1. Dr Gareth James ¾ time GP
Danetre Medical Practice, Daventry, Northamptonshire
Undertake vasectomies at DMP for Northamptonshire CCG
Also work as Vasectomy Surgeon for other companies in Leicester,, and until last month Bromsgrove
2500 Procedures over 15 years
Over 2000 via Non-Scalpel technique
ASPC lead on Audit

2. What am I covering in this session?
Audit results for Vasectomies undertaken in 2014/15
Improve your return rates
Operational Issues survey
What have you learned in the last 12 months
What have I learned in the last 12 months?
Syringe size audit
Vasectomy and a serious complication published..
Where has it all gone wrong????

3. ASPC Conference 2016
Vasectomy Audit Covering Vasectomies undertaken between: 1st April March 31st 2015

4. Numbers of Audits
I received 39 completed audits in time for the conference
In previous years the number of vasectomies undertaken were:
vasectomies
vasectomies
vasectomies
vasectomies
2012/ vasectomies
2013/ vasectomies
This year ( ) we have 6431 vasectomies in the Audit

5. Average Sterility Rates
Out of 6431 Vasectomies we have sterility figures from
4635 are Confirmed Sterile = 72%
[Previous years: 71; 65; 63; 63 ;63; 79]
Special Clearance
142 Pts were given SC = 3%
[Previous years:3; 4; 2; 5]
So, more than 1 in 33 patients were informed they are Sterile via Special Clearance

6. Late Failures
How many detected since last audit? 2

7. Early Failures From this Audit Cycle: 28
Failures not from before Audit Cycle: 7

8. Early Failures Early Failures out of Vasectomies Failure rate = 0.44%
1 in 227 procedures

9. Overall over the lifetime of NSV’s
Figures from Lifetime Audit 2 years ago was
215 failures out of 65,292 NSV = 0.33%
1 in 304 procedures
Adding this LAST FEW YEARS since
Total is 303 out of = 0.35%
Or now 1 in 284 procedures……
If you’ve not started to I would thus recommend changing the rate you tell prospective patients from 1 in 500 to 1 in 300 chance of an Early Failure

10. Sterile Rates 90% use 1 test to prove sterility
36% use a postal method
3 practices partly use Postal
How do you get the highest rates of TESTING
And thus STERILITY?
1 test?
2 tests?
Postal?

11. How to get the best Sterile rates
Those using 1 test and Postal method 84% (36% = 14 Clinics) (previous years:-66%; 76%; 77%; 81%; 81%) Those using 1 test and Non-Postal method 68% (46% = 18 Clinics) (previous years:- 58%; 58%; 54%; 57%, 64%) Those using 2 tests and Non-Postal method 70% (3 Clinics) (previous years:- 43%; 43%; 37%, 43%, 64%)

12. Sterile rates
At 84% this just shows that using just 1 test via a Postal method is the best way to get your best Semen Sample returns
Just Do ONE test >12 weeks
As now ratified by the British Andrological Guidelines April 2016
(more on them in the next session!!!)

13. NHS v Private Vasectomies
Of those private 77% of those were undertaken by One provider only!
Only 1 providers in the audit undertook 16 or more private Vasectomies during this Audit time frame
Rent a Vasectomy Surgeon
About 8 of us now work and get a flat fee per vasectomy
This ranged from £80 to £115 per vasectomy undertaken
The Average payment per Vasectomy was £100

14. NHS TARIFF FOR VASECTOMIES
/ / /15
Average Cost
of NHS £226 £ £ £224 £ £ £ £264
Vasectomy:
Of Private £264 £ £ £270 £ £ £ £329
17 out of 39 have to PAY for their sperm tests out of the Cost, cutting profit.
NHS NET cost ranges from £156 to £480

15. NHS TARIFF FOR VASECTOMIES
For the first time ever if you pay for your sperm tests (but only do one test) then your average payment is more than those who don’t pay for sperm test
Those who pay for their sperm tests
Average payment = £268
(though profit drops the more test you do….)
Those don’t pay for sperm test
Average payment = £256
Sperm testing can cost ~£15 Acculabs
Live tests ranged from £11.50 to £35

