A Comparison of In-Person and Telemedicine Triage in Otolaryngology.

INTRODUCTION: The integration of virtual visits has been met with skepticism by many surgical specialties, including otolaryngology, due to the lack of a complete physical exam. Analysis of differences in the workup between patients triaged virtually or in-person is warranted. METHODS: A chart review was performed for a cohort of adults undergoing septoplasty (January 2021-May 2022). Groups (telemedicine, in-person) were compared by 2-sample t-test and chi-square test to determine the difference in the number of preoperative visits and to assess the variation in patients with preoperative laboratory testing, imaging, or referrals. RESULTS: Of 338 patients, initial evaluation was in-person for 225 (66.5%) and via telemedicine for 113 (33.5%). The groups were similar in demographics (mean age 39.1 years for telemedicine vs 38.8 years for in-person, female 28.9% vs male 37.7%, P = 0.088). The telemedicine group had a significantly higher number of preoperative visits (3.03) compared to the in-person group (2.38, P = 0.001). There was no significant difference in patients who underwent preoperative laboratory testing, imaging, or referrals. Patients triaged via telemedicine experienced a shorter time to surgery compared to those triaged in person (434 vs 208, P = 0.003). DISCUSSION: In this cohort, triage by telemedicine allowed otolaryngology patients to have an expedited path to surgery despite having more visits. There is no evidence to suggest that otolaryngologists had an overreliance on diagnostic modalities when triaging by telemedicine. CONCLUSION: Among patients undergoing septoplasty, those initially evaluated by telemedicine were more likely to have more preoperative visits and shorter time to surgery than those evaluated in person. Telemedicine can serve as an effective method for triaging surgical patients without excess diagnostics.

Secondary Surgery Following Lapidus Bunionectomy.

While the Lapidus bunionectomy is a common procedure utilized to address hallux valgus, the incidence of secondary surgery is not well established. Our primary goal was to determine the incidence of revision surgery and hardware removal following the Lapidus bunionectomy in addition to the risk factors associated with each. A retrospective nested case-control study of adult patients who underwent a Lapidus bunionectomy for symptomatic hallux valgus over a 9-year period was performed. The incidence rates and 95% confidence intervals (CI) of secondary surgery in the 3 years following the procedure along with the estimated independent associations and odds ratios between baseline demographic, clinical, and radiographic characteristics were calculated. Of the original cohort of 2540 patients, 127 were identified (5.0%; CI: 4.1%, 5.8%) who underwent revision surgery and 165 (6.5%; CI: 5.5%, 7.5%) who underwent hardware removal following Lapidus bunionectomy. Initially, the hallux valgus angle, intermetatarsal angle, and tibial sesamoid position were risk factors for revision surgery. However, in adjusted analyses for revision surgery, using a screw for third point of fixation emerged as the only independent risk factor (odds ratio [OR] = 3.01; CI: 1.59, 5.69). In adjusted analyses for hardware removal, female sex (OR = 2.33; CI: 1.08, 5.00) and third point of fixation (OR = 2.92; CI: 1.82, 4.69) emerged as independent risk factors. While the overall risks associated with Lapidus bunionectomy are low and the need for revision surgery are low, this study helps to identify specific risk factors for secondary surgery and hardware removal to help in evaluation and discussion with patients.

The Association of Body Mass Index and Early Outcomes Following Orthognathic Surgery.

BACKGROUND: The existing data on the link between body mass index (BMI), operative characteristics, and surgical outcomes across orthognathic surgery are limited. PURPOSE: The purpose was to measure the association between BMI and early postoperative outcomes in orthognathic surgery. STUDY DESIGN, SETTING, AND SAMPLE: This is a retrospective cohort study of patients (n = 118) aged > 14 years undergoing bimaxillary orthognathic surgery between 2015 and 2018 by a single surgeon within the Kaiser Permanente Northern California-integrated healthcare system. Patients undergoing unilateral or additional procedures, history of prior orthognathic surgery, or pre-existing pain conditions were excluded. PREDICTOR VARIABLE: The predictor variable was BMI measured as a continuous (kg/m2) and categorical variable (underweight/normal, overweight, obese). MAIN OUTCOME VARIABLE(S): The primary outcome variables were additional postoperative antibiotics, increased postoperative visits, wound dehiscence, and wound infection. The secondary outcome variables were total operative and anesthesia time. COVARIATES: The demographic covariates included age, sex, and race/ethnicity. The clinical covariates included history of obstructive sleep apnea, Mallampati score, tobacco use, American Society of Anesthesia classification, thyromental distance, history of difficult intubation, and Angle's classification. ANALYSES: Bivariate and multivariate analyses were performed to measure the associations between BMI and the primary and secondary outcomes. Multivariable logistic regression analyses were used to measure associations between BMI and the postoperative outcomes. Statistical significance was defined as P < .05. RESULTS: The study sample was composed of 118 subjects with a mean age of 26.91 years (standard deviation 9.43). Forty-seven percent (n = 55) were male, and the mean BMI was 25.13 (standard deviation 5.19). BMI category was significantly associated with age, with increasing age associated with higher BMI category (P = .02). According to the bivariate and multivariable logistic regression analyses, controlling for age, race/ethnicity, BMI, and total operative time, increased total operative time was associated with additional postoperative antibiotics (odds ratio = 1.03, 95% confidence interval: 1.01, 1.05), and increased postoperative appointments (odds ratio = 1.02, 95% confidence interval: 1.01, 1.04). No significant association between BMI and other clinical or operative characteristics was seen aside from American Society of Anesthesia classification. CONCLUSION AND RELEVANCE: Elevated BMI was not associated with worsened operative characteristics or postoperative outcomes. This supports the suitability of orthognathic surgery in a BMI-diverse population.

