Kemi M. Doll

Surgeon Volume and Outcomes in Benign Hysterectomy

Annual surgeon case volume has been linked to patient outcome in a variety of surgical fields, although limited data focus on gynecologic surgery performed by general gynecologists. Herein we review the literature addressing the associations between intraoperative injury, postoperative morbidity, and resource use among surgeons performing a low vs high volume of hysterectomies. Although study design and populations differ, individual and composite morbidity outcomes consistently favored high-volume surgeons. Given the growing emphasis on competency-based evaluation in surgery, gynecology departments may soon consider volume requirements a component of privileging.

High-grade endometrial cancer: Revisiting the impact of tumor size and location on outcomes

OBJECTIVE Research on tumor size (TS) and intracavitary tumor location in endometrial cancer has focused primarily on low-grade tumors. Data in patients with high-grade histology are limited. Our goal is to determine if TS or lower uterine segment (LUS) involvement, is associated with nodal disease and recurrence in women with high-grade endometrial cancer. METHODS This is an IRB-approved, multi-institutional cohort study of patients with clinically early-stage, high-grade endometrial cancer who underwent comprehensive surgical staging. Records were reviewed for demographic, pathologic, and treatment data. Nodal involvement and recurrence as a function of TS and location were estimated with odds ratios and hazard ratios. RESULTS From 2005 to 2012, 208 patients were identified. Of these, 188 patients had tumor location and 183 had TS reported. There were 75 endometrioid (36.1%), 35 serous (16.8%), 12 clear cell (5.8%), and 26 carcinosarcoma (12.5%) cases, and 60 (28.8%) undifferentiated or mixed histologies. There were 55 recurrences (median follow up 17.2 mo). LUS tumors were associated with pelvic and para-aortic nodal disease (OR 3.83, 95% CI 1.70-8.60, p<0.01, OR 5.13, 95% CI 1.96-13.45, p<0.01). TS ≥ 2 cm was associated with pelvic nodal disease (27.4% vs. 0%, p=0.01; OR 10.00, p=0.01). Neither TS nor LUS location was independently associated with recurrence. CONCLUSIONS In high-grade endometrial cancers, tumor involvement of the LUS and TS>2 cm was associated with pelvic nodal disease, and LUS involvement was also significantly associated with para-aortic nodal disease. There was no association between LUS involvement or TS>2 cm and recurrence.

Preoperative quality of life and surgical outcomes in gynecologic oncology patients: A new predictor of operative risk?

OBJECTIVE Quality of life (QoL) for women with gynecologic malignancies is predictive of chemotherapy related toxicity and overall survival but has not been studied in relation to surgical outcomes and hospital readmissions. Our goal was to evaluate the association between baseline, pre-operative QoL measures and 30-day post-operative morbidity and health resource utilization by gynecologic oncology patients. METHODS We analyzed prospectively collected survey data from an institution-wide cohort study. Patients were enrolled from 8/2012 to 6/2013 and medical record data was abstracted (demographics, comorbid conditions, and operative outcomes). Responses from several validated health-related QoL instruments were collected. Bivariate tests and multivariable linear and logistic regression models were used to evaluate factors associated with QoL scores. RESULTS Of 182 women with suspected gynecologic malignancies, 152 (84%) were surveyed pre-operatively and 148 (81%) underwent surgery. Uterine (94; 63.5%), ovarian (26; 17.5%), cervical (15; 10%), vulvar/vaginal (8; 5.4%), and other (5; 3.4%) cancers were represented. There were 37 (25%) cases of postoperative morbidity (PM), 18 (12%) unplanned ER visits, 9(6%) unplanned clinic visits, and 17 (11.5%) hospital readmissions (HR) within 30days of surgery. On adjusted analysis, lower functional well-being scores resulted in increased odds of PM (OR 1.07, 95%CI 1.01-.1.21) and HR (OR 1.11, 95%CI 1.03-1.19). A subjective global assessment score was also strongly associated with HR (OR 1.89, 95%CI 1.14, 3.16). CONCLUSION Lower pre-operative QoL scores are significantly associated with post-operative morbidity and hospital readmission in gynecologic cancer patients. This relationship may be a novel indicator of operative risk.

Black Lives Matter: Claiming a Space for Evidence-Based Outrage in Obstetrics and Gynecology

The authors reflect on the Black Lives Matter (BLM) social movement in relation to the pregnancy-related deaths of black women in the U.S., and it mentions evidence-based outrage, racial disparities in medical research, and a call for obstetricians and gynecologists to prioritize racial equity in womens health care in America. The use of the phrase BLM in medical literature is examined, along with issues such as family planning for black women, maternal fetal medicine, and infertility.

