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Collaborative depression care model offers promise in rural practice
An ob.gyn. practice in rural Washington state has successfully implemented a collaborative care model for depression management that relies on “depression care managers” and a consulting psychiatrist to aid ob.gyns. in providing effective depression care.
The initiative was a rural test run of the DAWN (Depression Attention for Women Now) intervention that was shown in a randomized controlled trial 2 years ago to improve depression outcomes for women in two urban ob.gyn. clinics affiliated with the University of Washington in Seattle. Both the trial and the pilot project were funded by the National Institute of Mental Health.
Nearly 75% of the 25 women enrolled in the rural pilot project had a significant improvement in their Patient Health Questionnaire-9 (PHQ-9) scores, and more than half improved their depression symptoms by at least 50%, Roger Rowles, MD, of the Generations practice in Yakima, Wash., and Susan D. Reed, MD, a coinvestigator of the original DAWN trial, reported at the annual meeting of the American College of Obstetricians and Gynecologists.
They urged others to consider taking a similar collaborative approach to depression care, especially now that the U.S. Preventive Services Task Force has recommended depression screening for all adults, including pregnant and postpartum women.
Previously, “when we identified someone with perinatal depression, we’d need a 30-minute initial consultation and then 15-20 minutes on a regular basis,” Dr. Rowles said. “We didn’t have the time to do that. ... And I had no training. Most of us felt we weren’t capable [of providing quality depression care].”
In the DAWN model, a social worker, nurse, medical assistant, or other staff member is trained to provide collaborative depression care and takes charge of this care, regularly meeting in-person or by phone with the patient to promote engagement and to closely monitor treatment progress.
Patients choose their initial treatment, including medication and Problem-Solving Treatment in Primary Care (PST-PC) therapy, an evidence-based brief behavioral intervention that helps identify stressors and improve problem solving. The depression care manager delivers the PST-PC therapy, tracks treatment response and compliance, and participates in weekly structured case reviews with the ob.gyn. and a consulting psychiatrist.
Results then and now
The original DAWN trial randomized women at two urban clinics to either 12 months of collaborative depression care or to usual care. Usual care included educational material, access to the clinic social worker, and possible psychiatry referral and prescriptions from the ob.gyn.
At 6 months, the reduction in depression scores as measured by the 20-item Hopkins Symptom Checklist was similar between the two groups, but at 12 months and at 18 months follow-up, the intervention group had significantly lower scores. They were more likely to have at least a 50% decrease in depressive symptoms at 12 months and were significantly more satisfied with their depression care (Obstet Gynecol. 2014 Jun;123[6]:1237-46).
The pilot project in Yakima, a farming community of 80,000 people, was of shorter duration than the randomized trial and focused on women coming for periconception, pregnancy, and postpartum care.
The majority – 74% – had significant improvement in their PHQ scores (a final score of less than 10), and almost one-third had a final score of less than 5. A score of 10 or more indicates the likelihood of having major depression. More than half – 59% – had at least a 50% improvement in depressive symptoms.
Unlike in the original DAWN trial, depression care managers in the Yakima project used text messaging in addition to phone calls to stay engaged with patients and monitor treatment. Almost all of the 25 enrolled women received PST-PC, and approximately 56% received antidepressants, for a mean treatment time of 14 weeks.
“Given that short duration of follow-up, the improvement we saw was very good,” said Amritha Bhat, MD, MBBS, the University of Washington psychiatrist who served as the consulting psychiatrist for the project.
Without a placebo-controlled arm, the researchers don’t know how much of the improvement was due to the collaborative care, Dr. Bhat said in an interview. “But we know now that it’s feasible in a rural setting.”
Depression care needs
Women have two times the rate of major depression as men, with prevalence rates of 13% annually and 21% over a lifetime, and low-income and minority women are at highest risk of depression and are also more likely to seek routine care from ob.gyns., according to Dr. Reed, who is a professor of ob.gyn at the University of Washington, Seattle, and chief of ob.gyn. at Harborview Medical Center.
Dr. Rowles said he was “astounded” that 30% of the screened patients in his practice had positive results. Many “either didn’t want to participate in the project or had exclusions, but even so we enrolled [our cohort] quickly,” he said.
The DAWN model stipulates that depression care managers support women as much as possible with social service interventions, facilitating financial assistance for medications, and serving as a “point person” for assistance with housing, food, domestic abuse, and other issues.
The task of integrating a social service element into depression care is necessary but can be daunting, Dr. Rowles said. In Yakima, he said, the significant need for basic assistance was a “big frustration” to the depression care managers involved in the project. “They wanted to do more, because they’d identified these problems and had a rapport [with the women], but our resources in Yakima are not that great.”
To prepare the Yakima practice for the intervention, a University of Washington team visited the clinic to educate staff about collaborative care, and three depression care managers were trained to deliver PST-PC and manage care. The depression care managers – a nurse employed by the local hospital, a nurse employed by another clinic for farm workers, and a local psychologist – “were the glue for this program,” Dr. Rowles said.
In other settings, depression care managers might more likely be clinic social workers or other members of the practice.
A psychiatrist’s involvement is also crucial, particularly when it comes to prescribing antidepressant medications at their full effective doses, Dr. Reed stressed. “You won’t feel comfortable pushing those doses to the max without [a psychiatrist to consult with],” Dr. Reed said at the ACOG meeting.
In the DAWN trial, similar numbers of patients in the collaborative care group and the usual care group were prescribed antidepressants, but more patients in the intervention group had their doses increased to an effective therapeutic range, and more patients adhered to their medication regimens, she said.
The 12-month DAWN intervention was provided at a cost per patient of up to $1,000.
Dr. Reed’s clinic has sustained funding for the intervention since the National Institute of Mental Health grant expired, and Dr. Rowles said he was seeking funding to continue DAWN at his Yakima clinic. Funding sources for ob.gyn. practices interested in implementing the model may include state funding agencies and organizations such as the March of Dimes, Dr. Reed said, noting that some states offer maternal services support that could be helpful for integrating collaborative depression care.
While the pilot project focused on pregnancy care, Dr. Reed urged ob.gyns. to think broadly. “Do you know when you catch these women? When they come in for their Pap smears and their routine care, before they become pregnant,” she said. “If you help them with their mood disorder early, they’ll do so much better with pregnancy.”
Information about DAWN – including resources on PST-PC and antidepressant medication, and an intervention manual – can be found at www.dawncare.org.
An ob.gyn. practice in rural Washington state has successfully implemented a collaborative care model for depression management that relies on “depression care managers” and a consulting psychiatrist to aid ob.gyns. in providing effective depression care.
The initiative was a rural test run of the DAWN (Depression Attention for Women Now) intervention that was shown in a randomized controlled trial 2 years ago to improve depression outcomes for women in two urban ob.gyn. clinics affiliated with the University of Washington in Seattle. Both the trial and the pilot project were funded by the National Institute of Mental Health.
Nearly 75% of the 25 women enrolled in the rural pilot project had a significant improvement in their Patient Health Questionnaire-9 (PHQ-9) scores, and more than half improved their depression symptoms by at least 50%, Roger Rowles, MD, of the Generations practice in Yakima, Wash., and Susan D. Reed, MD, a coinvestigator of the original DAWN trial, reported at the annual meeting of the American College of Obstetricians and Gynecologists.
They urged others to consider taking a similar collaborative approach to depression care, especially now that the U.S. Preventive Services Task Force has recommended depression screening for all adults, including pregnant and postpartum women.
Previously, “when we identified someone with perinatal depression, we’d need a 30-minute initial consultation and then 15-20 minutes on a regular basis,” Dr. Rowles said. “We didn’t have the time to do that. ... And I had no training. Most of us felt we weren’t capable [of providing quality depression care].”
In the DAWN model, a social worker, nurse, medical assistant, or other staff member is trained to provide collaborative depression care and takes charge of this care, regularly meeting in-person or by phone with the patient to promote engagement and to closely monitor treatment progress.
Patients choose their initial treatment, including medication and Problem-Solving Treatment in Primary Care (PST-PC) therapy, an evidence-based brief behavioral intervention that helps identify stressors and improve problem solving. The depression care manager delivers the PST-PC therapy, tracks treatment response and compliance, and participates in weekly structured case reviews with the ob.gyn. and a consulting psychiatrist.
Results then and now
The original DAWN trial randomized women at two urban clinics to either 12 months of collaborative depression care or to usual care. Usual care included educational material, access to the clinic social worker, and possible psychiatry referral and prescriptions from the ob.gyn.
At 6 months, the reduction in depression scores as measured by the 20-item Hopkins Symptom Checklist was similar between the two groups, but at 12 months and at 18 months follow-up, the intervention group had significantly lower scores. They were more likely to have at least a 50% decrease in depressive symptoms at 12 months and were significantly more satisfied with their depression care (Obstet Gynecol. 2014 Jun;123[6]:1237-46).
The pilot project in Yakima, a farming community of 80,000 people, was of shorter duration than the randomized trial and focused on women coming for periconception, pregnancy, and postpartum care.
The majority – 74% – had significant improvement in their PHQ scores (a final score of less than 10), and almost one-third had a final score of less than 5. A score of 10 or more indicates the likelihood of having major depression. More than half – 59% – had at least a 50% improvement in depressive symptoms.
Unlike in the original DAWN trial, depression care managers in the Yakima project used text messaging in addition to phone calls to stay engaged with patients and monitor treatment. Almost all of the 25 enrolled women received PST-PC, and approximately 56% received antidepressants, for a mean treatment time of 14 weeks.
“Given that short duration of follow-up, the improvement we saw was very good,” said Amritha Bhat, MD, MBBS, the University of Washington psychiatrist who served as the consulting psychiatrist for the project.
Without a placebo-controlled arm, the researchers don’t know how much of the improvement was due to the collaborative care, Dr. Bhat said in an interview. “But we know now that it’s feasible in a rural setting.”
Depression care needs
Women have two times the rate of major depression as men, with prevalence rates of 13% annually and 21% over a lifetime, and low-income and minority women are at highest risk of depression and are also more likely to seek routine care from ob.gyns., according to Dr. Reed, who is a professor of ob.gyn at the University of Washington, Seattle, and chief of ob.gyn. at Harborview Medical Center.
Dr. Rowles said he was “astounded” that 30% of the screened patients in his practice had positive results. Many “either didn’t want to participate in the project or had exclusions, but even so we enrolled [our cohort] quickly,” he said.
The DAWN model stipulates that depression care managers support women as much as possible with social service interventions, facilitating financial assistance for medications, and serving as a “point person” for assistance with housing, food, domestic abuse, and other issues.
The task of integrating a social service element into depression care is necessary but can be daunting, Dr. Rowles said. In Yakima, he said, the significant need for basic assistance was a “big frustration” to the depression care managers involved in the project. “They wanted to do more, because they’d identified these problems and had a rapport [with the women], but our resources in Yakima are not that great.”
To prepare the Yakima practice for the intervention, a University of Washington team visited the clinic to educate staff about collaborative care, and three depression care managers were trained to deliver PST-PC and manage care. The depression care managers – a nurse employed by the local hospital, a nurse employed by another clinic for farm workers, and a local psychologist – “were the glue for this program,” Dr. Rowles said.
In other settings, depression care managers might more likely be clinic social workers or other members of the practice.
A psychiatrist’s involvement is also crucial, particularly when it comes to prescribing antidepressant medications at their full effective doses, Dr. Reed stressed. “You won’t feel comfortable pushing those doses to the max without [a psychiatrist to consult with],” Dr. Reed said at the ACOG meeting.
In the DAWN trial, similar numbers of patients in the collaborative care group and the usual care group were prescribed antidepressants, but more patients in the intervention group had their doses increased to an effective therapeutic range, and more patients adhered to their medication regimens, she said.
The 12-month DAWN intervention was provided at a cost per patient of up to $1,000.
Dr. Reed’s clinic has sustained funding for the intervention since the National Institute of Mental Health grant expired, and Dr. Rowles said he was seeking funding to continue DAWN at his Yakima clinic. Funding sources for ob.gyn. practices interested in implementing the model may include state funding agencies and organizations such as the March of Dimes, Dr. Reed said, noting that some states offer maternal services support that could be helpful for integrating collaborative depression care.
While the pilot project focused on pregnancy care, Dr. Reed urged ob.gyns. to think broadly. “Do you know when you catch these women? When they come in for their Pap smears and their routine care, before they become pregnant,” she said. “If you help them with their mood disorder early, they’ll do so much better with pregnancy.”
Information about DAWN – including resources on PST-PC and antidepressant medication, and an intervention manual – can be found at www.dawncare.org.
An ob.gyn. practice in rural Washington state has successfully implemented a collaborative care model for depression management that relies on “depression care managers” and a consulting psychiatrist to aid ob.gyns. in providing effective depression care.
The initiative was a rural test run of the DAWN (Depression Attention for Women Now) intervention that was shown in a randomized controlled trial 2 years ago to improve depression outcomes for women in two urban ob.gyn. clinics affiliated with the University of Washington in Seattle. Both the trial and the pilot project were funded by the National Institute of Mental Health.
Nearly 75% of the 25 women enrolled in the rural pilot project had a significant improvement in their Patient Health Questionnaire-9 (PHQ-9) scores, and more than half improved their depression symptoms by at least 50%, Roger Rowles, MD, of the Generations practice in Yakima, Wash., and Susan D. Reed, MD, a coinvestigator of the original DAWN trial, reported at the annual meeting of the American College of Obstetricians and Gynecologists.
They urged others to consider taking a similar collaborative approach to depression care, especially now that the U.S. Preventive Services Task Force has recommended depression screening for all adults, including pregnant and postpartum women.
Previously, “when we identified someone with perinatal depression, we’d need a 30-minute initial consultation and then 15-20 minutes on a regular basis,” Dr. Rowles said. “We didn’t have the time to do that. ... And I had no training. Most of us felt we weren’t capable [of providing quality depression care].”
In the DAWN model, a social worker, nurse, medical assistant, or other staff member is trained to provide collaborative depression care and takes charge of this care, regularly meeting in-person or by phone with the patient to promote engagement and to closely monitor treatment progress.
Patients choose their initial treatment, including medication and Problem-Solving Treatment in Primary Care (PST-PC) therapy, an evidence-based brief behavioral intervention that helps identify stressors and improve problem solving. The depression care manager delivers the PST-PC therapy, tracks treatment response and compliance, and participates in weekly structured case reviews with the ob.gyn. and a consulting psychiatrist.
Results then and now
The original DAWN trial randomized women at two urban clinics to either 12 months of collaborative depression care or to usual care. Usual care included educational material, access to the clinic social worker, and possible psychiatry referral and prescriptions from the ob.gyn.
At 6 months, the reduction in depression scores as measured by the 20-item Hopkins Symptom Checklist was similar between the two groups, but at 12 months and at 18 months follow-up, the intervention group had significantly lower scores. They were more likely to have at least a 50% decrease in depressive symptoms at 12 months and were significantly more satisfied with their depression care (Obstet Gynecol. 2014 Jun;123[6]:1237-46).
The pilot project in Yakima, a farming community of 80,000 people, was of shorter duration than the randomized trial and focused on women coming for periconception, pregnancy, and postpartum care.
The majority – 74% – had significant improvement in their PHQ scores (a final score of less than 10), and almost one-third had a final score of less than 5. A score of 10 or more indicates the likelihood of having major depression. More than half – 59% – had at least a 50% improvement in depressive symptoms.
Unlike in the original DAWN trial, depression care managers in the Yakima project used text messaging in addition to phone calls to stay engaged with patients and monitor treatment. Almost all of the 25 enrolled women received PST-PC, and approximately 56% received antidepressants, for a mean treatment time of 14 weeks.
“Given that short duration of follow-up, the improvement we saw was very good,” said Amritha Bhat, MD, MBBS, the University of Washington psychiatrist who served as the consulting psychiatrist for the project.
Without a placebo-controlled arm, the researchers don’t know how much of the improvement was due to the collaborative care, Dr. Bhat said in an interview. “But we know now that it’s feasible in a rural setting.”
Depression care needs
Women have two times the rate of major depression as men, with prevalence rates of 13% annually and 21% over a lifetime, and low-income and minority women are at highest risk of depression and are also more likely to seek routine care from ob.gyns., according to Dr. Reed, who is a professor of ob.gyn at the University of Washington, Seattle, and chief of ob.gyn. at Harborview Medical Center.
Dr. Rowles said he was “astounded” that 30% of the screened patients in his practice had positive results. Many “either didn’t want to participate in the project or had exclusions, but even so we enrolled [our cohort] quickly,” he said.
The DAWN model stipulates that depression care managers support women as much as possible with social service interventions, facilitating financial assistance for medications, and serving as a “point person” for assistance with housing, food, domestic abuse, and other issues.
