News for Your Practice

Thanks for joining Co-chairs Tommaso Falcone and Mickey Karram, who gathered top surgeon faculty at Paris in Las Vegas December 10-12, 2015, to discuss the latest advances in all facets of gynecologic surgery. See below for conference highlights. We hope to see next year in Las Vegas for PAGS 2016!

Thanks for joining Co-chairs Tommaso Falcone and Mickey Karram, who gathered top surgeon faculty at Paris in Las Vegas December 10-12, 2015, to discuss the latest advances in all facets of gynecologic surgery. See below for conference highlights. We hope to see next year in Las Vegas for PAGS 2016!

Thanks for joining Co-chairs Tommaso Falcone and Mickey Karram, who gathered top surgeon faculty at Paris in Las Vegas December 10-12, 2015, to discuss the latest advances in all facets of gynecologic surgery. See below for conference highlights. We hope to see next year in Las Vegas for PAGS 2016!

When investigators compared the cost of vaginal hysterectomy with robot-assisted laparoscopic hysterectomy head to head, they found hospital costs of $4,579 and $7,059, respectively, with no other significant differences between the approaches. Accordingly, they concluded that vaginal hysterectomy should be the “first-choice” approach when it is feasible.

The randomized controlled trial by Lönnerfors and colleagues also compared “traditional” minimally invasive hysterectomy (vaginal or laparoscopic approach) with robot-assisted hysterectomy in 122 women undergoing hysterectomy for benign conditions. Women with a uterine size of 16 gestational weeks or smaller were randomly allocated to:

• traditional minimally invasive hysterectomy (n = 61) or
• robotic assisted hysterectomy (n = 61).

In the traditional group, vaginal hysterectomy was the first-choice approach when it was feasible; otherwise, laparoscopic hysterectomy was performed. Vaginal hysterectomy was possible in 41% of cases in this group.

When costs for vaginal and laparoscopic approaches were consolidated and compared with the cost of the robot-assisted approach, the differential was $993 for the robotic approach when the robot was considered a preexisting investment. The hospital cost increased by $1,607 for the robotic approach when investment costs and maintenance expenses were included.

When laparoscopic hysterectomy was compared directly with robot-assisted hysterectomy, costs were similar ($7,016 vs $7,059, respectively) when the robot was considered a preexisting investment, and the robotic approach was associated with less blood loss and fewer postoperative complications.

Investigators noted that: “per-protocol analysis indicates that laparoscopic and robotic-assisted hysterectomy can be performed at similar hospital cost because of higher robot capacity that entails excluding the cost of investment and maintenance, i.e., the basic cost of the robot. This cost differs among institutions, depending on the number of procedures performed; however, the difference becomes less pronounced when 300 to 400 procedures or more are performed annually and the cost for instruments and disposables accounts for most of the cost of the procedure.”

This randomized controlled trial was awarded the Robert B. Hunt Award at the 2015 AAGL Global Congress in Las Vegas as the best paper published over the past year in the Journal of Minimally Invasive Gynecology.

When investigators compared the cost of vaginal hysterectomy with robot-assisted laparoscopic hysterectomy head to head, they found hospital costs of $4,579 and $7,059, respectively, with no other significant differences between the approaches. Accordingly, they concluded that vaginal hysterectomy should be the “first-choice” approach when it is feasible.

The randomized controlled trial by Lönnerfors and colleagues also compared “traditional” minimally invasive hysterectomy (vaginal or laparoscopic approach) with robot-assisted hysterectomy in 122 women undergoing hysterectomy for benign conditions. Women with a uterine size of 16 gestational weeks or smaller were randomly allocated to:

• traditional minimally invasive hysterectomy (n = 61) or
• robotic assisted hysterectomy (n = 61).

In the traditional group, vaginal hysterectomy was the first-choice approach when it was feasible; otherwise, laparoscopic hysterectomy was performed. Vaginal hysterectomy was possible in 41% of cases in this group.

When costs for vaginal and laparoscopic approaches were consolidated and compared with the cost of the robot-assisted approach, the differential was $993 for the robotic approach when the robot was considered a preexisting investment. The hospital cost increased by $1,607 for the robotic approach when investment costs and maintenance expenses were included.

When laparoscopic hysterectomy was compared directly with robot-assisted hysterectomy, costs were similar ($7,016 vs $7,059, respectively) when the robot was considered a preexisting investment, and the robotic approach was associated with less blood loss and fewer postoperative complications.

Investigators noted that: “per-protocol analysis indicates that laparoscopic and robotic-assisted hysterectomy can be performed at similar hospital cost because of higher robot capacity that entails excluding the cost of investment and maintenance, i.e., the basic cost of the robot. This cost differs among institutions, depending on the number of procedures performed; however, the difference becomes less pronounced when 300 to 400 procedures or more are performed annually and the cost for instruments and disposables accounts for most of the cost of the procedure.”

This randomized controlled trial was awarded the Robert B. Hunt Award at the 2015 AAGL Global Congress in Las Vegas as the best paper published over the past year in the Journal of Minimally Invasive Gynecology.

When investigators compared the cost of vaginal hysterectomy with robot-assisted laparoscopic hysterectomy head to head, they found hospital costs of $4,579 and $7,059, respectively, with no other significant differences between the approaches. Accordingly, they concluded that vaginal hysterectomy should be the “first-choice” approach when it is feasible.

The randomized controlled trial by Lönnerfors and colleagues also compared “traditional” minimally invasive hysterectomy (vaginal or laparoscopic approach) with robot-assisted hysterectomy in 122 women undergoing hysterectomy for benign conditions. Women with a uterine size of 16 gestational weeks or smaller were randomly allocated to:

• traditional minimally invasive hysterectomy (n = 61) or
• robotic assisted hysterectomy (n = 61).

In the traditional group, vaginal hysterectomy was the first-choice approach when it was feasible; otherwise, laparoscopic hysterectomy was performed. Vaginal hysterectomy was possible in 41% of cases in this group.

When costs for vaginal and laparoscopic approaches were consolidated and compared with the cost of the robot-assisted approach, the differential was $993 for the robotic approach when the robot was considered a preexisting investment. The hospital cost increased by $1,607 for the robotic approach when investment costs and maintenance expenses were included.

When laparoscopic hysterectomy was compared directly with robot-assisted hysterectomy, costs were similar ($7,016 vs $7,059, respectively) when the robot was considered a preexisting investment, and the robotic approach was associated with less blood loss and fewer postoperative complications.

Investigators noted that: “per-protocol analysis indicates that laparoscopic and robotic-assisted hysterectomy can be performed at similar hospital cost because of higher robot capacity that entails excluding the cost of investment and maintenance, i.e., the basic cost of the robot. This cost differs among institutions, depending on the number of procedures performed; however, the difference becomes less pronounced when 300 to 400 procedures or more are performed annually and the cost for instruments and disposables accounts for most of the cost of the procedure.”

This randomized controlled trial was awarded the Robert B. Hunt Award at the 2015 AAGL Global Congress in Las Vegas as the best paper published over the past year in the Journal of Minimally Invasive Gynecology.

When investigators from the Penn State Milton S. Hershey Medical Center randomly allocated 144 women to robot-assisted or standard laparoscopic hysterectomy (n = 72 in each arm) and recorded complications for 12 weeks, they found no significant differences between groups in estimated blood loss.¹ In addition, mean operative times (surgeon incision to surgeon stop, including docking in the robot-assisted group) were similar (73.9 min for robot-assisted surgery vs 74.9 min for standard laparoscopy), as were complication rates. In this trial, operative time was the primary outcome.

Pain was assessed at 2 postoperative hours and was found to be similar between groups.

Two intraoperative complications occurred in the robot-assisted group, compared with none for standard laparoscopy (P = .50). Six postoperative complications occurred in the robot-assisted group, compared with 9 in the standard laparoscopy group (P = 0.58).

Complications included: a need for reoperation/readmission (2 patients in each group; P = 1.00), infection (1 patient in each group; P = 1.00), hemorrhage/transfusion (4 in the standard laparoscopy group; P = 0.12), and vaginal cuff dehiscence (2 in the robot-assisted group vs 1 for standard laparoscopy; P = 1.00).

Investigators concluded that robot-assisted hysterectomy is “noninferior” to standard laparoscopy with regard to operative time when it is performed by experienced minimally invasive surgeons.

Gerald J. Harkins, MD, an author and primary surgeon of the trial, notes that it is the first randomized comparison involving surgeons with expertise in both robot-assisted and standard laparoscopic hysterectomy. As such, its findings represent Level I evidence. Dr. Harkins had completed more than 600 robot-assisted cases prior to initiation of the trial.

Cost was not analyzed in this study, the abstract of which won the Jay M. Cooper Award as the best paper on minimally invasive gynecology by a fellow and was presented on November 17 at the AAGL annual meeting in Las Vegas.

