Scott B. Ransom

Maternal bisphenol-A levels at delivery: a looming problem?

Objective:The objective was to determine whether bisphenol-A (BPA) is found in maternal circulation of pregnant women in the US population and is related to gestational length and birth weight.Method:Circulating levels of BPA were quantified by high performance liquid chromatography-tandem mass spectrometry at delivery in 40 southeastern Michigan mothers and correlated with gestational length and birth weight of offspring.Result:Maternal levels of unconjugated BPA ranged between 0.5 and 22.3 ng ml−1 in southeastern Michigan mothers. There was no correlation between BPA concentrations and gestational length or birth weight of offspring.Conclusion:This is the first study to document measurable levels of BPA in maternal blood of the US population. Long-term follow-up studies of offspring are needed to validate or refute concerns over human fetal exposure to synthetic exogenous steroids.

Assessing Dynamic Breast Cancer Screening Policies

Questions regarding the relative value and frequency of mammography screening for premenopausal women versus postmenopausal women remain open due to the conflicting age-based dynamics of both the disease (increasing incidence, decreasing aggression) and the accuracy of the test results (increasing sensitivity and specificity). To investigate these questions, we formulate a partially observed Markov chain model that captures several of these age-based dynamics not previously considered simultaneously. Using sample-path enumeration, we evaluate a broad range of policies to generate the set of “efficient” policies, as measured by a lifetime breast cancer mortality risk metric and an expected mammogram count, from which a patient may select a policy based on individual circumstance. We demonstrate robustness with respect to small changes in the input data and conclude that, in general, to efficiently achieve a lifetime risk comparable to the current risk among U.S. women, screening should start relatively early in life and continue relatively late in life regardless of the screening interval(s) adopted. The frontier also exhibits interesting patterns with respect to policy type, where policy type is defined by the relationship between the screening interval prescribed in younger years and that prescribed later in life.

Reduced medicolegal risk by compliance with obstetric clinical pathways: a case–control study☆

OBJECTIVE To estimate whether guideline compliance affected medicolegal risk in obstetrics and whether malpractice claims data can provide useful information on guideline noncompliance by focusing on the claims experience of a large health system delivering approximately 12,000 infants annually. METHODS We retrospectively identified 290 delivery-related (diagnosis-related groups 370–374) malpractice claims and 262 control deliveries at the health system during the period from 1988 to 1998. Clinical pathways for vaginal and cesarean delivery implemented in 1998 were used as a “standard of care.” We compared rates of non-compliance with the pathways in the claims and control groups, calculated an odds ratio for increased risk of being sued given departure from the guideline standards, and calculated the elevated risk of litigation introduced by noncompliance. We also compared the frequencies of different types of departures across claims and control groups. RESULTS Claims closely resembled controls on several descriptive measures (mothers age, location of delivery, type of delivery, and complication rates), but noncompliance with the clinical pathway was significantly more common among claims than controls (43.2% versus 11.7%, P < .001; odds ratio = 5.76, 95% confidence interval 3.59, 9.2). In 81 (79.4%) of the claims involving noncompliance with the pathway, the main allegation in the claim related directly to the departure from the pathway. The excess malpractice risk attributable to noncompliance explained approximately one third (104 of 290) of the claims filed (attributable risk = 82.6%). There were no significant differences in the types of deviation from the guidelines across claims and control groups. CONCLUSION In addition to reducing clinical variation and improving clinical quality of care, adherence to clinical pathways might protect clinicians and institutions against malpractice litigation. Malpractice data might also be a useful resource in understanding breakdowns in processes of care.

Synthetic graft placement in the treatment of fascial dehiscence with necrosis and infection.

OBJECTIVE The objective of this study was to describe the use of synthetic grafts in repairing fascial dehiscence complicated by fascial necrosis and infection after obstetric and gynecologic operations. STUDY DESIGN A retrospective review of the operating room records at Hutzel Hospital (Detroit, Mich) was performed to find all cases of fascial dehiscence repaired during a 6-year period between January 1, 1991, and December 31, 1996. Patients with partial or complete disruption of the fascia with evidence of fascial necrosis and infection were included in this study. Demographic information; the initial surgical procedure, including type of incision; suture material; use of synthetic graft and closure technique for repair of dehiscence; postoperative complications, microbiologic results; antibiotic therapy; subsequent operations; length of hospital stay; and late complications were recorded. RESULTS During the study period 52 patients underwent repair of fascial dehiscence; 36 of these had concurrent fascial necrosis and infection, including 4 women with necrotizing fasciitis. Eighteen patients were from the obstetric service and 18 were from the benign or cancer gynecology service. Ninety-one bacterial isolates were recovered from the infected wounds. Extensive fascial resection precluded closure without tension in 18 cases and necessitated synthetic graft placement to prevent evisceration. Graft materials included polypropylene (11 cases) and polyglactin (7 cases). Late complications of graft placement included extrusion of the graft in 3 patients and incisional hernia in 1. CONCLUSIONS Extensive fascial débridement with resection prevents primary closure of wound dehiscence. Synthetic grafts permit primary closure of large fascial defects and can be used with extensive débridement in the presence of infection.