The task of integrating a social service element into depression care is necessary but can be daunting, Dr. Rowles said. In Yakima, he said, the significant need for basic assistance was a “big frustration” to the depression care managers involved in the project. “They wanted to do more, because they’d identified these problems and had a rapport [with the women], but our resources in Yakima are not that great.”
To prepare the Yakima practice for the intervention, a University of Washington team visited the clinic to educate staff about collaborative care, and three depression care managers were trained to deliver PST-PC and manage care. The depression care managers – a nurse employed by the local hospital, a nurse employed by another clinic for farm workers, and a local psychologist – “were the glue for this program,” Dr. Rowles said.
In other settings, depression care managers might more likely be clinic social workers or other members of the practice.
A psychiatrist’s involvement is also crucial, particularly when it comes to prescribing antidepressant medications at their full effective doses, Dr. Reed stressed. “You won’t feel comfortable pushing those doses to the max without [a psychiatrist to consult with],” Dr. Reed said at the ACOG meeting.
In the DAWN trial, similar numbers of patients in the collaborative care group and the usual care group were prescribed antidepressants, but more patients in the intervention group had their doses increased to an effective therapeutic range, and more patients adhered to their medication regimens, she said.
The 12-month DAWN intervention was provided at a cost per patient of up to $1,000.
Dr. Reed’s clinic has sustained funding for the intervention since the National Institute of Mental Health grant expired, and Dr. Rowles said he was seeking funding to continue DAWN at his Yakima clinic. Funding sources for ob.gyn. practices interested in implementing the model may include state funding agencies and organizations such as the March of Dimes, Dr. Reed said, noting that some states offer maternal services support that could be helpful for integrating collaborative depression care.
While the pilot project focused on pregnancy care, Dr. Reed urged ob.gyns. to think broadly. “Do you know when you catch these women? When they come in for their Pap smears and their routine care, before they become pregnant,” she said. “If you help them with their mood disorder early, they’ll do so much better with pregnancy.”
Information about DAWN – including resources on PST-PC and antidepressant medication, and an intervention manual – can be found at www.dawncare.org.
Study helps set upper boundary for leukocytosis after prenatal corticosteroids
WASHINGTON – Maternal leukocytosis after prenatal corticosteroid administration peaks at up to 24 hours after therapy, with the highest second standard deviation from the mean being 18.3 x 109/L, according to a systematic review and meta-analysis.
There has been limited data available on the magnitude and timing of leukocytosis after corticosteroid administration, making it difficult to interpret the significance of elevated white blood cell counts, Dr. Samuel Bauer, of Beaumont Health, Royal Oak, Mich., said at the annual meeting of the American College of Obstetricians and Gynecologists.
“We know corticosteroids cause leukocytosis, but we haven’t really known what the upper boundary is,” he said.
Driven by concerns about maternal sepsis and the ability to recognize early signs, Dr. Bauer and his colleagues identified six studies that reported white blood cell counts prior to corticosteroid administration, and between 24 and 96 hours afterward in healthy women with singleton gestations. The studies also met the inclusion criterion of having “excluded infected parturients between 23 and 34 weeks of gestation,” he said.
Mean maternal white blood cell count values prior to corticosteroid administration and up to 24 hours, 48 hours, 72 hours, and 96 hours after corticosteroid administration were 10.2, 13.7, 12.8, 11.5, and 11.1 x 109/L, respectively.
The highest second standard deviation from the mean of 18.3 x 109/L did not occur after 24 hours, he emphasized, and by 72 hours, mean values had returned to 11.5 x 109/L.
The findings need to be applied “cautiously” in practice, Dr. Bauer said, since the analysis did not include women with signs of infection and because some women who develop serious infections “have a very low white blood cell count.”
Still, the findings “establish a temporal trend and give us an upper boundary” for the level of leukocytosis that can be expected with prenatal corticosteroids. This can be helpful – along with other considerations – in determining whether an infectious workup is needed when white blood cell counts are high, he said in an interview.
It is not uncommon in clinical practice for maternal leukocytosis at 5-6 days or a week after corticosteroid administration to be attributed to the corticosteroids, he said. But the parameters drawn by this analysis of healthy, non-infected patients show this is a faulty assumption, he added.
The analysis covered 524 patients and 1,406 observations. Dr. Bauer and his coinvestigators did not report any financial disclosures.
WASHINGTON – Maternal leukocytosis after prenatal corticosteroid administration peaks at up to 24 hours after therapy, with the highest second standard deviation from the mean being 18.3 x 109/L, according to a systematic review and meta-analysis.
There has been limited data available on the magnitude and timing of leukocytosis after corticosteroid administration, making it difficult to interpret the significance of elevated white blood cell counts, Dr. Samuel Bauer, of Beaumont Health, Royal Oak, Mich., said at the annual meeting of the American College of Obstetricians and Gynecologists.
“We know corticosteroids cause leukocytosis, but we haven’t really known what the upper boundary is,” he said.
Driven by concerns about maternal sepsis and the ability to recognize early signs, Dr. Bauer and his colleagues identified six studies that reported white blood cell counts prior to corticosteroid administration, and between 24 and 96 hours afterward in healthy women with singleton gestations. The studies also met the inclusion criterion of having “excluded infected parturients between 23 and 34 weeks of gestation,” he said.
Mean maternal white blood cell count values prior to corticosteroid administration and up to 24 hours, 48 hours, 72 hours, and 96 hours after corticosteroid administration were 10.2, 13.7, 12.8, 11.5, and 11.1 x 109/L, respectively.
The highest second standard deviation from the mean of 18.3 x 109/L did not occur after 24 hours, he emphasized, and by 72 hours, mean values had returned to 11.5 x 109/L.
The findings need to be applied “cautiously” in practice, Dr. Bauer said, since the analysis did not include women with signs of infection and because some women who develop serious infections “have a very low white blood cell count.”
Still, the findings “establish a temporal trend and give us an upper boundary” for the level of leukocytosis that can be expected with prenatal corticosteroids. This can be helpful – along with other considerations – in determining whether an infectious workup is needed when white blood cell counts are high, he said in an interview.
It is not uncommon in clinical practice for maternal leukocytosis at 5-6 days or a week after corticosteroid administration to be attributed to the corticosteroids, he said. But the parameters drawn by this analysis of healthy, non-infected patients show this is a faulty assumption, he added.
The analysis covered 524 patients and 1,406 observations. Dr. Bauer and his coinvestigators did not report any financial disclosures.
WASHINGTON – Maternal leukocytosis after prenatal corticosteroid administration peaks at up to 24 hours after therapy, with the highest second standard deviation from the mean being 18.3 x 109/L, according to a systematic review and meta-analysis.
There has been limited data available on the magnitude and timing of leukocytosis after corticosteroid administration, making it difficult to interpret the significance of elevated white blood cell counts, Dr. Samuel Bauer, of Beaumont Health, Royal Oak, Mich., said at the annual meeting of the American College of Obstetricians and Gynecologists.
“We know corticosteroids cause leukocytosis, but we haven’t really known what the upper boundary is,” he said.
Driven by concerns about maternal sepsis and the ability to recognize early signs, Dr. Bauer and his colleagues identified six studies that reported white blood cell counts prior to corticosteroid administration, and between 24 and 96 hours afterward in healthy women with singleton gestations. The studies also met the inclusion criterion of having “excluded infected parturients between 23 and 34 weeks of gestation,” he said.
Mean maternal white blood cell count values prior to corticosteroid administration and up to 24 hours, 48 hours, 72 hours, and 96 hours after corticosteroid administration were 10.2, 13.7, 12.8, 11.5, and 11.1 x 109/L, respectively.
The highest second standard deviation from the mean of 18.3 x 109/L did not occur after 24 hours, he emphasized, and by 72 hours, mean values had returned to 11.5 x 109/L.
The findings need to be applied “cautiously” in practice, Dr. Bauer said, since the analysis did not include women with signs of infection and because some women who develop serious infections “have a very low white blood cell count.”
Still, the findings “establish a temporal trend and give us an upper boundary” for the level of leukocytosis that can be expected with prenatal corticosteroids. This can be helpful – along with other considerations – in determining whether an infectious workup is needed when white blood cell counts are high, he said in an interview.
It is not uncommon in clinical practice for maternal leukocytosis at 5-6 days or a week after corticosteroid administration to be attributed to the corticosteroids, he said. But the parameters drawn by this analysis of healthy, non-infected patients show this is a faulty assumption, he added.
The analysis covered 524 patients and 1,406 observations. Dr. Bauer and his coinvestigators did not report any financial disclosures.
AT ACOG 2016
Key clinical point: Leukocytosis attributable to prenatal corticosteroids, rather than infection, has a definable upper boundary.
Major finding: Maternal leukocytosis peaks at up to 24 hours after administration of antenatal corticosteroids. The highest second standard deviation from the mean was 18.3 x 109/L.
Data source: A systematic review and meta-analysis.
Disclosures: Dr. Bauer reported that he and his coinvestigators had no financial disclosures.
Remote prenatal care monitoring is a hit with patients
WASHINGTON – Is it time to reconsider the standard prenatal care model of 12-14 in-office prenatal visits?
As pregnant women increasingly use digital technology, and as the array of available health monitoring tools grows larger and smarter, the question looms.
Research findings reported at the annual meeting of the American College of Obstetricians and Gynecologists suggest that women with low-risk pregnancies have equivalent outcomes but are more satisfied with models that reduce the number of office visits and utilize remote monitoring.
At the Mayo Clinic in Rochester, Minn., 300 women deemed to have low-risk pregnancies were randomized to either 12 planned office visits with a physician or midwife, or to the clinic’s “OB Nest” model of care consisting of 8 planned clinic visits with a physician or midwife, 6 virtual visits with a nurse (by phone or email), home monitoring with an automatic blood pressure cuff and a hand-held fetal Doppler monitor, and access to an online prenatal care community.
The clinic’s OB Nest model “was born out of concern that the traditional model no longer met the needs of our patients,” said Dr. Yvonne S. Butler Tobah, a senior associate consultant to the department of obstetrics and gynecology at Mayo.
The goal, she said, is to “shift our prenatal clinic’s culture … to a wellness care model and to strengthen the autonomy, confidence, self-awareness and empowerment of our patients.”
Patients in the OB Nest group were encouraged to get blood pressure readings once a week, and weekly Doppler readings of fetal heart rate between weeks 12 and 28. They could use the cuff and monitor anytime they chose, however.
Values were recorded in a pregnancy journal – along with weight – and reported during the scheduled virtual visits. The patients could send in concerning readings or otherwise communicate with dedicated OB Nest nurses at any time they chose by phone or via an online portal. Emergencies were to be reported immediately.
The online prenatal care community is an invitation-only, Mayo-specific social platform, monitored by the OB Nest nurses, which gave patients the opportunity to share and discuss issues.
Patient satisfaction, as measured at 36 weeks with a 16-item validated satisfaction scale, was significantly higher in the OB Nest group; these patients had a mean score of 93.9 on a 1-100 point scale, compared with a mean score of 78.9 in the usual care group.
Levels of pregnancy-related stress – measured at three points in time with a 9-item prenatal maternal stress survey – were also significantly lower at 14 weeks and lower at 36 weeks in the OB Nest group compared with usual care. Stress levels were similar in both groups at 24 weeks.
Perceived quality of care was assessed at 36 weeks using a modified version of a prenatal processes-of-care scale that addressed communication and decision making, and no differences were observed.
“OB Nest significantly improved patient satisfaction with care and reduced maternal stress,” Dr. Tobah said. “And it did this while maintaining perceived quality of care and maintaining [safe] outcomes.”
The study was not sufficiently powered to detect statistically significant differences in clinical outcomes, which were the study’s secondary outcomes. However, there were no differences observed in maternal-fetal events or delivery outcomes, with the exception of a 4.5% rate of gestational diabetes in the OB Nest group, compared with none in the usual care group, Dr. Tobah explained.
Of the 150 patients randomized to each group, 19 and 20 were lost to follow-up in the OB Nest group and usual care group, respectively. Patients in the study had a mean age of 29, and the majority were white and married. “It was a highly educated, low-risk group,” she said. “Patients said [at the end] that they liked the general accessibility and consistent communication with a provider on an ongoing basis.”
While patients in the OB Nest group ultimately had 3.4 fewer in-office appointments than did usual care patients, they required more out-of-office nursing time and the length of in-office visits was significantly higher, Dr. Tobah noted.
In another study of remote prenatal care monitoring reported at the ACOG meeting, low-risk patients assigned to an alternative prenatal care schedule of 8 in-office visits supplemented with digital monitoring of blood pressure and weight similarly had higher patient satisfaction scores than did low-risk patients assigned to 14 prenatal visits.
Patient satisfaction was measured several times during pregnancy. Scores were significantly higher at 20 weeks in the 49-patient alternative care group “and evened out [with the 41-patient usual-care group] at the tail end of pregnancy,” said Dr. Nihar Ganju of George Washington University, Washington. “And there was no difference in pregnancy outcomes.”
This study used the Babyscripts mobile app connected to a wireless weight scale and a wireless blood pressure cuff. Patients were instructed to check their weight and blood pressure at least once a week.
They were “highly engaged,” Dr. Ganju said, checking their blood pressure a mean of 1.4 times weekly and their weight almost twice weekly. Providers received “four notifications of abnormal values,” he said.
Dr. Ganju and his colleagues are hopeful that the digital health tool “can really be effective in addressing the issue of excessive weight gain,” he said at the ACOG meeting. They are also beginning a study on remote monitoring for patients with chronic hypertension.
Findings on the effectiveness of remote personalized weight management are also expected to come from the soon-to-be-completed LIFE-Moms study, a national project looking at how overweight and obese women can best manage weight gain in pregnancy and improve their maternal and fetal outcomes.
Dr. Ganju reported having no disclosures. Two coauthors reported a nonfinancial advisory relationship with 1Eq Inc., the mobile app company that developed Babyscripts and helped fund the study. Another author is an employee of 1Eq. Dr. Tobah reported that she had no disclosures.
WASHINGTON – Is it time to reconsider the standard prenatal care model of 12-14 in-office prenatal visits?
As pregnant women increasingly use digital technology, and as the array of available health monitoring tools grows larger and smarter, the question looms.
Research findings reported at the annual meeting of the American College of Obstetricians and Gynecologists suggest that women with low-risk pregnancies have equivalent outcomes but are more satisfied with models that reduce the number of office visits and utilize remote monitoring.
At the Mayo Clinic in Rochester, Minn., 300 women deemed to have low-risk pregnancies were randomized to either 12 planned office visits with a physician or midwife, or to the clinic’s “OB Nest” model of care consisting of 8 planned clinic visits with a physician or midwife, 6 virtual visits with a nurse (by phone or email), home monitoring with an automatic blood pressure cuff and a hand-held fetal Doppler monitor, and access to an online prenatal care community.
The clinic’s OB Nest model “was born out of concern that the traditional model no longer met the needs of our patients,” said Dr. Yvonne S. Butler Tobah, a senior associate consultant to the department of obstetrics and gynecology at Mayo.
The goal, she said, is to “shift our prenatal clinic’s culture … to a wellness care model and to strengthen the autonomy, confidence, self-awareness and empowerment of our patients.”
Patients in the OB Nest group were encouraged to get blood pressure readings once a week, and weekly Doppler readings of fetal heart rate between weeks 12 and 28. They could use the cuff and monitor anytime they chose, however.
Values were recorded in a pregnancy journal – along with weight – and reported during the scheduled virtual visits. The patients could send in concerning readings or otherwise communicate with dedicated OB Nest nurses at any time they chose by phone or via an online portal. Emergencies were to be reported immediately.
The online prenatal care community is an invitation-only, Mayo-specific social platform, monitored by the OB Nest nurses, which gave patients the opportunity to share and discuss issues.
Patient satisfaction, as measured at 36 weeks with a 16-item validated satisfaction scale, was significantly higher in the OB Nest group; these patients had a mean score of 93.9 on a 1-100 point scale, compared with a mean score of 78.9 in the usual care group.
Levels of pregnancy-related stress – measured at three points in time with a 9-item prenatal maternal stress survey – were also significantly lower at 14 weeks and lower at 36 weeks in the OB Nest group compared with usual care. Stress levels were similar in both groups at 24 weeks.
Perceived quality of care was assessed at 36 weeks using a modified version of a prenatal processes-of-care scale that addressed communication and decision making, and no differences were observed.
“OB Nest significantly improved patient satisfaction with care and reduced maternal stress,” Dr. Tobah said. “And it did this while maintaining perceived quality of care and maintaining [safe] outcomes.”
The study was not sufficiently powered to detect statistically significant differences in clinical outcomes, which were the study’s secondary outcomes. However, there were no differences observed in maternal-fetal events or delivery outcomes, with the exception of a 4.5% rate of gestational diabetes in the OB Nest group, compared with none in the usual care group, Dr. Tobah explained.
