The VA operates the largest integrated health care system in the country, consisting of 144 hospitals and 1,221 outpatient clinics. This system provides medical care for about 22 million veterans. In 2015, women accounted for nearly 10% of the veteran population and are expected to increase to about 16% by 2040.¹ With an expected population increase of 18,000 per year over the next 10 years, women are the fastest growing group of veterans.

The VA acknowledges that women are an integral part of the veteran community and that a paradigm shift must occur to meet their unique health needs. Although clinical services specific to women veterans’ health needs have been introduced within the VA, gynecologic surgical services must be addressed in order to improve access and provide comprehensive women’s health care within the VA system.

About 600,000 hysterectomies are performed annually in the U.S., making this procedure one of the most commonly performed in women.² Over the past 30 years, technologic advances have allowed surgeons to perform more hysterectomies via minimally invasive methods. Both the American Congress of Obstetricians and Gynecologists and American Association of Gynecologic Laparoscopists have published consensus statements that minimally invasive hysterectomy should be the standard of care.^3,4 Studies in non-VA facilities have shown that practice patterns in the route of hysterectomy have evolved with the advancement of surgical equipment and techniques.

It is uncertain, however, whether these changes in practice patterns exist in the VA, because there are limited published data. Given the frequency of hysterectomies in the U.S., the rate and route of this procedure are easily identifiable measures that can be evaluated and utilized as a comparison model for health care received within the VA vs the civilian sector.

The aim of this study was to assess the changes in rate and surgical approach to benign hysterectomy for women veterans at VAMCs and referrals to non-VA facilities over a 10-year period. The authors’ hypothesis was that a minimally invasive approach would be more common in recent years. This study also compares published national data to evaluate whether the VA is offering comparable surgical services to the civilian sector.

Methods

The institutional review boards of Indiana University and the Richard L. Roudebush VAMC in Indianapolis, Indiana, approved this retrospective cross-sectional study. The VHA Support Service Center (VSSC) authorized access to VA database information.

All women veterans who underwent hysterectomy for benign indications from fiscal years (FY) 2005 to 2014 were included. In order to identify this group, the authors queried the VA Corporate Data Warehouse (CDW) and the Non-VA Care Cube for all hysterectomy current procedural terminology (CPT) codes typically performed for benign indications, including 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290, 58291, 58292, 58293, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, and 58573. For each patient identified, the following variables were collected: date of the procedure, facility location, primary CPT code, primary ICD-9 code, and patient age. Patients whose primary ICD-9 code was for a malignancy of gynecologic origin were excluded from the study.

The CDW is a national database collected by the VA Office of Information and Technology to provide clinical data for VA analytical purposes. The Non-VA Care Cube identifies services purchased for veterans with non-VA care dollars and, therefore, captures women veterans who were referred outside the VA for a hysterectomy. Additional data collected include age, gender, hospital complexity, place of care, payment location, primary CPT, primary ICD-9, and several other parameters. The annual number of women veterans accessing VA health care was extracted from the VSSC Unique Patients Cube.

Laparoscopic hysterectomy was defined as total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, laparoscopic-supracervical hysterectomy, and robotic-assisted laparoscopic hysterectomy. Minimally invasive hysterectomy was defined as all laparoscopic and vaginal hysterectomies.

Frequency distributions between categoric variables were compared using chi-squared tests. The population-adjusted hysterectomy rates were estimated by dividing the total number of hysterectomies by the number of women veterans accessing VA medical care. Hysterectomy rates are reported as rate per 1,000 women per year. A time trend analysis was performed with linear regression to evaluate the slopes of trends for each route of hysterectomy, using Microsoft Excel 2010 (Redmond, WA). The authors analyzed the relationship between route of hysterectomy and fiscal year, using a multivariable logistic regression that was adjusted for age, district, and surgical diagnosis. The adjusted relative risk (RR) for each type of hysterectomy was reported with 95% confidence intervals (CI). All statistical analyses were performed using SPSS 12.0 (Chicago, IL) with P < .05 defined as being statistically significant.To ensure the accuracy of the CDW data, the documented CPT and ICD-9 codes were compared between the CDW and the VA electronic medical records (EMR) for 400 charts selected at random. This cohort represents about 5% of the total charts and was felt to be an adequate measure of the entire sample since the CPT and ICD-9 codes were verified and matched 100% of the time. Demographic and descriptive data regarding body mass index, level of education, race, smoking status, medical comorbidities, and surgical history were excluded from the study because it was either not available or not consistently reported within the CDW.

Results

A retrospective query of the CDW identified 8,327 hysterectomies performed at the VA for benign indications from fiscal year (FY) 2005 to FY 2014. The total number of annual hysterectomies at the VA increased 30.7% from 710 in FY 2004 to 1,025 in FY 2014. The annual number of women veterans who accessed VA health care increased 30.8% from 412,271 to 596,011 during the same time frame. Thus, the population adjusted hysterectomy rate remained stable at 1.72 (Figure 1).

The authors also analyzed the VA data by district and decided to highlight the most recent data trends, as this is most applicable to how the VA currently operates. During FY 2014, the VA hysterectomy rates were as follows: district 1 (North Atlantic) 1.52; district 2 (Southeast) 2.21; district 3 (Midwest) 1.47; district 4 (Continental) 1.43; and district 5 (Pacific) 1.64 (Figure 2)

During the study period, calculated hysterectomy rates based on route at the VA showed that the laparoscopic hysterectomy rate increased from 0.11 to 0.53, the vaginal hysterectomy rate remained relatively stable at 0.34 to 0.37, and the abdominal hysterectomy rate declined from 1.28 to 0.8 (Figure 3).

Discussion

Although the total hysterectomy rate within the VA remained stable during the study period, the minimally invasive hysterectomy rate increased significantly. In FY 2014, the majority of hysterectomies at the VA were performed via a minimally invasive approach. Minimally invasive hysterectomy has many recognized advantages over abdominal hysterectomy as it offers a significant reduction in postoperative pain, narcotic use, length of stay, intraoperative blood loss, fever, deep venous thrombosis, and a faster recovery with return to baseline functioning thus improving overall quality of life.^5-7 Previous literature of VA hysterectomy data from 1991 to 1997 reported an abdominal hysterectomy percentage of 74%, vaginal hysterectomy percentage of 22%, and laparoscopic assisted vaginal hysterectomy percentage of 4%.⁸

Additionally, previous literature of the civilian sector reported a national laparoscopic hysterectomy percentage of 32.4% in 2012, which is comparable to the laparoscopic hysterectomy percentage found in this study.^9,10 These data highlight the growth of laparoscopic hysterectomy at the VA, which is comparable to that of the civilian sector.The Nationwide Inpatient Sample reported an abdominal hysterectomy percentage of 66.1% in 2003 and 52.8% in 2012.^9,10 The authors observed a similar decline in the abdominal hysterectomy rate at the VA over the period studied. Although many factors may have contributed to this decline, the growth of laparoscopic hysterectomy was a possible contributing factor since the vaginal hysterectomy rate remained stable over the study period. Future studies are needed to evaluate surgical complications and readmission rates in order to more accurately assess the quality of gynecologic surgical care provided by the VA compared with the civilian sector.

Strengths and Limitations

This study has several important strengths. First, the large sample size from VA nationwide databases included information from all VAMC performing hysterectomies. Second, this study included 10 years of data, with the latest data from 2014, allowing for depiction of both long-term and recent trends.

Potential issues with large databases such as the CDW and the Non-VA Care Cube included inaccurate coding of procedures and diagnoses as well as missing data. This possible limitation was addressed by randomly selecting 400 patients in the database to verify the database information against the patient’s EMR, which matched 100% of the time. In addition, the authors calculated the hysterectomy rates using a denominator based on all women veterans accessing VA health care, which included women who had previously had a hysterectomy. Therefore, the true hysterectomy rate may have been underestimated.

Conclusion

The VA operates the largest health care system in the U.S. with more than 500,000 women veterans currently utilizing VA health care.¹¹ The VA provides services to women veterans living in urban, suburban, and rural areas. The breadth of geographic locations, the declining number of VA facilities offering gynecologic surgical services, and the growing population of female veterans present unique challenges to providing accessible and comparable health care to these female patients.

