Patient-centered endometriosis care implementation at tertiary and secondary care hospitals in Indonesia

Background

Endometriosis has a high recurrence rate within five years (40-50 %). High recurrence remarkably reduces Health-Related Quality of Life (HRQOL). Patient-centered endometriosis care (PCEC) is a range of care that respects the patient's preferences and needs while being guided by the patient's values and may provide better treatment for patients. Our study is the first to evaluate the implementation of PCEC in Indonesia.

Materials and methods

We evaluated PCEC at Dr. Cipto Mangunkusumo Hospital in Jakarta (Center-1), Raden Mattaher Hospital in Jambi, and dr. Zainoel Abidin Hospital in Aceh (Center-2) from October 2021 to May 2022. Center-1 represented tertiary care, and center-2 represented secondary care. This study used the ENDOCARE Questionnaire (ECQ) instrument, which produced mean important score (MIS), percentage of negative performance (PNP), and patient-centeredness score (PCS) as outcomes. Higher PCS reflects greater patient-centered care of the center.

Results

A total of 73 patients were recruited and divided into two groups of centers. Patients from Center-1 had significantly higher patient-centeredness scores vs. patients in centers without the training and guideline: dimension "Respect for patients' values, preferences, and needs" (Center-1 7.33, 6-10, Center-2 6, 6-6; p < 0.001), dimension "Coordination and integration of care" (Center-1 6, 4.44-8.67, Center-2 5.5, 4-6; p = 0.006), dimension "Information, communication, and education" (Center-1 7.14, 6-8.29, Center-2 5.14, 5.14-6; p < 0.001), dimension "Physical comfort" (Center-1 6, 6-8, Center-2 6, 6-6; p = 0.033), dimension "Endometriosis clinical staff" (Center-1 6, 6-9, Center-2 6, 6-6, p = 0.049). Subjects with higher education and experienced endometriosis recurrences statistically had higher patient-centeredness scores.

Conclusion

Our findings suggest that endometriosis training and having endometriosis clinical guidelines could improve patients' experience in receiving PCEC. Information for patients should be made simple so they can understand the purpose of the treatment.

Guideline No. 449: Diagnosis and Impact of Endometriosis - A Canadian Guideline

OBJECTIVE

To provide a contemporary approach to the understanding of the impact and methods for the diagnosis of endometriosis in Canada.

TARGET POPULATION

Individuals, families, communities, health care providers, and health care administrators who are affected by, care for patients with, or manage delivery of services for endometriosis.

OPTIONS

The diagnosis of endometriosis is facilitated by a detailed history, examination, and imaging tests with providers who are experienced in endometriosis care. Surgical evaluation with pathology confirms a diagnosis of endometriosis; however, it is not required for those whose diagnosis was confirmed with imaging.

OUTCOMES

There is a need to address earlier recognition of endometriosis to facilitate timely access to care and support. Education directed at the public, affected individuals and families, health care providers, and health care administrators are essential to reduce delays in diagnosis and treatment.

BENEFITS, HARMS, AND COSTS

Increased awareness and education about the impact and approach to diagnosis may support timely access to care for patients and families affected by endometriosis. Earlier and appropriate care may support a reduced health care system burden; however, improved clinical evaluation may require initial investments.

EVIDENCE

Each section was reviewed with a unique search strategy representative of the evidence available in the literature related to the area of focus. The literature searches for each section of this guideline are listed in Appendix A and include information from published systematic reviews described in the text.

VALIDATION METHODS

The recommendations were developed following two rounds of review by a national expert panel through an iterative 2-year consensus process. Further details on the process are shared in Appendix B. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix C (Table C1 for definitions and Table C2 for interpretations of strong and conditional recommendations).

INTENDED AUDIENCE

This guideline is intended to support health care providers and policymakers involved in the care of those impacted by endometriosis and the systems required to support them.

