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Getting Research into Practice GRiP; D&C

Appropriate D&C

A seminal paper on the appropriate level of dilation and curettage procedures compared in the USA, UK and Oxford Region was published in 1993 by Angela Coulter and her colleagues. The main finding was that the trends for D&C procedures in the UK had been more or less constant between 1977 and 1989, during which period there had been a roughly 9-fold reduction in rates in the USA.

In 1989 the rate in the USA was 10.8 per 10,000 women, compared with 71.1 per 10,000 in England, 65.2 per 10,000 in Scotland and 56.6 per 10,000 in the Oxford Region.

Large differences in rates

In the Oxford Region, the age-specific rates for D&C peaked in the 45-49 age group, but a significant percentage of the total occurred below age 40 years (39% of total).

There was considerable variation between districts for D&C overall, and especially in procedures in women below 40 years; for the latter, the spread in age-standardised rates between the highest and lowest districts was nearly 8-fold.

Is D&C effective?

The procedure was originally thought to have a therapeutic effect on dysfunctional uterine bleeding, but studies have failed to support this. The procedure may be used for diagnostic purposes to exclude endometrial malignancy, but this has been questioned. It is, of course, a useful procedure for removing the products of conception, and the figures quoted refer only to the use of D&C for dysfunctional bleeding.

An age cut-off at 40?

Critics argue that D&C should be restricted to women aged over 40 on the grounds that serious pathology is uncommon in younger women.

Cost implications

The Coulter paper argues that D&C procedures in the Oxford Region cost about £2 million at 1992 prices. Much of this could be saved by reducing the number of diagnostic investigations on young women and by resorting to outpatient procedures for the remainder. D&C involves a general anaesthetic and often a two-day hospital stay: the Audit Commission estimates that up to 86% of patients could be treated as day cases.

Buckinghamshire GRiP

The Buckinghamshire GRiP initiative began with a review of standardised admission rates for residents of the three localities within the Health Authority for D&C, and the recognition that there were large differences across the Authority, particularly for women under 40 years.

The aim, therefore, was to develop, implement and evaluate a protocol for the treatment of women under 40 with dysfunctional uterine bleeding. This protocol is to become the standard for treatment in Buckinghamshire.

Evaluation is to include an economic evaluation, comparing treatment costs before introduction of the protocol with those afterwards, an evaluation of the effect of the protocol on clinical practice, and a comparison of the change in clinical practice in the county with practice in another DHA where no protocol has been introduced.

How to do it

Essentially through co-operation, with public heath physicians acting as facilitators with gynaecologists and general practitioners. This group devised a draft protocol (not a trivial matter) for discussion with relevant professional groups.

The Buckinghamshire Health Authority will be incorporating the protocol into the 1994/5 contracts with Acute NHS Trusts, and will also be expecting audit of the management of dysfunctional bleeding to be undertaken.

April 1994 saw the introduction of the protocol, and so now it's wait and see time.

Reference:

Coulter et al, British Medical Journal 1993 306: 236-9.
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