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Coyne K, Purdy MP, Bews KA, Habermann EB, Khan Z. Risk of hysterectomy at the time of myomectomy: an underestimated surgical risk. Fertil Steril 2024; 121:107-116. [PMID: 37777107 DOI: 10.1016/j.fertnstert.2023.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/21/2023] [Accepted: 09/22/2023] [Indexed: 10/02/2023]
Abstract
OBJECTIVE To evaluate the risk of hysterectomy at the time of myomectomy and the associated 30-day postoperative morbidity. DESIGN Cohort study. PATIENTS Patients who underwent myomectomies identified from the American College of Surgeons' National Surgical Quality Improvement Program from 2010 to 2021. INTERVENTION Unplanned hysterectomy at the time of a myomectomy procedure. MAIN OUTCOME MEASURES The Current Procedural Terminology codes were used to identify myomectomies performed with or without concurrent hysterectomy. Preoperative characteristics and morbidity outcomes were obtained. The univariate analysis was performed using the chi-square and Fisher exact tests, as appropriate. Multivariate logistic regression reported risk factors for individuals who underwent hysterectomy at the time of myomectomy. P values of <.05 were considered statistically significant. RESULTS A total of 13,213 individuals underwent myomectomy, and 399 (3.0%) had a hysterectomy performed during myomectomy. Concurrent hysterectomy was most frequently performed with the laparoscopic approach (7.1%), followed by the abdominal (3.2%) and hysteroscopic (1.9%) approaches. Age ≥43 years, obesity class II and higher, American Society of Anesthesiologists (ASA) class greater than II, tobacco use, longer operative time (>85 minutes), and laparoscopic approach were associated with a significantly increased risk of hysterectomy. When adjusting for age, body mass index, race, ASA class, case type, surgical approach, operative time, preoperative transfusion, preoperative hematocrit, and high fibroid burden, an increased odds of hysterectomy was noted for white race, longer operative time, ASA class III or higher, obesity, laparoscopic approach, and low fibroid burden. Patients who underwent concurrent hysterectomy had a longer median length of hospital stay (2 vs. 1 day), longer median operative time (161 vs. 126 minutes), increased intraoperative/postoperative blood transfusions (14.5% vs. 9.0%), and higher rates of organ/space surgical site infections (1.5% vs. 0.5%) and return to surgery (2.0% vs. 0.7%) than those who did not (P<.05). The risk of a major complication within 30 days of myomectomy increased in patients who underwent concurrent hysterectomy after adjusting for relevant confounders (adjusted odds ratio, 2.4; 95% confidence interval, 1.8-3.2). CONCLUSION The risk of hysterectomy during a myomectomy is higher than previously reported. The patient age of ≥43 years, obesity, white race, ASA class III or higher, longer operative time, and laparoscopic approach were associated with higher odds of hysterectomy. Identification of patients with these risk factors can aid in patient counseling and surgical planning, which may help reduce the unexpectedly high rates of hysterectomy at planned myomectomy.
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Affiliation(s)
- Kathryn Coyne
- Division of Reproductive Endocrinology and Infertility, University Hospitals, Cleveland, Ohio.
| | | | - Katherine A Bews
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, Minnesota
| | - Zaraq Khan
- Division of Reproductive Endocrinology and Infertility, Mayo Clinic, Rochester, Minnesota; Division of Minimally Invasive Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota
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Wieslander CK, Grimes CL, Balk EM, Hobson DTG, Ringel NE, Sanses TVD, Singh R, Richardson ML, Lipetskaia L, Gupta A, White AB, Orejuela F, Meriwether K, Antosh DD. Health Care Disparities in Patients Undergoing Hysterectomy for Benign Indications: A Systematic Review. Obstet Gynecol 2023; 142:1044-1054. [PMID: 37826848 DOI: 10.1097/aog.0000000000005389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/30/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE To explore how markers of health care disparity are associated with access to care and outcomes among patients seeking and undergoing hysterectomy for benign indications. DATA SOURCES PubMed, EMBASE, and ClinicalTrials.gov were searched through January 23, 2022. METHODS OF STUDY SELECTION The population of interest included patients in the United States who sought or underwent hysterectomy by any approach for benign indications. Health care disparity markers included race, ethnicity, geographic location, insurance status, and others. Outcomes included access to surgery, patient level outcomes, and surgical outcomes. Eligible studies reported multivariable regression analyses that described the independent association between at least one health care disparity risk marker and an outcome. We evaluated direction and strengths of association within studies and consistency across studies. TABULATION, INTEGRATION, AND RESULTS Of 6,499 abstracts screened, 39 studies with a total of 46 multivariable analyses were included. Having a Black racial identity was consistently associated with decreased access to minimally invasive, laparoscopic, robotic, and vaginal hysterectomy. Being of Hispanic ethnicity and having Asian or Pacific Islander racial identities were associated with decreased access to laparoscopic and vaginal hysterectomy. Black patients were the only racial or ethnic group with an increased association with hysterectomy complications. Medicare insurance was associated with decreased access to laparoscopic hysterectomy, and both Medicaid and Medicare insurance were associated with increased likelihood of hysterectomy complications. Living in the South or Midwest or having less than a college degree education was associated with likelihood of prior hysterectomy. CONCLUSION Studies suggest that various health care disparity markers are associated with poorer access to less invasive hysterectomy procedures and with poorer outcomes for patients who are undergoing hysterectomy for benign indications. Further research is needed to understand and identify the causes of these disparities, and immediate changes to our health care system are needed to improve access and opportunities for patients facing health care disparities. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021234511.