TWEETABLE ABSTRACT

Endometriosis impact and diagnosis updated guidelines for Canadian health care providers and policymakers.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Towards comprehensive management of symptomatic endometriosis: beyond the dichotomy of medical versus surgical treatment

Except when surgery is the only option because of organ damage, the presence of suspicious lesions, or the desire to conceive, women with endometriosis-associated pain often face a choice between medical and surgical treatment. In theory, the description of the potential benefits and potential harms of the two alternatives should be standardized, unbiased, and based on strong evidence, enabling the patient to make an informed decision. However, doctor's opinion, intellectual competing interests, local availability of specific services and (mis)information obtained from social media, and online support groups can influence the type of advice given and affect patients' choices. This is compounded by the paucity of robust data from randomized controlled trials, and the anxiety of distressed women who are eager to do anything to alleviate their disabling symptoms. Vulnerable patients are more likely to accept the suggestions of their healthcare provider, which can lead to unbalanced and physician-centred decisions, whether in favour of either medical or surgical treatment. In general, treatments should be symptom-orientated rather than lesion-orientated. Medical and surgical modalities appear to be similarly effective in reducing pain symptoms, with medications generally more successful for severe dysmenorrhoea and surgery more successful for severe deep dyspareunia caused by fibrotic lesions infiltrating the posterior compartment. Oestrogen-progestogen combinations and progestogen monotherapies are generally safe and well tolerated, provided there are no major contraindications. About three-quarters of patients with superficial peritoneal and ovarian endometriosis and two-thirds of those with infiltrating fibrotic lesions are ultimately satisfied with their medical treatment although the remainder may experience side effects, which may result in non-compliance. Surgery for superficial and ovarian endometriosis is usually safe. When fibrotic infiltrating lesions are present, morbidity varies greatly depending on the skill of the individual surgeon, the need for advanced procedures, such as bowel resection and ureteral reimplantation, and the availability of expert colorectal surgeons and urologists working together in a multidisciplinary approach. The generalizability of published results is adequate for medical treatment but very limited for surgery. Moreover, on the one hand, hormonal drugs induce disease remission but do not cure endometriosis, and symptom relapse is expected when the drugs are discontinued; on the other hand, the same drugs should be used after lesion excision, which also does not cure endometriosis, to prevent an overall cumulative symptom and lesion recurrence rate of 10% per postoperative year. Therefore, the real choice may not be between medical treatment and surgery, but between medical treatment alone and surgery plus postoperative medical treatment. The experience of pain in women with endometriosis is a complex phenomenon that is not exclusively based on nociception, although the role of peripheral and central sensitization is not fully understood. In addition, trauma, and especially sexual trauma, and pelvic floor disorders can cause or contribute to symptoms in many individuals with chronic pelvic pain, and healthcare providers should never take for granted that diagnosed or suspected endometriosis is always the real, or the sole, origin of the referred complaints. Alternative treatment modalities are available that can help address most of the additional causes contributing to symptoms. Pain management in women with endometriosis may be more than a choice between medical and surgical treatment and may require comprehensive care by a multidisciplinary team including psychologists, sexologists, physiotherapists, dieticians, and pain therapists. An often missing factor in successful treatment is empathy on the part of healthcare providers. Being heard and understood, receiving simple and clear explanations and honest communication about uncertainties, being invited to share medical decisions after receiving detailed and impartial information, and being reassured that a team member will be available should a major problem arise, can greatly increase trust in doctors and transform a lonely and frustrating experience into a guided and supported journey, during which coping with this chronic disease is gradually learned and eventually accepted. Within this broader scenario, patient-centred medicine is the priority, and whether or when to resort to surgery or choose the medical option remains the prerogative of each individual woman.

Women's lived experience of endometriosis-related fertility issues

OBJECTIVE

The aim of the present study is to conduct a qualitative investigation to provide a deeper understanding of women's views about endometriosis, fertility and their perception of reproductive options.

METHODS

Semi-structured interviews were conducted by two female psychiatrists, specialized in gynecology and obstetrical consultation-liaison psychiatry, trained in qualitative procedures, with experience in qualitative studies and in psychological support of women attending infertility consultations. No prior relationship with respondents was established before data collection. Interviews were tape-recorded and transcribed. Interviews lasted 45-75 minutes. The transcripts were then analysed using thematic content analysis.

RESULTS

Twenty-nine women were contacted. Twelve agreed to an interview at the hospital's infertility clinic. Eleven women with diverse sociodemographic characteristics were included. The key findings of thematic content analysis can be grouped into four topics: (1) Diagnostic announcement and initial delay; (2) Negative perceptions of initial care: pre-diagnosis phase; (3) Struggle with endometriosis and its treatment; (4) Issues related to health problems, fertility and reproductive options.

