- Email: [email protected]
Factors that determine patient satisfaction after surgical treatment of ectopic pregnancy: improving the patient journey!
G Model
EURO-8499; No. of Pages 6 European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Factors that determine patient satisfaction after surgical treatment of ectopic pregnancy: improving the patient journey! Janga Deepa *, Olowu Oladimeji, Odejinmi Funlayo Department of Obstetrics and Gynaecology, Whipps Cross University Hospital, Barts Health London, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 October 2013 Received in revised form 17 March 2014 Accepted 31 March 2014
Objectives: The aim of our study is to identify factors that influence the woman’s perception of satisfaction during the process of treatment for this potentially life threatening condition. To evaluate the patient characteristics and factors surrounding the diagnosis and subsequent management of women with ectopic pregnancy and the influence of these on the overall satisfaction rates after discharge from hospital in order to improve quality of care. Study design: This is a prospective cohort study undertaken over a period of 4 years (January 2009– December 2012) in a busy early pregnancy unit, in a London university hospital, catering to a multiethnic diverse population. Six weeks after surgery a self-administered satisfaction questionnaire was filled in either after a clinician face to face or telephone interview for women who had undergone operative laparoscopy for the treatment for ectopic pregnancy. The data was analysed using SPSS version 14.0. Results: A total of 324 women underwent operative laparoscopy for the treatment of ectopic pregnancy during the study period. Of this cohort 299 (92.3%) were included in the study, as 25 women (8.4%) were lost to follow-up. 247 (82.6%) were followed up in the clinic and 52 (17.4%) by telephone interview. In 69.5% of the cases the diagnosis was made by a single ultrasound scan, and 69% were discharged within 24 h of surgery. The amount of haemoperitoneum and subsequent need for blood transfusion had a significant influence on the overall satisfaction rates (blood loss <200 ml – 94% satisfied, 200–800 ml – 81% and >800 ml – 72%, p = 0.001). While age, parity, ethnicity, desire for future pregnancy did not affect the satisfaction outcome, waiting time from diagnosis to surgery (<6 h – 87% satisfied, 7–12 h – 70%, >13 h – 67%, p = 0.03), good communication pre-operatively (87% satisfaction with good communication vs. 30% without, p < 0.001), provision of post-operative leaflets prior to discharge (90% vs. 68%, p = 0.001) and adequate pain relief (89% vs. 64%, p = 0.001) resulted in good patient experience. There was no statistical difference in the overall satisfaction in the clinic follow up group (85%), and the women followed up by telephone (86%). Conclusions: With increasing surgical expertise and advanced diagnostic aids, patient satisfaction has become an important attribute of quality control and health care goal. Good communication and providing information leaflets and adequate pain relief have a positive influence on the woman’s reaction to this stressful condition. Our study also suggests that telephone conversation for follow-up is quite an effective means to follow these women after the surgery. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Ectopic pregnancy Laparoscopy Patient satisfaction
Introduction Ectopic pregnancy is the presence of a pregnancy outside the uterine cavity. The rate of EP is 11 per 1000 pregnancies, with a maternal mortality of 0.4 per 1000 ectopic pregnancies in the United Kingdom [1]. With the use of high-resolution ultrasonography and
* Corresponding author. Tel.: +44 2085395522. E-mail address: [email protected] (J. Deepa).
improved operator skills, ectopic pregnancies are now diagnosed earlier. The management has shifted from radical to conservative methods, aimed at preserving fertility and minimising morbidity. Advances in laparoscopic surgery have enabled a laparoscopic approach in the majority of patients with tubal EP [2]. The diagnosis of EP has an adverse effect on the quality of life of the affected woman. Women react to early pregnancy loss in different ways and the current management aims at improving patient satisfaction and reducing psychological morbidity. Surprisingly there is only one study published to date, which
http://dx.doi.org/10.1016/j.ejogrb.2014.03.038 0301-2115/ß 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Deepa J, et al. Factors that determine patient satisfaction after surgical treatment of ectopic pregnancy: improving the patient journey!. Eur J Obstet Gynecol (2014), http://dx.doi.org/10.1016/j.ejogrb.2014.03.038
G Model
EURO-8499; No. of Pages 6 J. Deepa et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2014) xxx–xxx
2
default position in our department is that those who require surgical management of EP are managed laparoscopically unless it is deemed to be clinically unsafe by the attending surgeon. The most experienced surgeon available operates on haemodynamically unstable patients [8]. The operating surgeon debriefs the patient after the procedure. All patients are offered counselling by a trained counsellor if required, and are given an information leaflet. Patients are discharged within 24–48 h after the procedure unless there are clinical indications for prolonged hospital stay. They are then seen in a dedicated EP clinic 6 weeks after surgery. In the last year of the study to further improve patient care a telephone clinic was set up and run by the individuals that had previously been responsible for the dedicated clinic. Those that were not contactable over the telephone were offered a clinic appointment. The questionnaire we used was devised by a multidisciplinary team consisting of a clinical psychologist, early pregnancy unit nurse and gynaecologists working in early pregnancy units. The questionnaire was tested and validated using a focus group. The questionnaire included questions based on criteria of aspects of care and overall satisfaction with the care provided. This explored the way patients were received, staff willingness to listen, quality of information provided, physical pain after surgery, desire and anxiety about future fertility. These questions were then analysed in relation to socio-demographic characteristics, medical and surgical history, volume of haemoperitoneum, desire for future pregnancy, repeat EP, time interval between the diagnosis and surgery) type of surgery and length of hospital stay after surgery. We considered 800 ml of blood in the peritoneal cavity as significant haemoperitoneum because these women would be classified as having at least category II haemorrhagic shock, having lost between 15% and 30% of their blood volume, as recognised by the American College of Surgeons [9,10]. All data was anonymized and entered into SPSS version 14.0 for Windows. In describing the data, the median and interquartile range (IQR) were used for non-parametric data. Differences in
addressed patient satisfaction after management of EP [3]. The experience of pregnancy loss can leave women feeling distressed, overwhelmed, and wanting answers to their questions. At the same time, health care providers often are pressured for time and may not be able to provide this support and information [4]. Women wish to know the cause of their pregnancy loss, when to expect their next menstrual period, when it is safe to attempt another pregnancy, risk of recurrence, and anticipated emotional reactions [5]. According to a meta-analysis of satisfaction literature, humaneness and technical quality of medical care were ranked highly. The bottom five indicators featured aspects of care that reflected the provider’s attention to other patient needs and the patient’s relation to the system as a whole [6]. The purpose of this study was to evaluate the patient related factors that influence satisfaction rates. Our aim was to determine which factors influence a woman’s perception of satisfaction, and ultimately improve the way we help women cope with this distressing situation. We also compared the satisfaction outcomes between the women followed up in a face-to-face clinic with those evaluated after surgery by a telephonic interview. Ultimately if we can avoid a hospital visit follow-up, it may be more convenient to the patient, less distressing, and also cost-effective to the health care provider. Materials and methods This was a prospective cohort study of all the women treated surgically for EP in a single centre, the early pregnancy assessment unit at Whipps cross university hospital London, over a period of 4 years: January 2009–December 2012. Information relating to the patient demographic characteristics, clinical history and findings, ultrasound, peri-operative and surgical findings, type of surgery, and length of hospital stay were collected prospectively from the units’ EP database. The guidelines for the management of EP are in keeping with that of the royal college of obstetricians and gynaecologists [7]. The
394 Women diagnosed with EP in the study period
319(98.5%) tr laparoscopically 324 women surgically treated for EP
299 women included in the satisfaction questionnaire study
25(8.4%) were lost to followup
Group 2 52 (17.4%) included in the telephonic follow up group
Group 1 247(82.6%) included in the face to face follow up clinic
85% women satisfied with the care provided
5 (1.5%) had open surgery
15% women less satisfied with the care provided
86% women satisfied with the care provided
14% women less satisfied with the care provided
Chart 1. Study design chart.