When investigators from the Penn State Milton S. Hershey Medical Center randomly allocated 144 women to robot-assisted or standard laparoscopic hysterectomy (n = 72 in each arm) and recorded complications for 12 weeks, they found no significant differences between groups in estimated blood loss.¹ In addition, mean operative times (surgeon incision to surgeon stop, including docking in the robot-assisted group) were similar (73.9 min for robot-assisted surgery vs 74.9 min for standard laparoscopy), as were complication rates. In this trial, operative time was the primary outcome.

Pain was assessed at 2 postoperative hours and was found to be similar between groups.

Two intraoperative complications occurred in the robot-assisted group, compared with none for standard laparoscopy (P = .50). Six postoperative complications occurred in the robot-assisted group, compared with 9 in the standard laparoscopy group (P = 0.58).

Complications included: a need for reoperation/readmission (2 patients in each group; P = 1.00), infection (1 patient in each group; P = 1.00), hemorrhage/transfusion (4 in the standard laparoscopy group; P = 0.12), and vaginal cuff dehiscence (2 in the robot-assisted group vs 1 for standard laparoscopy; P = 1.00).

Investigators concluded that robot-assisted hysterectomy is “noninferior” to standard laparoscopy with regard to operative time when it is performed by experienced minimally invasive surgeons.

Gerald J. Harkins, MD, an author and primary surgeon of the trial, notes that it is the first randomized comparison involving surgeons with expertise in both robot-assisted and standard laparoscopic hysterectomy. As such, its findings represent Level I evidence. Dr. Harkins had completed more than 600 robot-assisted cases prior to initiation of the trial.

Cost was not analyzed in this study, the abstract of which won the Jay M. Cooper Award as the best paper on minimally invasive gynecology by a fellow and was presented on November 17 at the AAGL annual meeting in Las Vegas.

When investigators from the Penn State Milton S. Hershey Medical Center randomly allocated 144 women to robot-assisted or standard laparoscopic hysterectomy (n = 72 in each arm) and recorded complications for 12 weeks, they found no significant differences between groups in estimated blood loss.¹ In addition, mean operative times (surgeon incision to surgeon stop, including docking in the robot-assisted group) were similar (73.9 min for robot-assisted surgery vs 74.9 min for standard laparoscopy), as were complication rates. In this trial, operative time was the primary outcome.

Pain was assessed at 2 postoperative hours and was found to be similar between groups.

Two intraoperative complications occurred in the robot-assisted group, compared with none for standard laparoscopy (P = .50). Six postoperative complications occurred in the robot-assisted group, compared with 9 in the standard laparoscopy group (P = 0.58).

Complications included: a need for reoperation/readmission (2 patients in each group; P = 1.00), infection (1 patient in each group; P = 1.00), hemorrhage/transfusion (4 in the standard laparoscopy group; P = 0.12), and vaginal cuff dehiscence (2 in the robot-assisted group vs 1 for standard laparoscopy; P = 1.00).

Investigators concluded that robot-assisted hysterectomy is “noninferior” to standard laparoscopy with regard to operative time when it is performed by experienced minimally invasive surgeons.

Gerald J. Harkins, MD, an author and primary surgeon of the trial, notes that it is the first randomized comparison involving surgeons with expertise in both robot-assisted and standard laparoscopic hysterectomy. As such, its findings represent Level I evidence. Dr. Harkins had completed more than 600 robot-assisted cases prior to initiation of the trial.

Cost was not analyzed in this study, the abstract of which won the Jay M. Cooper Award as the best paper on minimally invasive gynecology by a fellow and was presented on November 17 at the AAGL annual meeting in Las Vegas.

The rate of congenital syphilis increased to 11.6 cases per 100,000 live births in 2014 in the United States—the highest rate documented since 2001, according to a new report from the Centers for Disease Control and Prevention (CDC).¹ The increase in the rate of congenital syphilis reflects a rise in the rate of primary and secondary syphilis among US women, from 0.9 to 1.1 cases per 100,000 women, during the same period.¹

The rate of congenital syphilis had declined between 2008 and 2012, from 10.5 cases to 8.4 cases per 100,000 live births.

Congenital syphilis occurs when an infected mother transmits the disease to her fetus during pregnancy. Among the adverse effects of congenital syphilis are deformities, stillbirth, and early infant death. “However, among mothers identified with syphilis who deliver past 20 weeks’ gestation, treatment with penicillin at least 30 days before delivery is 98% effective at preventing [congenital syphilis],” the CDC report notes.¹

For the purposes of the CDC report, congenital syphilis includes “both infants and stillbirths with clinical evidence” of the disease, “as well as those infants and stillbirths born to mothers with untreated or inadequately treated syphilis, regardless of the infant’s manifestation of clinical disease.”¹

CDC recommendations
The CDC notes that most of the increases in the rates of maternal and congenital syphilis likely stem from inadequate prenatal care.

“A large percentage of [congenital syphilis] cases continue to be attributable to a lack of prenatal care; even among those receiving some prenatal care, the detection and treatment of maternal syphilis is often not early enough….At particular risk are those who are uninsured or underinsured and those with substance use issues.”¹

Among the recommendations of the CDC:

• Screen all pregnant women for syphilis at their first prenatal visit.
• Screen women at elevated risk for syphilis, as well as those who live in “high-morbidity geographic areas” at the beginning of the third trimester and again at delivery.
• In cases where prenatal care has been lacking, screen the woman for syphilis using a rapid plasma reagin (RPR) card and treat the patient who tests positive at the time the pregnancy is confirmed.
• Do not discharge an infant from the hospital unless the syphilis serologic status of the mother has been tested at least once during pregnancy and, preferably, again at delivery (in high-risk cases).
• Test any woman who delivers a stillborn infant for syphilis.

The rate of congenital syphilis increased to 11.6 cases per 100,000 live births in 2014 in the United States—the highest rate documented since 2001, according to a new report from the Centers for Disease Control and Prevention (CDC).¹ The increase in the rate of congenital syphilis reflects a rise in the rate of primary and secondary syphilis among US women, from 0.9 to 1.1 cases per 100,000 women, during the same period.¹

The rate of congenital syphilis had declined between 2008 and 2012, from 10.5 cases to 8.4 cases per 100,000 live births.

Congenital syphilis occurs when an infected mother transmits the disease to her fetus during pregnancy. Among the adverse effects of congenital syphilis are deformities, stillbirth, and early infant death. “However, among mothers identified with syphilis who deliver past 20 weeks’ gestation, treatment with penicillin at least 30 days before delivery is 98% effective at preventing [congenital syphilis],” the CDC report notes.¹

For the purposes of the CDC report, congenital syphilis includes “both infants and stillbirths with clinical evidence” of the disease, “as well as those infants and stillbirths born to mothers with untreated or inadequately treated syphilis, regardless of the infant’s manifestation of clinical disease.”¹

CDC recommendations
The CDC notes that most of the increases in the rates of maternal and congenital syphilis likely stem from inadequate prenatal care.

“A large percentage of [congenital syphilis] cases continue to be attributable to a lack of prenatal care; even among those receiving some prenatal care, the detection and treatment of maternal syphilis is often not early enough….At particular risk are those who are uninsured or underinsured and those with substance use issues.”¹

Among the recommendations of the CDC:

• Screen all pregnant women for syphilis at their first prenatal visit.
• Screen women at elevated risk for syphilis, as well as those who live in “high-morbidity geographic areas” at the beginning of the third trimester and again at delivery.
• In cases where prenatal care has been lacking, screen the woman for syphilis using a rapid plasma reagin (RPR) card and treat the patient who tests positive at the time the pregnancy is confirmed.
• Do not discharge an infant from the hospital unless the syphilis serologic status of the mother has been tested at least once during pregnancy and, preferably, again at delivery (in high-risk cases).
• Test any woman who delivers a stillborn infant for syphilis.

The rate of congenital syphilis increased to 11.6 cases per 100,000 live births in 2014 in the United States—the highest rate documented since 2001, according to a new report from the Centers for Disease Control and Prevention (CDC).¹ The increase in the rate of congenital syphilis reflects a rise in the rate of primary and secondary syphilis among US women, from 0.9 to 1.1 cases per 100,000 women, during the same period.¹

The rate of congenital syphilis had declined between 2008 and 2012, from 10.5 cases to 8.4 cases per 100,000 live births.

Congenital syphilis occurs when an infected mother transmits the disease to her fetus during pregnancy. Among the adverse effects of congenital syphilis are deformities, stillbirth, and early infant death. “However, among mothers identified with syphilis who deliver past 20 weeks’ gestation, treatment with penicillin at least 30 days before delivery is 98% effective at preventing [congenital syphilis],” the CDC report notes.¹

For the purposes of the CDC report, congenital syphilis includes “both infants and stillbirths with clinical evidence” of the disease, “as well as those infants and stillbirths born to mothers with untreated or inadequately treated syphilis, regardless of the infant’s manifestation of clinical disease.”¹

CDC recommendations
The CDC notes that most of the increases in the rates of maternal and congenital syphilis likely stem from inadequate prenatal care.