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Affiliation(s)
- Cecilia K Wieslander
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, California; the Division of Urogynecology & Reconstructive Pelvic Surgery, Departments of Obstetrics and Gynecology and Urology, New York Medical College, Valhalla, New York; the Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, Wayne State University School of Medicine, Detroit, Michigan; the Division of Urogynecology & Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Yale School of Medicine, New Haven, Connecticut; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, Howard University College of Medicine, Washington, DC; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, University of Florida Health, Jacksonville, Florida; Occom Health, Newton, Massachusetts; the Division of Urogynecology & Reconstructive Pelvic Surgery, Cooper Health University, Cooper Medical School at Rowan University, Camden, New Jersey; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, University of Louisville Health, Louisville, Kentucky; the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, University of Texas at Austin Dell Medical School, Austin, and the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, Baylor College of Medicine, the Division of Urogynecology, Department of Obstetrics & Gynecology, Houston Methodist Hospital, Houston, Texas; and the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, University of New Mexico, Albuquerque, New Mexico
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Barrington DA, Meade CE, Cosgrove CM, Cohn DE, Felix AS. Racial and ethnic disparities in readmission risk following the surgical management of endometrial cancer. Gynecol Oncol 2022; 166:543-551. [PMID: 35882610 DOI: 10.1016/j.ygyno.2022.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/12/2022] [Accepted: 07/15/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Most women diagnosed with endometrial cancer undergo primary surgical management with hysterectomy. Although racial disparities in readmission risk following hysterectomy for non-cancerous conditions have been reported, data among women with endometrial cancer are absent. This study evaluates racial differences in readmission risk among women undergoing endometrial cancer-related hysterectomy. METHODS In the National Cancer Database, women who underwent surgical management for endometrial cancer from 2004 to 2018 were identified. Readmission and minimally invasive hysterectomy (MIH) proportions were plotted according to year of diagnosis and race/ethnicity. Multivariable logistic regression models were used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for associations between readmission risk and epidemiological, facility, tumor, and surgical characteristics. A base model was sequentially adjusted to incorporate significant covariates. RESULTS There were 350,631 patients included in the study. The proportion of MIH increased among all race/ethnicities over the study period; however, MIH rates were lower among Black women. Readmission proportions were 2.7% among White, 4.2% among Black, 2.9% among Hispanic, 2.4% among Asian, 2.1% among American Indian/Alaska Native, and 3.1% among Native Hawaiian/Pacific Islander women. In the fully adjusted model incorporating surgical approach, Black women (OR: 1.20, 95% CI = 1.13, 1.28) and Native Hawaiian/Pacific Islander women (OR: 1.54, 95% CI = 1.09, 2.18) were more commonly readmitted compared to White women. CONCLUSIONS In this study, Black and Native Hawaiian/Pacific Islander women with endometrial cancer had significantly higher readmission risk than White women. Optimizing perioperative care for minority women is an essential component of overcoming racially disparate endometrial cancer outcomes.
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Affiliation(s)
- David A Barrington
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, The Ohio State University Wexner Medical Center, Arthur G James Cancer Center, Columbus, OH, USA
| | - Caitlin E Meade
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Casey M Cosgrove
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, The Ohio State University Wexner Medical Center, Arthur G James Cancer Center, Columbus, OH, USA
| | - David E Cohn
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, The Ohio State University Wexner Medical Center, Arthur G James Cancer Center, Columbus, OH, USA
| | - Ashley S Felix
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA.
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Incidence of and Risk Factors for Postoperative Urinary Tract Infection After Abdominal and Vaginal Colpopexy. Female Pelvic Med Reconstr Surg 2021; 27:e75-e81. [PMID: 32205555 DOI: 10.1097/spv.0000000000000814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The aims of the study were to determine the rate of urinary tract infection (UTI) in women undergoing colpopexy and to evaluate risk factors and timing for postoperative UTI. METHODS This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2017. Patients were grouped into those with and without UTI. Pairwise analysis between groups was performed using χ2 and Fisher exact test. Multivariable logistic regression was used to identify independent predictors of UTI. RESULTS Of 23,097 women who underwent colpopexy, 1079 (4.7%) experienced a postoperative UTI. Urinary tract infection was most frequently diagnosed in the second week after surgery (38.2%), compared with week 1 (19.9%), 3 (22.8%), and 4 (19.1%) (P < 0.001). Patients diagnosed with a UTI were more likely to have insulin-dependent diabetes (2.8% vs 1.7%, P = 0.006), coagulopathy (1.3% vs 0.7%, P = 0.04), and chronic steroid use (2.7% vs 1.8%, P = 0.004). Patients with a UTI versus those without a UTI were more likely to have undergone an intraperitoneal or extraperitoneal vaginal colpopexy (37.8% vs 30.5%, P < 0.001) and (29.8% vs 25.6%, P = 0.003), respectively, and more likely to undergo combined anterior and posterior colporrhaphy (17.1% vs 12.2%, P < 0.001). After logistic regression, intraoperative cystotomy repair (adjusted odds ratio = 2.93, 95% confidence interval = 1.54-5.59) was the most significant risk factor. CONCLUSIONS Postoperative UTI after colpopexy occurred less frequently than previously reported. Vaginal colpopexy is associated with a higher risk of UTI than abdominal or laparoscopic colpopexy.
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Pollack LM, Lowder JL, Keller M, Chang SH, Gehlert SJ, Olsen MA. Racial/Ethnic Differences in the Risk of Surgical Complications and Posthysterectomy Hospitalization among Women Undergoing Hysterectomy for Benign Conditions. J Minim Invasive Gynecol 2021; 28:1022-1032.e12. [PMID: 33395578 DOI: 10.1016/j.jmig.2020.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/25/2020] [Accepted: 12/27/2020] [Indexed: 10/22/2022]
Abstract
STUDY OBJECTIVE Evaluate whether 30- and 90-day surgical complication and postoperative hospitalization rates after hysterectomy for benign conditions differ by race/ethnicity and whether the differences remain after controlling for patient, hospital, and surgical characteristics. DESIGN Retrospective cohort study using administrative data. The exposure was race/ethnicity. The outcomes included 5 different surgical complications/categories and posthysterectomy inpatient hospitalization, all identified through 30 and 90 days after hysterectomy hospital discharge, with the exception of hemorrhage/hematoma, which was only identified through 30 days. To examine the association between race/ethnicity and each outcome, we used logistic regression with clustering of procedures within hospitals, adjusting for patient and hospital characteristics and surgical approach. SETTING Multistate, including Florida and New York. PATIENTS Women aged ≥18 years who underwent hysterectomy for benign conditions using State Inpatient Databases and State Ambulatory Surgery Databases. INTERVENTIONS Hysterectomy for benign conditions. MEASUREMENTS AND MAIN RESULTS We included 183 697 women undergoing hysterectomy for benign conditions from January 2011 to September 2014. In analysis, adjusting for surgery route and other factors, black race was associated with increased risk of 30-day digestive system complications (multivariable adjusted odds ratio [aOR], 1.98; 95% confidence interval [CI], 1.78-2.21), surgical-site infection (aOR, 1.34; 95% CI, 1.18-1.53), posthysterectomy hospitalization (aOR, 1.31; 95% CI, 1.22-1.40), and urologic complications (aOR, 1.16; 95% CI, 1.01-1.34) compared with white race. Asian/Pacific Islander race was associated with increased risk of 30-day urologic complications (aOR, 1.48; 95% CI, 1.08-2.03), intraoperative injury to abdominal/pelvic organs (aOR, 1.46; 95% CI, 1.23-1.75), and hemorrhage/hematoma (aOR, 1.33; 95% CI, 1.06-1.67) compared with white race. Hispanic ethnicity was associated with increased risk of 30-day posthysterectomy hospitalization (aOR, 1.11; 95% CI, 1.02-1.20) compared with white race. All findings were similar at 90 days. CONCLUSION Black and Asian/Pacific Islander women had higher risk of some 30- and 90-day surgical complications after hysterectomy than white women. Black and Hispanic women had higher risk of posthysterectomy hospitalization. Intervention strategies aimed at identifying and better managing disparities in pre-existing conditions/comorbidities could reduce racial/ethnic differences in outcomes.
