Doug Brunk

Among premenopausal California women undergoing nonradical hysterectomies over a 7-year period, more than one-third underwent concurrent oophorectomies for no apparent reason.

“Regardless of what our national guidelines are telling us to do, we’re still not doing a good enough job of educating our patients and providing guideline-driven care,” Dr. Amandeep S. Mahal said in an interview prior to the annual scientific meeting of the Society of Gynecologic Surgeons.

Emerging evidence suggests that premenopausal oophorectomy is associated with worsened long-term health outcomes, including increased mortality and risk of cardiovascular events, said Dr. Mahal, a second-year fellow in the department of obstetrics and gynecology at Stanford (Calif.) University Hospital. The current recommendation by the American College of Obstetricians and Gynecologists (ACOG) is that “strong consideration should be given to retaining normal ovaries in premenopausal women who are not at increased genetic risk of ovarian cancer. However, given the risk of ovarian cancer in postmenopausal women, ovarian removal at the time of hysterectomy should be considered for these women” (Obstet. Gynecol. 2008;111[1]:231-41).

In an effort to determine the rate of potentially unnecessary oophorectomies being performed in premenopausal women for benign indications, the researchers reviewed 259,294 inpatient, nonradical hysterectomies performed in California hospitals between 2005 and 2011. Women younger than age 50 were categorized as premenopausal. The records were obtained from California’s Office of Statewide Health Planning patient discharge database, which includes all non–federal hospital discharges. Each discharge contains a primary diagnosis as well as up to 19 secondary procedure codes and 24 secondary diagnosis codes. Dr. Mahal and his associates considered oophorectomies as appropriate if a supporting ICD-9 code such as “ovarian cyst” or “endometriosis” was linked to it, and inappropriate if no such codes were linked.

Of the 259,294 benign hysterectomies performed during the study period, 37% included concomitant removal of all ovaries, and 53% of the oophorectomies were performed in premenopausal women. Of the oophorectomies in premenopausal women, 37% were deemed to be “inappropriate” based on the documented reason for removal. The researchers observed that the total number of premenopausal hysterectomies with oophorectomy decreased from 10,166 per year in 2004 to 4,672 per year in 2011, but the percentage of oophorectomies deemed to be inappropriate remained stable, in the range of 36%-38%.

“We were very diligent and went through every possible diagnosis we could think of that would give you a reason to remove ovaries,” Dr. Mahal said. “Even being exhaustive in that manner, we could not find a reason why for more than one in three women who underwent oophorectomy prior to natural menopause.”

Logistic regression analysis revealed Hispanic and black race as the only demographic factors associated with an increased odds of inappropriate oophorectomy at the time of hysterectomy (P less than .001). Hospital characteristics and type of insurance did not account for any observed differences.

Even if premenopausal women have no risk factors for ovarian cancer in the future, undergoing an oophorectomy “is a decision they should make with their physician,” Dr. Mahal said. “One of the things we don’t know [about this study] is how many patients had a conversation with their doctor, understood the risks, and decided ‘it’s worth it for me to go ahead and remove the ovaries at the time of the hysterectomy.’ ”

The meeting was jointly sponsored by the American College of Surgeons.

Dr. Mahal reported having no financial disclosures.

[email protected]

Among premenopausal California women undergoing nonradical hysterectomies over a 7-year period, more than one-third underwent concurrent oophorectomies for no apparent reason.

“Regardless of what our national guidelines are telling us to do, we’re still not doing a good enough job of educating our patients and providing guideline-driven care,” Dr. Amandeep S. Mahal said in an interview prior to the annual scientific meeting of the Society of Gynecologic Surgeons.

Emerging evidence suggests that premenopausal oophorectomy is associated with worsened long-term health outcomes, including increased mortality and risk of cardiovascular events, said Dr. Mahal, a second-year fellow in the department of obstetrics and gynecology at Stanford (Calif.) University Hospital. The current recommendation by the American College of Obstetricians and Gynecologists (ACOG) is that “strong consideration should be given to retaining normal ovaries in premenopausal women who are not at increased genetic risk of ovarian cancer. However, given the risk of ovarian cancer in postmenopausal women, ovarian removal at the time of hysterectomy should be considered for these women” (Obstet. Gynecol. 2008;111[1]:231-41).

In an effort to determine the rate of potentially unnecessary oophorectomies being performed in premenopausal women for benign indications, the researchers reviewed 259,294 inpatient, nonradical hysterectomies performed in California hospitals between 2005 and 2011. Women younger than age 50 were categorized as premenopausal. The records were obtained from California’s Office of Statewide Health Planning patient discharge database, which includes all non–federal hospital discharges. Each discharge contains a primary diagnosis as well as up to 19 secondary procedure codes and 24 secondary diagnosis codes. Dr. Mahal and his associates considered oophorectomies as appropriate if a supporting ICD-9 code such as “ovarian cyst” or “endometriosis” was linked to it, and inappropriate if no such codes were linked.

Of the 259,294 benign hysterectomies performed during the study period, 37% included concomitant removal of all ovaries, and 53% of the oophorectomies were performed in premenopausal women. Of the oophorectomies in premenopausal women, 37% were deemed to be “inappropriate” based on the documented reason for removal. The researchers observed that the total number of premenopausal hysterectomies with oophorectomy decreased from 10,166 per year in 2004 to 4,672 per year in 2011, but the percentage of oophorectomies deemed to be inappropriate remained stable, in the range of 36%-38%.

“We were very diligent and went through every possible diagnosis we could think of that would give you a reason to remove ovaries,” Dr. Mahal said. “Even being exhaustive in that manner, we could not find a reason why for more than one in three women who underwent oophorectomy prior to natural menopause.”

Logistic regression analysis revealed Hispanic and black race as the only demographic factors associated with an increased odds of inappropriate oophorectomy at the time of hysterectomy (P less than .001). Hospital characteristics and type of insurance did not account for any observed differences.

Even if premenopausal women have no risk factors for ovarian cancer in the future, undergoing an oophorectomy “is a decision they should make with their physician,” Dr. Mahal said. “One of the things we don’t know [about this study] is how many patients had a conversation with their doctor, understood the risks, and decided ‘it’s worth it for me to go ahead and remove the ovaries at the time of the hysterectomy.’ ”

The meeting was jointly sponsored by the American College of Surgeons.

Dr. Mahal reported having no financial disclosures.

[email protected]

Among premenopausal California women undergoing nonradical hysterectomies over a 7-year period, more than one-third underwent concurrent oophorectomies for no apparent reason.

“Regardless of what our national guidelines are telling us to do, we’re still not doing a good enough job of educating our patients and providing guideline-driven care,” Dr. Amandeep S. Mahal said in an interview prior to the annual scientific meeting of the Society of Gynecologic Surgeons.

Emerging evidence suggests that premenopausal oophorectomy is associated with worsened long-term health outcomes, including increased mortality and risk of cardiovascular events, said Dr. Mahal, a second-year fellow in the department of obstetrics and gynecology at Stanford (Calif.) University Hospital. The current recommendation by the American College of Obstetricians and Gynecologists (ACOG) is that “strong consideration should be given to retaining normal ovaries in premenopausal women who are not at increased genetic risk of ovarian cancer. However, given the risk of ovarian cancer in postmenopausal women, ovarian removal at the time of hysterectomy should be considered for these women” (Obstet. Gynecol. 2008;111[1]:231-41).

In an effort to determine the rate of potentially unnecessary oophorectomies being performed in premenopausal women for benign indications, the researchers reviewed 259,294 inpatient, nonradical hysterectomies performed in California hospitals between 2005 and 2011. Women younger than age 50 were categorized as premenopausal. The records were obtained from California’s Office of Statewide Health Planning patient discharge database, which includes all non–federal hospital discharges. Each discharge contains a primary diagnosis as well as up to 19 secondary procedure codes and 24 secondary diagnosis codes. Dr. Mahal and his associates considered oophorectomies as appropriate if a supporting ICD-9 code such as “ovarian cyst” or “endometriosis” was linked to it, and inappropriate if no such codes were linked.

