Use of hospital discharge data to monitor uterine rupture--Massachusetts, 1990-1997

Uterine rupture (UR), a potentially life-threatening condition for both mother and infant, occurs in <0.1% of all pregnant women and <1% of women attempting vaginal birth after cesarean section (VBAC) (1-4). During 1990-1997, the proportion of vaginal deliveries among women who had previous cesarean sections (CS) in Massachusetts increased 50%, from 22.3% to 33.5% (5). Concern about a corresponding increase in UR prompted the Massachusetts Department of Public Health and CDC to initiate a state-wide investigation that included an assessment of the validity and reliability of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) (6), codes in hospital discharge data to identify UR cases. This report summarizes the results of the investigation, which indicate that ICD-9-CM codes related to UR, designed before increased concern about UR, lack adequate specificity for UR surveillance and have not been applied consistently over time.     

Endometrial resection in the treatment of persistent metrorrhagia

STUDY OBJECTIVE: To evaluate the efficacy of hysteroscopic endometrial resection such us a surgical alternative to hysterectomy in treating abnormal uterine bleeding unresponsive to treatment with progestogens. METHODES: A retrospective analysis was carried out on 54 patients who underwent endometrial ablation for abnormal uterine bleeding unresponsive to conservative medical management between January 1, 1991, and December 31, 1998. The average patient was 43 years (Range: 36-57 years) and was followed for a mean of 37 months (range 12-80 months). RESULTS: 83.3% of women were satisfied during the study period. The overall amenorrhea rate was 29.62%. Only 16.66% of subjects reported no improvement. Histologic analysis of the endomyometrial specimens revelated hyperplasia in 48.1% of cases, atrophy in 3.7% of cases and adenomyosis in 44.6% of cases. 8 women (14.8%) needed secondary hysterectomy for continued symptoms during a mean follow up of 10 months. Adenomyosis was present in 4 specimens (50%), myomas in 3 specimens (37.5%), and the association in 1 specimen (12.5%). CONCLUSION: Endometrial ablation is a safe and effective hysteroscopic procedure for dysfunctional uterine bleeding, its prognosis depends of several factors, that shows the importance of patients selection.     

Hysterectomy and socioeconomic position in Rome,Italy

STUDY OBJECTIVE: There exists conflicting evidence regarding the higher risk of hysterectomy among women of a lower educational and economic level. This study aims to assess whether in Italy socioeconomic level is related to hysterectomy undertaken for different medical reasons. DESIGN: An area based index was used to assign socieconomic status (SES; four levels defined) to 3141 women (aged 35 years or older) who underwent a hysterectomy in 1997 and were residing in Rome. Data were taken from hospital discharge records. Direct age standardised hospitalisation rates by SES level were calculated for overall hysterectomies and for those performed for either malignant or non-malignant causes. Statistical differences were detected using the ratios of standardised rates and the test for linear trend. MAIN RESULTS: The hysterectomy rate was 36.7 per 10 000 women aged 35 years or more. Hysterectomy for uterine leiomyoma accounted for 41% of all operations and was more frequent among women aged 35-49 years than for those aged 50 years or more (crude rates: 28.6 and 7.7 per 10 000, respectively). The risk of hysterectomy was 35% higher for the lowest SES group, compared with the highest group. No association was found between SES and hysterectomy rates for malignant causes, although less affluent women in age group 35-49 years had 87% higher risk of hysterectomy compared with most affluent women. The inverse association between SES and hysterectomy rates attributable to non-malignant causes was statistically significant for women aged 35-49 years but not for those aged 50 years or more. CONCLUSIONS: The inverse relation between hysterectomy and SES is largely attributable to benign disorders of the uterus, namely leiomyoma and prolapse. More affluent women may have a greater uptake of less invasive techniques for removing uterine leiomyoma compared with less affluent women, who are more likely to undergo unnecessary hysterectomies irrespective of their reproductive age.     