CONCLUSION

Our analysis of the interviews corroborates the distressing impact of the trivialization of pain and the uncertainty of or the long quest for diagnosis. The findings also stress various associated issues, from the diagnostic delay to the low success rates of fertility treatments. This qualitative analysis contributes to better understand the accumulation of negative emotions within the illness trajectory and the poor dyadic adjustment within the couple.

Endometriosis and Depression: A Double Agony for Women

Background

Endometriosis is defined as a condition in which a formation of abnormal endometrial tissue outside the uterus takes place. Irrespective of any ethnic and socioeconomic class, the prevalence of the diseases has been seen among women of reproductive age. Endometriosis has been seen adversely affect the physical, psychological, social, and career of women.

Summary

This paper aims to identify and describe the experiences and outcomes of endometriosis healthcare by reviewing the existing literature on social and psychological effects of endometriosis. The study serves the purpose of providing insights on women's dual suffering (mental and social health) and critical comments on the present state of knowledge in order to make future recommendations for psycho-social research. The review included systematic search of the articles from various disciplines like, biology, psychology, sociology, anthropology, etc. A structured process of screening with specific inclusion and exclusion criteria was used to select the articles. The analysis of the articles resulted that woman diagnosed with endometriosis reported poor quality of life and the following symptoms such as anxiety, stress, Chronic Pelvic Pain (CPP), anxiety, dyspareunia, and dysmenorrhea. However, depression appears prominent among women diagnosed with endometriosis. There are few strategies mentioned that can be used to deal with endometriosis.

Key Message

The most promising causes of endometriosis include abnormality in immune functioning, atypical endometriotic growth, genetics, epigenetic, embryogenetic theory, and endocrine disruptors. The ill effects have been noted in the following domains of women's life such as work, close relationships, social well-being, and education, deteriorating their quality-of-life manifold. Psychological intervention is required to deal with the disorder as only medical treatment with pain may not be sufficient. Though, the condition can be improved by providing awareness regarding the severity of the disorder at the school and community levels.

The Relation between Patient-Centered Care and Quality of Life in Women with Endometriosis

OBJECTIVE

The objective of this study was to examine the hypothesis that experiences with patient-centered endometriosis care are related to the endometriosis-specific quality of life dimensions "emotional well-being" and "social support."

DESIGN

A secondary regression analysis of two cross-sectional studies was conducted. Participants/Materials: In total, data from 300 women were eligible for analysis. The participating women all had surgically proven endometriosis.

SETTING

The study was conducted in one secondary and two tertiary endometriosis clinics in the Netherlands. Questionnaires were disseminated between 2011 and 2016.

METHODS

Both included studies investigated patient-centeredness of endometriosis care and endometriosis-specific quality of life using, respectively, the ENDOCARE questionnaire (ECQ) and the Endometriosis Health Profile 30 (EHP-30). To increase power, the regression analysis focused on the previously found relation between the ten dimensions of the ECQ and the EHP-30 domains "emotional well-being" and "social support" rather than all five EHP-30 domains. After the Bonferroni correction to limit type 1 errors, the adjusted p value was 0.003 (0.05/20).

RESULTS

The participating women had a mean age of 35.7 years and had predominantly been diagnosed with moderate to severe endometriosis. None of the relations between patient-centered endometriosis care and the EHP-30 domain "emotional well-being" were significant. Three dimensions of patient-centered endometriosis care proved to be significantly related to the EHP-30 domain "social support": "information, communication, and education" (p < 0.001, beta = 0.436), "coordination and integration of care" (p = 0.001, beta = 0.307), and "emotional support and alleviation of fear and anxiety" (p = 0.002, beta = 0.259).

LIMITATIONS

This cross-sectional study identified relations rather than proving causality between experiencing less patient-centeredness of care and having lower quality of life. Nevertheless, it is very tangible that some causality exists, either directly or indirectly (e.g., through empowerment) and that by improving patient-centeredness, quality of life might be improved as well.

