Ambulatory Gynecology Research Articles

Telehealth Care in a Pediatric and Adolescent Gynecology Clinic During the COVID-19 Pandemic

Since the onset of the COVID-19 pandemic, healthcare systems have increased their telehealth services to meet the changing public health needs. Prior to the pandemic, telehealth was used primarily in surgical specialties for post-op visits and rural medicine. However, out of necessity, nearly all medical and surgical subspecialties incorporated this virtual technology to improve patient access in healthcare access limited time. Few studies have addressed telehealth in Pediatric and Adolescent Gynecology (PAG) to date. To describe the large-scale utilization of telehealth visits and assess patient experience and improve access to care in a large academic ambulatory gynecology PAG clinic. This retrospective, cross-sectional quality improvement study was performed by administering patient surveys and compiling aggregate data from the EPIC electronic health record (EHR) in the Division of Pediatric and Adolescent Gynecology (PAG) clinics at a single children's hospital between March 2020 and March 2021. Patient demographics, payer characteristics, visit type and purpose, and patient experience were reviewed. Wider expansion of telehealth in PAG clinics at a single institution RESULTS: : A total of 6,159 telehealth appointments were performed, involving 6 clinic sites and 9 providers. Telehealth visits comprised 50% of the total ambulatory volume (12,527). Most patients were located within the institution's state (99.5%), and the remaining called into their telehealth visits from a neighboring state. Most patients were 18 years of age or younger (73%). Video visits lasted 15-30 minutes and included routine follow-up (66.3%), new/consult (28.4%), post-op (1.6%), and urgent follow-up (0.2%). The patient population was ethnically diverse by self-identification: 61.4% White, 38.4% Hispanic, 16% Black, 4.4% Asian, 0.40% Native Hawaiian/American Indian/Alaska Native. Payor mix included self-pay (45.5%), private payer (32.2%), and Medicaid/CHIP (22.3%). Conditions seen ranged from menstrual management (71%) and routine preventative or acute gynecologic concerns (21%) to surgical evaluation for congenital anomalies, endometriosis, fertility preservation, genital concerns or pelvic masses (8%). Telehealth visits met patient expectations in 87.3% of respondents. Patient-reported opportunities for improvement included: improving set-up instructions and more consistent audio/video connections. Challenges identified by providers included: difficulty utilizing interpreters, technology limitations, and privacy constraints during HEADSS examination. This study demonstrates how a large, diverse volume of patients with PAG needs received appropriate care through a telehealth format during the COVID pandemic. Patients were satisfied with the services, but opportunities for improvement were elicited to allow for continued refining of this healthcare delivery tool in the future.

Sleep Habits of Women With Infertility.

Sleep plays important roles in metabolic and reproductive function, and polycystic ovary syndrome (PCOS) is associated with sleep disturbances, including increased prevalence of obstructive sleep apnea. We sought to evaluate sleep parameters in infertile women with PCOS compared with women with unexplained infertility (UI) and identify risk factors for disturbed sleep. At private and academic ambulatory gynecology and infertility practices, we evaluated a prospective cohort of women diagnosed with PCOS or UI from 2 randomized clinical trials. We included 1603 infertile women enrolled in 2 concurrent randomized clinical trials. The main outcome measures were self-reported sleep measures. Sleep duration <6 hours (6.1% vs 2.7%; P < .001), habitual snoring (37.8% vs 19.0%; P < .001), and clinical sleepiness (12.0% vs 8.6%; P < .026) were more common in women with PCOS than those with UI. After adjusting for covariates, PCOS and elevated fasting insulin were associated (P = .010) with clinical symptoms of obstructive sleep apnea (OSA) diagnosis, whereas PCOS, elevated insulin (P = .003), WC >88 cm (P = .003), and current smoking (P = .012) were associated with habitual snoring. Clinical depression score (P < .001) and PCOS diagnosis (P = .002) were associated with perceived daytime sleepiness. Short sleep duration and clinical symptoms of OSA were not associated with conception and live birth rates. Infertile women with PCOS more commonly report sleep disturbances than those with UI. Markers of insulin resistance are associated with previous diagnosis of OSA, habitual snoring, and short sleep duration. The presence of clinical symptoms of OSA or short sleep duration does not affect fertility treatment response.

