M.M. El-Sayed, S.A. Mohamed & M.H. Jones Cost-effectiveness of ultrasound use by on-call registrars in an acute gynaecology setting 10/05/2012

Introduction Drivers for the study: Cancelled theatre lists Patient complaints Quality agenda (efficiency) Background research English & Australian studies ? 1 st study to address this issue 10/05/2012

Objectives Compare cost-effectiveness of 2 models of care in acute gynaecology: Traditional One-stop, ultrasound-based 10/05/2012

Methodology Prospective comparative study (not RCT) 8 weeks between December 09 & February 10 2 groups: (140 consecutive patients) Traditional (Registrars do not use USS.) One-stop (Registrars use USS.) Sample size Data from handover file and case notes CI for significant difference 10/05/2012

Comparative statistics of women in the two groups ParameterGroup 1Group 295% CI70 Mean age (years) to +6 Pregnancy51/70 (73%)49/70 (70%)-13 to +16% Main presentation: Pelvic pain33/70 (47%)23/70 (33%)-3 to +29% Vaginal bleeding15/70 (21%)21/70 (30%)-21 to +7% Pain & bleeding14/70 (20%)20/70 (30%)-22 to +5% Source of referral: Ward3/70 (4%)0/70 (0%)-2 to +7% A&E67/70 (96%)70/70 (100%)-7 to +2% 10/05/2012

Working diagnosis after the initial assessment of women in the two groups DiagnosisGroup 1Group 295% CI70 Ectopic pregnancy: Confirmed3 (4%)0 (0%) -2 to +8% Suspected1 (1%)28 (40%) -51 to -24% IUP with no follow-up26 (37%)0 (0%)+22 to +50% Inconclusive scan: PUL3 (4%)0 (0%) -2 to +7% IUP for later viability scan7 (10%)0 (0%) +3 to +17% Miscarriage9 (13%) * 18 (26%) ^ -24 to -2% Postoperative complication5 (7%) + 7 (10%) -10 to +8% Hyperemesis1 (1.4%)2 (2.8%)-6 to +3% Bartholin abscess1 (1.4%)1 (1.4%)-4 to +4% Pelvic inflammatory disease2 (2.8%)4 (5.7%)-6 to +3% Non-specific pain7 (10%)4 (5.7%)-6 to +12% Ovarian cyst4 (5.7%)4 ^ (5.7%) Dysfunctional bleeding1 (1.4%)1 (1.4%) Ascites1 (1.4%)0 (0%)-1 to +4% Vaginal tear0 (0%)1 (1.4%)-4 to +1% * confirmed, ^ suspected, + including 2 post-ERPC cases 10/05/2012

Outcomes after the initial assessment in the two groups OutcomeGroup 1Group 295% CI (n = 70 – 3)(n = 70) Discharge (no FU)53% (36/67)4% (3/70)+32 to +63% Discharge (FU)28% (19/67)28% (20/70) -15 to +15% Discharge for later ERPC3% (2/67)0% (0/70)-2 to +6% Already inpatient4% (3/70)0% (0/70)-9 to +4% Admission:947 Admission rate13% (9/67)67% (47/70)-69 to -36% Admission rate (pregnant)8% (4/50)69% (34/49)-79 to -40% Admission rate (gynaecology)29% (5/17)62% (13/21)-64 to +1% 10/05/2012

Bed occupancy in the two groups Parameter Group 1 Group 2 95% CI (n = ) (n = 70) Bed occupancy (days) Bed-days/patient 14/67 (0.209) 64/70 (0.914) to – 0.52 Cost savings /1000 patients = X £400 X 1000 = (£ 282,000) 10/05/2012

Conclusion The one-stop approach in AGU: Cost-effective (less admission) Better care through timely diagnosis and treatment Better patient satisfaction USS training (challenge) RCOG modules Clinical governance Taking it forward 10/05/2012