Route of hysterectomy influence and teaching hospital status.

OBJECTIVE: The purpose of this study was to evaluate whether teaching hospitals are more likely to perform abdominal (laparotomy) compared with nonabdominal (vaginal, laparoscopic) hysterectomies for benign indications. METHODS: We conducted a retrospective, observational study comparing abdominal and nonabdominal inpatient hysterectomies performed in Illinois between 2000 and 2005 using the COMPdata database. Obvious cancer, prolapse, or indicated-abdominal surgeries (infection and pregnancy-related cases) were excluded. The final analysis included 94,599 cases. Diagnoses and patient demographics were analyzed from the database and hospitals' teaching status, as determined by telephone interviews. The relationship between route of hysterectomy and teaching hospital status was modeled using multivariable logistic regression with a P value cutoff of less than 0.05. RESULTS: Eight-two percent of hysterectomies performed at teaching hospitals were performed abdominally compared with 77% at nonteaching hospitals. After adjusting for age and diagnoses, teaching hospitals were less likely to perform hysterectomy by abdominal approach (odds ratio 0.69, 95% confidence interval 0.49-0.97, P<.035). Clinical variables associated positively with vaginal hysterectomies included primary diagnoses of menstrual disorders, other female genital disorders, and menopausal disorders. Complication rate did not differ by teaching status. Laparoscopic hysterectomy, even after adjustment for confounders, was associated with fewer complications compared with both abdominal and vaginal routes. CONCLUSION: The route of hysterectomy is only minimally influenced by teaching hospital status. These findings are important for clinician-educators responsible for teaching the nation's next generation of gynecologic surgeons. Strategies to overcome presumed physician-level factors are needed to optimize patient outcomes through appropriate use of nonlaparotomy surgery. LEVEL OF EVIDENCE: III.

Obstetric care provider engagement in a perinatal depression screening program.

To investigate obstetric care provider attitudes toward perinatal depression screening and factors associated with variable screening rates. Provider attitudes about depression screening were investigated via structured interviews (open-ended and rating scale questions) and analyzed using qualitative content analysis. Most providers (86%) found screening effective at identifying women at risk for perinatal depression (average rating of 8.7 on 10-point analog scale). However, 95% overestimated their own screening rates and 67% inaccurately thought they achieved universal screening. Providers not directly involved in their office-based screening process demonstrated lower average screening rates (37%) than those who maintained active involvement (59%; p = 0.07). Obstetric care providers support perinatal depression screening in the context of a program that assumes responsibility for processing screens, conducts assessments of at-risk women and provides referrals to mental health professionals. Provider participation in screening and tying screening to routine obstetric outpatient activities such as glucose tolerance testing are associated with higher screening rates.

The utility of maternal depression screening in the third trimester.

OBJECTIVE: The purpose of this study was to estimate the prevalence of maternal depressive risk in patients during the third trimester and to determine whether unique at-risk women are identified when the data are compared with postpartum screening. STUDY DESIGN: As part of a comprehensive program for universal perinatal depression screening and behavioral health referral of at-risk women, patients completed the Edinburgh Postnatal Depression Scale both during pregnancy (24-28 weeks of gestation) and again at 6 weeks after delivery. Based on Edinburgh Postnatal Depression Scale scores of > or =12, the prevalence of antepartum depressive risk and the rates of concordant/discordant risk status with the corresponding postpartum results were calculated. Discordant-risk cases were further analyzed to determine whether obstetric, psychosocial, or demographic variables were associated with changing risk status over time. RESULTS: We screened 1584 women in the third trimester and again after delivery: 7.7% and 6.8% of the women scored in the at-risk range in the antepartum and postpartum time frames, respectively; 88.9% of patients had the same risk status, and 11.1% were discordant before and after delivery. Statistically significant associations were found between premature birth, newborn infant admission to the intensive care nursery, and acquisition of postpartum depressive risk. CONCLUSION: Screening for depression in the third trimester resulted in a comparable prevalence rate of depressive risk identification when compared with the postpartum time frame. Unique women were identified before and after delivery who may have been missed if screening had not been performed twice.

Reducing high-order perineal laceration during operative vaginal delivery.

OBJECTIVE: This study was undertaken to assess the impact of a focused intervention on reducing high-order (third and fourth degree) perineal lacerations during operative vaginal delivery. STUDY DESIGN: The following recommendations for clinical management were promulgated by departmental lectures, distribution of pertinent articles and manuals, training of physicians, and prominent display of an instructional poster: (1) increased utilization of vacuum extraction over forceps delivery; (2) conversion of occiput posterior to anterior positions before delivery; (3) performance of mediolateral episiotomy if episiotomy was deemed necessary; (4) flexion of the fetal head and maintenance of axis traction; (5) early disarticulation of forceps; and (6) reduced maternal effort at expulsion. Peer comparison was encouraged by provision of individual and departmental statistics. Clinical data were extracted from the labor and delivery database and the medical record. RESULTS: One hundred fifteen operative vaginal deliveries occurred in the 3 quarters preceding the intervention, compared with 100 afterward (P = .36). High-order laceration with operative vaginal delivery declined from 41% to 26% (P = .02), coincident with increased use of vacuum (16% vs 29% of operative vaginal deliveries, P = .02); fewer high-order lacerations after episiotomy (63% vs 22%, P = .003); a nonsignificant reduction in performance of episiotomy (30% vs 23%, P = .22); and a nonsignificant increase in mediolateral episiotomy (14% vs 30% of episiotomies, P = .19). CONCLUSION: Introduction of formal practice recommendations and performance review was associated with diminished high-order perineal injury with operative vaginal delivery.