2495 A Retrospective Review of Outpatient Endometrial Ablation Using Minitouch for Treatment of Heavy Menstrual Bleeding

Study Objective To determine the outcomes of using Minitouch endometrial ablation as outpatient treatment for heavy menstrual bleeding (HMB) at an established ambulatory gynecology center in a UK teaching hospital. Design Retrospective cohort study. Setting Procedures were performed as outpatient at Central Treatment Suite at Royal Stoke University Hospital, as per department-approved protocol by one of six gynecology consultants. Patients were reviewed from 4 months post-op at consultation or by telephone. Patients or Participants Between March 2017 and March 2019, 35 patients with HMB who opted for outpatient endometrial ablation received the treatment. Interventions Minitouch without/with intracervical local anesthesia. Diagnostic outpatient hysteroscopy +/- endometrial sampling was performed immediately before treatment procedure confirming suitability. Where present, intrauterine device was removed before ablation. Patients were not selected for timing of their menstrual cycle and received no endometrial pre-treatment. Measurements and Main Results In 24 months, 35 patients received treatment. Average patient age was 46 (range 31-55). One patient was nulliparous, 9(26%) had previous caesarean section, 30(86%) received previous treatment for HMB. Utero-cervical length ranged from 6-10cm. Histology confirmed normal endometrium in all cases. Procedure was well tolerated overall with no failure of equipment. Average treatment time was 145s (Range 33-229s). Vasovagal episode was the only observed peri-operative complication (2/35, 5.7%) requiring conservative management. No uterine perforation occurred. No patient required emergency hospital admission post-op. To date, 22 patients were reviewed. Average time to follow-up was 4.9 months. 91% reported satisfactorily improved bleeding patterns including amenorrhea or oligomenorrhoea (14/22, 64%) and less HMB (6/22, 27%). 9% reported same or worsened bleeding requiring further management. Conclusion With its flexibility and smaller size over other devices minimizing the need for cervical dilatation and patient discomfort, the use of Minitouch for outpatient treatment of HMB at our center was shown to be well-tolerated, with high reliability of procedure completion, good safety and efficacy outcomes.

Malpractice Risk and Vulnerabilities Ambulatory Obstetrics and Gynecology Practice [6I

INTRODUCTION: Malpractice claims may play an important role in the high cost of health care and may provide a lens through which patient’s perspectives of healthcare deficiencies are revealed. Learning from potential mistakes - or from the patient’s perception of harm - can help to identify areas for improvement in patient care. METHODS: This is a retrospective cohort study of claims from the CRICO Strategies National Comparative Benchmarking System (CBS) for malpractice cases asserted during the period 2006 and 2016. Cases selected for this analysis were open and closed malpractice claims and lawsuits from obstetric outpatient claims. Cases meeting selection criteria were qualitatively analyzed to determine contributing factors prompting harm and/or perceived harm. RESULTS: Of the 113,932 malpractice claims during this ten year period, 2,730 were obstetric-related, 548 originated within the outpatient setting, and 296 were associated with severe patient harm and/or death. Of these 296 claims, the top 5 contributing factors leading to the filing of the claim were perceived lapse of clinical judgment (45%), ineffective communication (25%), poor documentation (14%), clinician behavior related (11%), and clinical systems breakdown (11%). CONCLUSION: This review provides insight into vulnerabilities within the outpatient obstetrics setting and identifies areas for improvement. To provide safe and effective care, clinicians and administrators need to understand malpractice vulnerabilities and develop strategies to reduce risk. Our data suggests that the development of training or tools to support clinical decision making, communication strategies, and appropriate documentation are priority areas to reduce malpractice risk in the outpatient obstetrics setting.

Endometrial Biopsy: American College of Nurse-Midwives.

Endometrial biopsy can be used to diagnose endometrial hyperplasia, endometrial cancer, and uterine infections. This cost-effective procedure has minimal side effects, and complications are rare. The purpose of this clinical bulletin is to provide clinicians with guidance about endometrial biopsy including the procedure's advantages and disadvantages, indications and contraindications, and side effects. In addition, step-by-step instructions for performing endometrial biopsy, the equipment required, selection of sampling devices, and care before and after the procedure are discussed.