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Affiliation(s)
- Lisa M Pollack
- Division of Public Health Sciences, Department of Surgery (Drs. Pollack, Chang, Gehlert, and Olsen); Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology (Dr. Lowder); Division of Infectious Diseases, Department of Medicine (Dr. Olsen and Mr. Keller), Washington University School of Medicine in St. Louis; Department of Public Health-Social Work, George Warren Brown School of Social Work, Washington University in St. Louis (Dr. Gehlert), St. Louis, Missouri; Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California (Dr. Gehlert).
| | - Jerry L Lowder
- Division of Public Health Sciences, Department of Surgery (Drs. Pollack, Chang, Gehlert, and Olsen); Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology (Dr. Lowder); Division of Infectious Diseases, Department of Medicine (Dr. Olsen and Mr. Keller), Washington University School of Medicine in St. Louis; Department of Public Health-Social Work, George Warren Brown School of Social Work, Washington University in St. Louis (Dr. Gehlert), St. Louis, Missouri; Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California (Dr. Gehlert)
| | - Matt Keller
- Division of Public Health Sciences, Department of Surgery (Drs. Pollack, Chang, Gehlert, and Olsen); Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology (Dr. Lowder); Division of Infectious Diseases, Department of Medicine (Dr. Olsen and Mr. Keller), Washington University School of Medicine in St. Louis; Department of Public Health-Social Work, George Warren Brown School of Social Work, Washington University in St. Louis (Dr. Gehlert), St. Louis, Missouri; Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California (Dr. Gehlert)
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery (Drs. Pollack, Chang, Gehlert, and Olsen); Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology (Dr. Lowder); Division of Infectious Diseases, Department of Medicine (Dr. Olsen and Mr. Keller), Washington University School of Medicine in St. Louis; Department of Public Health-Social Work, George Warren Brown School of Social Work, Washington University in St. Louis (Dr. Gehlert), St. Louis, Missouri; Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California (Dr. Gehlert)
| | - Sarah J Gehlert
- Division of Public Health Sciences, Department of Surgery (Drs. Pollack, Chang, Gehlert, and Olsen); Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology (Dr. Lowder); Division of Infectious Diseases, Department of Medicine (Dr. Olsen and Mr. Keller), Washington University School of Medicine in St. Louis; Department of Public Health-Social Work, George Warren Brown School of Social Work, Washington University in St. Louis (Dr. Gehlert), St. Louis, Missouri; Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California (Dr. Gehlert)
| | - Margaret A Olsen
- Division of Public Health Sciences, Department of Surgery (Drs. Pollack, Chang, Gehlert, and Olsen); Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology (Dr. Lowder); Division of Infectious Diseases, Department of Medicine (Dr. Olsen and Mr. Keller), Washington University School of Medicine in St. Louis; Department of Public Health-Social Work, George Warren Brown School of Social Work, Washington University in St. Louis (Dr. Gehlert), St. Louis, Missouri; Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California (Dr. Gehlert)
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Clancy AA, Chen I, Pascali D, Minassian VA. Surgical approach and unplanned readmission following pelvic organ prolapse surgery: a retrospective cohort study using data from the National Surgical Quality Improvement Program Database (NSQIP). Int Urogynecol J 2020; 32:945-953. [PMID: 32840658 DOI: 10.1007/s00192-020-04505-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 08/17/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND HYPOTHESIS To define the reasons for hospital readmissions following surgery for pelvic organ prolapse by surgical approach. METHODS Patients undergoing surgery for pelvic organ prolapse from 2012 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Current Procedural Terminology and International Classification of Diseases codes. Hazard risks of readmission by surgical approach (vaginal, laparoscopic, abdominal, or combined) were determined by multivariable cox regression. Diagnoses and timing of readmission by surgical approach were examined. RESULTS Of 57,233 women undergoing surgery for pelvic organ prolapse during the study period, 1073 (1.9%) were readmitted to the hospital within 30 days postoperatively. After adjusting for prespecified potential confounders, laparoscopic and abdominal surgical approaches were associated with higher risks of readmission relative to a vaginal approach (aHR 1.30, 95% CI 1.08-1.57, and 1.97, 95% CI 1.44-2.71, respectively). The most common reason for readmission was a gastrointestinal issue among those undergoing both laparoscopic (28.0%) and abdominal surgery (30.2%). Surgical site infection was the most common readmission diagnosis among women undergoing vaginal surgery (16.2%). Of the 418 women readmitted within 7 days of surgery, the most common diagnoses were gastrointestinal issues (26.6%), medical disorders (12.0%), or surgical complications (e.g., bleeding) (11.0%). CONCLUSIONS Women undergoing laparoscopic or abdominal surgery for pelvic organ prolapse were at higher risk of readmission relative to those undergoing surgery via a vaginal approach. The reasons and timing of readmission differed based on surgical approach.
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Affiliation(s)
- Aisling A Clancy
- Department of Obstetrics and Gynecology, The Ottawa Hospital, Urogynecology Clinic, The Ottawa Hospital Riverside Campus, 1967 Riverside Drive, Ottawa, ON, Canada.
- T.H. Chan School of Public Health, Harvard University, Boston, MA, USA.
| | - Innie Chen
- Department of Obstetrics and Gynecology, The Ottawa Hospital, Urogynecology Clinic, The Ottawa Hospital Riverside Campus, 1967 Riverside Drive, Ottawa, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Dante Pascali
- Department of Obstetrics and Gynecology, The Ottawa Hospital, Urogynecology Clinic, The Ottawa Hospital Riverside Campus, 1967 Riverside Drive, Ottawa, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Vatche A Minassian
- T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
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Strozyk S, Wernecke KD, Sehouli J, David M. Factors Influencing Postoperative Recovery and Time Off Work of Patients with Benign Indications for Surgery - Results of a Prospective Study. Geburtshilfe Frauenheilkd 2020; 80:723-732. [PMID: 32675834 PMCID: PMC7360394 DOI: 10.1055/a-1157-8996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/08/2020] [Indexed: 10/28/2022] Open
Abstract
Objectives The study aimed to answer a number of questions: Which medical, psychological and sociodemographic factors affect the recovery of women after gynecological surgery for benign indications? Does patients' health-related quality of life improve after surgical intervention? How long are patients signed off work postoperatively? How do patients assess their own capacity to work? Method Study population: All women between the ages of 18 and 67 years who underwent gynecological surgery for benign indications at the Charité Campus Virchow Clinic over a 7-month period were consecutively enrolled in the study. Four standardized patient surveys (the first survey [T0] was carried out in hospital, T1 at 1 week, T2 at 6 weeks and T3 at 7 - 8 months after discharge by telephone interview) were carried out using evaluated questionnaires to record patients' recovery (Recovery Index), quality of life (RAND-36), satisfaction, complications, sociodemographic information and time off work with a medical sick note. Relevant medical and demographic data were also collected. Statistical analysis was carried out using univariate statistical tests for descriptive analysis and complex multifactorial statistical procedures to record observations over time. Results A total of 182 patients were included in this study (participation rate: 70%). Relevant prior operations (p = 0.01), in-hospital (p = 0.004) and postoperative complications (p < 0.001), preoperative psychological wellbeing (p = 0.01), physical functioning (p = 0.005) and postoperative anxiety (p = 0,006) had a significant impact on recovery (Recovery Index) and changed significantly over time (p < 0.001). The invasiveness of the surgery or sociodemographic parameters (including migration background) had no significant effect. Health-related quality of life (measured with the RAND-36 questionnaire) also improved postoperatively. More invasive surgical interventions were associated with longer sick leave times and, to a certain extent, with a poorer evaluation of patients' capacity to work. Conclusion Recovery after gynecological surgery is a multifactorial process. This survey of a patient population identified psychological and physical factors which influence recovery but did not find significant sociodemographic parameters affecting recovery. Irrespective of these findings, gynecological surgery for benign indications resulted in an improvement in health-related quality of life. Prospective studies need to investigate whether psychological interventions could reduce preoperative fear and thereby improve postoperative recovery.
