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Decreased waiting periods in a public pregnancy termination clinic
Contraception 77 (2008) 105 – 107
Original research article
Decreased waiting periods in a public pregnancy termination clinic Ashlesha Patel a,⁎, Hemang Panchal a , Rupesh Patel b , Louis Keith a,c a
Division of Family Planning, Department of Obstetrics and Gynecology, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL 60612, USA b Department of Maternal Fetal Medicine, Rockford Memorial Hospital, Rockford, IL 61103, USA c Section of Undergraduate Education and Medical Student Affairs, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA Received 20 February 2007; revised 23 August 2007; accepted 23 August 2007
Abstract Background: In our public hospital, first-trimester pregnancy termination historically had been performed in an operating room by suction curettage on a separate day following the initial clinic visit. To increase efficiency, we instituted three changes over a 2-year period: (a) pregnancy termination procedures were relocated to the outpatient area; (b) same-day service was initiated; and (c) manual vacuum aspiration was introduced. Our primary objective was to assess the effects of these changes on the waiting period in days from the intake visit to the day of termination procedure. Our secondary objectives included assessing any decrease in gestational age at the time of procedure, increases in the numbers of procedures at b9 weeks, the numbers of procedures per session and the proportion done on the day of intake. Methods: This is a retrospective cross-sectional review of the clinical records of patients who requested pregnancy termination. Data were obtained on 625 patients who underwent a surgical termination of pregnancy from February 1, 2004, to January 31, 2006. Results: The waiting period decreased from 20.3 to 3.6 days (pb.01), and mean gestational age at termination decreased from 11 to 9 weeks (pb.01). The proportion at b9 weeks' gestation increased from 1.7% to 40% (pb.01). The number of procedures per session increased by 52.7% (pb.01). The percentage of same-day procedures increased from 7% to 62%. Conclusion: We improved efficiency of care by reducing the waiting period and terminating pregnancies earlier in gestation with manual equipment. © 2008 Elsevier Inc. All rights reserved. Keywords: Abortion; Pregnancy termination; Waiting time; Manual aspiration; Early gestational age
1. Introduction In 2002, almost 1.3 million abortions were performed in the United States [1]. Although the rate of abortion decreased somewhat in the past decade, a disproportionate share of terminations occur in women with low income who lack resources for care in a private clinic [2]. Our hospital is a public institution offering first-trimester terminations for low-income women. This service operated under constraints that reduced programmatic efficiency and patient satisfaction while, at the same time, increasing institutional costs and patient waiting periods. Two visits were required, the first for intake and the second for the procedure itself. The operations were performed in the main operating room by suction
⁎ Corresponding author. Tel.: +1 312 864 5935; fax: + 1 312 864 9269. E-mail address: [email protected] (A. Patel). 0010-7824/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.contraception.2007.08.007
curettage. The waiting period often exceeded 3 weeks, leading to terminations at later gestational age and placing women at increased risks of morbidity [3,4]. Recognizing the shortcomings of our approach, we implemented three changes over the course of 2 years: (a) moving from the operating room to a new outpatient area, (b) changing from a 2-day to a 1-day service model and (c) addition of vacuum aspiration to electric suction curettage. The purpose of this study was to examine the impact of each change on patient waiting period in terms of days from first intake visit to procedure and to assess gestational age at the time of procedure. 2. Method This study, which was approved by the institutional review board, is a retrospective cross-sectional review of the clinical records of patients undergoing elective first-trimester
106
A. Patel et al. / Contraception 77 (2008) 105–107
Table 1 Changes made in our pregnancy termination clinic Procedure and sample description
Type A (controls)
Type B (first change)
Type C (second change)
Type D (third change)
Duration
Feb 2004– Jun 2004 5
Jul 2004– Mar 2005 9
Apr 2005– Sep 2005 6