“A large percentage of [congenital syphilis] cases continue to be attributable to a lack of prenatal care; even among those receiving some prenatal care, the detection and treatment of maternal syphilis is often not early enough….At particular risk are those who are uninsured or underinsured and those with substance use issues.”¹

Among the recommendations of the CDC:

• Screen all pregnant women for syphilis at their first prenatal visit.
• Screen women at elevated risk for syphilis, as well as those who live in “high-morbidity geographic areas” at the beginning of the third trimester and again at delivery.
• In cases where prenatal care has been lacking, screen the woman for syphilis using a rapid plasma reagin (RPR) card and treat the patient who tests positive at the time the pregnancy is confirmed.
• Do not discharge an infant from the hospital unless the syphilis serologic status of the mother has been tested at least once during pregnancy and, preferably, again at delivery (in high-risk cases).
• Test any woman who delivers a stillborn infant for syphilis.

When the American Cancer Society (ACS) updated its guidelines for screening mammography earlier this week,¹ the effect was that of a stone being tossed into a tranquil pond, generating ripples in all directions.

The new guidelines focus on women at average risk for breast cancer (TABLE 1) and were updated for the first time since 2003, based on new evidence, a new emphasis on eliminating as many screening harms as possible, and a goal of “supporting the interplay among values, preferences, informed decision making, and recommendations.”¹ Earlier ACS guidelines recommended annual screening starting at age 40.
 

The new guidelines are graded according to the strength of the rec ommendation as being either “strong” or “qualified.” The ACS defines a “strong” recommendation as one that most individuals should follow. “Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator,” the guidelines note.¹

A “qualified” recommendation indicates that “Clinicians should acknowledge that different choices will be appropriate for different patients and that clinicians must help each patient arrive at a management decision consistent with her or his values and preferences.”¹

The recommendations are:

ACOG weighs in
Shortly after publication of the new ACS guidelines, the American College of Obstetricians and Gynecologists (ACOG) issued a formal statement in response²:

Response of the USPSTF
The US Preventive Services Task Force (USPSTF) also issued a statement in response to the new ACS guidelines:

The USPSTF currently recommends biennial screening beginning at age 50.

A leader in breast health cites pros and cons of ACS recommendations
Mark Pearlman, MD, professor of obstetrics and gynecology at the University of Michigan health system, is a nationally recognized expert on breast cancer screening. He sits on the National Comprehensive Cancer Network (NCCN) breast cancer screening and diagnosis group, helped author ACOG guidelines on mammography screening, and serves as a Contributing Editor to OBG Management.

“I believe the overall ACS mammography benefit evidence synthesis is reasonable and is in keeping with both NCCN and ACOG’s current recommendations. NCCN and ACOG mammography screening recommendations have both valued lives saved more highly than the ‘harms’ such as recalls and needle biopsies,” Dr. Pearlman says.

“If one combines ACS ‘strong’ and ‘qualified’ recommendations, ACS recommendations are similar to current ACOG and NCCN recommendations for mammography,” he adds.

Dr. Pearlman finds 7 areas of agreement between NCCN/ACOG and ACS recommendations, using both strong and qualified recommendations:

Where the ACS and ACOG/NCCN disagree is over the issue of the physical exam (abandoning CBE in average-risk women).

In regard to this last item, Dr. Pearlman says, “The ACS made a qualified recommendation against clinical breast exam. There is no high-level data to support such a marked change in practice. For example, when recommendations against breast self-examinations (BSE) were made, there were randomized controlled trials (RCTs) showing a lack of benefit and significant harms with BSE. With RCT-level data, it made sense to make a recommendation against the long-taught practice of SBE in average-risk women. That was not the case here. In fact, there are small amounts of data showing benefits of clinical breast exam.”

“One of my biggest concerns is not just the recommendation against CBE,” says Dr. Pearlman, “but that this may lead many women to interpret [this statement] as if they do not need to see their health care provider anymore. As you may recall, the American College of Physicians (ACP) recommended against annual pelvic examinations in asymptomatic patients. The ACS recommendation statement—taken together with the ACP statement—basically suggests that average-risk women don’t ever need to see a provider for a pelvic or breast examination except every 5 years for a Pap smear. That thinking does not recognize the importance of the clinical encounter (not just the CBE or pelvic exam), which is the opportunity to perform risk assessment and provide risk-reduction recommendations and healthy lifestyle recommendations.”

Radiologists resist new recommendations
Although the American College of Radiology (ACR) and the Society of Breast Imaging (SBI) agree with the ACS that mammography screening saves lives and should be available to women aged 40 and older, the 2 imaging organizations continue to recommend that annual screening begin at age 40. Their rationale: The latest ACS breast cancer screening guidelines, and earlier data used by the USPSTF to create its recommendations, both note that starting annual mammography at age 40 “saves the most lives.”

Where the organizations differ from the ACR is summed up by a formal statement on the ACR Web site: “The ACR and SBI strongly encourage women to obtain the maximum lifesaving benefits from mammography by continuing to get annual screening.”⁴

When OBG Management touched base with radiologist Barbara Monsees, MD, professor of radiology and Evens Professor of Women’s Health at Washington University Medical Center in St. Louis, Missouri, she expressed dismay at early news reports on the ACS guidelines.

“I’m dismayed that the headlines don’t seem to correlate with what the ACS actually recommended. The ACS did not state that women should wait until age 45 to begin screening. I believe the ACS was going for a more nuanced approach, but since that’s a bit complicated, I think that reporters have misconstrued what was intended,” Dr. Monsees says.

“The ACS guideline says that women between 40 and 44 years should have the opportunity to begin annual screening,” she says, noting that this recommendation was graded as “qualified.”

“The ACS states that a qualified recommendation indicates that ‘there is clear evidence of benefit of screening, but less certainty about the balance of benefits and harms, or about patients’ values and preferences, which could lead to different decisions about screening.’” The guideline also articulates the view “that the meaning of a qualified recommendation for patients is that the ‘majority of individuals in this situation would want the suggested course of action, but many would not.’ Therefore, I find it mind-boggling that this has been interpreted to mean that women should not begin screening until age 45.”¹

“It is my opinion that it is clear that if women want to achieve the most lifesaving benefit from screening, they should adhere to a schedule of yearly mammograms beginning at age 40,” says Dr. Monsees. However, she also agrees with the ACS notation that clinicians should acknowledge that “different choices will be appropriate for different patients and that clinicians must help each patient arrive at a management decision consistent with her values and preferences.”¹

The word from an expert ObGyn
“By changing its guidance to begin screening at age 45 instead of 40, and in recommending biennial rather than annual screens in women 55 years of age and older, the updated ACS guidance will reduce harms (overdiagnosis and unnecessary additional imaging and biopsies) and moves closer to USPSTF guidance,” says Andrew M. Kaunitz, MD. He is University of Florida Research Foundation Professor and Associate Chairman, Department of Obstetrics and Gynecology, at the University of Florida College of Medicine–Jacksonville. He also serves on the OBG Management Board of Editors.

“As one editorialist points out, the ACS recommendation that women begin screening at age 45 years is based on observational comparisons of screened and unscreened cohorts—a type of analysis which the USPSTF does not consider due to concerns regarding bias,” notes Dr. Kaunitz.⁵

“The ACS recommendation for annual screening in women aged 45 to 54 is largely based on the findings of a report showing that, for premenopausal (but not postmenopausal) women, tumor stage was higher and size larger for screen-detected lesions among women undergoing biennial screens."⁶

As for the recommendation against screening CBE, Dr. Kaunitz considers that “a dramatic change from prior guidance. It is based on the absence of data finding benefits with CBE (alone or with screening mammography). Furthermore, the updated ACS guidance does not change its 2003 guidance, which does not support routine performance of or instruction regarding SBE.”

“These updated ACS guidelines should result in more women starting screening mammograms later in life, and they endorse biennial screening for many women, meaning that patients following ACS guidance will have fewer lifetime screens than with earlier recommendations,” says Dr. Kaunitz.

“Another plus is that performing fewer breast examinations during well-woman visits will allow us more time to assess family history and other risk factors for breast cancer, and to discuss screening recommendations.”

The bottom line
What is one to make of the many viewpoints on screening? For now, it probably is best to adhere to either the new ACS guidelines or current ACOG guidelines (TABLE 2), says OBG Management Editor in Chief Robert L. Barbieri, MD. He is chief of the Department of Obstetrics and Gynecology at Brigham and Women’s Hospital in Boston, and Kate Macy Ladd Professor of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School.
 

ACOG recommends screening mammography every year for women starting at age 40. ACOG also states that “breast self-awareness has the potential to detect palpable breast cancer and can be recommended”; it also recommends CBE every year for women aged 19 or older.

These recommendations may change early next year, after ACOG convenes a consensus conference on the subject. The aim: “To develop a consistent set of uniform guidelines for breast cancer screening that can be implemented nationwide. Major organizations and providers of women’s health care, including ACS, will gather to evaluate and interpret the data in greater detail.”²

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

When the American Cancer Society (ACS) updated its guidelines for screening mammography earlier this week,¹ the effect was that of a stone being tossed into a tranquil pond, generating ripples in all directions.

The new guidelines focus on women at average risk for breast cancer (TABLE 1) and were updated for the first time since 2003, based on new evidence, a new emphasis on eliminating as many screening harms as possible, and a goal of “supporting the interplay among values, preferences, informed decision making, and recommendations.”¹ Earlier ACS guidelines recommended annual screening starting at age 40.
 

