Okay, good evening. Welcome to the Augs FPMRS webinar series. I'm Teni Brown, moderator for today's webinar. Today's webinar is entitled Health Services Research in FPMRS presented by Dr. Jennifer Anger. Dr. Anger will present for 45 minutes and in the last 15 minutes of the webinar will be dedicated to questions and answers. For those of you who don't know, Dr. Anger is professor of urology and OBGYN as well as the director of benign urological research at Cedars-Sinai Medical Center. After her fellowship in FPMRS urological construction at Duke University, Dr. Anger completed her master's degree in public health at UCLA under the mentorship of Dr. Mark Litwin, a pioneer in urological health services research. She has over 10 years of research experience using administrative claims, including data from the VA. She received a mentored career development award, K23 from the NIDDK to support quality of care indicators for women with pelvic floor disorders, evaluating the quality of urinary incontinence and prolapse treatment equipped. She was the administrative PI for the Cedars-Sinai's multidisciplinary approach to the study of chronic pelvic pain map site in which she led two basic science genomics and proteomics teams. And she's currently PI on the CDC funded study of the epidemiology of interstitial cystitis. Before we begin, I'd like to review some housekeeping items. This webinar is being recorded and will be live streamed. Please use the Q&A function of the Zoom webinar to ask any of your speaker questions. That's located at the bottom of your screen next to the portion where you can see the chat. And then we'll get to those at the end of the webinar. With that, I'm gonna turn it over to Dr. Anger. Thank you, Dr. Brown for that kind introduction. I will talk a lot about some of the basics of health services research, but also sprinkle in my own research experience. And then I did save some time at the end just to talk a little bit about NIH funding and that sort of pathway for those who might be interested and crazy enough to do that. So greeting from Cedars-Sinai Medical Center. We're in the West Hollywood area of Los Angeles. I like to say I was trained by the four founding fathers of female urology. And this is different, a little bit different than urogynecology where our fields have definitely merged in a positive way. To the left is Jerry Blavis with whom I trained during residency. George Webster was my mentor for my fellowship at Duke in 2003. I then worked at UCLA. I spent two years as a fellow and then was faculty there for four years with Dr. Ross. And Dr. Ed McGuire, may he rest in peace, trained Cyndia Munson who trained me. And I learned a lot from my year at Duke because Dr. Webster and Munson worked very so well together and really taught me the importance of urologists and urogynecologists working side by side. I've had the benefit of training from gynecologists even after my training. I went back and learned robotic urogynecology from Kim Kenton, Pat Culligan, Chris Tarney at UCLA. And then I went and watched the folks at UC San Diego. And so I'm grateful to have been trained by urogyne because it has really expanded my clinical armamentarium as a urologist. So my second fellowship was with Dr. Mark Litwin studying the field of outcomes research which is sort of how we loosely term it but it's focused on the study of access to care, costs of care and quality of care. Dr. Litwin was really one of the first in the world, you know, urology was highly focused on cancer in particular prostate cancer. And it used to be all about getting out the cancer. And with Dr. Litwin's work, it was really about, well, what's the cost of taking out prostate cancer? And it always, well, not always, but about half of men experience erectile dysfunction and a small but significant portion of men have urinary incontinence after prostate surgery. So it was really Dr. Litwin who made us start thinking about quality of life as an important outcome. And in our field of FPMRS, quality of life is our main outcome. And my partner gave a lecture today, Dr. Karen Eilber on patient satisfaction. And it's interesting, you know, we always, I think when you're in a quality of life field, patient satisfaction, we actually have like a higher standard because we're not, you know, patients who are getting cancer treated, you know, there's poor outcomes, but it's sort of like, oh, well that goes with taking out the cancer. But with us, it's actually, the expectations for our outcomes are actually, I would argue higher. Pelvic floor disorders, as you know, are a group of conditions of any condition that affects the pelvic floor. So we have pain syndromes, incontinence, overactive bladder, stress incontinence, voiding dysfunction, incomplete emptying, underactive bladder, pelvic organ prolapse. And you could argue that pregnancy is even a pelvic floor disorder. So there's a broad range of disorders that we encompass in our field. And I don't really need to talk to you, this audience, about what a cysticeal is and what apical prolapse is, but I can tell you that most people outside of our field often get it wrong. And I remember not until I was already faculty did I feel comfortable differentiating a cysticeal from apical prolapse on pelvic exam. And when you try to explain these concepts to patients, it's confusing even for the highly health literate patient to kind of help them figure out what's bulging where and how do we treat it and why. So pelvic prolapse is a confusing field. Epidemiology is part of health services research. It's understanding the burden of disease. And I don't think the Olson paper ever gets too old when we talk about one in 10 or 11 women undergoing surgery for incontinence