Of the 150 patients randomized to each group, 19 and 20 were lost to follow-up in the OB Nest group and usual care group, respectively. Patients in the study had a mean age of 29, and the majority were white and married. “It was a highly educated, low-risk group,” she said. “Patients said [at the end] that they liked the general accessibility and consistent communication with a provider on an ongoing basis.”
While patients in the OB Nest group ultimately had 3.4 fewer in-office appointments than did usual care patients, they required more out-of-office nursing time and the length of in-office visits was significantly higher, Dr. Tobah noted.
In another study of remote prenatal care monitoring reported at the ACOG meeting, low-risk patients assigned to an alternative prenatal care schedule of 8 in-office visits supplemented with digital monitoring of blood pressure and weight similarly had higher patient satisfaction scores than did low-risk patients assigned to 14 prenatal visits.
Patient satisfaction was measured several times during pregnancy. Scores were significantly higher at 20 weeks in the 49-patient alternative care group “and evened out [with the 41-patient usual-care group] at the tail end of pregnancy,” said Dr. Nihar Ganju of George Washington University, Washington. “And there was no difference in pregnancy outcomes.”
This study used the Babyscripts mobile app connected to a wireless weight scale and a wireless blood pressure cuff. Patients were instructed to check their weight and blood pressure at least once a week.
They were “highly engaged,” Dr. Ganju said, checking their blood pressure a mean of 1.4 times weekly and their weight almost twice weekly. Providers received “four notifications of abnormal values,” he said.
Dr. Ganju and his colleagues are hopeful that the digital health tool “can really be effective in addressing the issue of excessive weight gain,” he said at the ACOG meeting. They are also beginning a study on remote monitoring for patients with chronic hypertension.
Findings on the effectiveness of remote personalized weight management are also expected to come from the soon-to-be-completed LIFE-Moms study, a national project looking at how overweight and obese women can best manage weight gain in pregnancy and improve their maternal and fetal outcomes.
Dr. Ganju reported having no disclosures. Two coauthors reported a nonfinancial advisory relationship with 1Eq Inc., the mobile app company that developed Babyscripts and helped fund the study. Another author is an employee of 1Eq. Dr. Tobah reported that she had no disclosures.
WASHINGTON – Is it time to reconsider the standard prenatal care model of 12-14 in-office prenatal visits?
As pregnant women increasingly use digital technology, and as the array of available health monitoring tools grows larger and smarter, the question looms.
Research findings reported at the annual meeting of the American College of Obstetricians and Gynecologists suggest that women with low-risk pregnancies have equivalent outcomes but are more satisfied with models that reduce the number of office visits and utilize remote monitoring.
At the Mayo Clinic in Rochester, Minn., 300 women deemed to have low-risk pregnancies were randomized to either 12 planned office visits with a physician or midwife, or to the clinic’s “OB Nest” model of care consisting of 8 planned clinic visits with a physician or midwife, 6 virtual visits with a nurse (by phone or email), home monitoring with an automatic blood pressure cuff and a hand-held fetal Doppler monitor, and access to an online prenatal care community.
The clinic’s OB Nest model “was born out of concern that the traditional model no longer met the needs of our patients,” said Dr. Yvonne S. Butler Tobah, a senior associate consultant to the department of obstetrics and gynecology at Mayo.
The goal, she said, is to “shift our prenatal clinic’s culture … to a wellness care model and to strengthen the autonomy, confidence, self-awareness and empowerment of our patients.”
Patients in the OB Nest group were encouraged to get blood pressure readings once a week, and weekly Doppler readings of fetal heart rate between weeks 12 and 28. They could use the cuff and monitor anytime they chose, however.
Values were recorded in a pregnancy journal – along with weight – and reported during the scheduled virtual visits. The patients could send in concerning readings or otherwise communicate with dedicated OB Nest nurses at any time they chose by phone or via an online portal. Emergencies were to be reported immediately.
The online prenatal care community is an invitation-only, Mayo-specific social platform, monitored by the OB Nest nurses, which gave patients the opportunity to share and discuss issues.
Patient satisfaction, as measured at 36 weeks with a 16-item validated satisfaction scale, was significantly higher in the OB Nest group; these patients had a mean score of 93.9 on a 1-100 point scale, compared with a mean score of 78.9 in the usual care group.
Levels of pregnancy-related stress – measured at three points in time with a 9-item prenatal maternal stress survey – were also significantly lower at 14 weeks and lower at 36 weeks in the OB Nest group compared with usual care. Stress levels were similar in both groups at 24 weeks.
Perceived quality of care was assessed at 36 weeks using a modified version of a prenatal processes-of-care scale that addressed communication and decision making, and no differences were observed.
“OB Nest significantly improved patient satisfaction with care and reduced maternal stress,” Dr. Tobah said. “And it did this while maintaining perceived quality of care and maintaining [safe] outcomes.”
The study was not sufficiently powered to detect statistically significant differences in clinical outcomes, which were the study’s secondary outcomes. However, there were no differences observed in maternal-fetal events or delivery outcomes, with the exception of a 4.5% rate of gestational diabetes in the OB Nest group, compared with none in the usual care group, Dr. Tobah explained.
Of the 150 patients randomized to each group, 19 and 20 were lost to follow-up in the OB Nest group and usual care group, respectively. Patients in the study had a mean age of 29, and the majority were white and married. “It was a highly educated, low-risk group,” she said. “Patients said [at the end] that they liked the general accessibility and consistent communication with a provider on an ongoing basis.”
While patients in the OB Nest group ultimately had 3.4 fewer in-office appointments than did usual care patients, they required more out-of-office nursing time and the length of in-office visits was significantly higher, Dr. Tobah noted.
In another study of remote prenatal care monitoring reported at the ACOG meeting, low-risk patients assigned to an alternative prenatal care schedule of 8 in-office visits supplemented with digital monitoring of blood pressure and weight similarly had higher patient satisfaction scores than did low-risk patients assigned to 14 prenatal visits.
Patient satisfaction was measured several times during pregnancy. Scores were significantly higher at 20 weeks in the 49-patient alternative care group “and evened out [with the 41-patient usual-care group] at the tail end of pregnancy,” said Dr. Nihar Ganju of George Washington University, Washington. “And there was no difference in pregnancy outcomes.”
This study used the Babyscripts mobile app connected to a wireless weight scale and a wireless blood pressure cuff. Patients were instructed to check their weight and blood pressure at least once a week.
They were “highly engaged,” Dr. Ganju said, checking their blood pressure a mean of 1.4 times weekly and their weight almost twice weekly. Providers received “four notifications of abnormal values,” he said.
Dr. Ganju and his colleagues are hopeful that the digital health tool “can really be effective in addressing the issue of excessive weight gain,” he said at the ACOG meeting. They are also beginning a study on remote monitoring for patients with chronic hypertension.
Findings on the effectiveness of remote personalized weight management are also expected to come from the soon-to-be-completed LIFE-Moms study, a national project looking at how overweight and obese women can best manage weight gain in pregnancy and improve their maternal and fetal outcomes.
Dr. Ganju reported having no disclosures. Two coauthors reported a nonfinancial advisory relationship with 1Eq Inc., the mobile app company that developed Babyscripts and helped fund the study. Another author is an employee of 1Eq. Dr. Tobah reported that she had no disclosures.
AT ACOG 2016
Key clinical point: Patient satisfaction improves with reduced clinic visits supplemented with remote monitoring.
Major finding: Patient satisfaction scores were significantly higher in alternative care groups, compared with usual care groups (12-14 in-office visits) in two studies.
Data source: A 300-patient randomized controlled trial of the OB Nest model at the Mayo Clinic, Rochester, Minn., and a 90-patient controlled study involving the Babyscripts tool at George Washington University, Washington.
Disclosures: Dr. Ganju reported having no disclosures. Two coauthors reported a nonfinancial advisory relationship with 1Eq Inc., the mobile app company that developed Babyscripts and helped fund the study. Another author is an employee of 1Eq. Dr. Tobah reported that she had no disclosures.
Sodium fluorescein emerges as alternative to indigo carmine in cystoscopy
WASHINGTON – Sodium fluorescein is proving to be an excellent agent for helping to verify ureteral efflux during intraoperative cystoscopy, Dr. Jay Goldberg said at the annual meeting of the American College of Obstetricians and Gynecologists.
Dr. Goldberg said he first read about the use of the dye as an alternative to indigo carmine, which is no longer available, in a study published in 2015; the study reported good results with a 10% preparation of sodium fluorescein administered at 0.25-1 mL intravenously during intraoperative cystoscopy (Obstet Gynecol. 2015 Mar;125[3]:548-50).
Since then, he and his colleagues at Einstein Medical Center, Philadelphia, have been evaluating the use of 0.1 mL of 10% sodium fluorescein IV during cystoscopies performed at the end of gynecologic surgeries, measuring the time to visualization and the level of satisfaction with the dye.
Thus far, in more than 50 cases, the average time until colored ureteral jets were seen has been 4.3 minutes (a range of 2-6.8 minutes, consistent with the 2015 study). And according to questionnaires completed by each surgeon, the degree of certainty for visualizing the ureteral jets was improved with fluorescein (a rating of 5 on a 5-point scale, compared with 2.9 without the dye).
Compared with both indigo carmine and methylene blue, fluorescein was preferred, Dr. Goldberg reported, with surgeons citing quicker onset, better color contrast, cheaper cost, and fewer side effects.
“Given that it’s at least equivalent and probably better, and that it’s 50 times cheaper [than indigo carmine], even if indigo carmine comes back again, I’m certainly not going to be switching back,” Dr. Goldberg said during a seminar on cystoscopy after hysterectomy.
Intravenous sodium fluorescein is routinely used in ophthalmology in retinal angiography, at a dosage of 5 mL of 10% fluorescein, he said. The most common complications reported in the literature are nausea, vomiting, and flushing or rash (rates of 2.9%, 1.2%, and 0.5%, respectively, according to a 1991 report). None of their patients has experienced any complications, Dr. Goldberg said.
Methylene blue (50 mg IV over a period of 5 minutes) appears to have been a common go-to dye for gynecologic surgeons, along with pyridium (a 200-mg oral dose prior to surgery), ever since production of indigo carmine was discontinued because of a lack of raw material.
“But with methylene blue, it may take longer to see the blue urine efflux from the ureteral orifices,” Dr. Goldberg said. And with pyridium, “by the time cystoscopy is performed, the bladder will have already been stained orange, making it more difficult to see the same colored urine jets.”
“Sodium fluorescein is very quick in onset. I wait [to have it administered] until I am actually ready to insert the cystoscope,” he said.
And at 60 cents per dose, fluorescein is less expensive than methylene blue ($1.50) and significantly less expensive than indigo carmine ($30 a dose), he said.
Dr. Goldberg reported having no relevant financial conflicts.
WASHINGTON – Sodium fluorescein is proving to be an excellent agent for helping to verify ureteral efflux during intraoperative cystoscopy, Dr. Jay Goldberg said at the annual meeting of the American College of Obstetricians and Gynecologists.
Dr. Goldberg said he first read about the use of the dye as an alternative to indigo carmine, which is no longer available, in a study published in 2015; the study reported good results with a 10% preparation of sodium fluorescein administered at 0.25-1 mL intravenously during intraoperative cystoscopy (Obstet Gynecol. 2015 Mar;125[3]:548-50).
Since then, he and his colleagues at Einstein Medical Center, Philadelphia, have been evaluating the use of 0.1 mL of 10% sodium fluorescein IV during cystoscopies performed at the end of gynecologic surgeries, measuring the time to visualization and the level of satisfaction with the dye.
Thus far, in more than 50 cases, the average time until colored ureteral jets were seen has been 4.3 minutes (a range of 2-6.8 minutes, consistent with the 2015 study). And according to questionnaires completed by each surgeon, the degree of certainty for visualizing the ureteral jets was improved with fluorescein (a rating of 5 on a 5-point scale, compared with 2.9 without the dye).
Compared with both indigo carmine and methylene blue, fluorescein was preferred, Dr. Goldberg reported, with surgeons citing quicker onset, better color contrast, cheaper cost, and fewer side effects.
“Given that it’s at least equivalent and probably better, and that it’s 50 times cheaper [than indigo carmine], even if indigo carmine comes back again, I’m certainly not going to be switching back,” Dr. Goldberg said during a seminar on cystoscopy after hysterectomy.
Intravenous sodium fluorescein is routinely used in ophthalmology in retinal angiography, at a dosage of 5 mL of 10% fluorescein, he said. The most common complications reported in the literature are nausea, vomiting, and flushing or rash (rates of 2.9%, 1.2%, and 0.5%, respectively, according to a 1991 report). None of their patients has experienced any complications, Dr. Goldberg said.
Methylene blue (50 mg IV over a period of 5 minutes) appears to have been a common go-to dye for gynecologic surgeons, along with pyridium (a 200-mg oral dose prior to surgery), ever since production of indigo carmine was discontinued because of a lack of raw material.
“But with methylene blue, it may take longer to see the blue urine efflux from the ureteral orifices,” Dr. Goldberg said. And with pyridium, “by the time cystoscopy is performed, the bladder will have already been stained orange, making it more difficult to see the same colored urine jets.”
“Sodium fluorescein is very quick in onset. I wait [to have it administered] until I am actually ready to insert the cystoscope,” he said.
And at 60 cents per dose, fluorescein is less expensive than methylene blue ($1.50) and significantly less expensive than indigo carmine ($30 a dose), he said.
Dr. Goldberg reported having no relevant financial conflicts.
WASHINGTON – Sodium fluorescein is proving to be an excellent agent for helping to verify ureteral efflux during intraoperative cystoscopy, Dr. Jay Goldberg said at the annual meeting of the American College of Obstetricians and Gynecologists.
Dr. Goldberg said he first read about the use of the dye as an alternative to indigo carmine, which is no longer available, in a study published in 2015; the study reported good results with a 10% preparation of sodium fluorescein administered at 0.25-1 mL intravenously during intraoperative cystoscopy (Obstet Gynecol. 2015 Mar;125[3]:548-50).
Since then, he and his colleagues at Einstein Medical Center, Philadelphia, have been evaluating the use of 0.1 mL of 10% sodium fluorescein IV during cystoscopies performed at the end of gynecologic surgeries, measuring the time to visualization and the level of satisfaction with the dye.
Thus far, in more than 50 cases, the average time until colored ureteral jets were seen has been 4.3 minutes (a range of 2-6.8 minutes, consistent with the 2015 study). And according to questionnaires completed by each surgeon, the degree of certainty for visualizing the ureteral jets was improved with fluorescein (a rating of 5 on a 5-point scale, compared with 2.9 without the dye).
Compared with both indigo carmine and methylene blue, fluorescein was preferred, Dr. Goldberg reported, with surgeons citing quicker onset, better color contrast, cheaper cost, and fewer side effects.
“Given that it’s at least equivalent and probably better, and that it’s 50 times cheaper [than indigo carmine], even if indigo carmine comes back again, I’m certainly not going to be switching back,” Dr. Goldberg said during a seminar on cystoscopy after hysterectomy.
Intravenous sodium fluorescein is routinely used in ophthalmology in retinal angiography, at a dosage of 5 mL of 10% fluorescein, he said. The most common complications reported in the literature are nausea, vomiting, and flushing or rash (rates of 2.9%, 1.2%, and 0.5%, respectively, according to a 1991 report). None of their patients has experienced any complications, Dr. Goldberg said.
Methylene blue (50 mg IV over a period of 5 minutes) appears to have been a common go-to dye for gynecologic surgeons, along with pyridium (a 200-mg oral dose prior to surgery), ever since production of indigo carmine was discontinued because of a lack of raw material.
“But with methylene blue, it may take longer to see the blue urine efflux from the ureteral orifices,” Dr. Goldberg said. And with pyridium, “by the time cystoscopy is performed, the bladder will have already been stained orange, making it more difficult to see the same colored urine jets.”
“Sodium fluorescein is very quick in onset. I wait [to have it administered] until I am actually ready to insert the cystoscope,” he said.
And at 60 cents per dose, fluorescein is less expensive than methylene blue ($1.50) and significantly less expensive than indigo carmine ($30 a dose), he said.
Dr. Goldberg reported having no relevant financial conflicts.
AT ACOG 2016
Key clinical point: Sodium fluorescein is an effective, and possibly superior, alternative to the unavailable indigo carmine.Major finding: In more than 50 cases of intraoperative cystoscopy, the average time from intravenous administration of the dye to visualization of colored ureteral jets has been 4.3 minutes.
Data source: An observational study of more than 50 cystoscopies.
Disclosures: Dr. Goldberg and his colleagues reported having no relevant financial conflicts.
Cystoscopy after hysterectomy: Consider more frequent use
WASHINGTON – Universal cystoscopy at the time of hysterectomy – or at least more frequent use of the procedure – is worth considering since delayed diagnosis of urinary tract injury causes increased morbidity for patients, and in all likelihood increases litigation, Dr. Jay Goldberg and Dr. Cheung Kim suggested at the annual meeting of the American College of Obstetricians and Gynecologists.