The new guidelines are graded according to the strength of the rec ommendation as being either “strong” or “qualified.” The ACS defines a “strong” recommendation as one that most individuals should follow. “Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator,” the guidelines note.¹

A “qualified” recommendation indicates that “Clinicians should acknowledge that different choices will be appropriate for different patients and that clinicians must help each patient arrive at a management decision consistent with her or his values and preferences.”¹

The recommendations are:

ACOG weighs in
Shortly after publication of the new ACS guidelines, the American College of Obstetricians and Gynecologists (ACOG) issued a formal statement in response²:

Response of the USPSTF
The US Preventive Services Task Force (USPSTF) also issued a statement in response to the new ACS guidelines:

The USPSTF currently recommends biennial screening beginning at age 50.

A leader in breast health cites pros and cons of ACS recommendations
Mark Pearlman, MD, professor of obstetrics and gynecology at the University of Michigan health system, is a nationally recognized expert on breast cancer screening. He sits on the National Comprehensive Cancer Network (NCCN) breast cancer screening and diagnosis group, helped author ACOG guidelines on mammography screening, and serves as a Contributing Editor to OBG Management.

“I believe the overall ACS mammography benefit evidence synthesis is reasonable and is in keeping with both NCCN and ACOG’s current recommendations. NCCN and ACOG mammography screening recommendations have both valued lives saved more highly than the ‘harms’ such as recalls and needle biopsies,” Dr. Pearlman says.

“If one combines ACS ‘strong’ and ‘qualified’ recommendations, ACS recommendations are similar to current ACOG and NCCN recommendations for mammography,” he adds.

Dr. Pearlman finds 7 areas of agreement between NCCN/ACOG and ACS recommendations, using both strong and qualified recommendations:

Where the ACS and ACOG/NCCN disagree is over the issue of the physical exam (abandoning CBE in average-risk women).

In regard to this last item, Dr. Pearlman says, “The ACS made a qualified recommendation against clinical breast exam. There is no high-level data to support such a marked change in practice. For example, when recommendations against breast self-examinations (BSE) were made, there were randomized controlled trials (RCTs) showing a lack of benefit and significant harms with BSE. With RCT-level data, it made sense to make a recommendation against the long-taught practice of SBE in average-risk women. That was not the case here. In fact, there are small amounts of data showing benefits of clinical breast exam.”

“One of my biggest concerns is not just the recommendation against CBE,” says Dr. Pearlman, “but that this may lead many women to interpret [this statement] as if they do not need to see their health care provider anymore. As you may recall, the American College of Physicians (ACP) recommended against annual pelvic examinations in asymptomatic patients. The ACS recommendation statement—taken together with the ACP statement—basically suggests that average-risk women don’t ever need to see a provider for a pelvic or breast examination except every 5 years for a Pap smear. That thinking does not recognize the importance of the clinical encounter (not just the CBE or pelvic exam), which is the opportunity to perform risk assessment and provide risk-reduction recommendations and healthy lifestyle recommendations.”

Radiologists resist new recommendations
Although the American College of Radiology (ACR) and the Society of Breast Imaging (SBI) agree with the ACS that mammography screening saves lives and should be available to women aged 40 and older, the 2 imaging organizations continue to recommend that annual screening begin at age 40. Their rationale: The latest ACS breast cancer screening guidelines, and earlier data used by the USPSTF to create its recommendations, both note that starting annual mammography at age 40 “saves the most lives.”

Where the organizations differ from the ACR is summed up by a formal statement on the ACR Web site: “The ACR and SBI strongly encourage women to obtain the maximum lifesaving benefits from mammography by continuing to get annual screening.”⁴

When OBG Management touched base with radiologist Barbara Monsees, MD, professor of radiology and Evens Professor of Women’s Health at Washington University Medical Center in St. Louis, Missouri, she expressed dismay at early news reports on the ACS guidelines.

“I’m dismayed that the headlines don’t seem to correlate with what the ACS actually recommended. The ACS did not state that women should wait until age 45 to begin screening. I believe the ACS was going for a more nuanced approach, but since that’s a bit complicated, I think that reporters have misconstrued what was intended,” Dr. Monsees says.

“The ACS guideline says that women between 40 and 44 years should have the opportunity to begin annual screening,” she says, noting that this recommendation was graded as “qualified.”

“The ACS states that a qualified recommendation indicates that ‘there is clear evidence of benefit of screening, but less certainty about the balance of benefits and harms, or about patients’ values and preferences, which could lead to different decisions about screening.’” The guideline also articulates the view “that the meaning of a qualified recommendation for patients is that the ‘majority of individuals in this situation would want the suggested course of action, but many would not.’ Therefore, I find it mind-boggling that this has been interpreted to mean that women should not begin screening until age 45.”¹

“It is my opinion that it is clear that if women want to achieve the most lifesaving benefit from screening, they should adhere to a schedule of yearly mammograms beginning at age 40,” says Dr. Monsees. However, she also agrees with the ACS notation that clinicians should acknowledge that “different choices will be appropriate for different patients and that clinicians must help each patient arrive at a management decision consistent with her values and preferences.”¹

The word from an expert ObGyn
“By changing its guidance to begin screening at age 45 instead of 40, and in recommending biennial rather than annual screens in women 55 years of age and older, the updated ACS guidance will reduce harms (overdiagnosis and unnecessary additional imaging and biopsies) and moves closer to USPSTF guidance,” says Andrew M. Kaunitz, MD. He is University of Florida Research Foundation Professor and Associate Chairman, Department of Obstetrics and Gynecology, at the University of Florida College of Medicine–Jacksonville. He also serves on the OBG Management Board of Editors.

“As one editorialist points out, the ACS recommendation that women begin screening at age 45 years is based on observational comparisons of screened and unscreened cohorts—a type of analysis which the USPSTF does not consider due to concerns regarding bias,” notes Dr. Kaunitz.⁵

“The ACS recommendation for annual screening in women aged 45 to 54 is largely based on the findings of a report showing that, for premenopausal (but not postmenopausal) women, tumor stage was higher and size larger for screen-detected lesions among women undergoing biennial screens."⁶

As for the recommendation against screening CBE, Dr. Kaunitz considers that “a dramatic change from prior guidance. It is based on the absence of data finding benefits with CBE (alone or with screening mammography). Furthermore, the updated ACS guidance does not change its 2003 guidance, which does not support routine performance of or instruction regarding SBE.”

“These updated ACS guidelines should result in more women starting screening mammograms later in life, and they endorse biennial screening for many women, meaning that patients following ACS guidance will have fewer lifetime screens than with earlier recommendations,” says Dr. Kaunitz.

“Another plus is that performing fewer breast examinations during well-woman visits will allow us more time to assess family history and other risk factors for breast cancer, and to discuss screening recommendations.”

The bottom line
What is one to make of the many viewpoints on screening? For now, it probably is best to adhere to either the new ACS guidelines or current ACOG guidelines (TABLE 2), says OBG Management Editor in Chief Robert L. Barbieri, MD. He is chief of the Department of Obstetrics and Gynecology at Brigham and Women’s Hospital in Boston, and Kate Macy Ladd Professor of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School.
 

ACOG recommends screening mammography every year for women starting at age 40. ACOG also states that “breast self-awareness has the potential to detect palpable breast cancer and can be recommended”; it also recommends CBE every year for women aged 19 or older.

These recommendations may change early next year, after ACOG convenes a consensus conference on the subject. The aim: “To develop a consistent set of uniform guidelines for breast cancer screening that can be implemented nationwide. Major organizations and providers of women’s health care, including ACS, will gather to evaluate and interpret the data in greater detail.”²

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

When the American Cancer Society (ACS) updated its guidelines for screening mammography earlier this week,¹ the effect was that of a stone being tossed into a tranquil pond, generating ripples in all directions.

The new guidelines focus on women at average risk for breast cancer (TABLE 1) and were updated for the first time since 2003, based on new evidence, a new emphasis on eliminating as many screening harms as possible, and a goal of “supporting the interplay among values, preferences, informed decision making, and recommendations.”¹ Earlier ACS guidelines recommended annual screening starting at age 40.
 

The new guidelines are graded according to the strength of the rec ommendation as being either “strong” or “qualified.” The ACS defines a “strong” recommendation as one that most individuals should follow. “Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator,” the guidelines note.¹

A “qualified” recommendation indicates that “Clinicians should acknowledge that different choices will be appropriate for different patients and that clinicians must help each patient arrive at a management decision consistent with her or his values and preferences.”¹

The recommendations are:

ACOG weighs in
Shortly after publication of the new ACS guidelines, the American College of Obstetricians and Gynecologists (ACOG) issued a formal statement in response²:

Response of the USPSTF
The US Preventive Services Task Force (USPSTF) also issued a statement in response to the new ACS guidelines:

The USPSTF currently recommends biennial screening beginning at age 50.

