Report on benign gynaecology services in English NHS Hospital Trusts 2015-16
Benign gynaecology services make a fundamental contribution to NHS hospital services, with more than 700,000 inpatient episodes in England in 2015-16. The RCOG’s clinical indicators programme systematically evaluated indicators with clinicians and women, and adjusted for case-mix, to lead in both: providing high-quality information that allows healthcare providers & commissioners to identify priority areas for improving care for women; & in supporting other initiatives that aim to promote quality improvement. Trusts are already actively engaged in efforts to reduce unwarranted variation and improve care: this report is intended to act as an enabler to those efforts.
Key messages and recommendations
We recommend NHS trusts & clinicians in England use these indicators as a basis for reflection on current practice, to identify both causes of variation at a local level and opportunities to improve care. Together with researchers, a programme of work is also needed to begin to define acceptable levels of variation and to understand relationships between indicators.
We show that administrative hospital data can be used to develop indicators for benign gynaecology.
We present national variation in: hysterectomy type, length of stay, emergency readmission within 30 days and reoperation within two years for procedures including hysterectomy, mid-urethral mesh tape for urinary incontinence, pelvic organ prolapse repair and endometrial ablation. However, these indicators do not cover important aspects of care, such as service user experience and primary or outpatient care as these could not be derived from inpatient hospital data
- Researchers should use data linkage to create a more balanced indicator suite; priority areas should be primary care (including consultation, treatment and referral data), outpatient visits in secondary care, and patient-reported measures of clinical outcomes, quality of life & experience
More than 40% of hysterectomies for benign conditions were performed abdominally, with substantial variation (mean proportion conducted abdominally: 17-67% (lowest vs. highest decile)).
- Where technically feasible hysterectomy should be performed using a minimally invasive or vaginal route
- Trusts should review whether they provide the full range of hysterectomy types so treatment decisions are not restricted by hospital factors
There was significant variation in length of stay for procedures often considered day cases, which may reflect differences in trust-level recovery and discharge procedures, or quality of care.
- Trusts should explore reasons for longer lengths of stay locally to identify opportunities to improve care
Emergency readmission rates varied substantially for all procedures between trusts in the highest vs. lowest decile
- Trusts should locally audit their rates of, and reasons for, emergency readmission
Surgical evaluation of prolapse is subjective
- Reoperation rates following pelvic organ prolapse repair may be amenable to reduction with increases in full prolapse assessments & multi-compartment repairs
Administrative hospital data cannot capture many issues that women may have faced after surgery for prolapse repair or mid-urethral mesh tape insertion for urinary incontinence, such as pain, dyspareunia or recurrence of the original condition where these did not lead to further surgery (a ‘reoperation’).
- Any future national prospective registry of mesh tape insertions for urinary incontinence & pelvic organ prolapse should include patient-reported outcomes
One in six trusts lay outside the funnel limits for more than one indicator
- Further work is needed to understand relationships between indicators, and to consider which indicators are best suited to different aims (safety, performance assessment, quality improvement)
On 10 July 2018, NHS Improvement and NHS England wrote to all acute trust CEOs and medical directors in England advising of the immediate implementation of a high vigilance restriction period regarding vaginal mesh.
This followed the announcement by the Government of a ‘pause’ in the use of surgical mesh/tape to treat stress urinary incontinence (SUI) and vaginal prolapse where the mesh is inserted through the vaginal wall.