Oct 2005– Jan 2006 4
Operating room 2 days
Outpatient clinic 2 days
Outpatient clinic Same day
Outpatient clinic Same day
Suction curettage
Suction curettage
Suction curettage
90
150
100
Manual vacuum aspiration 60
400
3. Results
9
15
10
6
40
118
208
174
120
620
The average age of all patients was 23.7 years. Ninetythree percent of the women were African Americans, 4% were Hispanic, 2% were Caucasian and 1% were from other ethnic groups. Table 1 shows general information on numbers of patients, as well as program changes and the date they were made. Comparing the four outcomes, a 74% reduction was noted in the waiting period for Type A compared with Type D (Fig. 1). The linear trend for waiting period was statistically significant (pb.01). The gestational age also declined significantly (pb1.3×10−8). The overall reduction in mean gestational duration at the time of termination amounted to 2 weeks over a period of 2 years (test of linear trend was statistically significant at pb.01; Fig. 1). Table 2 shows the increase in the number of procedures performed at b9 weeks, the number of procedures performed per session and the percentage of same-day procedures. Besides increase in the percentage
Number of months Procedure setting Procedure days after initial visit Type of procedure Total number of sessions Number of sample sessions Number of patients
Total
plete and were thus excluded, and the remaining 620 records were included in the final analysis. The three changes made during the 2 years were categorized into four types as shown in Table 1. Our primary outcome measure was waiting period in days between the intake visit and the procedure. Our secondary outcomes were gestational age at the time of the abortion, the number of terminations at b9 weeks, the number of terminations per session and the proportion accomplished on the day of intake. All data from 620 patients were analyzed using single-factor ANOVA, and a trend analysis of the four outcome variables was performed. p values b.05 were considered significant.
24
termination of pregnancies between February 1, 2004, and January 31, 2006, in a large public hospital in a large city. Data were abstracted from the electronic database and the patients' medical records. The numbers of abortion procedures for 2004, 2005 and 2006 were 2399, 3383 and 295, respectively. Because we did not know how many we would need to adequately assess the effects of program changes, we reviewed the records of every 10th clinical visit consecutively starting from the 1st clinical visit to assess changes over time. Demographic information, waiting period from intake to procedure and mean gestational age at the time of procedure were recorded. Records with incorrect procedure dates or reports without gestational age noted were excluded from further analysis. A total of 625 records were identified in our cross-sectional examination; 5 records were incom-
Table 2 Comparison between the four types based on the results Type A (operating room, 2-day procedure, suction curettage)
Fig. 1. Declining waiting periods and mean gestational age at the time of procedure by type of change instituted to shorten total length of procedure.
Percentage of procedures at b9 weeks' gestational age Percentage of procedures at ≥9 weeks' gestational age Procedures per session Percentage of same-day procedures
Type B (outpatient, 2-day procedure, suction curettage)
Type C (outpatient, same-day procedure, suction curettage)
Type D (outpatient, same-day procedure, manual vacuum aspiration)
1.7
6.2
28.4
40.0
98.3
93.8
71.6
60.0
13.1
13.9
17.4
20.1
0
0
7
62
A. Patel et al. / Contraception 77 (2008) 105–107
of same-day procedures, all other secondary outcomes were statistically significant with a p value b.01. A 23.5-fold linear trend increase in percentage of terminations b9 weeks' gestation was highly significant (χ2 for trend=35.3; p value b.00001). The number of procedures per session also increased in a linear trend (Table 2), with an overall increase of 52.7% over a period of 2 years.
107
number of complications, convenience of use in the outpatient setting and minimum operating time [12,13], although the evidence is controversial in one of the studies [11]. This study has certain limitations. The first is its retrospective design. The second was our inability to assess the confounding biases attributed to new leadership and restructuring of our abortion clinic. The variables examined were those most easily identified and measurable by retrospective review of records.