Please cite this article in press as: Deepa J, et al. Factors that determine patient satisfaction after surgical treatment of ectopic pregnancy: improving the patient journey!. Eur J Obstet Gynecol (2014), http://dx.doi.org/10.1016/j.ejogrb.2014.03.038
G Model
EURO-8499; No. of Pages 6 J. Deepa et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2014) xxx–xxx
satisfaction rates were tested using a Cochran–Mantel–Haenszel chi-squared test. p 0.05 was considered statistically significant. Adjusted odds ratio and confidence intervals were calculated by univariate analysis for the factors, which have showed significant satisfaction rates. Results During the study period a total of 324 patients underwent surgical management for EP, 319 (98.5%) had operative laparoscopy and 5 (1.5%) had open surgery. 100% of haemodynamically stable patients had operative laparoscopy. Of the 324 women 299 (92.3%) were included in the study and 288 had complete data available for analysis. Twenty-five women (8.4%) were lost to follow up. In the study group 247 (82.6%) were followed up in the clinic and 52 (17.4%) by telephone interview (Chart 1). Of the total number of patients, 54% were Caucasian, 22% Black and 24% Asian. A total of 94% were tubal and the rest were extratubal pregnancies. The mean age of the cohort was 30.3 years, with range 17–50 years. The majority of women (n = 151, 53%) were multiparous, the rest (n = 136, 47%) were nulliparous. Most women were keen to preserve their fertility (n = 266, 93%), and in 87% of the cases the pregnancy was a planned event. Exploring the previous history, 269 (94%) had no previous sub-fertility, 15% had previously terminated a pregnancy, 9% had previously had pelvic inflammatory disease, 27% had a previous miscarriage, and 12% had a history of previous pelvic surgery. Eighty two percent denied smoking. The rate of recurrence in EP in our cohort was 10%. Comparing the recurrent EP group with those with primary EP there was no difference in global satisfaction with the care provided (86% in the recurrent group vs. 85% in the primary ectopic pregnancy group, p = 0.9). In 69.5% of the cases the diagnosis was made by a single ultrasound scan, and 69% were discharged within 24 h of surgery.
3
Out of the 25 that were lost to follow-up (LTF) after being treated surgically for EP in our unit, 10 women were out-of area and were actually visiting friends or family at the time of diagnosis. So we presume that they have left after the treatment and did not return for follow-up, and their not returning cannot be extrapolated as dissatisfaction with medical care. Four women were not registered with a local general practitioner, and we could not contact them on the address given at time of admission. The demographic details including age and the other risk factors did not differ between the study group and the LTF group. There was one woman in this group who had expressed dissatisfaction with the care, as she required two scans to confirm the diagnosis and waiting period was not acceptable to her (Table 1). By analysing factors that affected our patients’ satisfaction we found that there was no significant difference in the satisfaction rates based on age (<25 yrs 86%, 26–35 yrs 87%, >35 yrs 78%, p = 0.187), ethnicity (Caucasian 86%, Black 75%, Asian 86%, p = 0.48) or parity (nulliparous 82%, multiparous 87%, p = 0.3). None of the factors in the past history influenced the satisfaction rates (cigarette smoking p = 0.88, prior pregnancy termination p = 0.74, previous PID p = 0.06, previous miscarriage p = 0.36). The satisfaction rates did not differ between women who desired future pregnancy (n = 266, 93%) in comparison with those who did not wish to conceive (p = 0.4). Having a repeat EP (n = 28, 10%) did not influence the satisfaction rates (p = 0.9) (Table 2). The haemoperitoneum volume and subsequent need for blood transfusion had a significant influence on the overall satisfaction rates (blood loss <200 ml – 94% satisfied, 200–800 ml – 81% and >800 ml – 72%, p = 0.001). Using multiple logistic regression analysis, significant haemoperitoneum is an independent factor for patient dissatisfaction (adjusted odds ratio 0.59, 95% confidence interval 0.277–1.254, p = 0.004). This is irrespective of whether the diagnosis is delayed or patient presents for the first time with signs
Table 1 Patient factors affecting the satisfaction outcomes. Women satisfied with care n = 244, n (%)
Not Satisfied n = 44, n (%)
p
Age
<25 yrs 26–35 yrs >35 yrs
51 (86%) 136 (87%) 57 (78%)
8 (14%) 20 (13%) 16 (22%)
0.187
Parity
Nulliparous Multiparous
112 (82%) 131 (87%)
24 (18%) 20 (13%)
0.3
Ethnicity
White Black Asian
136 (86%) 47 (75%) 61 (86%)
22 (14%) 12 (20%) 10 (15%)
0.48
Smoker
Yes No
44 (86%) 199 (85%)
7 (14%) 36 (15%)
0.88
Previous TOP
Yes No
35 (83%) 209 (85%)
7 (17%) 36 (15%)
0.74
Previous PID
Yes No
23 (85%) 221 (85%)
4 (15%) 39 (15%)
0.06
Planned pregnancy
Yes No
211 (85%) 33 (85%)
38 (15%) 6 (15%)
0.42
H/o Infertility
Yes No
16 (89%) 228 (85%)
2 (11%) 41 (15%)
0.63
Previous miscarriage
Yes No
63 (82%) 181 (86%)
14 (18%) 29 (14%)
0.36
Prior pelvic surgery
Yes No
31 (89%) 213 (84.5%)
4 (11%) 39 (15.5%)
0.53
Previous ectopic pregnancy
Yes No
24 (86%) 220 (85%)
4 (14%) 39 (15%)
0.9
Desire for future pregnancy
Yes No
226 (85%) 14 (78%)
40 (15%) 4 (22%)
0.4
Factor
Please cite this article in press as: Deepa J, et al. Factors that determine patient satisfaction after surgical treatment of ectopic pregnancy: improving the patient journey!. Eur J Obstet Gynecol (2014), http://dx.doi.org/10.1016/j.ejogrb.2014.03.038
G Model
EURO-8499; No. of Pages 6 J. Deepa et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2014) xxx–xxx
4
Table 2 Treatment factors affecting the satisfaction outcomes. Factor
Satisfied women n = 244, n (%)
Not satisfied n = 44, n (%)
p
Number of scans
0 1 >1
6 (67%) 172 (86%) 65 (86%)
3 (33%) 28 (14%) 11 (14%)
0.28
FHR seen on scan
Yes No
22 (82%) 222 (85%)
5 (18%) 38 (15%)
0.58
Amount of haemoperitoneum
<200 ml 200–800 ml >800 ml
108 (94%) 97 (81.5%) 39 (72%)
7 (6%) 22 (18.5%) 15 (28%)
0.001
Blood transfusion
Yes No
217 (86%) 26 (74%)
35 (14%) 9 (26%)
0.07
Given adequate information
Yes No
241 (87%) 3 (30%)
37 (13%) 7 (70%)
<0.001
Postop leaflets provided
Yes No
196 (90%) 47 (68%)
22 (10%) 22 (32%)
0.001
Treatment options discussed
Yes No
32 (91%) 211 (84%)
3 (9%) 41 (16%)
0.45
Adequate pain relief postop
Yes No
208 (89%) 32 (64%)
26 (11%) 18 (36%)
<0.001
Early discharge after surgery (<24 h)
Yes No
172 (86%) 68 (80%)
27 (14%) 17 (20%)
0.17
Waiting time for surgery
<6 h 7–12 h >13 h
214 (87%) 21 (70%) 4 (67%)
33 (13%) 9 (30%) 2 (33%)
0.028
Mode of follow-up
Face–face clinic Telephone interview
208 (85%) 36 (86%)
38 (15%) 6 (14%)
0.8