VA district 4 (Continental) has the lowest population density as well as the lowest VA hysterectomy rate in FY 2014, which may be attributable to the aforementioned challenges. As a result of these challenges, an increasing number of gynecologic surgical referrals to non-VA facilities was observed during the study period. The VA has made considerable progress in supporting and promoting health care for women by strategically enhancing services and access for women veterans. Although the number of hysterectomies has increased across VA facilities offering gynecologic surgical services, about 1 in 3 women veterans are referred to non-VA facilities for their gynecologic surgical needs. The VA has a challenging opportunity to expand gynecologic surgical services and improve access for the growing population of women veterans. To accommodate this growth, the VA may consider strategically increasing the number of facilities providing gynecologic surgical services or expanding established gynecologic surgical departments.

The VA operates the largest integrated health care system in the country, consisting of 144 hospitals and 1,221 outpatient clinics. This system provides medical care for about 22 million veterans. In 2015, women accounted for nearly 10% of the veteran population and are expected to increase to about 16% by 2040.¹ With an expected population increase of 18,000 per year over the next 10 years, women are the fastest growing group of veterans.

The VA acknowledges that women are an integral part of the veteran community and that a paradigm shift must occur to meet their unique health needs. Although clinical services specific to women veterans’ health needs have been introduced within the VA, gynecologic surgical services must be addressed in order to improve access and provide comprehensive women’s health care within the VA system.

About 600,000 hysterectomies are performed annually in the U.S., making this procedure one of the most commonly performed in women.² Over the past 30 years, technologic advances have allowed surgeons to perform more hysterectomies via minimally invasive methods. Both the American Congress of Obstetricians and Gynecologists and American Association of Gynecologic Laparoscopists have published consensus statements that minimally invasive hysterectomy should be the standard of care.^3,4 Studies in non-VA facilities have shown that practice patterns in the route of hysterectomy have evolved with the advancement of surgical equipment and techniques.

It is uncertain, however, whether these changes in practice patterns exist in the VA, because there are limited published data. Given the frequency of hysterectomies in the U.S., the rate and route of this procedure are easily identifiable measures that can be evaluated and utilized as a comparison model for health care received within the VA vs the civilian sector.

The aim of this study was to assess the changes in rate and surgical approach to benign hysterectomy for women veterans at VAMCs and referrals to non-VA facilities over a 10-year period. The authors’ hypothesis was that a minimally invasive approach would be more common in recent years. This study also compares published national data to evaluate whether the VA is offering comparable surgical services to the civilian sector.

Methods

The institutional review boards of Indiana University and the Richard L. Roudebush VAMC in Indianapolis, Indiana, approved this retrospective cross-sectional study. The VHA Support Service Center (VSSC) authorized access to VA database information.

All women veterans who underwent hysterectomy for benign indications from fiscal years (FY) 2005 to 2014 were included. In order to identify this group, the authors queried the VA Corporate Data Warehouse (CDW) and the Non-VA Care Cube for all hysterectomy current procedural terminology (CPT) codes typically performed for benign indications, including 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290, 58291, 58292, 58293, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, and 58573. For each patient identified, the following variables were collected: date of the procedure, facility location, primary CPT code, primary ICD-9 code, and patient age. Patients whose primary ICD-9 code was for a malignancy of gynecologic origin were excluded from the study.

The CDW is a national database collected by the VA Office of Information and Technology to provide clinical data for VA analytical purposes. The Non-VA Care Cube identifies services purchased for veterans with non-VA care dollars and, therefore, captures women veterans who were referred outside the VA for a hysterectomy. Additional data collected include age, gender, hospital complexity, place of care, payment location, primary CPT, primary ICD-9, and several other parameters. The annual number of women veterans accessing VA health care was extracted from the VSSC Unique Patients Cube.

Laparoscopic hysterectomy was defined as total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, laparoscopic-supracervical hysterectomy, and robotic-assisted laparoscopic hysterectomy. Minimally invasive hysterectomy was defined as all laparoscopic and vaginal hysterectomies.

Frequency distributions between categoric variables were compared using chi-squared tests. The population-adjusted hysterectomy rates were estimated by dividing the total number of hysterectomies by the number of women veterans accessing VA medical care. Hysterectomy rates are reported as rate per 1,000 women per year. A time trend analysis was performed with linear regression to evaluate the slopes of trends for each route of hysterectomy, using Microsoft Excel 2010 (Redmond, WA). The authors analyzed the relationship between route of hysterectomy and fiscal year, using a multivariable logistic regression that was adjusted for age, district, and surgical diagnosis. The adjusted relative risk (RR) for each type of hysterectomy was reported with 95% confidence intervals (CI). All statistical analyses were performed using SPSS 12.0 (Chicago, IL) with P < .05 defined as being statistically significant.To ensure the accuracy of the CDW data, the documented CPT and ICD-9 codes were compared between the CDW and the VA electronic medical records (EMR) for 400 charts selected at random. This cohort represents about 5% of the total charts and was felt to be an adequate measure of the entire sample since the CPT and ICD-9 codes were verified and matched 100% of the time. Demographic and descriptive data regarding body mass index, level of education, race, smoking status, medical comorbidities, and surgical history were excluded from the study because it was either not available or not consistently reported within the CDW.

Results

A retrospective query of the CDW identified 8,327 hysterectomies performed at the VA for benign indications from fiscal year (FY) 2005 to FY 2014. The total number of annual hysterectomies at the VA increased 30.7% from 710 in FY 2004 to 1,025 in FY 2014. The annual number of women veterans who accessed VA health care increased 30.8% from 412,271 to 596,011 during the same time frame. Thus, the population adjusted hysterectomy rate remained stable at 1.72 (Figure 1).

The authors also analyzed the VA data by district and decided to highlight the most recent data trends, as this is most applicable to how the VA currently operates. During FY 2014, the VA hysterectomy rates were as follows: district 1 (North Atlantic) 1.52; district 2 (Southeast) 2.21; district 3 (Midwest) 1.47; district 4 (Continental) 1.43; and district 5 (Pacific) 1.64 (Figure 2)

During the study period, calculated hysterectomy rates based on route at the VA showed that the laparoscopic hysterectomy rate increased from 0.11 to 0.53, the vaginal hysterectomy rate remained relatively stable at 0.34 to 0.37, and the abdominal hysterectomy rate declined from 1.28 to 0.8 (Figure 3).

Discussion

Although the total hysterectomy rate within the VA remained stable during the study period, the minimally invasive hysterectomy rate increased significantly. In FY 2014, the majority of hysterectomies at the VA were performed via a minimally invasive approach. Minimally invasive hysterectomy has many recognized advantages over abdominal hysterectomy as it offers a significant reduction in postoperative pain, narcotic use, length of stay, intraoperative blood loss, fever, deep venous thrombosis, and a faster recovery with return to baseline functioning thus improving overall quality of life.^5-7 Previous literature of VA hysterectomy data from 1991 to 1997 reported an abdominal hysterectomy percentage of 74%, vaginal hysterectomy percentage of 22%, and laparoscopic assisted vaginal hysterectomy percentage of 4%.⁸

Additionally, previous literature of the civilian sector reported a national laparoscopic hysterectomy percentage of 32.4% in 2012, which is comparable to the laparoscopic hysterectomy percentage found in this study.^9,10 These data highlight the growth of laparoscopic hysterectomy at the VA, which is comparable to that of the civilian sector.The Nationwide Inpatient Sample reported an abdominal hysterectomy percentage of 66.1% in 2003 and 52.8% in 2012.^9,10 The authors observed a similar decline in the abdominal hysterectomy rate at the VA over the period studied. Although many factors may have contributed to this decline, the growth of laparoscopic hysterectomy was a possible contributing factor since the vaginal hysterectomy rate remained stable over the study period. Future studies are needed to evaluate surgical complications and readmission rates in order to more accurately assess the quality of gynecologic surgical care provided by the VA compared with the civilian sector.

Strengths and Limitations

This study has several important strengths. First, the large sample size from VA nationwide databases included information from all VAMC performing hysterectomies. Second, this study included 10 years of data, with the latest data from 2014, allowing for depiction of both long-term and recent trends.

Potential issues with large databases such as the CDW and the Non-VA Care Cube included inaccurate coding of procedures and diagnoses as well as missing data. This possible limitation was addressed by randomly selecting 400 patients in the database to verify the database information against the patient’s EMR, which matched 100% of the time. In addition, the authors calculated the hysterectomy rates using a denominator based on all women veterans accessing VA health care, which included women who had previously had a hysterectomy. Therefore, the true hysterectomy rate may have been underestimated.

Conclusion

The VA operates the largest health care system in the U.S. with more than 500,000 women veterans currently utilizing VA health care.¹¹ The VA provides services to women veterans living in urban, suburban, and rural areas. The breadth of geographic locations, the declining number of VA facilities offering gynecologic surgical services, and the growing population of female veterans present unique challenges to providing accessible and comparable health care to these female patients.

