Human Factors Integration in Robotic Surgery

OBJECTIVE

Using the example of robotic-assisted surgery (RAS), we explore the methodological and practical challenges of technology integration in surgery, provide examples of evidence-based improvements, and discuss the importance of systems engineering and clinical human factors research and practice.

BACKGROUND

New operating room technologies offer potential benefits for patients and staff, yet also present challenges for physical, procedural, team, and organizational integration. Historically, RAS implementation has focused on establishing the technical skills of the surgeon on the console, and has not systematically addressed the new skills required for other team members, the use of the workspace, or the organizational changes.

RESULTS

Human factors studies of robotic surgery have demonstrated not just the effects of these hidden complexities on people, teams, processes, and proximal outcomes, but also have been able to analyze and explain in detail why they happen and offer methods to address them. We review studies on workload, communication, workflow, workspace, and coordination in robotic surgery, and then discuss the potential for improvement that these studies suggest within the wider healthcare system.

CONCLUSION

There is a growing need to understand and develop approaches to safety and quality improvement through human-systems integration at the frontline of care.Precis: The introduction of robotic surgery has exposed under-acknowledged complexities of introducing complex technology into operating rooms. We explore the methodological and practical challenges, provide examples of evidence-based improvements, and discuss the implications for systems engineering and clinical human factors research and practice.

Longitudinal study of cognitive decline among women with and without urinary incontinence

BACKGROUND

Cross-sectional and short-term cohort studies have demonstrated an association between urinary incontinence and dementia, as well as lower performance on cognitive testing. The Health and Retirement Study, a longitudinal study of community-dwelling older adults, offers an opportunity to assess the temporal association between these conditions because it included an assessment of incontinence symptoms and biennial assessments of cognitive function.

OBJECTIVE

This study aimed to evaluate if urinary incontinence before the age of 70 years had an effect on changes in cognitive function among women participating in the Health and Retirement Study.

STUDY DESIGN

This secondary analysis included data from female respondents in the Health and Retirement Study aged 58 to 67 years with ≥2 cognitive assessments. Urinary incontinence was defined as any involuntary loss of any urine in the preceding 12 months. A control group without incontinence was reweighted for better comparability using coarsened exact matching for age and comorbidities. Validated methods, including neuropsychological test data, estimated a memory score and dementia probability for each participant biennially. Coprimary outcomes were the changes in memory score and dementia probability. Linear regression models were used to estimate the association of urinary incontinence with change in memory score and dementia probability, adjusting for baseline demographics and comorbidities. A subgroup analysis was performed to assess the effects of urinary incontinence frequency on these outcomes. The infrequent subgroup reported <15 days of leakage per month and the frequent subgroup reported ≥15 days of leakage per month.

RESULTS

Among eligible female respondents, 40.6% reported urinary incontinence between the ages of 58 and 69 years. Baseline memory scores and dementia probability were similar between those with urinary incontinence (n=1706) and controls (n=2507). Memory score declined significantly in both cohorts, indicating poorer memory over time (-0.222 among those with incontinence [95% confidence interval, -0.245 to -0.199] vs -0.207 in controls [95% confidence interval, -0.227 to -0.188]). The decline of memory score was not statistically significantly different between cases and controls (mean difference, -0.015; 95% confidence interval, -0.045 to 0.015). Dementia probability increased significantly in both groups, indicating a greater probability of developing dementia by 0.018 among those with incontinence (95% confidence interval, 0.015-0.020) and by 0.020 among controls (95% confidence interval, 0.017-0.022). The change in dementia probability was not significantly different between groups (mean difference, -0.002; 95% confidence interval, -0.006 to 0.002). Frequent urinary incontinence was reported in 105 of 1706 (6%) of those with urinary incontinence. Memory score declined and dementia probability increased with time (P<.001) in frequent and infrequent urinary incontinence subgroups. There was no dose-response relationship.

