{"paper_id":"d42dee7c-b76c-42e3-8307-28d575db4f64","body_text":"NPWomenshealthcare.COM February 2023 Women’s Healthcare  41 \nReliable evidence-based \nscreening protocol for \nendometriosis\nBy Sarah M. King, DNP, WHNP-BC, AGN-BC; \nKathryn A. Adams, DNP, RNC-OB, C-EFM; and \nCaroline E. Peterson, DO, FACOOG\nW omens Healthcare. 2023;11(1):41-44. doi: 10.51256/WHC022341  \n© 2023 HealthCom Media. All rights reserved.\nEndometriosis is a gynecologic condition in which \nendometrial cells normally lining the uterus grow outside \nthe uterine cavity, predominately attaching to fallopian \ntubes, ovaries, bowel, and bladder.1 The prevalence of \nendometriosis is reported to be as high as 10% in women \nof reproductive age and is known for its distinguishing \nsymptoms of debilitating pelvic pain, dysmenorrhea, dys-\npareunia, and menstrual gastrointestinal distress.1 Endo-\nmetriosis is most common among women age 30 to 45 \nyears and typically resolves at the onset of menopause.2 \nGold standard diagnosis of endometriosis is by visual in-\nspection with laparoscopy and histologic verification.3\nUnfortunately, despite its common occurrence, there \nis a disappointing amount of public and provider aware-\nness, leading to an average of 10 years before diagnosis \nis made.4 Contributing factors delaying diagnosis are \nmultisymptom presentation, inability to be visualized on \nultrasound, insufficient use of screening guidelines, and \nthe existing stigma of expected pain during menses.5 Ex-\ntended diagnostic timeframes impede treatment causing \nsignificant impact on quality of life, fertility preservation, \nand employment status.5,6 Endometriosis also increases \nrisk for other comorbidities including autoimmune disor-\nders, cardiovascular conditions, and atopic diseases.2\nThe National Institute for Health and Care Excellence \n(NICE) released guidelines to improve endometriosis  \ndiagnosis and management in September 2017.3  \nAlthough this is a step in the right direction, the guide-\nlines are underutilized and a specific self-reported \nscreening questionnaire has not been developed.2 His-\ntorically, self-reported screening questionnaires have \nproved beneficial in expediting the diagnosis of other \ndiseases such as binge eating disorders, psoriasis, and \nfibromyalgia. Further, patient-based screening tools \ncreate an opportunity for patients to discreetly report \nsymptoms and allow for healthcare providers to discuss \nopenly during an office visit.4 \nPurpose \nThe purpose of the DNP quality improvement (QI) project \nwas to create and execute an evidence-based screening \nprotocol in a gynecologic setting for endometriosis mod-\neled after NICE guidelines with the development of a \nself-reported screening questionnaire. The project goals \nwere to achieve a 20% increase in diagnosis of endome-\ntriosis by laparoscopy and to identify symptoms prior to \n10 years of onset. A standardized screening protocol for \nendometriosis was not utilized at the chosen gynecology \npractice prior to the QI project.\nDescription of setting and \npopulation \nThe QI project took place at three offices within the \nsame gynecology practice located throughout Central \nOhio and led by a physician and two nurse practitioners. \nThe site provided complete gynecologic services to a \npredominantly White population with approximately \ntwo-thirds of patients with private insurance and the \nremaining one-third having government-issued insur-\nance. Women age 18 to 49 years were targeted for the QI \nproject. During implementation, typical patient volume \nranged from approximately 15 to 25 daily. \nDescription of the quality \nimprovement project\nThe QI project was approved by the Institutional Review \nBoard at Missouri State University. A self-reported screen-\ning questionnaire was developed after selecting five \nquestions derived from content found in the algorithm \nprovided by NICE guidelines for endometriosis screening \nDNP projects: Spotlight on practice\n\n42 February 2023 Women’s Healthcare  NPWomenshealthcare.COM  \n(Figure 1).3 An educational workshop was held with the \nintent of increasing staff knowledge about endometriosis \nand the need for the QI project. Participants completed \npre and post educational surveys. Identity was protected \nby blind numerical assignment to each pair of surveys. \nOver the course of a 22-week period, the questionnaires \ncontaining only patient identification number were \nadministered. Specifically targeted were gynecologic \nagreeable patients being seen for  annual examinations \nor acute visits with complaints of dysmenorrhea, dyspa-\nreunia, and abdominal and/or pelvic pain after reading \na disclosure statement detailing the intent for use of \ninformation. Questionnaires were then reviewed by the \nprovider