or prolapse in her lifetime. One in three requiring a reoperation, although I think we're doing better at that now. Prolapse is a leading cause of a lot of procedures and a lot of reoperations. And one of my favorite works is from Dr. Jennifer Wu, who actually used modeling to predict the number of procedures and how they will go up as our older generation ages. And that we are gonna be staying in business. I think that's something important for all of us to know. And costs of prolapse and incontinence are over $1 billion in the US. And that's important. And what's also important when we think about costs are that treatment costs are only a small portion of the incontinence cost. And the greatest cost goes to the patient in pads and bedding and in particular in older adults in nursing home, those sort of costs in that of living with incontinence play a huge role. We know the risk factors of prolapse, parity, age, obesity. Parity has been shown to be among the strongest risk factors and then some studies show African-American race can be protective. Hispanic ethnicity can be a risk factor for higher prevalence of disease. Of note, which is another, this is another very confusing concepts for patient is that prolapse is normal. Most women, and this is one of my favorite papers from Dr. Swift in 2000 is showing that actually the majority of women have prolapse up to stage two without symptoms. And that that's actually normal. So then when we say symptomatic prolapse is when we start treating it, which is often stage three but sometimes people have bother at stage two. And Jenna Donovan found that Hispanic women and Native American women were more likely to have bother at stage two than Caucasian women who are more likely to bother at stage three. So we really see some differences and possibly disparities in the area of FPMRS. So briefly talking about costs when we're looking at in our health services research model costs of care, quality of care and access to care. Direct costs are really the diagnosis costs, diagnosis costs, treatment costs and routine care costs like pads. And those are very, can be very large. And then you look at indirect costs, lost wages due to lost work productivity due to absenteeism. So maybe they have surgery and then they lose, they don't go to work. So that would be considered like an indirect cost. An intangible cost is pain and suffering and decreased health-related quality of life. So an intangible cost is sometimes we talk about it of a quality, a quality adjusted life year and often trade-offs. So when we look at, let's say again, prostate cancer, would you rather, what's more important to you, not having cancer or not having incontinence? So we think about these things in terms of trade-offs for different patients. And we all know that patients experience different degrees of pain and suffering from incontinence and prolapse. And so where some patients feel a slight bulge, others actually walk around with prosedentia and we're always like amazed that they do it. And so it's a, there's a very different sort of patient experience with their condition. Routine costs, Dr. Subak showed routine costs incontinence is $900 per year, which is substantial. Now I wanna talk about access to care. And because this is an AUGS audience, I'm gonna give you my feminist version of this talk. I have a urology audience where I often take a lot of these slides out. But access to care is something that's unique, unique when it comes to prolapse and incontinence and I'll explain why. So there's a stigma. The community does not talk about pelvic floor disorders. And like, I had a family member who had prolapse surgery and I couldn't tell my family what she had because people don't want people to know about that. And so we talk about access and we typically talk about lack of insurance as being a number one cause of lack of access. Rural communities often have lack of access to a hospital. They have to travel far away. So those are what we think about when we typically think about access to care. But prolapse and incontinence and pelvic floor disorders actually have a very unique access problem. Not only because they're confusing and not only because they do disproportionately affect underserved populations, but pelvic floor disorders are more than a woman's health issue. They're actually a gender issue. And I think that's really important because we don't think of gender medicine when we think of women's health, but it's really important here. So I wanna talk about the Anderson Healthcare Utilization Model, and which is, this is from, Anderson was actually UCLA, and it's aimed at looking at factors that lead to the use of health services. According to the model, health service use or access to healthcare is determined by predisposing factors, enabling factors, as well as need. So predisposing factors can be patient characteristics, race, age, health beliefs. People who don't trust the healthcare system may not wanna go to the doctor, and that can be a predisposing factor. But again, could also be like distance from a hospital. Then you have enabling factors. So support, health insurance, community support. An enabling factor would be like community programs to help with exercise among older adults, to help with incontinence, for example. So, and then patient need represents both perceived and actual need for healthcare services. So this is just an example of the Anderson Model, looking at the different characteristics which lead a patient to accessing care and using care. And then that use of healthcare then will affect their outcomes that they have from treatment. So why do we have an access problem in FPMRS? Well, we have a problem because the community doesn't