Satisfaction With an Electronic Feedback Tool for the OBGYN Clerkship

Local Mentor: Bruce Meyer, MD, MBA APGO Advisor: Alice R. Goepfert, MD PURPOSE: To develop an electronic feedback tool and evaluate clerkship student and faculty satisfaction. BACKGROUND: Provision of formative feedback during clerkships is mandated by the Liaison Council on Medical Education as important in the development of clinical competence. A common concern in medical student education is the dichotomy wherein faculty believe that feedback has been provided but students do not recognize feedback was given. There is need for a simple tool that documents and collects feedback. No recent literature has cited use of an electronic feedback tool. METHODS: An electronic feedback tool, using elements of the AAMC Entrustable Professional Activities, was developed following a needs assessment survey administered to students and ObGyn faculty. This tool, housed on a secure institutional website, was available to both clerkship students and faculty using smartphone, tablet or computer. The project was IRB exempt. EVALUATION PLAN: The electronic tool was offered at family planning and ambulatory gynecology clinics to 31 clerkship students and the 11 attending faculty. Thirty student satisfaction surveys and 7 faculty satisfaction surveys were collected. Satisfaction with the electronic tool was assessed using an online survey. Sixty percent of students and 100% faculty were neutral or dissatisfied with the electronic tool. Commonly cited issues were electronic access problems and adequacy of training. DISSEMINATION: Information in this survey will be helpful in the further development of electronic tools in the clinical setting. REFLECTIVE CRITIQUE: Future development will need to incorporate strategies to enrich faculty training and improve access.

A patient-preference cohort study of office versus inpatient uterine polyp treatment for abnormal uterine bleeding

Uterine polyps can cause abnormal bleeding in women. Conventional practise is to remove them under general anaesthesia but advances in technology have made it possible to perform polypectomy in the office setting. We conducted a patient-preference study to explore women’s preferences for treatment setting and to evaluate the effectiveness and treatment experience of women undergoing uterine polypectomy. Three hundred ninety-nine women with abnormal uterine bleeding who were found to have uterine polyps at diagnostic hysteroscopy were recruited. Office polypectomies were performed in office hysteroscopy clinics, and inpatient procedures were undertaken in operating theatres. Three hundred twenty-four of 399 (81 %) expressed a preference for office treatment. There was no difference found between office treatment and inpatient treatment in terms of alleviating abnormal uterine bleeding as assessed by patients and in improving disease-specific quality of life. Acceptability was lower and patient pain scores were significantly higher in the office group. When offered a choice of treatment setting for uterine polypectomy, patients have a preference for office over inpatient treatment. Ambulatory gynaecology services should be available within healthcare systems to meet patient demand.

Interpersonal Violence Screening for Ambulatory Gynecology Patients

Interpersonal Violence Screening for Ambulatory Gynecology Patients

Interpersonal Violence Screening for Ambulatory Gynecology Patients

To estimate the effects of patient and health care provider variables on rates of interpersonal violence screening in an ambulatory gynecology practice. A cross-sectional study of 300 patients were chosen randomly from annual health care visits during 2007 at a university-affiliated ambulatory gynecology clinic. All encounters were recorded on a standardized health history form, which included questions about abuse history. Data on patient and health care provider characteristics were collected. The association of health care provider screening with selected patient variables was assessed using multivariable logistic regression. The median age of the study population was 29 years (range 15-73 years). The cohort was racially and ethnically diverse, and the majority was on government assistance. Sixty-seven percent (194 of 291) had children living at home, and 57% (164 of 286) were single. Of the 300 patients, 243 (81%) had documentation of abuse screening in their medical records. Variables previously found to be associated with higher rates of partner abuse such as younger age or increased parity did not influence whether patients were screened. Similarly, differences in screening by health care provider type (nurse practitioner or resident) or health care provider gender did not emerge. Patients were, however, significantly more likely to be questioned about partner violence when they received other preventive screening (adjusted odds ratio 2.50, 95% confidence interval 1.26-4.99) or presented with a somatic pain complaint (adjusted odds ratio 2.55, 95% confidence interval 1.12-5.83). Ambulatory gynecology patients were more likely to be screened for interpersonal violence when health care providers performed other preventive health screening using a standardized health history form. II.