and treatment recommendations discussed \nwith patients at visits. \nMethods to evaluate outcomes \nA paired t-test was used to compare pre- and post-test \nsurvey scores. Completed questionnaires were catego-\nrized as negative, suspicious, or positive for endometrio-\nsis with use of a designated screening scale constructed \nfrom NICE screening guidelines. With the exception of \nthe negative forms, an Excel spreadsheet was used to log \nthe following information: patient identification number; \ndate of visit; new or established; age; years with symp-\ntoms; and recommended treatment plan. Patients whose \ntreatment plan indicated the need for surgical laparos-\ncopy and excision procedures were classified separately \nand outcome data recorded. Data were analyzed using a \npaired t-test comparing laparoscopies performed from \nJune 14, 2020, to January 31, 2021, and during project \nimplementation from June 14, 2021, to January 31, 2022. \nData collection ceased November 14, 2022, to allow for \ntypical surgical wait times of 8 to 10 weeks. The number \nof years with symptoms was calculated using descriptive \nstatistics and reported in the form of a percentage.\nOutcomes\nReliability analysis subscales were deemed reliable and \nconsistent for all 11 completed surveys. Paired t-tests \nrevealed for categories knowledge (t = -5.05, P = .001, \nd = -1.46); screening (t = -2.72, P = .020, d = 0.78), and \nbarriers (t = -2.81, P = .017, d = -0.81) were statistically \nsignificant indicating an increase in clerical and medical \nstaff awareness. Of the 911 completed screenings, 141 \npatients were identified as suspicious for endometriosis. \nRecommended treatment varied based on severity and \nlongevity of symptoms and previous failed treatments, \nwith 49 patients advised to trial hormonal suppression of \nmenses, five choosing to try for pregnancy, and 87 to un-\ndergo surgical laparoscopy. The total number of patients \nwho had laparoscopies was 65; 22 failed to undergo lap-\naroscopy secondary to infection with Covid-19, transfer \nof care, or noncompliance of ordered testing. A paired \nt-test comparing the number of laparoscopies performed \npre and post screening had a statistically significant in-\ncrease (t = -2.39, P = .042, d = -0.85). As seen in Figure 2, \nthere was an overall 25% increase, exceeding the project \ngoal of 20%. As pictured in Figure 3, 76.6% of the 141 \npatients were identified prior to an average diagnostic \ntimeframe of 10 years. Also important to note, more than \nhalf of those who had laparoscopies were discovered to \nbe in the early stages of endometriosis, with 27 patients \nin stage 1, 24 in stage 2, 10 in stage 3, and four in stage \n4. Unexcepted outcomes with use of screening included \nmodifications in treatment plans for 26 patients with ex-\nisting endometriosis. \nDiscussion and implication for \npractice \nThere was a steady increase in diagnostic laparoscopy \nand laser removal of endometriosis, with the exception of \nthe month of November. Needed surgical days were un-\navailable for patient volume and therefore overflow can \nFigure 1. Self-reported screening \nquestionnaire\n1.  In the last 6 months, have you had pelvic pain or cramps during \nyour periods that affected your normal activity or required pain \nmedication? Circle the best answer.\n Never    Occasional (1–2 periods)    Often (3–5 periods)    Always\n2.  In the last 6 months, have you had pelvic pain or cramps in between \nyour periods that affected your normal activity or required pain \nmedication? Circle the best answer.\n Never        Occasional        Often         Always \n3.  a) If you are experiencing pelvic pain or cramps during or between \nyour periods, circle the level of pain you experience at its worst. \n 1     2       3       4       5       6       7       8       9      10 \n b) Circle the number of years you have been experiencing pain:\n 1–3 years  3– 5 years  6– 9 years  10+ years   \n4. a)  Do you often experience gastrointestinal symptoms during your \nperiod? If Yes, circle which ones below:\n Nausea/vomiting    Diarrhea    Constipation    Pain with bowel movements\n  b) If you frequently experience nausea/vomiting and/or diarrhea, \nand/or constipation, and/or pain with bowel movements, is it worse \nwhile on your period?    YES or NO \n5.  Do you experience deep pain during or after sexual intercourse?\n Never        Occasional        Often         Always\n\nNPWomenshealthcare.COM February 2023 Women’s Healthcare  43 \nFigure 2. Number of laparoscopies pre versus post implementation\nNote: This figure displays the increase in diagnostic laparoscopies for endometriosis before and after QI project implementation.\nNote: This figure displays the number of years a patient was experiencing endometriosis prior to completing screening.