Implication of Neighborhood Deprivation Index on Pelvic Organ Prolapse Management.

IMPORTANCE: Differences in the rate of diagnosis of POP have been described based on race and ethnicity; however, there are few data available on the management and treatment patterns of POP based on multiple factors of socioeconomic status and deprivation. OBJECTIVE: The objective of this study was to investigate the association between pelvic organ prolapse (POP) management and the Neighborhood Deprivation Index (NDI), a standardized multidimensional measure of socioeconomic status. METHODS: This retrospective cohort study included female members of a large integrated health care delivery system who were 18 years or older and had ≥4 years of continuous health care membership from January 1, 2015, to December 31, 2019. Demographic, POP diagnosis, urogynecology consultation, and surgical treatment of POP were obtained from the electronic medical record. Neighborhood Deprivation Index data were extrapolated via zip code and were reported in quartiles, with higher quartiles reflecting greater deprivation. Descriptive, bivariate, and logistic regression analyses were conducted by NDI. RESULTS: Of 1,087,567 patients identified, 34,890 (3.2%) had a POP diagnosis. Q1, the least deprived group, had the highest prevalence of POP (26.3%). Most patients with POP identified as White (57.3%) and represented approximately a third of Q1. Black patients had the lowest rate of POP (5.8%) and comprised almost half of Q4, the most deprived quartile. A total of 13,730 patients (39.4%) had a urogynecology consultation, with rates ranging from 23.6% to 26.4% (P < 0.01). Less than half (12.8%) of patients with POP underwent surgical treatment, and the relative frequencies of procedure types were similar across NDI quartiles except for obliterative procedures (P = 0.01). When controlling for age, no clinically significant difference was demonstrated. CONCLUSIONS: Differences in urogynecology consultation, surgical treatment, and surgical procedure type performed for prolapse across NDI quartiles were not found to be clinically significant. Our findings suggest that equitable evaluation and treatment of prolapse can occur through a membership-based integrated health care system.

Mid-term Incidence of Tarsometatarsal Joint Arthrodesis Following Open Reduction With Internal Fixation (ORIF) of Lisfranc Injuries.

Open reduction with internal fixation (ORIF) of Lisfranc injuries are associated with an increased risk for secondary surgery including hardware removal and salvage arthrodesis. In the current literature, rates of salvage arthrodesis vary due to small sample sizes and a low incidence of Lisfranc injuries. There is little evidence to identify specific surgical and patient-related variables that may result in later arthrodesis. The purpose of this study is to determine the rate of tarsometatarsal joint arthrodesis following Lisfranc ORIF in a relatively large sample size. This retrospective review included patients who underwent ORIF for a Lisfranc injury between January 2007 and December 2012. A total of 146 patients met our criteria. Trans-articular fixation was used in 109 (74.6%) patients, 33 (22.6%) received percutaneous fixation and 4 (2.7%) extraarticular fixation. Five out of 120 (4.2%) patients required a salvage arthrodesis for post-traumatic arthritis that had a follow-up greater than 5 y but up to 10 y. The mean age of patients who underwent arthrodesis after ORIF was 24.5 ± 11.95 (16-48) y compared to 40.9 ± 15.8 (16-85) y. Patients who required an arthrodesis also had earlier hardware removal than patients who did not have an arthrodesis, 71.2 ± 28.3 (38-100) days and 131.4 ±101.2 (37-606) days, respectively. Patients who required salvage arthrodesis tended to be younger and hardware was removed earlier compared to those patients who did not require an arthrodesis. Four of the 5 patients who underwent a secondary arthrodesis had a loss of correction after hardware removal.

Neighborhood Disadvantage, Race and Ethnicity, and Postpartum Depression.