16. COMPLICATIONS
/ / /15
Failures: %
Haematomas: %
Infections: %
PVPs: %
Admissions: x x NSV lifetime = %
Total % 3.2% 2.2% 2.7% 2.53% 3.4% % %
Comps: (119) (76) (74) (114) (112) (247) (270) (208)

17. Hospital Admissions 6 hospital admissions out of 6431 procedures
= 0.09%
1 in 1000 operations
These occurred to 13% of us, 5 different Surgeon/Surgery sites
1 patient went to hospital regarding a golf ball sized haematoma.
One haematoma (traditional vasectomy) Difficult vasectomy done in a training list
Scrotal haematoma requiring surgical drainage
2 x Scrotal swelling and pain
1 x Infection
I couldn't stop bleeding during the operation
All these happened to highly experienced NSV Surgeons
THESE THINGS HAPPEN TO ALL SURGEONS!!!!

18. INFECTIONS 65% of us had a patient who needed antibiotics
[78%, 61% previous years]
A total of 95 infections between us all = 1.40%
[91, 95 and 1.3%, 1.4% previous years]
55% of the Antibiotics known to have been prescribed were given by the Vasectomy Surgeon (Previous years 46%; 40%; 50%; 26%; 34%)
9 out of 178 (5%) were classed as experiencing a Haematoma PLUS they received Antibiotics
(Previous years 8%, 10%)
People didn’t answer that question well….

19. INFECTIONS Lets say you had 10 Haematomas, and 10 Infections.
Turns out 5 of those haematomas ALSO had infections
So you’re complication rate is 15 not 20.
That’s the point of this question……
How many patients who had a Haematoma were ALSO given Antibiotics?
Haematomas + Infections (Total)
Haematomas who also had Antibiotics
Don't Know/Not sure
If you don’t write the correct numbers, I will ignore it!!! Your figures look worse so please do it correctly!!!!!

20. Haematomas
We now count a haematoma as a swelling double your original testicle size,
AND the swelling is PAINFUL
Quite a range of results!
66% of us reported that at least 1 of our patients suffered a Haematoma post surgery [Previous years 63%, 61%)
83 haematomas in total were counted
But big increase……
29% of these swellings were described as large as a Cricket ball (or larger) [Previous years 14%, 9% last year]

21. Post Vasectomy Pain 18% of us reported at least 1 PVPS patient
8 reported in total
[Previous years 18, 5 cases]
5 from this Audit Cycle, and 3 from previous years
What treatments offered:-
Analgesia. Patient also stated that ejaculation alleviated pain.
Simple analgesic for 5 months.
Urology referral
Analgesia only.
Neuropathic analgesia, reassurance.
none
course of antibiotics from GP

22. Post Vasectomy Pain
Are you following up these patients to discover if their pains have resolved? Only 2 Surgeon knew the outcome of their patients, and that their pain had eventually settled…. Surely we can do better than that???

23. Post Vasectomy Pain
What is PVP? Why do patients get it? What can be done about it? This is the focus of our Vas Study day 30th September 2016 See Soon to register!!!

24. PEER REVIEWS & APPRASIAL
3 Surgeons have not been Peer reviewed in the last 3 years
(Improving, figures in previous years were 13,8 )
Though 3 didn’t answer!!!
Via a combination of NSV colleagues, and Hospital surgeons
68% had their GP Appraiser appraise their vasectomy service
They should be!!!

25. TRAINERS
We are in desperate need for trainers, with Laurel retiring, Tony reducing his training input, we are suddenly bereft of trainers We have 2 members who are trained as trainers, and 1 willing learn…. If you are interested, please see Tony

26. Why bother doing Audit? Self Improvement – BE THE BEST YOU CAN!
Confidence to the patient
Feel good factor
Ticks the boxes for your CCG
Appraisal, Reaccreditation, Revalidation
Win contracts!

