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Ferrari A, Bellè N, Giannini A, Simoncini T, Vainieri M. Determinants of women's preferences for surgical versus conservative management for pelvic organ prolapse: a survey-based study from Italy. BMJ Open 2024; 14:e084034. [PMID: 39053952 DOI: 10.1136/bmjopen-2024-084034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Pelvic organ prolapse (POP) affects 40% of women, with a 12%-19% lifetime surgical risk. Italy showed high practice variation in POP surgery, possibly impacting equity of access to healthcare services, a central goal of Beveridge-like health systems. According to the literature, unwarranted variation, influenced by physician attitudes or resource allocation, must be reduced. We aimed to identify determinants influencing women's choice when asked whether they prefer surgical or conservative POP management. DESIGN, SETTING AND POPULATION In this nationwide prospective study, we distributed a Qualtrics questionnaire via social media to any Italian women over 18 years old who voluntarily decided to participate in the survey. INTERVENTION A grade 3 POP scenario was presented. Women were asked how likely they would have surgery. Each woman randomly received only 1 question out of 11: 1 question was the reference question ('How likely would you have surgery?') while 10 questions contained a potential determinant influencing woman's choice ('How likely would you have surgery if…?'). OUTCOME The outcome was the chance of choosing surgery expressed as a percentage. We analysed the effect of each factor on the outcome by using adjusted beta regression models. RESULTS Respondents (n=222) opted for surgery with a median probability of 61.5%. Factors significantly increasing the chance of choosing surgery were advice from physicians, the presence of a trusted physician during hospitalisation, surgical approach with low complication rates, uterine-sparing surgery, the absence of postoperative abdominal scars and nearby hospital. CONCLUSIONS Our findings provide health managers and policy-makers with new evidence to better understand women's decision-making and partly capture the determinants of unwarranted variation. These inputs may also be used as attributes for a future discrete choice experiment.
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Affiliation(s)
- Amerigo Ferrari
- Institute of Management, MeS (Management and Health) Laboratory, Scuola Superiore Sant'Anna, Pisa, Italy
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynaecology, University of Pisa, Pisa, Italy
| | - Nicola Bellè
- Institute of Management, MeS (Management and Health) Laboratory, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Andrea Giannini
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynaecology, University of Pisa, Pisa, Italy
| | - Tommaso Simoncini
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynaecology, University of Pisa, Pisa, Italy
| | - Milena Vainieri
- Institute of Management, MeS (Management and Health) Laboratory, Scuola Superiore Sant'Anna, Pisa, Italy
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Ferrari A, Seghieri C, Giannini A, Mannella P, Simoncini T, Vainieri M. Driving time drives the hospital choice: choice models for pelvic organ prolapse surgery in Italy. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:1575-1586. [PMID: 36630004 PMCID: PMC9833017 DOI: 10.1007/s10198-022-01563-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 12/22/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE The Italian healthcare jurisdiction promotes patient mobility, which is a major determinant of practice variation, thus being related to the equity of access to health services. We aimed to explore how travel times, waiting times, and other efficiency- and quality-related hospital attributes influenced the hospital choice of women needing pelvic organ prolapse (POP) surgery in Tuscany, Italy. METHODS We obtained the study population from Hospital Discharge Records. We duplicated individual observations (n = 2533) for the number of Tuscan hospitals that provided more than 30 POP interventions from 2017 to 2019 (n = 22) and merged them with the hospitals' list. We generated the dichotomous variable "hospital choice" assuming the value one when hospitals where patients underwent surgery coincided with one of the 22 hospitals. We performed mixed logit models to explore between-hospital patient choice, gradually adding the women's features as interactions. RESULTS Patient choice was influenced by travel more than waiting times. A general preference for hospitals delivering higher volumes of interventions emerged. Interaction analyses showed that poorly educated women were less likely to choose distant hospitals and hospitals providing greater volumes of interventions compared to their counterpart. Women with multiple comorbidities more frequently chose hospitals with shorter average length of stay. CONCLUSION Travel times were the main determinants of hospital choice. Other quality- and efficiency-related hospital attributes influenced hospital choice as well. However, the effect depended on the socioeconomic and clinical background of women. Managers and policymakers should consider these findings to understand how women behave in choosing providers and thus mitigate equity gaps.