talk about pelvic floor disorders. Access is poor, but again, it's because there's a shame and silence associated with pelvic floor disorders. So we actually, and so we talk about gender medicine. I didn't know, this is a long time ago, but I was the only woman in my urology program. And so I was like, well, is it being a woman in a man's field? No, that's not gender medicine. Is it being a, is it work-life balance for a woman in medicine? That's not it either. So what is it? How, and we know gender medicine incorporates transgender care, but when we're looking at cis women with pelvic floor disorders, how is it a gender issue? Because men don't get prolapse. Well, gender specific medicine is the study of how diseases differ between men and women in terms of progression, clinical signs, therapeutic approach, prognosis, psychological and social impact. It is a neglected dimension of medicine. So an example is women with MI are less likely to have guideline-based diagnosis and less invasive treatment than men. Women obtain dialysis often later than men and tend to undergo fewer kidney transplants, although this is actually improving over time. On the other hand, men are less likely to be diagnosed with depression and even osteoporosis. And in, from our work, we've definitely seen major misdiagnosis of men with bladder pain syndrome because they think of IC as a woman's disease. So men are often misdiagnosed and underdiagnosed. So when you go back to the health services research definition, when we talk about access to care, shame and silence create a barrier to care for women with pelvic floor disorders. And this is the barrier to access. So we have a lot of expectations on our vagina. The vagina is supposed to look like a Barbie, taste like a peach and smell like a rose and also have a large baby and still maintain a pre-partum vagina. So there's societal expectations are very unrealistic. And then there's also compounding problems with trends in let's say shaving, where now that they're, you know, now everyone wants a hairless vagina. So women all of a sudden don't realize that labia minora are normal and it's okay to see them. But so now we're having a large increase in labiaplasty because if you want to have a Barbie vagina without hair, then you can't have any labia. And so there's more, even more expectations on women. And so this is, you don't see this sort of phenomenon with men. So this leads to our study where we wanted to understand when we're talking about access, what are the access problems for women? So this was work that I did with Dr. Becky Rogers and Jenna Donovan and our colleagues at UCLA, Dr. Wieslander and Dr. Aulis, who's now in Texas. So we sought to understand women's experience with prolapse and we wanted to study women in English speaking groups that also underserved Latinas. So we conducted focus groups in English and Spanish. And we wanted to use what's called qualitative analysis, which is really hypothesis generating data. So when do you do qualitative analysis? Well, qualitative analysis is something you do. It comes from the nursing literature. It's when you don't even know, it reminds me of Passover for those of you who are Jewish, you don't even know like enough to ask the question. So when we don't even know what to look for or we don't have a hypothesis, qualitative methods are what we call hypothesis generating. You wanna get an idea from the community or from patients what the problems are. And then from that, you have hypotheses generated. So what we do with qualitative research is we actually record data from patients talking, either from individual interviews or from focus groups. And then we actually, from the recordings, you get transcripts. So verbatim transcripts of what the data was that you collected, and then you code them. So you'll use a little highlighter and you'll see some really cool quotes, what we call in vivo quotes, and I'll show you some examples. But it's really taking notes about what people are saying. And then you'll find these phrases will end up forming preliminary themes. Then you can group themes into general categories. And then emergent themes arise from the data, which I think of as sort of this like a bigger, big picture take-home message. And so that's sort of the basis behind this kind of research. And so what we found was a really important theme of silence and shame. So in, this is our, in English-speaking groups. So they never knew, no one knows what prolapse is. You know, there's a lot of really great, you know, public efforts to raise awareness about women's cancer, but it's hard to get a spokesperson who's going to say, my bladder was hanging down to my knees and it's back up. And so you really see that there, people have prolapse and they don't even know what it is. And so they're embarrassed. They don't want to tell people it's humiliating. And this is the worst, right? My OBGYN said, wow, no one would have ever mistaken the fact that you had kids. It was humiliating to me. And she's like, you know, in the focus group, crying over this experience. I feel like a freak of nature. This is so unattractive, so unsexy. And like, this like kills me, right? Because women have babies. You go through life's experience and have to feel like a freak of nature. Now, this is interesting. So the Spanish-speaking group had the same themes, but there were some other kind of additional themes. One was fear. So they didn't know what they had. They thought maybe this would be cancer. When your bladder hangs out, it's like a mask. So of course you might feel like this could be cancer. And then also really like depression, like real depression as a result of sort of difficulty with coping. So these are some really