CONCLUSION

"Information, communication, and education"; "coordination and integration of care"; and "emotional support and alleviation of fear and anxiety" as dimensions of patient-centered endometriosis care are related to the quality of life domain "social support" of women with endometriosis. Improving the patient-centeredness of endometriosis care was already considered an important goal, but even more so given its relation with women's quality of life, which is increasingly considered the ultimate measure of health care quality. Quality improvement projects focusing on "information, communication, and education" are expected to impact women's quality of life the most.

Demographic and clinical characteristics determining patient-centeredness in endometriosis care

PURPOSE

The primary aim of this study was to assess patient-centeredness of endometriosis care in a national sample of Swedish women with endometriosis. The secondary aims were to assess the importance of different dimensions of endometriosis care and to analyze demographic and clinical determinants associated with the experience of patient-centeredness.

METHODS

This cross-sectional study included 476 women with confirmed endometriosis. An invitation to participate was sent to 1000 randomly selected women aged ≥ 18 years having any endometriosis diagnosis and who had visited a gynecological clinic due to endometriosis problems any time during the past five years. Participants were recruited from ten different-sized gynecology clinics all over Sweden. The invitation letter had a link to the digital survey, which consisted of demographic and clinical questions, and the ENDOCARE questionnaire (ECQ). ECQ measures experiences, importance and patient-centeredness of ten dimensions of endometriosis care. Univariate and multiple regression analyses were used to analyze which patient-specific demographic and clinical determinants were associated with the experience of patient-centeredness.

RESULTS

The response rate was 48%. The results indicate that Swedish women with endometriosis experience low patient-centeredness and rate relational aspects with healthcare professionals as the most important aspects of care. Having a gynecologist with patient responsibility was an independent predictor for high patient-centeredness.

CONCLUSION

Women with endometriosis in Sweden experience low patient-centeredness, reflecting the urgent need for improvement. More effort should be given to develop the relational aspects of care. Women with endometriosis should have a responsible gynecologist to care for treatment and follow-up.

Real-world assessment of the patient-centredness of endometriosis care: European countries benchmarked by patients

European patients cross the borders of their countries to receive more patient-centred healthcare. Benchmarking across European countries for the patient-centredness of endometriosis care had yet to be performed. This study proved the factorial structure and reliability of translation of the ENDOCARE questionnaire in nine different languages. Moreover, the benchmark potential of the ENDOCARE questionnaire was shown by the significant between-country variance for case-mix-adjusted overall and dimensional patient-centredness scores, explaining 3-9% of the total variance in patient-centredness assessed across 10 European countries. Compared with the least patient-centred country, endometriosis care was more patient-centred in Denmark, Italy and Belgium. 'Reaching a diagnosis quickly' and 'physicians demarcating the endometriosis complexity level which they can treat' were consistently rated of more-than-average importance and were experienced negatively by more than half of the European sample. National and European policymakers and specialized clinics are prompted to monitor their patient-centredness and set up improvement projects.

The impact of the COVID-19 pandemic on infertility patients and endometriosis patients in the Netherlands

Research question

How do infertility patients, endometriosis patients and health-care providers rate virtual care as an alternative to physical consultations during the first lockdown of the coronavirus disease 2019 (COVID-19) pandemic in the Netherlands, and how does this influence quality of life and quality of care?

Design

Infertility patients and endometriosis patients from a university hospital and members of national patient organizations, as well as healthcare providers in infertility and endometriosis care, were asked to participate between May and October 2020. The distributed online questionnaires consisted of an appraisal of virtual care and an assessment of fertility-related quality of life (FertiQol) and patient-centredness of endometriosis care (ENDOCARE).

Results

Questionnaires were returned by 330 infertility patients, 181 endometriosis patients and 101 healthcare providers. Of these, 75.9% of infertility patients, 64.8% of endometriosis patients and 80% of healthcare providers rated telephone consultations as a good alternative to physical consultations during the COVID-19-pandemic. Only 21.3%, 14.8% and 19.2% of the three groups rated telephone consultations as a good replacement for physical consultations in the future. A total of 76.6% and 35.9% of the infertility and endometriosis patients reported increased levels of stress during the pandemic. Infertility patients scored lower on the FertiQol, while the ENDOCARE results care seem comparable to the reference population.

