Delivering an effective outpatient service in gynaecology: an assessment of patient preference

Marsh, Fiona; Taylor, L.J.; Kremer, Christian; Black, Jean; Duffy, Sean

doi:10.1111/j.1365-2508.2002.00543.x

Cited by 10 publications

(9 citation statements)

References 6 publications

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“…Nowadays, diagnostic hysteroscopy is performed according to the so‐called vaginoscopic approach without use of speculum or tenaculum, reducing discomfort significantly 101 . Furthermore, as a result of recent advances in endoscopic instrumentation there is evidence suggesting that outpatient therapeutic hysteroscopic procedures provide significant cost savings and are preferred by women compared to day case procedures 102,103 . Whether these improvements make diagnostic hysteroscopy comparable to saline infusion sonography regarding cost‐effectiveness and patient compliance remains unclear.…”

Section: Discussionmentioning

confidence: 99%

Diagnostic hysteroscopy in abnormal uterine bleeding: a systematic review and meta‐analysis

Dongen

Kroon

Jacobi

et al. 2007

BJOG

212

105

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Background This study was conducted to assess the accuracy and feasibility of diagnostic hysteroscopy in the evaluation of intrauterine abnormalities in women with abnormal uterine bleeding.Search strategy Electronic databases were searched from 1 January 1965 to 1 January 2006 without language selection. The medical subject heading (MeSH) and textwords for the following terms were used: hysteroscopy, diagnosis, histology, histopathology, hysterectomy, biopsy, sensitivity and specificity.Setting University Hospital.Selection criteria The inclusion criteria were report on accuracy of diagnostic hysteroscopy in women with abnormal uterine bleeding compared to histology collected with guided biopsy during hysteroscopy, operative hysteroscopy or hysterectomy.Data collection and analysis Electronic databases were searched for relevant studies and references were cross-checked. Validity was assessed and data were extracted independently by two authors. Heterogeneity was calculated and data were pooled. Subgroup analysis was performed according to validity criteria, study quality, menopausal state, time, setting and performance of the procedure. The pooled sensitivity, specificity, likelihood ratios, post-test probabilities and feasibility of diagnostic hysteroscopy on the prediction of uterine cavity abnormalities. Post-test probabilities were derived from the likelihood ratios and prevalence of intrauterine abnormalities among included studies. Feasibility included technical success rate and complication rate.Main results One population of homogeneous data could be identified, consisting of patients with postmenopausal bleeding. In this subgroup the positive and negative likelihood ratios were 7.9 (95% CI 4.79-13.10) and 0.04 (95% CI 0.02-0.09), raising the pretest probability from 0.61 to a post-test probability of 0.93 (95% CI 0.88-0.95) for positive results and reducing it to 0.06 (95% CI 0.03-0.13) for negative results. The pooled likelihood ratios of all studies included, calculated with the random effects model, were 6.5 (95% CI 4.1-10.4) and 0.08 (95% CI 0.07-0.10), changing the pre-test probability of 0.46 to post-test probabilities of 0.85 (95% CI 0.78-0.90) and 0.07 (0.06-0.08) for positive and negative results respectively. Subgroup analyses gave similar results. The overall success rate of diagnostic hysteroscopy was estimated at 96.9% (SD 5.2%, range 83-100%).Conclusions This systematic review and meta-analysis shows that diagnostic hysteroscopy is both accurate and feasible in the diagnosis of intrauterine abnormalities.

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Section: Discussionmentioning

confidence: 99%

Diagnostic hysteroscopy in abnormal uterine bleeding: a systematic review and meta‐analysis

Dongen

Kroon

Jacobi

et al. 2007

BJOG

212

105

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“…These include the avoidance of general anaesthesia and its associated risks, faster return to normal activities and less time away from home and work 7 . Furthermore, there is evidence to suggest that outpatient gynaecological procedures provide significant cost savings and are preferred by women when compared with daycase procedures 8,9 …”

Section: Introductionmentioning

confidence: 99%

A randomised controlled trial comparing outpatient versus daycase endometrial polypectomy