Outpatient mastectomy: clinical, payer, and geographic influences

OBJECTIVE: To determine (1) the use of outpatient services for all surgical breast procedures for breast cancer and (2) the influence of payer and state on the use of outpatient services for complete mastectomy in light of state and federal length-of-stay managed care legislation. DATA SOURCES: Healthcare Cost and Utilization Project representing all discharges from hospitals and ambulatory surgery centers for five states (Colorado, Connecticut, Maryland, New Jersey, and New York) and seven years (1990-96). STUDY DESIGN: Longitudinal, cross-sectional analyses of all women undergoing inpatient and outpatient complete mastectomy (CMAS), subtotal mastectomy (STMAS), and lumpectomy (LUMP) for cancer were employed. Total age-adjusted rates and percentage of outpatient CMAS, STMAS, and LUMP were compared. Independent influence of state and HMO payer on likelihood of receiving an outpatient CMAS was determined from multivariate models, adjusting for clinical characteristics (age < 50 years, comorbidity, metastases, simple mastectomy, breast reconstruction) and hospital characteristics (teaching, ownership, urban). PRINCIPAL FINDINGS: In 1993, 1 to 2 percent of CMASs were outpatient in all states. By 1996, 8 percent of CMASs were outpatient in Connecticut, 13 percent were outpatient in Maryland, and 22 percent were outpatient in Colorado. In comparison, LUMPs were 78 to 88 percent outpatient, and by 1996, 43 to 72 percent of STMASs were outpatient. In 1996, women were 30 percent more likely to receive an outpatient CMAS in New York, 2.5 times more likely in Connecticut, 4.7 times more likely in Maryland, and 8.6 times more likely in Colorado compared to New Jersey. In addition, women with Medicare, Medicaid, or private commercial insurance were less likely to receive an outpatient CMAS compared to women with an HMO payer. CONCLUSIONS: LUMP is an outpatient procedure, and STMAS is becoming primarily outpatient. CMAS, while still primarily inpatient, is increasingly outpatient in some states. Although clinical characteristics remain important, the state in which a woman receives care and whether she has an HMO payer are strong determinants of whether she receives an outpatient CMAS.     

宫内节育器术时子宫内膜细胞学检测600例分析

目的:探讨不同状态子宫内膜对不同宫内节育器(IUD)的临床反应。方法:应用子宫内膜细胞采集器在募集对象放置宫内节育器时采取子宫内膜组织制片,样本集中寄往北京大学附属医院妇产科宫腔细胞学检测中心统一专人阅片。结果:普通人群与高危因素人群对比,术前子宫内膜细胞良性增生性改变及不典型增生性改变发生率差异均有统计学意义(P<0.05),术后常见不良反应发生率差异均无统计学意义(P>0.05);术前子宫内膜状态为良性增生性改变及与不典型增生性改变的人群放置IUD后不良反应发生率明显高于未见异常细胞人群(P<0.01);不同类型IUD人群术前子宫内膜细胞学诊断两两对比差异无统计学意义(P>0.05);各种节育器术后常见不良反应两两对比,复合γ环与普通活性γ环的子宫异常出血发生率差异有统计学意义(P<0.05),其余无统计学意义。结论:放置IUD时子宫内膜细胞学检测可以了解受术者术前内膜细胞状态,评估其对IUD的初步适应性,可帮助诊治术后不良反应,还可以在无症状的人群中发现子宫内膜疾病,为IUD的安全有效应用提供科学依据。对于术后不良反应人群还可以作为一种跟踪监测措施,适时应用和评估IUD对子宫内膜的影响,科学指导临床诊断和治疗。     

经阴道三维超声成像对宫腔病变的诊断价值

目的：探讨经阴道三维超声（3D-TVS）在宫腔病变诊断中的临床价值。方法对125例宫腔病变患者进行经阴道二维超声（2D-TVS）和3D-TVS 检查,计算子宫内膜体积（EV）,比较两种检查方法诊断宫腔病变与病理结果的符合率,并比较绝经后良恶性宫腔病变患者的 EV 值。结果3D-TVS 诊断子宫内膜增生、子宫内膜息肉、黏膜下肌瘤、子宫内膜癌的符合率均高于2D-TVS,诊断宫腔病变的符合率也高于2D-TVS,差异均有统计学意义;绝经后子宫内膜癌患者 EV 值[（12.9±2.3）cm3]高于宫腔良性病变患者[（9.8±2.7）cm3],差异有统计学意义。结论3D-TVS 可获得宫腔病变冠状面图像,图像清晰显示病灶的形态、大小、回声及其与周围组织的关系,在宫腔病变诊断中具有重要价值,结合 EV 值的测定可提高对绝经后宫腔病变的良恶性鉴别能力。     