Conclusions

Virtual care seems to be a good alternative for infertility and endometriosis patients in circumstances where physical consultations are not possible. Self-reported stress is especially high in infertility patients during the COVID-19-pandemic. Healthcare providers should aim to improve their patients’ ability to cope.

Translation, Cross-Cultural Adaptation, and Psychometric Evaluation of the Swedish Version of ENDOCARE: An Instrument to Measure Patient Centeredness of Endometriosis Care

OBJECTIVES

The need for quality improvement within endometriosis healthcare is widely acknowledged. The ENDOCARE questionnaire (ECQ) measures patient centeredness of endometriosis care. The aims of this study were (1) to translate and culturally adapt ECQ into Swedish, (2) to evaluate validity (construct validity), and (3) to measure reliability (internal consistency and test-retest reliability).

DESIGN

This is a cross-sectional randomized study. Participants, Setting, and Methods: ECQ was first translated according to a well-established guideline and was thereafter sent to 500 randomly selected women with endometriosis, who had visited participating clinics during the past 3 years. The first 150 women who returned their questionnaires were immediately sent the same questionnaire again. The ECQ consists of 3 parts. The first part contains demographic and clinical questions, while part II has 38 items that are answered according to 2 aspects: percentage of negative experience of care and mean personal importance. A patient-centeredness score (PCS) is calculated based on these 2 aspects. The items are also divided into 10 dimensions of care. Part III is a grading of overall experience and an open-ended question on any missing aspect in the questionnaire.

RESULTS

A total of 187 native Swedish-speaking women participated. Data completeness was high (>90%). The overall PCS median was 3.5. The highest median PCS was found in the dimension regarding endometriosis clinic staff and the lowest in emotional support and alleviation of fear and anxiety and the involvement of significant others. Factor analysis could roughly confirm 2 of the 10 dimensions. The Cronbach's α coefficient for PCS ranged from 0.35 to 0.73. The test-rest analysis showed acceptable reliability.

LIMITATIONS

The most important limitation was the relatively low participation rate and the risk of recall bias. It is likely that women gave their answers based on their most recent experiences.

CONCLUSIONS

Overall, our results indicate that the Swedish version of the ECQ is a usable instrument to measure patient centeredness in endometriosis care, but due to the unstable factor analysis, conclusions based on the dimensions should be made with caution.

A systematic review and secondary analysis of two studies identifying demographic and medical characteristics determining patient-centeredness in endometriosis care as experienced by patients

STUDY QUESTION

What are the patient-specific determinants associated with patient-centered endometriosis care as measured by the ENDOCARE questionnaire (ECQ)?

SUMMARY ANSWER

‘Overall grade for endometriosis care’, ‘educational level’, ‘membership of a patient organization’ and ‘having seen other specialists for endometriosis complaints’ are correlated with overall patient-centeredness scores (PCS).

WHAT IS KNOWN ALREADY

Patient-centeredness of endometriosis care can be evaluated using the validated ECQ. The ECQ leads to an overall PCS and separate PCS for 10 dimensions of endometriosis care. Previously, educational level and quality of life scores were found to be associated with ECQ results.

STUDY DESIGN, SIZE, DURATION

First, a systematic literature review was performed (PROSPERO registration number: CRD42020169872). MEDLINE, Cochrane CENTRAL and EMBASE databases were searched from inception to May 2020 for studies in any language reporting on the results of the ECQ in patients with endometriosis. Two studies were identified. From the two studies, all original data were merged. In total, data from 546 patients were available for analysis. Second, univariate and multivariate regression analyses were performed to identify determinants for patient-centeredness of endometriosis care.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The two included studies evaluated patient-centeredness in four endometriosis care centers in Belgium and the Netherlands. All participants had surgically proven endometriosis. Possible patient-specific determinants were selected from the demographic and medical questions from the first part of the ECQ. These determinants were evaluated using linear regression analysis and all possible determinants with a P > 0.2 in the univariate analysis were selected for stepwise multivariate analysis. Separate analyses were performed for overall PCS and each of the 10 dimensions.