Preoperative surgical case review program in a community-based, academic medical center: a feasibility study.

OBJECTIVE: To assess the feasibility of applying postoperative objective criteria for preoperative evaluation of scheduled gynecologic cases. STUDY DESIGN: A preoperative evaluation program was introduced in which all surgeons were asked to voluntarily submit a 1-page case summary questionnaire for each elective gynecologic surgical procedure. A committee of departmental peers reviewed each submission for appropriateness of indications and completeness of preoperative evaluation. Cases were evaluated against quality assessment criteria sets created by the American College of Obstetricians and Gynecologists. Reviewed summaries were categorized as either meeting criteria, not meeting criteria but appropriate, not meeting criteria or no pertinent criteria available for the procedure planned. RESULTS: In all, 2,005 elective gynecologic surgical procedures were performed by 70 active surgeons during the 1-year study period; 1,166 procedures (58%) were reported. Of 70 surgeons, 57 reported at least 1 procedure, but only 6 were 100% compliant with their surgical submissions. In total, 1,008 procedures (86% of reported cases) met the criteria or were deemed appropriate by committee review. In 166 instances, additional information was requested from and provided by the surgeon before the case could be adjudicated. CONCLUSION: A voluntary program of preoperative surgical case review for scheduled gynecologic procedures appeared feasible but resulted in only modest initial participation.

Universal perinatal depression screening in an Academic Medical Center.

OBJECTIVE: To develop a department-based program to identify and treat women at risk for perinatal depression. METHODS: Private and employed physician groups were engaged to conduct antepartum maternal depression screening using the Edinburgh Postnatal Depression Scale. A comprehensive program was established to ensure that patients identified as being at risk would receive appropriate care. The program 1) developed a network of existing community mental health providers to accommodate screen-positive referrals, 2) created a 24/7 hotline staffed by mental health workers to respond to urgent/emergent patient needs, 3) provided nursing and physician education via a comprehensive curriculum on perinatal depression, and 4) facilitated outpatient depression screening that included a centralized scoring and referral system. RESULTS: A total of 4,322 women completed 4,558 screens during the initial 24 months (June 2003-May 2005). Although initial uptake of the screening program was gradual, all 20 departmental obstetric practices were screening their patients at the end of the first year. Depression screening was accomplished between 28-32 weeks of gestation, and postpartum screening (during the 6-week postpartum visit) was subsequently added. Overall, 11.1% of women screened positive in the antenatal period, and 7.3% screened positive in the postnatal period. Three hundred three women were referred for evaluation and care. CONCLUSION: Department-based, perinatal depression screening was feasible when individual physician practices were not required to develop the infrastructure necessary to respond to at-risk patients. We believe that the provision of clinical safety nets (mental health provider network and the hotline) were essential to the universal acceptance of this program by practitioners. LEVEL OF EVIDENCE: III.

Geographic and temporal analysis of folate-sensitive fetal malformations.

OBJECTIVE: To identify potential geographic and temporal clustering of folate-sensitive fetal malformations as a prelude to a targeted preconception curriculum in folic acid supplementation. METHODS: Our comprehensive prenatal anomaly database was queried to select fetal malformations presumed to be sensitive to preconception folate insufficiency. Evidence of geographic clustering was evaluated by distribution of individual cases using zip codes of maternal residence. Potential temporal clustering of anomalies was sought by tabulating the frequency of each anomaly category during 5 consecutive 2-year intervals between 1992 and 2001. RESULTS: Over a 10-year period, approximately 2000 fetal anomalies were identified, of which 400 (20%) were considered potentially folate sensitive. We found geographic clustering of ventral wall defects as well as obstructive uropathy by zip code analysis. Significant increases in the frequencies of cardiac defects (P <.001) and obstructive uropathy (P <.001) were noted during the epoch of this study. A moderate increase in anomaly frequency was also seen in the diagnostic subcategory of gastroschisis, in which 15 of 27 total gastroschisis cases occurred in 2000-2001. CONCLUSIONS: Geographic clustering and temporal trends in anomaly rates were noted in certain folate-sensitive malformation categories. Identification of specific, high-incidence regions may provide an opportunity for targeted interventions designed to supplement the national folic acid campaign.