Of the 259,294 benign hysterectomies performed during the study period, 37% included concomitant removal of all ovaries, and 53% of the oophorectomies were performed in premenopausal women. Of the oophorectomies in premenopausal women, 37% were deemed to be “inappropriate” based on the documented reason for removal. The researchers observed that the total number of premenopausal hysterectomies with oophorectomy decreased from 10,166 per year in 2004 to 4,672 per year in 2011, but the percentage of oophorectomies deemed to be inappropriate remained stable, in the range of 36%-38%.

“We were very diligent and went through every possible diagnosis we could think of that would give you a reason to remove ovaries,” Dr. Mahal said. “Even being exhaustive in that manner, we could not find a reason why for more than one in three women who underwent oophorectomy prior to natural menopause.”

Logistic regression analysis revealed Hispanic and black race as the only demographic factors associated with an increased odds of inappropriate oophorectomy at the time of hysterectomy (P less than .001). Hospital characteristics and type of insurance did not account for any observed differences.

Even if premenopausal women have no risk factors for ovarian cancer in the future, undergoing an oophorectomy “is a decision they should make with their physician,” Dr. Mahal said. “One of the things we don’t know [about this study] is how many patients had a conversation with their doctor, understood the risks, and decided ‘it’s worth it for me to go ahead and remove the ovaries at the time of the hysterectomy.’ ”

The meeting was jointly sponsored by the American College of Surgeons.

Dr. Mahal reported having no financial disclosures.

[email protected]

INDIAN WELLS, CALIF. – Unplanned, 30-day readmissions after hysterectomy for benign indications mainly occur because of surgical complications, regardless of approach, with the most common issue being surgical site infections.

Additionally, there is an increased vulnerability to readmission shortly after discharge, especially within the first 15 days.

Those are the key findings from an analysis of the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database participant user file for 2012 and 2013, presented by Dr. Courtney Penn at the annual scientific meeting of the Society of Gynecologic Surgeons.

“A seminal article in 2009 found that one in five Medicare patients are readmitted within 30 days, and unplanned readmissions account for 17% of total hospital payments from Medicare, or $17.4 billion annually,” said Dr. Penn, the lead study author and a resident in the department of obstetrics and gynecology at the University of Michigan, Ann Arbor. “Thus, addressing the problem of hospital readmissions is viewed as a golden opportunity to reduce healthcare costs and improve patient care quality. Despite this national focus on hospital readmissions, little is known about readmissions after hysterectomy.”

In an effort to characterize the most common reasons for unplanned 30-day readmissions following hysterectomy, and to characterize the timing of readmissions, the researchers retrospectively evaluated data from the ACS NSQIP database participant user file for 2012 and 2013. After using the International Classification of Diseases, Ninth Revision, Clinical Modification to identify common readmission diagnoses, they divided reasons for readmission into several categories: surgical site infection, surgical injury, non-infectious wound complications, gastrointestinal, genitourinary, venous thromboembolic, pain, medical, and “other” reasons. Results were stratified based on surgical approach.

Dr. Penn reported results from 40,580 patients who underwent hysterectomies at hospitals that participated in the ACS NSQIP. The overall, unadjusted readmission rate following hysterectomy was 2.8%, and was highest among those who underwent the procedure by abdominal approach (3.7%), followed by those who underwent the procedure by laparoscopic and vaginal approaches (2.6% vs. 2.1%, respectively).

After adjusting for potential confounding factors such as age, race, BMI, and operative time, readmissions were not significantly more likely when performed laparoscopically than with the vaginal approach. However, readmissions were significantly more likely when hysterectomy was performed via the open abdominal route, compared with the vaginal approach.

When categorizing reasons for reasons for readmission, traditional surgical complications, including surgical site infection, visceral entities, and non-infectious wound complications, were more common reasons for readmission than traditional medical complications, such as venous thromboembolism, myocardial infarction, and pulmonary edema. Slightly more than half of all readmissions (52%) were surgical in nature, compared with 9% that were attributable to traditional medical complications.

“This trend held true regardless of surgical approach, whether vaginal, laparoscopic, or abdominal,” Dr. Penn said.

Surgical site infections were the most common primary readmission diagnosis overall. “It was the underlying reason for readmission in approximately one-third of total readmissions,” she said. It was also the most common reason for readmission diagnosis for each surgical approach: 37% of abdominal, 28% of laparoscopic, and 33% of vaginal hysterectomy readmissions had a surgical site infection as the primary readmission diagnosis.

The researchers observed a few differences on reasons for readmission based on surgical approach. For example, surgical injury – such as hematoma and visceral injury – was higher after laparoscopic and vaginal hysterectomy, compared with that observed for abdominal cases (odds ratio, 2.4 and 2.8, respectively). Additionally, the proportion of readmissions related to gastrointestinal complications was higher after abdominal hysterectomies, compared with that observed among laparoscopic and vaginal cases (OR, 2.4 and 2.8, respectively).

For all surgical approaches, there was an increased likelihood of unplanned readmission within the first 15 days of discharge. In fact, 82% of all readmissions occurred within the first 15 days after discharge.

“We found that all major readmissions categories had a median time to readmission within the first 10 days after discharge, and the median time to readmission varied based on readmission diagnosis,” Dr. Penn said at the meeting, which was jointly sponsored by the American College of Surgeons. “Pain-related reasons for readmission had the shortest time to readmission, with a median of 3 days, and non-infectious wound complications had the longest time to readmission, with a median of 10 days.”

She acknowledged certain limitations of the study including the retrospective design, the database’s over-representation of urban and academic medical centers, as well the study’s reliance on one readmission diagnosis to capture the principal cause of readmission, “when the true reason for readmission may be multifactorial.”

Dr. Penn reported having no financial disclosures.

[email protected]

INDIAN WELLS, CALIF. – Unplanned, 30-day readmissions after hysterectomy for benign indications mainly occur because of surgical complications, regardless of approach, with the most common issue being surgical site infections.

Additionally, there is an increased vulnerability to readmission shortly after discharge, especially within the first 15 days.

Those are the key findings from an analysis of the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database participant user file for 2012 and 2013, presented by Dr. Courtney Penn at the annual scientific meeting of the Society of Gynecologic Surgeons.

“A seminal article in 2009 found that one in five Medicare patients are readmitted within 30 days, and unplanned readmissions account for 17% of total hospital payments from Medicare, or $17.4 billion annually,” said Dr. Penn, the lead study author and a resident in the department of obstetrics and gynecology at the University of Michigan, Ann Arbor. “Thus, addressing the problem of hospital readmissions is viewed as a golden opportunity to reduce healthcare costs and improve patient care quality. Despite this national focus on hospital readmissions, little is known about readmissions after hysterectomy.”

In an effort to characterize the most common reasons for unplanned 30-day readmissions following hysterectomy, and to characterize the timing of readmissions, the researchers retrospectively evaluated data from the ACS NSQIP database participant user file for 2012 and 2013. After using the International Classification of Diseases, Ninth Revision, Clinical Modification to identify common readmission diagnoses, they divided reasons for readmission into several categories: surgical site infection, surgical injury, non-infectious wound complications, gastrointestinal, genitourinary, venous thromboembolic, pain, medical, and “other” reasons. Results were stratified based on surgical approach.

Dr. Penn reported results from 40,580 patients who underwent hysterectomies at hospitals that participated in the ACS NSQIP. The overall, unadjusted readmission rate following hysterectomy was 2.8%, and was highest among those who underwent the procedure by abdominal approach (3.7%), followed by those who underwent the procedure by laparoscopic and vaginal approaches (2.6% vs. 2.1%, respectively).

After adjusting for potential confounding factors such as age, race, BMI, and operative time, readmissions were not significantly more likely when performed laparoscopically than with the vaginal approach. However, readmissions were significantly more likely when hysterectomy was performed via the open abdominal route, compared with the vaginal approach.