unique, what I call gender medicine issues related to pelvic floor disorders that you just don't see with other conditions. And again, you don't see like fundraisers, right? Here's like our wonderful cardiologist at Cedars-Noel Barrymores with Barbara Streisand for heart disease, you know? And Beth Carlin is at UCLA with ovarian cancer awareness, right? And we don't see that with prolapse. So how do we break these barriers? And this is an example of some qualitative work we've done using social media. And this is a picture of Europe, but each color represents a language being used in social media. And it really reflects the actual country. That's like Italy's blue, you can see the blue boot. And so this is really just sort of showing how widely used social media is. So we actually did similar work, but instead of focus groups, we applied what's called digital ethnography, which is, and this was part funded as a pilot from the PLUS Network, the Prevention of Lower Urinary Tract Symptoms Network. So digital ethnography is online research that adapts ethnographic methods to study free range, non-experimental communities. But because it's digital, we do it through social interaction that we use through different postings online. And so we identified patients with LUTs and we looked at different forms. And this was work from Gabby Gonzalez, who's now an intern in urology at UC Davis. And she did a lot of this analysis. And what was really interesting, so first we found that there was a lot of lack of evidence that goes on in social media. So patients really want holistic strategies, which is great, but there's also a bit of a problem here. And because a lot of you look at these, so recommendations that patients or people, not necessarily patients, but they give recommendations on the internet. And what we found was that a lot had very poor data. Now some had good level one evidence, like 21% of data was supported in the literature, but a lot is really not evidence-based. Some things like fire-breathing posture for prolapse. And I had never heard of that. And so a lot of these things that are being recommended are not necessarily evidence-based. But what was really neat about it is we showed that a lot of the shame that we found in focus groups was absent. And I think that's because patients found a lot of information online and they could actually be very, because of the anonymity that's online, they could really speak candidly. And so I think it's even... And what's interesting is a lot of the themes were very similar. What was different was in focus groups conducted through our like offices, they're through the provider's office. So they tended to be very pro-doctor because like we didn't have the doctors in the room, but they were at the doctor's clinic. So they're not gonna say, well, this doctor gave me bad care. But what we found was online, people can really say, get yourself to a specialist. You need to go to a different doctor. So they were able to really vent about the care they received. And you can see a lot of frustration in care in those really hard to manage conditions such as recurrent UTIs, interstitial cystitis. And a lot more where patients with like surgical stress incontinence and prolapse, there was a lot of information given, like go to a specialist, make sure you get a referral. And even like in England, you could tell there were certain cues would tell you what country things were happening in, but that there would be barriers to specialty access, which could be really problematic. So now I wanna talk about quality. So I've talked about access and this is sort of what's been my passion in research is quality of care, which according to Avetis Donabedian, and this is from 1964, and he was at Michigan, his framework examines health services research. And according to the model, information about quality of care can be drawn from three categories, structure, process, and outcomes. So the structure of care is really the setting of care. And what do you have at your facility? So do you have your dynamics equipment? Because if you do, it might influence whether or not patients get your dynamics. This one thing people often talk about is like in a private practice office, in particular in urology, if they have their own CT scanner, we see patients that come from some of these other practices and they all get a CT scan, right? So having certain elements actually predisposes you to getting certain what we call processes of care. A process of care is what's actually the interaction between the provider and the patient. So testing, what's done, surgery, surgical technique is important. And then outcomes, morbidity, mortality, and also cost. And in particular in our field, quality of life outcomes. So in our field, we seem to have a problem with quality. That led us to a big mesh controversy, as you all know. We have a problem with safety because we tend to love to rapidly adopt new technology. And we adopt it before we have evidence to show whether or not it's safe. And also we still have some serious needs for good translational research and mechanistic research in many areas in FPMRS. And in particular, I think of pelvic pain, UTIs, and even tissue studies of quality of tissue. So quality of care is pretty suboptimal in particular in the primary care setting. So we develop quality of care indicators, which are like a, they're kind of like a clinical guideline, but they're more like of the floor of care. So like when you look at primary care, if a patient comes to the office with incontinence, they should have a urinalysis, right? And hopefully a pelvic exam within a few months. Ideally, you should differentiate stress versus urge and maybe a primary care doctor