Reliable evidence-based screening protocol for endometriosis

to evaluate outcomes A paired t-test was used to compare pre- and post-test survey scores. Completed questionnaires were catego- rized as negative, suspicious, or positive for endometrio- sis with use of a designated screening scale constructed from NICE screening guidelines. With the exception of the negative forms, an Excel spreadsheet was used to log the following information: patient identification number; date of visit; new or established; age; years with symp- toms; and recommended treatment plan. Patients whose treatment plan indicated the need for surgical laparos- copy and excision procedures were classified separately and outcome data recorded. Data were analyzed using a paired t-test comparing laparoscopies performed from June 14, 2020, to January 31, 2021, and during project implementation from June 14, 2021, to January 31, 2022. Data collection ceased November 14, 2022, to allow for typical surgical wait times of 8 to 10 weeks. The number of years with symptoms was calculated using descriptive statistics and reported in the form of a percentage. Outcomes Reliability analysis subscales were deemed reliable and consistent for all 11 completed surveys. Paired t-tests revealed for categories knowledge (t = -5.05, P = .001, d = -1.46); screening (t = -2.72, P = .020, d = 0.78), and barriers (t = -2.81, P = .017, d = -0.81) were statistically significant indicating an increase in clerical and medical staff awareness. Of the 911 completed screenings, 141 patients were identified as suspicious for endometriosis. Recommended treatment varied based on severity and longevity of symptoms and previous failed treatments, with 49 patients advised to trial hormonal suppression of menses, five choosing to try for pregnancy, and 87 to un- dergo surgical laparoscopy. The total number of patients who had laparoscopies was 65; 22 failed to undergo lap- aroscopy secondary to infection with Covid-19, transfer of care, or noncompliance of ordered testing. A paired t-test comparing the number of laparoscopies performed pre and post screening had a statistically significant in- crease (t = -2.39, P = .042, d = -0.85). As seen in Figure 2, there was an overall 25% increase, exceeding the project goal of 20%. As pictured in Figure 3, 76.6% of the 141 patients were identified prior to an average diagnostic timeframe of 10 years. Also important to note, more than half of those who had laparoscopies were discovered to be in the early stages of endometriosis, with 27 patients in stage 1, 24 in stage 2, 10 in stage 3, and four in stage 4. Unexcepted outcomes with use of screening included modifications in treatment plans for 26 patients with ex- isting endometriosis.

and implication for practice There was a steady increase in diagnostic laparoscopy and laser removal of endometriosis, with the exception of the month of November. Needed surgical days were un- available for patient volume and therefore overflow can Figure 1. Self-reported screening questionnaire 1. In the last 6 months, have you had pelvic pain or cramps during your periods that affected your normal activity or required pain medication? Circle the best answer. Never Occasional (1–2 periods) Often (3–5 periods) Always 2. In the last 6 months, have you had pelvic pain or cramps in between your periods that affected your normal activity or required pain medication? Circle the best answer. Never Occasional Often Always 3. a) If you are experiencing pelvic pain or cramps during or between your periods, circle the level of pain you experience at its worst. 1 2 3 4 5 6 7 8 9 10 b) Circle the number of years you have been experiencing pain: 1–3 years 3– 5 years 6– 9 years 10+ years 4. a) Do you often experience gastrointestinal symptoms during your period? If Yes, circle which ones below: Nausea/vomiting Diarrhea Constipation Pain with bowel movements b) If you frequently experience nausea/vomiting and/or diarrhea, and/or constipation, and/or pain with bowel movements, is it worse while on your period? YES or NO 5. Do you experience deep pain during or after sexual intercourse? Never Occasional Often Always NPWomenshealthcare.COM February 2023 Women’s Healthcare 43 Figure 2. Number of laparoscopies pre versus post implementation Note: This figure displays the increase in diagnostic laparoscopies for endometriosis before and after QI project implementation. Note: This figure displays the number of years a patient was experiencing endometriosis prior to completing screening. Figure 3. Frequency of timeframe in identified patients 60 50 40 30 20 10 0 June July August September October November December January 2020 2021 2022 14 25 28 16.5 Number of laparoscopies 10+ years 23% 1-3 years 37% 3-5 years 27% 6-9 years 13% 31 35 50 40 32 38 35 29 36 57 51 20 1-3 years 3-5 years 6-9 years 10+ years 44 February 2023 Women’s Healthcare NPWomenshealthcare.COM be seen in December and January figures. Facilitators included healthcare providers, office man- agement staff, and other personnel at the project site. It is poignant to note additional assistance was received from the following staff at Missouri State University: proj- ect chair; director of DNP program, and RSTAT depart- ment. Implementation of the QI project did not cause financial strain or major disruption in workflow. The co- operation and willingness of stakeholders to facilitate the intended project plan allotted for successful completion and achievement of project outcomes. Barriers for the QI project were inability to effectively observe implementation simultaneously in all office loca- tions. Only 70% of qualifying patients appearing on pro- vider schedules received the questionnaire, lowering the expected sample size. No shows, patient refusal to partic- ipate, misplaced screening forms, or failure of front office staff to administer forms were likely causative factors. Lack of provider consistency in addressing the screening form at visits also lowered the expected number of iden- tified patients. Lessons learned include the need to edit the screening questionnaire based on patient feedback. Frequent con- fusion occurred with use of the term “pelvic pain, ” with “cramps” being more widely understood and assessment of gastrointestinal symptoms. Project sustainability is likely due to its simplistic nature and ease of replication. Key findings are of the 141 patients identified as suspi- cious of endometriosis; 64 were established, highlighting former unrecognition of symptoms.