When categorizing reasons for reasons for readmission, traditional surgical complications, including surgical site infection, visceral entities, and non-infectious wound complications, were more common reasons for readmission than traditional medical complications, such as venous thromboembolism, myocardial infarction, and pulmonary edema. Slightly more than half of all readmissions (52%) were surgical in nature, compared with 9% that were attributable to traditional medical complications.

“This trend held true regardless of surgical approach, whether vaginal, laparoscopic, or abdominal,” Dr. Penn said.

Surgical site infections were the most common primary readmission diagnosis overall. “It was the underlying reason for readmission in approximately one-third of total readmissions,” she said. It was also the most common reason for readmission diagnosis for each surgical approach: 37% of abdominal, 28% of laparoscopic, and 33% of vaginal hysterectomy readmissions had a surgical site infection as the primary readmission diagnosis.

The researchers observed a few differences on reasons for readmission based on surgical approach. For example, surgical injury – such as hematoma and visceral injury – was higher after laparoscopic and vaginal hysterectomy, compared with that observed for abdominal cases (odds ratio, 2.4 and 2.8, respectively). Additionally, the proportion of readmissions related to gastrointestinal complications was higher after abdominal hysterectomies, compared with that observed among laparoscopic and vaginal cases (OR, 2.4 and 2.8, respectively).

For all surgical approaches, there was an increased likelihood of unplanned readmission within the first 15 days of discharge. In fact, 82% of all readmissions occurred within the first 15 days after discharge.

“We found that all major readmissions categories had a median time to readmission within the first 10 days after discharge, and the median time to readmission varied based on readmission diagnosis,” Dr. Penn said at the meeting, which was jointly sponsored by the American College of Surgeons. “Pain-related reasons for readmission had the shortest time to readmission, with a median of 3 days, and non-infectious wound complications had the longest time to readmission, with a median of 10 days.”

She acknowledged certain limitations of the study including the retrospective design, the database’s over-representation of urban and academic medical centers, as well the study’s reliance on one readmission diagnosis to capture the principal cause of readmission, “when the true reason for readmission may be multifactorial.”

Dr. Penn reported having no financial disclosures.

[email protected]

INDIAN WELLS, CALIF. – Unplanned, 30-day readmissions after hysterectomy for benign indications mainly occur because of surgical complications, regardless of approach, with the most common issue being surgical site infections.

Additionally, there is an increased vulnerability to readmission shortly after discharge, especially within the first 15 days.

Those are the key findings from an analysis of the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database participant user file for 2012 and 2013, presented by Dr. Courtney Penn at the annual scientific meeting of the Society of Gynecologic Surgeons.

“A seminal article in 2009 found that one in five Medicare patients are readmitted within 30 days, and unplanned readmissions account for 17% of total hospital payments from Medicare, or $17.4 billion annually,” said Dr. Penn, the lead study author and a resident in the department of obstetrics and gynecology at the University of Michigan, Ann Arbor. “Thus, addressing the problem of hospital readmissions is viewed as a golden opportunity to reduce healthcare costs and improve patient care quality. Despite this national focus on hospital readmissions, little is known about readmissions after hysterectomy.”

In an effort to characterize the most common reasons for unplanned 30-day readmissions following hysterectomy, and to characterize the timing of readmissions, the researchers retrospectively evaluated data from the ACS NSQIP database participant user file for 2012 and 2013. After using the International Classification of Diseases, Ninth Revision, Clinical Modification to identify common readmission diagnoses, they divided reasons for readmission into several categories: surgical site infection, surgical injury, non-infectious wound complications, gastrointestinal, genitourinary, venous thromboembolic, pain, medical, and “other” reasons. Results were stratified based on surgical approach.

Dr. Penn reported results from 40,580 patients who underwent hysterectomies at hospitals that participated in the ACS NSQIP. The overall, unadjusted readmission rate following hysterectomy was 2.8%, and was highest among those who underwent the procedure by abdominal approach (3.7%), followed by those who underwent the procedure by laparoscopic and vaginal approaches (2.6% vs. 2.1%, respectively).

After adjusting for potential confounding factors such as age, race, BMI, and operative time, readmissions were not significantly more likely when performed laparoscopically than with the vaginal approach. However, readmissions were significantly more likely when hysterectomy was performed via the open abdominal route, compared with the vaginal approach.

When categorizing reasons for reasons for readmission, traditional surgical complications, including surgical site infection, visceral entities, and non-infectious wound complications, were more common reasons for readmission than traditional medical complications, such as venous thromboembolism, myocardial infarction, and pulmonary edema. Slightly more than half of all readmissions (52%) were surgical in nature, compared with 9% that were attributable to traditional medical complications.

“This trend held true regardless of surgical approach, whether vaginal, laparoscopic, or abdominal,” Dr. Penn said.

Surgical site infections were the most common primary readmission diagnosis overall. “It was the underlying reason for readmission in approximately one-third of total readmissions,” she said. It was also the most common reason for readmission diagnosis for each surgical approach: 37% of abdominal, 28% of laparoscopic, and 33% of vaginal hysterectomy readmissions had a surgical site infection as the primary readmission diagnosis.

The researchers observed a few differences on reasons for readmission based on surgical approach. For example, surgical injury – such as hematoma and visceral injury – was higher after laparoscopic and vaginal hysterectomy, compared with that observed for abdominal cases (odds ratio, 2.4 and 2.8, respectively). Additionally, the proportion of readmissions related to gastrointestinal complications was higher after abdominal hysterectomies, compared with that observed among laparoscopic and vaginal cases (OR, 2.4 and 2.8, respectively).

For all surgical approaches, there was an increased likelihood of unplanned readmission within the first 15 days of discharge. In fact, 82% of all readmissions occurred within the first 15 days after discharge.

“We found that all major readmissions categories had a median time to readmission within the first 10 days after discharge, and the median time to readmission varied based on readmission diagnosis,” Dr. Penn said at the meeting, which was jointly sponsored by the American College of Surgeons. “Pain-related reasons for readmission had the shortest time to readmission, with a median of 3 days, and non-infectious wound complications had the longest time to readmission, with a median of 10 days.”

She acknowledged certain limitations of the study including the retrospective design, the database’s over-representation of urban and academic medical centers, as well the study’s reliance on one readmission diagnosis to capture the principal cause of readmission, “when the true reason for readmission may be multifactorial.”

Dr. Penn reported having no financial disclosures.

[email protected]

With few exceptions, the rates of complications, readmissions, and reoperations were similar among patients who underwent robotic hysterectomy for benign indications, compared with those who underwent the procedure by other minimally invasive routes, results from a large analysis demonstrated.

Yet the price tag for nonrobotic, minimally invasive approaches to hysterectomy was 24% lower overall per case.

“In general, people tend to favor newer technologies over older ones because the assumption is that because it’s new, it’s better,” Dr. Carolyn W. Swenson, lead study author, said in an interview before the annual scientific meeting of the Society of Gynecologic Surgeons. “Physicians are not immune to this kind of thinking. But in medicine, we have an obligation to use evidence-based practices to try and optimize outcomes for our patients. If study after study is concluding that, for benign hysterectomy, the additional cost of the robot doesn’t produce better outcomes, then we should be seriously evaluating why and how we choose to use this tool.”

In the past 10 years, use of the robot for benign hysterectomy has increased by more than 25-fold in the Unites States, while other routes of minimally invasive hysterectomy (vaginal and conventional laparoscopic) have decreased, according to Dr. Swenson, a specialist in female pelvic medicine and reconstructive surgery at the University of Michigan, Ann Arbor.

“We know that robot-assisted technology adds, on average, $2,000 to $3,000 per hysterectomy, but that major complications are no different when compared to conventional laparoscopy,” she said. “Vaginal hysterectomy is actually the most minimally invasive and most cost-effective route and it’s also associated with lower complications compared to abdominal and conventional laparoscopic routes. But vaginal hysterectomy is often left out of comparative studies with robotic hysterectomy. So what we’ve been missing up to this point is a study comparing outcomes between robot-assisted laparoscopy and all other routes of minimally invasive hysterectomy, including vaginal and vaginal-assisted laparoscopic routes in addition to conventional laparoscopy.”