Book Reviews

Published by the Royal College of Obstetricians and Gynaecologists, this book discusses a relatively new outpatient, ‘one-stop’ approach to gynaecological treatments; an approach originating in the USA. The aim of ambulatory gynaecology is to reduce costs in the treatment of women with common gynaecological complaints, while at the same time increasing satisfaction through the reduction of waiting times and inpatient hospital stays. Using established care pathways, national guidelines and good practice it is argued that setting up ambulatory gynaecological services would be reasonably simple and cost-effective. This patient-centred, cost-conscious approach to service delivery fits well with targets across all of the devolved government areas in the UK.

Change in knowledge of women about cervix cancer, human papilloma virus (HPV) and HPV vaccination due to introduction of HPV vaccines

Objectives Test knowledge of HPV, cervix cancer awareness and acceptance of HPV vaccination of women now and a year ago. Study design Questionnaires were filled out by 305 women visiting four gynaecologists of the Regional Hospital Heilig Hart, Tienen, Belgium during two subsequent weeks. Fisher T or Chi 2 were used as statistical methods to compare the data with the survey of 381 women exactly one year before. Results Knowledge about HPV as a cause of cervix cancer and the presence of a vaccine rose from roughly 50% in 2007 to over 80% in 2008 ( p < 0.0001). Level of education and having daughters, sons or no children no longer influenced the level of knowledge or willingness to accept the vaccine. Most parents favor the age group 12–16 years as an ideal time for vaccination. In contrast with the 2007 survey, women below 26 years had now acquired almost equivalent knowledge to older women about the virus, cervix cancer and the vaccine, but they were far less likely to accept the vaccine due to its cost, unless it would be reimbursed (OR 4.2 (1.6–11) p = 0.0055). Conclusion One year after introduction of the first two HPV vaccines, over 75% of women attending an ambulatory gynaecology clinic know HPV causes cervix cancer and that you can get vaccinated against it. Compared with a year earlier, young and lower educated women had dramatically improved their knowledge. However, women below 26 years are less prepared to pay the cost for vaccination if it is not reimbursed.

Medical student evaluation of teaching quality between obstetrics and gynecology residents and faculty as clinical preceptors in ambulatory gynecology

This study was undertaken to compare teaching quality between obstetrics/gynecology resident and faculty preceptors in ambulatory gynecology as determined by medical student evaluation. A prospective assessment of medical student evaluations of resident and faculty preceptors in ambulatory gynecology was conducted at Brigham and Women's Hospital. Forty-eight third-year medical students evaluated preceptors on 15 teaching quality items and recorded their clinical experience during their obstetrics/gynecology clerkship from July 2004 to June 2005 for a total of 138 evaluations. Faculty scores were statistically higher than resident scores on 4 of the 15 teaching quality items; acting as an appropriate clinical role model, emphasizing evidence-based learning, being enthusiastic about teaching and patient care (P < .05). Students performed significantly more Papanicolaou tests and pelvic and breast examinations during ambulatory sessions with residents than with faculty (P < .001). Residents and faculty contribute important and different aspects of teaching experiences for medical students in ambulatory gynecology.

Ambulatory gynaecology: a new concept in the delivery of healthcare for women

Ambulatory gynaecology is a concept that combines ‘one stop’ clinics and ‘day surgery’ operations as an alternative to traditional out patient consultations and in patient surgery. This management philosophy shortens the care pathway for patients and saves resources. In order to deliver this service, gynaecologists will have to learn new skills and accept different ways of working where they are part of a multidisciplinary team rather than acting as a lone consultant skilled in every aspect of gynaecology. The concept of Ambulatory Gynaecology is in keeping with the strategic vision set in the NHS delivery plan. Therefore, a unique opportunity to trasnsform healthcare for women in the UK currently exists.

Teaching residents coding and documentation: Effectiveness of a problem-oriented approach

We sought to assess the effectiveness of a problem-oriented approach to teaching residents accurate coding and documentation of ambulatory gynecology visits. This was a pilot before-and-after study. Nine resident volunteers underwent 4 individual instructional sessions on coding and documentation with a trained faculty member over 6 weeks. Outcomes were assessed by comparing the appropriateness of procedure and diagnostic codes billed in participant continuity clinic prior to and in the 6 to 9 months following the intervention. Following the intervention, participants demonstrated an increase in the accuracy of coding the correct category of the evaluation and management service, an increase in the appropriate use of modifiers, and a decline in undercoding errors. Problem-oriented interactive learning appears to be an effective method of teaching residents proper coding and documentation.