Market reform in New Jersey and the effect on mortality from acute myocardial infarction

OBJECTIVE: To determine whether mortality rates for patients with acute myocardial infarction (AMI) changed in New Jersey after implementation of the Health Care Reform Act, which reduced subsidies for hospital care for the uninsured and changed hospital payment to price competition from a rate-setting system based on hospital cost. DATA SOURCES/STUDY SETTING: Patient discharge data from hospitals in New Jersey and New York from 1990 through 1996 and the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS). STUDY DESIGN: A comparison between states over time of unadjusted and risk-adjusted mortality and cardiac procedure rates. DATA COLLECTION: Discharge data were obtained for 286,640 patients with the primary diagnosis of AMI admitted to hospitals in New Jersey or New York from 1990 through 1996. Records of 364,273 NIS patients were used to corroborate time trends. PRINCIPAL FINDINGS: There were no significant differences in AMI mortality among insured patients in New Jersey relative to New York or the NIS. However, there was a relative increase in mortality of 41 to 57 percent among uninsured New Jersey patients post-reform, and their rates of expensive cardiac procedures decreased concomitantly. CONCLUSIONS: The introduction of hospital price competition and reductions in subsidies for hospital care of the uninsured were associated with an increased mortality rate among uninsured New Jersey AMI patients. A relative decrease in the use of cardiac procedures in New Jersey may partly explain this finding. Additional studies should be done to identify whether other market reforms have been associated with changes in the quality of care.     

Update: West Nile Virus activity--Eastern United States, 2000

Data reported to CDC through the West Nile Virus (WNV) Surveillance System have shown an increase in the geographic range of WNV activity in 2000 compared with 1999, the first year that WNV was reported in the Western Hemisphere. In response to this occurrence of WNV, 17 states along the Atlantic and Gulf coasts, New York City, and the District of Columbia conducted WNV surveillance, which included monitoring mosquitoes, sentinel chicken flocks, wild birds, and potentially susceptible mammals (e.g., horses and humans). In 1999, WNV was detected in four states (Connecticut, Maryland, New Jersey, and New York) . In 2000, epizootic activity in birds and/or mosquitoes was reported from 12 states (Connecticut, Delaware, Maryland, Massachusetts, New Hampshire, New Jersey, New York, North Carolina, Pennsylvania, Rhode Island, Vermont, and Virginia) and the District of Columbia. Of the 13 jurisdictions, seven also reported severe neurologic WNV infections in humans, horses, and/or other mammal species. This report presents surveillance data reported to CDC from January 1 through November 15.     

Routine vaginal cuff smear testing in post-hysterectomy patients with benign uterine conditions: when is it indicated?

BACKGROUND: By the age of 60 years, an estimated 33% of women will have undergone a hysterectomy. Approximately 85% of these hysterectomies are performed for benign disease. The object of this study was to evaluate cytologic findings from vaginal cuff smears in patients who have undergone hysterectomy for benign uterine conditions. METHODS: We conducted a community-based retrospective study and follow-up of women with vaginal cuff cytologic smears who had had a hysterectomy for benign uterine conditions. A total of 220 women were randomly selected who had one or more vaginal cuff smears. The main outcomes measures were invasive carcinoma, dysplastic lesions, and infections detected by vaginal cuff smear testing. The setting was a large inner-city hospital. RESULTS: Ninety-seven percent of 220 women who underwent hysterectomy for benign uterine conditions and who were observed for an average of 89 months had no cytologic abnormalities on vaginal cuff smears. Cytologic evaluation found no invasive carcinomas. Dysplastic lesions were detected in 7 patients (3%). Seventy percent of patients (n = 154) had one or more infections; these infections included bacterial vaginosis (106), trichomoniasis (95), candidiasis (40), koilocytosis suggestive of human papilloma virus (HPV) infection (3), and cytopathic effect of herpes (4). The prevalence of koilocytosis was much higher in the patients with dysplasia (P = .0003). CONCLUSIONS: Most routine vaginal cuff cytology screening tests need not be performed in women who have had a hysterectomy for benign uterine conditions.     