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Affiliation(s)
- Sophie Strozyk
- Klinik für Chirurgie, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Klaus-Dieter Wernecke
- Charité - Universitätsmedizin Berlin, Berlin, Germany.,Sostana GmbH, Berlin, Germany
| | - Jalid Sehouli
- Klinik für Gynäkologie mit Zentrum für onkologische Chirurgie, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias David
- Klinik für Gynäkologie mit Zentrum für onkologische Chirurgie, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Society of gynecologic oncology future of physician payment reform task force: Lessons learned in developing and implementing surgical alternative payment models. Gynecol Oncol 2020; 156:701-709. [PMID: 31916980 DOI: 10.1016/j.ygyno.2019.12.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 12/23/2019] [Indexed: 11/24/2022]
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Xiong Z, Rindos NB, Lee T. Increasing the Rate of Laparoscopic Hysterectomy Safely for Benign Gynecologic Disease. J Gynecol Surg 2019. [DOI: 10.1089/gyn.2019.0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Zhoufang Xiong
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Noah B. Rindos
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Magee–Women's Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ted Lee
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Magee–Women's Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA
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Shaffer BK, Cui Y, Wanderer JP. Validation of the LACE readmission and mortality prediction model in a large surgical cohort: Comparison of performance at preoperative assessment and discharge time points. J Clin Anesth 2019; 58:22-26. [PMID: 31055196 DOI: 10.1016/j.jclinane.2019.04.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/24/2019] [Accepted: 04/26/2019] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE The LACE index (Length of stay, admission Acuity, Charlson comorbidity index, and Emergency department visits within 6 months of current admission) is a practical tool designed to predict the risk of readmission or mortality within 30 days of hospital discharge. We sought to validate and examine its performance in a large surgical population at both the preoperative assessment and discharge time points. DESIGN Retrospective cohort study. SETTING We identified all admissions with a surgery or procedure at Vanderbilt University Medical Center (VUMC) between 2010 and 2015. PATIENTS A total of 192,670 admissions (age ≥ 18) were included in the study. INTERVENTIONS None. MEASUREMENTS LACE scores were calculated and analyzed with multivariable logistic regression. Discrimination was assessed with the c-statistic, calibration was assessed with calibration plots, and overall performance evaluated with the Brier score. Four models were created: admissions with any surgery or procedure, surgical admissions using actual length of stay (ALOS), surgical admissions using estimated length of stay (ELOS) and non-surgical procedural admissions. MAIN RESULTS 192,670 admissions were included. The all admissions model c-statistic was 0.77 with a Brier score of 0.13. Surgical admissions with ALOS and ELOS had a c-statistic of 0.80, 0.82 and a Brier score of 0.10, 0.08 respectively. Non-surgical procedural admissions had a c-statistic of 0.76 and a Brier score of 0.14. Calibration for all models was adequate. CONCLUSIONS The LACE model for surgical and procedural admissions had good discrimination and adequate calibration. Analysis of the model applied to surgical admissions using ELOS demonstrated slightly better overall performance than ALOS, suggesting that LACE could be utilized for readmission risk stratification at the time of preoperative assessment. Clinical Trial and Registry URL: Not applicable.
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Affiliation(s)
- Brett K Shaffer
- Vanderbilt University Medical Center, 2301 Vanderbilt University Hospital, Nashville, TN 37232, USA
| | - Yu Cui
- Chengdu Women and Children Central Hospital, No.1617, Riyue Avenue, Qingyang district, Chengdu 610091, China
| | - Jonathan P Wanderer
- Vanderbilt University Medical Center, 2301 Vanderbilt University Hospital, Nashville, TN 37232, USA.
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Monsour MA, Wiley W, Le CH, Lee J, Brown KP, Robinson M, Elsamadicy EA. Infectious Causes of 30-Day Unplanned Hospital Encounters and Readmissions After Hysterectomies: A Single Institutional Study. J Gynecol Surg 2019. [DOI: 10.1089/gyn.2018.0052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Meredith A. Monsour
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Whittney Wiley
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Chi H. Le
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Jaclyn Lee
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Kelsei P. Brown
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Marc Robinson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Emad A. Elsamadicy
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
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12
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Hysterectomy and risk of ovarian cancer: a systematic review and meta-analysis. Arch Gynecol Obstet 2019; 299:599-607. [DOI: 10.1007/s00404-018-5020-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 12/12/2018] [Indexed: 01/11/2023]
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13
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Ko EM, Havrilesky LJ, Alvarez RD, Zivanovic O, Boyd LR, Jewell EL, Timmins PF, Gibb RS, Jhingran A, Cohn DE, Dowdy SC, Powell MA, Chalas E, Huang Y, Rathbun J, Wright JD. Society of Gynecologic Oncology Future of Physician Payment Reform Task Force report: The Endometrial Cancer Alternative Payment Model (ECAP). Gynecol Oncol 2018; 149:232-240. [DOI: 10.1016/j.ygyno.2018.02.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/14/2018] [Accepted: 02/17/2018] [Indexed: 01/07/2023]
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Agrawal S, Chen L, Tergas AI, Hou JY, St Clair CM, Ananth CV, Hershman DL, Wright JD. Identifying modifiable and non-modifiable risk factors associated with prolonged length of stay after hysterectomy for uterine cancer. Gynecol Oncol 2018; 149:545-553. [PMID: 29559171 DOI: 10.1016/j.ygyno.2018.03.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 03/12/2018] [Accepted: 03/12/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE We examined the influence of modifiable (intraoperative factors and complications) and non-modifiable (clinical and demographic characteristics) factors on length of stay (LOS) for women who underwent hysterectomy for uterine cancer. METHODS The National Surgical Quality Improvement Program database was used to identify women who underwent hysterectomy for uterine cancer from 2006 to 2015. The association between demographic, preoperative, intraoperative, and postoperative factors and LOS was examined. The primary outcome was prolonged LOS (>75th an3 >90th percentiles). Model fit statistics were used to assess the importance of each group of characteristics. RESULTS Of 19,084 women identified, 6082 (31.9%) underwent abdominal and 13,002 (68.1%) underwent minimally invasive hysterectomy. In the abdominal hysterectomy group, the 75th and 90th percentiles for LOS were 5 and 8days, respectively. All risk factors combined accounted for 23.6% of the variation in LOS >75th percentile. Demographic characteristics explained 4.0%, preoperative factors 7.0%, intraoperative factors 7.9%, and postoperative characteristics 9.7% of variation in prolonged LOS. In the minimally invasive group, the 75th and 90th percentiles for LOS were 1 and 2days, respectively. The combined risk factors explained 16.2% of the variation in prolonged LOS. Demographic characteristics accounted for 6.2%, preoperative factors 4.1%, intraoperative factors 6.9%, and postoperative characteristics 1.3% of variation in prolonged LOS. Similar patterns were seen when prolonged LOS was defined as >90th percentile. CONCLUSION Perioperative risk factors account for approximately one quarter of the variation in prolonged LOS. Overall, a substantial proportion of the variation in LOS remains unexplained by measurable patient and hospital factors which may limit the utility of LOS as a quality metric for endometrial cancer.
