SQU Med J, February 2012, Vol. 12, Iss. 1, pp. 93-96, Epub. 7th Feb 12. Submitted 1st May 11 Revision Req. 10th Oct 11, Revision recd. 24th Oct 11 Accepted 16th Nov 11 Department of 1Obstetrics & Gynaecology and 2Family Medicine & Public Health, Sultan Qaboos University Hospital, Muscat, Oman. *Corresponding Author e-mail: m.khaduri@gmail.com ُمَعّدل الّتقنية كُمؤّشر جودة للّتمّيز يف أمراض الّنساء مها اخل�سوري، يحيى الفار�سي هذه الطريقة: ُعمان. يف جامعي ثالثي رعاية م�ست�سفى يف الّرحم ا�ستئ�سال لعمليات الّتقنية معّدل ح�ساب درا�سة الأهداف: امللخ�س: درا�سة ا�ستعادية �سملت املري�سات اللواتي خ�سعن لعمليات ا�ستئ�سال الّرحم يف م�ست�سفى جامعة ال�سلطان قابو�س املرجعي للفرتة من 2003 اإىل 2009. مت اإح�ساء الرتددات الرتاكمية جلميع اأنواع عمليات ا�ستئ�سال الرحم، كما مّت ح�ساب موؤ�رص التقنية لكل عام. النتائج: َبَلَغ جمموع عمليات ا�ستئ�سال الرحم 258 عملّية، منها 6 )%2.3( عن طريق ا�ستخدام املنظار، 42 )%16.3( عن طريق امِلهَبل، و 208 )%80.6( عن طريق فتح البطن. كان متو�سط ُمَعّدل التقنية %19 )258/84( وتراوحت بني %11 اإىل %24. وتراوحت نزعة مرة النخفا�س اإىل لتعود ثم من 2004–2006، الفرتة خالل تدريجيا �سنة 2003 لرتتفع فكانت %16 يف ال�سنني، ح�سب التغيري اأخرى خالل �سنتي 2007 – 2008 ب�سكل معتّد اإح�سائيا )P=0.02(. ُتعزى هذه النزعة املنخف�سة واملتذبذبة ب�سكل رئي�سي اإىل عدم قابو�س ال�سلطان جامعة مب�ست�سفى التقنية معدل حت�سني ميكن اخلال�صة: املنظار. واأجهزة امُلَدّربني اجلّراحني من كافية اأعداد توفر بزيادة َعدد عملّيات ا�ستئ�سال الرحم عن طريق املنظار وذلك عن طريق توفري اأدوات املنظار وتوفري اجلّراحني امُلدّربني. مفتاح الكلمات: َمن�َسب )دليل( التقنية، ا�ستئ�سال الرحم، موؤ�رص اجلودة، علم اأمرا�س الن�ساء، ُعمان. abstract: Objectives: The objective of this study was to calculate the technicity index (TI) for hysterectomies at a tertiary care university hospital in Oman. Methods: This is a retrospective chart review of patients who had hysterectomies at Sultan Qaboos University Hospital (SQUH), a tertiary care university hospital. Profiles were reviewed for all patients who had hysterectomies at SQUH in the period 2003–2009. The cumulative frequencies for all types of hysterectomies were tallied and the year-specific TI was calculated. Results: Overall, we enumerated a total of 258 hysterectomies, of which 6 (2.3%) were laparoscopic assisted hysterectomies, 42 (16.3%) vaginal hysterectomies, and 208 (80.6%) total abdominal hysterectomies. The average TI was 19% (48/258), and it ranged from 11% to 24%. The trend of change fluctuated over the years starting with 16% (2003) and increasing gradually during 2004–2006, but then declining again during 2007–2008 (trend P value 0.02). This low and fluctuating trend was mainly attributed to the inconsistency in the availability of trained surgeons and laparoscopic equipment. Conclusion: TI at our institution can be improved by increasing the number of minimally invasive hysterectomies through providing more trained surgeons and laparoscopic equipment. Keywords: Technicity Index; Hysterectomy; Quality indicator; Gynaecology; Oman. BRIEF COMMUNICATION Technicity as a Quality Indicator of Excellence in Gynaecology *Maha Al-Khaduri1 and Yahya Al- Farsi2 In recent years, international and national health regulatory bodies have been advocating the use of indicators as a means of improving the quality of patient care.1 Quality indicators are defined as specific and measurable elements of practice that can be used to assess the quality of patient care. They are usually derived from retrospective reviews of medical records or routine information sources.2 With the advancement of minimally invasive surgery (MIS) in gynaecology, new quality and performance indicators are required to evaluate the use of procedures which benefit patients and may be more cost effective as a result of a reduced hospital stay.3,4 One such indicator is the Technicity Index (TI) which is a relatively new quality metric in gynaecology. It was initially proposed for hysterectomies and is defined as the percentage of minimally invasive hysterectomies which includes vaginal hysterectomies (VH), laparoscopic assisted hysterectomies (LAH), laparoscopic assisted vaginal hysterectomies (LAVH), total laparoscopic hysterectomies (TLH), and supracervical hysterec- tomies (LSH) over the total number of hysterec- tomies (total abdominal hysterectomies (TAH), VH and LAH), performed in a single hospital in one Technicity as a Quality Indicator of Excellence in Gynaecology 94 | SQU Medical