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Methodology

Process

Indicators are statistics that can describe clinical performance.  They can be used for identifying possible problems and opportunities for improvement, informing policymaking and comparative benchmarking.

A number of national initiatives are involved in improving the quality of care in gynaecology.  The RCOG clinical indicators programme aims to add to and support existing initiatives by using a rigorous, tried-and-tested approach to systematically evaluate the proposed indicators. 

We use four criteria to ensure the indicators we present are:

  • Clinically meaningful (criterion: validity)
  • Made up of events or procedures that occur frequently enough to identify variation (criterion: statistical power)
  • Able to be well-defined using the data available (criterion: technical specification)
  • Adjusted for patient characteristics that may influence indications for procedures and treatments, as well as influencing outcomes (criterion: fairness).

Fairness is particularly important and an area where this RCOG project adds to the work done by other quality improvement initiatives.  Indicators should only be used for comparative purposes where key differences between populations of patients (case-mix) have been accounted for, and many other initiatives do not do this yet.

Our aim is to illustrate national variation, not to identify individual trusts as ‘outliers’, and to demonstrate the feasibility of using routinely-collected hospital data to define performance indicators for benign gynaecology care.  This report is intended as a supportive tool to empower trusts in their existing efforts to identify causes of variation at a local level and opportunities to improve care.

 

Methods

In this report we present seven indicators.  These were selected and developed from a review of international literature, with guidance from a national group of women with experience of benign gynaecology services in the English NHS and clinical and methodological experts.  Several indicators are presented for more than one procedure, shown in the table below.  Some indicators (length of stay and emergency readmission) are also presented by type of hysterectomy, as this may influence outcomes.

 

Indicator

Procedures indicator is calculated for

Proportion of all hysterectomies conducted abdominally

Hysterectomy

 

Proportion of all hysterectomies conducted laparoscopically

Hysterectomy

 

Proportion of abdominal/laparoscopic hysterectomies conducted laparoscopically

Abdominal + laparoscopic hysterectomy

Length of inpatient stay (nights)

Hysterectomy

  •  Abdominal hysterectomy
  •  Vaginal hysterectomy
  •  Laparoscopic hysterectomy

Mid-urethral mesh tape insertions

Prolapse repair procedures

Endometrial ablation procedures

Emergency readmission to hospital within 30 days of surgery

Hysterectomy

  •  Abdominal hysterectomy
  •  Vaginal hysterectomy
  •  Laparoscopic hysterectomy

Mid-urethral mesh tape insertions

Prolapse repair procedures

Endometrial ablation procedures

Reoperation for stress urinary incontinence within 2 years of mid-urethral mesh tape insertion

Mid-urethral mesh tape insertions

Reoperation for pelvic organ prolapse within 2 years of pelvic organ prolapse repair

Prolapse repair procedures

 

We use data from a database called Hospital Episode Statistics, or HES. All inpatient admissions to NHS hospitals in England are captured in HES. These data are collected during a patient's time in hospital and allows hospitals to be paid for the care they provide. These data can also be used for research and planning health services. HES captures a range of information about each inpatient admission, including:

  • clinical information about diagnoses and operations
  • patient information, such as age group, gender and ethnicity
  • administrative information, such as dates and methods of admission and discharge
  • geographical information such as where patients are treated and the area where they live

We present annual statistics for each English NHS trust that met the minimum data standards for each indicator. Indicator definitions are provided in the report.

We use funnel plots to highlight variation between trusts over and above what would be expected due to chance alone, taking their size into account. This is important because the amount a trust’s indicator value may vary by chance is related to the number of procedures conducted.

We included trusts which conducted at least 500 benign gynaecology procedures in the financial year 2015/16. The impact of random fluctuations on the indicator values of trusts conducting fewer than 500 procedures per year would be large so they are excluded.

We account for patient characteristics available in HES (age, ethnicity and area-level deprivation) as these may influence indications for procedures and treatments, and outcomes. For the type of hysterectomy indicators, we also account for prolapse diagnosis, which can influence the procedure performed.