VA district 4 (Continental) has the lowest population density as well as the lowest VA hysterectomy rate in FY 2014, which may be attributable to the aforementioned challenges. As a result of these challenges, an increasing number of gynecologic surgical referrals to non-VA facilities was observed during the study period. The VA has made considerable progress in supporting and promoting health care for women by strategically enhancing services and access for women veterans. Although the number of hysterectomies has increased across VA facilities offering gynecologic surgical services, about 1 in 3 women veterans are referred to non-VA facilities for their gynecologic surgical needs. The VA has a challenging opportunity to expand gynecologic surgical services and improve access for the growing population of women veterans. To accommodate this growth, the VA may consider strategically increasing the number of facilities providing gynecologic surgical services or expanding established gynecologic surgical departments.

The VA operates the largest integrated health care system in the country, consisting of 144 hospitals and 1,221 outpatient clinics. This system provides medical care for about 22 million veterans. In 2015, women accounted for nearly 10% of the veteran population and are expected to increase to about 16% by 2040.¹ With an expected population increase of 18,000 per year over the next 10 years, women are the fastest growing group of veterans.

The VA acknowledges that women are an integral part of the veteran community and that a paradigm shift must occur to meet their unique health needs. Although clinical services specific to women veterans’ health needs have been introduced within the VA, gynecologic surgical services must be addressed in order to improve access and provide comprehensive women’s health care within the VA system.

About 600,000 hysterectomies are performed annually in the U.S., making this procedure one of the most commonly performed in women.² Over the past 30 years, technologic advances have allowed surgeons to perform more hysterectomies via minimally invasive methods. Both the American Congress of Obstetricians and Gynecologists and American Association of Gynecologic Laparoscopists have published consensus statements that minimally invasive hysterectomy should be the standard of care.^3,4 Studies in non-VA facilities have shown that practice patterns in the route of hysterectomy have evolved with the advancement of surgical equipment and techniques.

It is uncertain, however, whether these changes in practice patterns exist in the VA, because there are limited published data. Given the frequency of hysterectomies in the U.S., the rate and route of this procedure are easily identifiable measures that can be evaluated and utilized as a comparison model for health care received within the VA vs the civilian sector.

The aim of this study was to assess the changes in rate and surgical approach to benign hysterectomy for women veterans at VAMCs and referrals to non-VA facilities over a 10-year period. The authors’ hypothesis was that a minimally invasive approach would be more common in recent years. This study also compares published national data to evaluate whether the VA is offering comparable surgical services to the civilian sector.

Methods

The institutional review boards of Indiana University and the Richard L. Roudebush VAMC in Indianapolis, Indiana, approved this retrospective cross-sectional study. The VHA Support Service Center (VSSC) authorized access to VA database information.

All women veterans who underwent hysterectomy for benign indications from fiscal years (FY) 2005 to 2014 were included. In order to identify this group, the authors queried the VA Corporate Data Warehouse (CDW) and the Non-VA Care Cube for all hysterectomy current procedural terminology (CPT) codes typically performed for benign indications, including 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290, 58291, 58292, 58293, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, and 58573. For each patient identified, the following variables were collected: date of the procedure, facility location, primary CPT code, primary ICD-9 code, and patient age. Patients whose primary ICD-9 code was for a malignancy of gynecologic origin were excluded from the study.

The CDW is a national database collected by the VA Office of Information and Technology to provide clinical data for VA analytical purposes. The Non-VA Care Cube identifies services purchased for veterans with non-VA care dollars and, therefore, captures women veterans who were referred outside the VA for a hysterectomy. Additional data collected include age, gender, hospital complexity, place of care, payment location, primary CPT, primary ICD-9, and several other parameters. The annual number of women veterans accessing VA health care was extracted from the VSSC Unique Patients Cube.

Laparoscopic hysterectomy was defined as total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, laparoscopic-supracervical hysterectomy, and robotic-assisted laparoscopic hysterectomy. Minimally invasive hysterectomy was defined as all laparoscopic and vaginal hysterectomies.

Frequency distributions between categoric variables were compared using chi-squared tests. The population-adjusted hysterectomy rates were estimated by dividing the total number of hysterectomies by the number of women veterans accessing VA medical care. Hysterectomy rates are reported as rate per 1,000 women per year. A time trend analysis was performed with linear regression to evaluate the slopes of trends for each route of hysterectomy, using Microsoft Excel 2010 (Redmond, WA). The authors analyzed the relationship between route of hysterectomy and fiscal year, using a multivariable logistic regression that was adjusted for age, district, and surgical diagnosis. The adjusted relative risk (RR) for each type of hysterectomy was reported with 95% confidence intervals (CI). All statistical analyses were performed using SPSS 12.0 (Chicago, IL) with P < .05 defined as being statistically significant.To ensure the accuracy of the CDW data, the documented CPT and ICD-9 codes were compared between the CDW and the VA electronic medical records (EMR) for 400 charts selected at random. This cohort represents about 5% of the total charts and was felt to be an adequate measure of the entire sample since the CPT and ICD-9 codes were verified and matched 100% of the time. Demographic and descriptive data regarding body mass index, level of education, race, smoking status, medical comorbidities, and surgical history were excluded from the study because it was either not available or not consistently reported within the CDW.

Results

A retrospective query of the CDW identified 8,327 hysterectomies performed at the VA for benign indications from fiscal year (FY) 2005 to FY 2014. The total number of annual hysterectomies at the VA increased 30.7% from 710 in FY 2004 to 1,025 in FY 2014. The annual number of women veterans who accessed VA health care increased 30.8% from 412,271 to 596,011 during the same time frame. Thus, the population adjusted hysterectomy rate remained stable at 1.72 (Figure 1).

The authors also analyzed the VA data by district and decided to highlight the most recent data trends, as this is most applicable to how the VA currently operates. During FY 2014, the VA hysterectomy rates were as follows: district 1 (North Atlantic) 1.52; district 2 (Southeast) 2.21; district 3 (Midwest) 1.47; district 4 (Continental) 1.43; and district 5 (Pacific) 1.64 (Figure 2)

During the study period, calculated hysterectomy rates based on route at the VA showed that the laparoscopic hysterectomy rate increased from 0.11 to 0.53, the vaginal hysterectomy rate remained relatively stable at 0.34 to 0.37, and the abdominal hysterectomy rate declined from 1.28 to 0.8 (Figure 3).

Discussion

Although the total hysterectomy rate within the VA remained stable during the study period, the minimally invasive hysterectomy rate increased significantly. In FY 2014, the majority of hysterectomies at the VA were performed via a minimally invasive approach. Minimally invasive hysterectomy has many recognized advantages over abdominal hysterectomy as it offers a significant reduction in postoperative pain, narcotic use, length of stay, intraoperative blood loss, fever, deep venous thrombosis, and a faster recovery with return to baseline functioning thus improving overall quality of life.^5-7 Previous literature of VA hysterectomy data from 1991 to 1997 reported an abdominal hysterectomy percentage of 74%, vaginal hysterectomy percentage of 22%, and laparoscopic assisted vaginal hysterectomy percentage of 4%.⁸

Additionally, previous literature of the civilian sector reported a national laparoscopic hysterectomy percentage of 32.4% in 2012, which is comparable to the laparoscopic hysterectomy percentage found in this study.^9,10 These data highlight the growth of laparoscopic hysterectomy at the VA, which is comparable to that of the civilian sector.The Nationwide Inpatient Sample reported an abdominal hysterectomy percentage of 66.1% in 2003 and 52.8% in 2012.^9,10 The authors observed a similar decline in the abdominal hysterectomy rate at the VA over the period studied. Although many factors may have contributed to this decline, the growth of laparoscopic hysterectomy was a possible contributing factor since the vaginal hysterectomy rate remained stable over the study period. Future studies are needed to evaluate surgical complications and readmission rates in order to more accurately assess the quality of gynecologic surgical care provided by the VA compared with the civilian sector.

Strengths and Limitations

This study has several important strengths. First, the large sample size from VA nationwide databases included information from all VAMC performing hysterectomies. Second, this study included 10 years of data, with the latest data from 2014, allowing for depiction of both long-term and recent trends.

Potential issues with large databases such as the CDW and the Non-VA Care Cube included inaccurate coding of procedures and diagnoses as well as missing data. This possible limitation was addressed by randomly selecting 400 patients in the database to verify the database information against the patient’s EMR, which matched 100% of the time. In addition, the authors calculated the hysterectomy rates using a denominator based on all women veterans accessing VA health care, which included women who had previously had a hysterectomy. Therefore, the true hysterectomy rate may have been underestimated.