“We’re often hesitant to do cystoscopy because we don’t want to add time,” said Dr. Kim. “But I always feel that no matter how much time it takes, I’ll be happier in the end if I do it. [And] if you have [experience], a routine, and readily available equipment, it can take as little as 10 minutes.”
Universal cystoscopy to confirm ureteral patency is “fairly straightforward, low risk, and more likely to detect most injuries [than visual inspection alone], particularly ureteral injuries,” Dr. Kim said. On the other hand, it adds to operating time and increases procedure cost, and there is some research suggesting it may be relatively “low yield” and lead to some false positives.
Dr. Kim and Dr. Goldberg both practice at the Einstein Healthcare Network in Philadelphia. Here are some of the findings they shared, and advice they gave, on the use of cystoscopy – universal or selective – after hysterectomy.
Conflicting findings
There is conflicting opinion as to whether universal or selective cystoscopy after hysterectomy is best, and “there’s data on both sides,” said Dr. Goldberg, vice chairman of ob.gyn. and director of the Philadelphia Fibroid Center at Einstein.
A prospective study done at Louisiana State University, New Orleans, to evaluate the impact of a universal approach, for instance, showed an incidence of urinary tract injury of 4.3% (2.9% bladder injury, 1.8% ureteral injury, plus cases of simultaneous injury) in 839 hysterectomies for benign disease. The injury detection rate using intraoperative cystoscopy was 97.4%, and the majority of injuries – 76% – were not suspected prior to cystoscopy being performed (Obstet Gynecol. 2009 Jan;113[1]:6-10).
But researchers in Boston who looked retrospectively at 1,982 hysterectomies performed for any gynecologic indication found a much lower incidence of complications, and reported that cystoscopy did not detect any of the bladder injuries (0.71%) or ureteral injuries (0.25%) incurred in the group. Cystoscopy was performed selectively, however, in 250 of the patients, and was either normal or omitted in the patients who had complications (Obstet Gynecol. 2012 Dec;120[6]:1363-70).
Cystoscopy failed to detect any of the bladder injuries, but “all five of the ureteral injuries occurred in patients who had not undergone cystoscopy,” said Dr. Kim, chairman of ob.gyn. at Einstein Medical Center Montgomery in East Norriton, Pa.
Possible false-positives
Cystoscopy may lead on occasion to an incorrect presumption of a ureteral injury in patients with a pre-existing nonfunctional kidney, Dr. Goldberg noted.
He relayed the case of a 42-year-old patient who underwent a total abdominal hysterectomy without apparent complication. Cystoscopy was then performed with indigo carmine. An efflux of dye was seen from the left ureteral orifice but not from the right orifice.
Urology was consulted and investigated the presumed ureteral injury with additional surgical exploration. An intraoperative intravenous pyelogram (IVP) was eventually performed and was unable to identify the right kidney. A CT then showed an atrophic right kidney with compensatory hypertrophy of the left kidney, probably due to congenital right multicystic dysplastic kidney.
An estimated 0.2% of the population – 1 in 500 – will have a unilateral nonfunctional kidney, the majority of which have not been previously diagnosed. Etiologies include multicystic dysplastic kidney, congenital unilateral renal agenesis, and vascular events. “As we do more and more cystoscopies, this scenario is going to come up every so often,” said Dr. Goldberg, who reported on two such cases last year (Obstet Gynecol. 2015 Sep;126[3]:635-7).
It is also possible, Dr. Kim noted, that a weak urine jet observed on cystoscopy may not necessarily reflect injury. In the LSU study evaluating a universal approach, there was no injury detected on further evaluation in each of the 21 cases of low, subnormal dye efflux from the ureteral orifices. “So it’s not a benign process to undergo cystoscopy in terms of what the ramifications might be,” Dr. Kim said.
Increasing use
Ob.gyn. residents are required by the Accreditation Council for Graduate Medical Education to have completed 15 cystoscopies by the time they graduate, and according to recent survey findings, residents are more likely to utilize universal cystoscopy at the time of hysterectomy than currently practicing gynecologic surgeons.
The survey of ob.gyn residents (n = 56) shows universal cystoscopy (defined as greater than 90%) was performed in only a minority of cases during residency: 27% of total laparoscopic hysterectomies (TLH), 14% of laparoscopically assisted vaginal hysterectomies (LAVH), 12% of vaginal hysterectomies (VH), 2% of total abdominal hysterectomies (TAH), and 0% of supracervical hysterectomies (SCH), for instance.
Yet for every hysterectomy type, residents planned to perform universal cystoscopy post-residency more often than they had during their training (49% TLH, 34% LAVH, 34% VH, 15% TAH, 12% SCH), and “residents familiar with the literature on cystoscopy were statistically more likely to plan to perform universal cystoscopy,” said Dr. Goldberg, the senior author of the paper (Womens Health (Lond Engl). 2015 Nov;11[6]:825-31).
Litigation possible
Failure to detect a urinary tract injury at the time of hysterectomy may result in the need for future additional surgeries. Litigation in the Philadelphia market suggests that “if you have an injury that’s missed, there’s a chance that litigation may result,” Dr. Kim said.
Plaintiff’s attorneys have argued that not recognizing ureteral injury during surgery is a deviation from acceptable practice, while defense attorneys have contended that unavoidable complications occur and that no evaluation is required, or supported by the medical literature, when injury is not intraoperatively suspected. Currently, as cystoscopy is performed less than 25% of the time for all types of hysterectomy, the standard of care does not require the procedure intraoperatively if no injury is suspected, Dr. Goldberg said.
Primary prevention of urinary tract injury is most important, both physicians emphasized. The best way to accomplish this is to meticulously identify the anatomy and know the path of the ureter, and to document that the ureter has been identified and viewed as outside of the operative area, they said.
Dr. Kim and Dr. Goldberg reported having no relevant financial disclosures.
WASHINGTON – Universal cystoscopy at the time of hysterectomy – or at least more frequent use of the procedure – is worth considering since delayed diagnosis of urinary tract injury causes increased morbidity for patients, and in all likelihood increases litigation, Dr. Jay Goldberg and Dr. Cheung Kim suggested at the annual meeting of the American College of Obstetricians and Gynecologists.
“We’re often hesitant to do cystoscopy because we don’t want to add time,” said Dr. Kim. “But I always feel that no matter how much time it takes, I’ll be happier in the end if I do it. [And] if you have [experience], a routine, and readily available equipment, it can take as little as 10 minutes.”
Universal cystoscopy to confirm ureteral patency is “fairly straightforward, low risk, and more likely to detect most injuries [than visual inspection alone], particularly ureteral injuries,” Dr. Kim said. On the other hand, it adds to operating time and increases procedure cost, and there is some research suggesting it may be relatively “low yield” and lead to some false positives.
Dr. Kim and Dr. Goldberg both practice at the Einstein Healthcare Network in Philadelphia. Here are some of the findings they shared, and advice they gave, on the use of cystoscopy – universal or selective – after hysterectomy.
Conflicting findings
There is conflicting opinion as to whether universal or selective cystoscopy after hysterectomy is best, and “there’s data on both sides,” said Dr. Goldberg, vice chairman of ob.gyn. and director of the Philadelphia Fibroid Center at Einstein.
A prospective study done at Louisiana State University, New Orleans, to evaluate the impact of a universal approach, for instance, showed an incidence of urinary tract injury of 4.3% (2.9% bladder injury, 1.8% ureteral injury, plus cases of simultaneous injury) in 839 hysterectomies for benign disease. The injury detection rate using intraoperative cystoscopy was 97.4%, and the majority of injuries – 76% – were not suspected prior to cystoscopy being performed (Obstet Gynecol. 2009 Jan;113[1]:6-10).
But researchers in Boston who looked retrospectively at 1,982 hysterectomies performed for any gynecologic indication found a much lower incidence of complications, and reported that cystoscopy did not detect any of the bladder injuries (0.71%) or ureteral injuries (0.25%) incurred in the group. Cystoscopy was performed selectively, however, in 250 of the patients, and was either normal or omitted in the patients who had complications (Obstet Gynecol. 2012 Dec;120[6]:1363-70).
Cystoscopy failed to detect any of the bladder injuries, but “all five of the ureteral injuries occurred in patients who had not undergone cystoscopy,” said Dr. Kim, chairman of ob.gyn. at Einstein Medical Center Montgomery in East Norriton, Pa.
Possible false-positives
Cystoscopy may lead on occasion to an incorrect presumption of a ureteral injury in patients with a pre-existing nonfunctional kidney, Dr. Goldberg noted.
He relayed the case of a 42-year-old patient who underwent a total abdominal hysterectomy without apparent complication. Cystoscopy was then performed with indigo carmine. An efflux of dye was seen from the left ureteral orifice but not from the right orifice.
Urology was consulted and investigated the presumed ureteral injury with additional surgical exploration. An intraoperative intravenous pyelogram (IVP) was eventually performed and was unable to identify the right kidney. A CT then showed an atrophic right kidney with compensatory hypertrophy of the left kidney, probably due to congenital right multicystic dysplastic kidney.
An estimated 0.2% of the population – 1 in 500 – will have a unilateral nonfunctional kidney, the majority of which have not been previously diagnosed. Etiologies include multicystic dysplastic kidney, congenital unilateral renal agenesis, and vascular events. “As we do more and more cystoscopies, this scenario is going to come up every so often,” said Dr. Goldberg, who reported on two such cases last year (Obstet Gynecol. 2015 Sep;126[3]:635-7).
It is also possible, Dr. Kim noted, that a weak urine jet observed on cystoscopy may not necessarily reflect injury. In the LSU study evaluating a universal approach, there was no injury detected on further evaluation in each of the 21 cases of low, subnormal dye efflux from the ureteral orifices. “So it’s not a benign process to undergo cystoscopy in terms of what the ramifications might be,” Dr. Kim said.
Increasing use
Ob.gyn. residents are required by the Accreditation Council for Graduate Medical Education to have completed 15 cystoscopies by the time they graduate, and according to recent survey findings, residents are more likely to utilize universal cystoscopy at the time of hysterectomy than currently practicing gynecologic surgeons.
The survey of ob.gyn residents (n = 56) shows universal cystoscopy (defined as greater than 90%) was performed in only a minority of cases during residency: 27% of total laparoscopic hysterectomies (TLH), 14% of laparoscopically assisted vaginal hysterectomies (LAVH), 12% of vaginal hysterectomies (VH), 2% of total abdominal hysterectomies (TAH), and 0% of supracervical hysterectomies (SCH), for instance.
Yet for every hysterectomy type, residents planned to perform universal cystoscopy post-residency more often than they had during their training (49% TLH, 34% LAVH, 34% VH, 15% TAH, 12% SCH), and “residents familiar with the literature on cystoscopy were statistically more likely to plan to perform universal cystoscopy,” said Dr. Goldberg, the senior author of the paper (Womens Health (Lond Engl). 2015 Nov;11[6]:825-31).
Litigation possible
Failure to detect a urinary tract injury at the time of hysterectomy may result in the need for future additional surgeries. Litigation in the Philadelphia market suggests that “if you have an injury that’s missed, there’s a chance that litigation may result,” Dr. Kim said.
Plaintiff’s attorneys have argued that not recognizing ureteral injury during surgery is a deviation from acceptable practice, while defense attorneys have contended that unavoidable complications occur and that no evaluation is required, or supported by the medical literature, when injury is not intraoperatively suspected. Currently, as cystoscopy is performed less than 25% of the time for all types of hysterectomy, the standard of care does not require the procedure intraoperatively if no injury is suspected, Dr. Goldberg said.
Primary prevention of urinary tract injury is most important, both physicians emphasized. The best way to accomplish this is to meticulously identify the anatomy and know the path of the ureter, and to document that the ureter has been identified and viewed as outside of the operative area, they said.
Dr. Kim and Dr. Goldberg reported having no relevant financial disclosures.
WASHINGTON – Universal cystoscopy at the time of hysterectomy – or at least more frequent use of the procedure – is worth considering since delayed diagnosis of urinary tract injury causes increased morbidity for patients, and in all likelihood increases litigation, Dr. Jay Goldberg and Dr. Cheung Kim suggested at the annual meeting of the American College of Obstetricians and Gynecologists.
“We’re often hesitant to do cystoscopy because we don’t want to add time,” said Dr. Kim. “But I always feel that no matter how much time it takes, I’ll be happier in the end if I do it. [And] if you have [experience], a routine, and readily available equipment, it can take as little as 10 minutes.”
Universal cystoscopy to confirm ureteral patency is “fairly straightforward, low risk, and more likely to detect most injuries [than visual inspection alone], particularly ureteral injuries,” Dr. Kim said. On the other hand, it adds to operating time and increases procedure cost, and there is some research suggesting it may be relatively “low yield” and lead to some false positives.
Dr. Kim and Dr. Goldberg both practice at the Einstein Healthcare Network in Philadelphia. Here are some of the findings they shared, and advice they gave, on the use of cystoscopy – universal or selective – after hysterectomy.
Conflicting findings
There is conflicting opinion as to whether universal or selective cystoscopy after hysterectomy is best, and “there’s data on both sides,” said Dr. Goldberg, vice chairman of ob.gyn. and director of the Philadelphia Fibroid Center at Einstein.
A prospective study done at Louisiana State University, New Orleans, to evaluate the impact of a universal approach, for instance, showed an incidence of urinary tract injury of 4.3% (2.9% bladder injury, 1.8% ureteral injury, plus cases of simultaneous injury) in 839 hysterectomies for benign disease. The injury detection rate using intraoperative cystoscopy was 97.4%, and the majority of injuries – 76% – were not suspected prior to cystoscopy being performed (Obstet Gynecol. 2009 Jan;113[1]:6-10).
But researchers in Boston who looked retrospectively at 1,982 hysterectomies performed for any gynecologic indication found a much lower incidence of complications, and reported that cystoscopy did not detect any of the bladder injuries (0.71%) or ureteral injuries (0.25%) incurred in the group. Cystoscopy was performed selectively, however, in 250 of the patients, and was either normal or omitted in the patients who had complications (Obstet Gynecol. 2012 Dec;120[6]:1363-70).
Cystoscopy failed to detect any of the bladder injuries, but “all five of the ureteral injuries occurred in patients who had not undergone cystoscopy,” said Dr. Kim, chairman of ob.gyn. at Einstein Medical Center Montgomery in East Norriton, Pa.
Possible false-positives
Cystoscopy may lead on occasion to an incorrect presumption of a ureteral injury in patients with a pre-existing nonfunctional kidney, Dr. Goldberg noted.
He relayed the case of a 42-year-old patient who underwent a total abdominal hysterectomy without apparent complication. Cystoscopy was then performed with indigo carmine. An efflux of dye was seen from the left ureteral orifice but not from the right orifice.
Urology was consulted and investigated the presumed ureteral injury with additional surgical exploration. An intraoperative intravenous pyelogram (IVP) was eventually performed and was unable to identify the right kidney. A CT then showed an atrophic right kidney with compensatory hypertrophy of the left kidney, probably due to congenital right multicystic dysplastic kidney.
An estimated 0.2% of the population – 1 in 500 – will have a unilateral nonfunctional kidney, the majority of which have not been previously diagnosed. Etiologies include multicystic dysplastic kidney, congenital unilateral renal agenesis, and vascular events. “As we do more and more cystoscopies, this scenario is going to come up every so often,” said Dr. Goldberg, who reported on two such cases last year (Obstet Gynecol. 2015 Sep;126[3]:635-7).
It is also possible, Dr. Kim noted, that a weak urine jet observed on cystoscopy may not necessarily reflect injury. In the LSU study evaluating a universal approach, there was no injury detected on further evaluation in each of the 21 cases of low, subnormal dye efflux from the ureteral orifices. “So it’s not a benign process to undergo cystoscopy in terms of what the ramifications might be,” Dr. Kim said.
Increasing use
Ob.gyn. residents are required by the Accreditation Council for Graduate Medical Education to have completed 15 cystoscopies by the time they graduate, and according to recent survey findings, residents are more likely to utilize universal cystoscopy at the time of hysterectomy than currently practicing gynecologic surgeons.
The survey of ob.gyn residents (n = 56) shows universal cystoscopy (defined as greater than 90%) was performed in only a minority of cases during residency: 27% of total laparoscopic hysterectomies (TLH), 14% of laparoscopically assisted vaginal hysterectomies (LAVH), 12% of vaginal hysterectomies (VH), 2% of total abdominal hysterectomies (TAH), and 0% of supracervical hysterectomies (SCH), for instance.
Yet for every hysterectomy type, residents planned to perform universal cystoscopy post-residency more often than they had during their training (49% TLH, 34% LAVH, 34% VH, 15% TAH, 12% SCH), and “residents familiar with the literature on cystoscopy were statistically more likely to plan to perform universal cystoscopy,” said Dr. Goldberg, the senior author of the paper (Womens Health (Lond Engl). 2015 Nov;11[6]:825-31).