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Affiliation(s)
- Surbhi Agrawal
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA
| | - Ling Chen
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA
| | - Ana I Tergas
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA; Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, USA; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, USA; New York Presbyterian Hospital, USA
| | - June Y Hou
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, USA; New York Presbyterian Hospital, USA
| | - Caryn M St Clair
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, USA; New York Presbyterian Hospital, USA
| | - Cande V Ananth
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA; Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, USA
| | - Dawn L Hershman
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA; Department of Medicine, Columbia University College of Physicians and Surgeons, USA; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, USA; New York Presbyterian Hospital, USA
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, USA; New York Presbyterian Hospital, USA.
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Readmission Rates after Same-Day Discharge Compared with Postoperative Day 1 Discharge after Benign Laparoscopic Hysterectomy. J Minim Invasive Gynecol 2018; 25:484-490. [DOI: 10.1016/j.jmig.2017.10.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 09/25/2017] [Accepted: 10/02/2017] [Indexed: 11/19/2022]
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16
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In-hospital complications of bilateral salpingo-oophorectomy at benign hysterectomy: a population-based cohort study. Menopause 2018; 24:187-195. [PMID: 27779566 DOI: 10.1097/gme.0000000000000746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The study compared the in-hospital complications and related outcomes between women who underwent bilateral salpingo-oophorectomy at hysterectomy for benign diseases and those who had hysterectomy only. METHODS We conducted a population-based, retrospective cohort study using data from Taiwan's National Health Insurance program. Women who underwent concurrent bilateral salpingo-oophorectomy at hysterectomy for benign indications (n = 34,509) were compared with those who had hysterectomy only (n = 176,305). Separate models were estimated to account for the effect of baseline comorbid condition, age, and hysterectomy approach on the relationship between bilateral salpingo-oophorectomy and study outcomes. A secondary analysis was also performed to evaluate the association of inpatient readmission within 30 days and complications among women who underwent bilateral salpingo-oophorectomy. RESULTS The addition of a bilateral salpingo-oophorectomy to hysterectomy was associated with a lower risk of surgical complications, a longer length of hospital stay, and an increased risk of inpatient readmission within 30 days. Among women who underwent bilateral salpingo-oophorectomy, women with complications were also more likely to require inpatient readmission within 30 days than those without complications. Our data also suggested that bilateral salpingo-oophorectomy was not associated with an overall risk of medical complications, with the exception of urethral obstruction. The relationships remained even after adjustments by age, surgical indications, hysterectomy approach, and health-related risk factors, such as baseline comorbid condition and status of any prior catastrophic illness. CONCLUSIONS Bilateral salpingo-oophorectomy at hysterectomy for benign conditions is not associated with an increased risk of in-hospital complications.
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Length of Catheter Use After Hysterectomy as a Risk Factor for Urinary Tract Infection. Female Pelvic Med Reconstr Surg 2018; 24:430-434. [DOI: 10.1097/spv.0000000000000486] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kreuninger JA, Cohen SL, Meurs EAIM, Cox M, Vitonis A, Jansen FW, Einarsson JI. Trends in readmission rate by route of hysterectomy - a single-center experience. Acta Obstet Gynecol Scand 2017; 97:285-293. [PMID: 29192965 DOI: 10.1111/aogs.13270] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 11/12/2017] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The aim of this study was to assess the 60-day readmission rates after hysterectomy according to route of surgery and analyze risk factors for postoperative readmission. MATERIAL AND METHODS This retrospective study included all women who underwent hysterectomy due to benign conditions from 2009 to 2015 at a large academic center in Boston. Readmission rates were compared among the following four types of hysterectomies: abdominal, laparoscopic, robotic and vaginal. RESULTS There were 3981 hysterectomy cases over the study period (628 abdominal hysterectomy, 2500 laparoscopic hysterectomy, 155 robotic hysterectomy and 698 vaginal hysterectomy). Intraoperative complications occurred more frequently in women undergoing abdominal hysterectomy (4.8%), followed by robotic hysterectomy (3.9%), vaginal hysterectomy (1.9%) and laparoscopic hysterectomy (1.6%) (p < 0.0001). Readmission rates were not significantly different among the groups; women receiving abdominal hysterectomy had an overall readmission rate of 3.5%, compared with 3.2% after robotic hysterectomy, 2.9% after vaginal hysterectomy and 1.9% after laparoscopic hysterectomy (p = 0.06). When stratifying for relevant variables, women who had an laparoscopic hysterectomy had a twofold reduction of readmission compared with abdominal hysterectomy (odds ratio 0.52, 95% confidence interval 0.31-0.87; p = 0.01). There was no significant difference in readmission when robotic hysterectomy or vaginal hysterectomy were compared individually with abdominal hysterectomy. Regarding risk factors related to readmission it was observed that perioperative complications were the largest driver of readmissions (odds ratio 667, 95% confidence interval 158-99; p < 0.0001). CONCLUSION The laparoscopic approach to hysterectomy was associated with fewer hospital readmissions compared with the abdominal route; vaginal, robotic and abdominal approaches had a similar risk of readmission. Perioperative complications represent the main driver of readmissions. After adjusting for perioperative factors such as surgeon type and complications, no difference in readmissions between the different routes of hysterectomy were found.