and or symptoms of haemodynamic instability. Waiting time from diagnosis to surgery also significantly affected satisfaction (<6 h – 87% satisfied, 7–12 h – 70%, >13 h – 67%, p = 0.03). The longer the time interval between the diagnosis and surgery, the lower the satisfaction rates (p = 0.028). Good communication pre-operatively (87% satisfaction with good communication vs. 30% without, p < 0.001), adequate pain relief (89% vs. 64%, p = 0.001), and provision of post-operative leaflets prior to discharge (90% vs. 68%, p = 0.001) resulted in good satisfaction scores. Early discharge from the hospital after the surgery did not significantly influence the satisfaction rates (86% satisfied if discharged within 24 h vs. 80%, p = 0.17). While the overall satisfaction in the clinic follow up was 85%, the women followed up by telephone reported 86% satisfaction rates (Table 2). There was a significant difference using a multivariate regression analysis with 95% CI with good communication, providing post-operative leaflets and good pain relief. There was a significant difference in the satisfaction rates with the amount of haemoperitoneum and waiting time for surgery, with shorter
waiting times and smaller volume of haemoperitoneum associated with better satisfaction rates (Table 3). Comments The management of ectopic pregnancy has evolved over the last half century, though there has been considerable reduction in mortality (RCOG), there is still considerable morbidity associated with ectopic pregnancy [11]. With any pregnancy loss the morbidity is not only physical but also psychological and all attempts should be made to improve our patients’ journey where possible [4]. Despite potentially life saving procedures and excellent clinical outcomes, the opinion regarding quality of care and patient satisfaction may differ between the recipient and healthcare providers [6]. One of the ways to improve care would be to seek the patients’ opinion on factors that would improve their satisfaction. From the clinical point of view one would expect that clinical factors would influence how patients perceive service provision. You would reasonably hypothesise that the sicker the
Table 3 Adjusted odds ratio and confidence intervals for the factors which have showed significant satisfaction rates in the univariate analysis. Factor
Adjusted OR
Good communication
Yes No
Provision of Information leaflets
Yes No
4.17 1
Postoperative pain relief
Yes No
4.5 1
Haemoperitoneum
<200 ml 200–800 ml >800 ml
1 0.286 0.59
<6 h >6 h
1 0.35
Waiting time for surgery
15.2 1
95% confidence interval
p
3.8–61.4
<0.001
2.13–8.16
<0.001
2.2–9.1
<0.001
0.117–0.698 0.277–1.254
0.001 0.004 0.16
0.16–0.78
0.028
Please cite this article in press as: Deepa J, et al. Factors that determine patient satisfaction after surgical treatment of ectopic pregnancy: improving the patient journey!. Eur J Obstet Gynecol (2014), http://dx.doi.org/10.1016/j.ejogrb.2014.03.038
G Model
EURO-8499; No. of Pages 6 J. Deepa et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2014) xxx–xxx
patient at the point of healthcare delivery, and the better their recovery the greater their degree of satisfaction, or that patients with the greatest volume of haemoperitoneum with the shortest hospital stay be most satisfied. In the first part we analysed patient characteristics and how they might influence the overall perception of satisfaction. Interestingly none of these patient demographic factors had a significant influence on the perception of satisfaction with the care provided. Neither differences in age and parity nor ethnic diversity determined satisfaction rates. The perception of satisfaction did not alter if women had a history of previous pelvic inflammatory disease or infertility. Neither did experiencing a previous miscarriage. Satisfaction did not differ between women who smoked and those that did not, though it is known to contribute to its causation [12,13]. There was no difference in satisfaction comparing women with repeat EP and first EP. Women with repeat EP tend to present earlier and have had a previous experience of management of their condition that may influence their perception of satisfaction. This was not the case in this study. We then compared patients looking at parity. A previous study assessed severity of grief relating to the type of early pregnancy loss using the Perinatal Grief Scale (PGS). This reported that women with no children with an ectopic pregnancy grieve significantly more than those with a child (p = 0.019), with no significant difference in severity of grief between women that had a miscarriage and EP (p = 0.14) [14]. On this basis we postulated that the overall satisfaction rates would be lower in women who desire children, in comparison to those who had children previously and did not wish for further pregnancies. In our series we found, no significant difference in the two groups (p = 0.4). We expected that a delay in diagnosis and rupture of the pregnancy at presentation would influence perception of satisfaction. In 69.5% of the cases the diagnosis was made by a single ultrasound scan (in keeping with literature quoted detection rates of ectopic pregnancy with a single scan 75% with a high specificity (99.9%)) [15]. 29.5% of our patients either needed multiple scans and or serial beta HCG (human chorionic gonadotropin) monitoring. Interestingly the women who had the diagnosis of ectopic pregnancy with one ultrasound scan reported exactly the same overall satisfaction, in comparison with those who needed more than one scan (n = 172/200, 86% satisfaction rates in single scan group; n = 65/76, 86% satisfaction in the multiple scan group, p = 0.28). Though the presence of ectopic pregnancy is distressing in itself, the presence of a foetal heart beat in the ectopic gestation, and thus a live non viable foetus, did not further influence the satisfaction outcome (p = 0.58). The fact that this is essentially non-viable live foetus does not further add to the distress or affect satisfaction. The women who did not have the diagnosis with one scan reported similar satisfaction with the group who had the diagnosis in the initial scan. This may be explained if women were reasonably patient and were happy with the care even if they there was a delayed diagnosis, as long as there was good communication and staff willingness to listen. Operative laparoscopy is regarded as the gold standard for the surgical management of EP in women who are haemodynamically stable though it is increasingly used in haemodynamically unstable women [9]. The volume of haemoperitoneum alone should not dictate the operative modality used [16], but the capacity of the surgeons and the safety with the operative team to perform operative laparoscopy on unstable patients. When the satisfaction rates were evaluated in relation to the amount of haemoperitoneum, women who were diagnosed and treated prior to rupture were better satisfied than those who had more blood loss intraperitoneally (blood loss <200 ml – 94% satisfied, 200–800 ml – 81% and >800 ml – 72%, p = 0.001). This finding was consistent with the available literature [3,17]. We attempt to
5