In an effort to compare the clinical outcomes and the estimated cost of robot-assisted hysterectomy to all other routes of minimally invasive hysterectomy for benign indications, the researchers analyzed records from a statewide database in Michigan for all such procedures performed from July 1, 2012, to July 1, 2014. They used propensity-matched scoring to control for demographic, clinical, and hospital factors and went on to perform a one-to-one match between women who had a hysterectomy with robotic assistance, and those had a hysterectomy by other minimally invasive routes (laparoscopic and vaginal, with or without laparoscopy). Next, they compared the two cohorts for perioperative outcomes, intraoperative bowel and bladder injury, 30-day postoperative complications, readmission, and reoperation.

Dr. Swenson reported results from 11,004 hysterectomy cases. Of these, 6,222 were performed with robotic assistance, while the remaining 4,782 were performed via other minimally-invasive surgical routes. Over the study period, the proportion of hysterectomies performed with robotic assistance ranged from 43% to 45%, while rates of laparoscopy were 10%-13%, and rates of vaginal hysterectomy (with or without laparoscopy) were 19%-24%.

“I was surprised at how many robotic hysterectomies are being done in the state of Michigan for benign indications,” she said. “The rate is over three times the national average.”

After the propensity score analysis was done, 1,338 hysterectomies from each group were successfully matched and the researchers found that compared with the other minimally invasive routes, hysterectomy cases done with robotic assistance had lower estimated blood loss (94.2 vs. 175.3 mL, respectively; P less than .0001); longer surgical time (2.3 vs. 2 hours; P less .0001), and larger specimen weights (178.9 vs. 160.6 grams; P less than .0001). Intraoperative and bladder complications were similar between the two groups.

Compared with the other minimally invasive hysterectomy routes, the rate of any postoperative complication was lower among cases performed with robotic assistance (3.5% vs. 5.6%; P = .01) and was driven by lower rates of superficial surgical site infections (SSIs) (.07% vs. .7%; P = .01) and blood transfusion (.8% vs. 1.9%; P = .02). However, rates of major complications including deep/organ space SSI, thromboembolic events, MI/stroke, pneumonia, sepsis or death, and readmission and reoperation rates did not differ between the two groups.

After applying hospital cost estimates drawn from published data to results from the hysterectomies included in the propensity match, Dr. Swenson and her associates estimated that the nonrobotic minimally invasive hysterectomy routes led to a 24% lower overall cost per case ($10,160, compared with $13,429 per case performed with robotic assistance), even when considering the cost of additional cases of superficial SSI and blood transfusion. This calculation excluded maintenance costs of the robot.

“Because utilization of robotic hysterectomy for benign indications in Michigan is so much higher than the national average, the generalizability our findings might be limited,” she said. “Also, our cost data were based on estimates from the literature and were not linked to cases in our database, which would have been ideal.”

The meeting was jointly sponsored by the American College of Surgeons.

Dr. Swenson reported having no financial disclosures.

[email protected]

With few exceptions, the rates of complications, readmissions, and reoperations were similar among patients who underwent robotic hysterectomy for benign indications, compared with those who underwent the procedure by other minimally invasive routes, results from a large analysis demonstrated.

Yet the price tag for nonrobotic, minimally invasive approaches to hysterectomy was 24% lower overall per case.

“In general, people tend to favor newer technologies over older ones because the assumption is that because it’s new, it’s better,” Dr. Carolyn W. Swenson, lead study author, said in an interview before the annual scientific meeting of the Society of Gynecologic Surgeons. “Physicians are not immune to this kind of thinking. But in medicine, we have an obligation to use evidence-based practices to try and optimize outcomes for our patients. If study after study is concluding that, for benign hysterectomy, the additional cost of the robot doesn’t produce better outcomes, then we should be seriously evaluating why and how we choose to use this tool.”

In the past 10 years, use of the robot for benign hysterectomy has increased by more than 25-fold in the Unites States, while other routes of minimally invasive hysterectomy (vaginal and conventional laparoscopic) have decreased, according to Dr. Swenson, a specialist in female pelvic medicine and reconstructive surgery at the University of Michigan, Ann Arbor.

“We know that robot-assisted technology adds, on average, $2,000 to $3,000 per hysterectomy, but that major complications are no different when compared to conventional laparoscopy,” she said. “Vaginal hysterectomy is actually the most minimally invasive and most cost-effective route and it’s also associated with lower complications compared to abdominal and conventional laparoscopic routes. But vaginal hysterectomy is often left out of comparative studies with robotic hysterectomy. So what we’ve been missing up to this point is a study comparing outcomes between robot-assisted laparoscopy and all other routes of minimally invasive hysterectomy, including vaginal and vaginal-assisted laparoscopic routes in addition to conventional laparoscopy.”

In an effort to compare the clinical outcomes and the estimated cost of robot-assisted hysterectomy to all other routes of minimally invasive hysterectomy for benign indications, the researchers analyzed records from a statewide database in Michigan for all such procedures performed from July 1, 2012, to July 1, 2014. They used propensity-matched scoring to control for demographic, clinical, and hospital factors and went on to perform a one-to-one match between women who had a hysterectomy with robotic assistance, and those had a hysterectomy by other minimally invasive routes (laparoscopic and vaginal, with or without laparoscopy). Next, they compared the two cohorts for perioperative outcomes, intraoperative bowel and bladder injury, 30-day postoperative complications, readmission, and reoperation.

Dr. Swenson reported results from 11,004 hysterectomy cases. Of these, 6,222 were performed with robotic assistance, while the remaining 4,782 were performed via other minimally-invasive surgical routes. Over the study period, the proportion of hysterectomies performed with robotic assistance ranged from 43% to 45%, while rates of laparoscopy were 10%-13%, and rates of vaginal hysterectomy (with or without laparoscopy) were 19%-24%.

“I was surprised at how many robotic hysterectomies are being done in the state of Michigan for benign indications,” she said. “The rate is over three times the national average.”

After the propensity score analysis was done, 1,338 hysterectomies from each group were successfully matched and the researchers found that compared with the other minimally invasive routes, hysterectomy cases done with robotic assistance had lower estimated blood loss (94.2 vs. 175.3 mL, respectively; P less than .0001); longer surgical time (2.3 vs. 2 hours; P less .0001), and larger specimen weights (178.9 vs. 160.6 grams; P less than .0001). Intraoperative and bladder complications were similar between the two groups.

Compared with the other minimally invasive hysterectomy routes, the rate of any postoperative complication was lower among cases performed with robotic assistance (3.5% vs. 5.6%; P = .01) and was driven by lower rates of superficial surgical site infections (SSIs) (.07% vs. .7%; P = .01) and blood transfusion (.8% vs. 1.9%; P = .02). However, rates of major complications including deep/organ space SSI, thromboembolic events, MI/stroke, pneumonia, sepsis or death, and readmission and reoperation rates did not differ between the two groups.

After applying hospital cost estimates drawn from published data to results from the hysterectomies included in the propensity match, Dr. Swenson and her associates estimated that the nonrobotic minimally invasive hysterectomy routes led to a 24% lower overall cost per case ($10,160, compared with $13,429 per case performed with robotic assistance), even when considering the cost of additional cases of superficial SSI and blood transfusion. This calculation excluded maintenance costs of the robot.

“Because utilization of robotic hysterectomy for benign indications in Michigan is so much higher than the national average, the generalizability our findings might be limited,” she said. “Also, our cost data were based on estimates from the literature and were not linked to cases in our database, which would have been ideal.”

The meeting was jointly sponsored by the American College of Surgeons.

Dr. Swenson reported having no financial disclosures.

[email protected]

With few exceptions, the rates of complications, readmissions, and reoperations were similar among patients who underwent robotic hysterectomy for benign indications, compared with those who underwent the procedure by other minimally invasive routes, results from a large analysis demonstrated.

Yet the price tag for nonrobotic, minimally invasive approaches to hysterectomy was 24% lower overall per case.

