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Ingraham C, Makai G. Perioperative visits in minimally invasive gynecologic surgery. Curr Opin Obstet Gynecol 2023; 35:316-320. [PMID: 37266572 DOI: 10.1097/gco.0000000000000883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
PURPOSE OF REVIEW Perioperative visits for gynecologic surgery patients have traditionally included in-person examinations and counseling, but the advent of telemedicine has prompted clinicians to consider varying approaches to perioperative care. We aim to educate readers on the optimal setting and context of perioperative visits and provide insight from our experience to optimize care. RECENT FINDINGS The widespread adoption of telemedicine and a focus on equity and access has prompted gynecologic surgeons to reconsider traditional preoperative and postoperative visits. SUMMARY This review summarizes evidence for new approaches to perioperative care for minimally invasive gynecologic surgery, including transition to telemedicine for preoperative and postoperative care, adjuvant tools for perioperative counseling, and the value of in-person visits for preoperative planning.
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Podolsky E, Hudek N, McCudden C, Presseau J, Yanikomeroglu S, Brouwers M, Brehaut JC. Choosing which in-hospital laboratory tests to target for intervention: a scoping review. Clin Chem Lab Med 2023; 61:388-401. [PMID: 36410390 PMCID: PMC9876731 DOI: 10.1515/cclm-2022-0910] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/03/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Some laboratory testing practices may be of low value, leading to wasted resources and potential patient harm. Our scoping review investigated factors and processes that developers report using to inform decisions about what tests to target for practice improvement. METHODS We searched Medline on May 30th, 2019 and June 28th, 2021 and included guidelines, recommendation statements, or empirical studies related to test ordering practices. Studies were included if they were conducted in a tertiary care setting, reported making a choice about a specific test requiring intervention, and reported at least one factor informing that choice. We extracted descriptive details, tests chosen, processes used to make the choice, and factors guiding test choice. RESULTS From 114 eligible studies, we identified 30 factors related to test choice including clinical value, cost, prevalence of test, quality of test, and actionability of test results. We identified nine different processes used to inform decisions regarding where to spend intervention resources. CONCLUSIONS Intervention developers face difficult choices when deciding where to put scarce resources intended to improve test utilization. Factors and processes identified here can be used to inform a framework to help intervention developers make choices relevant to improving testing practices.
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Affiliation(s)
- Eyal Podolsky
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada,Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Natasha Hudek
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Christopher McCudden
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada,Division of Biochemistry, Department of Pathology and Laboratory Medicine, The Ottawa Hospital, Ottawa, ON, Canada,Eastern Ontario Regional Laboratory Association, Ottawa, ON, Canada
| | - Justin Presseau
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada,Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Sezgi Yanikomeroglu
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Melissa Brouwers
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Jamie C. Brehaut
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada,Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
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Factors Associated With Increased Estimated Blood Loss and Factors Associated With Utilization of Type and Screen in Benign Gynecology: A Retrospective Chart Review. UROGYNECOLOGY (HAGERSTOWN, MD.) 2023; 29:195-201. [PMID: 36735434 DOI: 10.1097/spv.0000000000001275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
IMPORTANCE There is minimal literature discussing factors associated with increased estimated blood loss (EBL) or transfusion in gynecologic surgery in tertiary academic centers. OBJECTIVE The aim of the study was to determine factors associated with transfusion and increased blood loss during gynecologic surgery. STUDY DESIGN This retrospective cohort investigated patients undergoing benign gynecologic procedures at a tertiary medical center. We excluded women undergoing surgery for known or suspected malignancy, emergent surgery, obstetrical procedures, or cases with another surgical specialty. Patient age, body mass index, American Society of Anesthesiologists class, medical history, EBL, arterial line placement, preoperative laboratory studies, and transfusion receipt for up to 6 weeks postoperatively were extracted. The primary outcome was transfusion within 6 weeks of surgery; risk factors for high blood loss (EBL >500 mL) and transfusion were explored. RESULTS Nine hundred seventy-five surgical procedures were included (59% vaginal, 36% laparoscopic, 4% robotic). Median EBL was 50 mL (interquartile range, 10-100 mL). Estimated blood loss increased with duration of surgery (P < 0.01). Transfusions were more likely to occur during open procedures (13%) compared with vaginal (2%), laparoscopic (2%), or robotic (3%). Arterial line placement (relative risk [RR], 11.8; 95% confidence interval [CI], 5.3-26.1) and additional intravenous placement (RR, 6.0; 95% CI, 2.6 to 13.7) were associated with transfusion. Vaginal surgery (RR, 0.13; 95% CI, 0.05 to 0.32) and urogynecologic procedures (RR, 0.1; CI, 0.01-0.7) were associated with reduced risk of needing transfusion. CONCLUSIONS Most benign gynecologic surgical procedures have minimal blood loss. Patients undergoing surgery through minimally invasive routes or urogynecologic procedures are at further decreased risk of transfusion.