Conclusion

The VA operates the largest health care system in the U.S. with more than 500,000 women veterans currently utilizing VA health care.¹¹ The VA provides services to women veterans living in urban, suburban, and rural areas. The breadth of geographic locations, the declining number of VA facilities offering gynecologic surgical services, and the growing population of female veterans present unique challenges to providing accessible and comparable health care to these female patients.

VA district 4 (Continental) has the lowest population density as well as the lowest VA hysterectomy rate in FY 2014, which may be attributable to the aforementioned challenges. As a result of these challenges, an increasing number of gynecologic surgical referrals to non-VA facilities was observed during the study period. The VA has made considerable progress in supporting and promoting health care for women by strategically enhancing services and access for women veterans. Although the number of hysterectomies has increased across VA facilities offering gynecologic surgical services, about 1 in 3 women veterans are referred to non-VA facilities for their gynecologic surgical needs. The VA has a challenging opportunity to expand gynecologic surgical services and improve access for the growing population of women veterans. To accommodate this growth, the VA may consider strategically increasing the number of facilities providing gynecologic surgical services or expanding established gynecologic surgical departments.

Photo by Bill Branson

A study of cancer drugs approved by the European Commission from 2009 to 2013 showed that few hematology drugs were known to provide a benefit in overall survival (OS) or quality of life (QOL) over existing treatments.

Of 12 drugs approved for 17 hematology indications, 3 drugs had been shown to provide a benefit in OS (for 3 indications) at the time of approval.

None of the other hematology drugs were known to provide an OS benefit even after a median follow-up of 5.4 years.

Two hematology drugs were shown to provide a benefit in QOL (for 2 indications) after approval, but none of the drugs were known to provide a QOL benefit at the time of approval.

These findings were published in The BMJ alongside a related editorial, feature article, and patient commentary.

All cancer drugs

Researchers analyzed reports on all cancer drug approvals by the European Commission from 2009 to 2013.

There were 48 drugs approved for 68 cancer indications during this period. Fifty-one of the indications were for solid tumor malignancies, and 17 were for hematologic malignancies.

For 24 indications (35%), research had demonstrated a significant improvement in OS at the time of the drugs’ approval. For 3 indications, an improvement in OS was demonstrated after approval.

There was a known improvement in QOL for 7 of the indications (10%) at the time of approval and for 5 indications after approval.

The median follow-up was 5.4 years (range, 3.3 years to 8.1 years).

Overall, there was a significant improvement in OS or QOL during the study period for 51% of the indications (35/68). For the other half (49%, n=33), it wasn’t clear if the drugs provide any benefits in OS or QOL.

All cancer trials

The 68 approvals of cancer drugs were supported by 72 clinical trials.

Sixty approvals (88%) were supported by at least 1 randomized, controlled trial. Eight approvals (12%) were based on a single-arm study. This included 6 of 10 conditional marketing authorizations and 2 of 58 regular marketing authorizations.

Eighteen of the approvals (26%) were supported by a pivotal study powered to evaluate OS as the primary endpoint. And 37 of the approvals (54%) had a supporting pivotal trial evaluating QOL, but results were not reported for 2 of these trials.

Hematology trials and drugs

Of the 12 drugs approved for 17 hematology indications, 4 were regular approvals, 5 were conditional approvals, and 8 had orphan drug designation.

The approvals were supported by data from 18 trials—13 randomized and 5 single-arm trials.

The study drug was compared to an active comparator in 9 of the trials. The drug was evaluated as an add-on treatment in 4 trials. And the drug was not compared to anything in 5 trials (the single-arm trials).

OS was the primary endpoint in 1 of the trials, and 17 trials had OS or QOL as a secondary endpoint.

There were 3 drugs that had demonstrated an OS benefit at the time of approval but no QOL benefit at any time:

• Decitabine used for first-line treatment of acute myeloid leukemia in adults 65 and older who are ineligible for chemotherapy
• Pomalidomide in combination with dexamethasone as third-line therapy for relapsed/refractory multiple myeloma (MM)
• Rituximab plus chemotherapy for first-line treatment of chronic lymphocytic leukemia (CLL).

There were 2 drugs that had demonstrated a QOL benefit, only after approval, but they were not known to provide an OS benefit at any time:

• Nilotinib as a treatment for adults with newly diagnosed, chronic phase, Ph+ chronic myeloid leukemia (CML)
• Ofatumumab for CLL that is refractory to fludarabine and alemtuzumab

For the remaining drugs, there was no evidence of an OS or QOL benefit at any time during the period studied. The drugs included:

• Bortezomib given alone or in combination with doxorubicin or dexamethasone as second-line therapy for MM patients ineligible for hematopoietic stem cell transplant (HSCT)
• Bortezomib plus dexamethasone with or without thalidomide as first-line therapy in MM patients eligible for HSCT
• Bosutinib as second- or third-line treatment of Ph+ CML (any phase)
• Brentuximab vedotin for relapsed or refractory systemic anaplastic large-cell lymphoma
• Brentuximab vedotin for relapsed or refractory, CD30+ Hodgkin lymphoma after autologous HSCT or as third-line treatment for patients ineligible for autologous HSCT
• Dasatinib for first-line treatment of chronic phase, Ph+ CML
• Pixantrone for multiply relapsed or refractory B-cell non-Hodgkin lymphoma
• Ponatinib for patients with Ph+ acute lymphoblastic leukemia who are ineligible for imatinib or have disease that is resistant or intolerant to dasatinib or characterized by T315I mutation
• Ponatinib for patients with any phase of CML who are ineligible for imatinib or have disease that is resistant or intolerant to dasatinib/nilotinib or characterized by T315I mutation
• Rituximab as maintenance after induction for patients with follicular lymphoma
• Rituximab plus chemotherapy for relapsed or refractory CLL
• Temsirolimus for relapsed or refractory mantle cell lymphoma.
  

Photo by Bill Branson

A study of cancer drugs approved by the European Commission from 2009 to 2013 showed that few hematology drugs were known to provide a benefit in overall survival (OS) or quality of life (QOL) over existing treatments.

Of 12 drugs approved for 17 hematology indications, 3 drugs had been shown to provide a benefit in OS (for 3 indications) at the time of approval.

None of the other hematology drugs were known to provide an OS benefit even after a median follow-up of 5.4 years.

Two hematology drugs were shown to provide a benefit in QOL (for 2 indications) after approval, but none of the drugs were known to provide a QOL benefit at the time of approval.

These findings were published in The BMJ alongside a related editorial, feature article, and patient commentary.

All cancer drugs

Researchers analyzed reports on all cancer drug approvals by the European Commission from 2009 to 2013.

There were 48 drugs approved for 68 cancer indications during this period. Fifty-one of the indications were for solid tumor malignancies, and 17 were for hematologic malignancies.

For 24 indications (35%), research had demonstrated a significant improvement in OS at the time of the drugs’ approval. For 3 indications, an improvement in OS was demonstrated after approval.

There was a known improvement in QOL for 7 of the indications (10%) at the time of approval and for 5 indications after approval.

The median follow-up was 5.4 years (range, 3.3 years to 8.1 years).

Overall, there was a significant improvement in OS or QOL during the study period for 51% of the indications (35/68). For the other half (49%, n=33), it wasn’t clear if the drugs provide any benefits in OS or QOL.

All cancer trials

The 68 approvals of cancer drugs were supported by 72 clinical trials.

Sixty approvals (88%) were supported by at least 1 randomized, controlled trial. Eight approvals (12%) were based on a single-arm study. This included 6 of 10 conditional marketing authorizations and 2 of 58 regular marketing authorizations.

Eighteen of the approvals (26%) were supported by a pivotal study powered to evaluate OS as the primary endpoint. And 37 of the approvals (54%) had a supporting pivotal trial evaluating QOL, but results were not reported for 2 of these trials.

Hematology trials and drugs

Of the 12 drugs approved for 17 hematology indications, 4 were regular approvals, 5 were conditional approvals, and 8 had orphan drug designation.

The approvals were supported by data from 18 trials—13 randomized and 5 single-arm trials.

The study drug was compared to an active comparator in 9 of the trials. The drug was evaluated as an add-on treatment in 4 trials. And the drug was not compared to anything in 5 trials (the single-arm trials).

OS was the primary endpoint in 1 of the trials, and 17 trials had OS or QOL as a secondary endpoint.