Importance: Postpartum depression (PPD) is a debilitating condition with higher rates among Black individuals. Increasingly, neighborhood disadvantage is being recognized as a contributor to poor health and may be associated with adverse postpartum mental health; however, associations between neighborhood disadvantage, race and ethnicity, and PPD have not been examined. Objective: To investigate the association between neighborhood disadvantage and PPD and evaluate the extent to which these associations may differ by race and ethnicity. Design, Setting, and Participants: This population-based cross-sectional study included 122 995 postpartum Kaiser Permanente Northern California members 15 years or older with a live birth between October 7, 2012, and May 31, 2017, and an address in the electronic health record. Analyses were conducted from June 1, 2022, through June 30, 2023. Exposures: Neighborhood disadvantage defined using quartiles of the Neighborhood Deprivation Index (NDI), a validated census-based socioeconomic status measure; self-reported race and ethnicity ascertained from Kaiser Permanente Northern California electronic health records. Main Outcomes and Measures: Multivariable Poisson regression was conducted to assess associations between neighborhood disadvantage, race and ethnicity, and a diagnosis of PPD. Results: Of 122 995 included postpartum individuals, 17 554 (14.3%) were younger than 25 years, 29 933 (24.3%) were Asian, 8125 (6.6%) were Black, 31 968 (26.0%) were Hispanic, 47 527 (38.6%) were White, 5442 (4.4%) were of other race and ethnicity, and 15 436 (12.6%) had PPD. Higher neighborhood disadvantage and race and ethnicity were associated with PPD after covariate adjustment. Compared with White individuals, Black individuals were more likely to have PPD (adjusted relative risk [ARR], 1.30; 95% CI, 1.24-1.37), whereas Asian (ARR, 0.48; 95% CI, 0.46-0.50), and Hispanic (ARR, 0.92; 95% CI, 0.89-0.96) individuals and those identified as having other race and ethnicity (ARR, 95% CI, 0.90; 0.85-0.98) were less likely to have PPD. Associations between NDI and PPD differed by race and ethnicity (likelihood ratio test for interaction, χ212 = 41.36; P < .001). Among Black individuals, the risk of PPD was the greatest overall and increased with neighborhood disadvantage in a dose-response manner (quartile [Q] 2 ARR, 1.39 [95% CI, 1.13-1.71]; Q3 ARR, 1.50 [95% CI, 1.23-1.83]; Q4 ARR, 1.60 [95% CI, 1.32-1.93]; Cochrane-Armitage test for trend, P < .001). Neighborhood disadvantage was associated with PPD among Asian (Q2 ARR, 1.17 [95% CI, 1.04-1.31]; Q3 ARR, 1.20 [95% CI, 1.06-1.35]) and White (Q3 ARR, 1.14 [95% CI, 1.07-1.21]; Q4 ARR, 1.17 [95% CI, 1.09-1.26]) individuals and those of other race and ethnicity (Q3 ARR, 1.34 [95% CI, 1.09-1.63]; Q4 ARR, 1.28 [95% CI, 1.03-1.58]), but the magnitude of risk was lower. Neighborhood disadvantage was not associated with PPD among Hispanic individuals (eg, Q2 ARR, 1.04 [95% CI, 0.94-1.14]; Q3 ARR, 1.00 [95% CI, 0.91-1.10]; Q4 ARR, 0.98 [95% CI, 0.90-1.08]). Conclusions and Relevance: In this cross-sectional study of postpartum individuals, residing in more disadvantaged neighborhoods was associated with PPD, except among Hispanic individuals. Neighborhood disadvantage may be associated with racial and ethnic differences in postpartum mental health. Geographic targeting of mental health interventions may decrease postpartum mental health inequities.

Pediatric Intensive Care Unit Early Mobility Program: Impact on Patient Functional Status.

INTRODUCTION: Patients admitted to the pediatric Intensive Care Unit (PICU) are frequently sedated, restrained, and placed on bed rest. These practices have known negative impacts including prolonged hospital stay and diminished functional status after discharge. The authors' objective was to investigate the impact of a PICU early mobility protocol on the frequency of orders for physical, occupational, and speech therapy (PT, OT, ST) and improvement in patient functional status. METHODS: Patients admitted in 2019 prior to the development of the PICU early mobility protocol were compared to those admitted in 2020 who underwent the protocol. Differences in clinical characteristics; PICU length of stay; rates of PT, OT, and ST orders; rates of bedside mobility activities; and functional status scores (FSSs) were assessed in bivariate and multivariate analyses. The protocol included early PT, OT, and ST order placement and frequent in-room mobility activities. RESULTS: Of the 384 patients included in the study, 216 (56%) were preprotocol patients, and 168 (44%) underwent the protocol. Patients in 2020 were more likely to receive a physical therapy order compared to their 2019 counterparts (79% vs 47%, p < 0.001). Patients in 2020 had a higher daily incidence of mobility activities compared to those in 2019 (4.88 activities vs 4.1 activities, p < 0.001). Changes in functional status scores were similar between the 2 groups. CONCLUSION: PICU early mobility was associated with increased physical, occupational, and speech therapy orders and daily mobility activities but was not associated with a reduction in functional morbidity at discharge or 3 months post-discharge.