explain this difference in the satisfaction rates due to the fact that larger volume haemoperitoneum is essentially due to a delayed diagnosis. This adds to the post-operative morbidity including the need for blood transfusion, increased pain and prolonged hospital stay. However hospital stay did not differ statistically between those with significant haemoperitoneum and those without, and this may be attributed to the laparoscopic approach in 85% of the haemodynamically unstable patients. Using multiple logistic regression analysis, significant haemoperitoneum is an independent factor for patient dissatisfaction (adjusted odds ratio 0.59, 95% confidence interval 0.277–1.254, p = 0.004). This is irrespective of whether the diagnosis is delayed or patient presents for the first time with signs and or symptoms of haemodynamic instability. Good communication pre-operatively (87% satisfaction with good communication vs. 30% without, p < 0.001) and provision of post-operative leaflets prior to discharge (90% satisfaction in the group provided with written information vs. 68%, p = 0.001) resulted in good patient experience. Women were better satisfied with the care provided when they were given adequate information. They may not be able to fully digest and recall information provided by clinicians at the time of loss due to the physical and emotional stress. Written information may therefore aid information retention [18]. The provision of written information alone can lead patients to perceive medical staff as uncaring; therefore it is best used in conjunction with verbal communication [19]. The longer the time interval between the diagnosis to surgery, the lower the satisfaction rates. Understandably the experience of postoperative pain resulted in lower satisfaction rates (89% satisfaction with good pain relief vs. 64% satisfied in the group without adequate pain relief, p = 0.001). Early discharge from the hospital after the surgery did not significantly influence the satisfaction rates (86% satisfied if discharged within 24 h vs. 80%, p = 0.17). This was contrary to our expectation, but the time of discharge was influenced by several factors such as the necessity for blood transfusion, or significant postoperative pain. These factors may further influence the patient satisfaction. While the overall satisfaction in the clinic follow up was 85%, the women followed up by telephone reported 86% satisfaction rates, p = 0.8. There was no difference in the overall satisfaction between these two groups and therefore telephonic interview is a feasible mode of communication in the post-operative follow up. This may be beneficial to the patient by avoiding additional hospital visits to the hospital, particularly when it may be associated with unpleasant memories following pregnancy loss. It may prove cost effective to the health care provider as it minimises the clinic attendance. Whatever the follow up method it is important not to miss an opportunity of further contact with the women during this stressful period. Another important factor of note in an ethnically diverse population like ours, there may be significant barriers to communication during a telephonic consultation in which could result in loss of the patient to follow-up. This is the second such study which has looked into the issue of patient satisfaction after surgical treatment for ectopic pregnancy, and the previous one was published more than a decade ago. Our findings show that the majority of women are satisfied with the care provided. Irrespective of the demographic diversity, women were satisfied overall with the care provided, when they were given adequate information and were received with compassion. Understanding the issues raised by women in this study can lead to improvement of the quality of care provided and improve patient satisfaction rates, a key indicator of good healthcare provision. References [1] Ectopic pregnancy and miscarriage. December 2012 NICE clinical guideline 154; guidance.nice.org.uk/cg154.
Please cite this article in press as: Deepa J, et al. Factors that determine patient satisfaction after surgical treatment of ectopic pregnancy: improving the patient journey!. Eur J Obstet Gynecol (2014), http://dx.doi.org/10.1016/j.ejogrb.2014.03.038
G Model
EURO-8499; No. of Pages 6 J. Deepa et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2014) xxx–xxx
6
[2] Sultana CJ, Easley K, Collins RL. Outcome of laparoscopic versus traditional surgery for ectopic pregnancies. Fertil Steril 1992;57:285–9. [3] Ego A, Subtil D, Di Pompeo C. Patient satisfaction with management of ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol 2001;98(September (1)):83–90. [4] Nikcevic AV, Kuczmierczyk AR, Nicolaides KH. Personal coping resources, responsibility, anxiety, and depression after early pregnancy loss. J Psychosom Obstet Gynaecol 1998;19:145–54. [5] Pamela AG, Christina P, Danielle K. Web-based resources for health care providers and women following pregnancy loss. JOGNN 2006;35:523–32. http://dx.doi.org/10.1111/J.1552-6909.2006.00065. [6] Hall JA, Dornan ME. What patients like about their medical care and how often they are asked. A meta-analysis of the satisfaction literature. Soc Sci Med 1988;27:935–9. [7] Royal College of Obstetricians and Gynaecologists. The management of tubal pregnancy. Guideline no. 21. London: RCOG Press; 2010. [8] Odejinmi FO, Rizzuto MI, Macrae RE, Thakur V. Changing trends in the laparoscopic management of ectopic pregnancy in a London district general hospital: 7-years experience. J Obstet Gynaecol 2008;28(August (6)):614–7. [9] Odejinmi F, Sangrithi M, Olowu O. Operative laparoscopy as the mainstay method in management of hemodynamically unstable patients with ectopic pregnancy. J Minim Invasive Gynecol 2011;18(March (2)):179–83. http://dx.doi.org/10.1016/j.jmig.2010.11.005. [10] American College of Surgeons Committee on Trauma. Advanced trauma life support student manual. Chicago, IL: American College of Surgeons; 1989. p.
47–59.
[11] van Mello NM, Zietse CS, Mol F, et al. Severe maternal morbidity in ectopic pregnancy is not associated with maternal factors but may be associated with quality of care. Fertil Steril 2012;97(March (3)):623–9. [12] Bouyer J, Coste J, Shojaei T, et al. Risk factors for ectopic pregnancy: a comprehensive analysis based on a large case–control, population-based study in France. Am J Epidemiol 2003;157(3):185–94. [13] Handler A, Davis F, Ferre C, et al. The relationship of smoking and ectopic pregnancy. Am J Public Health 1989;79:1239–42. [14] Purandare N, Ryan G, Ciprike V, Trevisan J, Sheehan J, Geary M. Grieving after early pregnancy loss – a common reality. Ir Med J 2012;105(November– December (10)):326–8. [15] Kirk E, Papageorghiou AT, Condous G, et al. The diagnostic effectiveness of an initial transvaginal scan in detecting ectopic pregnancy. Hum Reprod 2007;22(11):2824–8. [16] Rizzuto MI, Oliver R, Odejinmi F. Laparoscopic management of ectopic pregnancy in the presence of a significant haemoperitoneum. Arch Gynecol Obstet 2008;277–80. [17] Ware Jr JE, Snyder MK, Wright WR, Davies AR. Defining and measuring patient satisfaction with medical care. Eval Program Plann 1983;6 (3–4):247–63. [18] Hamilton SM. Should follow-up be provided after miscarriage. Br J Obstetr Gynaecol 1989;96:743–5. [19] Paton F, Wood R, Bor R, Nitsun M. Grief in miscarriage patients and satisfaction with care in a London hospital. J Reprod Infant Psychol 1999;17:301–15.