Litigation possible
Failure to detect a urinary tract injury at the time of hysterectomy may result in the need for future additional surgeries. Litigation in the Philadelphia market suggests that “if you have an injury that’s missed, there’s a chance that litigation may result,” Dr. Kim said.
Plaintiff’s attorneys have argued that not recognizing ureteral injury during surgery is a deviation from acceptable practice, while defense attorneys have contended that unavoidable complications occur and that no evaluation is required, or supported by the medical literature, when injury is not intraoperatively suspected. Currently, as cystoscopy is performed less than 25% of the time for all types of hysterectomy, the standard of care does not require the procedure intraoperatively if no injury is suspected, Dr. Goldberg said.
Primary prevention of urinary tract injury is most important, both physicians emphasized. The best way to accomplish this is to meticulously identify the anatomy and know the path of the ureter, and to document that the ureter has been identified and viewed as outside of the operative area, they said.
Dr. Kim and Dr. Goldberg reported having no relevant financial disclosures.
EXPERT ANALYSIS FROM ACOG 2016
Care bundle reduces cesarean surgical site infections
WASHINGTON – The rate of cesarean delivery surgical site infections fell significantly at Yale New Haven (Conn.) Hospital after implementation of a multidisciplinary care bundle with protocols covering preoperative, intraoperative, and postoperative care.
An analysis of two 3-month sampling periods – one before implementation of the bundle of care and one after – showed a drop in the surgical site infection (SSI) rate among total cesarean sections from 3.4% to 2.2%.
At the annual meeting of the American College of Obstetricians and Gynecologists, Dr. Ashley Pritchard of the hospital described the care bundle and urged obstetricians to consider the impact of even small reductions in SSIs after a cesarean.
“Infection is the most common complication following cesarean delivery … 2.5%-16% of all cesarean deliveries will result in a surgical site infection, and there is significant underestimation as between 15% to 80% of infections are diagnosed after patients leave the hospital,” she said.
A cesarean delivery SSI task force created by the hospital’s obstetric patient safety program developed the care bundle after reviewing best practices, guidelines, and evidence-based reviews.
Preoperative protocols for planned cesareans focused on patient education and included a preoperative appointment and instructions for showering the night before surgery, not shaving for more than 24 hours prior to scheduled surgery, using 2% chlorhexidine wipes both the night prior to surgery and the day of surgery, and other hygiene processes.
“We know from numerous studies that chlorhexidine is superior to iodine, but we also have found that with these wipes you get a level of antibiosis on the skin surface that decreases surgical site infections at the time of incisions,” Dr. Pritchard said.
For the operative care part of the bundle, staff were reeducated about the scrubbing protocol, proper attire and limits on operating room traffic, and the correct and timely use of antibiotics (for example, a cephalosporin administered within 30 minutes of incision). Staff also watched a video and were quizzed on the proper technique and timing for preoperative skin preparation.
Increased attention was paid to normothermia and included preoperative use of warming blankets and proper temperature in the operating room and post–anesthesia care unit.
“We’ve learned from colorectal and trauma surgery that normothermia and patient warming lead to reduced SSI,” Dr. Pritchard said. “This hasn’t been proven with cesarean delivery, but we know there’s improved maternal and fetal well-being with preoperative warming.”
Postoperatively, the use of supplemental oxygen was discontinued unless clinically indicated “since it’s been shown to have no positive effect on SSI,” she said. Incision dressing application and removal were also standardized, with sterile dressings maintained for at least 24 hours – with a tag labeling the date and time of application – and no more than 48 hours. At discharge, patients were given clear discharge instructions and a postpartum appointment for an incision check.
During the 3-month sampling period prior to implementation of the care bundle, there were 382 cesarean deliveries, and 147 patients presented for a postpartum appointment (either the prescribed visit or a later “issue visit”) within 30 days (38%). Of these patients, 8.6% were diagnosed with an SSI.
In the postimplementation sampling period, which began 6 months after rollout, there were 361 cesarean deliveries at the hospital, and 297 patients (77%) presented for postpartum care. Of these patients, 2.9% were diagnosed with an SSI.
An analysis based on the total number of cesarean deliveries performed at the hospital (planned and unplanned) during the two 3-month periods showed a decline in the cesarean delivery SSI rate from 3.4% to 2.2%. “This is statistically significant. It shows a dramatic decline in the SSI rate in our patient population … a clear impact of the bundle of care,” Dr. Pritchard said.
The Yale team attributes the significant increase in postoperative visit attendance to the preoperative protocol for planned cesareans. “We think it had something to do with our creating better relationships by having [patients] present preoperatively and starting their care prior to incision,” she said.
The preoperative visit also provided an opportunity to identify and treat any active skin infections, upper respiratory infections, or chronic colonizations (without evidence of completion of treatment) before delivery. “If necessary and if possible, [we could] push back their cesarean section date to ensure adequate treatment had been achieved,” Dr. Pritchard said.
All aspects of the care bundle were rolled out simultaneously. Next steps for the New Haven team include further analysis of provider and patient views, a look at the sustainability of the bundle of care and its impact, and a cost analysis. “We reduced our SSIs, but we’ve also added a number of elements to our care spectrum, pre- and postoperatively,” Dr. Pritchard said.
For now, one thing seems clear: “We learned from cardiac and colorectal surgery that there really is strength in the bundle, that the sum of the parts is greater than the individual aspects,” she said.
Dr. Pritchard reported that she and her coinvestigators have no relevant financial disclosures.
WASHINGTON – The rate of cesarean delivery surgical site infections fell significantly at Yale New Haven (Conn.) Hospital after implementation of a multidisciplinary care bundle with protocols covering preoperative, intraoperative, and postoperative care.
An analysis of two 3-month sampling periods – one before implementation of the bundle of care and one after – showed a drop in the surgical site infection (SSI) rate among total cesarean sections from 3.4% to 2.2%.
At the annual meeting of the American College of Obstetricians and Gynecologists, Dr. Ashley Pritchard of the hospital described the care bundle and urged obstetricians to consider the impact of even small reductions in SSIs after a cesarean.
“Infection is the most common complication following cesarean delivery … 2.5%-16% of all cesarean deliveries will result in a surgical site infection, and there is significant underestimation as between 15% to 80% of infections are diagnosed after patients leave the hospital,” she said.
A cesarean delivery SSI task force created by the hospital’s obstetric patient safety program developed the care bundle after reviewing best practices, guidelines, and evidence-based reviews.
Preoperative protocols for planned cesareans focused on patient education and included a preoperative appointment and instructions for showering the night before surgery, not shaving for more than 24 hours prior to scheduled surgery, using 2% chlorhexidine wipes both the night prior to surgery and the day of surgery, and other hygiene processes.
“We know from numerous studies that chlorhexidine is superior to iodine, but we also have found that with these wipes you get a level of antibiosis on the skin surface that decreases surgical site infections at the time of incisions,” Dr. Pritchard said.
For the operative care part of the bundle, staff were reeducated about the scrubbing protocol, proper attire and limits on operating room traffic, and the correct and timely use of antibiotics (for example, a cephalosporin administered within 30 minutes of incision). Staff also watched a video and were quizzed on the proper technique and timing for preoperative skin preparation.
Increased attention was paid to normothermia and included preoperative use of warming blankets and proper temperature in the operating room and post–anesthesia care unit.
“We’ve learned from colorectal and trauma surgery that normothermia and patient warming lead to reduced SSI,” Dr. Pritchard said. “This hasn’t been proven with cesarean delivery, but we know there’s improved maternal and fetal well-being with preoperative warming.”
Postoperatively, the use of supplemental oxygen was discontinued unless clinically indicated “since it’s been shown to have no positive effect on SSI,” she said. Incision dressing application and removal were also standardized, with sterile dressings maintained for at least 24 hours – with a tag labeling the date and time of application – and no more than 48 hours. At discharge, patients were given clear discharge instructions and a postpartum appointment for an incision check.
During the 3-month sampling period prior to implementation of the care bundle, there were 382 cesarean deliveries, and 147 patients presented for a postpartum appointment (either the prescribed visit or a later “issue visit”) within 30 days (38%). Of these patients, 8.6% were diagnosed with an SSI.
In the postimplementation sampling period, which began 6 months after rollout, there were 361 cesarean deliveries at the hospital, and 297 patients (77%) presented for postpartum care. Of these patients, 2.9% were diagnosed with an SSI.
An analysis based on the total number of cesarean deliveries performed at the hospital (planned and unplanned) during the two 3-month periods showed a decline in the cesarean delivery SSI rate from 3.4% to 2.2%. “This is statistically significant. It shows a dramatic decline in the SSI rate in our patient population … a clear impact of the bundle of care,” Dr. Pritchard said.
The Yale team attributes the significant increase in postoperative visit attendance to the preoperative protocol for planned cesareans. “We think it had something to do with our creating better relationships by having [patients] present preoperatively and starting their care prior to incision,” she said.
The preoperative visit also provided an opportunity to identify and treat any active skin infections, upper respiratory infections, or chronic colonizations (without evidence of completion of treatment) before delivery. “If necessary and if possible, [we could] push back their cesarean section date to ensure adequate treatment had been achieved,” Dr. Pritchard said.
All aspects of the care bundle were rolled out simultaneously. Next steps for the New Haven team include further analysis of provider and patient views, a look at the sustainability of the bundle of care and its impact, and a cost analysis. “We reduced our SSIs, but we’ve also added a number of elements to our care spectrum, pre- and postoperatively,” Dr. Pritchard said.
For now, one thing seems clear: “We learned from cardiac and colorectal surgery that there really is strength in the bundle, that the sum of the parts is greater than the individual aspects,” she said.
Dr. Pritchard reported that she and her coinvestigators have no relevant financial disclosures.
WASHINGTON – The rate of cesarean delivery surgical site infections fell significantly at Yale New Haven (Conn.) Hospital after implementation of a multidisciplinary care bundle with protocols covering preoperative, intraoperative, and postoperative care.
An analysis of two 3-month sampling periods – one before implementation of the bundle of care and one after – showed a drop in the surgical site infection (SSI) rate among total cesarean sections from 3.4% to 2.2%.
At the annual meeting of the American College of Obstetricians and Gynecologists, Dr. Ashley Pritchard of the hospital described the care bundle and urged obstetricians to consider the impact of even small reductions in SSIs after a cesarean.
“Infection is the most common complication following cesarean delivery … 2.5%-16% of all cesarean deliveries will result in a surgical site infection, and there is significant underestimation as between 15% to 80% of infections are diagnosed after patients leave the hospital,” she said.
A cesarean delivery SSI task force created by the hospital’s obstetric patient safety program developed the care bundle after reviewing best practices, guidelines, and evidence-based reviews.
Preoperative protocols for planned cesareans focused on patient education and included a preoperative appointment and instructions for showering the night before surgery, not shaving for more than 24 hours prior to scheduled surgery, using 2% chlorhexidine wipes both the night prior to surgery and the day of surgery, and other hygiene processes.
“We know from numerous studies that chlorhexidine is superior to iodine, but we also have found that with these wipes you get a level of antibiosis on the skin surface that decreases surgical site infections at the time of incisions,” Dr. Pritchard said.
For the operative care part of the bundle, staff were reeducated about the scrubbing protocol, proper attire and limits on operating room traffic, and the correct and timely use of antibiotics (for example, a cephalosporin administered within 30 minutes of incision). Staff also watched a video and were quizzed on the proper technique and timing for preoperative skin preparation.
Increased attention was paid to normothermia and included preoperative use of warming blankets and proper temperature in the operating room and post–anesthesia care unit.
“We’ve learned from colorectal and trauma surgery that normothermia and patient warming lead to reduced SSI,” Dr. Pritchard said. “This hasn’t been proven with cesarean delivery, but we know there’s improved maternal and fetal well-being with preoperative warming.”
Postoperatively, the use of supplemental oxygen was discontinued unless clinically indicated “since it’s been shown to have no positive effect on SSI,” she said. Incision dressing application and removal were also standardized, with sterile dressings maintained for at least 24 hours – with a tag labeling the date and time of application – and no more than 48 hours. At discharge, patients were given clear discharge instructions and a postpartum appointment for an incision check.
During the 3-month sampling period prior to implementation of the care bundle, there were 382 cesarean deliveries, and 147 patients presented for a postpartum appointment (either the prescribed visit or a later “issue visit”) within 30 days (38%). Of these patients, 8.6% were diagnosed with an SSI.
In the postimplementation sampling period, which began 6 months after rollout, there were 361 cesarean deliveries at the hospital, and 297 patients (77%) presented for postpartum care. Of these patients, 2.9% were diagnosed with an SSI.
An analysis based on the total number of cesarean deliveries performed at the hospital (planned and unplanned) during the two 3-month periods showed a decline in the cesarean delivery SSI rate from 3.4% to 2.2%. “This is statistically significant. It shows a dramatic decline in the SSI rate in our patient population … a clear impact of the bundle of care,” Dr. Pritchard said.
The Yale team attributes the significant increase in postoperative visit attendance to the preoperative protocol for planned cesareans. “We think it had something to do with our creating better relationships by having [patients] present preoperatively and starting their care prior to incision,” she said.
The preoperative visit also provided an opportunity to identify and treat any active skin infections, upper respiratory infections, or chronic colonizations (without evidence of completion of treatment) before delivery. “If necessary and if possible, [we could] push back their cesarean section date to ensure adequate treatment had been achieved,” Dr. Pritchard said.
All aspects of the care bundle were rolled out simultaneously. Next steps for the New Haven team include further analysis of provider and patient views, a look at the sustainability of the bundle of care and its impact, and a cost analysis. “We reduced our SSIs, but we’ve also added a number of elements to our care spectrum, pre- and postoperatively,” Dr. Pritchard said.
For now, one thing seems clear: “We learned from cardiac and colorectal surgery that there really is strength in the bundle, that the sum of the parts is greater than the individual aspects,” she said.
Dr. Pritchard reported that she and her coinvestigators have no relevant financial disclosures.
AT ACOG 2016
Key clinical point: A multidisciplinary bundle of care was effective in reducing the rate of surgical site infections with cesarean delivery.
Major finding: The rate of cesarean delivery SSIs decreased from 3.4% to 2.2% after implementation of a care bundle.
Data source: An analysis of a quality improvement project at Yale New Haven Hospital.
Disclosures: Dr. Pritchard reported that she and her coinvestigators have no relevant financial disclosures.
Cervical length screening adopted in most academic programs
WASHINGTON – Universal cervical length screening to prevent preterm birth has been implemented by more two-thirds of institutions with maternal-fetal medicine fellowship programs, but less than half of these programs screen with transvaginal ultrasound, a national survey has found.
The survey of 78 accredited programs also revealed geographic variations in the use of routine screening and the ultrasound approach employed, Dr. Adeeb Khalifeh reported at the annual meeting of the American College of Obstetricians and Gynecologists.
All 78 programs responded to the survey. Fifty-three programs (68%) indicated they had implemented a universal screening program, defined as cervical length screening of women with singleton gestations who had not had a prior spontaneous preterm delivery. Of these, 28 use transabdominal ultrasound (TAU) and 25 use transvaginal ultrasound (TVU) for screening.
While the survey shows that a majority of academic institutions now perform universal cervical length screening, it also reveals that “almost one-third do not,” despite strong evidence of an inverse relationship between cervical length and risk of spontaneous preterm birth, said Dr. Khalifeh, a maternal-fetal medicine fellow at Thomas Jefferson University Hospital in Philadelphia who conducted the survey in 2015 with other physicians there.
Both ACOG and the Society for Maternal-Fetal Medicine recommend transvaginal measurements of cervical length for physicians who decide to implement universal cervical length screening.
ACOG’s 2012 Practice Bulletin on Prediction and Prevention of Preterm Birth, which does not mandate universal screening but supports its consideration, notes that, “if second trimester transabdominal scanning of the lower uterine segment suggests that the cervix may be short or have some other abnormality, it is recommended that a subsequent transvaginal ultrasound examination be performed to better visualize the cervix and establish its length” (Obstet Gynecol. 2012 Oct;120:964-73).
Cervical length assessment performed with TAU is unreliable, and it is less cost effective then assessment using TVU, Dr. Khalifeh said.
Vaginal progesterone as a treatment for short cervix in patients with singleton gestations was assessed and proven to be valuable in studies using TVU, not TAU, he noted.
Institutions in the Midwest had the highest rate of universal screening (94%) and the highest use of TVU (58% of programs with routine screening), while programs in the South had the lowest rate of university screening (58%) and the lowest use of TVU (12.5%).
In the Northeast, universal screening was reported by 60% of institutions, and the use of TVU by 40%. Among institutions in the West, 69% reported performing universal screening, with 40% of these programs using TVU.
Obstetrical volume did not impact the implementation of, or approach to, universal cervical length screening; there were no significant differences between institutions with a higher obstetrical volume (more than 3,000 deliveries annually) and a lower volume.
