Jennifer T Anger

Cedars-Sinai Medical Center, Los Ángeles, California, United States

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Publications (124)412.12 Total impact

  • Jennifer Anger · Karyn Eilber
    Evidence-Based Medicine 09/2015; DOI:10.1136/ebmed-2015-110254
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    ABSTRACT: To identify areas of overuse and underuse in the preoperative evaluation of patients undergoing mid-urethral sling (MUS) surgery. We also estimated the effect of overuse of preoperative testing on health care costs. A retrospective review of women who underwent sling surgery with or without concomitant prolapse repair between 2012 and 2013 was conducted. Physician orders for preoperative electrocardiogram (ECG), chest x-ray (CXR), basic metabolic panel (BMP), complete blood count (CBC), coagulation studies, and urinalysis (UA) were classified as appropriate or inappropriate based on summary guidelines from the American Academy of Family Physicians. The additional costs for inappropriate tests were estimated using the 2014 Medicare clinical laboratory and physician fee schedules. A total of 101 women who underwent MUS surgery were identified, and 346 preoperative tests were ordered. Seventy-six percent of coagulation profiles, 73% of CBCs, 47% of BMPs, 39% of CXRs, and 21% of ECGs ordered did not have an appropriate clinical indication. Six percent of ECGs and 22% of CXRs, and 10% of UAs were not ordered despite an appropriate indication. The estimated charges of overused tests were $1,844.15 for the cohort, or $18 per patient. Preoperative testing is both overused and underused in patients undergoing sling surgery. The greatest variation occurred with the use of ECGs, CXRs, and UAs. Poor adherence to national guidelines leads to increased health care costs and warrants the need for awareness to follow evidence-based guidelines. Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
    The Journal of urology 08/2015; DOI:10.1016/j.juro.2015.07.110 · 4.47 Impact Factor
  • Alexandriah N Alas · Jennifer T Anger
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    ABSTRACT: Pelvic organ prolapse is a prevalent condition, with up to 12 % of women requiring surgery in their lifetime. This manuscript reviews the treatment options for apical prolapse, specifically. Both conservative and surgical management options are acceptable and should be based on patient preferences. Pessaries are the most commonly used conservative management options. Guided pelvic floor muscle training is more beneficial than self-taught Kegel exercises, though may not be effective for high stage or apical prolapse. Surgical treatment options include abdominal and vaginal approaches, the latter of which can be performed open, laparoscopically, and robotically. A systematic review has demonstrated that sacrocolpopexy has better long-term success for treatment of apical prolapse than vaginal techniques, but vaginal surgery can be considered an acceptable alternative. Recent data has demonstrated equal efficacy between uterosacral ligament suspension and sacrospinous ligament suspension at 1 year. To date, two randomized controlled trials have demonstrated equal efficacy between robotic and laparoscopic sacrocolpopexy. Though abdominal approaches may have increased long-term durability, when counseling their patients, surgeons should consider longer operating times and increased pain and cost with these procedures compared to vaginal surgery. • Pelvic floor physical therapy (PFPT) with a physical therapist is the best approach to conservative management of apical prolapse [10]. • Pessaries should be managed with regular follow-up care to minimize complications [14•]. • Minimally invasive sacrocolpopexy appears as effective as the gold standard abdominal sacrocolpopexy (ASC) [42•]. • Robotic assisted sacrocolpopexy (RASC) and laparoscopic assisted sacrocolpopexy (LASC) are equally effective and should be utilized by pelvic floor surgeons based on their skill level and expertise in laparoscopy [44, 45•]. • Uterosacral ligament suspension (USLS) and sacrospinous ligament suspension (SSLS) are considered equally effective procedures and can be combined with a vaginal hysterectomy. • Obliterative procedures are effective but are considered definitive surgery [24••]. • The use of transvaginal mesh has been shown in some studies to be superior to native tissue repairs with regard to anatomic outcomes, but complication rates are higher. Transvaginal mesh should be reserved for surgeons with adequate training so that complications are minimized.
    Current Urology Reports 05/2015; 16(5):498. DOI:10.1007/s11934-015-0498-6 · 1.51 Impact Factor
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    The Journal of Urology 04/2015; 193(4):e573. DOI:10.1016/j.juro.2015.02.450 · 4.47 Impact Factor
  • The Journal of Urology 04/2015; 193(4):e281. DOI:10.1016/j.juro.2015.02.1155 · 4.47 Impact Factor
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    The Journal of Urology 04/2015; 193(4):e644-e645. DOI:10.1016/j.juro.2015.02.1900 · 4.47 Impact Factor
  • The Journal of Urology 04/2015; 193(4):e474. DOI:10.1016/j.juro.2015.02.1436 · 4.47 Impact Factor
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    The Journal of Urology 04/2015; 193(4):e1048. DOI:10.1016/j.juro.2015.02.2016 · 4.47 Impact Factor
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    The Journal of Urology 04/2015; 193(4):e282. DOI:10.1016/j.juro.2015.02.1157 · 4.47 Impact Factor