There were 3 drugs that had demonstrated an OS benefit at the time of approval but no QOL benefit at any time:

• Decitabine used for first-line treatment of acute myeloid leukemia in adults 65 and older who are ineligible for chemotherapy
• Pomalidomide in combination with dexamethasone as third-line therapy for relapsed/refractory multiple myeloma (MM)
• Rituximab plus chemotherapy for first-line treatment of chronic lymphocytic leukemia (CLL).

There were 2 drugs that had demonstrated a QOL benefit, only after approval, but they were not known to provide an OS benefit at any time:

• Nilotinib as a treatment for adults with newly diagnosed, chronic phase, Ph+ chronic myeloid leukemia (CML)
• Ofatumumab for CLL that is refractory to fludarabine and alemtuzumab

For the remaining drugs, there was no evidence of an OS or QOL benefit at any time during the period studied. The drugs included:

• Bortezomib given alone or in combination with doxorubicin or dexamethasone as second-line therapy for MM patients ineligible for hematopoietic stem cell transplant (HSCT)
• Bortezomib plus dexamethasone with or without thalidomide as first-line therapy in MM patients eligible for HSCT
• Bosutinib as second- or third-line treatment of Ph+ CML (any phase)
• Brentuximab vedotin for relapsed or refractory systemic anaplastic large-cell lymphoma
• Brentuximab vedotin for relapsed or refractory, CD30+ Hodgkin lymphoma after autologous HSCT or as third-line treatment for patients ineligible for autologous HSCT
• Dasatinib for first-line treatment of chronic phase, Ph+ CML
• Pixantrone for multiply relapsed or refractory B-cell non-Hodgkin lymphoma
• Ponatinib for patients with Ph+ acute lymphoblastic leukemia who are ineligible for imatinib or have disease that is resistant or intolerant to dasatinib or characterized by T315I mutation
• Ponatinib for patients with any phase of CML who are ineligible for imatinib or have disease that is resistant or intolerant to dasatinib/nilotinib or characterized by T315I mutation
• Rituximab as maintenance after induction for patients with follicular lymphoma
• Rituximab plus chemotherapy for relapsed or refractory CLL
• Temsirolimus for relapsed or refractory mantle cell lymphoma.
  

Photo by Bill Branson

A study of cancer drugs approved by the European Commission from 2009 to 2013 showed that few hematology drugs were known to provide a benefit in overall survival (OS) or quality of life (QOL) over existing treatments.

Of 12 drugs approved for 17 hematology indications, 3 drugs had been shown to provide a benefit in OS (for 3 indications) at the time of approval.

None of the other hematology drugs were known to provide an OS benefit even after a median follow-up of 5.4 years.

Two hematology drugs were shown to provide a benefit in QOL (for 2 indications) after approval, but none of the drugs were known to provide a QOL benefit at the time of approval.

These findings were published in The BMJ alongside a related editorial, feature article, and patient commentary.

All cancer drugs

Researchers analyzed reports on all cancer drug approvals by the European Commission from 2009 to 2013.

There were 48 drugs approved for 68 cancer indications during this period. Fifty-one of the indications were for solid tumor malignancies, and 17 were for hematologic malignancies.

For 24 indications (35%), research had demonstrated a significant improvement in OS at the time of the drugs’ approval. For 3 indications, an improvement in OS was demonstrated after approval.

There was a known improvement in QOL for 7 of the indications (10%) at the time of approval and for 5 indications after approval.

The median follow-up was 5.4 years (range, 3.3 years to 8.1 years).

Overall, there was a significant improvement in OS or QOL during the study period for 51% of the indications (35/68). For the other half (49%, n=33), it wasn’t clear if the drugs provide any benefits in OS or QOL.

All cancer trials

The 68 approvals of cancer drugs were supported by 72 clinical trials.

Sixty approvals (88%) were supported by at least 1 randomized, controlled trial. Eight approvals (12%) were based on a single-arm study. This included 6 of 10 conditional marketing authorizations and 2 of 58 regular marketing authorizations.

Eighteen of the approvals (26%) were supported by a pivotal study powered to evaluate OS as the primary endpoint. And 37 of the approvals (54%) had a supporting pivotal trial evaluating QOL, but results were not reported for 2 of these trials.

Hematology trials and drugs

Of the 12 drugs approved for 17 hematology indications, 4 were regular approvals, 5 were conditional approvals, and 8 had orphan drug designation.

The approvals were supported by data from 18 trials—13 randomized and 5 single-arm trials.

The study drug was compared to an active comparator in 9 of the trials. The drug was evaluated as an add-on treatment in 4 trials. And the drug was not compared to anything in 5 trials (the single-arm trials).

OS was the primary endpoint in 1 of the trials, and 17 trials had OS or QOL as a secondary endpoint.

There were 3 drugs that had demonstrated an OS benefit at the time of approval but no QOL benefit at any time:

• Decitabine used for first-line treatment of acute myeloid leukemia in adults 65 and older who are ineligible for chemotherapy
• Pomalidomide in combination with dexamethasone as third-line therapy for relapsed/refractory multiple myeloma (MM)
• Rituximab plus chemotherapy for first-line treatment of chronic lymphocytic leukemia (CLL).

There were 2 drugs that had demonstrated a QOL benefit, only after approval, but they were not known to provide an OS benefit at any time:

• Nilotinib as a treatment for adults with newly diagnosed, chronic phase, Ph+ chronic myeloid leukemia (CML)
• Ofatumumab for CLL that is refractory to fludarabine and alemtuzumab

For the remaining drugs, there was no evidence of an OS or QOL benefit at any time during the period studied. The drugs included:

• Bortezomib given alone or in combination with doxorubicin or dexamethasone as second-line therapy for MM patients ineligible for hematopoietic stem cell transplant (HSCT)
• Bortezomib plus dexamethasone with or without thalidomide as first-line therapy in MM patients eligible for HSCT
• Bosutinib as second- or third-line treatment of Ph+ CML (any phase)
• Brentuximab vedotin for relapsed or refractory systemic anaplastic large-cell lymphoma
• Brentuximab vedotin for relapsed or refractory, CD30+ Hodgkin lymphoma after autologous HSCT or as third-line treatment for patients ineligible for autologous HSCT
• Dasatinib for first-line treatment of chronic phase, Ph+ CML
• Pixantrone for multiply relapsed or refractory B-cell non-Hodgkin lymphoma
• Ponatinib for patients with Ph+ acute lymphoblastic leukemia who are ineligible for imatinib or have disease that is resistant or intolerant to dasatinib or characterized by T315I mutation
• Ponatinib for patients with any phase of CML who are ineligible for imatinib or have disease that is resistant or intolerant to dasatinib/nilotinib or characterized by T315I mutation
• Rituximab as maintenance after induction for patients with follicular lymphoma
• Rituximab plus chemotherapy for relapsed or refractory CLL
• Temsirolimus for relapsed or refractory mantle cell lymphoma.
  

The US Food and Drug Administration (FDA) has approved the first test designed to screen blood donations for Zika virus.

The cobas Zika test is a qualitative nucleic acid test that can detect Zika virus RNA in individual plasma specimens obtained from donors of whole blood and blood components and from living organ donors.

The test is not intended for the individual diagnosis of Zika virus infection.

The cobas Zika test is intended for use on the fully automated cobas 6800 and cobas 8800 systems. These systems and the test are manufactured by Roche Molecular Systems, Inc.

“Today’s action represents the first approval of a Zika virus detection test for use with screening the nation’s blood supply,” said Peter Marks, MD, PhD, director of the FDA’s Center for Biologics Evaluation and Research.

“Screening blood donations for the Zika virus is critical to preventing infected donations from entering the US blood supply. Today’s approval is the result of a commitment by the manufacturer to work rapidly and collaboratively with the FDA and the blood collection industry to respond to a public health crisis and ensure the safety of blood in the US and its territories.”

In August 2016, the FDA issued a guidance document recommending that all states and territories screen individual units of whole blood and blood components with an investigational blood screening test available under an investigational new drug (IND) application, or use an approved test when available.

Several blood collection establishments have used the cobas Zika test under an IND. The data collected from this testing and additional studies performed by the manufacturer demonstrated that the test is effective in screening blood donors for Zika virus infection, according to the FDA.

The test’s clinical specificity was evaluated by testing individual samples from blood donations at 5 external laboratory sites, and the specificity exceeded 99%.

The US Food and Drug Administration (FDA) has approved the first test designed to screen blood donations for Zika virus.

The cobas Zika test is a qualitative nucleic acid test that can detect Zika virus RNA in individual plasma specimens obtained from donors of whole blood and blood components and from living organ donors.

The test is not intended for the individual diagnosis of Zika virus infection.