It’s “hard to extrapolate the practice of academic centers [to the community at large], so the findings might not be representative of what’s happening nationwide,” Dr. Khalifeh said.
He reported that he and his coinvestigators had no relevant financial disclosures.
WASHINGTON – Universal cervical length screening to prevent preterm birth has been implemented by more two-thirds of institutions with maternal-fetal medicine fellowship programs, but less than half of these programs screen with transvaginal ultrasound, a national survey has found.
The survey of 78 accredited programs also revealed geographic variations in the use of routine screening and the ultrasound approach employed, Dr. Adeeb Khalifeh reported at the annual meeting of the American College of Obstetricians and Gynecologists.
All 78 programs responded to the survey. Fifty-three programs (68%) indicated they had implemented a universal screening program, defined as cervical length screening of women with singleton gestations who had not had a prior spontaneous preterm delivery. Of these, 28 use transabdominal ultrasound (TAU) and 25 use transvaginal ultrasound (TVU) for screening.
While the survey shows that a majority of academic institutions now perform universal cervical length screening, it also reveals that “almost one-third do not,” despite strong evidence of an inverse relationship between cervical length and risk of spontaneous preterm birth, said Dr. Khalifeh, a maternal-fetal medicine fellow at Thomas Jefferson University Hospital in Philadelphia who conducted the survey in 2015 with other physicians there.
Both ACOG and the Society for Maternal-Fetal Medicine recommend transvaginal measurements of cervical length for physicians who decide to implement universal cervical length screening.
ACOG’s 2012 Practice Bulletin on Prediction and Prevention of Preterm Birth, which does not mandate universal screening but supports its consideration, notes that, “if second trimester transabdominal scanning of the lower uterine segment suggests that the cervix may be short or have some other abnormality, it is recommended that a subsequent transvaginal ultrasound examination be performed to better visualize the cervix and establish its length” (Obstet Gynecol. 2012 Oct;120:964-73).
Cervical length assessment performed with TAU is unreliable, and it is less cost effective then assessment using TVU, Dr. Khalifeh said.
Vaginal progesterone as a treatment for short cervix in patients with singleton gestations was assessed and proven to be valuable in studies using TVU, not TAU, he noted.
Institutions in the Midwest had the highest rate of universal screening (94%) and the highest use of TVU (58% of programs with routine screening), while programs in the South had the lowest rate of university screening (58%) and the lowest use of TVU (12.5%).
In the Northeast, universal screening was reported by 60% of institutions, and the use of TVU by 40%. Among institutions in the West, 69% reported performing universal screening, with 40% of these programs using TVU.
Obstetrical volume did not impact the implementation of, or approach to, universal cervical length screening; there were no significant differences between institutions with a higher obstetrical volume (more than 3,000 deliveries annually) and a lower volume.
It’s “hard to extrapolate the practice of academic centers [to the community at large], so the findings might not be representative of what’s happening nationwide,” Dr. Khalifeh said.
He reported that he and his coinvestigators had no relevant financial disclosures.
WASHINGTON – Universal cervical length screening to prevent preterm birth has been implemented by more two-thirds of institutions with maternal-fetal medicine fellowship programs, but less than half of these programs screen with transvaginal ultrasound, a national survey has found.
The survey of 78 accredited programs also revealed geographic variations in the use of routine screening and the ultrasound approach employed, Dr. Adeeb Khalifeh reported at the annual meeting of the American College of Obstetricians and Gynecologists.
All 78 programs responded to the survey. Fifty-three programs (68%) indicated they had implemented a universal screening program, defined as cervical length screening of women with singleton gestations who had not had a prior spontaneous preterm delivery. Of these, 28 use transabdominal ultrasound (TAU) and 25 use transvaginal ultrasound (TVU) for screening.
While the survey shows that a majority of academic institutions now perform universal cervical length screening, it also reveals that “almost one-third do not,” despite strong evidence of an inverse relationship between cervical length and risk of spontaneous preterm birth, said Dr. Khalifeh, a maternal-fetal medicine fellow at Thomas Jefferson University Hospital in Philadelphia who conducted the survey in 2015 with other physicians there.
Both ACOG and the Society for Maternal-Fetal Medicine recommend transvaginal measurements of cervical length for physicians who decide to implement universal cervical length screening.
ACOG’s 2012 Practice Bulletin on Prediction and Prevention of Preterm Birth, which does not mandate universal screening but supports its consideration, notes that, “if second trimester transabdominal scanning of the lower uterine segment suggests that the cervix may be short or have some other abnormality, it is recommended that a subsequent transvaginal ultrasound examination be performed to better visualize the cervix and establish its length” (Obstet Gynecol. 2012 Oct;120:964-73).
Cervical length assessment performed with TAU is unreliable, and it is less cost effective then assessment using TVU, Dr. Khalifeh said.
Vaginal progesterone as a treatment for short cervix in patients with singleton gestations was assessed and proven to be valuable in studies using TVU, not TAU, he noted.
Institutions in the Midwest had the highest rate of universal screening (94%) and the highest use of TVU (58% of programs with routine screening), while programs in the South had the lowest rate of university screening (58%) and the lowest use of TVU (12.5%).
In the Northeast, universal screening was reported by 60% of institutions, and the use of TVU by 40%. Among institutions in the West, 69% reported performing universal screening, with 40% of these programs using TVU.
Obstetrical volume did not impact the implementation of, or approach to, universal cervical length screening; there were no significant differences between institutions with a higher obstetrical volume (more than 3,000 deliveries annually) and a lower volume.
It’s “hard to extrapolate the practice of academic centers [to the community at large], so the findings might not be representative of what’s happening nationwide,” Dr. Khalifeh said.
He reported that he and his coinvestigators had no relevant financial disclosures.
AT ACOG 2016
Key clinical point: Universal cervical length screening is performed at a majority of academic institutions.
Major finding: More than two-thirds of institutions have adopted universal cervical length screening, but just under half use transvaginal ultrasound.
Data source: A national survey of 78 institutions with accredited maternal-fetal medicine fellowship programs.
Disclosures: Dr. Khalifeh and his coinvestigators reported having relevant financial disclosures.
Postpartum readmissions rise in 8-year multistate analysis
WASHINGTON – The postpartum readmission rate increased over a recent 8-year period from 1.72% to 2.16%, with readmitted patients more likely to be publicly insured and more likely to have multiple comorbidities, a multistate analysis shows.
The rise in readmissions from 2004 to 2011 “isn’t solely explained by the increasing cesarean rate,” and appears to be significantly influenced “by increasing maternal comorbidities,” said Dr. Mark A. Clapp, who reported preliminary findings at the annual meeting of the American College of Obstetricians and Gynecologists.
Dr. Clapp and his coinvestigators analyzed postpartum readmissions occurring in the first 6 weeks after delivery in women in California, Florida, and New York – 3 states whose combined 1 million deliveries a year represent approximately a quarter of all deliveries in the United States. Of approximately 8 million deliveries identified over the study period, 6 million were eligible for analysis.
Medical and surgical readmission rates are used in various specialties as indicators of quality and linked to reimbursement, but “very little is known about readmissions in obstetrics,” he said.
The researchers identified deliveries and postpartum readmissions in state inpatient databases and compared maternal, pregnancy, and delivery characteristics of women who were readmitted with those who weren’t readmitted. This included both “primary” indications for readmissions and “associated diagnoses” listed for these patients.
The most common primary indication for readmission, they found, was wound infection or breakdown (15.5%), followed by hypertensive disease (9.3%), and psychiatric illness (7.7%). The most common associated diagnosis among readmitted patients was psychiatric disease, followed by hypertensive disease.
Women who were readmitted “were more likely to have comorbidities across the board,” said Dr. Clapp, a resident at Brigham and Women’s Hospital, Boston. The readmitted women had higher rates of all “associated diagnoses” listed in the state databases, from asthma and diabetes to obesity and thyroid disease, but the most significant differences were in the rates of hypertensive disease, psychiatric disease, and substance abuse.
Regarding mode of delivery, 37.2% of those who were readmitted had undergone a cesarean delivery versus 32.9% of those not readmitted. Patients who were readmitted also were more likely to have had a multiple gestation, preterm labor, or a placental abnormality.
The majority of readmitted patients in the retrospective cohort study were publicly insured: 54% versus 42%. Readmitted patients also were more likely to be older, with a mean age of 36 years, compared with 28 years in the non-readmitted group. They also were more likely to be black (19% of readmitted patients versus 14% of non-readmitted). Over 50% of readmissions occurred in the first week.
The impact of cesarean delivery on readmission risk needs further investigation, Dr. Clapp said, noting that cesarean delivery was an inconsistent predictor of readmission. In Florida, for instance, patients who had cesarean deliveries in 2011 were actually less likely to be readmitted than those who delivered vaginally.
Psychiatric comorbidities also need to be better understood, as does the “influence of increasing maternal comorbidities, which I suspect is driving the increase in readmissions, rather than the mode of delivery,” Dr. Clapp said.
“Hopefully, we can build a body of evidence to either support or refute the use of readmissions as a measure of quality in our field,” he said.
Dr. Clapp and his coauthors reported no relevant financial disclosures. The study was funded by an ACOG health policy grant.
WASHINGTON – The postpartum readmission rate increased over a recent 8-year period from 1.72% to 2.16%, with readmitted patients more likely to be publicly insured and more likely to have multiple comorbidities, a multistate analysis shows.
The rise in readmissions from 2004 to 2011 “isn’t solely explained by the increasing cesarean rate,” and appears to be significantly influenced “by increasing maternal comorbidities,” said Dr. Mark A. Clapp, who reported preliminary findings at the annual meeting of the American College of Obstetricians and Gynecologists.
Dr. Clapp and his coinvestigators analyzed postpartum readmissions occurring in the first 6 weeks after delivery in women in California, Florida, and New York – 3 states whose combined 1 million deliveries a year represent approximately a quarter of all deliveries in the United States. Of approximately 8 million deliveries identified over the study period, 6 million were eligible for analysis.
Medical and surgical readmission rates are used in various specialties as indicators of quality and linked to reimbursement, but “very little is known about readmissions in obstetrics,” he said.
The researchers identified deliveries and postpartum readmissions in state inpatient databases and compared maternal, pregnancy, and delivery characteristics of women who were readmitted with those who weren’t readmitted. This included both “primary” indications for readmissions and “associated diagnoses” listed for these patients.
The most common primary indication for readmission, they found, was wound infection or breakdown (15.5%), followed by hypertensive disease (9.3%), and psychiatric illness (7.7%). The most common associated diagnosis among readmitted patients was psychiatric disease, followed by hypertensive disease.
Women who were readmitted “were more likely to have comorbidities across the board,” said Dr. Clapp, a resident at Brigham and Women’s Hospital, Boston. The readmitted women had higher rates of all “associated diagnoses” listed in the state databases, from asthma and diabetes to obesity and thyroid disease, but the most significant differences were in the rates of hypertensive disease, psychiatric disease, and substance abuse.
Regarding mode of delivery, 37.2% of those who were readmitted had undergone a cesarean delivery versus 32.9% of those not readmitted. Patients who were readmitted also were more likely to have had a multiple gestation, preterm labor, or a placental abnormality.
The majority of readmitted patients in the retrospective cohort study were publicly insured: 54% versus 42%. Readmitted patients also were more likely to be older, with a mean age of 36 years, compared with 28 years in the non-readmitted group. They also were more likely to be black (19% of readmitted patients versus 14% of non-readmitted). Over 50% of readmissions occurred in the first week.
The impact of cesarean delivery on readmission risk needs further investigation, Dr. Clapp said, noting that cesarean delivery was an inconsistent predictor of readmission. In Florida, for instance, patients who had cesarean deliveries in 2011 were actually less likely to be readmitted than those who delivered vaginally.
Psychiatric comorbidities also need to be better understood, as does the “influence of increasing maternal comorbidities, which I suspect is driving the increase in readmissions, rather than the mode of delivery,” Dr. Clapp said.
“Hopefully, we can build a body of evidence to either support or refute the use of readmissions as a measure of quality in our field,” he said.
Dr. Clapp and his coauthors reported no relevant financial disclosures. The study was funded by an ACOG health policy grant.
WASHINGTON – The postpartum readmission rate increased over a recent 8-year period from 1.72% to 2.16%, with readmitted patients more likely to be publicly insured and more likely to have multiple comorbidities, a multistate analysis shows.
The rise in readmissions from 2004 to 2011 “isn’t solely explained by the increasing cesarean rate,” and appears to be significantly influenced “by increasing maternal comorbidities,” said Dr. Mark A. Clapp, who reported preliminary findings at the annual meeting of the American College of Obstetricians and Gynecologists.
Dr. Clapp and his coinvestigators analyzed postpartum readmissions occurring in the first 6 weeks after delivery in women in California, Florida, and New York – 3 states whose combined 1 million deliveries a year represent approximately a quarter of all deliveries in the United States. Of approximately 8 million deliveries identified over the study period, 6 million were eligible for analysis.
Medical and surgical readmission rates are used in various specialties as indicators of quality and linked to reimbursement, but “very little is known about readmissions in obstetrics,” he said.
The researchers identified deliveries and postpartum readmissions in state inpatient databases and compared maternal, pregnancy, and delivery characteristics of women who were readmitted with those who weren’t readmitted. This included both “primary” indications for readmissions and “associated diagnoses” listed for these patients.
The most common primary indication for readmission, they found, was wound infection or breakdown (15.5%), followed by hypertensive disease (9.3%), and psychiatric illness (7.7%). The most common associated diagnosis among readmitted patients was psychiatric disease, followed by hypertensive disease.
Women who were readmitted “were more likely to have comorbidities across the board,” said Dr. Clapp, a resident at Brigham and Women’s Hospital, Boston. The readmitted women had higher rates of all “associated diagnoses” listed in the state databases, from asthma and diabetes to obesity and thyroid disease, but the most significant differences were in the rates of hypertensive disease, psychiatric disease, and substance abuse.
Regarding mode of delivery, 37.2% of those who were readmitted had undergone a cesarean delivery versus 32.9% of those not readmitted. Patients who were readmitted also were more likely to have had a multiple gestation, preterm labor, or a placental abnormality.
The majority of readmitted patients in the retrospective cohort study were publicly insured: 54% versus 42%. Readmitted patients also were more likely to be older, with a mean age of 36 years, compared with 28 years in the non-readmitted group. They also were more likely to be black (19% of readmitted patients versus 14% of non-readmitted). Over 50% of readmissions occurred in the first week.
The impact of cesarean delivery on readmission risk needs further investigation, Dr. Clapp said, noting that cesarean delivery was an inconsistent predictor of readmission. In Florida, for instance, patients who had cesarean deliveries in 2011 were actually less likely to be readmitted than those who delivered vaginally.
Psychiatric comorbidities also need to be better understood, as does the “influence of increasing maternal comorbidities, which I suspect is driving the increase in readmissions, rather than the mode of delivery,” Dr. Clapp said.
“Hopefully, we can build a body of evidence to either support or refute the use of readmissions as a measure of quality in our field,” he said.
Dr. Clapp and his coauthors reported no relevant financial disclosures. The study was funded by an ACOG health policy grant.
AT ACOG 2016
Key clinical point: Postpartum readmission rates rise, and reasons are not limited to increasing cesarean deliveries.
Major finding: Postpartum admission rates rose in the 2004-2011 period from 1.72% to 2.16%.
Data source: A retrospective cohort study of data in three state inpatient databases.
Disclosures: The study was funded by a health policy grant awarded by ACOG. Dr. Clapp and his coauthors reported no relevant financial disclosures.
Women reach for the top in ob.gyn.
Dr. Gloria E. Sarto was one of just six women in her medical school graduating class of 76 in 1958 – a time when many medical schools, she recalled, had quota systems for women and minorities. Later, she became the first female ob.gyn. resident at the University of Wisconsin–Madison.
“When I was interviewing for a residency position, the department chair told me ‘I’m going to treat you like one of the boys,’” the 86-year-old professor emeritus said. “And I said, ‘If you do that, it will be just fine.’”
Yet she still had to lobby sometimes for equal treatment – convincing the department chief in one instance that sleeping on a delivery table during hospital duty because there weren’t any rooms for women was not being treated “like one of the boys.” And she was often bothered by her observation that, in general, “the women [residents] weren’t noticed... they weren’t being recognized.”
Dr. Sarto has since chaired two ob.gyn. departments and was the first woman president of the American Gynecological and Obstetrical Society. Today, however, as she continues mentoring junior faculty and works to ensure the smooth succession of programs she founded, she sees a much different field – one in which women not only command more respect but where they make up a majority of ob.gyns.
Impact on women’s health
In 2014, 62% of all ob.gyns. were women (Obstet Gynecol. 2016 Jan;127[1]:148-52). The majority has been years in the making; more women than men have been entering the specialty since 1993. And if current trends continue, the percentage of women active in the specialty will only increase further. In 2010, women comprised more than 80% of all ob.gyn. residents/fellows, more than any other specialty, according to data from the Association of American Medical Colleges.