A leader in breast health cites pros and cons of ACS recommendations
Mark Pearlman, MD, professor of obstetrics and gynecology at the University of Michigan health system, is a nationally recognized expert on breast cancer screening. He sits on the National Comprehensive Cancer Network (NCCN) breast cancer screening and diagnosis group, helped author ACOG guidelines on mammography screening, and serves as a Contributing Editor to OBG Management.

“I believe the overall ACS mammography benefit evidence synthesis is reasonable and is in keeping with both NCCN and ACOG’s current recommendations. NCCN and ACOG mammography screening recommendations have both valued lives saved more highly than the ‘harms’ such as recalls and needle biopsies,” Dr. Pearlman says.

“If one combines ACS ‘strong’ and ‘qualified’ recommendations, ACS recommendations are similar to current ACOG and NCCN recommendations for mammography,” he adds.

Dr. Pearlman finds 7 areas of agreement between NCCN/ACOG and ACS recommendations, using both strong and qualified recommendations:

Where the ACS and ACOG/NCCN disagree is over the issue of the physical exam (abandoning CBE in average-risk women).

In regard to this last item, Dr. Pearlman says, “The ACS made a qualified recommendation against clinical breast exam. There is no high-level data to support such a marked change in practice. For example, when recommendations against breast self-examinations (BSE) were made, there were randomized controlled trials (RCTs) showing a lack of benefit and significant harms with BSE. With RCT-level data, it made sense to make a recommendation against the long-taught practice of SBE in average-risk women. That was not the case here. In fact, there are small amounts of data showing benefits of clinical breast exam.”

“One of my biggest concerns is not just the recommendation against CBE,” says Dr. Pearlman, “but that this may lead many women to interpret [this statement] as if they do not need to see their health care provider anymore. As you may recall, the American College of Physicians (ACP) recommended against annual pelvic examinations in asymptomatic patients. The ACS recommendation statement—taken together with the ACP statement—basically suggests that average-risk women don’t ever need to see a provider for a pelvic or breast examination except every 5 years for a Pap smear. That thinking does not recognize the importance of the clinical encounter (not just the CBE or pelvic exam), which is the opportunity to perform risk assessment and provide risk-reduction recommendations and healthy lifestyle recommendations.”

Radiologists resist new recommendations
Although the American College of Radiology (ACR) and the Society of Breast Imaging (SBI) agree with the ACS that mammography screening saves lives and should be available to women aged 40 and older, the 2 imaging organizations continue to recommend that annual screening begin at age 40. Their rationale: The latest ACS breast cancer screening guidelines, and earlier data used by the USPSTF to create its recommendations, both note that starting annual mammography at age 40 “saves the most lives.”

Where the organizations differ from the ACR is summed up by a formal statement on the ACR Web site: “The ACR and SBI strongly encourage women to obtain the maximum lifesaving benefits from mammography by continuing to get annual screening.”⁴

When OBG Management touched base with radiologist Barbara Monsees, MD, professor of radiology and Evens Professor of Women’s Health at Washington University Medical Center in St. Louis, Missouri, she expressed dismay at early news reports on the ACS guidelines.

“I’m dismayed that the headlines don’t seem to correlate with what the ACS actually recommended. The ACS did not state that women should wait until age 45 to begin screening. I believe the ACS was going for a more nuanced approach, but since that’s a bit complicated, I think that reporters have misconstrued what was intended,” Dr. Monsees says.

“The ACS guideline says that women between 40 and 44 years should have the opportunity to begin annual screening,” she says, noting that this recommendation was graded as “qualified.”

“The ACS states that a qualified recommendation indicates that ‘there is clear evidence of benefit of screening, but less certainty about the balance of benefits and harms, or about patients’ values and preferences, which could lead to different decisions about screening.’” The guideline also articulates the view “that the meaning of a qualified recommendation for patients is that the ‘majority of individuals in this situation would want the suggested course of action, but many would not.’ Therefore, I find it mind-boggling that this has been interpreted to mean that women should not begin screening until age 45.”¹

“It is my opinion that it is clear that if women want to achieve the most lifesaving benefit from screening, they should adhere to a schedule of yearly mammograms beginning at age 40,” says Dr. Monsees. However, she also agrees with the ACS notation that clinicians should acknowledge that “different choices will be appropriate for different patients and that clinicians must help each patient arrive at a management decision consistent with her values and preferences.”¹

The word from an expert ObGyn
“By changing its guidance to begin screening at age 45 instead of 40, and in recommending biennial rather than annual screens in women 55 years of age and older, the updated ACS guidance will reduce harms (overdiagnosis and unnecessary additional imaging and biopsies) and moves closer to USPSTF guidance,” says Andrew M. Kaunitz, MD. He is University of Florida Research Foundation Professor and Associate Chairman, Department of Obstetrics and Gynecology, at the University of Florida College of Medicine–Jacksonville. He also serves on the OBG Management Board of Editors.

“As one editorialist points out, the ACS recommendation that women begin screening at age 45 years is based on observational comparisons of screened and unscreened cohorts—a type of analysis which the USPSTF does not consider due to concerns regarding bias,” notes Dr. Kaunitz.⁵

“The ACS recommendation for annual screening in women aged 45 to 54 is largely based on the findings of a report showing that, for premenopausal (but not postmenopausal) women, tumor stage was higher and size larger for screen-detected lesions among women undergoing biennial screens."⁶

As for the recommendation against screening CBE, Dr. Kaunitz considers that “a dramatic change from prior guidance. It is based on the absence of data finding benefits with CBE (alone or with screening mammography). Furthermore, the updated ACS guidance does not change its 2003 guidance, which does not support routine performance of or instruction regarding SBE.”

“These updated ACS guidelines should result in more women starting screening mammograms later in life, and they endorse biennial screening for many women, meaning that patients following ACS guidance will have fewer lifetime screens than with earlier recommendations,” says Dr. Kaunitz.

“Another plus is that performing fewer breast examinations during well-woman visits will allow us more time to assess family history and other risk factors for breast cancer, and to discuss screening recommendations.”

The bottom line
What is one to make of the many viewpoints on screening? For now, it probably is best to adhere to either the new ACS guidelines or current ACOG guidelines (TABLE 2), says OBG Management Editor in Chief Robert L. Barbieri, MD. He is chief of the Department of Obstetrics and Gynecology at Brigham and Women’s Hospital in Boston, and Kate Macy Ladd Professor of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School.
 

ACOG recommends screening mammography every year for women starting at age 40. ACOG also states that “breast self-awareness has the potential to detect palpable breast cancer and can be recommended”; it also recommends CBE every year for women aged 19 or older.

These recommendations may change early next year, after ACOG convenes a consensus conference on the subject. The aim: “To develop a consistent set of uniform guidelines for breast cancer screening that can be implemented nationwide. Major organizations and providers of women’s health care, including ACS, will gather to evaluate and interpret the data in greater detail.”²

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Menopause experts Andrew M. Kaunitz, MD, and JoAnn E. Manson, MD, DrPH, provide a comprehensive review of various treatments for menopausal symptoms in an article recently published ahead of print in Obstetrics and Gynecology.¹ They discuss hormonal and nonhormonal options to treat vasomotor symptoms, genitourinary syndrome of menopause (GSM), and considerations for the use of hormone therapy in special populations: women with early menopause, women with a history of breast cancer and those who carry the BRCA gene mutation, and women with a history of venous thrombosis.¹

The authors write that, “given the lower rates of adverse events on HT among women close to menopause onset and at lower baseline risk of cardiovascular disease, risk stratification and personalized risk assessment appear to represent a sound strategy for optimizing the benefit–risk profile and safety of HT.”¹ They suggest that instead of stopping systemic HT at age 65 years, the length of treatment be individualized based on a woman’s risk profile and preferences. The authors encourage gynecologists and other clinicians to use benefit–risk profile tools for both hormonal and nonhormonal options to help women make sound decisions on treating menopausal symptoms.¹

Readthe full Clinical Expert Series here.

Menopause experts Andrew M. Kaunitz, MD, and JoAnn E. Manson, MD, DrPH, provide a comprehensive review of various treatments for menopausal symptoms in an article recently published ahead of print in Obstetrics and Gynecology.¹ They discuss hormonal and nonhormonal options to treat vasomotor symptoms, genitourinary syndrome of menopause (GSM), and considerations for the use of hormone therapy in special populations: women with early menopause, women with a history of breast cancer and those who carry the BRCA gene mutation, and women with a history of venous thrombosis.¹

The authors write that, “given the lower rates of adverse events on HT among women close to menopause onset and at lower baseline risk of cardiovascular disease, risk stratification and personalized risk assessment appear to represent a sound strategy for optimizing the benefit–risk profile and safety of HT.”¹ They suggest that instead of stopping systemic HT at age 65 years, the length of treatment be individualized based on a woman’s risk profile and preferences. The authors encourage gynecologists and other clinicians to use benefit–risk profile tools for both hormonal and nonhormonal options to help women make sound decisions on treating menopausal symptoms.¹

Readthe full Clinical Expert Series here.