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    ABSTRACT: Over 90,000 legal claims for complications related to transvaginal mesh have been filed to date. Safety issues specifically related to the use of transvaginal mesh for pelvic organ prolapse have not been appropriately differentiated from the use of mesh for stress urinary incontinence by either attorneys or the media. This litigious environment and nebulous communication on the safety issues have led to patient and physician concern regarding mesh slings for the treatment of stress urinary incontinence. The ultimate result is likely to be a decrease in use of the gold standard of care for stress urinary incontinence—the mid-urethral synthetic sling.
    Current Bladder Dysfunction Reports 03/2015; 10(1). DOI:10.1007/s11884-014-0278-z
  • Winter Meeting of the; 02/2015
  • Winter Meeting of the; 02/2015
  • Journal of Investigative Medicine 01/2015; 63(1):157-157. · 1.69 Impact Factor
  • Journal of Investigative Medicine 01/2015; 63(1):161-162. · 1.69 Impact Factor
  • Christopher J Dru · Jennifer T Anger
    BMJ Clinical Research 12/2014; 349(dec22 2):g7698. DOI:10.1136/bmj.g7698 · 14.09 Impact Factor
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    ABSTRACT: Introduction and hypothesis: Limited data exist on women's experience with pelvic organ prolapse (POP) symptoms. We aimed to describe factors that prevent disease understanding among Spanish-speaking and English-speaking women. Methods: Women with POP were recruited from female urology and urogynecology clinics in Los Angeles, California, and Albuquerque, New Mexico. Eight focus groups were conducted, four in Spanish and four in English. Topics addressed patients' emotional responses when noticing their prolapse, how they sought support, what verbal and written information was given, and their overall feelings of the process. Additionally, patients were asked about their experience with their treating physician. All interview transcripts were analyzed using grounded theory qualitative methods. Results: Qualitative analysis yielded two preliminary themes. First, women had misconceptions about what POP is as well as its causes and treatments. Second, there was a great deal of miscommunication between patient and physician which led to decreased understanding about the diagnosis and treatment options. This included the fact that women were often overwhelmed with information which they did not understand. The concept emerged that there is a strong need for better methods to achieve disease and treatment understanding for women with POP. Conclusions: Our findings emphasize that women with POP have considerable misconceptions about their disease. In addition, there is miscommunication during the patient-physician interaction that leads to further confusion among Spanish-speaking and English-speaking women. Spending more time explaining the diagnosis of POP, rather than focusing solely on treatment options, may reduce miscommunication and increase patient understanding.
    International Urogynecology Journal 12/2014; 26(4). DOI:10.1007/s00192-014-2562-z · 1.96 Impact Factor
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    ABSTRACT: Health care providers are increasingly being evaluated by the quality of care they provide. Our aim was to assess the feasibility of recently developed quality indicators (QIs) for pelvic organ prolapse (POP) and identify possible deficits in care. A panel ranked 14 QIs based on the RAND appropriateness method assessing screening and diagnosis, pessary management, and surgery for POP. Retrospective chart abstraction was performed after identifying patients with a diagnosis of POP evaluated within a hospital-based multispecialty group using International Classification of Diseases, ninth edition, diagnosis codes. Of 283 patients identified, 98% of those with a new complaint of vaginal bulge had a pelvic examination. The POP was described but not staged in 6% and not documented at all in 25.1%. Among those managed with pessaries, 98% had vaginal examinations at least every 6 months. Forty-nine percent of the patients who had surgery had complete preoperative POP staging. Only 20% of women undergoing apical surgery had documentation of counseling regarding different surgical options, and of the women who underwent a hysterectomy for POP, only 48% had a concomitant vault suspension. Although 71% had documentation about the risk of postoperative stress incontinence, only 14.5% had documented counseling regarding risks of mesh. Only 37% of patients implanted with mesh for POP had documented follow-up at 1 year. An intraoperative cystoscopy was performed in 86% undergoing cystocele repair or apical surgery. The quality of care for women with POP can be feasibly measured with QIs. Processes of care were deficient in many areas, and our findings can serve as a basis for quality improvement interventions. Copyright © 2015 Elsevier Inc. All rights reserved.
    American Journal of Obstetrics and Gynecology 10/2014; 212(4). DOI:10.1016/j.ajog.2014.10.1105 · 4.70 Impact Factor
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    ABSTRACT: Interstitial cystitis/painful bladder syndrome (IC) is a chronic syndrome of unknown etiology that presents with bladder pain, urinary frequency, and urgency. The lack of specific biomarkers and a poor understanding of underlying molecular mechanisms presents challenges for disease diagnosis and therapy. The goals of this study were to identify non-invasive biomarker candidates for IC from urine specimens and potentially gain new insight into disease mechanisms using a nuclear magnetic resonance (NMR)-based global metabolomics analysis of urine from female IC patients and controls. Principal component analysis (PCA) suggested that the urinary metabolome of IC and controls was clearly different, with 140 NMR peaks significantly altered in IC patients (FDR<0.05), compared to controls. Based on strong correlation scores, eight metabolite peaks were nominated as the strongest signature of IC. Among those signals that were higher in the IC groups, three peaks were annotated as tyramine, the pain-related neuromodulator. Two peaks were annotated as 2-oxoglutarate. Levels of tyramine and 2-oxoglutarate were significantly elevated in urine specimens of IC subjects. An independent analysis using mass spectrometry also showed the significantly increased levels of tyramine and 2-oxoglutarate in IC patients, compared to controls. Functional studies showed that 2-oxoglutarate, but not tyramine, retarded growth of normal bladder epithelial cells. These preliminary findings suggest that analysis of urine metabolites has promise in biomarker development in the context of IC.