4. Discussion Our study shows that the clinical practice changes implemented during the study period significantly decreased the waiting period between the intake visit and the procedure. Prolonged waiting can increase patients' anxiety [5]. Waiting to terminate a pregnancy after a decision has been made increases not only anxiety but also gestational age at the time of abortion and thereby increases morbidity [3]. Most women prefer a single visit for pregnancy termination [6], and multiday visits pose a substantial barrier for access to quality care [2]. In our setting, a woman with an unintended pregnancy previously had to wait for an average of 3 weeks after her initial clinic visit. Although the overall reduction of the waiting period from 20 to 3 days clearly had an important impact on patient care and service delivery, we were unable to reduce it further due to organizational constraints, including the fact that the pregnancy termination clinic was only open 4 days a week and same-day procedures occurred on only 3 of these days. Efforts are presently underway to make all procedures “same day.” Initially, all terminations at our hospital were by electric suction curettage, generally after 9 weeks' gestation. The percentage performed at b9 weeks' gestation increased in each of the three study periods, but the most significant difference occurred after initiation of same-day procedures. Abortions performed at earlier gestations are associated with lower risk of maternal mortality and morbidity [3,4]. The risk of death increases by 38% for each additional week of gestational age [3], and it has been estimated that up to 87% of deaths in women undergoing abortions after 8 weeks may have been avoided if the abortion had been performed before 8 weeks [3]. Although the number of procedures per session increased after each successive change, the most significant difference was seen after introducing the same-day procedures (28.9% increase) and manual vacuum aspiration (14.9% increase). Compared to electric aspiration, manual suction curettage is cost-effective and quiet [7–9]. The manual syringe is sterilizable and reusable [10]. This method allows easier identification of the gestational sac and chorionic villi and results in fewer uterine reaspirations [11]. Also of great clinical significance in a low-income population where relative clinical anemia may be common, blood loss in the procedures performed manually is significantly lower than when electric curettage is employed [9]. Advantages of manual procedures include simplicity of procedure, minimal
5. Conclusion Access to abortion service remains difficult for many women in the United States, particularly for minority women with low income. Although the model we ultimately selected has been widely used in private or not-for-profit clinics, many public hospital settings still are not able to offer outpatient, same-day terminations with manual aspiration. We believe that our improved service delivery model provides increased access to safer abortion services for women with low income. References [1] Elam-Evans LD, Strauss LT, Herndon J, et al. Centers for Disease Control and Prevention. Abortion surveillance — United States, 2000. MMWR Surveill Summ 2003;52:1–32. [2] Physicians for Reproductive Choice and Health (PRCH) and Guttmacher Institute. An overview of abortion in United States. www.guttmacher.org/presentations/abort_slides.pdf [Accessed on October 2006]. [3] Bartlett LA, Berg CJ, Shulman HB, et al. Rick factors for legal induced abortion-related mortality in the United States. Obstet Gynecol 2004;103:729–37. [4] Henshaw SK. Factors hindering access to abortion services. Fam Plann Perspect 1995;27:54–9, 87. [5] Slade P, Heke S, Fletcher J, Stewart P. Termination of pregnancy: patients' perceptions of care. J Fam Plann Reprod Health Care 2001;27:72–7. [6] Henshaw SK, Finer LB. The accessibility of abortion services in the United States, 2001. Perspect Sex Reprod Health 2003;35:16–24. [7] Bird ST, Harvey SM, Nichols MD, Edelman A. Comparing the acceptability of manual vacuum aspiration and electric vacuum aspiration as methods of early abortion. J Am Med Womens Assoc 2001;56:124–6. [8] Blumenthal PD, Remsburg RE. A time and cost analysis of the management of incomplete abortion with manual vacuum aspiration. Int J Gynaecol Obstet 1994;45:261–7. [9] Hemlin J, Moller B. Manual vacuum aspiration, a safe and effective alternative in early pregnancy termination. Acta Obstet Gynecol Scand 2001;80:563–7. [10] MVA — frequently asked questions, Ipas. http://ipas.org/english/ products/mva/faq.asp [Accessed on May 2007]. [11] Goldberg AB, Dean G, Kang MS, Youssof S, Darney PD. Manual versus electric vacuum aspiration for early first-trimester abortion: a controlled study of complication rates. Obstet Gynecol 2004;103:101–7. [12] Dalton VK, Harris L, Weisman CS, Guire K, Castleman L, Lebovic D. Patient preferences, satisfaction, and resource use in office evacuation of early pregnancy failure. Obstet Gynecol 2006;108:103–10. [13] Meyer Jr JH. Early office termination of pregnancy by soft cannula vacuum aspiration. Am J Obstet Gynecol 1983;147:202–7.