Uterine adenomyosis. Clinical and therapeutic study. Report of 87 cases

STUDY OBJECTIVE: The aim of our study is the analysis of Pound epidemiological, clinical, paraclinical and therapeutic aspects of adenomyosis. METHODES: A retrospective analysis was carried out on 87 patients who underwent hysterectomy for a variety of raisons (except for prolapse) between January 1, 1990, and December 31, 1997; and whose Histologic analysis of hysterectomy specimen revelated adenomyosis. RESULTS: 586 hysterectomy (except prolapse) was performed during the study period: frequency of adenomyosis in hysterectomy specimen is of 14.85%. The mean age of our patients is 43.97 years (Range: 26-64 years). 29.88% of them are postmenopausal and 41.37% had a past history of uterine trauma. Main symptoms were pelvic pain (71.22%) and abnormal uterine bleeding (82.77%). Preoperative diagnosis has been suspected on hysteroscopy in 63.22% of cases, hysterography in 58.46% and transvaginal sonography in 40.5%. A radical surgery first has been indicated in 57 cases, after failure of medical treatment in 16 cases and after failure of endometrial resection in 14 cases. Histologic analysis of the hysterectomy specimen shows associated myoma in 32.18% of cases, hyperplasia in 13.79%, polyps in 5.74% and atrophy in 3.44%. CONCLUSION: Adenomyosis, enigmatic disease, escapes always to a well-codified therapeutic strategy and bound closely related to hysterectomy. Earliest diagnosis could avoid the systematic evolution toward the radical treatments.     

宫腔镜诊断与治疗绝经后子宫出血90例临床分析

目的:探讨宫腔镜对绝经后异常子宫出血的诊断及治疗价值。方法:对90例绝经后出血的患者进行宫腔镜检查,分析导致绝经后出血的宫腔内因素。对镜下诊断为子宫粘膜下肌瘤、子宫内膜息肉、子宫颈肌瘤及息肉的47例行宫腔镜手术治疗,9例子宫内膜癌患者接受开腹手术,并最终获得组织病理诊断。随诊观察手术疗效。结果:绝经后异常子宫出血的原因以子宫腔内良性占位病变居首位(子宫内膜息肉27例,子宫粘膜下肌瘤7例,宫颈管息肉13例)共47例,其次是萎缩性子宫内膜炎共31例,子宫内膜癌为第3位共9例。绝经后良性宫腔占位47例均采用宫腔镜手术治疗,手术时间短,创伤小,术后恢复快,无一例手术并发症。结论:宫腔镜检查直观准确,是绝经后异常子宫出血病因检查的首选方法;宫腔镜手术创伤小、疗效高,是目前治疗绝经后宫腔良性占位所致异常子宫出血的最佳方法。     

Does the family cap influence birthrates? Two new studies say "no"

Some have argued that imposing a cap upon welfare benefits would reduce birthrates among welfare recipients. However, recent studies in New Jersey and Arkansas determined that denying an increase in cash assistance to women who have another child while on welfare has no effect upon births in the states. When New Jersey became the first state, 4 years ago, to impose a family cap, then-governor James Florio declared the cap a success after just 2 months. An analysis by researchers at Rutgers University released in September 1997 disagrees. While birthrates among welfare recipients declined between August 1992 and July 1995, the decline was no different from that observed in a control group which continued to receive a benefit increase if they had another child. Among both groups, and consistent with birthrates in the general New Jersey population, birthrates fell from 11% in 1992-93 to 6% in 1994-95. These results did not change when researchers controlled for the age and race of the almost 8500 women studied. Abortion rates in the state declined both among women subject to the cap and among the control group. Although researchers studying the impact of the family cap in Arkansas could not determine its effect upon abortion rates because Arkansas fails to pay for abortions under Medicaid, no statistically significant difference was observed between the birthrates of women subject to the cap and a control group. The findings of these 2 studies cast doubt upon the notion that an increase in monthly benefits after the birth of a new baby is an incentive for welfare recipients to have more children.     

