Healthcare Resource Utilization Following Minimally Invasive Sacrocolpopexy: Impact of Concomitant Rectopexy.

INTRODUCTION AND HYPOTHESIS: Combined surgical procedures with sacrocolpopexy (SCP) and rectopexy (RP) are more commonly being performed for treatment of multicompartment pelvic organ prolapse. This study aimed to compare healthcare resource utilization (HRU) within 6 weeks following combined surgery (SCP-RP) versus SCP alone (SCP-only). We hypothesized that concomitant RP does not impact HRU. METHODS: A retrospective cohort study of patients who underwent minimally invasive SCP from 2017 to 2022 was conducted at a tertiary referral center. Patients were grouped based on the performance of concomitant RP. HRU was defined as a composite of unscheduled office visits, emergency department visits, and readmissions before the 6-week postoperative visit. HRU was compared in the SCP-RP and SCP-only groups. Multivariable regression analysis was performed to identify factors associated with HRU. RESULTS: There were 144 patients in the SCP-RP group and 405 patients in the SCP-only group. Patient characteristics were similar between the two groups, with the following exceptions: the SCP-RP group was older, more likely to have comorbid conditions, and live >60 miles from the hospital. Of the 549 patients, 183 (33.3%) had ≥1 HRU encounter within 6 weeks after surgery. However, there was no difference between the SCP-RP and SCP-only groups in composite HRU (34.0% vs 33.1%, p = 0.84). The most common reasons for HRU were pain, urinary tract infection symptoms, and wound issues. Concomitant mid-urethral sling was associated with a two-fold increased risk of HRU after surgery. CONCLUSIONS: One in 3 patients undergoing minimally invasive SCP had at least one unanticipated encounter within 6 weeks after surgery. Concomitant RP was not associated with increased postoperative HRU.

Characteristics of Female Sexual Health Programs and Providers in the United States.

BACKGROUND: Female sexual dysfunction is a prevalent condition affecting 12% of women, yet few academic centers in the US have female sexual medicine programs. AIM: To characterize female sexual health programs in the United States, services offered, and training of female sexual health providers. METHODS: We performed an internet search to identify female sexual health programs and clinics in the US. From each programs' website we abstracted the location, clinic setting (academic vs private), training of providers, and whether the clinic provided investigational services (ie, PRP injections, laser/radiofrequency therapy). We categorized clinics as specialized in sexual medicine, specialized with a focus on cancer patients, general, aesthetics-focused, general & aesthetic, or specialized & aesthetic. We used Chi-square and Fisher's exact test to evaluate association between practice setting and provision of investigational therapies with a Bonferroni-adjusted critical P-value of 0.017. OUTCOMES: Our outcomes were the number of clinics in each setting, in each category, and each state, as well as the number of providers by training type. RESULTS: We identified 235 female sexual medicine programs in the United States. Seventeen percent were in the academic setting. Clinics in the non-academic setting were significantly (α = 0.017) more likely to offer PRP injections (0% vs 47%, P < .001), laser/radiofrequency therapy (14% vs 56%, P < .0001), and shockwave therapy (0% vs 14%, P = .011). Among all clinics, 22% provided specialized care, 2% provided care for cancer patients, 29% were more general clinics that advertised female sexual healthcare, 23% were aesthetics-focused, 22% were general practices that provided aesthetics services, and 2% were specialized clinics that offered aesthetics services. 81% of aesthetics-focused clinics advertised PRP injections. Seven states had no clinics and 26 states lacked a clinic specializing in female sexual health. The most frequent providers were OB/Gyns (40%), nurse practitioners (22%), urologists (13%), and physicians assistants (10%). CLINICAL IMPLICATIONS: The geographic distribution of clinics and pervasiveness of clinics offering investigational services for female sexual dysfunction may be a barrier for patients seeking care. LIMITATIONS: As a result of our internet search methodology, we likely did not capture all clinics providing female sexual health services. Further, the accuracy of our data depends on the level of detail provided on each clinics' website. CONCLUSION: Online search identified few clinics providing female sexual healthcare in academic medicine: development of such clinics could benefit patients by improving access to evidence-based care and promoting training of future providers. Elizabeth E. Stanley and Rachel J. Pope, Characteristics of Female Sexual Health Programs and Providers in the United States. Sex Med 2022;10:100524.