Menopause experts Andrew M. Kaunitz, MD, and JoAnn E. Manson, MD, DrPH, provide a comprehensive review of various treatments for menopausal symptoms in an article recently published ahead of print in Obstetrics and Gynecology.¹ They discuss hormonal and nonhormonal options to treat vasomotor symptoms, genitourinary syndrome of menopause (GSM), and considerations for the use of hormone therapy in special populations: women with early menopause, women with a history of breast cancer and those who carry the BRCA gene mutation, and women with a history of venous thrombosis.¹

The authors write that, “given the lower rates of adverse events on HT among women close to menopause onset and at lower baseline risk of cardiovascular disease, risk stratification and personalized risk assessment appear to represent a sound strategy for optimizing the benefit–risk profile and safety of HT.”¹ They suggest that instead of stopping systemic HT at age 65 years, the length of treatment be individualized based on a woman’s risk profile and preferences. The authors encourage gynecologists and other clinicians to use benefit–risk profile tools for both hormonal and nonhormonal options to help women make sound decisions on treating menopausal symptoms.¹

Readthe full Clinical Expert Series here.

An analysis of 882 obstetric claims closed between 2007 and 2014 highlighted 3 common allegationsby patients¹:

Together, these 3 allegations accounted for 59% of claims. Other allegations included diagnosis-related claims, delay in delivery, improper performance of operative delivery, retained foreign bodies, and improper choice of delivery method.¹

The Obstetrics Closed Claims Study findings were released earlier this spring by the Napa, California−based Doctors Company, the nation’s largest physician-owned medical malpractice insurer.¹ Susan Mann, MD,a spokesperson for the company, provided expert commentary on the study at the 2015 Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in San Francisco (see “Frequent sources of malpractice claims” below).

Top 7 factors contributing to patient injury
The Doctors Company identified specific factors that contributed to patient injury in the closed claims¹:  

“Studying obstetrical medical malpractice claims sheds light on the wide array of problems that may arise during pregnancy and in labor and delivery,” the study authors conclude. “Many of these cases reflect unusual maternal or neonatal conditions that can be diagnosed only with vigilance. Examples include protein deficiencies, clotting abnormalities, placental abruptions, infections, and genetic abnormalities. More common conditions should be identified with close attention to vital signs, laboratory studies, changes to maternal and neonatal conditions, and patient complaints.”¹ See “Tips for reducing malpractice claims in obstetrics” below.

“Obstetric departments must plan for clinical emergencies by developing and maintaining physician and staff competencies through mock drills and simulations that reduce the likelihood of injuries to mothers and their infants,” the study authors conclude.¹

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

An analysis of 882 obstetric claims closed between 2007 and 2014 highlighted 3 common allegationsby patients¹:

Together, these 3 allegations accounted for 59% of claims. Other allegations included diagnosis-related claims, delay in delivery, improper performance of operative delivery, retained foreign bodies, and improper choice of delivery method.¹

The Obstetrics Closed Claims Study findings were released earlier this spring by the Napa, California−based Doctors Company, the nation’s largest physician-owned medical malpractice insurer.¹ Susan Mann, MD,a spokesperson for the company, provided expert commentary on the study at the 2015 Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in San Francisco (see “Frequent sources of malpractice claims” below).

Top 7 factors contributing to patient injury
The Doctors Company identified specific factors that contributed to patient injury in the closed claims¹:  

“Studying obstetrical medical malpractice claims sheds light on the wide array of problems that may arise during pregnancy and in labor and delivery,” the study authors conclude. “Many of these cases reflect unusual maternal or neonatal conditions that can be diagnosed only with vigilance. Examples include protein deficiencies, clotting abnormalities, placental abruptions, infections, and genetic abnormalities. More common conditions should be identified with close attention to vital signs, laboratory studies, changes to maternal and neonatal conditions, and patient complaints.”¹ See “Tips for reducing malpractice claims in obstetrics” below.

“Obstetric departments must plan for clinical emergencies by developing and maintaining physician and staff competencies through mock drills and simulations that reduce the likelihood of injuries to mothers and their infants,” the study authors conclude.¹

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

An analysis of 882 obstetric claims closed between 2007 and 2014 highlighted 3 common allegationsby patients¹:

Together, these 3 allegations accounted for 59% of claims. Other allegations included diagnosis-related claims, delay in delivery, improper performance of operative delivery, retained foreign bodies, and improper choice of delivery method.¹

The Obstetrics Closed Claims Study findings were released earlier this spring by the Napa, California−based Doctors Company, the nation’s largest physician-owned medical malpractice insurer.¹ Susan Mann, MD,a spokesperson for the company, provided expert commentary on the study at the 2015 Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in San Francisco (see “Frequent sources of malpractice claims” below).

Top 7 factors contributing to patient injury
The Doctors Company identified specific factors that contributed to patient injury in the closed claims¹:  

“Studying obstetrical medical malpractice claims sheds light on the wide array of problems that may arise during pregnancy and in labor and delivery,” the study authors conclude. “Many of these cases reflect unusual maternal or neonatal conditions that can be diagnosed only with vigilance. Examples include protein deficiencies, clotting abnormalities, placental abruptions, infections, and genetic abnormalities. More common conditions should be identified with close attention to vital signs, laboratory studies, changes to maternal and neonatal conditions, and patient complaints.”¹ See “Tips for reducing malpractice claims in obstetrics” below.

“Obstetric departments must plan for clinical emergencies by developing and maintaining physician and staff competencies through mock drills and simulations that reduce the likelihood of injuries to mothers and their infants,” the study authors conclude.¹

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

At least half of all cases of maternal morbidity and mortality could be prevented, or so studies suggest.^1,2

The main stumbling block?

Faulty communication.

That’s the word from the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, the American College of Nurse-Midwives, and the Association of Women’s Health, Obstetric and Neonatal Nurses.³

In a joint “blueprint” to transform communication and enhance the safety culture in intrapartum care, these organizations, led by Audrey Lyndon, PhD, RN, from the University of California, San Francisco, School of Nursing, describe the extent of the problem, steps that various team members can take to improve safety, notable success stories, and communication strategies.³ In this article, the joint blueprint is summarized, with a focus on steps obstetricians can take to improve the intrapartum safety culture.

Scope of the problem
A study of more than 3,282 physicians, midwives, and registered nurses produced a troubling statistic: More than 90% of respondents said that they had “witnessed shortcuts, missing competencies, disrespect, or performance problems” during the preceding year of practice.⁴ Few of these clinicians reported that they had discussed their concerns with the parties involved.

A second study of 1,932 clinicians found that 34% of physicians, 40% of midwives, and 56% of registered nurses had witnessed patients being put at risk within the preceding 2 years by other team members’ inattentiveness or lack of responsiveness.⁵

These findings suggest that health care providers often witness weak links in intrapartum safety but do not always address or report them. Among the reasons team members may be hesitant to speak up when they perceive a potential problem:

Although Lyndon and colleagues acknowledge that it is impossible to eliminate adverse outcomes entirely or completely eradicate human error, they argue that significant improvements can be made by adopting a number of manageable strategies.³

Recommended strategies
Lyndon and colleagues describe some of the challenges of effective communication in a health care setting:

Lyndon and colleagues go on to mention a number of strategies to improve communication, boost safety, and reduce medical errors.³

1. Remember that the patient is part of the team
The patient and her family play a key role in identifying the potential for harm during labor and delivery, Lyndon and colleagues assert. Patients should be considered members of the intrapartum team, care should be patient-focused, and any communications from the patient should not only be heard but fully considered. In fact, explicit elicitation of her experience and concerns is recommended.³

2. Consider that you might be part of the problem
It is human nature to attribute a communication problem to the other people involved, rather than take responsibility for it oneself. One potential solution to this mindset is team training, where all members are encouraged to communicate clearly and listen attentively. Organizations that have been successful at improving their culture of safety have implemented such training, as well as the use of checklists, training in fetal heart-rate monitoring, formation of a patient safety committee, external review of safety practices, and designation of a key clinicianto lead the safety program and oversee team training.

3. Structure handoffs
The team should standardize handoffs so that they occur smoothly and all channels of communication remain open and clear.

“Having structured formats for debriefing and handoffs are steps in the right direction, but solving the problem of communication breakdowns is more complicated than standardizing the flow and format of information transfer,” Lyndon and colleagues assert. “Indeed, solving communication breakdowns is a matter of individual, group, organizational, and professional responsibility for creating and sustaining an environment of mutual respect, curiosity, and accountability for behavior and performance.”³

4. Learn to communicate responsibly
“Differences of opinion about clinical assessments, goals of care, and the pathway to optimal outcomes are bound to occur with some regularity in the dynamic environment of labor and delivery,” note Lyndon and colleagues. “Every person has the responsibility to contribute to improving how we relate to and communicate with each other. Collectively, we must create environments in which every team member (woman, family member, physician, midwife, nurse, unit clerk, patient care assistant, or scrub tech) is comfortable expressing and discussing concerns about safety or performance, is encouraged to do so, and has the support of the team to articulate the rationale for and urgency of the concern without fear of put-downs, retribution, or receiving poor-quality care.”³

5. Be persistent and proactive
When team members have differing expectations and communication styles, useful approaches include structured communication tools such as situation, background, assessment, recommendation (SBAR); structured handoffs; board rounds; huddles; attentive listening; and explicit elicitation of the patient’s concerns and desires.³

If someone fails to pay attention to a concern you raise, be persistent about restating that concern until you elicit a response.

