Predicting compliance with follow-up recommendations after colposcopy among indigent urban women.

OBJECTIVE: To determine correlates of compliance with follow-up recommendations after colposcopy. METHODS: Between October 1, 1992, and June 30, 1997, management recommendations were made to 451 consecutive women who attended a resident colposcopy clinic. Compliance was determined after 8-12 months. Correlates of compliance were assessed by univariate and multivariate analyses. RESULTS: Recommendations included repeat cytology in 6 months for 252 women, loop excision for 114, conization for 27, repeat colposcopy for 51, other for three, and not recorded for four. Rates of ever complying were 81% for loop excision, 85% for conization, 62% for repeat colposcopy, and 36% for repeat cytology. In multivariate analysis, the only significant predictors of compliance were history of genital herpes simplex infection (odds ratio [OR] 0.20; 95% confidence interval [CI] 0.05, 0.86, P = .03) and the nature of the recommendation (OR 4.73; CI 2.51, 8.92 for loop excision; OR 8.72; CI 2.57, 29.6 for conization; and OR 2.53; CI 1.30, 4.93 for repeat colposcopy, all against observation, P<.001). CONCLUSION: After colposcopy, women were more likely to comply with earlier, more intensive interventions, although the relative effect of follow-up interval and intervention could not be distinguished.     

Management of endometrioma prior to IVF: compliance with ESHRE guidelines

Management of endometrioma before IVF remains controversial. As well as some measurable benefits from surgical treatment, there are also potential risks that should be discussed with the patients to help them make an informed decision. When surgery is compared with expectant management, there appear to be no statistically significant differences in pregnancy rate and ovarian response to exogenous stimulation. The objectives of this European Society of Human Reproduction and Embryology (ESHRE)-sponsored survey were to acquire knowledge of current strategies for the management of endometrioma (>3 cm) prior to IVF and to explore adherence to ESHRE guidelines. A validated, peer-reviewed online questionnaire made of 14 questions was sent to 396 members of the ESHRE Special Interest Groups (Reproductive Surgery and Endometriosis/Endometrium), with a response rate of 27%. Surgical management is the most common treatment (82.2%), with drainage and excision of the cyst wall being the preferred surgical approach (78.5%). Monthly depot gonadotrophin-releasing hormone analogues are the preferred choice of medical treatment of endometriomas before IVF, with an average duration of treatment of 3 months. The findings demonstrate that surgery remains the commonest treatment offered for women with endometrioma before IVF. This is in line with the recommendations of the ESHRE guidelines.     

Audit of compliance with NICE guidelines on the use of tension-free vaginal tape slings for stress incontinence.

The aim of this audit was to assess adherence to the National Institute of Clinical Excellence (NICE) guidelines in inserting tension-free vaginal tape (TVT) slings for urodynamic stress incontinence, in gynaecology and urology settings in a district general hospital. It included 95 patients (79 inserted by gynaecologists and 16 by urologists) who had TVT sling insertion from 2002 until 2005, at the Royal Bournemouth Hospital. Conservative measures were tried by 43 patients (45.3%) and documentation of risk factors varied between 70% for failure and intermittent catheterisation and 1% for laparotomy and dyspareunia. Compliance was significantly better and more consent was obtained by senior medical staff when insertions were carried out by gynaecologists than when they were carried out by urologists. All insertions were carried out by consultants or under their direct supervision. The audit highlighted the need to ensure that conservative measures are tried before resorting to this minimally invasive technique and that proper patient counselling is documented on the consent form. Development of patient information leaflets and specific consent forms as well as better cooperation between gynaecologists and urologists is likely to improve compliance with the guideline.     

Obstetricians' compliance with CDC guidelines on maternal screening and intrapartum prophylaxis for group B streptococcus.

How obstetricians' opinions regarding universal screening of pregnant woman for group B streptococcus and their attitude regarding chemoprophylaxis vary from the Centres for Disease Control (CDC) guidelines were studied, and the physician characteristics that predict divergent opinions were determined. Five hundred and eighty-two obstetricians in the Flanders region of Belgium were contacted by a postal survey. Ordinal logistic regression was used to assess obstetricians' characteristics that predict divergence.Only 44% agreed with routine prenatal screening for group B streptococcus of whom 72% would screen at 35 weeks. Intrapartum prophylaxis would be done on the basis of risk factors alone in 38%. Multivariate analysis revealed significant provincial differences (best in Antwerp, worst in West-Flanders) and increasing age was associated with decreasing compliance. It is concluded that a minority of the obstetricians believes in routine prenatal screening and one-third would give prophylaxis on the basis of risk factors alone. Obstetrician's age and province of practice predict divergent opinions.     

Influenza vaccination during pregnancy and factors for lacking compliance with current CDC guidelines

Background.?The Center for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists (ACOG) recommend influenza vaccination for all pregnant women during the influenza season. However, the actual rate of vaccination is substantially below the target levels. Given the recent emergence of novel influenza strains, there is an important need to address knowledge gaps in women and their healthcare providers to improve vaccination coverage for pregnant women during inter-pandemic and pandemic periods. This study attempted to identify potentially remediable attitudinal factors among women and their physicians that may present barriers to influenza vaccination and then assess the impact of interventions to increase the influenza vaccination rate in pregnant women.