射频消融治疗围绝经期功血的临床研究

目的:探讨自凝刀射频消融子宫内膜(RFAE)在治疗围绝经期功血中的临床疗效。方法:选择2004年1月~2005年1月自愿接受自凝刀射频治疗围绝经期功血患者52例,在B超实时动态监测下,将自凝刀经阴道宫颈置入宫腔介入到内膜,治疗后观察术后1个月、3个月、6个月功血患者出血量的改变及定期B超复查,观察子宫大小和子宫内膜情况。结果:52例患者经治疗后,子宫体积均不同程度缩小,术后3个月复查,35例(67.3%)已闭经,13例(25.0%)月经量较前明显减少,4例(7.7%)较前好转;B超探查,35例闭经者无明显内膜,13例较前明显减少者的内膜为2~3mm,4例较前好转者内膜为3~4mm,子宫腔大小、形态与3个月相比无明显改变。6个月复查,完全闭经者49例,占94.2%。月经量明显减少2例,占3.84%,1例较前月经好转,占1.96%。总有效率100%。无1例出现再流血现象。结论:超声引导下射频子宫内膜消融是治疗功血简单、安全、快速、有效、痛苦小的微创介入治疗新技术,可替代子宫切除,值得推广应用。     

射频消融子宫内膜去除术治疗异常子宫出血的临床观察

目的:探讨射频消融子宫内膜去除术(RFEA)治疗异常子宫出血的临床效果。方法:对84例排除子宫内膜癌及癌前病变的异常子宫出血者行RFEA治疗,术前行刮宫术薄化子宫内膜,术后1、3、6、12、24个月随访观察患者症状改善及副作用发生情况。结果:84例中23例合并严重内科疾病,均成功RFEA,术中无并发症发生;术后发生子宫内膜炎6例,宫腔积血2例;53例合并贫血者术前血红蛋白83±24g/L,术后3个月上升至118±19g/L,差异有统计学意义(P0.01)。绝经前患者78例中,术后闭经49例(62.8%),少量不规则阴道流血2例(2.6%),月经正常27例(34.6%),治疗有效率为97.4%(76/78);痛经改善率75.0%(18/24),60例随访至术后2年以上,疗效稳定。绝经后患者6例;术后均无出血。结论:RFEA操作简单,治疗效果安全可靠。     

There are critical reasons for not further delaying the implementation of the new ICD-10 coding system

On April 17, 2012, the Department of Health and Human Services (HHS) published a rule proposing postponement of the implementation date for the International Classification of Diseases, 10th Edition diagnosis codes (ICD-10-CM) and procedure codes (ICD-10-PCS) by one year to October 1, 2014. An article in Health Affairs titled "There Are Important Reasons For Delaying the Implementation Of The New ICD-10 Coding System" asserts that the ICD-10-CM conversion will be "expensive, arduous, disruptive, and of limited direct clinical benefit." Contrary to the conclusions in this article, implementation of the ICD-10-CM and ICD-10-PCS code sets will provide major advantages over the existing ICD-9-CM code set. Implementation is long overdue and will provide significant cost benefits. Any further implementation delay will increase the cost of the transition as well as perpetuate the costs and negative consequences associated with continued reliance on imprecise diagnosis and procedure information.     

Do nonprofit HMOs eliminate racial disparities in cardiac care?

African-Americans have far less access to treatment for heart disease than similar white Americans. In this article, we explore the sector difference theory hypothesis that treatment provided by a nonprofit Medicaid managed care plan can reduce or even eliminate the race gap. Specifically, we compare the treatment offered to patients in for-profit Medicaid managed care programs to the treatment offered to similar patients in nonprofit Medicaid managed care programs. Data are from the Maryland Health Services Cost Review Commission and cover all patients discharged from hospitals in Maryland during calendar year 1998 with principal diagnoses indicating diseases of the circulatory system (ICD-9-CM codes 390 through 459) or chest pain (ICD-9-CM codes 786.50 through 786.52 and code 786.59). African-Americans were significantly less likely to receive the three treatments of interest, even after controlling for principal diagnosis, blood pressure, co-morbidities, and age. In regard to African-American access to treatment, there were no significant differences between the sectors.     