27. AUDIT Only asking ‘Did you have any problems?’
is simply NOT good enough...

28. AUDIT IS ONLY AS GOOD AS THE DATA WHICH HAS BEEN COLLECTED....
WHICH IS ONLY AS GOOD AS THE QUESTIONS WHICH HAVE BEEN ASKED....

29. Questionnaires 2009 onwards
What do we want to specifically ask the patients?
Did you experience any:-
Infection – who gave the antibiotics? What reason?
Swelling – how big? Was it painful, how long for?
Pain – how long, how bad, have you still got any?
Other Complications – Hospital admissions etc...
Plus their
e) Experience – before, during, after…

30. Official ASPC Questionnaires
2 different questionnaires
The First - Immediate Post Vasectomy
(before they leave the Clinic)
Good for CCG’s, focusing on the patients experience of the operation, doctors competence and manner, and the operative environment, plus ‘Friends and Family’
The Second - At least 4 months after Vasectomy
(most often sent with letter confirming Sterility)
This is your MAIN provider of audit data in relation to any complications the patient experiences after his operation

31. The ASPC Immediate Post Op Questionnaires
67% said they were using the official standardised ASPC questionnaire
13 % said they were partly using it
This gives us a good comparison tool, and with it we can see what the Surgeons with the highest scores are doing....
So, in total we have data for 27 Clinics that were using the Questionnaire in
That’s some 4173 vasectomy feedback Immediately Post Operation!!

32. The ASPC Immediate Post Op Questionnaires
But when I asked what return rates you were getting I was rather surprised!!
The idea is you give the patient is form is fill in BEFORE they leave the surgery
He is your captive until you allow him to leave!
There’s very few reasons patient wont fill out there and then (unless you admit them, or they are faint, or they run away!!) so you should have very high 90’s return.
If not, why not?
You also should also be using the Immediate Post-OP as your spring board to tell them to fill the 4m one out, and how important it is, etc, etc…..
So instead of feedback on 4173, we have instead only have feedback on 3884

33. ASPC Immediate Post Operation Questionnaire Averages
What percentage Returns rates are you getting?
92%
[ranges 21 to 100%]
What percentage said NO to: 1. Did you experience any problems booking your vasectomy appointment?
97% [Previous years 97, 98]
What percentage said TOTALLY ADEQUATE to 2. Do you feel you were given adequate patient & clinic information in the leaflet sent to you prior to your appointment?
91% [Previous years 96, 95]
What percentage said VERY USEFUL or FAIRLY USEFUL to 3. How useful did you find the consultation with the Doctor/Nurse before the operation?

34. ASPC Immediate Post Operation Questionnaire Averages
What percentage said COMPLETLY AT EASE or VERY COMFORTABLE to 4. Did you feel comfortable having this procedure done at this surgery?
96% [Previous years 97, 98]
What percentage said EXCELLENT or VERY GOOD to 5. How do you rate the theatre, premises and facilities available here for today's operation?
95% [Previous years 98, 96]
What percentage said EXCELLENT or VERY GOOD to 6. How did you rate the Doctor's manner and communication during the operation?
99% [Previous years 98, 99.7]

35. ASPC Immediate Post Operation Questionnaire Averages
What percentage said NO PAIN AND also said SLIGHTLY PAINFUL to 7.How would you describe the level of pain you felt during the operation?
No pain % [Previous years 43, 48]
Slight Discomfort %
Total percentage of BOTH % [Previous years 87, 92]
What percentage said MUCH BETTER or BETTER to 8. How was the operation in relation to how you expected it to be? % [Previous years 78, 83]
What percentage said EXCELLENT or VERY GOOD to 9. What was your overall impression of having your vasectomy undertaken here? % [Previous years 94, 98]
Moved from 4m Post Op - What percentage said VERY LIKELY to:
10. How likely are you to recommend our clinic to friends or family if they needed similar care or treatment?
93% [last year on 4m – 84%]

