59), and the only complication was an external iliac vein trauma requiring laparotomy. Both VRH and ARH groups were comparable in terms of age, weight, parity, stage, histology, and tumor volume. The mean blood loss was 400 cc for VRH vs 450 cc for ARH, operating time was 270 min vs 280 min, blood transfusion in 5 vs 4 women, and postoperative stay was 7 days for both groups. The only intraoperative complication in addition to the vein trauma was a cystotomy which occurred in 2 VRH patients. Febrile morbidity was noted in 4 VRH patients vs 9 ARH patients. There were one preperitoneal abscess and one hematoma in the VRH group vs 4 wound infections and 1 hematoma after ARH. Ileus occurred in 1 VRH vs 4 ARH patients. The current mean follow-up time is 27 months (8-52) and there has been one recurrence so far in the ARH group. Even though this is a retrospective study, our data indicate that VRH and ARH are comparable, except for the absence of an abdominal scar and less febrile morbidity with the vaginal approach. However, in our opinion, the main advantage in learning the Schauta operation is that the experience gained allows one to offer radical trachelectomy to selected young patients who wish to preserve their fertility.