Please cite this article in press as: Deepa J, et al. Factors that determine patient satisfaction after surgical treatment of ectopic pregnancy: improving the patient journey!. Eur J Obstet Gynecol (2014), http://dx.doi.org/10.1016/j.ejogrb.2014.03.038
EURO-8499; No. of Pages 6 European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Factors that determine patient satisfaction after surgical treatment of ectopic pregnancy: improving the patient journey! Janga Deepa *, Olowu Oladimeji, Odejinmi Funlayo Department of Obstetrics and Gynaecology, Whipps Cross University Hospital, Barts Health London, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 October 2013 Received in revised form 17 March 2014 Accepted 31 March 2014
Objectives: The aim of our study is to identify factors that influence the woman’s perception of satisfaction during the process of treatment for this potentially life threatening condition. To evaluate the patient characteristics and factors surrounding the diagnosis and subsequent management of women with ectopic pregnancy and the influence of these on the overall satisfaction rates after discharge from hospital in order to improve quality of care. Study design: This is a prospective cohort study undertaken over a period of 4 years (January 2009– December 2012) in a busy early pregnancy unit, in a London university hospital, catering to a multiethnic diverse population. Six weeks after surgery a self-administered satisfaction questionnaire was filled in either after a clinician face to face or telephone interview for women who had undergone operative laparoscopy for the treatment for ectopic pregnancy. The data was analysed using SPSS version 14.0. Results: A total of 324 women underwent operative laparoscopy for the treatment of ectopic pregnancy during the study period. Of this cohort 299 (92.3%) were included in the study, as 25 women (8.4%) were lost to follow-up. 247 (82.6%) were followed up in the clinic and 52 (17.4%) by telephone interview. In 69.5% of the cases the diagnosis was made by a single ultrasound scan, and 69% were discharged within 24 h of surgery. The amount of haemoperitoneum and subsequent need for blood transfusion had a significant influence on the overall satisfaction rates (blood loss <200 ml – 94% satisfied, 200–800 ml – 81% and >800 ml – 72%, p = 0.001). While age, parity, ethnicity, desire for future pregnancy did not affect the satisfaction outcome, waiting time from diagnosis to surgery (<6 h – 87% satisfied, 7–12 h – 70%, >13 h – 67%, p = 0.03), good communication pre-operatively (87% satisfaction with good communication vs. 30% without, p < 0.001), provision of post-operative leaflets prior to discharge (90% vs. 68%, p = 0.001) and adequate pain relief (89% vs. 64%, p = 0.001) resulted in good patient experience. There was no statistical difference in the overall satisfaction in the clinic follow up group (85%), and the women followed up by telephone (86%). Conclusions: With increasing surgical expertise and advanced diagnostic aids, patient satisfaction has become an important attribute of quality control and health care goal. Good communication and providing information leaflets and adequate pain relief have a positive influence on the woman’s reaction to this stressful condition. Our study also suggests that telephone conversation for follow-up is quite an effective means to follow these women after the surgery. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Ectopic pregnancy Laparoscopy Patient satisfaction
Introduction Ectopic pregnancy is the presence of a pregnancy outside the uterine cavity. The rate of EP is 11 per 1000 pregnancies, with a maternal mortality of 0.4 per 1000 ectopic pregnancies in the United Kingdom [1]. With the use of high-resolution ultrasonography and
* Corresponding author. Tel.: +44 2085395522. E-mail address: [email protected] (J. Deepa).
improved operator skills, ectopic pregnancies are now diagnosed earlier. The management has shifted from radical to conservative methods, aimed at preserving fertility and minimising morbidity. Advances in laparoscopic surgery have enabled a laparoscopic approach in the majority of patients with tubal EP [2]. The diagnosis of EP has an adverse effect on the quality of life of the affected woman. Women react to early pregnancy loss in different ways and the current management aims at improving patient satisfaction and reducing psychological morbidity. Surprisingly there is only one study published to date, which
http://dx.doi.org/10.1016/j.ejogrb.2014.03.038 0301-2115/ß 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Deepa J, et al. Factors that determine patient satisfaction after surgical treatment of ectopic pregnancy: improving the patient journey!. Eur J Obstet Gynecol (2014), http://dx.doi.org/10.1016/j.ejogrb.2014.03.038
G Model
EURO-8499; No. of Pages 6 J. Deepa et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2014) xxx–xxx
2
default position in our department is that those who require surgical management of EP are managed laparoscopically unless it is deemed to be clinically unsafe by the attending surgeon. The most experienced surgeon available operates on haemodynamically unstable patients [8]. The operating surgeon debriefs the patient after the procedure. All patients are offered counselling by a trained counsellor if required, and are given an information leaflet. Patients are discharged within 24–48 h after the procedure unless there are clinical indications for prolonged hospital stay. They are then seen in a dedicated EP clinic 6 weeks after surgery. In the last year of the study to further improve patient care a telephone clinic was set up and run by the individuals that had previously been responsible for the dedicated clinic. Those that were not contactable over the telephone were offered a clinic appointment. The questionnaire we used was devised by a multidisciplinary team consisting of a clinical psychologist, early pregnancy unit nurse and gynaecologists working in early pregnancy units. The questionnaire was tested and validated using a focus group. The questionnaire included questions based on criteria of aspects of care and overall satisfaction with the care provided. This explored the way patients were received, staff willingness to listen, quality of information provided, physical pain after surgery, desire and anxiety about future fertility. These questions were then analysed in relation to socio-demographic characteristics, medical and surgical history, volume of haemoperitoneum, desire for future pregnancy, repeat EP, time interval between the diagnosis and surgery) type of surgery and length of hospital stay after surgery. We considered 800 ml of blood in the peritoneal cavity as significant haemoperitoneum because these women would be classified as having at least category II haemorrhagic shock, having lost between 15% and 30% of their blood volume, as recognised by the American College of Surgeons [9,10]. All data was anonymized and entered into SPSS version 14.0 for Windows. In describing the data, the median and interquartile range (IQR) were used for non-parametric data. Differences in
addressed patient satisfaction after management of EP [3]. The experience of pregnancy loss can leave women feeling distressed, overwhelmed, and wanting answers to their questions. At the same time, health care providers often are pressured for time and may not be able to provide this support and information [4]. Women wish to know the cause of their pregnancy loss, when to expect their next menstrual period, when it is safe to attempt another pregnancy, risk of recurrence, and anticipated emotional reactions [5]. According to a meta-analysis of satisfaction literature, humaneness and technical quality of medical care were ranked highly. The bottom five indicators featured aspects of care that reflected the provider’s attention to other patient needs and the patient’s relation to the system as a whole [6]. The purpose of this study was to evaluate the patient related factors that influence satisfaction rates. Our aim was to determine which factors influence a woman’s perception of satisfaction, and ultimately improve the way we help women cope with this distressing situation. We also compared the satisfaction outcomes between the women followed up in a face-to-face clinic with those evaluated after surgery by a telephonic interview. Ultimately if we can avoid a hospital visit follow-up, it may be more convenient to the patient, less distressing, and also cost-effective to the health care provider. Materials and methods This was a prospective cohort study of all the women treated surgically for EP in a single centre, the early pregnancy assessment unit at Whipps cross university hospital London, over a period of 4 years: January 2009–December 2012. Information relating to the patient demographic characteristics, clinical history and findings, ultrasound, peri-operative and surgical findings, type of surgery, and length of hospital stay were collected prospectively from the units’ EP database. The guidelines for the management of EP are in keeping with that of the royal college of obstetricians and gynaecologists [7]. The
394 Women diagnosed with EP in the study period
319(98.5%) tr laparoscopically 324 women surgically treated for EP
299 women included in the satisfaction questionnaire study
25(8.4%) were lost to followup
Group 2 52 (17.4%) included in the telephonic follow up group
Group 1 247(82.6%) included in the face to face follow up clinic
85% women satisfied with the care provided
5 (1.5%) had open surgery
15% women less satisfied with the care provided
86% women satisfied with the care provided
14% women less satisfied with the care provided
Chart 1. Study design chart.