MAIN RESULTS AND THE ROLE OF CHANCE

The two included studies provided data from 546 patients. After adjustment for care center, multivariate analysis showed that a higher ‘grade for endometriosis care’ (B = 0.66), a ‘lower educational level’ (B = 0.50), ‘being member of a patient organization’ (B = 0.49) and ‘having seen other specialists for endometriosis complaints’ (B = 0.34) were independently associated with higher overall PCS (R² = 0.41). ‘Grade for endometriosis care’ was a determinant for all dimensions of endometriosis care. ‘Having seen other specialists for endometriosis complaints’ was positively associated with the care dimensions ‘respect for patients’ values, preferences and expressed needs’, ‘continuity and transition’ and ‘technical skills’. Members of a patient organization showed higher scores on the care dimensions ‘emotional support and alleviation of fear and anxiety’, ‘continuity and transition’ and ‘endometriosis clinic staff’. Furthermore, we found that having a higher level of education is associated with lower scores in the care dimensions ‘physical comfort’, ‘emotional support and alleviation of fear and anxiety’ and ‘involvement of significant other’.

LIMITATIONS, REASONS FOR CAUTION

These results delineate the patient-specific determinants of patient-centered care as measured using the Dutch ECQ. Whether results are generalizable to other countries should be investigated in an international study. This requires the ECQ to be validated in other languages first.

WIDER IMPLICATIONS OF THE FINDINGS

The aforementioned determinants of patient-centered care are of value for studies benchmarking clinics for their patient-centeredness. In addition, they help clinicians to determine how to tailor their care to individual patients. At every visit, patients could be asked to grade the endometriosis care (on a scale of 0–10) to easily investigate patient-centeredness. When there is more time, women with endometriosis should be asked to complete the entire ECQ to investigate patient-centeredness in depth.

STUDY FUNDING/COMPETING INTEREST(S)

The department of reproductive medicine (involving C.B.L. and V.M.) of the Amsterdam UMC, Vrije Universiteit Amsterdam has received several research and educational grants from Guerbet, Merck and Ferring. The authors have no conflict of interest related to this manuscript.

Towards more patient-centred endometriosis care: a cross-sectional survey using the ENDOCARE questionnaire

STUDY QUESTION

What is the performance of the patient-centredness of endometriosis care in a secondary and a tertiary care setting and how can it be improved?

SUMMARY ANSWER

Overall, patient-centredness was comparable in the two endometriosis care centres, but differed regarding ‘physical comfort’ and ‘continuity and transition’; both centres can learn how to improve several of their targets from the other’s strengths.

WHAT IS KNOWN ALREADY

The ENDOCARE questionnaire (ECQ) is a validated questionnaire for assessing the important quality dimension ‘patient-centredness’. Patient-centredness is associated with quality of life, although this should be explored further by larger-scale studies.

STUDY DESIGN, SIZE, DURATION

A cross-sectional survey, relying on the ECQ, was performed (during 2015 and 2016) among 407 women with surgically diagnosed endometriosis.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This study was conducted in a secondary and a tertiary care centre in the Netherlands. A total of 209 Dutch-speaking women who had endometriosis surgery (2013–2014), completed the ECQ after a postal invitation and, if needed, postal reminders. The assessed outcomes were: overall patient-centredness, the patient-centredness for each of its 10 dimensions, and the patient-centred strengths and targets for improvement. Case-mix adjusted patient-centredness scores (PCS) were compared and strengths and targets for improvement were identified with a matrix modelling importance against experience. The need to improve the targets was quantified with quality impact indices.

MAIN RESULTS AND THE ROLE OF CHANCE

No difference was demonstrated between the overall PCS of the secondary and tertiary centres (respectively: 4.8 and 4.5; P = 0.15). No difference was found in PCS per dimension between the two clinics except for the secondary care centre performing better regarding ‘physical comfort’ (respectively: 4.5 and 3.0; P = 0.01) and ‘continuity and transition’ (respectively: 6.0 and 4.2; P = 0.01). The two centres had nine targets for improvement in common. The secondary and tertiary centres, respectively, had five and seven additional centre-specific targets for improvement. Cross-centre learning is encouraged as 9 out the 12 additional centre-specific targets were strengths in the other centre. The main improvement targets were being able to contact the centre in case of emergency (both centres), the involvement of a significant other (secondary centre), diagnostic delay (secondary centre), personal follow-up (tertiary centre) and disclosing the level of competence of healthcare providers (tertiary centre).