Providing Evidence for Dogma: Risk of Epistaxis After COVID-19 Nasal-Screening Swab.

OBJECTIVE: There is anecdotal evidence SARS-CoV-2 (COVID) RT-PCR screening nasal swabs confer an elevated epistaxis risk. We aimed to assess the association between epistaxis and exposure to a COVID nasal swab. STUDY DESIGN: A matched pairs design was used. SETTING: The study was performed in a single, integrated health care system. METHODS: All patients who received a single COVID nasal swab at our institution between April 2020 and March 2021 were included. McNemar's test was used to compare rates of epistaxis between the 7 days following the index COVID swab (hazard period), and the 7 days preceding the index COVID swab (control period). Conditional logistic regression was used to evaluate sociodemographic and clinical risk factors for epistaxis. RESULTS: A total of 827,987 participants were included, with 1047 epistaxis encounters. The prevalence of epistaxis during the hazard and control periods were 0.08% and 0.04%, respectively. Swab exposure was associated with 1.92-fold odds of epistaxis during the hazard period (95% confidence interval [1.73, 2.12]). Older age, Asian/Pacific Islander (PI) (compared to white), male sex, hypertension, prior facial trauma, and warfarin or direct-acting oral anticoagulant use were also associated with significantly increased odds of epistaxis (p ≦ 0.01). CONCLUSION: COVID nasal swabs are associated with increased odds of epistaxis. Physicians should counsel patients, particularly those at the highest risk, including a history of prior facial trauma, anticoagulants/antiplatelets, or hypertension.

Hereditary Breast and Ovarian Cancer Genetic Risk: Screening and Treatment Among Transgender and Gender Diverse Patients.

IntroductionTransgender and gender diverse (TGD) populations with hereditary cancer syndromes face unique barriers to care and thus may not be accessing appropriate cancer screening or risk-reducing procedures. Our objective was to evaluate health care utilization of TGD patients with hereditary cancer syndromes. This includes counseling received, cancer screenings conducted, and risk-reducing procedures performed. MethodsA case series of TGD patients (N = 11) with hereditary breast and ovarian cancer (n = 9) or Lynch syndrome (n = 2) who received care within Kaiser Permanente Northern California between 2009 and 2019. ResultsAll patients received counseling and prophylactic options. Three patients (27%) completed all recommended screening, 6 (54%) had partial screening, 1 (9%) received no screening, and 1 (9%) did not require any screening. Six (55%) underwent a risk-reducing procedure. DiscussionThis case series highlights that despite all the study participants being appropriately counseled by practitioners about their risk of cancer, screening, and prophylactic options, in many cases, the screening received was partial or absent. Relatively few completed all the recommended screenings based on their clinical risk factors. ConclusionMany of the TGD patients with hereditary cancer syndromes in this cohort did not complete all the recommended cancer screening. This can be an area of focus in order to improve the quality of care provided to this vulnerable population.

Food Insecurity Screening in a Pediatric Clinic: Findings on Documentation and Multidimensional Care Needs.

Background The American Academy of Pediatrics recommends routine screening and resource provision for food insecurity (FI). The authors describe documentation of FI, as well as social, developmental, and health care utilization characteristics, among patients with and without FI in a pediatric clinic. Methods This data-only case-control study describes patients with and without FI seen by pediatricians who identified at least 10 patients with FI between January 2019 and January 2020. Controls were seen by the same pediatrician on the same day, matched 2:1 with cases. Chart review identified FI documentation. Bivariate analyses were used to describe demographic, clinical, and health care utilization characteristics. Results The authors identified 74 patients with FI (cases) and 144 controls. Pediatricians documented FI in the medical record for 76% of patients identified with FI, although only 43% had FI in the problem list. There were no differences between cases and controls in the distribution of age or sex. A larger proportion of cases used the emergency department (25.7% vs 9.6%; p < 0.05), were Black (36.5% vs 15.3%; p < 0.05) or Hispanic (44.6% vs 18.8%; p < 0.05), utilized Medi-Cal (41.9% vs 16.7%; p < 0.05), had developmental delay (13.5% vs 4.2%; p < 0.05), received speech therapy (20.3% vs 4.9%; p < 0.05), or were referred to a social worker (37.8% vs 3.5%; p < 0.05). Discussion Our findings show inconsistent documentation of FI in medical records and that FI is associated with increased social, developmental, and health care utilization needs. Conclusion Further research is needed to assess the impact of documenting FI in patient charts.

Impaired Fasting Glucose in Pregnancy: Improved Perinatal Outcomes with Active Glycemic Management.