36. ASPC 4 Month Post Operation Questionnaires
51% said they were using the official standardised ASPC questionnaire [previous years 60%, 49%]
8% said they were partly using it
This again gives us a good comparison tool, and with it we can see what the Surgeons with the highest scores are doing....
Results, and returns were a bit of a mixed bag.
I excluded taking data from 5 practices who had return rates of less than 10%.
I had 1 practices that were partly using the questionnaire and some of their data has been used
So, in total we have data for 18 Clinics that were using the Questionnaire in
This gives complete audit data on 914 vasectomies (out of vasectomies) and how they fared post operation

37. ASPC 4 Month Post Operation Questionnaires
What percentage of questionnaire returns did you achieve in this Audit Cycle?
Range 10% to 73% % [Previous years 33, 30,33]
Only 7 practices got above 33% [last year 9 practices]
Yes, return rates are poor if you leave it to the patient…..
There is NO other way of getting this information from the patients!!!
YOU need to find a good method of collecting OR have a system to chase them up
SAE s
Weblinks
Facebook
Acculabs
Phone calls
The chasing DOES NOT have to be the Surgeon, any clerical staff could undertake

38. ASPC 4 Month Post Operation Questionnaires
Under the guidance of Prof Michel Labreque, we changed the pain rating score from a 5 point scale, to a 10 point scale, where zero was no pain, up to 10 being agony
What percentages did you get for 1. Please rate the pain you felt for the first few days after the Vasectomy
2012/ No Pain18% A Little Pain 44% Some Pain 28% Very Painful 9% Agony 1%
2014/15
0/1 = 14% last year15% = 9% last year 6%
2 = 21% last year 20% = 8 % last year 6%
3 = 19% last year 24% = 2% last year 3%
4 = 16% last year 14% = 1% last year 1%
5 = 10% last year 8% = 0 % last year 1%
Total (1-5) = 79% (last year 81%)
Overall then, the figures are not dramatically different from last years
Difficult to quantify that to patients though, so new scale in this years questionnaires, same as the Immediate Post Op

39. 4 Month Post Op Quest Results
What percentage said YES to 2. Did you experience a pain or an ache for over a week?
37% [Previous years 33,27]
If over a week, what was the average for the
Pain to settle? days [Previous years11,12 days]
Ache to settle days [Previous year18,13 days]
What percentage said COMPLETLY or PRETTY ADEQUATE to 5. Were you given adequate advice after the operation in the post-op information sheet?
93% [Previous years 90,92]
What percentage said YES to 6. Were you provided with a contact number if follow up advice was needed?
93% [Previous years 94,95]
And what percentage said the contact number was their 'Vasectomy Surgeon'?
64% [Previous years 69,70]

40. 4 Month Post Op Quest Results
What percentage said YES to 9. Did you have to take more time off work than you anticipated
8% [Previous years 9,8]
Days to return to work days [Previous years 5,8 ]
Days expected to be off – 3 days
Difference? Average of 2 extra days
What percentage said MUCH BETTER or BETTER to 12. How was the whole process of having a Vasectomy in relation to how you expected it to be?
73% [Previous years ]
What percentage said EXCELLENT or VERY GOOD to 14. Please rate your overall satisfaction with our service
88% [Previous years 94, 95]

41. Please remember
If you were going in for an operation, wouldn’t you want to know some of these details?:-
1) 90% say they felt only some discomfort but no pain during the actual procedure
2) About 20% will experience >5/10 on a rating of pain post operation, with 1 in 10 experiencing a lot of pain post operation.
3) Over one third will still be experiencing pain or an ache after a week
4) On average if it lasts > 1 week then the pain and ache can take a further week to settle
5) 1 in 12 will need some time off work, at an average of 6 days

42. What about results for those who had over 33% return rates?
Last year I showed that those with higher rates of 4M post Op returns had higher rates of complications. Or should I say TRUER figures? Lets see what happened this year…… As last year is there much difference between those who received over the average of 33% returns, as compared to those who didn’t? 7 practices received over 33% return rates – actually averaging 58% return rates between themselves Their results then compared to everyone else's….