CONCLUSION

Measures of cognitive performance declined during approximately 10 years of observation. The changes in performance were not associated with the presence of urinary incontinence in the participants' younger years.

Antibiotic use, best practice statement adherence, and UTI rate for intradetrusor onabotulinumtoxin-A injection for overactive bladder: A multi-institutional collaboration from the SUFU Research Network (SURN)

INTRODUCTION

Onabotulinumtoxin A (BTX-A) is a well-established treatment for overactive bladder (OAB). The American Urological Association (AUA) 2008 Antibiotic Best Practice Statement (BPS) recommended trimethoprim-sulfamethoxazole or fluoroquinolone for cystoscopy with manipulation. The aim of the study was to evaluate concordance with antibiotic best practices at the time of BTX-A injection and urinary tract infection (UTI) rates based on antibiotic regimen.

METHODS

Men and women undergoing first-time BTX-A injection for idiopathic OAB with 100 units in 2016, within the SUFU Research Network (SURN) multi-institutional retrospective database were included. Patients on suppressive antibiotics were excluded. The primary outcome was concordance of periprocedural antibiotic use with the AUA 2008 BPS antimicrobials of choice for "cystoscopy with manipulation." As a secondary outcome we compared the incidence of UTI among women within 30 days after BTX-A administration. Each outcome was further stratified by procedure setting (office vs. operating room; OR).

RESULTS

Of the cohort of 216 subjects (175 women, 41 men) undergoing BTX-A, 24 different periprocedural antibiotic regimens were utilized, and 98 (45%) underwent BTX-A injections in the OR setting while 118 (55%) underwent BTX-A injection in the office. Antibiotics were given to 86% of patients in the OR versus 77% in office, and 8.3% of subjects received BPS concordant antibiotics in the OR versus 82% in office. UTI rates did not vary significantly among the 141 subjects who received antibiotics and had 30-day follow-up (8% BPS-concordant vs. 16% BPS-discordant, CI -2.4% to 19%, p = 0.13). A sensitivity analysis of UTI rates based on procedure setting (office vs. OR) did not demonstrate any difference in UTI rates (p = 0.14).

CONCLUSIONS

This retrospective multi-institutional study demonstrates that antibiotic regimens and adherence to the 2008 AUA BPS were highly variable among providers with lower rates of BPS concordant antibiotic use in the OR setting. UTI rates at 30 days following BTX-A did not vary significantly based on concordance with the BPS or procedure setting.

Does MDMA have treatment potential in sexual dysfunction? A systematic review of outcomes across the female and male sexual response cycles

INTRODUCTION

Sexual health, an integral component of overall well-being, is frequently compromised by common yet underdiagnosed sexual dysfunctions. Traditional interventions encompass pharmaceutical and psychological treatments. Unconventional therapies, like MDMA, offer hope for sexual dysfunction. This review delves into MDMA's effects on sexual responsiveness and its potential role in treating sexual dysfunction.

OBJECTIVES

The purpose of this review is to elucidate effects of MDMA on different domains of the female and male sexual response cycles.

METHODS

We conducted a systematic review on the effects of MDMA on each domain of the female and male sexual response cycles. PubMed, MEDLINE, and EMBASE were queried, and results were screened using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Search terms utilized were "MDMA" or "ecstasy" in combination with "desire," "arousal," "lubrication," "orgasm," "pleasure," "libido," "erection," and "ejaculation." Inclusion criteria for this review were MDMA use by study subjects and sexual outcomes in at least 1 domain of the female and/or male sexual response cycles were described and measured. Randomized controlled trials, cohort studies (both prospective and retrospective), surveys, and literature reviews published between January 2000 and June 2022 were included. Case reports and studies that did not address conditions of interest were excluded from analysis. Duplicated search results were screened out. The remaining studies were then read in full text to ensure they met inclusion and exclusion criteria for analysis.