should start some basic management Kegel exercises. Now it's unfair for us to put all this on a primary doctor because they have a lot to do. Like this is all we do. So of course we're gonna be better at care, yet there are big, you know, like the agency of healthcare quality and research wants to improve primary care level of management of incontinence because it's gonna help communities reduce incontinence and also reduce costs because specialists are expensive. So, but we did also find that there was in the, when we looked at specialty care that many who had, let's say sling, there wasn't documentation of counseling about mesh, which can end up being problematic when, if a mesh complication occurs, especially in such controversial topics where there's lawsuits, for example. So we conducted, we've worked on conducting pilots to improve care at the primary care level. And that's hard to do. There's a lot of barriers to implementing care, but there's some methods. One method I love, because we talk about, you know, how do we make care better with, and one thing you can do is you educate. That's a big part, but that only has like a small impact on care. But one thing we found, which is really cool, because we always assume that county care is gonna be worse than specialist care. But we looked at a county system, Harbor UCLA, and they have an electronic consult system. So if a doctor just refers to, like where we have it at Cedars and even at UCLA, you can refer someone for incontinence by like an email click. Like the patient says, I have incontinence, and the doctor's like, okay, I'll put in a referral. And then they come to us, so we end up seeing primary care incontinence in our specialty office. And the care is good, but it's also expensive. And what we found was Harbor UCLA has an e-consult system, and Dr. Taji Yazdani has done a lot of work with this in developing the system. But if a doctor refers in the county system, they refer without any prior workup at all, it gets kicked back, and they're like, no, you need to, you know, reduce fluid intake, do Kegel exercises, and for urgent continence, start medication, right? And then what they found was when we compared the care in the private sector to the public sector, the public sector did 50% better care, sorry, 50% of recommended care compared to only 40% in primary care offices in the private sector. So what this shows is you can actually improve care and actually improve what we would say is like public care and make it much better than private care by implementing these sort of forced measures, like you have to do this before we'll take the referral. And that I thought was really interesting. So we've done some other work based on work that's been done in Michigan in urology to improve care with people in the community. So then we have a problem with safety, and this is interesting, this was from the Urologic Diseases in America project that I had done in 2007, and Lisa Rogogupta, who's at Stanford, continued this and showed even like an increased use of slings over time. But what it showed was that we rapidly changed from needle suspension to collagen to slings. And many of you know, like one of the first randomized trials, which was a sister trial, which showed that slings were better than birch, although with a side effect of more complications, that didn't even come out until Dr. Albo's paper in 2007, but we switched, we rapidly switched to sling way before there was level one data to support it. And that ended up not being too much of a problem with slings, but it was a big problem with prolapse kits. So here we see, you know, claims from the mod database and a rapid rise in legal cases. And this is because of mesh kit complications. And this is likely because we adopted mesh kits really quickly. Now there was also a big problem in that with mass media attention, which led to massive litigation, which was probably out of proportion to the complication rate, which is actually relatively low when you look at complications in the literature. But those mesh kits were taken off the market. And so this was just an example of the risk of adopting things really quickly. So what about robotics? Well, robotic surgery, we think of as a really great method of providing a really good standard of care. And in our field, we think about the copalpexy, but there is again, rapid innovation. Now we're onto the single port robot. So, you know, the robotic generation changes rapidly. And in prostatectomy, there was a huge rise in cases where men went from open prostatectomy to robotic, and they also went from radiation therapy to robotic prostatectomy. So they basically changed their, because of the robot, they actually know like the number of radiation procedures went down because of the introduction of the robot in robotic prostatectomy. Now, however, it's important to know that there are, this was a mod database, there are instrument malfunctions and even rarely death. And it's important to try to adopt in a safe way. So how can we adopt safely? And that's where what's called human factors comes in. And the human factors research is the study of the interaction between humans and systems. And I sort of got connected with some human factors researchers here at Cedars-Sinai. Ken Catchpole, who did a lot of work with motor racing and seeing how you can have a four second pit stop while the car is in the middle of a race and we'll get a tune up. And every single person has a specific role in the tune up so that they just go tune it up and step away. And there's also amazing work that's been done in aeronautical engineering and in making airplane safer. So we've applied this to robotic surgery and actually using a pit stop model, Colby