OBJECTIVE: This study aimed to assess the association between active glycemic management and large for gestational age (LGA) neonates and cesarean delivery (CD) among pregnant women with impaired fasting glucose (IFG). STUDY DESIGN: Retrospective cohort study using electronic health record data of women with IFG who delivered at the Kaiser Permanente Northern California from 2012 to 2017. IFG was defined as isolated fasting glucose ≥95 mg/dL. Women with gestational diabetes mellitus (GDM) or in whom GDM could not be ruled out were excluded. Baseline and treatment characteristics, and pregnancy outcomes were compared among women with IFG who participated in telephonic home glucose monitoring and glycemic management through a centralized standardized program (participants) with those who did not participate (nonparticipants). The relative risks (RRs) of perinatal complications associated with participation versus nonparticipation were estimated with Poisson's regression models. RESULTS: We identified 1,584 women meeting inclusion criteria of whom 1,151 (72.7%) were participants and 433 (27.3%) were nonparticipants. There were no differences between groups in baseline characteristics or comorbidities, except for higher mean levels of fasting glucose (FG) at the time of IFG diagnosis in participants than in nonparticipants (98.9 vs. 98.0 mg/dL, p = 0.01). Participants received hypoglycemic medications more frequently than nonparticipants (68.2 vs. 0.9%, p < 0.01). The rate of LGA was significantly lower in participants compared with nonparticipants (19.1 vs. 25.0%, p = 0.01). After adjusting for age, race/ethnicity, education, body mass index, and level of FG impairment, the RR for LGA for participants compared with nonparticipants was 0.68, 95% CI: 0.55-0.84. The risk of CD did not differ significantly by participation status, in unadjusted or adjusted analyses. CONCLUSION: Active standardized glycemic management was associated with a decreased risk of LGA for women with IFG. This finding supports an active glycemic management strategy for patients with IFG during pregnancy to reduce the risk of LGA, similar to GDM management. KEY POINTS: · Pregnant women with IFG have increased rates of LGA.. · Active management of IFG is associated with a decreased LGA.. · Treatment of IFG like GDM may improve perinatal outcomes..

Impact of COVID-19 on the Incidence and Severity of Obstetric and Gynecologic Emergency Department Visits in an Integrated Health Care System.

OBJECTIVE: COVID-19 has had an unprecedented impact on medical care use and delivery, including stark reductions in emergency department (ED) volume. The aim of this study was to assess changes in incidence of OB/GYN ED visits and disease severity at time of presentation during the COVID-19 pandemic. STUDY DESIGN: We conducted a multicenter retrospective study of OB/GYN-related ED visits before and during the COVID-19 pandemic. Incidence rates (IRs) and severity measures were compared across time periods and years. RESULTS: A total of 18,668 OB/GYN ED encounters occurred between January 1 and December 31, 2020, compared to 21,014 encounters between January 1 and December 31, 2019. During shelter-in-place, visits decreased by 41% compared to the pre-pandemic period in 2020 before returning to typical rates (incidence rate ratio (IRR) = 0.98 in fall/winter). We found a similar proportion of patients with hemoglobin < 7 g/dL for diagnoses associated with bleeding and patients with white blood cell count > 12,000 per µL in the setting of infection comparing corresponding time periods in 2019 and 2020. There were fewer formal OB/GYN consults, hospital admissions at time of presentation, and urgent surgical procedures performed across all periods in 2020; however, hospitalization within 7 days substantially increased in the first half of 2020. CONCLUSION: The incidence of OB/GYN ED visits declined substantially between March and August 2020 but then returned to pre-pandemic levels by fall/winter 2020. The decreased incidence was not accompanied by an increase in severity of presentation.

Downstream Acute Care Utilization Following Initial Prescription of an Opioid Pain Reliever Among Emergency Department Patients With Low-Severity Conditions.

INTRODUCTION: We sought to investigate the association between receipt of an opioid pain reliever (OPR) in the emergency department (ED) and downstream acute health care utilization. METHODS: Within Kaiser Permanente Northern California, we identified opioid-naïve patients, ages 18-64, who were treated and discharged from the ED for a painful, low-severity condition between January 1, 2017, and December 31, 2017. We also identified patients who received an OPR, either administered in the ED or obtained at a Kaiser Permanente Northern California pharmacy within 7 days of ED arrival, and investigated subsequent acute care utilization in cases with at least 1 ED, urgent care, or inpatient visit within 1 month or 3 months of the index encounter or 2 visits within 12 months. RESULTS: Of the 39,468 adults included in our study, 50.7% were female, 55.0% were non-White, and 25.2% received an OPR in association with their index ED encounter. After adjustment, we found that patients who received an OPR had greater odds of downstream acute care utilization than those who did not, with odds ratios of 1.68, 1.53, and 1.50 at 1, 3, and 12 months, respectively (all p < 0.05). CONCLUSION: Patients who received an OPR at their index encounter had substantially increased odds of a subsequent ED, urgent care, or inpatient visit. This effect was most pronounced early in follow-up and persisted for the duration of the study period. Receipt of an OPR among opioid-naïve adults for a painful, low-severity condition is associated with increased downstream acute care utilization.