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Affiliation(s)
- Jennifer A Kreuninger
- Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Division of Minimally Invasive Gynecologic Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Sarah L Cohen
- Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Elsemieke A I M Meurs
- Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Mary Cox
- Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Allison Vitonis
- Department of Obstetrics and Gynecology Epidemiology Center, Brigham and Women's Hospital, Boston, MA, USA
| | - Frank W Jansen
- Division of Minimally Invasive Gynecologic Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Jon I Einarsson
- Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, MA, USA
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Preventable Surgical Harm in Gynecologic Oncology: Optimizing Quality and Patient Safety. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0226-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Patterns of Specialty-Based Referral and Perioperative Outcomes for Women With Endometrial Cancer Undergoing Hysterectomy. Obstet Gynecol 2017; 130:81-90. [PMID: 28594765 DOI: 10.1097/aog.0000000000002100] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine patterns of referral to gynecologic oncologists and perioperative outcomes based on surgeon specialty for women with endometrial cancer and hyperplasia. METHODS The National Surgical Quality Improvement Program database was used to perform a retrospective cohort study of women with endometrial cancer and hyperplasia who underwent hysterectomy from 2014 to 2015. Patients were stratified based on treatment by a gynecologic oncologist or other health care provider. Patterns of referral to a gynecologic oncologist was the primary outcome, and mode of hysterectomy and complications were secondary outcomes. RESULTS A total of 6,510 women were identified. Gynecologic oncologists performed 90.9% (95% confidence interval [CI] 90.1-91.7) of the hysterectomies for endometrial cancer, 66.8% (95% CI 63.1-70.4) for complex atypical endometrial hyperplasia, and 49.3% (95% CI 44.7-53.8) for endometrial hyperplasia without atypia. Older women and those with a higher American Society of Anesthesiology score were more likely to be treated by an oncologist. Minimally invasive hysterectomy was performed in 73.6% (95% CI 72.1-75.1) of women with endometrial cancer operated on by gynecologic oncologists compared with 73.8% (95% CI 68.8-78.2) of those treated by other physicians (odds ratio [OR] 0.99, 95% CI 0.80-1.23); lymphadenectomy was performed in 56.3% of women treated by gynecologic oncologists compared with 34.8% of those treated by other specialists (OR 2.42, 95% CI 1.99-2.94). Severe complications were uncommon and there was no difference in complication rates based on specialty, 2.6% (95% CI 2.2-3.1) compared with 2.0% (95% CI 0.8-3.3). CONCLUSION Gynecologic oncologists provide care for the majority of women with endometrial cancer who undergo hysterectomy in the United States and are also involved in the care of a large percentage of women with endometrial hyperplasia.
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Timing of and Reasons for Unplanned 30-Day Readmission After Hysterectomy for Benign Disease. Obstet Gynecol 2017; 128:889-897. [PMID: 27607868 DOI: 10.1097/aog.0000000000001599] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To characterize timing and reasons associated with unplanned 30-day readmissions after hysterectomy for benign indications. METHODS We performed a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Project database files from 2012 to 2013. We identified patterns of 30-day readmission after benign hysterectomy for all surgical approaches (abdominal, laparoscopic, vaginal). Readmission timing was determined from discharge date and readmission diagnoses were tabulated. Statistical analyses included χ tests and multivariable logistic regression. RESULTS The 30-day readmission rate was 2.8% (1,118/40,580 hysterectomies). Readmissions complicated 3.7% (361/9,869) of abdominal, 2.6% (576/22,266) of laparoscopic, and 2.1% (181/8,445) of vaginal hysterectomies. Readmissions were more likely when hysterectomy was performed abdominally (adjusted odds ratio [OR] 1.45, 95% confidence interval [CI] 1.2-1.76) but not laparoscopically (adjusted OR 1.1, 95% CI 0.9-1.4) compared with a vaginal approach. Eighty-two percent of readmissions occurred within 15 days of discharge. The shortest median time to readmission was associated with pain (3 days), and the longest was associated with noninfectious wound complications (10 days). Surgical site infection was the most common diagnosis (abdominal 36.6%, laparoscopic 28.3%, vaginal 32.6%). Surgical site infections, surgical injuries, and wound complications combined accounted for 51.5% of abdominal, 51.9% of laparoscopic, and 50.8% of vaginal hysterectomy readmissions. Medical complications such as cardiovascular events and venous thromboembolism were responsible for 5.8% of abdominal, 6.9% of laparoscopic, and 8.8% of vaginal hysterectomy readmissions. Surgical injuries were responsible for more readmissions after laparoscopic (unadjusted OR 2.3, 95% CI 1.48-3.65) and vaginal hysterectomies (unadjusted OR 2.3, 95% CI 1.29-3.97) than abdominal cases. CONCLUSION Readmissions after hysterectomy tend to occur shortly after discharge. Most readmissions are related to surgical issues, most commonly surgical site infection. Medical complications, including venous thromboembolism, account for less than 10% of readmissions. Readmission reduction efforts should focus on early postdischarge follow-up, preventing infectious complications, and determining preventability of surgical-related reasons for readmission.
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Mehta A, Xu T, Hutfless S, Makary MA, Sinno AK, Tanner EJ, Stone RL, Wang K, Fader AN. Patient, surgeon, and hospital disparities associated with benign hysterectomy approach and perioperative complications. Am J Obstet Gynecol 2017; 216:497.e1-497.e10. [PMID: 28034651 PMCID: PMC5576033 DOI: 10.1016/j.ajog.2016.12.020] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 12/13/2016] [Accepted: 12/19/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hysterectomy is among the most common major surgical procedures performed in women. Approximately 450,000 hysterectomy procedures are performed each year in the United States for benign indications. However, little is known regarding contemporary US hysterectomy trends for women with benign disease with respect to operative technique and perioperative complications, and the association between these 2 factors with patient, surgeon, and hospital characteristics. OBJECTIVE We sought to describe contemporary hysterectomy trends and explore associations between patient, surgeon, and hospital characteristics with surgical approach and perioperative complications. STUDY DESIGN Hysterectomies performed for benign indications by general gynecologists from July 2012 through September 2014 were analyzed in the all-payer Maryland Health Services Cost Review Commission database. We excluded hysterectomies performed by gynecologic oncologists, reproductive endocrinologists, and female pelvic medicine and reconstructive surgeons. We included both open hysterectomies and those performed by minimally invasive surgery, which included vaginal hysterectomies. Perioperative complications were defined using the Agency for Healthcare Research and Quality patient safety indicators. Surgeon hysterectomy volume during the 2-year study period was analyzed (0-5 cases annually = very low, 6-10 = low, 11-20 = medium, and ≥21 = high). We utilized logistic regression and negative binomial regression to identify patient, surgeon, and hospital characteristics associated with minimally invasive surgery utilization and perioperative complications, respectively. RESULTS A total of 5660 hospitalizations were identified during the study period. Most patients (61.5%) had an open hysterectomy; 38.5% underwent a minimally invasive surgery procedure (25.1% robotic, 46.6% laparoscopic, 28.3% vaginal). Most surgeons (68.2%) were very low- or low-volume surgeons. Factors associated with a lower likelihood of undergoing minimally invasive surgery included older patient age (reference 45-64 years; 20-44 years: adjusted odds ratio, 1.16; 95% confidence interval, 1.05-1.28), black race (reference white; adjusted odds ratio, 0.70; 95% confidence interval, 0.63-0.78), Hispanic ethnicity (adjusted odds ratio, 0.62; 95% confidence interval, 0.48-0.80), smaller hospital (reference large; small: adjusted odds ratio, 0.26; 95% confidence interval, 0.15-0.45; medium: adjusted odds ratio, 0.87; 95% confidence interval, 0.79-0.96), medium hospital hysterectomy volume (reference ≥200 hysterectomies; 100-200: adjusted odds ratio, 0.78; 95% confidence interval, 0.71-0.87), and medium vs high surgeon volume (reference high; medium: adjusted odds ratio, 0.87; 95% confidence interval, 0.78-0.97). Complications occurred in 25.8% of open and 8.2% of minimally invasive hysterectomies (P < .0001). Minimally invasive hysterectomy (adjusted odds ratio, 0.22; 95% confidence interval, 0.17-0.27) and large hysterectomy volume hospitals (reference ≥200 hysterectomies; 1-100: adjusted odds ratio, 2.26; 95% confidence interval, 1.60-3.20; 101-200: adjusted odds ratio, 1.63; 95% confidence interval, 1.23-2.16) were associated with fewer complications, while patient payer, including Medicare (reference private; adjusted odds ratio, 1.86; 95% confidence interval, 1.33-2.61), Medicaid (adjusted odds ratio, 1.63; 95% confidence interval, 1.30-2.04), and self-pay status (adjusted odds ratio, 2.41; 95% confidence interval, 1.40-4.12), and very-low and low surgeon hysterectomy volume (reference ≥21 cases; 1-5 cases: adjusted odds ratio, 1.73; 95% confidence interval, 1.22-2.47; 6-10 cases: adjusted odds ratio, 1.60; 95% confidence interval, 1.11-2.23) were associated with perioperative complications. CONCLUSION Use of minimally invasive hysterectomy for benign indications remains variable, with most patients undergoing open, more morbid procedures. Older and black patients and smaller hospitals are associated with open hysterectomy. Patient race and payer status, hysterectomy approach, and surgeon volume were associated with perioperative complications. Hysterectomies performed for benign indications by high-volume surgeons or by minimally invasive techniques may represent an opportunity to reduce preventable harm.