Original research article
Decreased waiting periods in a public pregnancy termination clinic Ashlesha Patel a,⁎, Hemang Panchal a , Rupesh Patel b , Louis Keith a,c a
Division of Family Planning, Department of Obstetrics and Gynecology, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL 60612, USA b Department of Maternal Fetal Medicine, Rockford Memorial Hospital, Rockford, IL 61103, USA c Section of Undergraduate Education and Medical Student Affairs, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA Received 20 February 2007; revised 23 August 2007; accepted 23 August 2007
Abstract Background: In our public hospital, first-trimester pregnancy termination historically had been performed in an operating room by suction curettage on a separate day following the initial clinic visit. To increase efficiency, we instituted three changes over a 2-year period: (a) pregnancy termination procedures were relocated to the outpatient area; (b) same-day service was initiated; and (c) manual vacuum aspiration was introduced. Our primary objective was to assess the effects of these changes on the waiting period in days from the intake visit to the day of termination procedure. Our secondary objectives included assessing any decrease in gestational age at the time of procedure, increases in the numbers of procedures at b9 weeks, the numbers of procedures per session and the proportion done on the day of intake. Methods: This is a retrospective cross-sectional review of the clinical records of patients who requested pregnancy termination. Data were obtained on 625 patients who underwent a surgical termination of pregnancy from February 1, 2004, to January 31, 2006. Results: The waiting period decreased from 20.3 to 3.6 days (pb.01), and mean gestational age at termination decreased from 11 to 9 weeks (pb.01). The proportion at b9 weeks' gestation increased from 1.7% to 40% (pb.01). The number of procedures per session increased by 52.7% (pb.01). The percentage of same-day procedures increased from 7% to 62%. Conclusion: We improved efficiency of care by reducing the waiting period and terminating pregnancies earlier in gestation with manual equipment. © 2008 Elsevier Inc. All rights reserved. Keywords: Abortion; Pregnancy termination; Waiting time; Manual aspiration; Early gestational age
1. Introduction In 2002, almost 1.3 million abortions were performed in the United States [1]. Although the rate of abortion decreased somewhat in the past decade, a disproportionate share of terminations occur in women with low income who lack resources for care in a private clinic [2]. Our hospital is a public institution offering first-trimester terminations for low-income women. This service operated under constraints that reduced programmatic efficiency and patient satisfaction while, at the same time, increasing institutional costs and patient waiting periods. Two visits were required, the first for intake and the second for the procedure itself. The operations were performed in the main operating room by suction
⁎ Corresponding author. Tel.: +1 312 864 5935; fax: + 1 312 864 9269. E-mail address: [email protected] (A. Patel). 0010-7824/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.contraception.2007.08.007
curettage. The waiting period often exceeded 3 weeks, leading to terminations at later gestational age and placing women at increased risks of morbidity [3,4]. Recognizing the shortcomings of our approach, we implemented three changes over the course of 2 years: (a) moving from the operating room to a new outpatient area, (b) changing from a 2-day to a 1-day service model and (c) addition of vacuum aspiration to electric suction curettage. The purpose of this study was to examine the impact of each change on patient waiting period in terms of days from first intake visit to procedure and to assess gestational age at the time of procedure. 2. Method This study, which was approved by the institutional review board, is a retrospective cross-sectional review of the clinical records of patients undergoing elective first-trimester
106
A. Patel et al. / Contraception 77 (2008) 105–107
Table 1 Changes made in our pregnancy termination clinic Procedure and sample description
Type A (controls)
Type B (first change)
Type C (second change)
Type D (third change)
Duration
Feb 2004– Jun 2004 5
Jul 2004– Mar 2005 9
Apr 2005– Sep 2005 6
Oct 2005– Jan 2006 4
Operating room 2 days
Outpatient clinic 2 days
