Physician and Hospital-level Variation in Hemostatic Agent Use in Benign Gynecologic Procedures.

STUDY OBJECTIVE: To identify recent nationwide trends in hemostatic agent (HA) use and to explore factors associated with HA use in 3 benign gynecologic surgery contexts: isolated hysterectomy, pelvic organ prolapse repair, and anti-incontinence surgery. DESIGN: Retrospective cohort study. SETTING: Vizient Clinical Database. PATIENTS: Three cohorts of female patients of ≥18 years who underwent benign isolated hysterectomy, pelvic organ prolapse repair, or anti-incontinence procedures were identified between October 2015 and December 2019. INTERVENTIONS: HAs are topically applied procoagulant products used for surgical hemostasis and use during included encounters was determined by charge codes. MEASUREMENTS AND MAIN RESULTS: Subject-, hospital-, and surgeon-level characteristics and costs were captured. Data were initially analyzed in the aggregate and based on procedure category using the chi-square test or independent samples t tests as appropriate. A bootstrap forest model was used to identify the factors most predictive of HA use. In the final cohort of 184 070 encounters, HAs were used most frequently in hysterectomy (20.7%) and least in anti-incontinence surgery (10.9%). The use of HAs increased from 15.6% in quarter 4 2015 to 19.2% in quarter 4 2019 (p <.001). Encounters using HAs cost more than encounters without HAs ($6271.10 vs $4572.00; p <.001). A bootstrap forest model inclusive of all variables found surgeon and hospital identity cumulatively predictive of 84.9% of HA use, 65.5% and 19.4%, respectively. There was significant variation in HA use among individual surgeons, with 59.9% never using HAs. Of those who did use HAs, 72.8% used HAs more frequently than the mean provider HA use rate (19.4%) and 9.2% used HAs in every case he/she performed. CONCLUSION: The significant variation in HA use is driven primarily by physician and hospital identity, suggesting that use of HA in these benign gynecologic surgical contexts may be determined more by physician- and hospital-level factors than patient-level factors.

Clinical utility of radiofrequency energy for female genitourinary dysfunction: past, present, and future.

INTRODUCTION AND HYPOTHESIS: Radiofrequency (RF) energy has been delivered in a variety of methods to the vagina, bladder, and periurethral tissue to improve myriad genitourinary complaints. Currently, practitioners are promoting transvaginal RF treatments with a minimal understanding of the various platforms and data to support or refute their utilization. This review explores how various RF technologies create desired tissue effects, review the published literature reporting outcomes of various treatment regimes, and peer into potential future uses of this technology in urogynecology. METHODS: A comprehensive literature review was performed for articles pertaining to RF energy use in women for genitourinary complaints with regard to stress urinary incontinence (SUI), genitourinary syndrome of menopause (GSM), female sexual dysfunction (FSD), and overactive bladder (OAB). RESULTS: Radiofrequency energy devices heat tissues via direct or micro-needling applications with the goal of stimulating collagen remodeling, neovascularization, and potentially modulation of nerve function. By altering the approach and location of energy application, many new devices have been marketed for treatment of conditions such as SUI, GSM, FSD, and OAB. Available studies demonstrate promising efficacy and favorable safety; however, interpretation of studies is greatly limited by poor study quality and reporting. CONCLUSIONS: Despite a lack of high-quality evidence for efficacy, safety, and durability in the literature, practitioners around the world continue to promote RF technology for a variety of genitourinary complaints. Currently, it appears that RF energy can potentially treat a variety of genitourinary conditions, but more robust data are needed to substantiate evidence-based use.

Topical Hemostatic Agents in Gynecologic Surgery for Benign Indications.

Since a variety of procoagulant products, collectively called hemostatic agents, became available to surgeons in the mid-20th century, their use has increased across multiple specialties, including gynecology. Congruent with past research on the causes of regional variation in the practice of medicine, available evidence suggests that a central predictor for use of these products is physician preference rather than documented clinical necessity. Use of these products adds risks and avoidable cost. This article seeks to highlight specific gynecologic circumstances in which evidence and surgical judgment supports hemostatic agent use and other settings in which use should be reconsidered.