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Affiliation(s)
- Ambar Mehta
- Johns Hopkins School of Medicine, Baltimore, MD
| | - Tim Xu
- Johns Hopkins School of Medicine, Baltimore, MD
| | - Susan Hutfless
- Department of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, MD
| | - Martin A Makary
- Department of Surgery, Johns Hopkins Medicine, Baltimore, MD
| | - Abdulrahman K Sinno
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, MD
| | - Edward J Tanner
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, MD
| | - Rebecca L Stone
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, MD
| | - Karen Wang
- Division of Gynecologic Specialties, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, MD
| | - Amanda N Fader
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, MD.
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Teoh D, Halloway RN, Heim J, Vogel RI, Rivard C. Evaluation of the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator in Gynecologic Oncology Patients Undergoing Minimally Invasive Surgery. J Minim Invasive Gynecol 2017; 24:48-54. [PMID: 27789387 PMCID: PMC6614862 DOI: 10.1016/j.jmig.2016.10.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/14/2016] [Accepted: 10/14/2016] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE To evaluate the ability of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator to predict discharge to postacute care and perioperative complications in gynecologic oncology patients undergoing minimally invasive surgery (MIS). DESIGN A retrospective chart review (Canadian Task Force classification II-1). SETTING A university hospital. PATIENTS All patients undergoing MIS on the gynecologic oncology service from January 1, 2009, to December 30, 2013. INTERVENTIONS Surgical procedures were reviewed, and appropriate Common Procedural Terminology codes were assigned. Twenty-one preoperative risk factors were abstracted from the chart and entered into the ACS NSQIP surgical risk calculator. The predicted risk of discharge to postacute care and 8 additional postoperative complications were calculated and recorded. Actual postoperative complications were abstracted from the medical record. The association between the calculated risk and the actual outcome was determined using logistic regression. The ability of the calculator to accurately predict a particular event was assessed using the c-statistic and Brier score. MEASUREMENTS AND MAIN RESULTS Of the 876 patients reviewed, a majority underwent hysterectomy (71.6%), with almost half of those patients undergoing additional cancer staging procedures (34.8%). Although the calculator was a poor predictor of postoperative complications, it was a strong predictor for discharge to postacute care (c-statistic = 0.91, Brier score = 0.02) with an odds ratio of 2.31 (95% confidence interval, 1.65-3.25; p < .0001). CONCLUSION The ACS NSQIP surgical risk calculator does not accurately predict postoperative complications or length of stay in gynecologic oncology patients undergoing MIS. Although it was a strong predictor of need for discharge to postacute care, it vastly overestimated the number of patients requiring this service. Therefore, the calculator's risk score for discharge to postacute care may be considered during preoperative counseling but should not be a predictor of whether or not the patient should proceed with surgery.
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Affiliation(s)
- Deanna Teoh
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, Minnesota.
| | | | - Jennifer Heim
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, Minnesota
| | - Rachel Isaksson Vogel
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, Minnesota; Biostatistics and Bioinformatics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Colleen Rivard
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, Minnesota
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Readmission and Reoperation After Surgery for Pelvic Organ Prolapse. Female Pelvic Med Reconstr Surg 2017; 23:131-135. [DOI: 10.1097/spv.0000000000000379] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Wilbur MB, Mannschreck DB, Angarita AM, Matsuno RK, Tanner EJ, Stone RL, Levinson KL, Temkin SM, Makary MA, Leung CA, Deutschendorf A, Pronovost PJ, Brown A, Fader AN. Unplanned 30-day hospital readmission as a quality measure in gynecologic oncology. Gynecol Oncol 2016; 143:604-610. [DOI: 10.1016/j.ygyno.2016.09.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 09/18/2016] [Accepted: 09/19/2016] [Indexed: 10/21/2022]
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Harris JA, Uppal S, Kamdar N, Swenson CW, Campbell D, Morgan DM. A retrospective cohort study of hemostatic agent use during hysterectomy and risk of post-operative complications. Int J Gynaecol Obstet 2016; 136:232-237. [PMID: 28099744 DOI: 10.1002/ijgo.12037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 09/07/2016] [Accepted: 11/03/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine if the use of intraoperative hemostatic agents was a risk factor for post-operative adverse events within 30 days of patients undergoing hysterectomy. METHOD A population-based retrospective cohort study included data from patients undergoing hysterectomy for any indication between January 1, 2013, and December 31, 2014, at 52 hospitals in Michigan, USA. Any individuals with missing covariate data were excluded, and multivariable logistic regression and propensity score-matching were used to estimate the rate of post-operative adverse events associated with intra-operative hemostatic agents independent of demographic and surgical factors. RESULTS There were 17 960 surgical procedures included in the analysis, with 4659 (25.9%) that included the use of hemostatic agents. Hemostatic agent use was associated with an increase in predicted hospital re-admissions (P=0.007). Among all hysterectomy approaches, and after adjusting for demographic and surgical factors, hemostatic agent use during robotic-assisted laparoscopic hysterectomy was associated with an increased predicted rate of blood transfusions (P=0.019), an increased predicted rate of pelvic abscess diagnoses (P=0.001), an increased predicted rate of hospital re-admission (P=0.001), and an increased predicted rate of re-operation (P=0.021). CONCLUSION Hemostatic agents should be used carefully owing to associations with increased post-operative re-admissions and re-operations when used during hysterectomy.