“In general, people tend to favor newer technologies over older ones because the assumption is that because it’s new, it’s better,” Dr. Carolyn W. Swenson, lead study author, said in an interview before the annual scientific meeting of the Society of Gynecologic Surgeons. “Physicians are not immune to this kind of thinking. But in medicine, we have an obligation to use evidence-based practices to try and optimize outcomes for our patients. If study after study is concluding that, for benign hysterectomy, the additional cost of the robot doesn’t produce better outcomes, then we should be seriously evaluating why and how we choose to use this tool.”

In the past 10 years, use of the robot for benign hysterectomy has increased by more than 25-fold in the Unites States, while other routes of minimally invasive hysterectomy (vaginal and conventional laparoscopic) have decreased, according to Dr. Swenson, a specialist in female pelvic medicine and reconstructive surgery at the University of Michigan, Ann Arbor.

“We know that robot-assisted technology adds, on average, $2,000 to $3,000 per hysterectomy, but that major complications are no different when compared to conventional laparoscopy,” she said. “Vaginal hysterectomy is actually the most minimally invasive and most cost-effective route and it’s also associated with lower complications compared to abdominal and conventional laparoscopic routes. But vaginal hysterectomy is often left out of comparative studies with robotic hysterectomy. So what we’ve been missing up to this point is a study comparing outcomes between robot-assisted laparoscopy and all other routes of minimally invasive hysterectomy, including vaginal and vaginal-assisted laparoscopic routes in addition to conventional laparoscopy.”

In an effort to compare the clinical outcomes and the estimated cost of robot-assisted hysterectomy to all other routes of minimally invasive hysterectomy for benign indications, the researchers analyzed records from a statewide database in Michigan for all such procedures performed from July 1, 2012, to July 1, 2014. They used propensity-matched scoring to control for demographic, clinical, and hospital factors and went on to perform a one-to-one match between women who had a hysterectomy with robotic assistance, and those had a hysterectomy by other minimally invasive routes (laparoscopic and vaginal, with or without laparoscopy). Next, they compared the two cohorts for perioperative outcomes, intraoperative bowel and bladder injury, 30-day postoperative complications, readmission, and reoperation.

Dr. Swenson reported results from 11,004 hysterectomy cases. Of these, 6,222 were performed with robotic assistance, while the remaining 4,782 were performed via other minimally-invasive surgical routes. Over the study period, the proportion of hysterectomies performed with robotic assistance ranged from 43% to 45%, while rates of laparoscopy were 10%-13%, and rates of vaginal hysterectomy (with or without laparoscopy) were 19%-24%.

“I was surprised at how many robotic hysterectomies are being done in the state of Michigan for benign indications,” she said. “The rate is over three times the national average.”

After the propensity score analysis was done, 1,338 hysterectomies from each group were successfully matched and the researchers found that compared with the other minimally invasive routes, hysterectomy cases done with robotic assistance had lower estimated blood loss (94.2 vs. 175.3 mL, respectively; P less than .0001); longer surgical time (2.3 vs. 2 hours; P less .0001), and larger specimen weights (178.9 vs. 160.6 grams; P less than .0001). Intraoperative and bladder complications were similar between the two groups.

Compared with the other minimally invasive hysterectomy routes, the rate of any postoperative complication was lower among cases performed with robotic assistance (3.5% vs. 5.6%; P = .01) and was driven by lower rates of superficial surgical site infections (SSIs) (.07% vs. .7%; P = .01) and blood transfusion (.8% vs. 1.9%; P = .02). However, rates of major complications including deep/organ space SSI, thromboembolic events, MI/stroke, pneumonia, sepsis or death, and readmission and reoperation rates did not differ between the two groups.

After applying hospital cost estimates drawn from published data to results from the hysterectomies included in the propensity match, Dr. Swenson and her associates estimated that the nonrobotic minimally invasive hysterectomy routes led to a 24% lower overall cost per case ($10,160, compared with $13,429 per case performed with robotic assistance), even when considering the cost of additional cases of superficial SSI and blood transfusion. This calculation excluded maintenance costs of the robot.

“Because utilization of robotic hysterectomy for benign indications in Michigan is so much higher than the national average, the generalizability our findings might be limited,” she said. “Also, our cost data were based on estimates from the literature and were not linked to cases in our database, which would have been ideal.”

The meeting was jointly sponsored by the American College of Surgeons.

Dr. Swenson reported having no financial disclosures.

[email protected]

An outbreak of measles in infants who were too young for routine immunization with the MMR vaccine occurred in an Illinois day care center, highlighting the vulnerability of infants younger than 1 year to measles infection.

“With the continued threat of measles importations from endemic countries and the recent resurgence of cases in the United States, it is critical to institute measures to protect this susceptible population,” researchers led by Dr. Whitney J. Clegg wrote online (J Pediatric Infect Dis Soc. 2016 March 24. doi: 10.1093/jpids/piw011). “Although infection among infants cannot be prevented through routine vaccination and herd immunity does not provide 100% protection, other strategies are effective in protecting this population from measles during future outbreaks. These include maintaining a high index of suspicion for measles in unvaccinated individuals presenting with a febrile rash illness and ensuring that those caring for infants have documented evidence of immunity.”

CDC/ Cynthia S. Goldsmith; William Bellini, Ph.D.

Dr. Clegg, an applied epidemiology fellow with the Illinois Department of Public Health, and his associates reported on an outbreak of 15 confirmed measles cases that occurred during January and February of 2015 in Cook County, Ill. Of the 15 cases, 12 (80%) occurred in infants aged 3-11 months who attended the same child care center. One of the cases, a 7-month-old male infant, was hospitalized for near-daily fevers and respiratory symptoms. Clinicians suspected Kawasaki disease, but that was ruled out 26 days after initial rash onset through positive measles-specific IgM serology. The child attended the day care only once during the time he was infectious, but delayed recognition of measles “led to continued transmission within the child care center,” the researchers wrote. “High vaccination rates in the community, especially among child care attendees aged [1 year and older] and among staff caring for the infants, likely led to containment of the outbreak primarily among individuals too young to receive their first dose of MMR vaccine.”

Among the 11 other infant cases, 5 visited outpatient clinics during their infectious period, exposing 33 infants. The three remaining confirmed measles cases were adult females who ranged in age from their late 20s to early 40s. One was the mother of a child care center attendee with confirmed measles.

“No direct connection could be made between the other two adults and the child care center attendees other than geographic proximity,” Dr. Clegg and his associates said. “The three adults reported unknown vaccination histories and denied personal or religious objections to immunizations; all had children that were up to date with their vaccinations. All cases resided in or attended child care in the same city within Cook County. No cases in this outbreak reported a travel history or contact with ill individuals who recently traveled.”

In all, 91 contacts of the 15 measles cases were monitored, and 20 received postexposure prophylaxis. The researchers noted that an important part of the outbreak investigation was identifying health care workers and child care center staff who worked closely with susceptible children and ensuring documentation of measles immunity. “Three health care workers with no vaccination records available were identified at the exposed pediatric clinics,” they noted. “Obtaining documentation of vaccinations, time taken away from regular clinic activities, and preventable work exclusions during an outbreak can be costly for health care facilities. These costs, as well as measles infection and transmission, could be avoided by ensuring all health care workers have the necessary documentation readily available at their facility.”

The report was supported in part by an appointment to the Applied Epidemiology Fellowship Program administered by the Council of State and Territorial Epidemiologists and funded by the Centers for Disease Control and Prevention. Dr. Clegg and his associates reported no relevant financial conflicts.

[email protected]

An outbreak of measles in infants who were too young for routine immunization with the MMR vaccine occurred in an Illinois day care center, highlighting the vulnerability of infants younger than 1 year to measles infection.