Please cite this article in press as: Deepa J, et al. Factors that determine patient satisfaction after surgical treatment of ectopic pregnancy: improving the patient journey!. Eur J Obstet Gynecol (2014), http://dx.doi.org/10.1016/j.ejogrb.2014.03.038
G Model
EURO-8499; No. of Pages 6 J. Deepa et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2014) xxx–xxx
satisfaction rates were tested using a Cochran–Mantel–Haenszel chi-squared test. p 0.05 was considered statistically significant. Adjusted odds ratio and confidence intervals were calculated by univariate analysis for the factors, which have showed significant satisfaction rates. Results During the study period a total of 324 patients underwent surgical management for EP, 319 (98.5%) had operative laparoscopy and 5 (1.5%) had open surgery. 100% of haemodynamically stable patients had operative laparoscopy. Of the 324 women 299 (92.3%) were included in the study and 288 had complete data available for analysis. Twenty-five women (8.4%) were lost to follow up. In the study group 247 (82.6%) were followed up in the clinic and 52 (17.4%) by telephone interview (Chart 1). Of the total number of patients, 54% were Caucasian, 22% Black and 24% Asian. A total of 94% were tubal and the rest were extratubal pregnancies. The mean age of the cohort was 30.3 years, with range 17–50 years. The majority of women (n = 151, 53%) were multiparous, the rest (n = 136, 47%) were nulliparous. Most women were keen to preserve their fertility (n = 266, 93%), and in 87% of the cases the pregnancy was a planned event. Exploring the previous history, 269 (94%) had no previous sub-fertility, 15% had previously terminated a pregnancy, 9% had previously had pelvic inflammatory disease, 27% had a previous miscarriage, and 12% had a history of previous pelvic surgery. Eighty two percent denied smoking. The rate of recurrence in EP in our cohort was 10%. Comparing the recurrent EP group with those with primary EP there was no difference in global satisfaction with the care provided (86% in the recurrent group vs. 85% in the primary ectopic pregnancy group, p = 0.9). In 69.5% of the cases the diagnosis was made by a single ultrasound scan, and 69% were discharged within 24 h of surgery.
3
Out of the 25 that were lost to follow-up (LTF) after being treated surgically for EP in our unit, 10 women were out-of area and were actually visiting friends or family at the time of diagnosis. So we presume that they have left after the treatment and did not return for follow-up, and their not returning cannot be extrapolated as dissatisfaction with medical care. Four women were not registered with a local general practitioner, and we could not contact them on the address given at time of admission. The demographic details including age and the other risk factors did not differ between the study group and the LTF group. There was one woman in this group who had expressed dissatisfaction with the care, as she required two scans to confirm the diagnosis and waiting period was not acceptable to her (Table 1). By analysing factors that affected our patients’ satisfaction we found that there was no significant difference in the satisfaction rates based on age (<25 yrs 86%, 26–35 yrs 87%, >35 yrs 78%, p = 0.187), ethnicity (Caucasian 86%, Black 75%, Asian 86%, p = 0.48) or parity (nulliparous 82%, multiparous 87%, p = 0.3). None of the factors in the past history influenced the satisfaction rates (cigarette smoking p = 0.88, prior pregnancy termination p = 0.74, previous PID p = 0.06, previous miscarriage p = 0.36). The satisfaction rates did not differ between women who desired future pregnancy (n = 266, 93%) in comparison with those who did not wish to conceive (p = 0.4). Having a repeat EP (n = 28, 10%) did not influence the satisfaction rates (p = 0.9) (Table 2). The haemoperitoneum volume and subsequent need for blood transfusion had a significant influence on the overall satisfaction rates (blood loss <200 ml – 94% satisfied, 200–800 ml – 81% and >800 ml – 72%, p = 0.001). Using multiple logistic regression analysis, significant haemoperitoneum is an independent factor for patient dissatisfaction (adjusted odds ratio 0.59, 95% confidence interval 0.277–1.254, p = 0.004). This is irrespective of whether the diagnosis is delayed or patient presents for the first time with signs
Table 1 Patient factors affecting the satisfaction outcomes. Women satisfied with care n = 244, n (%)
Not Satisfied n = 44, n (%)
p
Age
<25 yrs 26–35 yrs >35 yrs
51 (86%) 136 (87%) 57 (78%)
8 (14%) 20 (13%) 16 (22%)
0.187
Parity
Nulliparous Multiparous
112 (82%) 131 (87%)
24 (18%) 20 (13%)
0.3
Ethnicity
White Black Asian
136 (86%) 47 (75%) 61 (86%)
22 (14%) 12 (20%) 10 (15%)
0.48
Smoker
Yes No
44 (86%) 199 (85%)
7 (14%) 36 (15%)
0.88
Previous TOP
Yes No
35 (83%) 209 (85%)
7 (17%) 36 (15%)
0.74
Previous PID
Yes No
23 (85%) 221 (85%)
4 (15%) 39 (15%)
0.06
Planned pregnancy
Yes No
211 (85%) 33 (85%)
38 (15%) 6 (15%)
0.42
H/o Infertility
Yes No
16 (89%) 228 (85%)
2 (11%) 41 (15%)
0.63
Previous miscarriage
Yes No
63 (82%) 181 (86%)
14 (18%) 29 (14%)
0.36
Prior pelvic surgery
Yes No
31 (89%) 213 (84.5%)
4 (11%) 39 (15.5%)
0.53
Previous ectopic pregnancy
Yes No
24 (86%) 220 (85%)
4 (14%) 39 (15%)
0.9
Desire for future pregnancy
Yes No
226 (85%) 14 (78%)
40 (15%) 4 (22%)
0.4
Factor
Please cite this article in press as: Deepa J, et al. Factors that determine patient satisfaction after surgical treatment of ectopic pregnancy: improving the patient journey!. Eur J Obstet Gynecol (2014), http://dx.doi.org/10.1016/j.ejogrb.2014.03.038
G Model
EURO-8499; No. of Pages 6 J. Deepa et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2014) xxx–xxx
4
Table 2 Treatment factors affecting the satisfaction outcomes. Factor
Satisfied women n = 244, n (%)
Not satisfied n = 44, n (%)
p
Number of scans
0 1 >1
6 (67%) 172 (86%) 65 (86%)
3 (33%) 28 (14%) 11 (14%)
0.28
FHR seen on scan
Yes No
22 (82%) 222 (85%)
5 (18%) 38 (15%)
0.58
Amount of haemoperitoneum
<200 ml 200–800 ml >800 ml
108 (94%) 97 (81.5%) 39 (72%)
7 (6%) 22 (18.5%) 15 (28%)
0.001
Blood transfusion
Yes No
217 (86%) 26 (74%)
35 (14%) 9 (26%)
0.07
Given adequate information
Yes No
241 (87%) 3 (30%)
37 (13%) 7 (70%)
<0.001
Postop leaflets provided
Yes No
196 (90%) 47 (68%)
22 (10%) 22 (32%)
0.001
Treatment options discussed
Yes No
32 (91%) 211 (84%)
3 (9%) 41 (16%)
0.45
Adequate pain relief postop
Yes No
208 (89%) 32 (64%)
26 (11%) 18 (36%)
<0.001
Early discharge after surgery (<24 h)
Yes No
172 (86%) 68 (80%)
27 (14%) 17 (20%)
0.17
Waiting time for surgery
<6 h 7–12 h >13 h
214 (87%) 21 (70%) 4 (67%)
33 (13%) 9 (30%) 2 (33%)
0.028
Mode of follow-up
Face–face clinic Telephone interview
208 (85%) 36 (86%)
38 (15%) 6 (14%)
0.8
