By Chiara Ghetti, MD
Associate Professor of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO
Dr. Ghetti reports no financial relationships relevant to this field of study.
Synopsis: Quality can be measured for women with pelvic organ prolapse, and in many areas the care of women with pelvic organ prolapse can be improved.
Source: Alas AN, et al. Measuring the quality of care provided to women with pelvic organ prolapse. Am J Obstet Gynecol 2015;212:471.e1-9.
The objective of this study was to assess the feasibility of recently developed quality indicators in the care of women with pelvic organ prolapse and identify areas with possible deficits in care. Previously, an expert panel developed quality indicators that addressed screening, diagnosis, and management of prolapse. Study subjects were identified in a hospital-based multispecialty group based on ICD-9 code for prolapse (codes 618.0-618.9), and eligible subjects needed to have a complaint of prolapse and qualify for at least one quality indicator. Trained nurses with experience in chart abstraction and quality assessment performed a retrospective chart abstraction. Care was assessed at the patient level, and abstractors considered all parts of the patient’s records when assessing whether a patient was eligible for and received the indicated care over a 6-month period of time. Ten percent of records were reabstracted to evaluate the interrater agreement, which was 97%.
In the 238 patients identified, 98% of those with a new complaint of prolapse had a pelvic exam. The extent of prolapse was not documented in 25%. Only 43% of records had documentation that pessary management was discussed with a patient. Among those managed with pessaries, the majority (98%) had vaginal exams at least every 6 months. Of those undergoing surgery, only 49% had complete prolapse staging preoperatively. Only 20% of women having apical surgery had documented counseling about different surgical options. Only 48% of women undergoing hysterectomy for prolapse had a concomitant vault suspension. Only 14% of patients had documented counseling regarding risks of mesh, and only one-third of women implanted with mesh for prolapse had documented follow-up at 1 year. In the majority of women (86%) undergoing anterior wall or apical repair, cystoscopy was performed.
COMMENTARY
Today’s healthcare environment is increasingly focused on patient-centered clinical outcomes and quality assessment and improvement. In recent years, the American Urogynecologic Society determined that quality-of-care research is needed in the area of pelvic floor disorders.1 This is one of the first studies evaluating the feasibility of assessing quality indicators in the care of women with prolapse. It also identified that care was insufficient and that only two-thirds of patients receive the minimum of care, including recommended evaluation, treatment, and follow-up, based on the quality indicators for which they qualified. A multispecialty group that included primary care providers, female pelvic medicine and reconstructive surgery specialists, general gynecologists, and urologists cared for the patients in the study.
Five of the 14 reported quality indicators were most striking in lack of compliance. These include: 1) documenting the extent of prolapse in all comportments (anterior, posterior, and apical); 2) ensuring all women with prolapse are offered conservative management as a first-line treatment; 3) counseling women who undergo surgery for an apical defect about alternative surgical approaches, unique success and failure rates, and complication profiles; 4) counseling women undergoing transvaginal mesh placement about the risk of mesh complications; and 5) performing concomitant apical support procedures at time of hysterectomies for prolapse. The findings of this study can serve as a basis for quality improvement interventions in our own practices.
While not a randomized trial, the findings of this study have immediate clinical impact to gynecologists and subspecialists alike. This study demonstrates that quality indicators can be successfully used to assess the care delivered to patients with prolapse. Most likely, hospitals, payers, and patients will use quality indicators in the near future to measure the quality of care provided by physicians. For providers who currently care for women with prolapse, quality indicators will likely be adopted that are very similar to those used in this study. It would behoove us to become familiar with these indicators and begin to incorporate them in our daily practice.
REFERENCE
- Nygaard I, et al. Summary of research recommendations from the Inaugural American Urogynecologic Society Research Summit. Female Pelvic Med Reconstr Surg 2011;17:4-7.
Quality can be measured for women with pelvic organ prolapse, and in many areas the care of women with this condition can be improved.
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