Societal Cost of Opioid Use in Symptomatic Knee Osteoarthritis Patients in the United States.

OBJECTIVE: Symptomatic knee osteoarthritis (SKOA) is a chronic, disabling condition, requiring long-term pain management; over 800,000 SKOA patients in the US use opioids on a prolonged basis. We aimed to characterize the societal economic burden of opioid use in this population. METHODS: We used the Osteoarthritis Policy Model, a validated computer simulation of SKOA, to estimate the opioid-related lifetime and annual cost generated by the US SKOA population. We included direct medical, lost productivity, criminal justice, and diversion costs. We modeled the SKOA cohort with a mean ± SD age of 54 ± 14 years and Western Ontario and McMaster Universities Osteoarthritis Index pain score of 29 ± 17 (0-100, 100 = worst). We estimated annual costs of strong ($1,381) and weak ($671) opioid regimens using Medicare fee schedules, Red Book, the Federal Supply Schedule, and published literature. The annual lost productivity and criminal justice costs of opioid use disorder (OUD), obtained from published literature, were $11,387 and $4,264, per-person, respectively. The 2015-2016 Medicare Current Beneficiary Survey provided OUD prevalence. We conducted sensitivity analyses to examine the robustness of our estimates to uncertainty in input parameters. RESULTS: Assuming 5.1% prevalence of prolonged strong opioid use, the total lifetime opioid-related cost generated by the US SKOA population was estimated at $14.0 billion, of which only $7.45 billion (53%) were direct medical costs. CONCLUSION: Lost productivity, diversion, and criminal justice costs comprise approximately half of opioid-related costs generated by the US SKOA population. Reducing prolonged opioid use may lead to a meaningful reduction in societal costs that can be used for other public health causes.

The Value of Total Knee Replacement in Patients With Knee Osteoarthritis and a Body Mass Index of 40 kg/m2 or Greater : A Cost-Effectiveness Analysis.

BACKGROUND: Total knee replacement (TKR) is an effective and cost-effective strategy for treating end-stage knee osteoarthritis. Greater risk for complications among TKR recipients with a body mass index (BMI) of 40 kg/m2 or greater has raised concerns about the value of TKR in this population. OBJECTIVE: To assess the value of TKR in recipients with a BMI of 40 kg/m2 or greater using a cost-effectiveness analysis. DESIGN: Osteoarthritis Policy Model to assess long-term clinical benefits, costs, and cost-effectiveness of TKR in patients with a BMI of 40 kg/m2 or greater. DATA SOURCES: Total knee replacement parameters from longitudinal studies and published literature, and costs from Medicare Physician Fee Schedules, the Healthcare Cost and Utilization Project, and published data. TARGET POPULATION: Recipients of TKR with a BMI of 40 kg/m2 or greater in the United States. TIME HORIZON: Lifetime. PERSPECTIVE: Health care sector. INTERVENTION: Total knee replacement. OUTCOME MEASURES: Cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs), discounted at 3% annually. RESULTS OF BASE-CASE ANALYSIS: Total knee replacement increased QALYs by 0.71 year and lifetime medical costs by $25 200 among patients aged 50 to 65 years with a BMI of 40 kg/m2 or greater, resulting in an ICER of $35 200. Total knee replacement in patients older than 65 years with a BMI of 40 kg/m2 or greater increased QALYs by 0.39 year and costs by $21 100, resulting in an ICER of $54 100. RESULTS OF SENSITIVITY ANALYSIS: In TKR recipients with a BMI of 40 kg/m2 or greater and diabetes and cardiovascular disease, ICERs were below $75 000 per QALY. Results were most sensitive to complication rates and preoperative pain levels. In the probabilistic sensitivity analysis, at a $55 000-per-QALY willingness-to-pay threshold, TKR had a 100% and 90% likelihood of being a cost-effective strategy for patients aged 50 to 65 years and patients older than 65 years, respectively. LIMITATION: Data are derived from several sources. CONCLUSION: From a cost-effectiveness perspective, TKR offers good value in patients with a BMI of 40 kg/m2 or greater, including those with multiple comorbidities. PRIMARY FUNDING SOURCE: National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health.