Methods.?This prospective study initially analyzed patient and physician knowledge regarding the influenza vaccine in pregnancy and then examined the impact of several interventions aimed to increase immunization rates implemented over the following year. Influenza vaccination rates were assessed before and after the interventions.

Results.?Five hundred twenty patients were enrolled in the study during the influenza season 2007/2008. Only 19% of those patients reported receiving the influenza vaccination and only 28% recalled that the vaccine was offered. Following this, in the summer and fall of 2008, we performed a physician education program and distributed posters advertising the influenza vaccine to all offices offering prenatal care in our area in order to increase patient awareness of the need for the vaccine. In the following influenza season, we again reassessed the vaccination rate and patient's knowledge and awareness of the vaccine in 480 postpartum women. Influenza vaccination rates increased from 19% to 31%. After the intervention, 51% of patients recalled that the vaccine was offered to them during the pregnancy as opposed to only 28% the year prior.

Conclusion.?Understanding the specific barriers to vaccination that our population faced was helpful in designing the interventions to improve knowledge and acceptance of influenza vaccination in pregnancy, which led to an increased vaccination rates in women.     

Modelling the cost-effectiveness and capacity impact of changes to colposcopy referral guidelines for women with mild dyskaryosis in the UK Cervical Screening Programme

Objective  To evaluate the capacity implications and health economic impact of new guidelines recommending referral to colposcopy after one mild result during cervical screening rather than after two consecutive mild results.
Design  A mathematical model of the country's colposcopy services and the clinical pathways from smear result through to treatment is constructed. The model incorporates national questionnaire data on referral numbers and management practices, routine data and published research results.
Setting  All English NHS colposcopy services.
Population  Women aged 25 to 64 years.
Methods  The national average workload impact of the change in referral guidelines is predicted, and the impact in differing local circumstances is evaluated within the model. A long-term health economic model examines the resulting costs and predicted change in quality-adjusted life years (QALYs).
Main outcome measures  Colposcopy workload implications for single mild dyskaryosis referral and cost per QALY analysis.
Results  We found that single mild dyskaryosis referral implies, on average, a 21% increase in colposcopy workload for services not currently operating this policy. The health economic model predicted a cost per QALY gained as a result of the implementation of the new referral guidelines of around £7,500.
Conclusions  Referral after one mild result will increase workload at colposcopy; however, it may be possible to counterbalance the additional workload by altering other clinical practice. The change to referral guidelines would be considered cost-effective in comparison with many interventions routinely available on the NHS.     

Evaluation of abnormal cervical cytology during pregnancy with colposcopy.

During a 6 1/2 year study period the authors used colposcopy to evaluate 174 pregnant patients with abnormal cervical cytology. The technique of colposcopy proved safe, accurate, and effective in determining the presence or absence of cervical cancer in the present patient's cervix. Colposcopy is mandatory for the evaluation of abnormal cervical cytology during pregancy.     

The value of human papillomavirus testing in the colposcopy clinic.

The aim of the study was to investigate if human papillomavirus (HPV) testing can help in treatment and management decision-making in patients referred to the colposcopy clinic with mildly dyskaryotic or borderline smears. Fifty-five patients referred to the colposcopy clinic in Benenden Hospital with mildly dyskaryotic or borderline smears had HPV testing in addition to colposcopy. Twenty-eight patients had a negative HPV test and normal colposcopy and were discharged back to their general practitioners for cytological surveillance. The most recent smear results of these 28 patients were obtained from their general practitioners to assess if any patient had progressed to a higher-grade smear. Twenty-one (75%) replies were obtained and in 17 (80.9%) patients smear results had regressed to normal. Three continued to have borderline or mildly dyskaryotic smear and one had progressed to moderate dyskaryosis. Our conclusion was that in the presence of normal colposcopic findings in patients with mildly dyskaryotic or borderline smears, negative HPV status justifies referral back to the general practitioner for cytological surveillance, thus reducing workload and cost.     

Intrapartum fetal surveillance: review of three national guidelines

Evidence-based guidelines regarding intrapartum fetal surveillance from three countries (United States, Canada, and Australia/New Zealand) were reviewed. The similarities in the three national guidelines (purported etiology, management of periodic changes, and intermittent auscultation for low-risk women) are understandable. Differences in recommendations (role of fetal admission test, amnioinfusion for variable decelerations, scalp pH, umbilical arterial acid-base status, and education in interpretation of fetal heart tracing) are not explained. The likelihood of recommendations being categorized as level A differed for the countries: United States, 41% (7/17); Canada, 18% (3/17); and Australia and New Zealand, 17% (2/12). Only one publication was cited by all three guidelines. To avoid confusion and possibly enhance their quality, national guidelines should acknowledge the presence of others on the same topic, and if there are differences then provide explanations for dissimilarities.     