RESULTS

We identified 181 studies, of which 6 met criteria for assessment of the female sexual response cycle and 8 met criteria for assessment of the male sexual response cycle. Four of 6 studies reported increased sexual desire with MDMA use among women. Arousal and lubrication were improved with MDMA use in 3 of 4 studies, but they were not affected in 1 randomized control study. In men, 7 studies evaluated the effects of MDMA on desire and/or arousal, 5 studies measured impact on erection, 3 on orgasm, and 2 on ejaculation. Sixty percent of interview-based studies reported increased sexual desire in men, while 40% reported mixed or no effect. Two studies reported impairment of erection, 2 reported mixed effects, and 1 reported fear of erection impairment. In both men and women, all studies evaluating orgasm reported delay in achieving orgasm but increased intensity and pleasure if achieved. Primary outcome measures were variable and largely qualitative.

CONCLUSION

Our findings suggest that MDMA generally increases sexual desire and intensifies orgasm when achieved. While producing conflicting evidence on sexual arousal in both sexes, MDMA may impair erectile and ejaculatory function in men.

Twelve Month Outcomes of Pelvic Organ Prolapse Surgery in Patients With Uterovaginal or Posthysterectomy Vaginal Prolapse Enrolled in the Multicenter Pelvic Floor Disorders Registry

OBJECTIVE

The aim of the study was to compare 12-month subjective and objective outcomes between 3 approaches to apical pelvic organ prolapse (POP) surgery in patients presenting with uterovaginal or posthysterectomy vaginal prolapse enrolled in the Pelvic Floor Disorders Registry for Research.

STUDY DESIGN

This was an analysis of a multicenter, prospective registry that collected both patient- and physician-reported data for up to 3 years after conservative (pessary) and surgical treatment for POP. Twelve-month subjective and anatomic outcomes for patients who underwent surgical treatment were extracted from the registry for analysis. Pelvic organ prolapse recurrence was defined as a composite outcome and compared between the 3 apical surgery groups (native tissue repair, sacrocolpopexy, colpocleisis) as well as the 2 reconstructive surgery groups (native tissue repair and sacrocolpopexy).

RESULTS

A total of 1,153 women were enrolled in the registry and 777 (67%) opted for surgical treatment, of whom 641 underwent apical repair and were included in this analysis (404 native tissue repair, 187 sacrocolpopexy, and 50 colpocleisis). The overall incidence of recurrence was as follows: subjective 6.5%, anatomic 4.7%, retreatment 7.2%, and composite 13.6%. The incidence of recurrence was not different between the 3 surgical groups. When baseline patient characteristics were controlled for, composite POP recurrence between the native tissue and sacrocolpopexy groups remained statistically nonsignificant. Concurrent perineorrhaphy with any type of apical POP surgery was associated with a lower risk of recurrence (adjusted odds ratio, 0.43; 95% confidence interval, 0.25-0.74; P = 0.002) and prior hysterectomy was associated with a higher risk (adjusted odds ratio, 1.77, 95% confidence interval, 1.04-3.03; P = 0.036).

CONCLUSION

Pelvic Floor Disorders Registry for Research participants undergoing native tissue apical POP repair, sacrocolpopexy, and colpocleisis surgery had similar rates of POP recurrence 12 months after surgery.

Association of Transgender or Gender Non-Binary Identity on Disease Characteristics and Survival Outcomes in Prostate Cancer

PURPOSE/OBJECTIVE(S)

While it is becoming increasingly common for people to identify as transgender or gender-non-binary, our understanding of the influence of gender identity on disease severity of hormone-sensitive malignancies, including prostate cancer (PC) is limited. The goal of this study is to compare the aggressiveness of disease and survival outcomes between transgender or gender non-binary (TG) and cis-gender (CG) patients with PC.