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Affiliation(s)
- John A Harris
- Division of Women's Health, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Shitanshu Uppal
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Neil Kamdar
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Carolyn W Swenson
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Darrell Campbell
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Daniel M Morgan
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
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Lee MS, Venkatesh KK, Growdon WB, Ecker JL, York-Best CM. Predictors of 30-day readmission following hysterectomy for benign and malignant indications at a tertiary care academic medical center. Am J Obstet Gynecol 2016; 214:607.e1-607.e12. [PMID: 26704895 DOI: 10.1016/j.ajog.2015.11.037] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 11/25/2015] [Accepted: 11/30/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hospital readmissions are costly, frequent, and increasingly under public scrutiny. With increased financial constraints on the medical environment, understanding the drivers of unscheduled readmissions following gynecologic surgery will become increasingly important to value-driven care. OBJECTIVE The current study was conducted to identify risk factors for 30-day readmission following hysterectomy for benign and malignant indications. STUDY DESIGN A retrospective cohort study was conducted from 2008 through 2010 of all nongravid hysterectomies at a single tertiary care academic medical center. Clinical, perioperative, and physician characteristics were collected. Multivariable logistic regression models were used to identify predictors of 30-day readmission, stratified by malignant and benign indications for hysterectomy. RESULTS Among 1649 women who underwent a hysterectomy (1009 for benign indications and 640 for malignancy), 6% were subsequently readmitted within 30 days (8.9% for malignancy vs 4.2% for benign; P < .0001). The mean time to readmission was 13 days (15 days for malignancy vs 10 days for benign; P = .004). The most common reasons for readmission were gastrointestinal (38%) and infectious (34%) etiologies, and 11.6% of readmitted patients experienced a perioperative complication. Among women undergoing hysterectomy for benign indications, a history of a laparotomy, including cesarean delivery (adjusted odds ratio [AOR], 2.12; 95% confidence interval [CI], 1.06-4.25; P = .03), as well as a perioperative complication (AOR, 2.41; 95% CI, 1.00-6.04; P = .05) were both associated with a >2-fold increased odds of readmission. Among women undergoing hysterectomy for malignancy, an American Society of Anesthesiologists Physical Status Classification of III or IV (AOR, 1.92; 95% CI, 1.05-3.50; P = .03), a longer length of initial hospitalization (3 days AOR, 7.83; 95% CI, 1.33-45.99; P = .02), and an estimated blood loss >500 mL (AOR, 3.29; 95% CI, 1.28-8.45; P = .01) were associated with a higher odds of readmission; however, women who underwent a laparoscopic hysterectomy (AOR, 0.32; 95% CI, 0.12-0.86; P = .02) and who were discharged on postoperative day 1 (AOR, 0.16; 95% CI, 0.03-0.82; P = .02) were at a decreased risk of readmission. Physician and operative characteristics were not significant predictors of readmission. CONCLUSION This study found that malignancy, perioperative complications, and prior open abdominal surgery, including cesarean delivery, are significant risk factors for consequent 30-day readmission following index hysterectomy. It may be possible to identify patients at highest risk for readmission at the time of hysterectomy, which can assist in developing interventions to reduce such events.
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Affiliation(s)
- Malinda S Lee
- Brigham and Women's Hospital/Massachusetts General Hospital Integrated Residency Program in Obstetrics and Gynecology, Boston, MA; Harvard Medical School, Boston, MA
| | - Kartik K Venkatesh
- Brigham and Women's Hospital/Massachusetts General Hospital Integrated Residency Program in Obstetrics and Gynecology, Boston, MA; Harvard Medical School, Boston, MA
| | - Whitfield B Growdon
- Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Jeffrey L Ecker
- Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Carey M York-Best
- Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.
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Uppal S, Penn C, del Carmen MG, Rauh-Hain JA, Reynolds RK, Rice LW. Readmissions after major gynecologic oncology surgery. Gynecol Oncol 2016; 141:287-292. [DOI: 10.1016/j.ygyno.2016.02.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 02/18/2016] [Accepted: 02/22/2016] [Indexed: 10/22/2022]
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Patankar S, Burke WM, Hou JY, Tergas AI, Huang Y, Ananth CV, Neugut AI, Hershman DL, Wright JD. Risk stratification and outcomes of women undergoing surgery for ovarian cancer. Gynecol Oncol 2015; 138:62-9. [PMID: 25976399 PMCID: PMC4469531 DOI: 10.1016/j.ygyno.2015.04.037] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 04/29/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Cytoreduction for ovarian cancer is associated with substantial morbidity. We examined the outcome of patients undergoing surgery for ovarian cancer to determine if there are sub-groups of patients who may benefit from alternative treatments. METHODS The National Surgical Quality Improvement Program database was used to identify women who underwent surgery for ovarian cancer from 2005-2012. Multivariable logistic regression models were used to examine the effect of age, race, functional status, ASA class, preoperative albumin and performance of extended cytoreductive procedures on morbidity, mortality and resource utilization. RESULTS A total of 2870 women were identified. The perioperative complication rate increased from 9.5% in women <50years, to 13.4% in those age 60-69years, and 14.6% in women ≥70years (P<0.0001). Similarly, complications rose from 7.3% in those who did not require any extended procedures to 12.9% after 1 procedure, 28.4% for those who had 2, and 30.0% in women who underwent ≥3 extended procedures (P<0.0001). In a series of multivariable models, the number of extended cytoreductive procedures performed and preoperative albumin were the factors most consistently associated with morbidity. Using a series of model fit statistics, compared to chance alone, the ability to predict any complication increased by 27.4% when procedure score was analyzed, 22.0% with preoperative albumin, 11% with age, and 4% with functional status. CONCLUSIONS While preoperative clinical and demographic factors may help predict the risk of adverse outcomes for women undergoing surgery for ovarian cancer, performance of extended cytoreductive procedures is the strongest risk factor for complications.
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Affiliation(s)
- Sonali Patankar
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA
| | - William M Burke
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, USA; New York Presbyterian Hospital, USA
| | - June Y Hou
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, USA; New York Presbyterian Hospital, USA
| | - Ana I Tergas
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, USA; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, USA; New York Presbyterian Hospital, USA
| | - Yongmei Huang
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA
| | - Cande V Ananth
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, USA
| | - Alfred I Neugut
- Department of Medicine, Columbia University College of Physicians and Surgeons, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, USA; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, USA; New York Presbyterian Hospital, USA
| | - Dawn L Hershman
- Department of Medicine, Columbia University College of Physicians and Surgeons, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, USA; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, USA; New York Presbyterian Hospital, USA
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, USA; New York Presbyterian Hospital, USA.
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