The screening protocol was successful in increasing timely identification of endometriosis. Although this is reassuring, results are limited due to a short implemen- tation period and use trialed in only one gynecology practice. Active screening for endometriosis allowed the opportunity for patient verbalization of previous dis- missal of symptoms, fueling the need for adoption of a standardized screening protocol in gynecology settings. Accelerating the diagnosis of endometriosis can allow for improved medical management. � Acknowledgment: The authors extend sincere thanks to Melissa Penkalski, DNP , APRN, CPNP-PC, AE-C; Brandie McGuire, WHNP-BC; Cindy Schaffer, Practice Manager; and Hannah Johnson, RSTAT, for QI project support. Sarah M. King practices obstetrics and gynecology at Progressive Women’s Healthcare in Dayton, Ohio. Kathryn A. Adams is Clinical Associate Professor for the School of Nursing at Missouri State University in Springfield, Missouri. Caroline E. Peterson practices obstetrics and gynecology at Progressive Women’s Healthcare in Dayton, Ohio. The authors have no actual or potential conflicts of interest in relation to the contents of this article.

1. Farshi N, Hasanpour S, Mirghafourvand M, Esmaeilpour K. Effect of self-care counselling on depression and anxiety in women with endometriosis: a randomized controlled trial. BMC Psychiatry. 2020;20(1):391. 2. V annuccini S, Lazzeri L, Orlandini C, et al. Mental health, pain symptoms and systemic comorbidities in a woman with endo- metriosis: a cross-sectional study. J Psychosom Obstet Gynaecol. 2018;39(4):315-320. 3. National Institute for Health and Care Excellence. Endometri- osis: diagnosis and management. National Guideline Alliance. NICE Guideline NG73. September 6, 2017. https://www.nice. org.uk/guidance/ng73. 4. Surrey E, Carter CM, Soliman AM, et al. Patient-completed or symptom-based screening tools for endometriosis: a scoping re- view. Arch Gynecol Obstet. 2017;296(2):153-165. 5. Surrey E, Soliman AM, T renz H, et al. Impact of endometriosis diagnostic delays on healthcare resource utilization and costs. Adv Ther. 2020;37(3):1087-1099. 6. van der Zanden M, T eunissen DAM, van der W oord IW , et al. Barriers and facilitators to the timely diagnosis of endometriosis in primary care in the Netherlands. Fam Pract. 2020;37(1):131-136. Active screening for endometriosis allowed the opportunity for patient verbalization of previous dismissal of symptoms, fueling the need for adoption of a standardized screening protocol in gynecology settings.