“With the continued threat of measles importations from endemic countries and the recent resurgence of cases in the United States, it is critical to institute measures to protect this susceptible population,” researchers led by Dr. Whitney J. Clegg wrote online (J Pediatric Infect Dis Soc. 2016 March 24. doi: 10.1093/jpids/piw011). “Although infection among infants cannot be prevented through routine vaccination and herd immunity does not provide 100% protection, other strategies are effective in protecting this population from measles during future outbreaks. These include maintaining a high index of suspicion for measles in unvaccinated individuals presenting with a febrile rash illness and ensuring that those caring for infants have documented evidence of immunity.”

CDC/ Cynthia S. Goldsmith; William Bellini, Ph.D.

Dr. Clegg, an applied epidemiology fellow with the Illinois Department of Public Health, and his associates reported on an outbreak of 15 confirmed measles cases that occurred during January and February of 2015 in Cook County, Ill. Of the 15 cases, 12 (80%) occurred in infants aged 3-11 months who attended the same child care center. One of the cases, a 7-month-old male infant, was hospitalized for near-daily fevers and respiratory symptoms. Clinicians suspected Kawasaki disease, but that was ruled out 26 days after initial rash onset through positive measles-specific IgM serology. The child attended the day care only once during the time he was infectious, but delayed recognition of measles “led to continued transmission within the child care center,” the researchers wrote. “High vaccination rates in the community, especially among child care attendees aged [1 year and older] and among staff caring for the infants, likely led to containment of the outbreak primarily among individuals too young to receive their first dose of MMR vaccine.”

Among the 11 other infant cases, 5 visited outpatient clinics during their infectious period, exposing 33 infants. The three remaining confirmed measles cases were adult females who ranged in age from their late 20s to early 40s. One was the mother of a child care center attendee with confirmed measles.

“No direct connection could be made between the other two adults and the child care center attendees other than geographic proximity,” Dr. Clegg and his associates said. “The three adults reported unknown vaccination histories and denied personal or religious objections to immunizations; all had children that were up to date with their vaccinations. All cases resided in or attended child care in the same city within Cook County. No cases in this outbreak reported a travel history or contact with ill individuals who recently traveled.”

In all, 91 contacts of the 15 measles cases were monitored, and 20 received postexposure prophylaxis. The researchers noted that an important part of the outbreak investigation was identifying health care workers and child care center staff who worked closely with susceptible children and ensuring documentation of measles immunity. “Three health care workers with no vaccination records available were identified at the exposed pediatric clinics,” they noted. “Obtaining documentation of vaccinations, time taken away from regular clinic activities, and preventable work exclusions during an outbreak can be costly for health care facilities. These costs, as well as measles infection and transmission, could be avoided by ensuring all health care workers have the necessary documentation readily available at their facility.”

The report was supported in part by an appointment to the Applied Epidemiology Fellowship Program administered by the Council of State and Territorial Epidemiologists and funded by the Centers for Disease Control and Prevention. Dr. Clegg and his associates reported no relevant financial conflicts.

[email protected]

An outbreak of measles in infants who were too young for routine immunization with the MMR vaccine occurred in an Illinois day care center, highlighting the vulnerability of infants younger than 1 year to measles infection.

“With the continued threat of measles importations from endemic countries and the recent resurgence of cases in the United States, it is critical to institute measures to protect this susceptible population,” researchers led by Dr. Whitney J. Clegg wrote online (J Pediatric Infect Dis Soc. 2016 March 24. doi: 10.1093/jpids/piw011). “Although infection among infants cannot be prevented through routine vaccination and herd immunity does not provide 100% protection, other strategies are effective in protecting this population from measles during future outbreaks. These include maintaining a high index of suspicion for measles in unvaccinated individuals presenting with a febrile rash illness and ensuring that those caring for infants have documented evidence of immunity.”

CDC/ Cynthia S. Goldsmith; William Bellini, Ph.D.

Dr. Clegg, an applied epidemiology fellow with the Illinois Department of Public Health, and his associates reported on an outbreak of 15 confirmed measles cases that occurred during January and February of 2015 in Cook County, Ill. Of the 15 cases, 12 (80%) occurred in infants aged 3-11 months who attended the same child care center. One of the cases, a 7-month-old male infant, was hospitalized for near-daily fevers and respiratory symptoms. Clinicians suspected Kawasaki disease, but that was ruled out 26 days after initial rash onset through positive measles-specific IgM serology. The child attended the day care only once during the time he was infectious, but delayed recognition of measles “led to continued transmission within the child care center,” the researchers wrote. “High vaccination rates in the community, especially among child care attendees aged [1 year and older] and among staff caring for the infants, likely led to containment of the outbreak primarily among individuals too young to receive their first dose of MMR vaccine.”

Among the 11 other infant cases, 5 visited outpatient clinics during their infectious period, exposing 33 infants. The three remaining confirmed measles cases were adult females who ranged in age from their late 20s to early 40s. One was the mother of a child care center attendee with confirmed measles.

“No direct connection could be made between the other two adults and the child care center attendees other than geographic proximity,” Dr. Clegg and his associates said. “The three adults reported unknown vaccination histories and denied personal or religious objections to immunizations; all had children that were up to date with their vaccinations. All cases resided in or attended child care in the same city within Cook County. No cases in this outbreak reported a travel history or contact with ill individuals who recently traveled.”

In all, 91 contacts of the 15 measles cases were monitored, and 20 received postexposure prophylaxis. The researchers noted that an important part of the outbreak investigation was identifying health care workers and child care center staff who worked closely with susceptible children and ensuring documentation of measles immunity. “Three health care workers with no vaccination records available were identified at the exposed pediatric clinics,” they noted. “Obtaining documentation of vaccinations, time taken away from regular clinic activities, and preventable work exclusions during an outbreak can be costly for health care facilities. These costs, as well as measles infection and transmission, could be avoided by ensuring all health care workers have the necessary documentation readily available at their facility.”

The report was supported in part by an appointment to the Applied Epidemiology Fellowship Program administered by the Council of State and Territorial Epidemiologists and funded by the Centers for Disease Control and Prevention. Dr. Clegg and his associates reported no relevant financial conflicts.

[email protected]

There is no apparent benefit to screening for chronic obstructive pulmonary disease in asymptomatic patients, a new recommendation from the U.S. Preventive Services Task Force (USPSTF) concludes.

The recommendation statement, which was published in the April 5 edition of JAMA, meets Grade D criteria, which the task force defines as having “moderate or high certainty that the service has no benefit or that the harms outweigh the benefits.”

©designer491/Thinkstockphotos.com

Led by Dr. Albert L. Siu of the Icahn School of Medicine at Mount Sinai, New York, the 16-member task force “found no studies that directly assessed the effects of screening for COPD [chronic obstructive pulmonary disease] in asymptomatic adults on morbidity, mortality, or health-related quality of life,” they wrote (JAMA. 2016 Apr; 315[13]:1372-7). “The USPSTF also found no studies that examined the effectiveness of screening on relevant immunization rates.” The five studies identified that assessed the effects of screening on smoking cessation “primarily examined the incremental value of adding spirometry testing to existing smoking cessation programs. One trial showed a statistically significant increase in smoking cessation rates between participants who received explanations of their spirometry results using ‘lung age’ and those who did not. The other four trials did not report any significant differences in smoking abstinence rates.”

The recommendations are based on a systematic review of evidence that was commissioned by the USPSTF and published in the same issue of JAMA. The reviewers set out to determine the accuracy of screening questionnaires and office-based screening pulmonary function testing and the efficacy and harms of treatment of screen-detected COPD. After reviewing 33 studies that met inclusion criteria, five experts led by Dr. Janelle M. Guirguis-Blake found “no direct evidence available to determine the benefits and harms of screening asymptomatic adults for COPD using questionnaires or office-based screening pulmonary function testing or to determine the benefits of treatment in screen-detected populations,” they wrote (JAMA. 2016 Apr; 315[13]:1378-93). “Indirect evidence suggests that the CDQ [COPD Diagnostic Questionnaire] has moderate overall performance for COPD detection. Among patients with mild to moderate COPD, the benefit of pharmacotherapy for reducing exacerbations was modest.”