MATERIALS/METHODS

The cohort included patients diagnosed with PC between 1999 and 2022 within the Veterans Health Administration (VHA) Database. TG patients were identified with an ICD 9 or 10 diagnosis code that occurred prior to PC diagnosis. Treatment information and baseline disease characteristics were ascertained through the VHA electronic health records. Multivariable logistic regressions were performed to estimate the association between TG status and presenting with Gleason > = 8, PSA > 20 ng/mL, and metastatic disease at diagnosis. Covariates in these models included age at diagnosis, race, ethnicity, marital status, and smoking status. Metastases were identified through natural language processing from cancer or radiology documents. Time to metastases was defined as the time from PC diagnosis to metastases, with other causes of death considered as competing risks. The association between TG identity status and metastatic disease was calculated with a Cox regression model. The difference in overall survival was assessed with the Kaplan-Meier method and log-rank test.

RESULTS

The final cohort was composed of 282,264 individuals, 219 (0.08%) of which were identified as TG. TG patients have similar odds of presenting with presenting with Gleason Score ≥8 (Odds Ratio (OR) 1.18, p = 0.31), PSA >20 ng/mL (OR 0.78, p = 0.59), and metastasis at diagnosis (OR 0.47, p = 0.29). There were 34,918 patients who develop metastatic disease at any time, 24 of which were TG. The 10-year cumulative incidence of metastases for TG and CG individuals was 11.5% (95% Confidence Interval (CI): 6.6-16.1%) and 13.9% (CI: 13.7-14.0%), respectively. There was no significant difference between TG status and risk of developing metastases (Hazard Ratio (HR) 0.93, p = 0.71). The 10-year overall survival for TG and CG was 73.4% (CI: 66.5-80.9%) and 65.0% (CI: 64.8-65.2%), respectively. There was no significant difference between TG status and overall survival (Hazard Ratio (HR) 0.83, p = 0.13).

CONCLUSION

TG individuals do not appear to have a difference in disease characteristics at diagnosis or survival compared to CG individuals. Future research should be done to determine the effect of gender affirming treatment on these outcomes. Furthermore, it is unclear if diagnosis codes are accurately identifying TG individuals.

Prostate Cancer Screening Uptake in Transgender Females

PURPOSE/OBJECTIVE(S)

Transgender females (TF) can experience aggressive forms of prostate cancer, but their uptake of prostate-specific antigen (PSA) screening for prostate cancer is not well-known. Although national guidelines recommend PSA screening based on age, they do not specify recommendations based on gender identity. We evaluate and compare factors associated with recent PSA screening between cisgender men (CM) and TF using Behavioral Risk Factor Surveillance System (BRFSS) survey data.

MATERIALS/METHODS

BRFSS 2018-2020 data was queried to identify CM and TF older than 40 who provided responses to BRFSS questions asking time since last PSA test and whether a provider discussed PSA advantages and disadvantages. Rates of recent screening, defined as receiving a PSA test in the last 2 years with no current or past history of prostate cancer, were calculated for CM and TF. Ages were grouped as younger than 55, 55-69, and 70 years and older based on national PSA screening guidelines, and a 1:4 age-matched cohort between CM and TF was created. Weighted multivariable logistic regressions to measure effects of gender identity, sociodemographic variables, and healthcare access on the odds of recent screening and were calculated and presented as odds ratios (ORs) [95% confidence intervals].

RESULTS

The age-matched cohort had 1,252 CM and 313 TF; TF had a lower overall screening rate than CM (24% vs. 42.3%). TF and CM had similar rates of primary care visits within the last year (85% vs. 86%), but TF were less likely to report that a PSA screen was recommended to them by a provider (33% vs. 49%, p<0.001). Even among all patients with this PSA screening recommendation, fewer TF were recently screened than CM (63% vs. 78%, p = 0.002). In a multivariable regression model, TF had lower odds of recent screening (OR = 0.5 [0.32-0.76], p<0.001) when compared to CM. Discussion of PSA advantages with a provider had higher odds (OR = 15 [10.6-21.5], p<0.001) while discussion of PSA disadvantages was not significantly associated with screening (OR = 0.84 [0.6-1.2], p = 0.3). A college education had higher odds of recent screening (OR = 2.66 [1.2-6.3], p = 0.02) than no high school education. In a multivariable regression model of TF patients, TF aged 70 years and older had higher odds of recent screening (OR = 2.8 [1.1-7.1], p = 0.002) than TF aged 55-69, with screening rates of 14%, 21% and 60% for the under 55, 55-69, and 70+ age groups, respectively. Similarly, to the overall cohort, provider-led discussion of PSA advantages had the strongest association with recent screening (OR = 15.4 [6.15-43.1], p < 0.001), followed by being college educated (OR = 5.7 [1.5-24.9], p = 0.01).