The cobas Zika test is intended for use on the fully automated cobas 6800 and cobas 8800 systems. These systems and the test are manufactured by Roche Molecular Systems, Inc.

“Today’s action represents the first approval of a Zika virus detection test for use with screening the nation’s blood supply,” said Peter Marks, MD, PhD, director of the FDA’s Center for Biologics Evaluation and Research.

“Screening blood donations for the Zika virus is critical to preventing infected donations from entering the US blood supply. Today’s approval is the result of a commitment by the manufacturer to work rapidly and collaboratively with the FDA and the blood collection industry to respond to a public health crisis and ensure the safety of blood in the US and its territories.”

In August 2016, the FDA issued a guidance document recommending that all states and territories screen individual units of whole blood and blood components with an investigational blood screening test available under an investigational new drug (IND) application, or use an approved test when available.

Several blood collection establishments have used the cobas Zika test under an IND. The data collected from this testing and additional studies performed by the manufacturer demonstrated that the test is effective in screening blood donors for Zika virus infection, according to the FDA.

The test’s clinical specificity was evaluated by testing individual samples from blood donations at 5 external laboratory sites, and the specificity exceeded 99%.

The US Food and Drug Administration (FDA) has approved the first test designed to screen blood donations for Zika virus.

The cobas Zika test is a qualitative nucleic acid test that can detect Zika virus RNA in individual plasma specimens obtained from donors of whole blood and blood components and from living organ donors.

The test is not intended for the individual diagnosis of Zika virus infection.

The cobas Zika test is intended for use on the fully automated cobas 6800 and cobas 8800 systems. These systems and the test are manufactured by Roche Molecular Systems, Inc.

“Today’s action represents the first approval of a Zika virus detection test for use with screening the nation’s blood supply,” said Peter Marks, MD, PhD, director of the FDA’s Center for Biologics Evaluation and Research.

“Screening blood donations for the Zika virus is critical to preventing infected donations from entering the US blood supply. Today’s approval is the result of a commitment by the manufacturer to work rapidly and collaboratively with the FDA and the blood collection industry to respond to a public health crisis and ensure the safety of blood in the US and its territories.”

In August 2016, the FDA issued a guidance document recommending that all states and territories screen individual units of whole blood and blood components with an investigational blood screening test available under an investigational new drug (IND) application, or use an approved test when available.

Several blood collection establishments have used the cobas Zika test under an IND. The data collected from this testing and additional studies performed by the manufacturer demonstrated that the test is effective in screening blood donors for Zika virus infection, according to the FDA.

The test’s clinical specificity was evaluated by testing individual samples from blood donations at 5 external laboratory sites, and the specificity exceeded 99%.

Research Hospital

New research suggests sperm banking may be underutilized by adolescent and young adult males with cancer who are at risk of infertility.

However, the study also showed that patients were more likely to attempt sperm banking if they were physically mature, met with fertility specialists, or their parents recommended sperm banking.

These findings were published in the Journal of Clinical Oncology.

“Research has found that the majority of males who survive childhood cancer desire biological children,” said study author James Klosky, PhD, of St. Jude Children’s Research Hospital in Memphis, Tennessee.

“Fertility preservation is also associated with a variety of benefits for survivors, including increased optimism about the future. While sperm banking is not for everyone, it is an effective method for preserving male fertility. Yet this study shows that sperm banking remains underutilized by at-risk patients with cancer.”

Dr Klosky and his colleagues surveyed 146 young males with cancer who were at risk of infertility. The researchers also surveyed 144 parents or guardians and 52 oncologists and other healthcare providers.

The patients’ mean age was 16.49 (range, 13.0-21.99). Diagnoses included leukemia and lymphoma (56.2%), solid tumor malignancies (37.7%), and brain tumors (6.2%).

Slightly more than half of the patients (53.4%, n=78) attempted sperm banking prior to starting treatment. Sixty-two, or 82.1%, of those who attempted sperm banking were successful.

In all, 43.8% of the patients successfully banked sperm.

Of the 68 patients who did not attempt sperm banking, 29 reported discussing the option with their families but deciding against it. Twenty-six patients indicated they did not believe sperm banking was necessary, and 9 patients were unsure what it was.

There were several factors that influenced the likelihood of patients making sperm collection attempts as well as successfully banking sperm.

In a multivariable analysis, the following factors were associated with an increased likelihood of attempting to bank sperm:

• Meeting with a fertility specialist (odds ratio[OR]=29.96; 95% CI, 2.48 to 361.41; P=0.007)
• Parent recommending banking (OR=12.30; 95% CI, 2.01 to 75.94; P=0.007)
• Higher Tanner stage (OR=5.42; 95% CI, 1.75 to 16.78; P=0.003).

In another multivariable analysis, successful sperm banking was associated with:

• Patient history of masturbation (OR=5.99; 95% CI, 1.25 to 28.50; P=0.025)
• Higher self-efficacy for banking coordination (OR=1.23; 95% CI, 1.05 to 1.45; P=0.012)
• Medical team member recommending banking (OR=4.26; 95% CI, 1.45 to 12.43; P=0.008)
• Parent recommending banking (OR=4.62; 95% CI, 1.46 to 14.73; P=0.010).

“These results highlight factors that providers can target to empower adolescents to actively participate in their own healthcare,” Dr Klosky said. “These decisions, which are typically made at the time of diagnosis, have high potential to affect their lives as survivors.”

Research Hospital

New research suggests sperm banking may be underutilized by adolescent and young adult males with cancer who are at risk of infertility.

However, the study also showed that patients were more likely to attempt sperm banking if they were physically mature, met with fertility specialists, or their parents recommended sperm banking.

These findings were published in the Journal of Clinical Oncology.

“Research has found that the majority of males who survive childhood cancer desire biological children,” said study author James Klosky, PhD, of St. Jude Children’s Research Hospital in Memphis, Tennessee.

“Fertility preservation is also associated with a variety of benefits for survivors, including increased optimism about the future. While sperm banking is not for everyone, it is an effective method for preserving male fertility. Yet this study shows that sperm banking remains underutilized by at-risk patients with cancer.”

Dr Klosky and his colleagues surveyed 146 young males with cancer who were at risk of infertility. The researchers also surveyed 144 parents or guardians and 52 oncologists and other healthcare providers.

The patients’ mean age was 16.49 (range, 13.0-21.99). Diagnoses included leukemia and lymphoma (56.2%), solid tumor malignancies (37.7%), and brain tumors (6.2%).

Slightly more than half of the patients (53.4%, n=78) attempted sperm banking prior to starting treatment. Sixty-two, or 82.1%, of those who attempted sperm banking were successful.

In all, 43.8% of the patients successfully banked sperm.

Of the 68 patients who did not attempt sperm banking, 29 reported discussing the option with their families but deciding against it. Twenty-six patients indicated they did not believe sperm banking was necessary, and 9 patients were unsure what it was.

There were several factors that influenced the likelihood of patients making sperm collection attempts as well as successfully banking sperm.

In a multivariable analysis, the following factors were associated with an increased likelihood of attempting to bank sperm:

• Meeting with a fertility specialist (odds ratio[OR]=29.96; 95% CI, 2.48 to 361.41; P=0.007)
• Parent recommending banking (OR=12.30; 95% CI, 2.01 to 75.94; P=0.007)
• Higher Tanner stage (OR=5.42; 95% CI, 1.75 to 16.78; P=0.003).

In another multivariable analysis, successful sperm banking was associated with:

• Patient history of masturbation (OR=5.99; 95% CI, 1.25 to 28.50; P=0.025)
• Higher self-efficacy for banking coordination (OR=1.23; 95% CI, 1.05 to 1.45; P=0.012)
• Medical team member recommending banking (OR=4.26; 95% CI, 1.45 to 12.43; P=0.008)
• Parent recommending banking (OR=4.62; 95% CI, 1.46 to 14.73; P=0.010).

“These results highlight factors that providers can target to empower adolescents to actively participate in their own healthcare,” Dr Klosky said. “These decisions, which are typically made at the time of diagnosis, have high potential to affect their lives as survivors.”

Research Hospital

New research suggests sperm banking may be underutilized by adolescent and young adult males with cancer who are at risk of infertility.

However, the study also showed that patients were more likely to attempt sperm banking if they were physically mature, met with fertility specialists, or their parents recommended sperm banking.

These findings were published in the Journal of Clinical Oncology.

“Research has found that the majority of males who survive childhood cancer desire biological children,” said study author James Klosky, PhD, of St. Jude Children’s Research Hospital in Memphis, Tennessee.