Elective primary caesarean delivery: accuracy of administrative data

The caesarean delivery rate has become a commonly used measure intended to reflect the quality of obstetric care. At least 25% of all primary caesarean deliveries occur electively, i.e. to women who are not in labour. This study is intended to validate a previously published model designed to use ICD-9-CM codes to identify and categorise cases of elective primary caesarean delivery by their indication. ICD-9-CM codes were compared with diagnoses written in the medical record for all women without a prior caesarean who delivered in the same month in a single hospital to examine the accuracy of the codes for 12 potential elective primary caesarean indications derived by the published model: malpresentation; bleeding; genital herpes; severe hypertension; uterine scar; multiple gestation; macrosomia; unengaged fetus; maternal soft tissue conditions; other hypertensive conditions; prematurity; and chromosomal anomalies. Of 440 eligible women, a total of 26 (5.9%) had an elective primary caesarean by medical record review vs. [27] (6.1%) by administrative data. Using medical record data as the gold standard, the sensitivity, specificity, and accuracy of administrative data for the identification of elective primary caesarean delivery were 73.1%, 98.1%, and 96.6%, respectively. Administrative coding for all of the 12 conditions was highly specific, although wide variability existed in its sensitivity; its accuracy ranged between 83.9% and 100%. These results suggest that, despite widespread use of caesarean delivery rates obtained through administrative data, more experience is needed to determine which obstetric codes may be sufficiently specific, sensitive, or prevalent to serve a monitoring or surveillance function reflecting the quality of obstetrical care. The results support continued efforts to use administrative data to monitor elective primary caesarean delivery.     

Acute pyelonephritis in US hospitals in 1997: hospitalization and in-hospital mortality

PURPOSE: To describe the 1997 incidence of hospitalization for acute pyelonephritis in the US and the risk factors for in-hospital mortality associated with acute pyelonephritis. METHODS: Cases were defined as those with ICD9-CM codes corresponding to acute pyelonephritis in the 1997 Health Care Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS). Frequencies and calculations were weighted to produce either national or state estimates. Hospitalization rates were calculated using 1997 US Census Bureau population projections for the denominator. RESULTS: Females were almost five times as likely as males to be hospitalized for acute pyelonephritis (11.7/10,000 vs. 2.4/10,000), but males had higher mortality rates (16.5/1000 vs. 7.3/1000); 30% greater after adjustment. Hospitalization and in-hospital mortality rates increased with age, but not with diabetes. Mortality rates increased with number of procedures, diagnoses and having a major diagnostic category other than disorders of the kidney and urinary tract. Persons living in zip codes with lower median incomes were also at higher risk of mortality. There was little variation in mortality by hospital size, ownership, location or teaching status. CONCLUSION: In hospital mortality for pyelonephritis was associated with patient rather than hospital characteristics suggesting uniform application of standard care across hospitals and populations.     

高频微波子宫内膜去除术后宫腔影像随访观察

目的:随访微波子宫内膜去除术(MEA)后宫腔影像改变情况;评价MEA宫腔镜检查的意义。方法:在2000～2008年349例行MEA手术患者中术后随机抽取53例进行宫腔镜检查,观察患者MEA术后宫腔内膜的破坏、宫腔粘连的形成及组织愈合的情况;同时随访患者术后月经改变情况,探讨术后宫腔形态的变化与患者术后月经情况的联系。随访时间为术后1个月至术后8年。结果:共53例MEA术后患者行宫腔镜检查。术后3个月内宫腔内主要为坏死脱落的内膜组织及退变的平滑肌,患者月经改变为不规则点滴出血;术后半年,宫腔内可见肉芽组织形成及纤维化改变,患者表现为规律的少量月经或闭经;术后1年以上,宫腔内主要为瘢痕组织覆盖,而患者月经改变主要为闭经;术后2年以上,宫腔镜检查可见不同形态的宫腔粘连。共28例(52.8%)发生术后宫腔粘连,其中1例表现为宫颈管粘连,12例(22.6%)发生宫底部位灶性粘连,11例(20.7%)形成管状宫腔,双侧宫角均封闭,4例(7.5%)宫腔完全粘连、闭锁。此28例患者中,22例月经表现为闭经,4例表现为不规则的点滴出血,2例出现月经减少。结论:微波子宫内膜去除术后宫腔形态改变差异十分显著,患者术后月经改变与术后宫腔形态改变密切相关。术后行宫腔镜检查有助于对MEA术后各种阴道出血进行鉴别。