CONCLUSION

TF patients were screened with PSA at a lower rate than CM. Discussing PSA screening benefits with a provider had the largest effect on recent screening among TF patients, highlighting the provider's role in screening uptake. Future studies should continue to evaluate the effects of provider perceptions and barriers to healthcare access on PSA screening in TF.

Adverse Event Reporting of Commonly Used Gender-Specific Implantable Medical Devices in the United States

BACKGROUND

Evidence suggests that more women are harmed by implantable medical devices than men. It is unknown whether this difference includes gender-specific devices.

METHODS

In this study, we examine the differences in reported adverse events between 6 female- and 5 male-specific implantable devices from the Manufacturer and User Facility Device Experience (MAUDE) database from 1993 to 2018. Primary endpoints were injury type (life-threatening, disability, death) and the rate of device evaluation by the manufacturer. Proportions of valid entries across these variables were compared using either the Fisher exact test or χ2 test.

RESULTS

Female-specific devices had higher rates of life-threatening outcomes (1.6% versus 0.3%, P < 0.001), disabilities (5.0% versus 4.3%, P < 0.001), and deaths (0.6% versus 0.1%, P < 0.001) compared with the male-specific devices. Of the 8159 devices that were evaluated by the manufacturer, 56% were female specific while 44% were male specific. Female-specific devices were evaluated far less frequently by the manufacturer (4.5% versus 38.2%, P < 0.001).

CONCLUSIONS

Increased adverse events reports for female-specific devices and associated high-grade complications necessitates improved postmarket surveillance.

Female sexual health digital resources: women and health care providers need more options

INTRODUCTION

Female sexual health and female sexual dysfunction (FSD) are usually poorly diagnosed and treated because of the numerous barriers providers and patients face. Internet platforms, such as mobile applications (apps) are potential tools that help overcome these barriers and improve patient access to education and management options for FSD.

OBJECTIVES

The aim of this review was to identify existing applications on female sexual health and evaluate their educational content and services.

METHODS

We searched the internet and Apple App Store using multiple keywords. A panel of physicians specialized in the treatment of FSD reviewed the apps for content quality, the scientific basis of provided information, interactivity, usability, and whether they would recommend it as a reference tool for patients.

RESULTS

Of the 204 apps identified, 17 met the inclusion criteria and were reviewed further. The selected apps were organized into groups based on common themes such as educational (n = 6), emotions and communication (n = 2), relaxation and meditation (n = 4), general sexual health (n = 2), and social and fun (n = 3). All apps from the educational category provided scientific information in collaboration with health experts. When assessed for usability, 1 app received good and 5 received excellent scores based on the System Usability Scale. Most apps (n = 5) provided information on pathology and treatments of orgasmic dysfunction, but only 1 app, created by a physician, provided comprehensive information on all the types of FSD.

CONCLUSION

Digital technology could be an effective way to overcome barriers to accessing information and ultimately care for female sexual health. Our review demonstrated that there is still a need for more accessible educational resources addressing female sexual health and FSD for patients and providers.

Is it time for doctors to Rx vibrators? A systematic review of pelvic floor outcomes

Introduction

Vibrators and similar devices are an underutilized treatment modality in pelvic and sexual medicine, likely because of the limited knowledge on the health benefits of their use.

Objectives

The aim of this study was to review available data regarding the effect of vibrator use on sexual function, pelvic floor function, and chronic unexplained vulvar pain.

