Robert C. Reiter

EVIDENCE-BASED MANAGEMENT OF CHRONIC PELVIC PAIN

Diagnosis and management of chronic pelvic pain are greatly facilitated by a multidisciplinary approach integrating medical intervention with identification and management of socioenvironmental problems, cognitive-behavioral pain strategies, and treatment of concurrent psychological morbidity. Available evidence suggests that outcomes, including pain severity, general health and functional status, and disability are more significantly improved after this approach than after isolated medical or surgical interventions. Because of the chronic nature of many of the underlying psychological and social factors predisposing to chronic symptom formation and maintenance, care of the patient with chronic pelvic pain must be continuous and longitudinal if recurrent adverse sequelae, including disability, inappropriate healthcare utilization, and recurrent depression, are to be prevented.

The impact of a quality assurance process on the frequency and confirmation rate of hysterectomy

A criteria-based quality assurance process for hysterectomy was instituted at a large teaching hospital. After this process was initiated, the overall frequency of hysterectomy decreased by 24%, p less than 0.001. Significant reductions were seen in hysterectomy rates for the following indications: chronic pelvic pain (77%, p less than 0.0001), recurrent uterine bleeding (46%, p less than 0.001), preinvasive disease of the uterus (55%, p less than 0.005), and severe infection (70%, p less than 0.025). Adenomyosis was the single indication for which an increase in hysterectomy rate was observed. This increase, however, was completely reversed during the last 2 years of the study. This quality assurance process also resulted in a significant increase in the histologic verification rate (i.e., 82% vs 93%, p less than 0.001). These observations suggest that using such a criteria-based process can reduce the number of hysterectomies performed and improve the accuracy of the preoperative diagnosis.

Outcomes of hospital-based managed care: A multivariate analysis of cost and quality**

Objective To determine the effects a hospital-based managed care intervention has on the cost and quality of care. Methods The intervention consisted of a CareMap and a nurse case manager. The CareMap contained both a critical path and a set of expected patient outcomes. The study population comprised all women who delivered by cesarean during the 18 months of the study and who were cared for in the maternity unit at a tertiary-level university hospital. The effects of the intervention were determined by comparing the after group with the before group in regard to length of stay and costs of care post-cesarean delivery, patient ratings of quality of care, and the physical recovery of the patients by discharge and 1 month later. Results After the implementation of hospital-based managed care, the average length of stay decreased 13.5% (0.7 days) and the average costs decreased 13.1% (

Quality assurance indicators and short-term outcome of hysterectomy

518). These decreases were statistically significant and remained so after controlling for co-morbid and complicating conditions. Patients perception of the quality of care increased from 4.26 to 4.41 on a 1–5 scale, a statistically significant increase. In particular, patients believed that they had an increased level of participation in their care. The physical recovery scores obtained at discharge did not change. Conclusion Hospital-based managed care can reduce resource use, length of stay, and cost associated with hospital care while maintaining or improving the quality of care. Whether these effects are reproducible and generalizable to other conditions should be addressed in future studies; the duration of these effects should also be examined.

Nonsurgical management of chronic pelvic pain: a multidisciplinary approach.

ACOG gynecologic indicators were highly accurate for identifying significant morbidity in hysterectomy patients but were less predictive with regard to the appropriateness of care

Psychogenic chronic pelvic pain: diagnosis and management

Experience with multidisciplinary management of CPP has demonstrated the importance of ruling out and of treating nongynecologic conditions such as myofascial syndrome, irritable bowel syndrome, urethral syndrome, and psychogenic pain in women with CPP and normal laparoscopies. Moreover, current data suggest that availability of a multidisciplinary pelvic pain clinic can reduce the frequency of hysterectomy for this disorder.

Validation of hysterectomy indications and the quality assurance process

By the time that the pelvalgia patient seeks treatment, her chronic tension, anxiety, stress, and related somatic symptoms, which usually have moderated her fear of repeat assault or punishment by the aggressor-parent, has begun to disintegrate. The patient usually has little or no insight into the fact that her feelings of being trapped, helpless, and victimized in her marriage, job, or other interpersonal relationships can be symbols of the original sexual trauma. The depressed patient may be unaware that suicidal thoughts and actions, if present, are a reflection of her sense of helplessness, hopelessness, and victimization. Hence, CPP may be a symptom of a wide spectrum of disorders, both organic and psychological. While the patient is undergoing evaluation of pelvic pain, it is essential that clinicians remain aware that the patients psychogenic symptoms are an attempt to reinforce a faltering ego. Additionally, it is important that they recognize that previous attempts at diagnosis and therapy of CPP and other somatic complaints usually have reinforced the belief that the symptoms are physically based and unrelated to any psychological factors. A number of prospective studies currently are underway to characterize further the relationships between complaints of chronic pelvic pain, personality functioning, and history of sexual trauma. Without data on very long-term follow-up, our understanding of the precise psychodevelopmental pathophysiology and long-term prognosis of CPP currently remains incomplete.

MANAGED CARE AND ASSESSMENT OF CLINICAL OUTCOMES

&NA; Hysterectomy is one of the most commonly performed major operations in the United States. Despite efforts to explain its high incidence, the perception remains that a significant number of hysterectomies are unjustified. More indications are listed for hysterectomy than for any other major operation. A quality assurance process is presented that requires the surgeon to select preoperatively one designated indication for each hysterectomy performed. The pathology report is expected to verify the surgical indication in 66% of the cases. The other 34% of hysterectomy specimens are not expected to show tissue pathology based on the listed indication. For these cases, predetermined validation criteria must be satisfied in the surgeons preoperative note. Applying the process in this series of 584 consecutive hysterectomies, 93% (N = 396) of the “pathology expected” indications were verified by the pathology report and 98% (N = 188) of the “no pathology expected” indications were validated by the surgeons preoperative note. The process of using a single designated indication and reviewing only two documents (the pathology report and the surgeons preoperative note) has greatly simplified the quality assurance process. This system enables a quality assurance committee to monitor easily the appropriateness of hysterectomy indications for their institution. Information obtained from this process can influence changes regarding the acceptability of certain indications. As a result of this study, adenomyosis, because of its low (38%) verification rate, is no longer considered a reliable preoperative indication for hysterectomy at San Diego Naval Hospital. (Obstet Gynecol 73: 1045, 1989)

Correlation between sexual abuse and somatization in women with somatic and nonsomatic chronic pelvic pain

While managed care strategies have been associated with reductions in the utilization of clinical resources, their impact on health care outcomes in general, and womens health services, in particular, remains unclear. This review summarizes recent literature regarding the impact of managed care on clinical resource use, outcomes of womens health services, and cost effectiveness of womens health care processes. Implications of these findings for womens health providers, womens health services and policy, and health services research are discussed.