and or symptoms of haemodynamic instability. Waiting time from diagnosis to surgery also significantly affected satisfaction (<6 h – 87% satisfied, 7–12 h – 70%, >13 h – 67%, p = 0.03). The longer the time interval between the diagnosis and surgery, the lower the satisfaction rates (p = 0.028). Good communication pre-operatively (87% satisfaction with good communication vs. 30% without, p < 0.001), adequate pain relief (89% vs. 64%, p = 0.001), and provision of post-operative leaflets prior to discharge (90% vs. 68%, p = 0.001) resulted in good satisfaction scores. Early discharge from the hospital after the surgery did not significantly influence the satisfaction rates (86% satisfied if discharged within 24 h vs. 80%, p = 0.17). While the overall satisfaction in the clinic follow up was 85%, the women followed up by telephone reported 86% satisfaction rates (Table 2). There was a significant difference using a multivariate regression analysis with 95% CI with good communication, providing post-operative leaflets and good pain relief. There was a significant difference in the satisfaction rates with the amount of haemoperitoneum and waiting time for surgery, with shorter
waiting times and smaller volume of haemoperitoneum associated with better satisfaction rates (Table 3). Comments The management of ectopic pregnancy has evolved over the last half century, though there has been considerable reduction in mortality (RCOG), there is still considerable morbidity associated with ectopic pregnancy [11]. With any pregnancy loss the morbidity is not only physical but also psychological and all attempts should be made to improve our patients’ journey where possible [4]. Despite potentially life saving procedures and excellent clinical outcomes, the opinion regarding quality of care and patient satisfaction may differ between the recipient and healthcare providers [6]. One of the ways to improve care would be to seek the patients’ opinion on factors that would improve their satisfaction. From the clinical point of view one would expect that clinical factors would influence how patients perceive service provision. You would reasonably hypothesise that the sicker the
Table 3 Adjusted odds ratio and confidence intervals for the factors which have showed significant satisfaction rates in the univariate analysis. Factor
Adjusted OR
Good communication
Yes No
Provision of Information leaflets
Yes No
4.17 1
Postoperative pain relief
Yes No
4.5 1
Haemoperitoneum
<200 ml 200–800 ml >800 ml
1 0.286 0.59
<6 h >6 h
1 0.35
Waiting time for surgery
15.2 1
95% confidence interval
p
3.8–61.4
<0.001
2.13–8.16
<0.001
2.2–9.1
<0.001
0.117–0.698 0.277–1.254
0.001 0.004 0.16
0.16–0.78
0.028
Please cite this article in press as: Deepa J, et al. Factors that determine patient satisfaction after surgical treatment of ectopic pregnancy: improving the patient journey!. Eur J Obstet Gynecol (2014), http://dx.doi.org/10.1016/j.ejogrb.2014.03.038
G Model
EURO-8499; No. of Pages 6 J. Deepa et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2014) xxx–xxx
patient at the point of healthcare delivery, and the better their recovery the greater their degree of satisfaction, or that patients with the greatest volume of haemoperitoneum with the shortest hospital stay be most satisfied. In the first part we analysed patient characteristics and how they might influence the overall perception of satisfaction. Interestingly none of these patient demographic factors had a significant influence on the perception of satisfaction with the care provided. Neither differences in age and parity nor ethnic diversity determined satisfaction rates. The perception of satisfaction did not alter if women had a history of previous pelvic inflammatory disease or infertility. Neither did experiencing a previous miscarriage. Satisfaction did not differ between women who smoked and those that did not, though it is known to contribute to its causation [12,13]. There was no difference in satisfaction comparing women with repeat EP and first EP. Women with repeat EP tend to present earlier and have had a previous experience of management of their condition that may influence their perception of satisfaction. This was not the case in this study. We then compared patients looking at parity. A previous study assessed severity of grief relating to the type of early pregnancy loss using the Perinatal Grief Scale (PGS). This reported that women with no children with an ectopic pregnancy grieve significantly more than those with a child (p = 0.019), with no significant difference in severity of grief between women that had a miscarriage and EP (p = 0.14) [14]. On this basis we postulated that the overall satisfaction rates would be lower in women who desire children, in comparison to those who had children previously and did not wish for further pregnancies. In our series we found, no significant difference in the two groups (p = 0.4). We expected that a delay in diagnosis and rupture of the pregnancy at presentation would influence perception of satisfaction. In 69.5% of the cases the diagnosis was made by a single ultrasound scan (in keeping with literature quoted detection rates of ectopic pregnancy with a single scan 75% with a high specificity (99.9%)) [15]. 29.5% of our patients either needed multiple scans and or serial beta HCG (human chorionic gonadotropin) monitoring. Interestingly the women who had the diagnosis of ectopic pregnancy with one ultrasound scan reported exactly the same overall satisfaction, in comparison with those who needed more than one scan (n = 172/200, 86% satisfaction rates in single scan group; n = 65/76, 86% satisfaction in the multiple scan group, p = 0.28). Though the presence of ectopic pregnancy is distressing in itself, the presence of a foetal heart beat in the ectopic gestation, and thus a live non viable foetus, did not further influence the satisfaction outcome (p = 0.58). The fact that this is essentially non-viable live foetus does not further add to the distress or affect satisfaction. The women who did not have the diagnosis with one scan reported similar satisfaction with the group who had the diagnosis in the initial scan. This may be explained if women were reasonably patient and were happy with the care even if they there was a delayed diagnosis, as long as there was good communication and staff willingness to listen. Operative laparoscopy is regarded as the gold standard for the surgical management of EP in women who are haemodynamically stable though it is increasingly used in haemodynamically unstable women [9]. The volume of haemoperitoneum alone should not dictate the operative modality used [16], but the capacity of the surgeons and the safety with the operative team to perform operative laparoscopy on unstable patients. When the satisfaction rates were evaluated in relation to the amount of haemoperitoneum, women who were diagnosed and treated prior to rupture were better satisfied than those who had more blood loss intraperitoneally (blood loss <200 ml – 94% satisfied, 200–800 ml – 81% and >800 ml – 72%, p = 0.001). This finding was consistent with the available literature [3,17]. We attempt to
5