Methods

We performed a systematic literature review of PubMed, Embase, and MEDLINE from inception to March 2021 per the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). The search was based on the following keywords: sex toy woman, pelvic vibrator, sexual stimulation vibrator, vaginal vibrator, vibrator pelvic floor, vibrator incontinence, and vulvar pain vibrator. An overall 586 articles were identified. Studies that met inclusion criteria were reviewed: original research, sample of women, vibrator use, and application to the pelvic/genital area. Exclusion criteria included case reports, unrelated content, vibrator not applied to the pelvic/genital area, male participants, or conditions of interest not addressed. A total of 17 original studies met the criteria and were reviewed in depth.

Results

After review of the literature and identification of articles appropriate for the study, there were 8 studies surrounding sexual function, 8 on pelvic floor function (muscle strength/urinary incontinence), and 1 on vulvar pain. Among the identified studies, vibrators were considered an accepted modality to enhance a woman’s sexual experience, improve pelvic floor muscle function, and facilitate treatment of vulvar pain.

Conclusions

Vibrators are not well studied, and given the promising benefits demonstrated in the articles identified, future research efforts should be directed toward investigating their utility. Considering the potential pelvic health benefits of vibrators, their recommendation to women could be included in our pelvic floor disorder treatment armamentarium.

Using Large-scale Social Media Analytics to Understand Patient Perspectives About Urinary Tract Infections: Thematic Analysis

Background

Current qualitative literature about the experiences of women dealing with urinary tract infections (UTIs) is limited to patients recruited from tertiary centers and medical clinics. However, traditional focus groups and interviews may limit what patients share. Using digital ethnography, we analyzed free-range conversations of an online community.

Objective

This study aimed to investigate and characterize the patient perspectives of women dealing with UTIs using digital ethnography.

Methods

A data-mining service was used to identify online posts. A thematic analysis was conducted on a subset of the identified posts. Additionally, a latent Dirichlet allocation (LDA) probabilistic topic modeling method was applied to review the entire data set using a semiautomatic approach. Each identified topic was generated as a discrete distribution over the words in the collection, which can be thought of as a word cloud. We also performed a thematic analysis of the word cloud topic model results.

Results

A total of 83,589 posts by 53,460 users from 859 websites were identified. Our hand-coding inductive analysis yielded the following 7 themes: quality-of-life impact, knowledge acquisition, support of the online community, health care utilization, risk factors and prevention, antibiotic treatment, and alternative therapies. Using the LDA topic model method, 105 themes were identified and consolidated into 9 categories. Of the LDA-derived themes, 25.7% (27/105) were related to online community support, and 22% (23/105) focused on UTI risk factors and prevention strategies.

Conclusions

Our large-scale social media analysis supports the importance and reproducibility of using online data to comprehend women’s UTI experience. This inductive thematic analysis highlights patient behavior, self-empowerment, and online media utilization by women to address their health concerns in a safe, anonymous way.

Addressing misconceptions of flow disruption studies in "Is non-stop always better? Examining assumptions behind the concept of flow disruptions in studies of robot-assisted surgery"

This letter to the editor provides a response to "Is non-stop always better? Examining assumptions behind the concept of flow disruptions in studies of robot-assisted surgery." The authors provide much needed clarification on misconceptions of flow disruption studies. The evolving methodology is not aimed at creating a "non-stop" flow, or optimizing efficiency, but understanding the clinical process from a systems perspective.

Work-system interventions in robotic-assisted surgery: a systematic review exploring the gap between challenges and solutions

BACKGROUND

The introduction of a robot into the surgical suite changes the dynamics of the work-system, creating new opportunities for both success and failure. An extensive amount of research has identified a range of barriers to safety and efficiency in Robotic Assisted Surgery (RAS), such as communication breakdowns, coordination failures, equipment issues, and technological malfunctions. However, there exists very few solutions to these barriers. The purpose of this review was to identify the gap between identified RAS work-system barriers and interventions developed to address those barriers.