Outpatient end of life discussions shorten hospital admissions in gynecologic oncology patients

OBJECTIVE The study goal was to determine whether prior outpatient exposure to hospice discussion altered the inpatient course and end-of-life (EOL) care among patients ultimately discharged to hospice. METHODS Medical records from January 2009 to June 2012 were reviewed and data were abstracted under an IRB-approved protocol. Hospice discussions were identified in the last outpatient clinical encounter prior to admission. Kaplan-Meier was used to estimate overall survival (OS) and the log-rank test was used to test for differences. RESULTS There were 89 hospitalizations resulting in discharge to hospice care: 41 women with ovarian (46%), 23 with uterine (29%), 19 with cervical (21.3%), and with 6 vulvar/vaginal (6.7%) cancers. 83 patients (93%) had outpatient clinical encounters prior to admission;18% (15/83) were exposed to a hospice discussion (HD) and 82% (68/83) were not (NHD). Median time from last outpatient encounter was 18 days (range 0-371). NHD patients had longer inpatient length of stay (median 7 days vs. 4 days, p=0.008) and were less likely to receive palliative care consults than the HD patients (65% vs. 93%, p=0.03). Median OS for HD patients was 33 days (95% CI 22d-61 d) vs. 60 days (95% CI 49 d-84 d) for NHD patients (p=0.01). There were no differences detected based on race, ethnicity, or insurance status. CONCLUSIONS HD patients had significantly shorter OS suggesting that providers were accurate in identifying patients nearing the EOL. Patients exposed to outpatient hospice discussions had a shorter length of stay and increased utilization of palliative care resources.

Trends in Inpatient and Outpatient Hysterectomy and Oophorectomy Rates Among Commercially Insured Women in the United States, 2000-2014.

Trends in Inpatient and Outpatient Hysterectomy and Oophorectomy Rates Among Commercially Insured Women in the United States, 2000-2014 A hysterectomy is the second most common surgical procedure among women in the United States, with approximately 600 000 performed annually for benign gynecologic conditions.1 Trends in hysterectomy rates are an important marker for innovation and quality in gynecology as treatment alternatives increase and as evidence of the underuse of these treatment alternatives emerges.2 The accurate identification of a hysterectomy requires capturing data from both inpatient and outpatient services, given the shifting setting of care over recent years. Yet, the highest-quality national trend estimates have been significantly limited by the exclusion of data on outpatient procedures due to the use of databases restricted to inpatient settings.3,4 Prior studies that included inpatient and outpatient settings have focused on small geographic areas only, limiting their generalizability.5 The lack of national outpatient data is a critical gap because the rapid dissemination of robotic surgery has likely shifted the proportion of hysterectomies that are performed in outpatient settings. The same shifting pattern may also be true for an oophorectomy, another common procedure among US women. As with hysterectomy rates, the ability to analyze trends in oophorectomy rates is limited by the use of data restricted to inpatient settings.

Obesity is associated with worse quality of life in women with gynecologic malignancies: An opportunity to improve patient‐centered outcomes

The objective of the current study was to evaluate the effect of obesity on pretreatment quality of life (QoL) in gynecologic oncology patients.

Cost-Effectiveness of Laparoscopic Hysterectomy With Morcellation Compared With Abdominal Hysterectomy for Presumed Myomas.

STUDY OBJECTIVE Hysterectomy for presumed leiomyomata is 1 of the most common surgical procedures performed in nonpregnant women in the United States. Laparoscopic hysterectomy (LH) with morcellation is an appealing alternative to abdominal hysterectomy (AH) but may result in dissemination of malignant cells and worse outcomes in the setting of an occult leiomyosarcoma (LMS). We sought to evaluate the cost-effectiveness of LH versus AH. DESIGN Decision-analytic model of 100 000 women in the United States assessing the incremental cost-effectiveness ratio (ICER) in dollars per quality-adjusted life-year (QALY) gained (Canadian Task Force classification III). SETTING U.S. hospitals. PATIENTS Adult premenopausal women undergoing LH or AH for presumed benign leiomyomata. INTERVENTIONS We developed a decision-analytic model from a provider perspective across 5 years, comparing the cost-effectiveness of LH to AH in terms of dollar (2014 US dollars) per QALY gained. The model included average total direct medical costs and utilities associated with the procedures, complications, and clinical outcomes. Baseline estimates and ranges for cost and probability data were drawn from the existing literature. MEASUREMENTS AND MAIN RESULTS Estimated overall deaths were lower in LH versus AH (98 vs 103). Death due to LMS was more common in LH versus AH (86 vs 71). Base-case assumptions estimated that average per person costs were lower in LH versus AH, with a savings of

The role of surgery in the management of gestational trophoblastic neoplasia.

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The health-related quality of life journey of gynecologic oncology surgical patients: Implications for the incorporation of patient-reported outcomes into surgical quality metrics

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