Such numerical strength is significant, but for Dr. Sarto and other leaders in the specialty who spoke about their experiences as female ob.gyns., it’s the impact that women physicians have had on women’s health that’s most important.
Dr. Sarto helped to start Lamaze classes in a hospital basement amidst widespread opposition from the male-dominated leadership and staff who felt that women didn’t need such help with labor. She also takes pride in her collaboration with Dr. Florence Haseltine, Phyllis Greenberger, and several other women to address biases in biomedical research. Their work with Congress led to a federal audit of National Institutes of Health policies and practices.
“We knew that when that report came out [in 1990], it would hit every newspaper in the country,” Dr. Sarto said. It just about did, and soon after that, the NIH Office of Research on Women’s Health was established to ensure that women were included in clinical trials and that gaps in knowledge of women’s health were addressed.
Dr. Barbara Levy, who left a private practice and two medical directorships in 2012 to become Vice President for Health Policy at the American College of Obstetricians and Gynecologists, recalls feeling early in her career that women’s health needed to be approached much more holistically.
“What I was seeing and experiencing didn’t match the textbooks,” she said. “The connection, for instance, between chronic pelvic pain and women who’d been victims of sexual abuse – there wasn’t anything in the literature. I’d see women with the same kinds of physical characteristics on their exams... and patients were willing to share with me things that they wouldn’t have been willing to share with my colleagues.”
Dr. Levy graduated from Princeton University in 1974 with the second class of admitted women, and after a year off, went west for medical school. She graduated in 1979 from the University of California, San Diego, with nine other women in a class of 110.
Her desire to care for the “whole patient” had her leaning toward family medicine until a beloved mentor, Dr. Donna Brooks, “reminded me that there were so few women to take care of women... and that as an ob.gyn. I could follow women through pregnancy, delivery, surgeries, hormone issues, and so many [other facets of their health].”
Dr. Levy, who served as president of the American Association of Gynecologic Laparoscopists in 1995, recalls a world “that was very tolerant of sexual harassment” and remembers the energy she needed to expend to be taken seriously and to correct unconscious bias.
When she applied for fellowship in the American College of Surgeons in the late 1980s, the committee members who conducted an interview “told me right away that I couldn’t expect to be a fellow if I hadn’t done my duty [serving on hospital committees],” Dr. Levy said.
“I told them I had volunteered for more than three committees every single year I’d been on staff, and had never been asked to serve,” she said. “They had no idea. Their assumption was that I had children at home and I wasn’t taking the time.”
Entering leadership
When it comes to leadership, a look at academic medicine suggests that women ob.gyns. have made significant strides. In 2013, compared with other major specialties, obstetrics and gynecology had the highest proportion of department leaders who were women. Yet the picture is mixed. According to an analysis published earlier in 2016, women in ob.gyn. and nine other major specialties “were not represented in the proportions in which they entered their fields” (Obstet Gynecol. 2016 Mar;127[3]:442-7).
Women comprised 57% of all faculty in departments of ob.gyn. in 2013. And, according to the analysis, they comprised 62% of ob.gyn. residency program directors, 30% of division directors, and 24% of department chairs.
The high numbers of women serving as residency program directors raises concern because such positions “do not result in advancement in the same way,” said Dr. Levy, adding that women have excelled in such positions and may desire them, but should be mentored early on about what tracks have the potential for upper-level leadership roles.
Dr. Maureen Phipps, who in 2013 was appointed as chair of ob.gyn. and assistant dean in the Warren Albert Medical School of Brown University in Providence, said she carries with her the fact that women are not yet proportionally represented at the upper levels. “I know that my being in this position and in other positions I’ve held is important for women to see,” she said.
Dr. Phipps graduated from the University of Vermont’s College of Medicine in 1994 as a part of a class in which men and women were fairly evenly represented. In addition to her role as department chair and assistant dean, she is also now chief of ob.gyn. at Women & Infants Hospital of Rhode Island, where she did her residency, and executive chief of ob.gyn for the Care New England Health System.
“I’ve had amazing male leaders and mentors in my career – the people who’ve gone to bat for me have been men,” said Dr. Phipps. Yet, “it’s important to have women in leadership... It’s known that we think differently and approach things differently. Having balance and a variety of different lenses will allow us to [further] grow the field.”
Gender pay gap
Both in academic medicine and in practice, a gender pay gap still reportedly affects women physicians across the board. Various reports and analyses have shown women earning disproportionately less than their male colleagues in similar positions.
Notably, a 2011 analysis in Health Affairs found a nearly $17,000 gap between the starting salaries for men and women physicians. This differential accounted for variables such as patient care hours, practice type, and location. It is possible, the study authors reported, that practices “may now be offering greater flexibility and family-friendly attributes that are more appealing but that come at the price of commensurately lower pay” (Health Aff. 2011:30;193-201).
The American Medical Women’s Association, which promotes advocacy on a gender pay gap, said in a statement about the study, however, that “gender discrimination still exists within the echelons of medicine, and gender stereotyping frequently leads to the devaluation of women physicians.”
From her perspective, Dr. Levy said it’s “complicated” to tease apart and understand all the factors that may be involved.
The challenges of balancing work and family/caregiving and are “still really tough” for women ob.gyns., she said, especially those who want to practice obstetrics. Dr. Levy said she gave up obstetrics when it became apparent that she and her husband would need to hire an additional child care provider.
While the hospitalist-laborist model has been a valuable addition to obstetrics, Dr. Phipps said, “it’s our challenge to continue to think creatively about how we can keep clinicians engaged when they’re in the earlier parts of their careers and challenged by family responsibilities and other commitments.”
Both she and Dr. Levy emphasized their concerns about burnout and their desire to keep career satisfaction high – especially now that women are such a big part of ob.gyn. – and both spoke of the importance of making time for whatever activities help women “recharge.”
“We should be doing what we’re doing because we love it,” Dr. Levy said. “We should focus on that every day. Our patients trust us. We need to remind ourselves of what incredible connections we have.”
Throughout 2016, Ob.Gyn. News will celebrate its 50th anniversary with exclusive articles looking at the evolution of the specialty, including the history of contraception, changes in gynecologic surgery, and the transformation of the well-woman visit. Look for these articles and more special features in the pages of Ob.Gyn. News and online at obgynnews.com.
Dr. Gloria E. Sarto was one of just six women in her medical school graduating class of 76 in 1958 – a time when many medical schools, she recalled, had quota systems for women and minorities. Later, she became the first female ob.gyn. resident at the University of Wisconsin–Madison.
“When I was interviewing for a residency position, the department chair told me ‘I’m going to treat you like one of the boys,’” the 86-year-old professor emeritus said. “And I said, ‘If you do that, it will be just fine.’”
Yet she still had to lobby sometimes for equal treatment – convincing the department chief in one instance that sleeping on a delivery table during hospital duty because there weren’t any rooms for women was not being treated “like one of the boys.” And she was often bothered by her observation that, in general, “the women [residents] weren’t noticed... they weren’t being recognized.”
Dr. Sarto has since chaired two ob.gyn. departments and was the first woman president of the American Gynecological and Obstetrical Society. Today, however, as she continues mentoring junior faculty and works to ensure the smooth succession of programs she founded, she sees a much different field – one in which women not only command more respect but where they make up a majority of ob.gyns.
Impact on women’s health
In 2014, 62% of all ob.gyns. were women (Obstet Gynecol. 2016 Jan;127[1]:148-52). The majority has been years in the making; more women than men have been entering the specialty since 1993. And if current trends continue, the percentage of women active in the specialty will only increase further. In 2010, women comprised more than 80% of all ob.gyn. residents/fellows, more than any other specialty, according to data from the Association of American Medical Colleges.
Such numerical strength is significant, but for Dr. Sarto and other leaders in the specialty who spoke about their experiences as female ob.gyns., it’s the impact that women physicians have had on women’s health that’s most important.
Dr. Sarto helped to start Lamaze classes in a hospital basement amidst widespread opposition from the male-dominated leadership and staff who felt that women didn’t need such help with labor. She also takes pride in her collaboration with Dr. Florence Haseltine, Phyllis Greenberger, and several other women to address biases in biomedical research. Their work with Congress led to a federal audit of National Institutes of Health policies and practices.
“We knew that when that report came out [in 1990], it would hit every newspaper in the country,” Dr. Sarto said. It just about did, and soon after that, the NIH Office of Research on Women’s Health was established to ensure that women were included in clinical trials and that gaps in knowledge of women’s health were addressed.
Dr. Barbara Levy, who left a private practice and two medical directorships in 2012 to become Vice President for Health Policy at the American College of Obstetricians and Gynecologists, recalls feeling early in her career that women’s health needed to be approached much more holistically.
“What I was seeing and experiencing didn’t match the textbooks,” she said. “The connection, for instance, between chronic pelvic pain and women who’d been victims of sexual abuse – there wasn’t anything in the literature. I’d see women with the same kinds of physical characteristics on their exams... and patients were willing to share with me things that they wouldn’t have been willing to share with my colleagues.”
Dr. Levy graduated from Princeton University in 1974 with the second class of admitted women, and after a year off, went west for medical school. She graduated in 1979 from the University of California, San Diego, with nine other women in a class of 110.
Her desire to care for the “whole patient” had her leaning toward family medicine until a beloved mentor, Dr. Donna Brooks, “reminded me that there were so few women to take care of women... and that as an ob.gyn. I could follow women through pregnancy, delivery, surgeries, hormone issues, and so many [other facets of their health].”
Dr. Levy, who served as president of the American Association of Gynecologic Laparoscopists in 1995, recalls a world “that was very tolerant of sexual harassment” and remembers the energy she needed to expend to be taken seriously and to correct unconscious bias.
When she applied for fellowship in the American College of Surgeons in the late 1980s, the committee members who conducted an interview “told me right away that I couldn’t expect to be a fellow if I hadn’t done my duty [serving on hospital committees],” Dr. Levy said.
“I told them I had volunteered for more than three committees every single year I’d been on staff, and had never been asked to serve,” she said. “They had no idea. Their assumption was that I had children at home and I wasn’t taking the time.”
Entering leadership
When it comes to leadership, a look at academic medicine suggests that women ob.gyns. have made significant strides. In 2013, compared with other major specialties, obstetrics and gynecology had the highest proportion of department leaders who were women. Yet the picture is mixed. According to an analysis published earlier in 2016, women in ob.gyn. and nine other major specialties “were not represented in the proportions in which they entered their fields” (Obstet Gynecol. 2016 Mar;127[3]:442-7).
Women comprised 57% of all faculty in departments of ob.gyn. in 2013. And, according to the analysis, they comprised 62% of ob.gyn. residency program directors, 30% of division directors, and 24% of department chairs.
The high numbers of women serving as residency program directors raises concern because such positions “do not result in advancement in the same way,” said Dr. Levy, adding that women have excelled in such positions and may desire them, but should be mentored early on about what tracks have the potential for upper-level leadership roles.
Dr. Maureen Phipps, who in 2013 was appointed as chair of ob.gyn. and assistant dean in the Warren Albert Medical School of Brown University in Providence, said she carries with her the fact that women are not yet proportionally represented at the upper levels. “I know that my being in this position and in other positions I’ve held is important for women to see,” she said.
Dr. Phipps graduated from the University of Vermont’s College of Medicine in 1994 as a part of a class in which men and women were fairly evenly represented. In addition to her role as department chair and assistant dean, she is also now chief of ob.gyn. at Women & Infants Hospital of Rhode Island, where she did her residency, and executive chief of ob.gyn for the Care New England Health System.
“I’ve had amazing male leaders and mentors in my career – the people who’ve gone to bat for me have been men,” said Dr. Phipps. Yet, “it’s important to have women in leadership... It’s known that we think differently and approach things differently. Having balance and a variety of different lenses will allow us to [further] grow the field.”
Gender pay gap
Both in academic medicine and in practice, a gender pay gap still reportedly affects women physicians across the board. Various reports and analyses have shown women earning disproportionately less than their male colleagues in similar positions.
Notably, a 2011 analysis in Health Affairs found a nearly $17,000 gap between the starting salaries for men and women physicians. This differential accounted for variables such as patient care hours, practice type, and location. It is possible, the study authors reported, that practices “may now be offering greater flexibility and family-friendly attributes that are more appealing but that come at the price of commensurately lower pay” (Health Aff. 2011:30;193-201).
The American Medical Women’s Association, which promotes advocacy on a gender pay gap, said in a statement about the study, however, that “gender discrimination still exists within the echelons of medicine, and gender stereotyping frequently leads to the devaluation of women physicians.”
From her perspective, Dr. Levy said it’s “complicated” to tease apart and understand all the factors that may be involved.
The challenges of balancing work and family/caregiving and are “still really tough” for women ob.gyns., she said, especially those who want to practice obstetrics. Dr. Levy said she gave up obstetrics when it became apparent that she and her husband would need to hire an additional child care provider.
While the hospitalist-laborist model has been a valuable addition to obstetrics, Dr. Phipps said, “it’s our challenge to continue to think creatively about how we can keep clinicians engaged when they’re in the earlier parts of their careers and challenged by family responsibilities and other commitments.”
Both she and Dr. Levy emphasized their concerns about burnout and their desire to keep career satisfaction high – especially now that women are such a big part of ob.gyn. – and both spoke of the importance of making time for whatever activities help women “recharge.”
“We should be doing what we’re doing because we love it,” Dr. Levy said. “We should focus on that every day. Our patients trust us. We need to remind ourselves of what incredible connections we have.”
Throughout 2016, Ob.Gyn. News will celebrate its 50th anniversary with exclusive articles looking at the evolution of the specialty, including the history of contraception, changes in gynecologic surgery, and the transformation of the well-woman visit. Look for these articles and more special features in the pages of Ob.Gyn. News and online at obgynnews.com.
Dr. Gloria E. Sarto was one of just six women in her medical school graduating class of 76 in 1958 – a time when many medical schools, she recalled, had quota systems for women and minorities. Later, she became the first female ob.gyn. resident at the University of Wisconsin–Madison.
“When I was interviewing for a residency position, the department chair told me ‘I’m going to treat you like one of the boys,’” the 86-year-old professor emeritus said. “And I said, ‘If you do that, it will be just fine.’”
Yet she still had to lobby sometimes for equal treatment – convincing the department chief in one instance that sleeping on a delivery table during hospital duty because there weren’t any rooms for women was not being treated “like one of the boys.” And she was often bothered by her observation that, in general, “the women [residents] weren’t noticed... they weren’t being recognized.”
Dr. Sarto has since chaired two ob.gyn. departments and was the first woman president of the American Gynecological and Obstetrical Society. Today, however, as she continues mentoring junior faculty and works to ensure the smooth succession of programs she founded, she sees a much different field – one in which women not only command more respect but where they make up a majority of ob.gyns.
Impact on women’s health
In 2014, 62% of all ob.gyns. were women (Obstet Gynecol. 2016 Jan;127[1]:148-52). The majority has been years in the making; more women than men have been entering the specialty since 1993. And if current trends continue, the percentage of women active in the specialty will only increase further. In 2010, women comprised more than 80% of all ob.gyn. residents/fellows, more than any other specialty, according to data from the Association of American Medical Colleges.
Such numerical strength is significant, but for Dr. Sarto and other leaders in the specialty who spoke about their experiences as female ob.gyns., it’s the impact that women physicians have had on women’s health that’s most important.
Dr. Sarto helped to start Lamaze classes in a hospital basement amidst widespread opposition from the male-dominated leadership and staff who felt that women didn’t need such help with labor. She also takes pride in her collaboration with Dr. Florence Haseltine, Phyllis Greenberger, and several other women to address biases in biomedical research. Their work with Congress led to a federal audit of National Institutes of Health policies and practices.
“We knew that when that report came out [in 1990], it would hit every newspaper in the country,” Dr. Sarto said. It just about did, and soon after that, the NIH Office of Research on Women’s Health was established to ensure that women were included in clinical trials and that gaps in knowledge of women’s health were addressed.
Dr. Barbara Levy, who left a private practice and two medical directorships in 2012 to become Vice President for Health Policy at the American College of Obstetricians and Gynecologists, recalls feeling early in her career that women’s health needed to be approached much more holistically.
“What I was seeing and experiencing didn’t match the textbooks,” she said. “The connection, for instance, between chronic pelvic pain and women who’d been victims of sexual abuse – there wasn’t anything in the literature. I’d see women with the same kinds of physical characteristics on their exams... and patients were willing to share with me things that they wouldn’t have been willing to share with my colleagues.”
Dr. Levy graduated from Princeton University in 1974 with the second class of admitted women, and after a year off, went west for medical school. She graduated in 1979 from the University of California, San Diego, with nine other women in a class of 110.