explain this difference in the satisfaction rates due to the fact that larger volume haemoperitoneum is essentially due to a delayed diagnosis. This adds to the post-operative morbidity including the need for blood transfusion, increased pain and prolonged hospital stay. However hospital stay did not differ statistically between those with significant haemoperitoneum and those without, and this may be attributed to the laparoscopic approach in 85% of the haemodynamically unstable patients. Using multiple logistic regression analysis, significant haemoperitoneum is an independent factor for patient dissatisfaction (adjusted odds ratio 0.59, 95% confidence interval 0.277–1.254, p = 0.004). This is irrespective of whether the diagnosis is delayed or patient presents for the first time with signs and or symptoms of haemodynamic instability. Good communication pre-operatively (87% satisfaction with good communication vs. 30% without, p < 0.001) and provision of post-operative leaflets prior to discharge (90% satisfaction in the group provided with written information vs. 68%, p = 0.001) resulted in good patient experience. Women were better satisfied with the care provided when they were given adequate information. They may not be able to fully digest and recall information provided by clinicians at the time of loss due to the physical and emotional stress. Written information may therefore aid information retention [18]. The provision of written information alone can lead patients to perceive medical staff as uncaring; therefore it is best used in conjunction with verbal communication [19]. The longer the time interval between the diagnosis to surgery, the lower the satisfaction rates. Understandably the experience of postoperative pain resulted in lower satisfaction rates (89% satisfaction with good pain relief vs. 64% satisfied in the group without adequate pain relief, p = 0.001). Early discharge from the hospital after the surgery did not significantly influence the satisfaction rates (86% satisfied if discharged within 24 h vs. 80%, p = 0.17). This was contrary to our expectation, but the time of discharge was influenced by several factors such as the necessity for blood transfusion, or significant postoperative pain. These factors may further influence the patient satisfaction. While the overall satisfaction in the clinic follow up was 85%, the women followed up by telephone reported 86% satisfaction rates, p = 0.8. There was no difference in the overall satisfaction between these two groups and therefore telephonic interview is a feasible mode of communication in the post-operative follow up. This may be beneficial to the patient by avoiding additional hospital visits to the hospital, particularly when it may be associated with unpleasant memories following pregnancy loss. It may prove cost effective to the health care provider as it minimises the clinic attendance. Whatever the follow up method it is important not to miss an opportunity of further contact with the women during this stressful period. Another important factor of note in an ethnically diverse population like ours, there may be significant barriers to communication during a telephonic consultation in which could result in loss of the patient to follow-up. This is the second such study which has looked into the issue of patient satisfaction after surgical treatment for ectopic pregnancy, and the previous one was published more than a decade ago. Our findings show that the majority of women are satisfied with the care provided. Irrespective of the demographic diversity, women were satisfied overall with the care provided, when they were given adequate information and were received with compassion. Understanding the issues raised by women in this study can lead to improvement of the quality of care provided and improve patient satisfaction rates, a key indicator of good healthcare provision. References [1] Ectopic pregnancy and miscarriage. December 2012 NICE clinical guideline 154; guidance.nice.org.uk/cg154.
Please cite this article in press as: Deepa J, et al. Factors that determine patient satisfaction after surgical treatment of ectopic pregnancy: improving the patient journey!. Eur J Obstet Gynecol (2014), http://dx.doi.org/10.1016/j.ejogrb.2014.03.038
G Model
EURO-8499; No. of Pages 6 J. Deepa et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2014) xxx–xxx
6
[2] Sultana CJ, Easley K, Collins RL. Outcome of laparoscopic versus traditional surgery for ectopic pregnancies. Fertil Steril 1992;57:285–9. [3] Ego A, Subtil D, Di Pompeo C. Patient satisfaction with management of ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol 2001;98(September (1)):83–90. [4] Nikcevic AV, Kuczmierczyk AR, Nicolaides KH. Personal coping resources, responsibility, anxiety, and depression after early pregnancy loss. J Psychosom Obstet Gynaecol 1998;19:145–54. [5] Pamela AG, Christina P, Danielle K. Web-based resources for health care providers and women following pregnancy loss. JOGNN 2006;35:523–32. http://dx.doi.org/10.1111/J.1552-6909.2006.00065. [6] Hall JA, Dornan ME. What patients like about their medical care and how often they are asked. A meta-analysis of the satisfaction literature. Soc Sci Med 1988;27:935–9. [7] Royal College of Obstetricians and Gynaecologists. The management of tubal pregnancy. Guideline no. 21. London: RCOG Press; 2010. [8] Odejinmi FO, Rizzuto MI, Macrae RE, Thakur V. Changing trends in the laparoscopic management of ectopic pregnancy in a London district general hospital: 7-years experience. J Obstet Gynaecol 2008;28(August (6)):614–7. [9] Odejinmi F, Sangrithi M, Olowu O. Operative laparoscopy as the mainstay method in management of hemodynamically unstable patients with ectopic pregnancy. J Minim Invasive Gynecol 2011;18(March (2)):179–83. http://dx.doi.org/10.1016/j.jmig.2010.11.005. [10] American College of Surgeons Committee on Trauma. Advanced trauma life support student manual. Chicago, IL: American College of Surgeons; 1989. p.
47–59.
[11] van Mello NM, Zietse CS, Mol F, et al. Severe maternal morbidity in ectopic pregnancy is not associated with maternal factors but may be associated with quality of care. Fertil Steril 2012;97(March (3)):623–9. [12] Bouyer J, Coste J, Shojaei T, et al. Risk factors for ectopic pregnancy: a comprehensive analysis based on a large case–control, population-based study in France. Am J Epidemiol 2003;157(3):185–94. [13] Handler A, Davis F, Ferre C, et al. The relationship of smoking and ectopic pregnancy. Am J Public Health 1989;79:1239–42. [14] Purandare N, Ryan G, Ciprike V, Trevisan J, Sheehan J, Geary M. Grieving after early pregnancy loss – a common reality. Ir Med J 2012;105(November– December (10)):326–8. [15] Kirk E, Papageorghiou AT, Condous G, et al. The diagnostic effectiveness of an initial transvaginal scan in detecting ectopic pregnancy. Hum Reprod 2007;22(11):2824–8. [16] Rizzuto MI, Oliver R, Odejinmi F. Laparoscopic management of ectopic pregnancy in the presence of a significant haemoperitoneum. Arch Gynecol Obstet 2008;277–80. [17] Ware Jr JE, Snyder MK, Wright WR, Davies AR. Defining and measuring patient satisfaction with medical care. Eval Program Plann 1983;6 (3–4):247–63. [18] Hamilton SM. Should follow-up be provided after miscarriage. Br J Obstetr Gynaecol 1989;96:743–5. [19] Paton F, Wood R, Bor R, Nitsun M. Grief in miscarriage patients and satisfaction with care in a London hospital. J Reprod Infant Psychol 1999;17:301–15.
Please cite this article in press as: Deepa J, et al. Factors that determine patient satisfaction after surgical treatment of ectopic pregnancy: improving the patient journey!. Eur J Obstet Gynecol (2014), http://dx.doi.org/10.1016/j.ejogrb.2014.03.038