METHODS

A search from three databases (PubMed, Web of Science, and Ovid Medline) was conducted for literature discussing system-level interventions for RAS that were published between January 1, 1985 to March 17, 2020. Articles describing interventions for systems-level issues that did not involve technical skills in RAS were eligible for inclusion.

RESULTS

A total of 30 articles were included in the review. Only seven articles (23.33%) implemented and evaluated interventions, while the remaining 23 articles (76.67%) provided suggested interventions for issues in RAS. Major barriers identified included disruptions, ergonomic issues, safety and efficiency, communication, and non-technical skills. Common solutions involved team training, checklist development, and workspace redesign.

CONCLUSION

The review identified a significant gap between issues and solutions in RAS. While it is important to continue identifying how the complexities of RAS affect operating room (OR) and team dynamics, future work will need to address existing issues with interventions that have been tested and evaluated. In particular, improving RAS-associated non-technical skills, task management, and technology management may lead to improved OR dynamics associated with greater efficiency, reduced costs, and better systems-level outcomes.

Robotic sacrocolpopexy: adverse events reported to the FDA over the last decade

INTRODUCTION AND HYPOTHESIS

As surgeons increase the volume of robotic abdominal sacrocolpopexies (rASCs) and become more experienced, a subsequent decrease in the number of adverse events is expected over time. Further, as the leading manufacturer of the operative robot (Intuitive Surgical) improves the technology, adverse events should also decrease. We hypothesized that there has been a decrease in adverse event reporting for rASCs and that serious adverse events are rare.

METHODS

We performed a search of the FDA Manufacturer and User Facility Device Experience (MAUDE) database. All entries with the manufacturer "Intuitive Surgical" were exported from 2007 to 2017. All entries with "sacrocolpopexy" were then isolated and analyzed.

RESULTS

The number of adverse events reported for rASC peaked in 2013 and 2014, at 107 and 124 respectively. In 2015 and 2016, the number dropped to 11 and 7 respectively. There were 334 reported adverse events from 2007 to 2017. Five (1.50%) were categorized as death, 33 (9.88%) as injury, and 296 (88.62%) as malfunction. Analysis of the malfunction reports found that 15 out of 296 (5.07%) were converted to open surgery, 4 out of 296 (1.3%) were converted to laparoscopic surgery, 4 out of 296 (1.3%) cases were aborted, and 6 out of 296 (2.03%) malfunctions resulted in patient injury.

CONCLUSIONS

Although the MAUDE database has its limitations, it does indicate that the number of adverse events reported for rASC peaked in 2013 and 2014 and has decreased annually since then. This may be due to improved proficiency of the surgeon and surgical team, in addition to improvements in the robot. When malfunctions do occur, they infrequently cause serious injury or have an impact on surgical approach.

Differences in Online Consumer Ratings of Health Care Providers Across Medical, Surgical, and Allied Health Specialties: Observational Study of 212,933 Providers

Background

Health care consumers are increasingly using online ratings to select providers, but differences in the distribution of scores across specialties and skew of the data have the potential to mislead consumers about the interpretation of ratings.

Objective

The objective of our study was to determine whether distributions of consumer ratings differ across specialties and to provide specialty-specific data to assist consumers and clinicians in interpreting ratings.

Methods

We sampled 212,933 health care providers rated on the Healthgrades consumer ratings website, representing 29 medical specialties (n=128,678), 15 surgical specialties (n=72,531), and 6 allied health (nonmedical, nonnursing) professions (n=11,724) in the United States. We created boxplots depicting distributions and tested the normality of overall patient satisfaction scores. We then determined the specialty-specific percentile rank for scores across groupings of specialties and individual specialties.