Journal, February 2012, Volume 12, Issue 1 year. The TI provides a comparative benchmark which may help in implementing strategies to improve performance which can be defined as an increase in MIS and decrease in the proportion of TAH. It was first used in France to rank gynaecology departments’ performance of hysterectomy. The highest TI in 2008 in France was reported as 90%, meaning that only 10% of hysterectomies were done by laparotomy.4 In Canada, the average TI has been reported to be approximately 30% and the highest estimate was 60% in one hospital during the period 2008–2009.5 To our knowledge, no prior report about technicity has been published from developing countries. This TI research project aims at assessing the practice of hysterectomy in Oman, an upper-middle income country in the Arabian Peninsula, with an approximate population of 3.5 million.6,7 There is a planned future extension of the project to assess the practice of hysterectomy in other hospitals in the country and the region. The objective of this study was to calculate TI as a quality indicator of excellence at our hospital. Methods We conducted a retrospective chart review of all hysterectomies performed at Sultan Qaboos University Hospital (SQUH), a 524 bed tertiary care hospital, in the period 2003 to 2009. The cumulative frequencies for all types of hysterectomies were tallied and the TI was calculated for each year. The Statistical Package for Social Sciences (SPSS) software (Version 16.0, IBM, Chicago, Illinois, USA) was used for data analysis. Chi- square analyses were used to evaluate the statistical significance of differences among proportions of categorical data, and a P value of <0.05 was used for all tests of statistical significance. The Fisher’s exact test (two-tailed) replaced the chi-square test if the assumptions underlying chi-square were violated, namely in the case of small sample size and where the expected frequency was less than five in any of the cells. The study protocol was evaluated and approved by the Medical Research Ethics Committee at Sultan Qaboos University, Muscat, Oman. Results Table 1 shows the frequency distribution and year- specific TI for hysterectomies at SQUH throughout the period 2003–2009. Overall, we enumerated a total of 258 hysterectomies, of which 6 (2.3%) were LAH, 42 (16.3%) VH, and 208 (80.6%) TAH. The average TI was 19% (48/258), and it ranged from 11% to 24%. The trend of change fluctuated over the years. It started with 16% (year 2003) and increased gradually during 2004–2006, but then declined gradually during 2007–2008 (trend P value 0.02). The fluctuating trend of TI is depicted schematically in Figure 1. Discussion The development of minimally invasive hysterectomy procedures in gynaecology has created a need for the development of quality Table 1: Year-specific technicity index (TI) for hysterectomies at Sultan Qaboos University Hospital, Muscat, Oman during the period 2003–2009. Year LAH VH TAH Total Technicity Index % 2003 0 7 36 43 16 2004 5 4 43 62 15 2005 0 10 32 42 24 2006 0 2 8 10 20 2007 0 2 17 19 11 2008 1 7 37 45 18 2009 0 4 33 38 11 Total 6 42 208 258 19 Legend: LAH = laparoscopic abdominal hysterectomy; VH = vaginal hysterectomy; TAH = total abdominal hysterectomy. 0% 5% 10% 16 15 24 20 11 11 18 15% 20% 25% 30% 2003 2004 2005 2006 2007 2008 2009 Figure 1: Trend of technicity index (TI) for hysterectomies at Sultan Qaboos University Hospital, Oman, in the period 2003–2009. Maha Al-Khaduri and Yahya Al- Farsi brief communication | 95 indicators in order to assess the performance of gynaecology departments. The TI provides a comparative benchmark which may help implement strategies to improve performance based on available evidence. The higher the TI in a department the better the quality of care for the procedure performed. The quality of care is determined by five criteria. These are complication rate, length of stay in the hospital, duration of surgery, hospital cost and quality of life. However, there is a need to decide on an acceptable TI level for hysterectomies for the region based on the available resources. The overall TI was found to be low at our institution which is due to the low number of LAH and VH performed. The low and fluctuating trend in TI was mainly attributed to the inconsistency in the availability of trained gynaecologists and laparoscopic equipment in the different years. The increase in TI in 