Minimally invasive myomectomy: practice trends and differences between Black and non-Black women within a large integrated healthcare system.

BACKGROUND: Although multiple professional organizations encourage minimally invasive surgical approaches whenever feasible, nationally, fewer than half of myomectomies are performed via minimally invasive routes. Black women are less likely than their non-Black counterparts to have minimally invasive surgery. OBJECTIVE: This study aimed to assess the trends in surgical approach among women who underwent minimally invasive myomectomies for uterine leiomyomas within a large integrated healthcare system as initiatives were implemented to encourage minimally invasive surgery, particularly evaluating differences in the proportion of minimally invasive surgery performed in Black vs non-Black women. STUDY DESIGN: We conducted a retrospective cohort study of women, aged ≥18 years, who underwent a myomectomy for a uterine leiomyoma within Kaiser Permanente Northern California between 2009 and 2019. Generalized estimating equations and Cochran-Armitage testing were used to assess myomectomy incidence and linear trend in the proportions of myomectomy by surgical route-abdominal myomectomy and minimally invasive myomectomy. Multivariable logistic regression analyses were used to assess the associations between surgical route and (1) race and ethnicity and (2) complications, controlling for patient demographic, clinical, and surgical characteristics. RESULTS: A total of 4033 adult women underwent a myomectomy during the study period. Myomectomy incidence doubled from 0.12 (95% confidence interval, 0.12-0.13) per 1000 women in 2009 to 0.25 (95% confidence interval, 0.24-0.25) per 1000 women in 2019 (P<.001). During the 11-year study period, the proportion of minimally invasive myomectomy increased from 6.0% to 89.5% (a 15-fold increase). The proportion of minimally invasive myomectomy in Black women remained lower than in non-Black women (54.5% vs 64.7%; P<.001). Black women undergoing myomectomy were younger (36.4±5.6 vs 37.4±5.8 years; P<.001), had a higher mean fibroid weight (436.0±505.0 vs 324.7±346.1 g; P<.001), and had a higher mean body mass index (30.8±7.3 vs 26.6±5.9 kg/m2; P<.001) than their non-Black counterparts. In addition to patient race, surgery performed between 2016 and 2019 compared with surgery performed between 2009 and 2012 and higher surgeon volume compared with low surgeon volume were associated with an increased proportion of minimally invasive myomectomy (adjusted relative risks, 12.58 [95% confidence interval, 9.96-15.90] and 6.63 [95% confidence interval, 5.35-8.21], respectively). Black race and fibroid weight of >500 g each independently conferred lower rates of minimally invasive myomectomy. In addition, there was an interaction between race and fibroid weight such that Black women with a fibroid weight of ≤500 g or >500 g were both less likely to have minimally invasive myomectomy than non-Black women with a fibroid weight of ≤500 g (adjusted relative risks, 0.74 [95% confidence interval, 0.58-0.95] and 0.26 [95% confidence interval, 0.18-0.36], respectively). Operative, perioperative, and medical complications were low during the 11-year study period. In regression analyses, after controlling for race, age, fibroid weight, parity, low-income residence, body mass index, surgeon volume, and year of myomectomy, the risk of complications was not markedly different comparing abdominal myomectomy with minimally invasive myomectomy. Similar results were found comparing laparoscopic minimally invasive myomectomy with robotic-assisted minimally invasive myomectomy except for women who underwent laparoscopic minimally invasive myomectomy had a lower risk of experiencing any medical complications than those who underwent robotic-assisted minimally invasive myomectomy (adjusted relative risk, 0.27; 95% confidence interval, 0.09-0.83; P=.02). CONCLUSION: Within an integrated healthcare delivery system, although initiatives to encourage minimally invasive surgery were associated with a marked increase in the proportion of minimally invasive myomectomy, Black women continued to be less likely to undergo minimally invasive myomectomy than their non-Black counterparts. Race and fibroid weight alone did not explain the disparities in minimally invasive myomectomy.

Variation in Vaginal Hysterectomy Rates in an Integrated Healthcare System.