Soders, who was our medical student and resident is now at UT Southwestern in her fellowship. We gave designated roles to turnover staff and significantly reduced turnover times for robotic surgery. What was interesting is we actually looked at room ready time was the actual time to turn over the room. And we also looked at total turnover time. What was interesting was by doing this pit stop model, which was designed to reduce room rate turnover, it actually had a even bigger effect and total turnover time was reduced. And that's because the whole, I think the whole culture changed and it actually had a pretty significant effect that lasted over time. We also applied human factors research to copepaxi and studied what's called a flow disruption, which is an interruption in the normal flow of an operation. So you have observers that sit through a whole robotic case and we basically found about an average of 50 flow disruption per case. And a flow disruption comes in many of these several categories. I like, my favorite is communication. Tammy, the blue grasper, I handed it to you. No, the other blue grasper. Missing equipment where staff, they don't have the right instrument, they leave the room for 10 minutes and then come back. Incoming cell phone calls is what we call an external factor. Or you can imagine in the middle of a really stressful part of the case and there's bleeding and your heart rate's 180 and they ask you how much longer, they come in into the room and ask you how much longer. That's like a classic flow disruption we all dislike. Malfunctioning equipment, that's pretty common with the older models of robot. They tend to be much better. Obesity can create flow disruptions, variant anatomy, and then how a flow disruption can be like an unnecessary instrument change or an extra instrument change. What we do is we identify these, and then we actually are in the process now of developing interventions. One looking at teamwork training, the other task design, like I talked about, those designated roles, and also workspace design. We're always tripping over cords, bumping the robot into the lights. We have rooms that are too small. How do we best make the workspace better? What's really cool, so we've actually taken human factors research and used it to improve patient understanding of stage 1 interstem, like after that stage 1, they have a battery, they're not quite sure how to handle it, and trying to make that process smoother. We ended up giving them an information sheet and really trying to get their meds ready so that they don't have to wait in the recovery room ordering the medications before surgery. We're also doing some of this in terms of, how do you most expediently do avoiding trial? What do nurses want you to do? Our nurses actually want us to leave a Foley so they can fill the bladder and take the catheter out themselves. So we have to, it's taking into consideration what all the team members want, not just the surgeons. So now I want to talk about RCTs, and I think the RCTs in our field are just the best. The Thomas trial, the sister trial. We did a trial, this is a funny example. I love Dr. Munson's Rosetta. I'm looking at Botox versus interstem. One thing we did, which is really funny is, it wasn't funny at the time, but I was junior faculty and have these really good friends, Kim Ken and Beth Mueller. They were both at Loyola and they were being nice to me. I'm like, let's apply for this robotic challenge grant. And they thought, they're just being nice to me. They're like, okay, sure, sure, we'll apply. And then it was to look at robotic versus open sacral copalpexy. And they never thought we'd get the grant. We didn't really think we'd get it. And then we get this miraculous grant. And then we sat down in Chicago. They sat me down and they're like, we're never going to be able to recruit to the open arm. So we actually changed the study with, well, were we asking for forgiveness or permission? We just kind of changed the study and we changed it to robotic versus lap and looked at cost. Why did we do that? Because again, robotic surgery had moved so quickly that we couldn't actually ask people to consent to the open arm. Because why would patients want to do that, right? So this was just an example of the rapid change where things change so quickly that you often can't even do the trial that you want to do to show that robotic is better than open. Like we kind of lost that window. So anyway, randomized trials are still really the gold standard when you want to look at one surgery over another. And we really look to the urogyne and the PFDN and all the great work that's been done in this field. Registries are great. We have a urology registry. The AUGS registry. And we actually participated. There's the quality registry, and then there's also the prolapse and incontinence registry, which I had the fortune to participate in with Dr. Bradley and Dr. Mawaly. And it's really great. Registries are really great because you get quality data that's also still real world. And so we actually showed, we looked with Aqua data, which is the kind of urology registry, that sling outcomes are really, really good. So it's a way to look at outcomes, but not just using a clinical trial, because clinical trials tend to have experts in the field and they tend to have better outcomes. So registries sort of give you a little bit more real world data to look at. And then I am, so this is just showing that using registry data, we showed that like, if you look at the third bullet here, like 1% sling revision, 3% repeat sling, these are good surgeries. And now I'm just gonna, because I'm running out of time, I'm gonna leave, end my talk by saying the importance of tying