Delay in gynecologic surgical treatment: a comparison of patients in managed care and fee-for-service plans.

OBJECTIVE: To determine whether membership in a managed care organization is associated with a delay in receiving definitive surgical treatment for benign gynecologic or gynecologic oncologic diseases. METHODS: Four hundred patients who had definitive surgery between 1994 and 1997 were divided into those with benign gynecologic (n = 207) and gynecologic oncologic diagnoses (n = 193). Each group was subdivided into managed care patients and fee-for-service patients. Subgroups were analyzed for delay in surgical treatment, emergency room visits, length of stay, age, clinic visits, prior evaluation, prior treatment, second opinions, operating room time, estimated blood loss, and surgical complications. RESULTS: There were 122 managed care and 85 fee-for-service patients with benign gynecologic diagnoses. The time from initial presentation to the date of definitive surgery was significantly longer for the managed care patients (133.7 +/- 21 days compared with 84.9 +/- 12.8 days, P = .03). Of the 193 patients with gynecologic cancer 96 were in the managed care group and 97 were under fee-for-service arrangements. There was no significant difference in the time from initial presentation to the date of definitive surgery between these two groups (35.7 +/- 7.4 days compared with 20.5 +/- 2.5 days, P = .29). There were no significant differences between groups in emergency room or clinic visits, prior evaluations or treatments, or surgical complications when stratified by diagnosis. The mean age of managed care patients was significantly lower than that of fee-for-service patients for gynecologic diagnoses (46.4 +/- 9.7 years compared with 56.5 +/- 14.9 years, P < .001), and gynecologic oncologic diagnoses (47.5 +/- 13.2 years compared with 60.9 +/- 15.8 years, P < .001). CONCLUSION: Membership in a managed care organization is associated with a delay in receiving definitive surgical care for benign gynecologic, but not gynecologic oncologic, diseases.

Uterine artery atherosclerotic disease: histologic features and clinical correlation.

OBJECTIVE: To determine whether uterine artery atherosclerosis is associated with known cardiovascular risk factors in women undergoing hysterectomy. METHODS: Seventy-four women undergoing hysterectomy between September 1995 and March 1996 were evaluated. Following hysterectomy, samples of the uterine artery were collected for histologic evaluation. Plaque complexity and histologic measurements were compared with regard to known cardiovascular risk factors. RESULTS: Among the 59 premenopausal women, 55.9% had intimal thickening 40.7% had simple plaques, and 3.7% had complex lesions in the uterine artery samples. Among postmenopausal women, 40% had intimal fibrosis, 20% had simple plaques, and 40% had complex lesions. Postmenopausal status was correlated strongly with the presence of advanced atherosclerotic disease (P < .001). Postmenopausal women had significantly greater intimal area (P = .01), intimal area/medial area (P = .002), intimal area/vessel area (P = .002), maximal intimal thickness/medial thickness (P = .01), and significantly less medial thickness (P < .001). A significant linear correlation existed between age and the intimal/medial ratio among premenopausal women (P = .04) and postmenopausal women (P = .01). Patients with electrocardiogram (ECG) abnormalities had significantly greater intimal/medial area as well (P = .02). Hypertension was associated with complex lesions among the postmenopausal patients (P = .01). Preoperative cholesterol levels greater than 200 mg/dL were associated with greater intimal thickness (P = .05) and intimal thickness/medial thickness (P = .03). CONCLUSION: The severity of uterine artery atherosclerosis is significantly correlated with known risk factors for cardiovascular disease: increasing age, postmenopausal status, ECG abnormalities, and hypertension. Uterine artery histologic analysis may provide a means of assessing the degree of atherosclerosis in other, critical, vascular beds.

Laparoscopic staging of endometrial cancer: the learning experience.

OBJECTIVE: To evaluate our learning-curve experience with laparoscopic management of endometrial carcinoma. METHODS: Retrospective review of our first 125 patients with endometrial cancer who were managed laparoscopically. The patient population was reviewed in a chronological manner, noting patient demographics, operative procedure and times, estimated blood loss, hospital stay, complications, and pathology. RESULTS: Overall, the mean age was 68.6 years (range 29-89), the mean weight was 160 pounds (range 97-328), and the mean Quetelet index was 27.8 (range 17.8-56.4). Metastatic disease was discovered in 28.8% (17/59) of patients with grade 2 or 3 lesions. There was no statistically significant variation in any of these parameters throughout the study. Operative times for staging without lymphadenectomy decreased significantly from a mean of 163 minutes to 99 minutes (p < .001). Operative times for staging with lymphadenectomy decreased from a mean of 196 minutes to 128 minutes (p < 0.02). Hospital stay decreased from a mean of 3.2 days in the first quarter of our study to 1.8 days (p < .0001). The overall average complication rate of 4% (two enterotomies, two cystotomies, and a transected ureter) did not vary. However, the rate of conversion to laparotomy dropped significantly from 8% (2/25) to 0% (0/100). CONCLUSIONS: We found that operative times and hospital stays for laparoscopic staging of endometrial cancer continued to drop after 125 cases. While the ability to detect metastatic disease and the rate of major complications appear unrelated to length of the operator experience, the conversion rate to laparotomy decreases with operator experience. Learning-curve parameters must be recognized by physicians, patients, and researchers for a host of reasons.

Relationship of biochemical pregnancy to pre-ovulatory endometrial thickness and pattern in patients undergoing ovulation induction.

In order to assess the relationship between pre-ovulatory endometrial thickness and pattern and biochemical pregnancy, the pregnancy outcome was retrospectively analysed in 81 patients undergoing ovulation induction evaluated by vaginal ultrasound on the day of human chorionic gonadotrophin (HCG) administration or luteinizing hormone (LH) surge. Biochemical pregnancies occurred in 7/32 (21.9%) pregnancies when endometrial thickness was < 9 mm, compared to 0/49 when endometrial thickness was > or = 9 mm on the day of HCG administration or LH surge (P < 0.0025). Clinical abortions occurred in 5/32 (15.6%) pregnancies when endometrial thickness was 6-8 mm, compared to 6/49 (12.2%) when endometrial thickness was 6-8 mm (NS). Endometrial thickness was related to the cycle day of HCG or LH surge (r = 0.37, P < 0.001) but was unrelated to oestradiol level on the day of HCG administration or LH surge (r = 0.12). Biochemical pregnancies were related to endometrial pattern (r = -0.22, P = 0.02) but were unrelated to maternal age or previous abortions. Clinical abortions were related to age (r = 0.26, P = 0.01) and to previous abortion (r = 0.25, P = 0.013) but were unrelated to endometrial pattern. Neither biochemical pregnancy nor clinical abortion was related to oestradiol or LH levels on the day of HCG administration or LH surge. These findings suggest that the majority of biochemical pregnancies do not result from karyotypically abnormal embryos, as do clinical abortions.