“Fertility preservation is also associated with a variety of benefits for survivors, including increased optimism about the future. While sperm banking is not for everyone, it is an effective method for preserving male fertility. Yet this study shows that sperm banking remains underutilized by at-risk patients with cancer.”

Dr Klosky and his colleagues surveyed 146 young males with cancer who were at risk of infertility. The researchers also surveyed 144 parents or guardians and 52 oncologists and other healthcare providers.

The patients’ mean age was 16.49 (range, 13.0-21.99). Diagnoses included leukemia and lymphoma (56.2%), solid tumor malignancies (37.7%), and brain tumors (6.2%).

Slightly more than half of the patients (53.4%, n=78) attempted sperm banking prior to starting treatment. Sixty-two, or 82.1%, of those who attempted sperm banking were successful.

In all, 43.8% of the patients successfully banked sperm.

Of the 68 patients who did not attempt sperm banking, 29 reported discussing the option with their families but deciding against it. Twenty-six patients indicated they did not believe sperm banking was necessary, and 9 patients were unsure what it was.

There were several factors that influenced the likelihood of patients making sperm collection attempts as well as successfully banking sperm.

In a multivariable analysis, the following factors were associated with an increased likelihood of attempting to bank sperm:

• Meeting with a fertility specialist (odds ratio[OR]=29.96; 95% CI, 2.48 to 361.41; P=0.007)
• Parent recommending banking (OR=12.30; 95% CI, 2.01 to 75.94; P=0.007)
• Higher Tanner stage (OR=5.42; 95% CI, 1.75 to 16.78; P=0.003).

In another multivariable analysis, successful sperm banking was associated with:

• Patient history of masturbation (OR=5.99; 95% CI, 1.25 to 28.50; P=0.025)
• Higher self-efficacy for banking coordination (OR=1.23; 95% CI, 1.05 to 1.45; P=0.012)
• Medical team member recommending banking (OR=4.26; 95% CI, 1.45 to 12.43; P=0.008)
• Parent recommending banking (OR=4.62; 95% CI, 1.46 to 14.73; P=0.010).

“These results highlight factors that providers can target to empower adolescents to actively participate in their own healthcare,” Dr Klosky said. “These decisions, which are typically made at the time of diagnosis, have high potential to affect their lives as survivors.”

Oregon researchers studying the effect of not recommending intranasal live attenuated influenza vaccines (LAIV) in favor of injected influenza vaccines (IIV) for the 2016-2017 flu season found that the change in recommendation had a minimal impact on overall flu vaccination rates, but that patients who had been given injected flu vaccine previously were slightly more likely to return for it the following season.

Yarinca/istockphoto

[email protected]

Oregon researchers studying the effect of not recommending intranasal live attenuated influenza vaccines (LAIV) in favor of injected influenza vaccines (IIV) for the 2016-2017 flu season found that the change in recommendation had a minimal impact on overall flu vaccination rates, but that patients who had been given injected flu vaccine previously were slightly more likely to return for it the following season.

Yarinca/istockphoto

[email protected]

Oregon researchers studying the effect of not recommending intranasal live attenuated influenza vaccines (LAIV) in favor of injected influenza vaccines (IIV) for the 2016-2017 flu season found that the change in recommendation had a minimal impact on overall flu vaccination rates, but that patients who had been given injected flu vaccine previously were slightly more likely to return for it the following season.

Yarinca/istockphoto

[email protected]

SAN DIEGO – In an era of rising antibiotic resistance, new potential treatment options and policy changes took the stage at the start of an annual scientific meeting on infectious diseases.

Presenters covered emerging topics addressing infectious diseases, with a strong focus on HIV. A common emphasis, among all presentations, was the pressing need to update availability of newer and more effective drugs.

“There’s always something hot in ID, and often it’s transient. But what isn’t transient is the overwhelming problem of antibiotic resistance,” said Stan Deresinski, MD, infectious disease specialist from Stanford (Calif.) University. He added that: “A fear come true is the merger of antibiotic resistance and increased virulence.”

MacXever/Thinkstock

[email protected]

On Twitter @eaztweets

SAN DIEGO – In an era of rising antibiotic resistance, new potential treatment options and policy changes took the stage at the start of an annual scientific meeting on infectious diseases.

Presenters covered emerging topics addressing infectious diseases, with a strong focus on HIV. A common emphasis, among all presentations, was the pressing need to update availability of newer and more effective drugs.

“There’s always something hot in ID, and often it’s transient. But what isn’t transient is the overwhelming problem of antibiotic resistance,” said Stan Deresinski, MD, infectious disease specialist from Stanford (Calif.) University. He added that: “A fear come true is the merger of antibiotic resistance and increased virulence.”

MacXever/Thinkstock

[email protected]

On Twitter @eaztweets

SAN DIEGO – In an era of rising antibiotic resistance, new potential treatment options and policy changes took the stage at the start of an annual scientific meeting on infectious diseases.

Presenters covered emerging topics addressing infectious diseases, with a strong focus on HIV. A common emphasis, among all presentations, was the pressing need to update availability of newer and more effective drugs.

“There’s always something hot in ID, and often it’s transient. But what isn’t transient is the overwhelming problem of antibiotic resistance,” said Stan Deresinski, MD, infectious disease specialist from Stanford (Calif.) University. He added that: “A fear come true is the merger of antibiotic resistance and increased virulence.”

MacXever/Thinkstock

[email protected]

On Twitter @eaztweets

The Food and Drug Administration has approved onabotulinumtoxinA, marketed as Botox Cosmetic by Allergan, for a third indication: the temporary improvement in the appearance of “moderate to severe forehead lines associated with frontalis muscle activity” in adults, according to the manufacturer.

[email protected]

The Food and Drug Administration has approved onabotulinumtoxinA, marketed as Botox Cosmetic by Allergan, for a third indication: the temporary improvement in the appearance of “moderate to severe forehead lines associated with frontalis muscle activity” in adults, according to the manufacturer.

[email protected]

The Food and Drug Administration has approved onabotulinumtoxinA, marketed as Botox Cosmetic by Allergan, for a third indication: the temporary improvement in the appearance of “moderate to severe forehead lines associated with frontalis muscle activity” in adults, according to the manufacturer.

[email protected]

CHICAGO – When a child’s worried parents bring him back to be rechecked on his 8th day of fever, what’s next? If the initial work-up is unrevealing, when is it time to consider hospitalization? And which children can safely be managed as outpatients?

These tough scenarios are part of why “most pediatricians really don’t enjoy fever of unknown origin (FUO),” said Brian Williams, MD, speaking at a pediatric infectious disease update at the annual meeting of the American Academy of Pediatrics. “It can be really time consuming and frustrating to tease all of this out.”

IPGGutenbergUKLtd/Thinkstock

[email protected]

On Twitter @karioakes

CHICAGO – When a child’s worried parents bring him back to be rechecked on his 8th day of fever, what’s next? If the initial work-up is unrevealing, when is it time to consider hospitalization? And which children can safely be managed as outpatients?

These tough scenarios are part of why “most pediatricians really don’t enjoy fever of unknown origin (FUO),” said Brian Williams, MD, speaking at a pediatric infectious disease update at the annual meeting of the American Academy of Pediatrics. “It can be really time consuming and frustrating to tease all of this out.”

IPGGutenbergUKLtd/Thinkstock

[email protected]

On Twitter @karioakes

CHICAGO – When a child’s worried parents bring him back to be rechecked on his 8th day of fever, what’s next? If the initial work-up is unrevealing, when is it time to consider hospitalization? And which children can safely be managed as outpatients?

These tough scenarios are part of why “most pediatricians really don’t enjoy fever of unknown origin (FUO),” said Brian Williams, MD, speaking at a pediatric infectious disease update at the annual meeting of the American Academy of Pediatrics. “It can be really time consuming and frustrating to tease all of this out.”

IPGGutenbergUKLtd/Thinkstock

[email protected]

On Twitter @karioakes

BARCELONA – The maxim that lower is better for LDL cholesterol continues to hold true, even at jaw-droppingly low levels of less than 10 mg/dL in a new analysis of data from the FOURIER trial.

The Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) trial was the pivotal efficacy and safety study for the proprotein convertase subtilisin–kexin type 9 (PCSK9) inhibitor evolocumab (Repatha) and enrolled patients with atherosclerotic cardiovascular disease and LDL cholesterol levels of at least 70 mg/dL (N Engl J Med. 2017 May 4;376[18]:1713-22).

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

BARCELONA – The maxim that lower is better for LDL cholesterol continues to hold true, even at jaw-droppingly low levels of less than 10 mg/dL in a new analysis of data from the FOURIER trial.

The Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) trial was the pivotal efficacy and safety study for the proprotein convertase subtilisin–kexin type 9 (PCSK9) inhibitor evolocumab (Repatha) and enrolled patients with atherosclerotic cardiovascular disease and LDL cholesterol levels of at least 70 mg/dL (N Engl J Med. 2017 May 4;376[18]:1713-22).

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

BARCELONA – The maxim that lower is better for LDL cholesterol continues to hold true, even at jaw-droppingly low levels of less than 10 mg/dL in a new analysis of data from the FOURIER trial.

The Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) trial was the pivotal efficacy and safety study for the proprotein convertase subtilisin–kexin type 9 (PCSK9) inhibitor evolocumab (Repatha) and enrolled patients with atherosclerotic cardiovascular disease and LDL cholesterol levels of at least 70 mg/dL (N Engl J Med. 2017 May 4;376[18]:1713-22).

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

Prescribing systemic antibiotics for acne remains a common clinical practice, despite recommendations to reduce antibiotic use, according to an extensive database review. The results were published in the Journal of the American Academy of Dermatology.

“Despite ... recent recommendations regarding the importance of antibiotic stewardship and appropriate use of antibiotics in patients with acne, it is unclear whether there have been any significant changes in practice patterns,” wrote John S. Barbieri, MD, and his coauthors in the departments of dermatology, and biostatistics and epidemiology, at the University of Pennsylvania, Philadelphia (J Am Acad Dermatol. 2017;77[3]:456-63).

To assess prescribing practices, the researchers reviewed data from the OptumInsight Clinformatics Data Mart, which included medical and pharmacy claims for approximately 12-14 million annual covered lives. The study population included 572,630 individuals with at least two acne claims who were aged 12-40 years at the start of treatment.

The number of courses of spironolactone prescribed for acne per 100 female patients treated by dermatologists increased by 291% during the study period, from 2.08 to 8.13. Among nondermatologists, the number of spironolactone courses prescribed per 100 female patients increased from 1.43 to 4.09 over the same period, a 186% increase.

Overall, the number of oral antibiotic courses increased from 26.24 to 27.08 per 100 patients among dermatologists, and from 19.99 to 22.48 per 100 patients among nondermatologists. The median length of treatment on oral antibiotics was 126 days for patients being treated by dermatologists and 129 days among patients treated by nondermatologists.

The use of spironolactone “remains relatively uncommon” compared with oral antibiotics, the researchers pointed out, noting that the 2013 data show that for every course of spironolactone, there were 2.8 courses of oral antibiotics prescribed by dermatologists and 4.6 courses prescribed by nondermatologists.

Other prescribing trends during the time period among dermatologists included a drop in the number of combined oral contraceptive courses per 100 female patients, from 34.31 to 30.74 (and an increase from 31.70 to 32.13 among nondermatologists); and a drop in the number of isotretinoin courses prescribed per 100 patients, from 5.43 to 5.35 (and a drop from 2.24 to1.45 among nondermatologists).

“Given the importance of judicious use of oral antibiotics to prevent potential complications, increasing the use of concomitant topical retinoids and additional work to identify those patients who would benefit most from alternative agents such as spironolactone, combined oral contraceptive pills, or isotretinoin represent potential opportunities to improve the care of patients with acne,” they concluded.

The findings were limited by several factors including the retrospective nature of the study and lack of data on combination therapy, severity of illness, and treatment outcomes, they said.

The researchers had no financial conflicts to disclose. There was no funding source.

Prescribing systemic antibiotics for acne remains a common clinical practice, despite recommendations to reduce antibiotic use, according to an extensive database review. The results were published in the Journal of the American Academy of Dermatology.

“Despite ... recent recommendations regarding the importance of antibiotic stewardship and appropriate use of antibiotics in patients with acne, it is unclear whether there have been any significant changes in practice patterns,” wrote John S. Barbieri, MD, and his coauthors in the departments of dermatology, and biostatistics and epidemiology, at the University of Pennsylvania, Philadelphia (J Am Acad Dermatol. 2017;77[3]:456-63).

To assess prescribing practices, the researchers reviewed data from the OptumInsight Clinformatics Data Mart, which included medical and pharmacy claims for approximately 12-14 million annual covered lives. The study population included 572,630 individuals with at least two acne claims who were aged 12-40 years at the start of treatment.

The number of courses of spironolactone prescribed for acne per 100 female patients treated by dermatologists increased by 291% during the study period, from 2.08 to 8.13. Among nondermatologists, the number of spironolactone courses prescribed per 100 female patients increased from 1.43 to 4.09 over the same period, a 186% increase.

Overall, the number of oral antibiotic courses increased from 26.24 to 27.08 per 100 patients among dermatologists, and from 19.99 to 22.48 per 100 patients among nondermatologists. The median length of treatment on oral antibiotics was 126 days for patients being treated by dermatologists and 129 days among patients treated by nondermatologists.

The use of spironolactone “remains relatively uncommon” compared with oral antibiotics, the researchers pointed out, noting that the 2013 data show that for every course of spironolactone, there were 2.8 courses of oral antibiotics prescribed by dermatologists and 4.6 courses prescribed by nondermatologists.

Other prescribing trends during the time period among dermatologists included a drop in the number of combined oral contraceptive courses per 100 female patients, from 34.31 to 30.74 (and an increase from 31.70 to 32.13 among nondermatologists); and a drop in the number of isotretinoin courses prescribed per 100 patients, from 5.43 to 5.35 (and a drop from 2.24 to1.45 among nondermatologists).

“Given the importance of judicious use of oral antibiotics to prevent potential complications, increasing the use of concomitant topical retinoids and additional work to identify those patients who would benefit most from alternative agents such as spironolactone, combined oral contraceptive pills, or isotretinoin represent potential opportunities to improve the care of patients with acne,” they concluded.

The findings were limited by several factors including the retrospective nature of the study and lack of data on combination therapy, severity of illness, and treatment outcomes, they said.

The researchers had no financial conflicts to disclose. There was no funding source.

Prescribing systemic antibiotics for acne remains a common clinical practice, despite recommendations to reduce antibiotic use, according to an extensive database review. The results were published in the Journal of the American Academy of Dermatology.

“Despite ... recent recommendations regarding the importance of antibiotic stewardship and appropriate use of antibiotics in patients with acne, it is unclear whether there have been any significant changes in practice patterns,” wrote John S. Barbieri, MD, and his coauthors in the departments of dermatology, and biostatistics and epidemiology, at the University of Pennsylvania, Philadelphia (J Am Acad Dermatol. 2017;77[3]:456-63).

To assess prescribing practices, the researchers reviewed data from the OptumInsight Clinformatics Data Mart, which included medical and pharmacy claims for approximately 12-14 million annual covered lives. The study population included 572,630 individuals with at least two acne claims who were aged 12-40 years at the start of treatment.

The number of courses of spironolactone prescribed for acne per 100 female patients treated by dermatologists increased by 291% during the study period, from 2.08 to 8.13. Among nondermatologists, the number of spironolactone courses prescribed per 100 female patients increased from 1.43 to 4.09 over the same period, a 186% increase.

Overall, the number of oral antibiotic courses increased from 26.24 to 27.08 per 100 patients among dermatologists, and from 19.99 to 22.48 per 100 patients among nondermatologists. The median length of treatment on oral antibiotics was 126 days for patients being treated by dermatologists and 129 days among patients treated by nondermatologists.

The use of spironolactone “remains relatively uncommon” compared with oral antibiotics, the researchers pointed out, noting that the 2013 data show that for every course of spironolactone, there were 2.8 courses of oral antibiotics prescribed by dermatologists and 4.6 courses prescribed by nondermatologists.

Other prescribing trends during the time period among dermatologists included a drop in the number of combined oral contraceptive courses per 100 female patients, from 34.31 to 30.74 (and an increase from 31.70 to 32.13 among nondermatologists); and a drop in the number of isotretinoin courses prescribed per 100 patients, from 5.43 to 5.35 (and a drop from 2.24 to1.45 among nondermatologists).

“Given the importance of judicious use of oral antibiotics to prevent potential complications, increasing the use of concomitant topical retinoids and additional work to identify those patients who would benefit most from alternative agents such as spironolactone, combined oral contraceptive pills, or isotretinoin represent potential opportunities to improve the care of patients with acne,” they concluded.

The findings were limited by several factors including the retrospective nature of the study and lack of data on combination therapy, severity of illness, and treatment outcomes, they said.

The researchers had no financial conflicts to disclose. There was no funding source.