2005 is explained by a greater number of LAVH procedures compared to other years which is likely due to the availability of a gynaecologist trained in LAVH. The lowest TI in 2007 was due to a decrease in the number of VH performed. It can also be argued that the type of cases at different times would influence the type of procedure performed and may partially explain the changing trend. There are several reasons for caution in extrapolating conclusions from this study. We were unable to compare our TI results with TI in other institutions in the region as there is as yet no published data. To our knowledge, we are the first to report TI for hysterectomy in the region. The TI at our institution is lower than the reported TI from Canada and France; however, these TI values are not comparable due to the difference in resources and training of gynaecologists in North America, Europe and the Middle East. Additionally, we could identify the following limitations to our study. First, the numbers of hysterectomy procedures performed per year at our institution are small with an annual incidence of 0.87%. Although we attempted to compensate for that by looking at the overall number of hysterectomies performed over seven years, the sample size remained small. Second, when looking at the different indications for hysterectomies, we found that 2.7% of cases were malignant conditions and the rest were benign. The details of the cases would not change the TI, but could shed light on possible reasons for not choosing the minimally invasive approach. For example, in the case of advanced uterine and ovarian cancer, the minimally invasive hysterectomy procedure may not be the standard of care. A more detailed analysis of the indications for hysterectomies during the period of study should be carried out in order to explain the results. We plan to include this in future expansions of our research project. Conclusion With the emphasis on moving towards minimally invasive procedures in gynaecology, it will be imperative to develop quality and performance indicators in order to measure the quality of patient care. The TI indicator is one of the first to be developed for minimally invasive procedures and can be perceived as a quality indicator of excellence in gynaecology. Knowing where we stand in terms of providing the best care for our patients is important. In addition, acknowledging that transparency in quality is the first step towards achieving excellence will improve acceptance of accountability. In this study, we were able to establish that the TI for hysterectomy at our institution can be improved by increasing the number of minimally invasive hysterectomies through providing more trained gynaecologists, operating theatre nurses trained in endoscopy procedures and availabitlity of appropriate laparoscopic equipment. As a result we expect that the TI at our institution will increase in the near future. c o n f l i c t o f i n t e r e s t The authors reported no conflict of interest. a c k n o w l e d g m e n t s An abstract of this study was accepted by the American Association of Gynecologic Laparoscopists (AAGL) for the 39th Global Congress on Minimally Invasive Gynecology, 8–12 November 2010 in Las Vegas, Nevada and published in the Journal of Minimally Invasive Gynaecology in November 2010 (17:S73). References 1. McLaughlin V, Leatherman S, Fletcher M, Owen JW. Improving performance using indicators. Recent experiences in the United States, the United Kingdom, and Australia. Int J Qual Health Care Technicity as a Quality Indicator of Excellence in Gynaecology 96 | SQU Medical Journal, February 2012, Volume 12, Issue 1 2001; 13:455-62. 2. Women’s Health Care Physicians (Committee on Patient Safety and Quality Improvement). Quality and Safety in Women’s Health care. 2nd Ed. Danvers, MA: American College of Obstetricians and Gynecologists, 2010. 3. Garry R, Fountain J, Mason S, Hawe J, Napp V, Abbott J, et al. The eVALuate study: Two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ 2004; 328:129-33. 4. Le Point. Hôpitaux le palmarès 2008. From : w w w.lepoint.fr/html/hopitaux-2008/chirurgie- gynecologique.jsp. Accessed: Aug 2010. 5. Laberge PY, Singh SS. Surgical approach to hysterectomy: Introducing the concept of technicity. J Obstet Gynaecol Can 2009; 31:1050-3. 6. Annual Health Report. Ministry of Health, Sultanate of Oman, 2008. Muscat: Ministry of Health, 2008.