Results

Allied health providers had higher median overall satisfaction scores (4.5, interquartile range [IQR] 4.0-5.0) than physicians in medical specialties (4.0, IQR 3.3-4.5) and surgical specialties (4.2, IQR 3.6-4.6, P<.001). Overall satisfaction scores were highly left skewed (normal between –0.5 and 0.5) for all specialties, but skewness was greatest among allied health providers (–1.23, 95% CI –1.280 to –1.181), followed by surgical (–0.77, 95% CI –0.787 to –0.755) and medical specialties (–0.64, 95% CI –0.648 to –0.628). As a result of the skewness, the percentages of overall satisfaction scores less than 4 were only 23% for allied health, 37% for surgical specialties, and 50% for medical specialties. Percentile ranks for overall satisfaction scores varied across specialties; percentile ranks for scores of 2 (0.7%, 2.9%, 0.8%), 3 (5.8%, 16.6%, 8.1%), 4 (23.0%, 50.3%, 37.3%), and 5 (63.9%, 89.5%, 86.8%) differed for allied health, medical specialties, and surgical specialties, respectively.

Conclusions

Online consumer ratings of health care providers are highly left skewed, fall within narrow ranges, and differ by specialty, which precludes meaningful interpretation by health care consumers. Specialty-specific percentile ranks may help consumers to more meaningfully assess online physician ratings.

Development of a core set of outcome measures for OAB treatment

INTRODUCTION AND HYPOTHESIS

Standardized measures enable the comparison of outcomes across providers and treatments giving valuable information for improving care quality and efficacy. The aim of this project was to define a minimum standard set of outcome measures and case-mix factors for evaluating the care of patients with overactive bladder (OAB).

METHODS

The International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group (WG) of leading clinicians and patients to engage in a structured method for developing a core outcome set. Consensus was determined by a modified Delphi process, and discussions were supported by both literature review and patient input.

RESULTS

The standard set measures outcomes of care for adults seeking treatment for OAB, excluding residents of long-term care facilities. The WG focused on treatment outcomes identified as most important key outcome domains to patients: symptom burden and bother, physical functioning, emotional health, impact of symptoms and treatment on quality of life, and success of treatment. Demographic information and case-mix factors that may affect these outcomes were also included.

CONCLUSIONS

The standardized outcome set for evaluating clinical care is appropriate for use by all health providers caring for patients with OAB, regardless of specialty or geographic location, and provides key data for quality improvement activities and research.

Trends and Reinterventions in the Surgical Management of Stress Urinary Incontinence among Female Medicare Beneficiaries

INTRODUCTION

We compare the use of bulking agents and slings for the treatment of stress urinary incontinence among female Medicare beneficiaries.

METHODS

We analyzed data from a 5% national random sample of Medicare claims from 2000 to 2011. Female beneficiaries who underwent a sling or bulking agent procedure were identified based on CPT-4 and ICD-9 procedure codes. Statistical analysis for categorical data determined differences in the distribution of patient demographics and comorbidities. The 90-day adverse events and reinterventions were compared between treatment groups. Time to event analysis was used to determine freedom from reintervention after therapy.

RESULTS

We identified 21,134 and 3,475 patients treated with sling and bulking procedures, respectively. There was a 29.7% increase in the number of sling procedures and a 59.5% decrease in bulking procedures from 2001 to 2011. Patients treated with bulking agents had higher rates of diabetes, cardiovascular disease, heart failure and renal failure (p <0.01). The 90-day adverse events after both procedures were rare, with the exception of urinary retention, which was increased in women treated with a sling but frequent in both groups (sling 11.3%, bulking agent 8.4%; p <0.01). A smaller proportion of patients who underwent sling surgery had reinterventions (repeat sling 7.4%, bulking agent 38.2%; p <0.01). Overall 53.2% of the patients treated with a sling and 76.3% treated with bulking agents who underwent subsequent procedures were treated with the same procedure at the first intervention.

CONCLUSIONS

Sling and bulking procedures are safe in terms of short-term performance, although the rates of retention were high in both groups. Patients treated with reinterventions tend to repeat the same therapy instead of converting to another procedure.