Objective perspective in colposcopy

Colposcopy is a widely used diagnostic procedure, primarily in the assessment of women with abnormal cervical cytology. It is used by appropriately trained individuals using techniques that allow a full assessment of the abnormality and plan for further investigation or treatment. Certain key features are specifically looked for, and a colposcopic impression formed. Using a systematic approach to the colposcopic assessment can improve the diagnostic accuracy. In this chapter, we review various factors and meta-analyses in relation to the diagnostic performance of colposcopy. Newer technologies are being developed that will assist the clinician in assessing the colposcopic changes. Quality assurance of the training and practise of colposcopy is important to maintain appropriate management for women with cytological abnormalities.     

Patient compliance with the first newborn visit appointment.

OBJECTIVE: To analyze patient compliance regarding the first newborn visit after hospital discharge. STUDY DESIGN: We selected at random 640 charts over a 1-year period from two community hospitals of healthy term newborns who were cared for by four practices in Kalamazoo, MI. We collected demographic data from the hospital chart and recorded the discharge order for time of posthospital follow-up. We then accessed the individual clinics' appointment logs to determine when the patient came for the first visit. Lateness was defined as appearance for appointment >24 hours after the time stated on the hospital discharge order. We studied patient lateness with respect to the clinic, maternal age, insurance status, and distance from the patient's home to the medical facility, using both univariate and multivariate analyses. RESULTS: We demonstrated a significant difference in lateness of the first appointment between Medicaid and non-Medicaid patients in both the univariate (p<0.001) and multivariate (p=0.0003) analyses. We also demonstrated significant differences in the univariate analysis in patient lateness among the different practices (p<0.001) as well as lateness with regard to maternal age (p=0.0009). We did not attain significance in either analysis for patient lateness with regard to distance of home from the medical facility, or the hospital in which the baby was born. CONCLUSION: We demonstrated a need to improve upon newborn follow-up from the hospital and suggest strategies for other communities to analyze the process and improve upon patient and practice compliance with that first appointment.     

Accuracy of colposcopy in the diagnostic setting compared with the screening setting

OBJECTIVE: To estimate the accuracy of colposcopy to identify cervical precancer in screening and diagnostic settings. METHODS: As part of a larger clinical trial to evaluate the diagnostic accuracy of optical spectroscopy, we recruited 1,850 patients into a diagnostic or a screening group depending on their history of abnormal findings on Papanicolaou tests. Colposcopic examinations were performed and biopsies specimens obtained from abnormal and normal colposcopic sites for all patients. The criterion standard of test accuracy was the histologic report of biopsies. We calculated sensitivities, specificities, likelihood ratios, receiver operating characteristic curves, and areas under the receiver operating characteristic curves. RESULTS: The prevalence of high-grade squamous intraepithelial lesions (HSIL) or cancer was 29.0% for the diagnostic group and 2.2% for the screening group. Using a disease threshold of HSIL, colposcopy had a sensitivity of 0.983 and a specificity of 0.451 in the diagnostic group when the test threshold was low-grade squamous intraepithelial lesions (LSIL), and a sensitivity of 0.714 and a specificity of 0.813 when the test threshold was HSIL. Using the same HSIL disease threshold, in the screening group, colposcopy had a sensitivity of 0.286 and a specificity of 0.877 when the test threshold was LSIL, and a sensitivity of 0.191 and a specificity of 0.961 when the threshold was HSIL. The colposcopy area under the receiver operating characteristic curve was 0.821 (95% confidence interval 0.79-0.85) in the diagnostic setting compared with 0.587 (95% confidence interval 0.56-0.62) in the screening setting. Changing the disease threshold to LSIL demonstrated similar patterns in the tradeoff of sensitivity and specificity and measure of accuracy. CONCLUSION: Colposcopy performs well in the diagnostic setting and poorly in the screening setting. Colposcopy should not be used to screen for cervical intraepithelial neoplasia. LEVEL OF EVIDENCE: II.     

Intrapartum fetal surveillance: Summary of four national evidence-based guidelines and need to develop Indian guidelines

Introduction

There are more deliveries in India than any country in the world, according to World Health Report. Review of seven articles published in The Journal of Obstetrics and Gynecology of India suggests that the perinatal mortality (PNM) in the country is 92/1,000 (16,339/177,998) births and the cause is asphyxia in about one fourth of the cases.

Methods

We reviewed the evidencebased guidelines on intrapartum fetal surveillance from four countries (UK, USA, Canada, and Australia/New Zealand).

Results

Overall there were 72 recommendations and whether they were level A, B, C, or D varied significantly (p=0.021) for the four national guidelines. The composite summary of these recommendations indicates that no single guideline is comprehensive, the composite may be better than any singular.

Conclusion

Each country needs its own recommendations to ameliorate the PNM. Accounting for the varied setting childbirths occurring in the country, a national guideline for clinicians in India may decrease the PNM secondary to asphyxia.