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Affiliation(s)
- Amerigo Ferrari
- Institute of Management, MeS (Management and Health) Laboratory, Sant'Anna School of Advanced Studies, Via San Zeno 2, 56127, Pisa, Italy.
| | - Chiara Seghieri
- Institute of Management, MeS (Management and Health) Laboratory, Sant'Anna School of Advanced Studies, Via San Zeno 2, 56127, Pisa, Italy
| | - Andrea Giannini
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynaecology, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Paolo Mannella
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynaecology, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Tommaso Simoncini
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynaecology, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Milena Vainieri
- Institute of Management, MeS (Management and Health) Laboratory, Sant'Anna School of Advanced Studies, Via San Zeno 2, 56127, Pisa, Italy
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Ferrari A, Giannini A, Seghieri C, Simoncini T, Vainieri M. Regional practice variation in pelvic organ prolapse surgery in Tuscany, Italy: a retrospective cohort study on administrative health data. BMJ Open 2023; 13:e068145. [PMID: 36882257 PMCID: PMC10008403 DOI: 10.1136/bmjopen-2022-068145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
OBJECTIVES To explore determinants of practice variation in both access, and quality and efficiency of surgical care for pelvic organ prolapse (POP). DESIGN AND SETTING A retrospective cohort study employing administrative health data from the Tuscany region, Italy. PARTICIPANTS All women over 40 years hospitalised for apical/multicompartmental POP reconstructive surgery (excluding anterior/posterior colporrhaphy without concomitant hysterectomy) from January 2017 to December 2019. OUTCOMES We first computed treatment rates just for women residing in Tuscany (n=2819) and calculated the Systematic Component of Variation (SCV) to explore variation in access to care among health districts. Then, using the full cohort (n=2959), we ran multilevel models for the average length of stay and reoperations, readmissions and complications, and computed the intraclass correlation coefficient to assess the individual and hospital determinants of efficiency and quality of care provided by hospitals. RESULTS The 5.4-fold variation between the lowest-rate (56/100 000 inhabitants) and the highest-rate (302/100 000) districts and the SCV over 10% confirmed high systematic variation in the access to care. Higher treatment rates were driven by greater provisions of robotic and/or laparoscopic interventions, which showed highly variable usage rates. Both individual and hospital factors influenced quality and efficiency provided by hospitals, but just low proportions of variation were explained by hospital and patient characteristics. CONCLUSIONS We found high and systematic variation in the access to POP surgical care in Tuscany and in quality and efficiency provided by hospitals. Such a variation may be mainly explained by user and provider preferences, which should be further explored. Also, supply-side factors may be involved, suggesting that wider and more uniform dissemination of robotic/laparoscopic procedures may reduce variation.
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Affiliation(s)
- Amerigo Ferrari
- Institute of Management, MeS (Management and Health) Laboratory, Sant'Anna School of Advanced Studies, Pisa, Italy
| | - Andrea Giannini
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynaecology, University of Pisa, Pisa, Italy
| | - Chiara Seghieri
- Institute of Management, MeS (Management and Health) Laboratory, Sant'Anna School of Advanced Studies, Pisa, Italy
| | - Tommaso Simoncini
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynaecology, University of Pisa, Pisa, Italy
| | - Milena Vainieri
- Institute of Management, MeS (Management and Health) Laboratory, Sant'Anna School of Advanced Studies, Pisa, Italy
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Caretto M, Misasi G, Giannini A, Russo E, Simoncini T. Menopause, aging and the failing pelvic floor: a clinician's view. Climacteric 2021; 24:531-532. [PMID: 34169785 DOI: 10.1080/13697137.2021.1936484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The management of pelvic organ disorders is common and challenging work. Nowadays, midlife women are more active than they were in the past, and the development of pelvic organ prolapse (POP) disrupts quality of life and impairs social and personal activities. The aging process and hormonal changes have a role in influencing the structure and function of the lower urinary and genital tract. Correct diagnosis of pelvic organ disorders and the identification of women's symptoms are the hallmarks of tailored management. Treatment is multimodal and multidisciplinary; it requires competence in pelvic medicine and surgery. When conservative treatments fail, women with symptomatic POP are candidates for reconstructive surgery: the optimal management requires clinicians who are familiar with all of the available strategies and who are able to choose the best strategies in a tailored manner. Knowing and understanding the management of POP should be integrated into the practice of health-care professionals dealing in menopause.