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Aviki EM, Gordhandas SB, Velzen J, Riley M, Manning-Geist B, Rice J, Weiss H, Abu-Rustum NR, Gardner GJ. Implementation of Evidence-Based Presurgical Testing Guidelines in Patients Undergoing Ambulatory Surgery for Endometrial Cancer. JCO Oncol Pract 2022; 18:e219-e224. [PMID: 34242066 PMCID: PMC8758118 DOI: 10.1200/op.21.00247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE The aim of this quality improvement intervention was to evaluate the safety and cost savings of presurgical testing (PST) guidelines for patients undergoing hysterectomy for endometrial pathology in the ambulatory setting. METHODS Evidence-based presurgical testing (PST) guidelines were developed by a multidisciplinary team. These guidelines were implemented on the gynecologic surgery service of a comprehensive cancer center in January 2016. All patients with a diagnosis of endometrial pathology who underwent ambulatory surgery during the specified time periods were included in this analysis. A pre-post analysis was performed (preperiod, July 2014-December 2015; postperiod, July 2016-December 2017). Rates of completed presurgical tests and perioperative adverse events were compared between time periods. Cost savings related to the reduction in PST were calculated using the direct cost of testing and reported in percentage cost reduction. RESULTS A total of 749 hysterectomies were completed in the preperiod and 775 in the postperiod. After implementation of PST guidelines, complete blood counts, coagulation testing, comprehensive metabolic panels, chest x-rays, and electrocardiograms were reduced by 13.4%, 78.1%, 36.8%, 39.0%, and 15.5%, respectively (all P < .001). Rates of perioperative cardiopulmonary adverse events (0% v 0%) and hematologic adverse events (3.3% v 2.0%; P = .10) were stable between time periods. There were no deaths within 90 days of surgery. There was a 41.4% reduction in direct costs related to PST in the postperiod. CONCLUSION The use of evidence-based PST guidelines for patients with endometrial pathology undergoing hysterectomy in the ambulatory setting is safe and cost-effective. A multidisciplinary approach is essential for successful development and implementation.
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Affiliation(s)
| | | | - Jeena Velzen
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Michael Riley
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Jonathan Rice
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hallie Weiss
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nadeem R. Abu-Rustum
- Memorial Sloan Kettering Cancer Center, New York, NY,Weill Cornell Medical College, New York, NY
| | - Ginger J. Gardner
- Memorial Sloan Kettering Cancer Center, New York, NY,Weill Cornell Medical College, New York, NY,Ginger J. Gardner, MD, Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065; e-mail:
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Utility of Routine Preoperative Laboratory Testing for Low-risk Patients in Ambulatory Gynecologic Surgery. J Minim Invasive Gynecol 2021; 28:1033-1040.e1. [PMID: 33429058 DOI: 10.1016/j.jmig.2021.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 12/30/2020] [Accepted: 01/03/2021] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVES To examine the current use of routine preoperative laboratory testing in low-risk patients undergoing ambulatory gynecologic surgery and to determine if such testing affects surgical outcomes. DESIGN The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for ambulatory gynecologic surgeries between 2015 and 2018. Low-risk patients included in this study were defined as being American Society of Anesthesiologists class 1 or 2. The rate of preoperative laboratory testing before ambulatory gynecologic surgery in low-risk patients was determined and factors associated with testing including patient characteristics and comorbidities were evaluated. NSQIP-defined complications were compared between those with and without preoperative laboratory testing. Preoperative laboratory testing was defined as chemistry, hematology, coagulation, or liver function studies obtained within 30 days preoperatively. SETTING National health systems that participate in the