Factors associated with use of antibiotic prophylaxis following dental procedures in total joint replacement recipients.

Background: Total joint replacement recipients (TJR) are at risk for prosthetic joint infection (PJI), particularly those with comorbidities such as diabetes mellitus (DM) and rheumatoid arthritis (RA). Methods: We mailed surveys to 1078 subjects undergoing primary TJR between 2011 and 2016 â€‹at an academic center. The survey asked about medical, dental, and orthopedic history and use of antibiotics prior to dental appointments. We generated adjusted relative risks (aRR) for using antibiotic prophylaxis less than always using Poisson regression, adjusting for demographic, clinical, and behavioral factors. Results: We received surveys from 639 subjects; 597 were eligible and formed the analytical sample. 66 â€‹% reported always using antibiotic prophylaxis. DM and RA were not associated with prophylaxis use. Factors associated with less frequent use included: BMI ≥30 (aRR â€‹= â€‹1.27, 95 â€‹% CI [1.01, 1.60]), dental cleanings <2 times/year (aRR â€‹= â€‹1.95, 95 â€‹% CI [1.56, 2.43]), and expressing little concern (compared to neutral) about getting PJI (aRR â€‹= â€‹1.23, 95 â€‹% CI [0.97, 1.55]), though this association was not statistically significant. Greater antibiotic use was reported in subjects who had ≥3 TJRs, (aRR â€‹= â€‹0.48, 95 â€‹% CI [0.29, 0.80]), underwent more invasive dental procedures (aRR â€‹= â€‹0.74, 95 â€‹% CI [0.59, 0.93]), and were concerned (vs. neutral) about PJI (aRR â€‹= â€‹0.53, 95 â€‹%CI [0.33, 0.84]). Conclusions: Two-thirds of TJR recipients in an academic center reported always using antibiotic prophylaxis prior to dental visits. Usage rates varied by demographics, BMI, number of TJRs, type of dental procedure, and behavioral factors -- but not by comorbidities associated with higher PJI risk.

Cost-effectiveness of dental antibiotic prophylaxis in total knee arthroplasty recipients with type II diabetes mellitus.

Objective: Type II diabetes mellitus (T2DM) is prevalent in knee osteoarthritis (OA) patients undergoing total knee arthroplasty (TKA) and increases risk for prosthetic joint infection (PJI). We examined the cost-effectiveness of antibiotic prophylaxis (AP) before dental procedures to reduce PJI in TKA recipients with T2DM. Design: We used the Osteoarthritis Policy Model, a validated computer simulation of knee OA, to compare two strategies among TKA recipients with T2DM (mean age 68 years, mean BMI 35.4 kg/m2): 1) AP before dental procedures and 2) no AP. Outcomes included quality-adjusted life expectancy (QALE) and lifetime medical costs. We used published efficacy of AP. We report incremental cost-effectiveness ratios (ICERs) and considered strategies with ICERs below well-accepted willingness-to-pay (WTP) thresholds cost-effective. We conducted sensitivity analyses to examine the robustness of findings to uncertainty in model input parameters. We used a lifetime horizon and healthcare sector perspective. Results: We found that AP added 1.0 quality-adjusted life-year (QALY) and $66,000 for every 1000 TKA recipients with T2DM, resulting in an ICER of $66,000/QALY. In sensitivity analyses, reduction of the probability of PJI, T2DM-associated risk of infection, or attribution of infections to dental procedures by 50% resulted in ICERs exceeding $100,000/QALY. Probabilistic sensitivity analyses showed that AP was cost-effective in 32% and 58% of scenarios at WTP of $50,000/QALY and $100,000/QALY, respectively. Conclusions: AP prior to dental procedures is cost-effective for TKA recipients with T2DM. However, the cost-effectiveness of AP depends on the risk of PJI and efficacy of AP in this population.