LIMITATIONS, REASON FOR CAUTION

Responders did not differ from non-responders in their stage of endometriosis, educational level, rating of endometriosis care and degree to which their complaints are suppressed. Endometriosis is a chronic condition and patient-centredness might be experienced differently at other points of the endometriosis care trajectory.

WIDER IMPLICATION OF THE FINDINGS

The ECQ is a useful tool to assess patient-centredness in both secondary and tertiary care centres. Further research should focus on how to improve endometriosis care.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used. V.M. and C.B.L. report grants from Guerbet, grants from Merck and grants from Ferring outside the submitted work. All authors declare that they have no competing interests concerning this publication.

Case-control study to develop and validate a questionnaire for the secondary prevention of endometriosis

Background

Endometriosis is a debilitating gynecologic disease characterized by the implantation of endometrial tissue in ectopic locations, with signs of severe and chronic inflammation. The new knowledge on endometriosis has highlighted the value of secondary prevention through the early diagnosis and treatment of lesions to reduce serious consequences, first of all, infertility and chronic pelvic pain. The purpose of this study is to assess the reliability and validity of the questionnaire, as a tool to precociously identify women with endometriosis, to prevent the progression of symptoms.

Method

We reviewed the literature and selected risk factors, symptoms, and phenotypic traits of the women affected by endometriosis to create the questionnaire divided into 8 modules, with 47 questions. A total of 151 women completed the questionnaires: 51 patients who have endometriosis (the cases) and 100 matched women without endometriosis (the controls). After data collection, bivariate and multivariate analyses were conducted.

Results

We retained four of the significant variables from a step-down logistic regression, namely chronic pelvic pain, dyspareunia with VAS≥3, painful defecation, and acne, to develop a final “predictive” logistic model achieving 90.2% sensitivity and 75% specificity.

Conclusion

Our pilot study demonstrated that the questionnaire provides a powerful tool for the secondary prevention of endometriosis.

What constitutes patient-centred care for women: a theoretical rapid review

BACKGROUND

Women experience disparities in health care delivery and outcomes. Patient-centred care for women (PCCW) is needed. This study examined how PCC has been conceptualized and operationalized in women's health research.

METHODS

We conducted a theoretical rapid review of PCCW in MEDLINE, EMBASE, CINAHL and SCOPUS from 2008 to 2018 for studies involving women aged 18 years or greater with any condition, and analyzed data using an established 6-domain framework of patient-centred communication.

RESULTS

We included 39 studies, which covered the following clinical areas: maternal care, cancer, diabetes, HIV, endometriosis, dementia, distal radius fracture, overactive bladder, and lupus erythematosus. The 34 (87.2%) studies that defined or described PCC varied in the PCC elements they addressed, and none addressed all 6 PCC domains. Common domains were exchanging information (25, 73.5%) and fostering the patient-clinician relationship (22, 64.7%). Fewer studies addressed making decisions (16, 47.1%), enabling patient self-management (15, 44.1%), responding to emotions (12, 35.3%), or managing uncertainty (1, 2.9%). Compared with mixed-gender studies, those comprised largely of women more frequently prioritized exchanging information above other domains. Few studies tested strategies to support PCCW or evaluated the impact of PCCW; those that did demonstrated beneficial impact on patient knowledge, satisfaction, well-being, self-care and clinical outcomes.

CONCLUSIONS

Studies varied in how they conceptualized PCCW, and in many it was defined narrowly. Few studies examined how to implement or measure PCCW; thus, we lack insight on how to operationlize PCCW. Thus, further research is needed to confirm this, and whether PCCW differs across conditions, knowledge needed to inform policies, guidelines and measures aimed at improving health care and associated outcomes for women.

Quality of life in women with endometriosis: a narrative overview

Endometriosis is a very complex condition and has a significant impact on the quality of life, psychological wellbeing and interpersonal relationships of affected women. Endometriosis symptoms progressively impair the woman's ability to carry out some daily activities and result in a perception of worsening health status and overall well-being. The impact of these symptoms has been only partially investigated, and further studies and clinical insights are needed to fully understand the extent of this condition. It has been shown that endometriosis is associated with considerable direct and indirect costs, comparable to those of major worldwide chronic diseases such as diabetes. In addition, endometriosis-related symptoms substantially interfere with the employment of affected women, resulting in many cases in several working days missed. In this scenario, the aim of this narrative review is to provide a general overview of the psychological and social impact of this disease, as well as the effects of different therapeutic options, on quality of life and general well-being.