Marsh

Rogerson

Duffy

2006

BJOG

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Objective To evaluate outpatient versus daycase endometrial polypectomy by comparing success rate, complications, patient tolerance, pain score, analgesia requirement and recovery.Design A randomised controlled trial.Setting A large UK Teaching hospital.Population Forty consecutive women diagnosed with an endometrial polyp at outpatient hysteroscopy were randomly assigned in equal proportions to outpatient or daycase polyp removal.Methods The outpatient cohort underwent endometrial polypectomy either using grasping forceps or a bipolar electrode (Versapoint TM ; Gynecare Inc., Menlo Park, CA, USA) introduced down the operating channel of a rigid hysteroscope (Versascope TM ; Gynecare Inc.). The daycase cohort underwent traditional endometrial polyp resection using a hysteroscopic, monopolar, electrosurgical resecting loop, performed under general anaesthetic.Main outcome measures The main outcome measures were as follows: success rates and intra or postoperative complications, time away from home, analgesia requirements, pain scores on the day of and one day after endometrial polypectomy, return to work and preoperative fitness and preference for the location of a future endometrial polypectomy.Results The majority of women from both cohorts were premenopausal (62.5%), parous (85%) and in paid employment (62.5%). One woman allocated to outpatient polypectomy had cervical stenosis and dilatation was unsuccessful in the outpatient setting. There were no other intra or postoperative complications in either arm of the study. The mean intraoperative visual analogue style (0-100 mm) pain score during outpatient polypectomy was 23.7 mm (1-62). A proportion of women (20%) described no intraoperative discomfort; however, the majority (75%) described mild or moderate intraoperative discomfort. More women in the outpatient cohort (58%) described themselves as pain free for the remainder of the day than in the daycase cohort (28%) (P = 0.09). The day after the procedure, all women from the outpatient group described slight or no discomfort compared with only 41% of women from the daycase group (P = 0.02). All women undergoing outpatient polypectomy had a significantly shorter mean time away from home (3.24 [1.5-5] hours) than women undergoing daycase polypectomy (7.42 [6-10.5] hours), P < 0.0005. Similarly, women from the outpatient cohort had a significantly faster mean return to preoperative fitness (1 [0-4] day versus 3.2 [1-13] days; P = 0.001) and required less postoperative analgesia than the daycase cohort. Ninety-five percent of women from the outpatient cohort and 82% of women from the daycase cohort stated they would prefer to undergo an endometrial polypectomy in the outpatient setting should they require a further polyp removal.Conclusion Endometrial polypectomy can be successfully performed in the outpatient setting with minimal intraoperative discomfort, a significantly shorter time away from home and faster recovery and is preferred by women when compared with daycase polypectomy. Resources need to be made ra...

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“…The reasons for the under‐utilisation of this service might include a perceived lack of women who would want the service, expensive capital outlay to purchase the equipment and a lack of expertise within the unit. However, a survey of women's preferences show they would favour an outpatient hysteroscopy if given a choice between that and daycase hysteroscopy 8 . This study has shown that although there is a higher capital equipment cost when setting up the outpatient hysteroscopy service, an overall cost saving is soon seen when compared with daycase hysteroscopy.…”

Section: Discussionmentioning

confidence: 84%

Delivering an effective outpatient service in gynaecology

Marsh

Kremer

Duffy

2004

BJOG

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Objective To examine the cost implications of outpatient versus daycase hysteroscopy to the National Health Service, the patient and their employer. Design and interventions Randomised controlled trial.Setting The gynaecology clinic of a large teaching hospital.Participants Ninety-seven women with abnormal uterine bleeding requiring investigation.Methods Women were randomly allocated to either outpatient or daycase hysteroscopy. They were asked to complete diaries recording expenses and time off work. The National Health Service costs were calculated for a standard outpatient and daycase hysteroscopy. Main outcome measures Costs to the National Health Service, costs to the employer, loss of income, childcare costs and travel expenses. Results The outpatient group required significantly less time off work compared with the daycase group (0.8 days vs 3.3 days), P < 0.001. Of those women who lost income due to the hysteroscopy, the average loss of income was twice as much in the daycase group (£20.40 in the outpatient group vs £50.60 in the daycase group). The average cost of childcare required to cover the time spent in hospital undergoing the hysteroscopy was similar in both groups, however, the number of women requiring childcare was small. Travel costs incurred by the women were 74% more in the daycase group compared with the outpatient group -with an average cost of £3.46 in the outpatient group and £6.02 in the daycase group. Daycase hysteroscopy costs the National Health Service approximately £53.88 more per patient, than performing an outpatient hysteroscopy. Purchasing the hysteroscopes necessary to perform an outpatient hysteroscopy is a more expensive outlay than those required for daycase hysteroscopy. However, there are so many other savings that only 38 patients need to undergo outpatient hysteroscopy (even with a 4% failure rate) rather than daycase hysteroscopy in order to recoup the extra money required to set up an outpatient hysteroscopy service. Conclusion Outpatient hysteroscopy offers many benefits over its traditional counterpart including faster recovery, less time away from work and home and cost savings to the woman and her employer and the National Health Service. Resources need to be made available to rapidly develop this service across the UK in order to better serve both patient and taxpayer.

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Delivering an effective outpatient service in gynaecology: an assessment of patient preference

Cited by 10 publications

References 6 publications

Diagnostic hysteroscopy in abnormal uterine bleeding: a systematic review and meta‐analysis

Diagnostic hysteroscopy in abnormal uterine bleeding: a systematic review and meta‐analysis

A randomised controlled trial comparing outpatient versus daycase endometrial polypectomy

Delivering an effective outpatient service in gynaecology

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