If someone exhibits disruptive behavior, point to or establish a code of conduct that clearly describes professional behavior.

If there is a difference of opinion on patient management, such as fetal monitoring and interpretation, conduct regular case reviews and standardize a plan for notification of complications.

6. If you’re a team leader, set clear goals
Then ask team members what will be needed to achieve the outcomes desired.

“Team leaders need to develop outstanding skills for listening and eliciting feedback and cross-monitoring (being aware of each other’s actions and performance) from other team members,” note Lyndon and colleagues.³

7. Increase public awareness of safety concepts
When these concepts and best practices are made known to the public, women and families become “empowered” to speak up when they have concerns about care.

And when they do speak up, it pays to listen.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

At least half of all cases of maternal morbidity and mortality could be prevented, or so studies suggest.^1,2

The main stumbling block?

Faulty communication.

That’s the word from the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, the American College of Nurse-Midwives, and the Association of Women’s Health, Obstetric and Neonatal Nurses.³

In a joint “blueprint” to transform communication and enhance the safety culture in intrapartum care, these organizations, led by Audrey Lyndon, PhD, RN, from the University of California, San Francisco, School of Nursing, describe the extent of the problem, steps that various team members can take to improve safety, notable success stories, and communication strategies.³ In this article, the joint blueprint is summarized, with a focus on steps obstetricians can take to improve the intrapartum safety culture.

Scope of the problem
A study of more than 3,282 physicians, midwives, and registered nurses produced a troubling statistic: More than 90% of respondents said that they had “witnessed shortcuts, missing competencies, disrespect, or performance problems” during the preceding year of practice.⁴ Few of these clinicians reported that they had discussed their concerns with the parties involved.

A second study of 1,932 clinicians found that 34% of physicians, 40% of midwives, and 56% of registered nurses had witnessed patients being put at risk within the preceding 2 years by other team members’ inattentiveness or lack of responsiveness.⁵

These findings suggest that health care providers often witness weak links in intrapartum safety but do not always address or report them. Among the reasons team members may be hesitant to speak up when they perceive a potential problem:

Although Lyndon and colleagues acknowledge that it is impossible to eliminate adverse outcomes entirely or completely eradicate human error, they argue that significant improvements can be made by adopting a number of manageable strategies.³

Recommended strategies
Lyndon and colleagues describe some of the challenges of effective communication in a health care setting:

Lyndon and colleagues go on to mention a number of strategies to improve communication, boost safety, and reduce medical errors.³

1. Remember that the patient is part of the team
The patient and her family play a key role in identifying the potential for harm during labor and delivery, Lyndon and colleagues assert. Patients should be considered members of the intrapartum team, care should be patient-focused, and any communications from the patient should not only be heard but fully considered. In fact, explicit elicitation of her experience and concerns is recommended.³

2. Consider that you might be part of the problem
It is human nature to attribute a communication problem to the other people involved, rather than take responsibility for it oneself. One potential solution to this mindset is team training, where all members are encouraged to communicate clearly and listen attentively. Organizations that have been successful at improving their culture of safety have implemented such training, as well as the use of checklists, training in fetal heart-rate monitoring, formation of a patient safety committee, external review of safety practices, and designation of a key clinicianto lead the safety program and oversee team training.

3. Structure handoffs
The team should standardize handoffs so that they occur smoothly and all channels of communication remain open and clear.

“Having structured formats for debriefing and handoffs are steps in the right direction, but solving the problem of communication breakdowns is more complicated than standardizing the flow and format of information transfer,” Lyndon and colleagues assert. “Indeed, solving communication breakdowns is a matter of individual, group, organizational, and professional responsibility for creating and sustaining an environment of mutual respect, curiosity, and accountability for behavior and performance.”³

4. Learn to communicate responsibly
“Differences of opinion about clinical assessments, goals of care, and the pathway to optimal outcomes are bound to occur with some regularity in the dynamic environment of labor and delivery,” note Lyndon and colleagues. “Every person has the responsibility to contribute to improving how we relate to and communicate with each other. Collectively, we must create environments in which every team member (woman, family member, physician, midwife, nurse, unit clerk, patient care assistant, or scrub tech) is comfortable expressing and discussing concerns about safety or performance, is encouraged to do so, and has the support of the team to articulate the rationale for and urgency of the concern without fear of put-downs, retribution, or receiving poor-quality care.”³

5. Be persistent and proactive
When team members have differing expectations and communication styles, useful approaches include structured communication tools such as situation, background, assessment, recommendation (SBAR); structured handoffs; board rounds; huddles; attentive listening; and explicit elicitation of the patient’s concerns and desires.³

If someone fails to pay attention to a concern you raise, be persistent about restating that concern until you elicit a response.

If someone exhibits disruptive behavior, point to or establish a code of conduct that clearly describes professional behavior.

If there is a difference of opinion on patient management, such as fetal monitoring and interpretation, conduct regular case reviews and standardize a plan for notification of complications.

6. If you’re a team leader, set clear goals
Then ask team members what will be needed to achieve the outcomes desired.

“Team leaders need to develop outstanding skills for listening and eliciting feedback and cross-monitoring (being aware of each other’s actions and performance) from other team members,” note Lyndon and colleagues.³

7. Increase public awareness of safety concepts
When these concepts and best practices are made known to the public, women and families become “empowered” to speak up when they have concerns about care.

And when they do speak up, it pays to listen.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

At least half of all cases of maternal morbidity and mortality could be prevented, or so studies suggest.^1,2

The main stumbling block?

Faulty communication.

That’s the word from the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, the American College of Nurse-Midwives, and the Association of Women’s Health, Obstetric and Neonatal Nurses.³

In a joint “blueprint” to transform communication and enhance the safety culture in intrapartum care, these organizations, led by Audrey Lyndon, PhD, RN, from the University of California, San Francisco, School of Nursing, describe the extent of the problem, steps that various team members can take to improve safety, notable success stories, and communication strategies.³ In this article, the joint blueprint is summarized, with a focus on steps obstetricians can take to improve the intrapartum safety culture.

Scope of the problem
A study of more than 3,282 physicians, midwives, and registered nurses produced a troubling statistic: More than 90% of respondents said that they had “witnessed shortcuts, missing competencies, disrespect, or performance problems” during the preceding year of practice.⁴ Few of these clinicians reported that they had discussed their concerns with the parties involved.

A second study of 1,932 clinicians found that 34% of physicians, 40% of midwives, and 56% of registered nurses had witnessed patients being put at risk within the preceding 2 years by other team members’ inattentiveness or lack of responsiveness.⁵

These findings suggest that health care providers often witness weak links in intrapartum safety but do not always address or report them. Among the reasons team members may be hesitant to speak up when they perceive a potential problem:

Although Lyndon and colleagues acknowledge that it is impossible to eliminate adverse outcomes entirely or completely eradicate human error, they argue that significant improvements can be made by adopting a number of manageable strategies.³

Recommended strategies
Lyndon and colleagues describe some of the challenges of effective communication in a health care setting:

Lyndon and colleagues go on to mention a number of strategies to improve communication, boost safety, and reduce medical errors.³

1. Remember that the patient is part of the team
The patient and her family play a key role in identifying the potential for harm during labor and delivery, Lyndon and colleagues assert. Patients should be considered members of the intrapartum team, care should be patient-focused, and any communications from the patient should not only be heard but fully considered. In fact, explicit elicitation of her experience and concerns is recommended.³

2. Consider that you might be part of the problem
It is human nature to attribute a communication problem to the other people involved, rather than take responsibility for it oneself. One potential solution to this mindset is team training, where all members are encouraged to communicate clearly and listen attentively. Organizations that have been successful at improving their culture of safety have implemented such training, as well as the use of checklists, training in fetal heart-rate monitoring, formation of a patient safety committee, external review of safety practices, and designation of a key clinicianto lead the safety program and oversee team training.

3. Structure handoffs
The team should standardize handoffs so that they occur smoothly and all channels of communication remain open and clear.

“Having structured formats for debriefing and handoffs are steps in the right direction, but solving the problem of communication breakdowns is more complicated than standardizing the flow and format of information transfer,” Lyndon and colleagues assert. “Indeed, solving communication breakdowns is a matter of individual, group, organizational, and professional responsibility for creating and sustaining an environment of mutual respect, curiosity, and accountability for behavior and performance.”³

4. Learn to communicate responsibly
“Differences of opinion about clinical assessments, goals of care, and the pathway to optimal outcomes are bound to occur with some regularity in the dynamic environment of labor and delivery,” note Lyndon and colleagues. “Every person has the responsibility to contribute to improving how we relate to and communicate with each other. Collectively, we must create environments in which every team member (woman, family member, physician, midwife, nurse, unit clerk, patient care assistant, or scrub tech) is comfortable expressing and discussing concerns about safety or performance, is encouraged to do so, and has the support of the team to articulate the rationale for and urgency of the concern without fear of put-downs, retribution, or receiving poor-quality care.”³

5. Be persistent and proactive
When team members have differing expectations and communication styles, useful approaches include structured communication tools such as situation, background, assessment, recommendation (SBAR); structured handoffs; board rounds; huddles; attentive listening; and explicit elicitation of the patient’s concerns and desires.³

If someone fails to pay attention to a concern you raise, be persistent about restating that concern until you elicit a response.