Endometriosis and perceived stress: impact of surgical and medical treatment

BACKGROUND

The aim of the study was to investigate the levels of perceived stress in a group of women with a long-term history of endometriosis in conjunction with surgical and/or medical treatments.

METHODS

A clinical trial was conducted at the Department of Molecular and Developmental Medicine, University of Siena, in collaboration with a non-profit association of women with endometriosis, A.P.E. Onlus. Patients (n = 204) with a previous diagnosis of endometriosis (for at least 3 years) were included in this study. Each patient completed a semi-structured questionnaire and a validated scale to assess perceived stress, the Perceived Stress Scale (PSS) by e-mail.

RESULTS

The study showed that in women with a long-term history of endometriosis, the level of perceived stress was increased by repeated surgical treatments and reduced by some medical treatments. The median PSS value was 23 (range 9-36) and 30.6% of the study population were included in the highest stress category (>26). The highest levels were found in patients who had undergone the most surgery. The use of progestins was associated with a lower perceived stress (p = 0.004) than in the patients treated with gonadotropin-releasing hormones.

CONCLUSIONS

Long-term endometriosis has a relevant impact on perceived stress, in particular in those undergoing repeated surgery.

The patient-centeredness of endometriosis care and targets for improvement: a systematic review

BACKGROUND

Endometriosis is a prevalent condition compromising physical and psychosocial health and thus requiring patient-centered care, which is guided by patients' values. This study aimed to find out what the patient's perspective on endometriosis care is and how the patient-centeredness of endometriosis care can be improved.

METHODS

Electronic databases were searched systematically, and study selection was based on eligibility and quality. Study methodology was examined. Specific care aspects valued by patients were organized according to 10 dimensions of patient-centered endometriosis care. Based on patients' assessments of service quality, patient-centered improvement targets and strengths were identified.

RESULTS

Twelve of 20 eligible studies had sufficient quality to be included. Endometriosis patients valued all 10 dimensions of patient-centered endometriosis care. Problematic service quality was reported for all dimensions but 'coordination and integration' and 'involvement of significant others'. Two patient-centered strengths and 29 patient-centered improvement targets were identified. The most frequently reported improvement targets on which studies agreed were 'timely diagnosis' and 'being believed and respected by staff'.

CONCLUSION

Endometriosis patients value patient-centeredness in addition to effectiveness and safety of care, and its 10 dimensions require attention in clinical practice. Research into the assessment and improvement of patient-centered endometriosis care is required.

Defining future directions for endometriosis research: workshop report from the 2011 World Congress of Endometriosis In Montpellier, France

Endometriosis, defined as estrogen-dependent lesions containing endometrial glands and stroma outside the uterus, is a chronic and often painful gynecological condition that affects 6% to 10% of reproductive age women. Endometriosis has estimated annual costs of US $12 419 per woman (approximately €9579), comprising one-third of the direct health care costs with two-thirds attributed to loss of productivity. Decreased quality of life is the most important predictor of direct health care and total costs. It has been estimated that there is a mean delay of 6.7 years between onset of symptoms and a surgical diagnosis of endometriosis, and each affected woman loses on average 10.8 hours of work weekly, mainly owing to reduced effectiveness while working. To encourage and facilitate research into this debilitating disease, a consensus workshop to define future directions for endometriosis research was held as part of the 11th World Congress on Endometriosis in September 2011 in Montpellier, France. The objective of this workshop was to review and update the endometriosis research priorities consensus statement developed following the 10th World Congress on Endometriosis in 2008.(1) A total of 56 recommendations for research have been developed, grouped under 6 subheadings: (1) diagnosis, (2) classification and prognosis, (3) clinical trials, treatment, and outcomes, (4) epidemiology, (5) pathophysiology, and (6) research policy. By producing this consensus international research priorities statement, it is the hope of the workshop participants that researchers will be encouraged to develop new interdisciplinary research proposals that will attract increased funding support for work on endometriosis.