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Affiliation(s)
- M Caretto
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - G Misasi
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - A Giannini
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - E Russo
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - T Simoncini
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Giannini A, Caretto M, Russo E, Mannella P, Simoncini T. Advances in surgical strategies for prolapse. Climacteric 2020; 22:60-64. [PMID: 30721638 DOI: 10.1080/13697137.2018.1543266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Pelvic floor dysfunctions are a complex condition in elderly women; pelvic organ prolapse, urinary or fecal incontinence, constipation, pelvic pain, and sexual dysfunction are common problems. The goal of surgical treatment is functional reconstruction with symptom management and repair of anatomic defects. The recent advancements in surgical treatment of pelvic floor dysfunction allow several good options for choosing the best surgery for each patient. The vaginal procedure is traditionally the gold standard approach for elderly patients, but abdominal surgery is increasing as a mini-invasive approach and the robotic approach is gaining acceptance for treatment of pelvic floor dysfunctions. In elderly individuals, a multitude of factors affects the final result of any reconstructive surgery such as postmenopausal or aging-associated changes in muscle tone and nerve function or changes in the function of the bladder or of the rectum: an understanding of the underlining functional status of pelvic organs is very important in aging women before proceeding to surgery. In this context, pelvic floor dysfunction, particularly in elderly women, should be addressed in a multidisciplinary manner and, at the forefront, centers for surgical planning could be helpful to perform safer, patient-tailored surgery.
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Affiliation(s)
- A Giannini
- a Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine , University of Pisa , Pisa , Italy
| | - M Caretto
- a Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine , University of Pisa , Pisa , Italy
| | - E Russo
- a Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine , University of Pisa , Pisa , Italy
| | - P Mannella
- a Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine , University of Pisa , Pisa , Italy
| | - T Simoncini
- a Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine , University of Pisa , Pisa , Italy
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Di Donato V, Benedetti Panici P. New diagnostic tools and therapeutic approaches in gynecology: considerations for innovative strategies. MINERVA GINECOLOGICA 2019; 71:1-3. [PMID: 30781937 DOI: 10.23736/s0026-4784.18.04344-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Violante Di Donato
- Department of Gynecology, Obstetrics Sciences and Urologic Sciences, Umberto I Hospital, Sapienza University, Rome, Italy -
| | - Pierluigi Benedetti Panici
- Department of Gynecology, Obstetrics Sciences and Urologic Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
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Computed-tomography image segmentation and 3D-reconstruction of the female pelvis for the preoperative planning of sacrocolpopexy: preliminary data. Int Urogynecol J 2018; 30:725-731. [DOI: 10.1007/s00192-018-3706-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 06/19/2018] [Indexed: 10/28/2022]
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Giannini A, Russo E, Mannella P, Morelli L, Perutelli A, Cela V, Melfi F, Simoncini T. Early Experience Using New Integrated Table Motion for the da Vinci Xi in Gynecologic Surgery: Feasibility, Safety, Efficacy. J Gynecol Surg 2018. [DOI: 10.1089/gyn.2017.0109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Andrea Giannini
- Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine, University of Pisa, Italy
| | - Eleonora Russo
- Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine, University of Pisa, Italy
| | - Paolo Mannella
- Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine, University of Pisa, Italy
| | - Luca Morelli
- General Surgery Unit, Department of Oncology, Transplantation and New Technologies, University of Pisa, Italy
| | - Alessandra Perutelli
- Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine, University of Pisa, Italy
| | - Vito Cela
- Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine, University of Pisa, Italy
| | - Franca Melfi
- Multidisciplinary Center of Robotic Surgery, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Tommaso Simoncini
- Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine, University of Pisa, Italy
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de Oliveira MS, Cavalcanti GDA, da Costa AAR. Native vaginal tissue repair for genital prolapse surgical treatment: a minimum of 30 months of results. Eur J Obstet Gynecol Reprod Biol 2016; 201:75-8. [PMID: 27082131 DOI: 10.1016/j.ejogrb.2016.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 03/03/2016] [Accepted: 03/17/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of this study was to assess the impact of using native vaginal tissue repair as a surgical treatment for pelvic organ prolapse (POP) on quality of life using validated questionnaires. STUDY DESIGN Fifty-one women underwent surgical POP repair. All of the women were evaluated by physical examination using the POP-Q, ICIQ-VS and P-QoL questionnaires prior to surgery as well as six and at least 30 months after surgery. RESULTS Fifty-one patients returned for assessment at least 30 months after surgery (median 36 months, range 30-50 months). There was significant improvement in most points - Aa, Ba, C, Bp, Ap, and hg - and at the stage of prolapse. There were statistically significant improvements in bulge symptoms after surgery (p<0.001), and significant differences were also seen regarding questions related to urinary and bowel symptoms. Indeed, most quality of life questionnaire domains showed significant differences before and after surgery. CONCLUSION Native vaginal tissue repair improved POP-related symptoms and quality of life after 30-50 months of assessment.
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