Outpatient clinic Same day
Outpatient clinic Same day
Suction curettage
Suction curettage
Suction curettage
90
150
100
Manual vacuum aspiration 60
400
3. Results
9
15
10
6
40
118
208
174
120
620
The average age of all patients was 23.7 years. Ninetythree percent of the women were African Americans, 4% were Hispanic, 2% were Caucasian and 1% were from other ethnic groups. Table 1 shows general information on numbers of patients, as well as program changes and the date they were made. Comparing the four outcomes, a 74% reduction was noted in the waiting period for Type A compared with Type D (Fig. 1). The linear trend for waiting period was statistically significant (pb.01). The gestational age also declined significantly (pb1.3×10−8). The overall reduction in mean gestational duration at the time of termination amounted to 2 weeks over a period of 2 years (test of linear trend was statistically significant at pb.01; Fig. 1). Table 2 shows the increase in the number of procedures performed at b9 weeks, the number of procedures performed per session and the percentage of same-day procedures. Besides increase in the percentage
Number of months Procedure setting Procedure days after initial visit Type of procedure Total number of sessions Number of sample sessions Number of patients
Total
plete and were thus excluded, and the remaining 620 records were included in the final analysis. The three changes made during the 2 years were categorized into four types as shown in Table 1. Our primary outcome measure was waiting period in days between the intake visit and the procedure. Our secondary outcomes were gestational age at the time of the abortion, the number of terminations at b9 weeks, the number of terminations per session and the proportion accomplished on the day of intake. All data from 620 patients were analyzed using single-factor ANOVA, and a trend analysis of the four outcome variables was performed. p values b.05 were considered significant.
24
termination of pregnancies between February 1, 2004, and January 31, 2006, in a large public hospital in a large city. Data were abstracted from the electronic database and the patients' medical records. The numbers of abortion procedures for 2004, 2005 and 2006 were 2399, 3383 and 295, respectively. Because we did not know how many we would need to adequately assess the effects of program changes, we reviewed the records of every 10th clinical visit consecutively starting from the 1st clinical visit to assess changes over time. Demographic information, waiting period from intake to procedure and mean gestational age at the time of procedure were recorded. Records with incorrect procedure dates or reports without gestational age noted were excluded from further analysis. A total of 625 records were identified in our cross-sectional examination; 5 records were incom-
Table 2 Comparison between the four types based on the results Type A (operating room, 2-day procedure, suction curettage)
Fig. 1. Declining waiting periods and mean gestational age at the time of procedure by type of change instituted to shorten total length of procedure.
Percentage of procedures at b9 weeks' gestational age Percentage of procedures at ≥9 weeks' gestational age Procedures per session Percentage of same-day procedures
Type B (outpatient, 2-day procedure, suction curettage)
Type C (outpatient, same-day procedure, suction curettage)
Type D (outpatient, same-day procedure, manual vacuum aspiration)
1.7
6.2
28.4
40.0
98.3
93.8
71.6
60.0
13.1
13.9
17.4
20.1
0
0
7
62
A. Patel et al. / Contraception 77 (2008) 105–107
of same-day procedures, all other secondary outcomes were statistically significant with a p value b.01. A 23.5-fold linear trend increase in percentage of terminations b9 weeks' gestation was highly significant (χ2 for trend=35.3; p value b.00001). The number of procedures per session also increased in a linear trend (Table 2), with an overall increase of 52.7% over a period of 2 years.
107
number of complications, convenience of use in the outpatient setting and minimum operating time [12,13], although the evidence is controversial in one of the studies [11]. This study has certain limitations. The first is its retrospective design. The second was our inability to assess the confounding biases attributed to new leadership and restructuring of our abortion clinic. The variables examined were those most easily identified and measurable by retrospective review of records.