in what we call health services research with basic science. So basic science is really what we need to do better. We can only do so much better with interstitial cystitis. We need to study the microbiome of the bladder and understand, is there an infectious etiology to some of these chronic pain conditions? And so basic science is always critical, but it's also important to know for people who are interested in health services research, that we can be involved in basic science. And I had this opportunity to be part of the MAP network without much of a basic science background. And we basically, the request for applications, which is called an RFA, there was a request for proteomics studies and genomics, which is microbiome studies. And so I went to my basic science colleagues, I'm like, do we have this stuff here? And then we found, we put together a team for this grant and by a miracle, which is often how grants get funded, we were able to get funded to study the proteome or the basically blood levels of proteins in patients with pain. And also with Lenny Ackerman, who's at UCLA now, she helped us study the microbiome of patients with pain. Does the microbiome vary by clinical phenotype of pain? Do Hunter's ulcers, lesions, do those host bacteria in the ulcer? So we're doing those kinds of studies. But my point of talking about basic science is that as health services researchers and clinical researchers, we have a role in basic science and we can often, I'm not a basic scientist myself, but it's important to partner with those people and really you can do some really exciting research. So I'm gonna end there so we can talk about if someone has any questions or comments, I'd love to hear them. All right. And I'll stop sharing. Just a reminder, everyone can submit your questions in the Q&A section. I will read the questions, Dr. Inger, okay? So our first question says, what are some of the gaps in health services research in FPMRS in your opinion? I think where there are gaps, I think is there's, and I'm biased because I have an exciting project with our fellow, Dr. Dubinskaya, who is actually studying female sexual dysfunction and there's a serious gap in care there. If you look at like all that's been done for men and what's even a further gap is in, is disparities in care in FPMRS. I think underserved Latinas have a high rate of prolapse and so I think there's a lot more to be done in understanding differences and disparities in care and also disparities in FSD. Next question says, for quality of care research, what is the process of determining metrics to determine high versus low quality care? Ooh, oh, I love that. Okay, so that's interesting. We developed what's called a quality of care indicator, which uses the Delphi method, which is a RAND appropriateness method. So this was some work I did as a junior faculty and we brought together a whole panel of specialists in urogyne, urology and primary care and develop what's called quality measures. But it's interesting because a lot of work's been done through the OGS Quality Committee and even AHRQ has put together a lot of measures for primary care docs. So when you think about high versus low quality, you wanna think about an equality measure as opposed to a clinical guideline, which we talk about the ceiling of care, a quality measure is really the floor of care. And so that's like, you should do a urinalysis, right? Or before a sling, you should do a post-void residual so you can kind of predict if they're gonna have trouble emptying. So there's a few different measures. So you have quality measures, which are often made by governing bodies and the OGS Quality Committee has done a lot of great work, but also many governing bodies have developed such metrics and you can use those in research as if you wanna like measure care, you're gonna look at those process measures, right? So you have structural measures, process measures and outcomes. So most of the measures that are actually measurable in the medical record are those process measures, like was this care done, right? And then we have a third question. Are there any additional health utilization frameworks in addition to the Anderson model that trainees should be aware of when doing health services research? I can think on my feet, but I'm gonna try. So I'm boring and biased, cause that's what I used, but there are like Pachanski's model. I'm totally winging this right now, by the way, I'm just quick on my feet, right? Pachanski's model, there's also like the IOM model of access monitoring and then the Anderson behavioral model. So there really are, there are, you know, and that's, this is a, I just, I'm talking on an aside, but the funniest thing I love messing with my, my fellow Kai Dallas, he's going next year to City of Hope, but he's like my statistician fellow. So I have like my FSD expert, Sasha, and then my statistician, Kai, and he helped me write a grant, which he's really good at understanding administrative codes and so, but grants, they want like a conceptual model. And the funniest thing I did was try to ask like a statistician to come up with a conceptual model, cause it's really, it's a very non-concrete way of thinking, but so a conceptual model is sort of like how you frame your research. Like, for example, with urinary incontinence, we look at a chronic care model, bringing the patient in to have like self efficacy, be part of their care. So anyway, but so there are other models in how you can sort of talk about access to care, but I'm most knowledge about, knowledgeable about the Anderson model. I think that's because, because I got my MPH at UCLA, that was sort of the focus, but how you look up models is, just going online and looking up