STUDY OBJECTIVE: To describe trends in minimally invasive hysterectomy (MIH) and assess patient, surgical, and provider characteristics associated with differences in vaginal versus laparoscopic rates within an integrated healthcare system. DESIGN: A retrospective cohort study. SETTING: Kaiser Permanente Northern California from 2008 to 2018. PATIENTS: Patients who underwent MIH for benign conditions excluding uterine prolapse and incontinence surgeries. INTERVENTIONS: Hysterectomies. MEASUREMENTS AND MAIN RESULTS: A total of 27518 hysterectomies were performed for benign indications. Of these, the proportion of MIH increased from 29.1% (2008) to 96.7% (2018) (p <.001). The proportion of vaginal hysterectomies (VHs) of all hysterectomies did not change significantly over the study period (p = .07); however, the proportion of VH among MIH cases decreased from a high of 50.6% in 2008 to 13.2% in 2018 (p <.001). VH rates were lower in obese and morbidly obese patients (p <.001 and p = .02, respectively) and in women with uterine weights >250 g (p <.001). The differences persisted after controlling for patient demographic, clinical, and surgery characteristics. Low surgical volume was inversely associated with VH (adjusted relative risk, 7.19; 95% confidence interval, 6.62-7.81; p <.001). VH rates ranged from 11.5% to 27.8% across service areas (hospitals). Service area remained a significant predictor of VH after controlling for patient (including body mass index and uterine weight) and surgery-related characteristics. Postoperative hospital stay decreased from 33.8 ± 16.4 hours (2008) to 6.1 ± 12.2 (2018) for VH. Operative time was shorter for VH than laparoscopic hysterectomies (LHs) (1.7 vs 2.5 hours; p <.001). Overall operative/perioperative complications were low and not significantly different (VH vs LH). CONCLUSION: As the proportion of MIH increased, LH became the preferred route despite similar rates of postoperative stay and intraoperative complications and shorter operative time for VH compared with LH. Service area and provider volume were independent predictors of MIH route, suggesting that training and evidence-based guidelines for route selection may help preserve VH rates.

Intrauterine device, subdermal contraceptive, and depot medroxyprogesterone use among transmasculine and cisgender patients over a 10-year period.

OBJECTIVE: To describe use of three types of longer-acting contraception-intrauterine devices, subdermal contraceptives, and depot medroxyprogesterone-among transmasculine and cisgender women patients. STUDY DESIGN: A repeated cross-sectional study using electronic medical records of patients, age 18 to 45, receiving care within Kaiser Permanente Northern California between 2009 and 2019. Variations in demographics, clinical characteristics and contraception method uptake were assessed using t tests for continuous variables and chi-square tests for categorical variables for patients enrolled in 2019. A linear trend test for each group was used to assess the age-adjusted uptake of contraception methods by study year. RESULTS: The transmasculine group was younger, with a mean age of 27.3 years (±7.2) vs 32.5 years (±7.8) years, respectively p < 0.001. The transmasculine group used more tobacco, alcohol, and illicit drugs. The uptake of these contraception methods increased from 2009 to 2019 for both groups (transmasculine: 0.7% to 4.1%; cisgender: 5.6% to 6.7%) with a positive linear trend for both groups (p = 0.003 and p < 0.001, respectively). The change in uptake of any intrauterine device from 2009 to 2019 was greater for the transmasculine group (0.3% to 2.3% vs 3.3% to 3.5%). Etonogestrel implant uptake had a positive linear trend from 2009 to 2019 for both groups (transmasculine: 0% to 0.5%, p = 0.02, and cisgender 0.1% to 1.2%, p < 0.001). CONCLUSION: Annual uptake of these contraception methods increased significantly for both transmasculine and cisgender groups, and this increase was greater for the transmasculine patients. Uptake of these contraception methods was higher in the cisgender population. IMPLICATIONS: These findings suggest an improvement in use of long-term contraception and menstrual suppression medications for the transmasculine population. Further research is needed to understand these differences and identify a possible unmet need for intrauterine and subdermal contraceptives and depot medroxyprogesterone use among this often-marginalized population.

Prophylactic transdermal scopolamine for the reduction of postoperative length of stay after uterine aspiration at Kaiser Permanente Northern California from 2017-2018.