Her desire to care for the “whole patient” had her leaning toward family medicine until a beloved mentor, Dr. Donna Brooks, “reminded me that there were so few women to take care of women... and that as an ob.gyn. I could follow women through pregnancy, delivery, surgeries, hormone issues, and so many [other facets of their health].”
Dr. Levy, who served as president of the American Association of Gynecologic Laparoscopists in 1995, recalls a world “that was very tolerant of sexual harassment” and remembers the energy she needed to expend to be taken seriously and to correct unconscious bias.
When she applied for fellowship in the American College of Surgeons in the late 1980s, the committee members who conducted an interview “told me right away that I couldn’t expect to be a fellow if I hadn’t done my duty [serving on hospital committees],” Dr. Levy said.
“I told them I had volunteered for more than three committees every single year I’d been on staff, and had never been asked to serve,” she said. “They had no idea. Their assumption was that I had children at home and I wasn’t taking the time.”
Entering leadership
When it comes to leadership, a look at academic medicine suggests that women ob.gyns. have made significant strides. In 2013, compared with other major specialties, obstetrics and gynecology had the highest proportion of department leaders who were women. Yet the picture is mixed. According to an analysis published earlier in 2016, women in ob.gyn. and nine other major specialties “were not represented in the proportions in which they entered their fields” (Obstet Gynecol. 2016 Mar;127[3]:442-7).
Women comprised 57% of all faculty in departments of ob.gyn. in 2013. And, according to the analysis, they comprised 62% of ob.gyn. residency program directors, 30% of division directors, and 24% of department chairs.
The high numbers of women serving as residency program directors raises concern because such positions “do not result in advancement in the same way,” said Dr. Levy, adding that women have excelled in such positions and may desire them, but should be mentored early on about what tracks have the potential for upper-level leadership roles.
Dr. Maureen Phipps, who in 2013 was appointed as chair of ob.gyn. and assistant dean in the Warren Albert Medical School of Brown University in Providence, said she carries with her the fact that women are not yet proportionally represented at the upper levels. “I know that my being in this position and in other positions I’ve held is important for women to see,” she said.
Dr. Phipps graduated from the University of Vermont’s College of Medicine in 1994 as a part of a class in which men and women were fairly evenly represented. In addition to her role as department chair and assistant dean, she is also now chief of ob.gyn. at Women & Infants Hospital of Rhode Island, where she did her residency, and executive chief of ob.gyn for the Care New England Health System.
“I’ve had amazing male leaders and mentors in my career – the people who’ve gone to bat for me have been men,” said Dr. Phipps. Yet, “it’s important to have women in leadership... It’s known that we think differently and approach things differently. Having balance and a variety of different lenses will allow us to [further] grow the field.”
Gender pay gap
Both in academic medicine and in practice, a gender pay gap still reportedly affects women physicians across the board. Various reports and analyses have shown women earning disproportionately less than their male colleagues in similar positions.
Notably, a 2011 analysis in Health Affairs found a nearly $17,000 gap between the starting salaries for men and women physicians. This differential accounted for variables such as patient care hours, practice type, and location. It is possible, the study authors reported, that practices “may now be offering greater flexibility and family-friendly attributes that are more appealing but that come at the price of commensurately lower pay” (Health Aff. 2011:30;193-201).
The American Medical Women’s Association, which promotes advocacy on a gender pay gap, said in a statement about the study, however, that “gender discrimination still exists within the echelons of medicine, and gender stereotyping frequently leads to the devaluation of women physicians.”
From her perspective, Dr. Levy said it’s “complicated” to tease apart and understand all the factors that may be involved.
The challenges of balancing work and family/caregiving and are “still really tough” for women ob.gyns., she said, especially those who want to practice obstetrics. Dr. Levy said she gave up obstetrics when it became apparent that she and her husband would need to hire an additional child care provider.
While the hospitalist-laborist model has been a valuable addition to obstetrics, Dr. Phipps said, “it’s our challenge to continue to think creatively about how we can keep clinicians engaged when they’re in the earlier parts of their careers and challenged by family responsibilities and other commitments.”
Both she and Dr. Levy emphasized their concerns about burnout and their desire to keep career satisfaction high – especially now that women are such a big part of ob.gyn. – and both spoke of the importance of making time for whatever activities help women “recharge.”
“We should be doing what we’re doing because we love it,” Dr. Levy said. “We should focus on that every day. Our patients trust us. We need to remind ourselves of what incredible connections we have.”
Throughout 2016, Ob.Gyn. News will celebrate its 50th anniversary with exclusive articles looking at the evolution of the specialty, including the history of contraception, changes in gynecologic surgery, and the transformation of the well-woman visit. Look for these articles and more special features in the pages of Ob.Gyn. News and online at obgynnews.com.
In newly diagnosed hypertension with OSA, adding CPAP augmented the benefits of losartan
In patients with new-onset hypertension and obstructive sleep apnea, continuous positive airway pressure (CPAP) therapy plus antihypertensive treatment with losartan led to reductions in systolic blood pressure beyond those achieved with losartan alone, a two-phase study found.
“Adding CPAP treatment to losartan may reduce blood pressure in a clinically relevant way if the patients are compliant with the device,” said Dr. Erik Thunström of the Sahlgrenska Academy at the University of Gothenburg, Sweden, and his associates.
In their open-label study, 89 men and women with new-onset untreated hypertension – 54 of whom were found to have obstructive sleep apnea (OSA) through a home sleep study and 35 of whom were determined to not have OSA – were treated for 6 weeks with losartan, 50 mg daily. Ambulatory 24-hour blood pressure monitoring was performed before and after treatment.
The patients with OSA were then randomized to receive 6 weeks of nightly add-on CPAP therapy or to continue losartan alone. Ambulatory 24-hour blood pressure monitoring was performed again.
Losartan alone reduced blood pressure in patients with hypertension and concomitant OSA, but the effect was smaller than that seen in patients without OSA. Statistically significant differences were seen in the mean net reduction in morning systolic blood pressure and morning mean arterial pressure. Overall, losartan appeared to be less effective at night and during the early morning hours in patients with OSA, the researchers reported.
After 6 weeks of losartan alone, a blood pressure less than 130/80 mm Hg was achieved by 12.5% of the patients with OSA and by 29% of the patients without OSA.
After 6 weeks of add-on CPAP therapy, 25% of patients with OSA achieved blood pressures less than 130/80 mm Hg. The differences in blood pressures for the OSA patients receiving CPAP plus losartan and those receiving losartan alone were 4.4 mm Hg for 24-hour systolic blood pressure, 1.9 mm Hg for diastolic, and 2.5 mm Hg for mean arterial pressure.
The most “robust” blood pressure changes were seen in the patients who used CPAP therapy for more than 4 hours every night, reducing the mean 24-hour systolic blood pressure by 6.5 mm Hg, the diastolic pressure by 3.8 mm Hg, and the mean arterial blood pressure by 4.6 mm Hg, the researchers reported (Am J Respir Crit Care Med. 2016 Feb.;193:310-20). “Adding CPAP to treatment with losartan reduced the mean 24-hour systolic blood pressure by 6.5 mm Hg in the subgroup of patients with OSA who were adherent with CPAP,” they wrote.
Patients included in the study all had a body mass index of 35 kg/m2; those with OSA had slightly higher BMIs that did not differ significantly from those without OSA.
That CPAP seems to have additive blood pressure–lowering effect when used concomitantly with losartan “favors the idea that it contributes to a further down-regulation of RAAS [renin-angiotensin-aldosterone system] activity in new-onset hypertension and OSA,” the authors wrote.
RAAS activity is often changed in hypertension, and in animal studies it has been shown to be up-regulated by intermittent hypoxia. Angiotensin II receptor antagonists are thus viewed as a good choice in the treatment of patients with OSA and new-onset hypertension, they wrote.
Treating OSA may make hypertension easier to address pharmacologically. The effect of CPAP on blood pressure is relatively small when all patients are considered but is more substantial and clinically important for those who use CPAP for more than 4 hours per night.
Can treatment of OSA effectively reduce blood pressure in an otherwise asymptomatic hypertensive patient with OSA? I believe the study would suggest that the answer remains “maybe.”
Most of the patients in the study would require a higher dose of losartan or an additional antihypertensive drug, even while using CPAP, to get to target blood pressures. Getting patients to use CPAP is a difficult task, as is adherence with any long-term pharmacologic management.
All in all, however, CPAP could contribute to blood pressure control while also improving quality of life and possibly reducing the risk for cardiovascular disease.
Dr. David P. White is with Harvard Medical School in Boston. His comments are excerpted from an accompanying editorial (Am J Respir Crit Care Med. 2016 Feb;193:238-9).
Treating OSA may make hypertension easier to address pharmacologically. The effect of CPAP on blood pressure is relatively small when all patients are considered but is more substantial and clinically important for those who use CPAP for more than 4 hours per night.
Can treatment of OSA effectively reduce blood pressure in an otherwise asymptomatic hypertensive patient with OSA? I believe the study would suggest that the answer remains “maybe.”
Most of the patients in the study would require a higher dose of losartan or an additional antihypertensive drug, even while using CPAP, to get to target blood pressures. Getting patients to use CPAP is a difficult task, as is adherence with any long-term pharmacologic management.
All in all, however, CPAP could contribute to blood pressure control while also improving quality of life and possibly reducing the risk for cardiovascular disease.
Dr. David P. White is with Harvard Medical School in Boston. His comments are excerpted from an accompanying editorial (Am J Respir Crit Care Med. 2016 Feb;193:238-9).
Treating OSA may make hypertension easier to address pharmacologically. The effect of CPAP on blood pressure is relatively small when all patients are considered but is more substantial and clinically important for those who use CPAP for more than 4 hours per night.
Can treatment of OSA effectively reduce blood pressure in an otherwise asymptomatic hypertensive patient with OSA? I believe the study would suggest that the answer remains “maybe.”
Most of the patients in the study would require a higher dose of losartan or an additional antihypertensive drug, even while using CPAP, to get to target blood pressures. Getting patients to use CPAP is a difficult task, as is adherence with any long-term pharmacologic management.
All in all, however, CPAP could contribute to blood pressure control while also improving quality of life and possibly reducing the risk for cardiovascular disease.
Dr. David P. White is with Harvard Medical School in Boston. His comments are excerpted from an accompanying editorial (Am J Respir Crit Care Med. 2016 Feb;193:238-9).
In patients with new-onset hypertension and obstructive sleep apnea, continuous positive airway pressure (CPAP) therapy plus antihypertensive treatment with losartan led to reductions in systolic blood pressure beyond those achieved with losartan alone, a two-phase study found.
“Adding CPAP treatment to losartan may reduce blood pressure in a clinically relevant way if the patients are compliant with the device,” said Dr. Erik Thunström of the Sahlgrenska Academy at the University of Gothenburg, Sweden, and his associates.
In their open-label study, 89 men and women with new-onset untreated hypertension – 54 of whom were found to have obstructive sleep apnea (OSA) through a home sleep study and 35 of whom were determined to not have OSA – were treated for 6 weeks with losartan, 50 mg daily. Ambulatory 24-hour blood pressure monitoring was performed before and after treatment.
The patients with OSA were then randomized to receive 6 weeks of nightly add-on CPAP therapy or to continue losartan alone. Ambulatory 24-hour blood pressure monitoring was performed again.
Losartan alone reduced blood pressure in patients with hypertension and concomitant OSA, but the effect was smaller than that seen in patients without OSA. Statistically significant differences were seen in the mean net reduction in morning systolic blood pressure and morning mean arterial pressure. Overall, losartan appeared to be less effective at night and during the early morning hours in patients with OSA, the researchers reported.
After 6 weeks of losartan alone, a blood pressure less than 130/80 mm Hg was achieved by 12.5% of the patients with OSA and by 29% of the patients without OSA.
After 6 weeks of add-on CPAP therapy, 25% of patients with OSA achieved blood pressures less than 130/80 mm Hg. The differences in blood pressures for the OSA patients receiving CPAP plus losartan and those receiving losartan alone were 4.4 mm Hg for 24-hour systolic blood pressure, 1.9 mm Hg for diastolic, and 2.5 mm Hg for mean arterial pressure.
The most “robust” blood pressure changes were seen in the patients who used CPAP therapy for more than 4 hours every night, reducing the mean 24-hour systolic blood pressure by 6.5 mm Hg, the diastolic pressure by 3.8 mm Hg, and the mean arterial blood pressure by 4.6 mm Hg, the researchers reported (Am J Respir Crit Care Med. 2016 Feb.;193:310-20). “Adding CPAP to treatment with losartan reduced the mean 24-hour systolic blood pressure by 6.5 mm Hg in the subgroup of patients with OSA who were adherent with CPAP,” they wrote.
Patients included in the study all had a body mass index of 35 kg/m2; those with OSA had slightly higher BMIs that did not differ significantly from those without OSA.
That CPAP seems to have additive blood pressure–lowering effect when used concomitantly with losartan “favors the idea that it contributes to a further down-regulation of RAAS [renin-angiotensin-aldosterone system] activity in new-onset hypertension and OSA,” the authors wrote.
RAAS activity is often changed in hypertension, and in animal studies it has been shown to be up-regulated by intermittent hypoxia. Angiotensin II receptor antagonists are thus viewed as a good choice in the treatment of patients with OSA and new-onset hypertension, they wrote.
In patients with new-onset hypertension and obstructive sleep apnea, continuous positive airway pressure (CPAP) therapy plus antihypertensive treatment with losartan led to reductions in systolic blood pressure beyond those achieved with losartan alone, a two-phase study found.
“Adding CPAP treatment to losartan may reduce blood pressure in a clinically relevant way if the patients are compliant with the device,” said Dr. Erik Thunström of the Sahlgrenska Academy at the University of Gothenburg, Sweden, and his associates.
In their open-label study, 89 men and women with new-onset untreated hypertension – 54 of whom were found to have obstructive sleep apnea (OSA) through a home sleep study and 35 of whom were determined to not have OSA – were treated for 6 weeks with losartan, 50 mg daily. Ambulatory 24-hour blood pressure monitoring was performed before and after treatment.
The patients with OSA were then randomized to receive 6 weeks of nightly add-on CPAP therapy or to continue losartan alone. Ambulatory 24-hour blood pressure monitoring was performed again.
Losartan alone reduced blood pressure in patients with hypertension and concomitant OSA, but the effect was smaller than that seen in patients without OSA. Statistically significant differences were seen in the mean net reduction in morning systolic blood pressure and morning mean arterial pressure. Overall, losartan appeared to be less effective at night and during the early morning hours in patients with OSA, the researchers reported.
After 6 weeks of losartan alone, a blood pressure less than 130/80 mm Hg was achieved by 12.5% of the patients with OSA and by 29% of the patients without OSA.
After 6 weeks of add-on CPAP therapy, 25% of patients with OSA achieved blood pressures less than 130/80 mm Hg. The differences in blood pressures for the OSA patients receiving CPAP plus losartan and those receiving losartan alone were 4.4 mm Hg for 24-hour systolic blood pressure, 1.9 mm Hg for diastolic, and 2.5 mm Hg for mean arterial pressure.
The most “robust” blood pressure changes were seen in the patients who used CPAP therapy for more than 4 hours every night, reducing the mean 24-hour systolic blood pressure by 6.5 mm Hg, the diastolic pressure by 3.8 mm Hg, and the mean arterial blood pressure by 4.6 mm Hg, the researchers reported (Am J Respir Crit Care Med. 2016 Feb.;193:310-20). “Adding CPAP to treatment with losartan reduced the mean 24-hour systolic blood pressure by 6.5 mm Hg in the subgroup of patients with OSA who were adherent with CPAP,” they wrote.
Patients included in the study all had a body mass index of 35 kg/m2; those with OSA had slightly higher BMIs that did not differ significantly from those without OSA.
That CPAP seems to have additive blood pressure–lowering effect when used concomitantly with losartan “favors the idea that it contributes to a further down-regulation of RAAS [renin-angiotensin-aldosterone system] activity in new-onset hypertension and OSA,” the authors wrote.
RAAS activity is often changed in hypertension, and in animal studies it has been shown to be up-regulated by intermittent hypoxia. Angiotensin II receptor antagonists are thus viewed as a good choice in the treatment of patients with OSA and new-onset hypertension, they wrote.
FROM AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE
Key clinical point: In patients with new-onset hypertension and obstructive sleep apnea, adding continuous positive airway pressure may reduce blood pressure levels further than achieved with losartan alone.
Major finding: In adherent patients, CPAP reduced the mean 24-hour systolic blood pressure by an additional 6.5 mm Hg as compared to the levels seen in patients on losartan alone.
Data source: A study of 89 men and women with new-onset untreated hypertension who were treated with losartan for 6 weeks and tested for OSA. In a second 6-week study, patients found to have OSA were randomized to receive CPAP or no CPAP.
Disclosures: The researchers had no relevant financial disclosures.
