INTRODUCTION: Creating high-volume surgeons improves perioperative outcomes and encourages surgeons to perform more minimally invasive gynecological procedures. Compared to open abdominal myomectomies (AM), minimally invasive myomectomies (MIM) for benign uterine leiomyomas have lower complication rates, costs, and recovery time. Despite this, approximately 40% of myomectomies nationally are performed via an abdominal approach. In 2011, Kaiser Permanente Northern California (KPNC) introduced a quality improvement initiative to increase the proportion of MIMs by developing a streamlined high-volume surgeon pool. This study examines the interplay between surgeon volume and route for myomectomy. METHODS: This was an institutional review board (IRB)-approved retrospective observational data-only cohort study of patients who received an AM or MIM for benign uterine leiomyomas between 2009 and 2019 within KPNC. Surgeon volume was categorized as low (20 cases/year). RESULTS: Over the 11-year study period, 4,033 adult women underwent a myomectomy. The proportion of MIMs went from 6.0% to 89.5%, a 15-fold increase. The number of MIM surgeons increased over time but remained below 50, even as MIM rates increased. Medium and high volume surgeons were significantly more likely to perform MIMs compared to their low volume peers. As the MIM surgeon pool decreased in size and experience increased, the likelihood of having a MIM increased significantly. CONCLUSION: Decreasing the number of obstetricians/gynecologists performing surgery by limiting the number of MIM-privileged surgeons effectively increased individual surgeon case volume and increased the rate of MIM over an 11-year period, even with a rise in overall myomectomy incidence.
INTRODUCTION:Little research has evaluated the influence of neighborhood deprivation index (NDI) on postpartum depression (PPD). This study evaluated the effects of NDI and race/ethnicity independently and jointly.METHODS:This is a retrospective cohort study of Kaiser Permanente Northern California members aged >15 years who delivered a live-born infant between October 7, 2012, and May 31, 2017. PPD was identified using depression diagnoses obtained the day after delivery through 12 months postpartum. NDI was categorized into quartiles; the top quartile represented the highest deprivation. Multivariable logistic regression was conducted to assess the association between NDI and PPD. We performed analyses stratified by race/ethnicity to assess for effect modification.RESULTS:Among 177,511 live births, 122,995 were to unique mothers; among those, 18,510 (12.5%) had PPD. PPD ranged from 20.8% in the lowest NDI quartile to 27.8% in the highest. Higher NDI was associated with greater odds of PPD (Q4, referent Q1: adjusted odds ratio [aOR], 1.16; 95% CI, 1.10–1.23). Associations between NDI and PPD varied by race/ethnicity. NDI was not associated with PPD among Hispanic women. Black women had the highest odds of PPD for all NDI quartiles (Q2: aOR, 1.50, 95% CI, 1.17–1.91; Q3: aOR, 1.64, 95% CI, 1.30–2.07; Q4: aOR, 1.78, 95% CI, 1.42–2.22; referent for all comparisons Q1).CONCLUSION:There were significant variations in PPD rates according to race and ethnicity that persisted regardless of NDI. Findings from this study suggest that while geographic targeting of mental health services may be informative, the role of systemic racism should be considered.
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