Gynaecology version 7

GENERAL COMMENTS

Dr Martin Ritossa Royal Australian and New Zealand College of Obstetricians and Gynaecologists Chair, ACHS Gynaecology Working Party Version 7

Dr Vijay Roach President, Royal Australian and New Zealand College of Obstetricians and Gynaecologists

Thank you to the HCOs that contributed to Gynaecological indicators in 2019. Participation continues to remain strong and it was good to see the greatest number of units choosing to participate in 2.1 Gynaecological surgery, injury to a major viscus which shows a strong focus on surgical quality.

Unplanned blood transfusion rates following surgery for benign conditions continue to fall, with a rate of 0.57 per 100 patients being the second lowest rate recorded. Unplanned blood transfusions following malignant disease remains stable at a rate of 6.5 per 100 cases, lower than last year. The outlier HCO rate for unplanned blood transfusion in benign disease was 3 times that of the average, suggesting room for improvement at some institutions. Whether this is due to surgical bleeding rates or transfusion protocols cannot be determined from this data but outlier HCO's should review their policies and procedures regarding blood transfusions.

Injury to a major viscus at gynaecology continues to trend down after a worrying spike in 2015/16. The rate of 0.18 per 100 cases suggests a high standard of surgical care in the participating units. One confounding factor may be the denominator which includes all gynaecological procedures. Given the decreasing hysterectomy rate and the increase of safer surgical alternatives such as endometrial ablation, the falling rate may be due to procedure selection rather than surgical technique. Regardless, it is a good outcome for our patients. There were six outlier HCOs whose rate were 1.5 per 100 patients, eight times the average rate. When incidents occur once or twice a year it is difficult to tell the difference between a cluster of cases and a worrying trend. Units should continue to regard injury to a major viscus as a significant event and review each case for educational and quality purposes.

Laparoscopic management of ectopic pregnancy is a marker for the uptake of laparoscopic surgery in the community and more importantly good quality care. Overall rates remain high and are trending up with the rate of 91.4 per 100 patients being the highest recorded. There were two outlier HCOs with a rate of 67.9 per 100 patients which has deteriorated. This may be due to patient complexity but also may indicate the skills of the surgeons or the equipment available. Having a team and equipment available to manage an ectopic pregnancy laparoscopically, should be considered essential for any specialist run unit.

Rates of thomboprophylaxis for major surgery remains high and continues to rise with a rate 99.4%. This is an outstanding result however, it is disappointing that only seven HCOs participated in this indicator. It is most likely that the reason for this is the difficulty in retrieving the data in paper-based system.

GYNAECOLOGY

The rate of mesh repair for pelvic organ prolapse, which includes trans-abdominal mesh for prolapse repair, has fallen in 2019 to 4.1 per 100 patients. This is a procedure that should only be performed for very specific indications in specialised units by appropriately credentialed surgeons. Of note all trans-vaginal mesh products for the repair of prolapse have been removed from the market. Even though abdominal placement of mesh is a recognised procedure for recurrent prolapse, we would expect this procedure to be performed in a small number of patients. Any outlier HCOs should undertake a review of procedures and policies in regard to mesh procedures for prolapse. It should be noted that urogynaecology subspecialty units would be expected to have a higher rate due to a referral bias.

The indicators would suggest that hysterectomy rates are continuing to fall and although the rate of 21.2 per 100 was higher than last year it is the second lowest recorded. Nonmetropolitan hospitals had a lower rate than metropolitan hospitals, which has not always been the case. There were two outlier HCOs with twice the rate of hysterectomy resulting in potentially 40 more women undergoing a hysterectomy than required. It is difficult to say whether this is a true difference or whether the variations are due to patient demographics. Overall the decreasing rate show an increased uptake in conservative treatments for menorrhagia.

In summary all the indicators are trending in the correct direction which is a credit to these indicators and all the participating HCOs.

GYNAECOLOGY

SUMMARY OF RESULTS

In 2019 there were 328 submissions from 56 HCOs for 8 CIs. Seven were analysed for trend, 6 of which improved and the remainder showed no evidence of trend. In 2019, significant stratum variation was observed in 2 CIs. Four CIs showed greater systematic variation, with centile gains in excess of 50% of all events. Outlier gains in excess of 25% of all events were observed in 1 CI. See Table of Indicator Results below.

Table of Indicator Results

Indicator

Blood transfusion 1.1 Gynaecological surgery for benign disease - unplanned intraoperative or postoperative blood transfusion (L) 1.2 Gynaecological surgery for malignant disease - unplanned intraoperative or postoperative blood transfusion (L) Aggregate rate %

Best Stratum Outlier HCOS (%)* Outlier Gains (%)+ Centile Gains (%)+ Events# Trend

0.57 Private 2 (5%) 18 (8%) 160 (75%) 212

6.5 1 (6%) 8 (9%) 21 (25%) 85

Injury to a major viscus 2.1 Gynaecological surgery - injury to a major viscus with repair (L) Laparoscopic management of an ectopic pregnancy 3.1 Ectopic pregnancy managed laparoscopically (H) 0.18 5 (9%) 30 (24%) 89 (72%) 124

91.4 NSW 2(7%) 9(17%) 34(63%) 54

Thromboprophylaxis for major gynaecological surgery 4.1 Thromboprophylaxis for major gynaecological surgery (H) 99.4 4.2 Re-admission for venous thromboembolism within 28 days (L) 0.041

Mesh repair 5.1 Use of mesh repair for pelvic organ prolapse (L) 4.0 6

1

2 (15%) 9 (33%) 22 (81%) 27

Menorrhagia 6.1 Surgical intervention for menorrhagia (L) 21.2 2 (15%) 40 (10%) 111 (29%) 389

# Number of undesirable or non-compliant events + % of events accounted for by outlier/centile gains * % of HCOs that are outliers