Aplicación de un protocolo de manejo de masas anexiales: ahorro en actividad clínicamente innecesaria y costes / Application of a protocol for the management of adnexal masses: savings in clinically unnecessary activity and costs

FUNDAMENTO: Evaluar si la implantación de un protocolo de masas anexiales basado en el sistema GI-RADS permite un correcto manejo de estas, evitando la actividad clínicamente innecesaria derivada del sobrediagnóstico y sobretratamiento, así como un ahorro en los costes. MÉTODO: Estudio de cohortes retrospectivo (julio 2015 - junio 2017). Incluyó mujeres atendidas en la consulta de Ginecología del Hospital Universitario Rey Juan Carlos (Móstoles, Madrid) con hallazgo de una masa anexial en ecografía de alta resolución. La masa anexial se catalogó con el sistema GI-RADS y, junto con la imagen ecográfica y el estatus menopáusico de la paciente, se decidió realizar cirugía o seguimiento. RESULTADOS: Se estudiaron 154 mujeres, el 24 % con imágenes sospechosas de malignidad (G4 y G5). Se intervinieron un 33,1 % de las masas anexiales, el 33,3 % de las cuales fueron cáncer de ovario, principalmente en mujeres postmenopáusicas con una imagen ecográfica sospechosa de malignidad (88,2 %). Un 3,2 % de las pacientes rechazaron la indicación de cirugía. Durante el seguimiento desaparecieron el 21,4 % de las masas anexiales, 61 pacientes (39,6 %) no habían sido intervenidas por presentar una masa anexial estable, y dos (1,3 %) por el riesgo quirúrgico. Al final del estudio se evitaron 96 (62,3 %) cirugías, logrando una reducción de costes de 57.683 euros. CONCLUSIONES: La aplicación de un protocolo basado en el sistema de clasificación GI-RADS evitó cirugías innecesarias y las consecuencias y costes derivados de ellas, por lo que constituye una herramienta útil y práctica en el control y tratamiento de las masas anexiales.Palabras clave. Masa anexial. Clasificación GI-RADS. Cirugías innecesarias. Seguridad del paciente

BACKGROUND: Evaluate whether the implementation of an adnexal masses protocol, based on the GI-RADS system, allows a correct management of these masses, avoiding unnecessary clinical activity produced by overdiagnosis and overtreatment, as well as cost savings. METHODS: Retrospective cohort study (July 2015 - June 2017) including women treated at the Gynaecology clinic of the Hospital Universitario Rey Juan Carlos (Móstoles, Madrid), with detection of an adnexal mass in high resolution echography. Adnexal masses were classified by the GI-RADS system, and together with the echographic image and menopausal status, surgery or follow-up was decided. RESULTS: A total of 154 women were studied, 24 % with images suggesting malignancy (G4 and G5). Surgery was performed on 33.1 % of adnexal masses; 33.3 % of them were ovarian carcinoma, mainly (88.2 %) in postmenopausal women with echographic images suggesting malignancy. Three point two percent of patients rejected the recommended surgery. During follow-up 21.4 % of the masses disappeared, 61 patients were only monitored due to a stable mass and two (1.3 %) due to surgical risk. Eventually, 96 (62.3 %) surgeries were avoided, achieving a 57,683 Euro saving. CONCLUSIONS: The application of a protocol based on the GI-RADS classification system avoided unnecessary surgeries, as well as the consequences and economical cost produced by them. Thus, this protocol is a useful and practical tool for the monitoring and treatment of adnexal masses

Limit, lean or listen? A typology of low-value care that gives direction in de-implementation.

BACKGROUND: Overuse of unnecessary care is widespread around the world. This so-called low-value care provides no benefit for the patient, wastes resources and can cause harm. The concept of low-value care is broad and there are different reasons for care to be of low-value. Hence, different strategies might be necessary to reduce it and awareness of this may help in designing a de-implementation strategy. Based on a literature scan and discussions with experts, we identified three types of low-value care. RESULTS: The type ineffective care is proven ineffective, such as antibiotics for a viral infection. Inefficient care is in essence effective, but is of low-value through inefficient provision or inappropriate intensity, such as chronic benzodiazepine use. Unwanted care is in essence appropriate for the clinical condition it targets, but is low-value since it does not fit the patients' preferences, such as a treatment aimed to cure a patient that prefers palliative care. In this paper, we argue that these three types differ in their most promising strategy for de-implementation and that our typology gives direction in choosing whether to limit, lean or listen. CONCLUSION: We developed a typology that provides insight in the different reasons for care to be of low-value. We believe that this typology is helpful in designing a tailor-made strategy for reducing low-value care.