43. Comparisons 2014/15 All T>33% returns 0/1 = 14% 14% 2 = 21% 21%
What percentages did you get for 1. Please rate the pain you felt for the first few days after the Vasectomy
2014/15 All T>33% returns
0/1 = % 14%
2 = % 21%
3 = % 16%
4 = % 20%
5 = % 10%
Totals 79% 80%
6 = 9% 7%
7 = 8% 1%
8 = 2% 3%
9 = 1% 1%
10 = 0% 0%

44. Comparisons 37% 41% 2014/15 All T>33% returns
What percentage said YES to 2. Did you experience a pain or an ache for over a week?
2014/15 All T>33% returns
37% 41%
Pain to settle? 11 days days
Ache to settle 14 days 18 days
What percentage said YES to 9. Did you have to take more time off work than you anticipated
8% %
Days to return to work 6 days 7 days

45. Complications rates based on whether using the 4M Quest
TOTAL Not Using Partly Using Using
+<33% returns >33% returns
Infections: 1.5% 1.5% 1.2% %
Last year 1.4% 1.1% 1.1% %
Haematomas: 1.3% 1.1% 1.1% %
Last year % 1.2% 2.5% %
Total Comps: 3.3% 3.1% 2.8% %
(208) (122) (46) (41)
Last Year 4.0% (270) 2.7% (70) 3.8% (100) 6.5% (100)
Thus those using the 4m questionnaire have
More Infections recorded
More Haematomas recorded
More Total Complications

46. ARE YOU REALLY RECIEVING ENOUGH INFORMATION POST OPERATION TO REALLY KNOW WHAT YOUR COMPLICATION RATES ARE?

47. DO YOU CARE??? OR DO YOU FEEL ‘OPERATION DONE’, NO NEED TO SEE WHAT HAPPENS NEXT….? IF YOU WERE THE PATIENT WOULD YOU NOT WANT TO KNOW THIS INFORMATION ABOUT YOUR SURGEON? Montgomery v Lanarkshire ?

48. How to improve Return Rates
4 Month ASPC questionnaire returns
Return rates for the 4 month questionnaire have been historically low

49. How to improve Return Rates
Inform them of 4 Month Q at pre-op counselling,
During the op, remind them to fill the 4m Q,
and when you give them the Immediate post op questionnaire to fill out
When you collect the Immed Post OP from them
If you send – remind them when they do their sperm test
Remind them when the letter of "sperm clear" is sent.
Or phone them to remind them
Take s addresses and them….
Keep telling them how important it is you receive feedback…..
The best return this year was 73% By Stephen Wild; Leyburn Practice
Out of the 7 practices above 33% - 5 used postal

50. POSTAL SERVICES/COLLECTION
I AM GETTING OVER 70% RETURN RATE BY ASKING PATIENT TO DO THE 4M ON THE DAY OF THEIR SPERM TEST AND PUT IT IN THE ENVELOPE TO ACCULABS
Acculabs collect it, and post every few months the completed forms
For free!!!
I would therefore suggest that utilising Acculabs kind offer to collate the 4 month questionnaires produces a far better rate of returns than anyone else using the official ASPC questionnaires has managed.
Those using Acculabs should consider moving to this method of collection.
For those not using Acculabs, this may be an added reason to consider using their service
Caveat: lets discuss Postal services later today after Lunch!

51. Online Questionnaires
Make collecting the results and thus compiling them easier for yourselves
Survey monkey is available to all paid ASPC Members for their Audits.
A powerful tool for your own improvement, and feedback from patients
Nicely printed off PDF’s for your appraisal
I have over 50 members now, with numbers increasing
I have some names to set up on SM, and I will sort those out in the next weeks – thank you for your patience
I simply cannot do the work for all of you now, so I now have ‘how to’ Videos on YouTube - this these take you through the processes involved in setting up.
But, I’m always here, via , if you need help
Personally I now do everything on paper then simply transpose the results onto SM.

52. For information pertaining to Vasectomies undertaken
Conference 2017
For information pertaining to Vasectomies undertaken
between
April 1st 2015 and 31st March 2016