    Journal of Proteome Research 10/2014; 14(1). DOI:10.1021/pr5007729 · 4.25 Impact Factor
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    ABSTRACT: Aims In the last decade, many new surgical treatments have been developed to achieve less invasive approaches to prolapse management. However, limited data exist on how the patterns of care for women with pelvic organ prolapse (POP) may have changed over the last decade, and whether mesh implantation techniques have influenced the type of specific compartment repair performed. We used a national dataset to analyze the temporal trends in patterns of care for women with pelvic organ prolapse. Methods Data were obtained from Public Use Files from the Centers for Medicare and Medicaid for a 5% random sample of national beneficiaries with an ICD-9-CM diagnosis of POP from 1999 to 2009. CPT-4 and ICD-9-CM procedure codes were used to evaluate non-surgical and surgical management trends for this cohort. Types of surgery were categorized by prolapse compartment and combinations of repairs. After 2005, when applicable codes became available, mesh or graft repairs were also analyzed. Results Over the study time period, the number of women with a diagnosis of pelvic organ prolapse in any one year in our 5% sample of Medicare beneficiaries remained relatively stable (range 21,245 and 23,268 per year). Rates of pessary insertion were also consistent at 11-13% over the study period. Of the women with a prolapse diagnosis, 14-15% underwent surgical repair, and there was little change over time in surgical management patterns based on compartment. Most commonly, multiple compartments were repaired simultaneously. There was a rapid increase in mesh use such that in 2009, 41% of all women who underwent surgery (5.8% of the total cohort) had mesh or graft inserted in their repair. Hysterectomy rates for prolapse decreased over time. Rates of vault suspension at the time of hysterectomy for prolapse were low, however showed a relative increase over time (22% in 1999 to 26% in 2009). Conclusions Patterns and rates of prolapse repairs remained relatively unchanged from 1999 to 2009, with an exception of a rapid rise in mesh use. These data suggests that the majority of mesh techniques were used for augmentation purposes only, but did not result in an increase in apical repairs performed in the U.S. There remains a disappointingly low rate of vault suspension repairs concomitantly at time of hysterectomy for POP.
    American Journal of Obstetrics and Gynecology 10/2014; 212(4). DOI:10.1016/j.ajog.2014.10.025 · 4.70 Impact Factor
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    Lauren N Wood · Jennifer T Anger
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    ABSTRACT: Urinary incontinence affects women of all ages. History, physical examination, and certain tests can guide specialists in diagnosing stress urinary incontinence, urgency urinary incontinence, and mixed urinary incontinence. First line management includes lifestyle and behavior modification, as well as pelvic floor strength and bladder training. Drug therapy is helpful in the treatment of urgency incontinence that does not respond to conservative measures. In addition, sacral neuromodulation, intravesical onabotulinumtoxinA injections, and posterior tibial nerve stimulation can be used in select patient populations with drug refractory urgency incontinence. Midurethral synthetic slings, including retropubic and transobturator approaches, are safe and efficacious surgical options for stress urinary incontinence and have replaced more invasive bladder neck slings that use autologous or cadaveric fascia. Despite controversy surrounding vaginal mesh for prolapse, synthetic slings for the treatment of stress urinary incontinence are considered safe and minimally invasive.
    BMJ Clinical Research 09/2014; 349(sep15 4):g4531. DOI:10.1136/bmj.g4531 · 14.09 Impact Factor

Publication Stats

1k Citations
412.12 Total Impact Points


  • 2011–2015
    • Cedars-Sinai Medical Center
      • • Cedars Sinai Medical Center
      • • Department of Surgery
      Los Ángeles, California, United States
  • 2014
    • Loyola University Chicago
      • Department of Obstetrics and Gynecology
      Chicago, Illinois, United States
  • 2004–2014
    • University of California, Los Angeles
      • • Department of Urology
      • • Department of Medicine
      Los Ángeles, California, United States
  • 2010
    • Santa Monica College
      Santa Monica, California, United States
  • 2009
    • CSU Mentor
      Long Beach, California, United States
  • 2008
    • Detroit Medical Center
      • Division of Urology
      Detroit, Michigan, United States
  • 2005–2006
    • Duke University Medical Center
      • Division of Urology
      Durham, North Carolina, United States
  • 2003–2004
    • Weill Cornell Medical College
      • Center for Male Reproductive Medicine and Microsurgery
      New York City, New York, United States