OBJECTIVE: To determine if transdermal scopolamine is associated with decreased postoperative nausea and vomiting and shorter length of stay in the postoperative care unit among patients undergoing uterine aspiration for abortion or early pregnancy loss. STUDY DESIGN: We conducted a retrospective cohort study at an integrated medical center that initiated a protocol to prescribe transdermal scopolamine to patients undergoing uterine aspiration under moderate sedation. We compared outcomes among patients who underwent uterine aspiration in 2017, before the institution enacted the protocol, with their counterparts in 2018, immediately after the institution instated the protocol. We reviewed patient charts for data on the postoperative length of stay, use of additional antiemetics, and a standardized clinician designated postoperative nausea and vomiting score. We analyzed outcomes by relevant demographic and clinical characteristics using chi-square or Fisher's exact tests for categorical variables and t tests for continuous variables. RESULTS: The final sample included 386 patients; 228 who did not receive scopolamine and 158 who did. The cohorts were comparable in terms of demographic and clinical characteristics. The cohort that received transdermal scopolamine had a similar mean postoperative length of stay (75.4 ± 54.1 vs 71.1 ± 50.8 minutes; p = 0.43). There were no differences in the proportions of patients who were provided additional antiemetics (26 ± 11.4 vs 17 ± 10.8; p = 0.84) or had transient vomiting and retching (3 ± 1.9 vs 3 ± 1.3; p = 0.69) between the cohorts. CONCLUSION: We found no evidence that prophylactic transdermal scopolamine reduces postoperative nausea, vomiting, or length of stay among patients undergoing uterine aspiration. IMPLICATIONS: Among patients who underwent uterine aspiration under moderate sedation, use of prophylactic transdermal scopolamine was not associated with shorter postoperative length of stay or lesser use of antiemetics. Prophylactic transdermal scopolamine is not likely to be useful for patients undergoing uterine aspiration and could be an unnecessary cost.

Active versus Passive Voiding Protocols after Same-day Minimally Invasive Hysterectomy.

STUDY OBJECTIVE: To determine the proportion of patients discharged with a urinary catheter after a same-day benign gynecologic minimally invasive hysterectomy (MIH) according to active vs passive voiding protocols. The secondary objectives included assessing postanesthesia care unit (PACU) duration and postoperative urinary retention (POUR) rate ≤2 weeks of discharge. DESIGN: Retrospective, observational cohort study. SETTING: Large integrated healthcare system serving approximately 40% of the Northern California population. PATIENTS: Patients aged 18 years or older undergoing same-day MIH without urogynecology procedures from 2015 to 2018 were categorized into active or passive voiding trial groups. Active voiding trials were defined as patients arriving in the PACU with a catheter, retrograde filling of the bladder with 300 mL saline then allowing for voiding ≥50% within 30 minutes. If the patients were unable to void this volume, they were discharged with a catheter to be removed within 24 hours. A passive voiding trial involved filling or not filling the bladder before PACU arrival without a catheter, then allowing for voiding or performing a straight catheterization if the patients were unable to void. INTERVENTIONS: Retrospective cohort study. MEASUREMENTS AND MAIN RESULTS: A total of 1644 (83.2%) patients underwent passive voiding trials, and 333 (16.8%) underwent active voiding trials. The proportion of patients discharged with a catheter was lower in the passive voiding group than in the active voiding group (5.4% vs 10.5%; p = .001). The passive group had a shorter mean PACU time than the active group (218 ± 86 vs 240 ± 93 minutes; p <.001). The crude POUR rates for the passive and active voiding groups were 1.8% and 3.0%, respectively (p = .16). CONCLUSION: Within an integrated healthcare system, patients who underwent passive voiding trials compared with those who underwent active voiding trials were discharged home from the PACU after a shorter duration. In addition, a larger proportion of the patients who underwent passive voiding trials were discharged home without a urinary catheter. There were no differences in the POUR rates. Our findings suggest that passive voiding trials can be safely used after a benign MIH to reduce hospital duration, optimize healthcare resources, and improve patient experience.

Disordered Eating, Body Image Dissatisfaction, and Associated Healthcare Utilization Patterns for Sexual Minority Youth.

PURPOSE: To determine the prevalence of disordered eating behaviors (DEBs) and body image dissatisfaction (BID) according to sexual minority youth (SMY) status and describe healthcare utilization patterns by SMY status. METHODS: Retrospective data from 107,528 adolescents, who had a Well Check in Kaiser Permanente Northern California in 2016, were used to compare DEB and BID by SMY status. Multivariate logistic models were used to examine the associations of SMY, birth-assigned sex, age, race/ethnicity, and body mass index on DEB and BID. The utilization of specialized eating disorder (ED) medical and mental health services and general mental health services was described at one Kaiser Permanente Northern California facility. RESULTS: BID was reported in 20,763 (19.3%) adolescents, DEB in 1,458 (1.7%) adolescents, and 5,363 (5%) adolescents identified as SMY. SMY had higher odds of having DEB and BID than non-SMY, respectively (adjusted odds ratio 2.0 95% confidence interval [1.9-2.2] and adjusted odds ratio 3.8 [3.4-4.2]). Regardless of SMY status, adolescents with older age, female sex, nonwhite race, and elevated body mass index had higher odds of ED risk factors. SMY with ED risk factors had higher ED medical utilization than non-SMY with ED risk factors (4.6% vs. 1.6%). However, SMY status was not associated with utilization of specialized ED mental health services. CONCLUSIONS: SMY had increased rates of DEB and BID but had underutilization of specialized ED mental health services. Future targeted efforts to prevent eating disorder-related mortality and morbidity for SMY should include targeted eating disorder screening and referral to specialized ED medical and mental health services.