\nFigure 3. Frequency of timeframe in identified patients\n60\n50\n40\n30\n20\n10\n0\nJune July August September October November December  January  \n2020 2021 2022\n \n14\n25\n28\n16.5\nNumber of laparoscopies\n10+ years\n23%\n1-3 years\n37%\n3-5 years\n27%\n6-9 years\n13%\n31\n35\n50\n40\n32\n38 35\n29\n36\n57\n51\n20\n1-3 years 3-5 years 6-9 years 10+ years\n\n44 February 2023 Women’s Healthcare  NPWomenshealthcare.COM  \nbe seen in December and January figures. \nFacilitators included healthcare providers, office man-\nagement staff, and other personnel at the project site. It \nis poignant to note additional assistance was received \nfrom the following staff at Missouri State University: proj-\nect chair; director of DNP program, and RSTAT depart-\nment. Implementation of the QI project did not cause \nfinancial strain or major disruption in workflow. The co-\noperation and willingness of stakeholders to facilitate the \nintended project plan allotted for successful completion \nand achievement of project outcomes.\nBarriers for the QI project were inability to effectively \nobserve implementation simultaneously in all office loca-\ntions. Only 70% of qualifying patients appearing on pro-\nvider schedules received the questionnaire, lowering the \nexpected sample size. No shows, patient refusal to partic-\nipate, misplaced screening forms, or failure of front office \nstaff to administer forms were likely causative factors. \nLack of provider consistency in addressing the screening \nform at visits also lowered the expected number of iden-\ntified patients.\nLessons learned include the need to edit the screening \nquestionnaire based on patient feedback. Frequent con-\nfusion occurred with use of the term “pelvic pain, ” with \n“cramps” being more widely understood and assessment \nof gastrointestinal symptoms. Project sustainability is \nlikely due to its simplistic nature and ease of replication. \nKey findings are of the 141 patients identified as suspi-\ncious of endometriosis; 64 were established, highlighting \nformer unrecognition of symptoms. \nConclusion\nThe screening protocol was successful in increasing \ntimely identification of endometriosis. Although this is \nreassuring, results are limited due to a short implemen-\ntation period and use trialed in only one gynecology \npractice. Active screening for endometriosis allowed the \nopportunity for patient verbalization of previous dis-\nmissal of symptoms, fueling the need for adoption of a \nstandardized screening protocol in gynecology settings. \nAccelerating the diagnosis of endometriosis can allow for \nimproved medical management. �\nAcknowledgment: The authors extend sincere thanks \nto Melissa Penkalski, DNP , APRN, CPNP-PC, AE-C; Brandie \nMcGuire, WHNP-BC; Cindy Schaffer, Practice Manager; \nand Hannah Johnson, RSTAT, for QI project support.\nSarah M. King practices obstetrics and gynecology \nat Progressive Women’s Healthcare in Dayton, Ohio. \nKathryn A. Adams is Clinical Associate Professor for \nthe School of Nursing at Missouri State University in \nSpringfield, Missouri. Caroline E. Peterson practices \nobstetrics and gynecology at Progressive Women’s \nHealthcare in Dayton, Ohio. The authors have no actual \nor potential conflicts of interest in relation to the \ncontents of this article.\nReferences\n1. Farshi N, Hasanpour S, Mirghafourvand M, Esmaeilpour K.  \nEffect of self-care counselling on depression and anxiety in \nwomen with endometriosis: a randomized controlled trial.  \nBMC Psychiatry. 2020;20(1):391. \n2. V annuccini S, Lazzeri L, Orlandini C, et al. Mental health, pain \nsymptoms and systemic comorbidities in a woman with endo-\nmetriosis: a cross-sectional study. J Psychosom Obstet Gynaecol. \n2018;39(4):315-320. \n3. National Institute for Health and Care Excellence. Endometri-\nosis: diagnosis and management. National Guideline Alliance. \nNICE Guideline NG73. September 6, 2017. https://www.nice.\norg.uk/guidance/ng73.\n4. Surrey E, Carter CM, Soliman AM, et al. Patient-completed or \nsymptom-based screening tools for endometriosis: a scoping re-\nview. Arch Gynecol Obstet. 2017;296(2):153-165.\n5. Surrey E, Soliman AM, T renz H, et al. Impact of endometriosis \ndiagnostic delays on healthcare resource utilization and costs. \nAdv Ther. 2020;37(3):1087-1099. \n6. van der Zanden M, T eunissen DAM, van der W oord IW , et al. \nBarriers and facilitators to the timely diagnosis of endometriosis in \nprimary care in the Netherlands. Fam Pract. 2020;37(1):131-136. \nActive screening for \nendometriosis allowed \nthe opportunity for patient \nverbalization of previous \ndismissal of symptoms, fueling \nthe need for adoption of a \nstandardized screening \nprotocol in gynecology \nsettings.","source_license":"CC0","license_restricted":false}