Lower genital tract infection and endometritis: insight into subclinical pelvic inflammatory disease

OBJECTIVE: To investigate the association between lower genital tract infections and subclinical PID. Fallopian tube damage is a common complication of acute symptomatic pelvic inflammatory disease (PID), yet most women with tubal factor infertility do not have a history of acute PID. Subclinical PID is believed to be an important cause of tubal factor infertility. METHODS: We conducted a cross-sectional study among women attending a sexually transmitted diseases or ambulatory gynecology clinic. A convenience sample of 556 women with bacterial vaginosis, gonorrhea, or chlamydia, or women at risk for gonorrhea or chlamydia were enrolled. Women diagnosed with acute PID were not eligible to participate. The main outcome was subclinical PID, as defined by the presence of histologic endometritis. RESULTS: Subclinical PID was more common in women with lower genital tract infection than in uninfected women. Subclinical PID was present in 27% of women with Chlamydia trachomatis (odds ratio 3.4; 95% confidence interval [CI] 1.8, 6.3) and in 26% of women infected with Neisseria gonorrhoeae (odds ratio 2.4; 95% CI 1.1, 5.1). Among women with bacterial vaginosis, 15% had endometritis (odds ratio 2.7; 95% CI 1.02, 7.2). CONCLUSION: Subclinical PID is common among women with lower genital tract infections. Additional prospective studies are necessary to determine the reproductive impact of these asymptomatic upper genital tract infections.

Prevalence and Incidence of Domestic Violence in an Ambulatory Gynecology Population and Associated Risk Factors

Prevalence and Incidence of Domestic Violence in an Ambulatory Gynecology Population and Associated Risk Factors

Prevalence and incidence of domestic violence in an ambulatory gynecology population and associated risk factors

Objective: To determine the prevalence and incidence of domestic violence in an ambulatory gynecology population and to describe risk factors associated with abuse. Methods: All patients presenting for initial ambulatory gynecology care at an urban private practice over 1 year were asked by a physician about the occurrence of domestic violence using a modified abuse assessment screen (AAS). The prevalence and incidence of physical, emotional, and sexual abuse were calculated. The patient’s records were abstracted for demographic and medical variables. Associations between these variables and the prevalence of abuse were analyzed. Results: Four hundred forty-three women were interviewed. No woman refused to answer the AAS. Among 424 women with completed AASs, 72 (16.2%) reported some form of domestic violence in the past. Among ever-abused women, 46 out of 72 (63.8%) reported physical abuse, 12 (16.6%) reported emotional abuse, and 4 (5.6%) reported sexual abuse. The incidence of physical abuse was 1.6%. In univariate analysis, risk factors associated with lifetime abuse included age greater than 40 ( P = 0.006), non-single status ( P = 0.003), black race ( P = 0.006), history of depression ( P = 0.0001), and sexual inactivity ( P = 0.007). A history of depression ( P = 0.001) and black race ( P = 0.01) were the only factors associated with a past history of domestic abuse in regression analysis. Conclusions: The prevalence of domestic abuse ascertained by the AAS in an ambulatory gynecology setting is high. Demographic and health factors do not accurately predict a history of domestic abuse. Screening of all patients for domestic violence should be a routine part of ambulatory gynecologic care.

Ambulatory gynecology.

Ambulatory gynecology.

Ambulatory Gynecology

Ambulatory Gynecology

Primary Care Internal Medicine Training and Women's Health

In this study, directors of primary care residency programs were sent a questionnaire that asked for information about their program and examined their perceptions of program curricula and resident mastery of seven preselected topics in women's health. An elective ambulatory gynecology experience was offered in 52% of programs, and 35% of programs had all residents experience such a rotation. All seven selected topics were felt to be important for residents to master, but the prevalence of structured teaching experiences and resident mastery for each topic varied widely. For the majority of programs, domestic violence was not a curricular component. However, 44% of respondents spontaneously commented that they were expanding their curriculum in the area of women's health.