A cost-effectiveness evaluation of preoperative type-and-screen testing for vaginal hysterectomy

OBJECTIVE Our purpose was to evaluate the usefulness and cost-effectiveness of routine preoperative type-and-screen testing before vaginal hysterectomy. STUDY DESIGN A retrospective review of all vaginal hysterectomies performed at Hutzel Hospital between 1988 and 1994 with an emphasis on those that required blood transfusion was done. All vaginal hysterectomies completed at Hutzel Hospital were included in this 6-year time period for all noncancerous indications, including fibroid uterus, endometriosis, menorrhagia, uterine prolapse, pelvic pain, cervical dysplasia, and adenomyosis. RESULTS Among 1063 patients who underwent vaginal hysterectomy, 26 needed a blood transfusion at the time of hospitalization. Medical records of the patients who needed blood transfusions were reviewed to determine the urgency and indication. Ten of the transfusions were given preoperatively because of anemia, 7 were given intraoperatively, and 9 were given postoperatively. The seven intraoperative transfusions were given because of the physicians perception of excessive blood loss; however, none of the patients received an emergency transfusion with extreme urgency. That is, the need for the intraoperative transfusion was not immediate. All patients who received a transfusion could have waited for 20 to 30 minutes for proper type and crossmatching and subsequent transfusion. CONCLUSION In the absence of preoperative indications, routine preoperative type-and-screen testing of blood before vaginal hysterectomy is not cost-effective, does not enhance patient care, and should be eliminated.

The effect of capitated and fee-for-service remuneration on physician decision making in gynecology

Objective To evaluate the variations in physician behavior leeding to performance of gynecologic surgical procedures related to fee-for-service and capitation reimbursement systems. Methods This study compared the physician practice utilization of surgical services for free-for-service and capitated contract reimbursement systems within a gynecology clicnic. Attending gynecologists were reimbursed on a fee-for-service basis for all surgical services performed during a 6-month interval; subsequently, the same physicians were reimbursed on a capitated basis for 6 months and received a fixed payment for the clinical and surgical services provided. Results Three thousand seven hundred eighty consecutive outpatient gynecology visits were evaluated at the university gynecology visits were evaluated at the university gynecology clinic during 1994. We found a 15% overall decrease in the number of surgical procedures that were performed during the capitated reimbursement period compared with the fee-for-service time interval. The procedure most responsible for the reduction of surgical services was elective sterilization by laparoscopy, which underwent a statistically significant decrease (P < .01). Conclusion The remuneration system in our review seemed to affect physician decision making for only the most elective procedures, whereas physicians maintained similar practice patterns for more severe conditions, fee-for-service seems to encourage, whereas capitation seems to discourage, gynecologists, from performing elective procedures.

Pelvic Floor Consequences of Cesarean Delivery on Maternal Request in Women with a Single Birth: A Cost-effectiveness Analysis

BACKGROUND The potential benefit in preventing pelvic floor disorders (PFDs) is a frequently cited reason for requesting or performing cesarean delivery on maternal request (CDMR). However, for primigravid women without medical/obstetric indications, the lifetime cost-effectiveness of CDMR remains unknown, particularly with regard to lifelong pelvic floor consequences. Our objective was to assess the cost-effectiveness of CDMR in comparison to trial of labor (TOL) for primigravid women without medical/obstetric indications with a single childbirth over their lifetime, while explicitly accounting for the management of PFD throughout the lifetime. METHODS We used Monte Carlo simulation of a decision model containing 249 chance events and 101 parameters depicting lifelong maternal and neonatal outcomes in the following domains: actual mode of delivery, emergency hysterectomy, transient maternal morbidity and mortality, perinatal morbidity and mortality, and the lifelong management of PFDs. Parameter estimates were obtained from published literature. The analysis was conducted from a societal perspective. All costs and quality-adjusted life-years (QALYs) were discounted to the present value at childbirth. RESULTS The estimated mean cost and QALYs were

Cost-effectiveness of routine blood type and screen testing before elective laparoscopy.

14,259 (95% confidence interval [CI]

The impact of medical legal risk on obstetrician-gynecologist supply.

8,964-

Cost of Racial Disparity in Preterm Birth: Evidence from Michigan

24,002) and 58.21 (95% CI 57.43-58.67) for CDMR and