The USPSTF last published an update on COPD in 2008. That report recommended against screening for COPD with spirometry in asymptomatic adults, a Grade D recommendation based on the conclusion that screening for COPD had no net benefit and large associated costs.

According to the current recommendations, an estimated 14% of U.S. adults aged 40-79 years have COPD, and it is the third leading cause of death in the U.S. Although postbronchodilator spirometry is required to make a definitive diagnosis, “prescreening questionnaires can elicit current symptoms and previous exposures to harmful particles or gases,” Dr. Siu and his fellow task force members wrote.

They acknowledged limitations of the recommendations, including the fact that many of the reviewed studies did not report results separately by current versus former smokers. “Future studies that stratify risk by smoking status could help identify different risk groups that may benefit from screening,” they wrote “In addition, trials are needed that assess the effects of screening among current and previous smokers in primary care on long-term health outcomes. Long-term trials of treatment of COPD in screen-detected patients are also needed. Better treatment options for COPD and long-term epidemiological studies of the natural history and heterogeneity of COPD progression could also help identify patients who are at greatest risk for clinical deterioration.”

The systematic review was funded by the Agency for Healthcare Research and Quality under a contract to support the USPSTF. The authors of the recommendation statement reported having no financial disclosures.

[email protected]

There is no apparent benefit to screening for chronic obstructive pulmonary disease in asymptomatic patients, a new recommendation from the U.S. Preventive Services Task Force (USPSTF) concludes.

The recommendation statement, which was published in the April 5 edition of JAMA, meets Grade D criteria, which the task force defines as having “moderate or high certainty that the service has no benefit or that the harms outweigh the benefits.”

©designer491/Thinkstockphotos.com

Led by Dr. Albert L. Siu of the Icahn School of Medicine at Mount Sinai, New York, the 16-member task force “found no studies that directly assessed the effects of screening for COPD [chronic obstructive pulmonary disease] in asymptomatic adults on morbidity, mortality, or health-related quality of life,” they wrote (JAMA. 2016 Apr; 315[13]:1372-7). “The USPSTF also found no studies that examined the effectiveness of screening on relevant immunization rates.” The five studies identified that assessed the effects of screening on smoking cessation “primarily examined the incremental value of adding spirometry testing to existing smoking cessation programs. One trial showed a statistically significant increase in smoking cessation rates between participants who received explanations of their spirometry results using ‘lung age’ and those who did not. The other four trials did not report any significant differences in smoking abstinence rates.”

The recommendations are based on a systematic review of evidence that was commissioned by the USPSTF and published in the same issue of JAMA. The reviewers set out to determine the accuracy of screening questionnaires and office-based screening pulmonary function testing and the efficacy and harms of treatment of screen-detected COPD. After reviewing 33 studies that met inclusion criteria, five experts led by Dr. Janelle M. Guirguis-Blake found “no direct evidence available to determine the benefits and harms of screening asymptomatic adults for COPD using questionnaires or office-based screening pulmonary function testing or to determine the benefits of treatment in screen-detected populations,” they wrote (JAMA. 2016 Apr; 315[13]:1378-93). “Indirect evidence suggests that the CDQ [COPD Diagnostic Questionnaire] has moderate overall performance for COPD detection. Among patients with mild to moderate COPD, the benefit of pharmacotherapy for reducing exacerbations was modest.”

The USPSTF last published an update on COPD in 2008. That report recommended against screening for COPD with spirometry in asymptomatic adults, a Grade D recommendation based on the conclusion that screening for COPD had no net benefit and large associated costs.

According to the current recommendations, an estimated 14% of U.S. adults aged 40-79 years have COPD, and it is the third leading cause of death in the U.S. Although postbronchodilator spirometry is required to make a definitive diagnosis, “prescreening questionnaires can elicit current symptoms and previous exposures to harmful particles or gases,” Dr. Siu and his fellow task force members wrote.

They acknowledged limitations of the recommendations, including the fact that many of the reviewed studies did not report results separately by current versus former smokers. “Future studies that stratify risk by smoking status could help identify different risk groups that may benefit from screening,” they wrote “In addition, trials are needed that assess the effects of screening among current and previous smokers in primary care on long-term health outcomes. Long-term trials of treatment of COPD in screen-detected patients are also needed. Better treatment options for COPD and long-term epidemiological studies of the natural history and heterogeneity of COPD progression could also help identify patients who are at greatest risk for clinical deterioration.”

The systematic review was funded by the Agency for Healthcare Research and Quality under a contract to support the USPSTF. The authors of the recommendation statement reported having no financial disclosures.

[email protected]

There is no apparent benefit to screening for chronic obstructive pulmonary disease in asymptomatic patients, a new recommendation from the U.S. Preventive Services Task Force (USPSTF) concludes.

The recommendation statement, which was published in the April 5 edition of JAMA, meets Grade D criteria, which the task force defines as having “moderate or high certainty that the service has no benefit or that the harms outweigh the benefits.”

©designer491/Thinkstockphotos.com

Led by Dr. Albert L. Siu of the Icahn School of Medicine at Mount Sinai, New York, the 16-member task force “found no studies that directly assessed the effects of screening for COPD [chronic obstructive pulmonary disease] in asymptomatic adults on morbidity, mortality, or health-related quality of life,” they wrote (JAMA. 2016 Apr; 315[13]:1372-7). “The USPSTF also found no studies that examined the effectiveness of screening on relevant immunization rates.” The five studies identified that assessed the effects of screening on smoking cessation “primarily examined the incremental value of adding spirometry testing to existing smoking cessation programs. One trial showed a statistically significant increase in smoking cessation rates between participants who received explanations of their spirometry results using ‘lung age’ and those who did not. The other four trials did not report any significant differences in smoking abstinence rates.”

The recommendations are based on a systematic review of evidence that was commissioned by the USPSTF and published in the same issue of JAMA. The reviewers set out to determine the accuracy of screening questionnaires and office-based screening pulmonary function testing and the efficacy and harms of treatment of screen-detected COPD. After reviewing 33 studies that met inclusion criteria, five experts led by Dr. Janelle M. Guirguis-Blake found “no direct evidence available to determine the benefits and harms of screening asymptomatic adults for COPD using questionnaires or office-based screening pulmonary function testing or to determine the benefits of treatment in screen-detected populations,” they wrote (JAMA. 2016 Apr; 315[13]:1378-93). “Indirect evidence suggests that the CDQ [COPD Diagnostic Questionnaire] has moderate overall performance for COPD detection. Among patients with mild to moderate COPD, the benefit of pharmacotherapy for reducing exacerbations was modest.”

The USPSTF last published an update on COPD in 2008. That report recommended against screening for COPD with spirometry in asymptomatic adults, a Grade D recommendation based on the conclusion that screening for COPD had no net benefit and large associated costs.

According to the current recommendations, an estimated 14% of U.S. adults aged 40-79 years have COPD, and it is the third leading cause of death in the U.S. Although postbronchodilator spirometry is required to make a definitive diagnosis, “prescreening questionnaires can elicit current symptoms and previous exposures to harmful particles or gases,” Dr. Siu and his fellow task force members wrote.

They acknowledged limitations of the recommendations, including the fact that many of the reviewed studies did not report results separately by current versus former smokers. “Future studies that stratify risk by smoking status could help identify different risk groups that may benefit from screening,” they wrote “In addition, trials are needed that assess the effects of screening among current and previous smokers in primary care on long-term health outcomes. Long-term trials of treatment of COPD in screen-detected patients are also needed. Better treatment options for COPD and long-term epidemiological studies of the natural history and heterogeneity of COPD progression could also help identify patients who are at greatest risk for clinical deterioration.”

The systematic review was funded by the Agency for Healthcare Research and Quality under a contract to support the USPSTF. The authors of the recommendation statement reported having no financial disclosures.

[email protected]

SAN DIEGO – College-aged men and women had positive attitudes toward human papillomavirus vaccination, yet perceived cost and access barriers factored into their decision to receive the vaccine, results from a large survey found.