models, but also asking sort of experts at your institution, what model they want. And sometimes it's really tricky. Like we're trying to look up frailty models and I'm asking experts in geriatrics and they're like, well, use this and use this. And like, I don't know if we ended up, I don't think we use the right one cause we didn't even get our grants scored, but anyway, so that's a long-winded answer to, yes, there's definitely other models. I think that Anderson's pretty comprehensive. So I do like that one when you're sort of looking at access for the first time. Yeah. And it says, what are your thoughts on the role of cost effectiveness analysis in health services research? Too many assumptions, helpful to determine best practices? I think it's really important, especially when we're looking at, like we're in a, you know, when you're in your own healthcare system, like our medical group is very focused on high value care. And so when you look at cost effectiveness and comparing two different, so in comparing two different strategies, you know, I think it is important to look at the cost of those practices. Now, where is it not that realistic? Well, we know that robotic is gonna be much more, well, it's case for case, it's probably similar in cost to laparoscopic copeplexy, but there's this whole $2 million robot that you have to pay for upfront. So we know robotic is more expensive. At the same time, there's a lot more of us who are good at robots than those of us who are good at lap. Maybe I'm speaking for urologists alone or maybe just myself. But so even if I know lap is cheaper, I have a robot, I'm gonna use it. Our institute has like, we have a lot of robots, so we're gonna use those. So that's where cost effectiveness, I think sometimes isn't always prioritized. But we've looked at things like, you can look at really simple ways to reduce cost is like we standardize, my partner, Karen Albers, standardize our tray for slings, because there's a few different docs who make a tray. And it actually made it a lot cheaper just by sort of reducing instruments. So I think cost is important and probably we need to look at it more and make more decisions around costs than we actually do. Would you recommend obtaining an MPH degree to become an expert in health services research like Dr. Enger? Oh, that's not what my fellow is like messing with me. So my mentor, Dr. Litwin said, you need an MPH to be taken seriously in health services research. And I think it adds value, especially if you're interested in a trajectory where you wanna apply for grants, which is really another talk in and of itself that it implies that you're serious about it. I'll be honest, I had this really amazing clinical fellowship. And then I kind of, I was like trying to get back to LA because my husband was here. You know, we were like long distance. It was a nightmare. I was like seven months pregnant. And then I ended up like kind of landing in LA and starting my fellowship. And I was like, I had this amazing clinical year. And then all of a sudden I'm like five week old baby and I'm taking classes with these like young kids who just finished college. And I'm like totally stopped operating. And so at the time I was like, why am I doing this? And you know, and in retrospect, I wish I like, I let it, I was just trying to survive. You know, when you have a young baby, it like kind of, you know, the other, like I wasn't able to really get as much out of my master's degree as I could have. Cause now I'm like, God, I wish I could like do that again. But I did learn a lot of really valuable methods from my master's classes. And I think it is valuable if you're interested in health services research and maybe NIH funding. If you're interested more in like an administrative role, you can get like administrative degrees. And if you're interested in business, you can get an MBA. So I would, you know, if you're thinking about an advanced degree, you want to sort of tailor it to what you want to do and make sure that it's like a right fit. Cause it's not, if you don't really want to do it, it can be, it's not a lot of work. I mean, we're doctors. It's nothing like medical school in terms of like, you know, degree of difficulty. But it is, it is like, it took me, like, you know, it was a one-year program, but it took me a couple of years cause I had like two babies in a row. But, you know, if you have that sort of, if you have, you know, you guys have a research year, it is a nice, you can kind of squeeze it in sometimes during your fellowship. And that is something that you could really do if you get that protected time. Okay, I think, I don't see any more questions coming in. Those were really great questions. Any other thoughts before I close it out? It's 6.58, that was fantastic. All right, oh, thanks so much for having me. And I'm available if anyone has any questions, I'm always happy to talk to you. So you can always email me, angerj.cshs.org, which is Cedars-Sinai Health System. Or you can tweet, you can message me on Twitter. Yep, so on behalf of AUGS, I'd like to thank Dr. Anger and everyone for joining us today. Our next FPMRS webinar will be held on Wednesday, April 14th at 7 p.m. Eastern time. Please visit the AUGS website to sign up and remember that this was recorded. So if you know someone who missed it and would benefit from this, please, please, please tell them to go check it out. And again, thank you so much, Dr. Anger, for your time. We appreciate it. Thanks so much. Thank you. Bye-bye.

Health Services Research

FPMRS

Female Pelvic Medicine and Reconstructive Surgery

Webinar

Dr. Jennifer Anger

Female Sexual Dysfunction

Disparities in Care

Cost-Effectiveness Analysis

Master of Public Health