If someone exhibits disruptive behavior, point to or establish a code of conduct that clearly describes professional behavior.

If there is a difference of opinion on patient management, such as fetal monitoring and interpretation, conduct regular case reviews and standardize a plan for notification of complications.

6. If you’re a team leader, set clear goals
Then ask team members what will be needed to achieve the outcomes desired.

“Team leaders need to develop outstanding skills for listening and eliciting feedback and cross-monitoring (being aware of each other’s actions and performance) from other team members,” note Lyndon and colleagues.³

7. Increase public awareness of safety concepts
When these concepts and best practices are made known to the public, women and families become “empowered” to speak up when they have concerns about care.

And when they do speak up, it pays to listen.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

The 65th and 66th presidents of the American College of Obstetricians and Gynecologists (ACOG) met May 4 at the College’s 2015 Annual Clinical Meeting in San Francisco to discuss highlights of the past and upcoming years. John C. Jennings, MD, outgoing president, described the “dynamic time we live in” and said his focus has been on shifting to efficient value-based health-care delivery based on ObGyns’ ability to work in multidisciplinary teams.

“What we’ve done this year is to bring together a collaborative practice task force to look at how we develop efficiently operating health care teams. And in doing that, I think, we’re going to be able to produce a model that is transportable to other specialties—not just obstetrics and gynecology but the overall delivery of women’s health care,” he said.

“We’ve had at the table with us the American College of Physicians, the American Academy of Pediatrics, colleagues in pharmacy, advanced nurse practitioners, and certified nurse midwives. We’ve also had representatives from the lay public. We have developed a document that will be polished off and published later this year,” he said. “Obviously I want that to be a living document that helps guide us—in particular, our Fellows—in developing effective team-based practice for the future.”

Mark S. DeFrancesco, MD, MBA, incoming president, noted that, with a team-based focus on practice, he will be able to “take it to the next level” and approach population health. “We need to recognize that many women patients—certainly, between the ages of 18 and 50—see their ObGyn primarily for health care. Short of an acute illness, they tend to not see other doctors.” Among the health issues that merit special attention among these women are obesity and smoking, Dr. DeFrancesco said.

“These two areas kill 780,000 people per year in this country. That’s compared to 70,000 who die from breast, uterine, ovarian, and cervical cancers. That’s a tenfold increase in deaths just from smoking and obesity. I’m saying let’s focus some of our zeal for healing on these issues, particularly if we build the teams that John’s talking about and, with our advanced practice RNs and nurse midwives, see patients more efficiently. Let’s do some real screening and attack these problems,” Dr. DeFrancesco said.

Obesity is an especially critical issue to address in obstetric care, Dr. DeFrancesco noted.

“Now there’s a whole body of knowledge developing about genetic changes that are driven by maternal and even paternal obesity,” he said. “I think that may be a lever to help us help our patients lose weight when we remind them that it’s not just about avoiding cesarean section but it’s about preventing a newborn from having a medically complicated life.”

Other issues Dr. DeFrancesco plans to address include physician burnout and dissatisfaction. “Unhappy doctors cannot provide high-quality care,” he noted.

“We’re also going to be doing a total review of our strategic plan,” he said. “It’s an awful lot to do and I’m going to see a few patients in between all these things. Fortunately, ACOG has fantastic senior management and staff, so it’s easier for me to kind of set the course and let the troops bring it the rest of the way.”

The 65th and 66th presidents of the American College of Obstetricians and Gynecologists (ACOG) met May 4 at the College’s 2015 Annual Clinical Meeting in San Francisco to discuss highlights of the past and upcoming years. John C. Jennings, MD, outgoing president, described the “dynamic time we live in” and said his focus has been on shifting to efficient value-based health-care delivery based on ObGyns’ ability to work in multidisciplinary teams.

“What we’ve done this year is to bring together a collaborative practice task force to look at how we develop efficiently operating health care teams. And in doing that, I think, we’re going to be able to produce a model that is transportable to other specialties—not just obstetrics and gynecology but the overall delivery of women’s health care,” he said.

“We’ve had at the table with us the American College of Physicians, the American Academy of Pediatrics, colleagues in pharmacy, advanced nurse practitioners, and certified nurse midwives. We’ve also had representatives from the lay public. We have developed a document that will be polished off and published later this year,” he said. “Obviously I want that to be a living document that helps guide us—in particular, our Fellows—in developing effective team-based practice for the future.”

Mark S. DeFrancesco, MD, MBA, incoming president, noted that, with a team-based focus on practice, he will be able to “take it to the next level” and approach population health. “We need to recognize that many women patients—certainly, between the ages of 18 and 50—see their ObGyn primarily for health care. Short of an acute illness, they tend to not see other doctors.” Among the health issues that merit special attention among these women are obesity and smoking, Dr. DeFrancesco said.

“These two areas kill 780,000 people per year in this country. That’s compared to 70,000 who die from breast, uterine, ovarian, and cervical cancers. That’s a tenfold increase in deaths just from smoking and obesity. I’m saying let’s focus some of our zeal for healing on these issues, particularly if we build the teams that John’s talking about and, with our advanced practice RNs and nurse midwives, see patients more efficiently. Let’s do some real screening and attack these problems,” Dr. DeFrancesco said.

Obesity is an especially critical issue to address in obstetric care, Dr. DeFrancesco noted.

“Now there’s a whole body of knowledge developing about genetic changes that are driven by maternal and even paternal obesity,” he said. “I think that may be a lever to help us help our patients lose weight when we remind them that it’s not just about avoiding cesarean section but it’s about preventing a newborn from having a medically complicated life.”

Other issues Dr. DeFrancesco plans to address include physician burnout and dissatisfaction. “Unhappy doctors cannot provide high-quality care,” he noted.

“We’re also going to be doing a total review of our strategic plan,” he said. “It’s an awful lot to do and I’m going to see a few patients in between all these things. Fortunately, ACOG has fantastic senior management and staff, so it’s easier for me to kind of set the course and let the troops bring it the rest of the way.”

The 65th and 66th presidents of the American College of Obstetricians and Gynecologists (ACOG) met May 4 at the College’s 2015 Annual Clinical Meeting in San Francisco to discuss highlights of the past and upcoming years. John C. Jennings, MD, outgoing president, described the “dynamic time we live in” and said his focus has been on shifting to efficient value-based health-care delivery based on ObGyns’ ability to work in multidisciplinary teams.

“What we’ve done this year is to bring together a collaborative practice task force to look at how we develop efficiently operating health care teams. And in doing that, I think, we’re going to be able to produce a model that is transportable to other specialties—not just obstetrics and gynecology but the overall delivery of women’s health care,” he said.

“We’ve had at the table with us the American College of Physicians, the American Academy of Pediatrics, colleagues in pharmacy, advanced nurse practitioners, and certified nurse midwives. We’ve also had representatives from the lay public. We have developed a document that will be polished off and published later this year,” he said. “Obviously I want that to be a living document that helps guide us—in particular, our Fellows—in developing effective team-based practice for the future.”

Mark S. DeFrancesco, MD, MBA, incoming president, noted that, with a team-based focus on practice, he will be able to “take it to the next level” and approach population health. “We need to recognize that many women patients—certainly, between the ages of 18 and 50—see their ObGyn primarily for health care. Short of an acute illness, they tend to not see other doctors.” Among the health issues that merit special attention among these women are obesity and smoking, Dr. DeFrancesco said.

“These two areas kill 780,000 people per year in this country. That’s compared to 70,000 who die from breast, uterine, ovarian, and cervical cancers. That’s a tenfold increase in deaths just from smoking and obesity. I’m saying let’s focus some of our zeal for healing on these issues, particularly if we build the teams that John’s talking about and, with our advanced practice RNs and nurse midwives, see patients more efficiently. Let’s do some real screening and attack these problems,” Dr. DeFrancesco said.

Obesity is an especially critical issue to address in obstetric care, Dr. DeFrancesco noted.

“Now there’s a whole body of knowledge developing about genetic changes that are driven by maternal and even paternal obesity,” he said. “I think that may be a lever to help us help our patients lose weight when we remind them that it’s not just about avoiding cesarean section but it’s about preventing a newborn from having a medically complicated life.”

Other issues Dr. DeFrancesco plans to address include physician burnout and dissatisfaction. “Unhappy doctors cannot provide high-quality care,” he noted.

“We’re also going to be doing a total review of our strategic plan,” he said. “It’s an awful lot to do and I’m going to see a few patients in between all these things. Fortunately, ACOG has fantastic senior management and staff, so it’s easier for me to kind of set the course and let the troops bring it the rest of the way.”