NSQIP. PATIENTS There were 19 855 patients who underwent an ambulatory gynecologic procedure. INTERVENTIONS Preoperative laboratory testing in low-risk patients before ambulatory gynecologic surgery. MEASUREMENTS AND MAIN RESULTS Of the 19 855 patients studied, 14 258 (71.8%) received preoperative laboratory testing. Statistically significant differences were seen between patients who underwent preoperative testing and patients who did not. The most frequent preoperative test was a complete blood cell count (70.4%). Among patients who received preoperative testing, 4053 (28.4%) had at least 1 abnormal result. No statistically significant difference was seen in overall postoperative complication rate when comparing patients who received preoperative laboratory testing with those who did not (2.5% vs 2.2%, p = .30). Specifically, no statistically significant difference was seen among wound complications (1.0% vs 1.0%, p = .78), major complications (1.0% vs 0.8%, p = .11), unplanned return to the operating room (0.1% vs 0.2%, p = .40), unplanned readmission (0.7% vs 0.5%, p = .10), or overall morbidity (2.1% vs 1.9%, p = .38). Chi-square analyses were performed to compare categoric variables. Continuous variables were compared using unpaired t tests. CONCLUSION This large study using a reputable national database revealed that despite updated evidence-based guidelines that recommend against the practice, preoperative laboratory testing continues to be performed for most low-risk patients undergoing ambulatory gynecologic surgery. This study also further supports current guidelines in demonstrating no difference in surgical outcomes between low-risk patients who did and did not receive preoperative laboratory testing. Preoperative laboratory testing practices for low-risk patients undergoing ambulatory gynecologic surgery do not follow current evidence-based guidelines and should be re-evaluated.
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Yang Z, Yin Q, Li X. Influences of UGT2B7 rs7439366 and rs12233719 Polymorphisms on Fentanyl Sensitivity in Chinese Gynecologic Patients. Med Sci Monit 2020; 26:e924153. [PMID: 32401749 PMCID: PMC7245057 DOI: 10.12659/msm.924153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background This study discussed potential influences of UDP glucuronosyltransferase family 2 member B7 (UGT2B7) rs7439366 and rs12233719 polymorphisms on fentanyl sensitivity among Chinese gynecologic patients. Material/Methods UGT2B7 polymorphisms were genotyped by polymerase chain reaction (PCR) and direct sequencing. Before surgery, baseline latency to pain perception (PPLpre) and pain perception latency of the dominant hand (PPLpost) at 3 minutes after injecting fentanyl were measured by cold pressor-induced pain test. Perioperative fentanyl adoption referred to the total of fentanyl administration during and after operation. Intensity of spontaneous pain was appraised adopting 100-mm visual analog scale (VAS). Factorial analysis was performed by Mann-Whitney U test and Kruskal-Wallis H test. Results Significant differences of PPLpost (CC/CT/TT, P=0.038) and preoperative analgesic effect (CC/CT/TT, P=0.028) were discovered between the rs7439366 genotypes. PPLpost was significantly different between the CT and TT groups (P=0.009) and the CC+CT and TT groups (P=0.026). Preoperative analgesic effect was significantly different between the CT and TT groups (P=0.007) and the CC+CT and TT groups (P=0.009). All of the clinical features studied had no close association with rs12233719 SNP. Conclusions Gynecologic patients with rs7439366 TT genotype had significantly lower fentanyl sensitivity than the other 2 genotype carriers.
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Affiliation(s)
- Zhenling Yang
- The Pain Management Department, The First Affiliated Hospital of Henan University, Kaifeng, Henan, China (mainland)
| | - Qingfeng Yin
- Institute of Evidence-Based Medicine and Clinical Transformation, Henan University, Kaifeng, Henan, China (mainland)
| | - Xiaodong Li
- Institutes of Evidence-Based Medicine and Knowledge Translation, Henan University, Kaifeng, Henan, China (mainland).,Huaihe Hospital of Henan University, Kaifeng, Henan, China (mainland)
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