“The people reporting the higher barrier scores were the same ones who had the highest intent to receive the vaccine,” Dr. Casey Nicol, lead study author, said in an interview at the annual meeting of the Society of Gynecologic Oncology. “It’s a shame, because these are people who want it, and there are ways for them to get vaccinated; they just don’t know about them. I think there’s a big opportunity for education and public health outreach.”

Doug Brunk/Frontline Medical News

Dr. Nicol and her associates sent an online survey to a random sample of 3,000 students at the University of Virginia, Charlottesville, who were between 18 and 26 years old. The survey included questions about their human papillomavirus (HPV) vaccination status and intention as well as 17 items from the modified Carolina HPV Immunization Attitudes and Beliefs Scale (CHIAS).

“A lot of the previous research I could find focused more on parental attitudes about HPV vaccination rather than adolescent and young adult attitudes,” said Dr. Nicol, who is a resident in the department of obstetrics and gynecology at the University of Virginia.

Of the 3,000 surveys sent, 776 were completed and used in the final analysis, for a response rate of 26%. More than two-thirds of the respondents (70%) were women, and their mean age was 20 years. In all, 67% of students reported having received at least one HPV vaccination, and the proportion was higher for women, compared with men (75% vs. 51%, respectively).

“In our college population we found that the vaccination rates were not as bad as we expected,” Dr. Nicol said. “It was about double the national average for our women and about 20 times the national average for our men.”

No sex differences were observed in responses to 14 of the 17 CHIAS items, and CHIAS factor means for men and women did not differ for any of the five factor groupings, which included barriers, harms, effectiveness, risk denial, and uncertainty.

Dr. Nicol reported that the barriers score was the factor most strongly associated with vaccination intent “today.” It was also strongly associated with vaccination intent for “the next 6 months” (P = .001).

Items in the barriers factor category included the following:

• “It would be hard to find a provider or clinic that would be easy to get to for getting vaccinated against HPV.”

• “It would be hard to find a provider or clinic where I could afford the HPV vaccine.”

• “It would be hard to find a provider or clinic that has the HPV vaccine available.”

• “It would be hard to find a provider or clinic where I don’t have to wait a long time to get an appointment to get vaccinated.”

Dr. Nicol said that the findings underscore the importance of decreasing cost and access barriers in order to improve HPV vaccination rates among young adults.

“If you don’t offer the HPV vaccine at your office, at least provide your patients with” cost information and the “location of the clinics that do have it available,” she advised. “It seems like that would increase the prevalence of more students getting vaccinated.”

Dr. Nicol reported having no relevant financial disclosures.

[email protected]

SAN DIEGO – College-aged men and women had positive attitudes toward human papillomavirus vaccination, yet perceived cost and access barriers factored into their decision to receive the vaccine, results from a large survey found.

“The people reporting the higher barrier scores were the same ones who had the highest intent to receive the vaccine,” Dr. Casey Nicol, lead study author, said in an interview at the annual meeting of the Society of Gynecologic Oncology. “It’s a shame, because these are people who want it, and there are ways for them to get vaccinated; they just don’t know about them. I think there’s a big opportunity for education and public health outreach.”

Doug Brunk/Frontline Medical News

Dr. Nicol and her associates sent an online survey to a random sample of 3,000 students at the University of Virginia, Charlottesville, who were between 18 and 26 years old. The survey included questions about their human papillomavirus (HPV) vaccination status and intention as well as 17 items from the modified Carolina HPV Immunization Attitudes and Beliefs Scale (CHIAS).

“A lot of the previous research I could find focused more on parental attitudes about HPV vaccination rather than adolescent and young adult attitudes,” said Dr. Nicol, who is a resident in the department of obstetrics and gynecology at the University of Virginia.

Of the 3,000 surveys sent, 776 were completed and used in the final analysis, for a response rate of 26%. More than two-thirds of the respondents (70%) were women, and their mean age was 20 years. In all, 67% of students reported having received at least one HPV vaccination, and the proportion was higher for women, compared with men (75% vs. 51%, respectively).

“In our college population we found that the vaccination rates were not as bad as we expected,” Dr. Nicol said. “It was about double the national average for our women and about 20 times the national average for our men.”

No sex differences were observed in responses to 14 of the 17 CHIAS items, and CHIAS factor means for men and women did not differ for any of the five factor groupings, which included barriers, harms, effectiveness, risk denial, and uncertainty.

Dr. Nicol reported that the barriers score was the factor most strongly associated with vaccination intent “today.” It was also strongly associated with vaccination intent for “the next 6 months” (P = .001).

Items in the barriers factor category included the following:

• “It would be hard to find a provider or clinic that would be easy to get to for getting vaccinated against HPV.”

• “It would be hard to find a provider or clinic where I could afford the HPV vaccine.”

• “It would be hard to find a provider or clinic that has the HPV vaccine available.”

• “It would be hard to find a provider or clinic where I don’t have to wait a long time to get an appointment to get vaccinated.”

Dr. Nicol said that the findings underscore the importance of decreasing cost and access barriers in order to improve HPV vaccination rates among young adults.

“If you don’t offer the HPV vaccine at your office, at least provide your patients with” cost information and the “location of the clinics that do have it available,” she advised. “It seems like that would increase the prevalence of more students getting vaccinated.”

Dr. Nicol reported having no relevant financial disclosures.

[email protected]

SAN DIEGO – College-aged men and women had positive attitudes toward human papillomavirus vaccination, yet perceived cost and access barriers factored into their decision to receive the vaccine, results from a large survey found.

“The people reporting the higher barrier scores were the same ones who had the highest intent to receive the vaccine,” Dr. Casey Nicol, lead study author, said in an interview at the annual meeting of the Society of Gynecologic Oncology. “It’s a shame, because these are people who want it, and there are ways for them to get vaccinated; they just don’t know about them. I think there’s a big opportunity for education and public health outreach.”

Doug Brunk/Frontline Medical News

Dr. Nicol and her associates sent an online survey to a random sample of 3,000 students at the University of Virginia, Charlottesville, who were between 18 and 26 years old. The survey included questions about their human papillomavirus (HPV) vaccination status and intention as well as 17 items from the modified Carolina HPV Immunization Attitudes and Beliefs Scale (CHIAS).

“A lot of the previous research I could find focused more on parental attitudes about HPV vaccination rather than adolescent and young adult attitudes,” said Dr. Nicol, who is a resident in the department of obstetrics and gynecology at the University of Virginia.

Of the 3,000 surveys sent, 776 were completed and used in the final analysis, for a response rate of 26%. More than two-thirds of the respondents (70%) were women, and their mean age was 20 years. In all, 67% of students reported having received at least one HPV vaccination, and the proportion was higher for women, compared with men (75% vs. 51%, respectively).

“In our college population we found that the vaccination rates were not as bad as we expected,” Dr. Nicol said. “It was about double the national average for our women and about 20 times the national average for our men.”

No sex differences were observed in responses to 14 of the 17 CHIAS items, and CHIAS factor means for men and women did not differ for any of the five factor groupings, which included barriers, harms, effectiveness, risk denial, and uncertainty.

Dr. Nicol reported that the barriers score was the factor most strongly associated with vaccination intent “today.” It was also strongly associated with vaccination intent for “the next 6 months” (P = .001).

Items in the barriers factor category included the following:

• “It would be hard to find a provider or clinic that would be easy to get to for getting vaccinated against HPV.”

• “It would be hard to find a provider or clinic where I could afford the HPV vaccine.”

• “It would be hard to find a provider or clinic that has the HPV vaccine available.”

• “It would be hard to find a provider or clinic where I don’t have to wait a long time to get an appointment to get vaccinated.”

Dr. Nicol said that the findings underscore the importance of decreasing cost and access barriers in order to improve HPV vaccination rates among young adults.

“If you don’t offer the HPV vaccine at your office, at least provide your patients with” cost information and the “location of the clinics that do have it available,” she advised. “It seems like that would increase the prevalence of more students getting vaccinated.”

Dr. Nicol reported having no relevant financial disclosures.

[email protected]