4. Discussion Our study shows that the clinical practice changes implemented during the study period significantly decreased the waiting period between the intake visit and the procedure. Prolonged waiting can increase patients' anxiety [5]. Waiting to terminate a pregnancy after a decision has been made increases not only anxiety but also gestational age at the time of abortion and thereby increases morbidity [3]. Most women prefer a single visit for pregnancy termination [6], and multiday visits pose a substantial barrier for access to quality care [2]. In our setting, a woman with an unintended pregnancy previously had to wait for an average of 3 weeks after her initial clinic visit. Although the overall reduction of the waiting period from 20 to 3 days clearly had an important impact on patient care and service delivery, we were unable to reduce it further due to organizational constraints, including the fact that the pregnancy termination clinic was only open 4 days a week and same-day procedures occurred on only 3 of these days. Efforts are presently underway to make all procedures “same day.” Initially, all terminations at our hospital were by electric suction curettage, generally after 9 weeks' gestation. The percentage performed at b9 weeks' gestation increased in each of the three study periods, but the most significant difference occurred after initiation of same-day procedures. Abortions performed at earlier gestations are associated with lower risk of maternal mortality and morbidity [3,4]. The risk of death increases by 38% for each additional week of gestational age [3], and it has been estimated that up to 87% of deaths in women undergoing abortions after 8 weeks may have been avoided if the abortion had been performed before 8 weeks [3]. Although the number of procedures per session increased after each successive change, the most significant difference was seen after introducing the same-day procedures (28.9% increase) and manual vacuum aspiration (14.9% increase). Compared to electric aspiration, manual suction curettage is cost-effective and quiet [7–9]. The manual syringe is sterilizable and reusable [10]. This method allows easier identification of the gestational sac and chorionic villi and results in fewer uterine reaspirations [11]. Also of great clinical significance in a low-income population where relative clinical anemia may be common, blood loss in the procedures performed manually is significantly lower than when electric curettage is employed [9]. Advantages of manual procedures include simplicity of procedure, minimal
5. Conclusion Access to abortion service remains difficult for many women in the United States, particularly for minority women with low income. Although the model we ultimately selected has been widely used in private or not-for-profit clinics, many public hospital settings still are not able to offer outpatient, same-day terminations with manual aspiration. We believe that our improved service delivery model provides increased access to safer abortion services for women with low income. References [1] Elam-Evans LD, Strauss LT, Herndon J, et al. Centers for Disease Control and Prevention. Abortion surveillance — United States, 2000. MMWR Surveill Summ 2003;52:1–32. [2] Physicians for Reproductive Choice and Health (PRCH) and Guttmacher Institute. An overview of abortion in United States. www.guttmacher.org/presentations/abort_slides.pdf [Accessed on October 2006]. [3] Bartlett LA, Berg CJ, Shulman HB, et al. Rick factors for legal induced abortion-related mortality in the United States. Obstet Gynecol 2004;103:729–37. [4] Henshaw SK. Factors hindering access to abortion services. Fam Plann Perspect 1995;27:54–9, 87. [5] Slade P, Heke S, Fletcher J, Stewart P. Termination of pregnancy: patients' perceptions of care. J Fam Plann Reprod Health Care 2001;27:72–7. [6] Henshaw SK, Finer LB. The accessibility of abortion services in the United States, 2001. Perspect Sex Reprod Health 2003;35:16–24. [7] Bird ST, Harvey SM, Nichols MD, Edelman A. Comparing the acceptability of manual vacuum aspiration and electric vacuum aspiration as methods of early abortion. J Am Med Womens Assoc 2001;56:124–6. [8] Blumenthal PD, Remsburg RE. A time and cost analysis of the management of incomplete abortion with manual vacuum aspiration. Int J Gynaecol Obstet 1994;45:261–7. [9] Hemlin J, Moller B. Manual vacuum aspiration, a safe and effective alternative in early pregnancy termination. Acta Obstet Gynecol Scand 2001;80:563–7. [10] MVA — frequently asked questions, Ipas. http://ipas.org/english/ products/mva/faq.asp [Accessed on May 2007]. [11] Goldberg AB, Dean G, Kang MS, Youssof S, Darney PD. Manual versus electric vacuum aspiration for early first-trimester abortion: a controlled study of complication rates. Obstet Gynecol 2004;103:101–7. [12] Dalton VK, Harris L, Weisman CS, Guire K, Castleman L, Lebovic D. Patient preferences, satisfaction, and resource use in office evacuation of early pregnancy failure. Obstet Gynecol 2006;108:103–10. [13] Meyer Jr JH. Early office termination of pregnancy by soft cannula vacuum aspiration. Am J Obstet Gynecol 1983;147:202–7.