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Right Decision Service newsletter: April 2024

Welcome to the Right Decision Service (RDS) newsletter for April 2024. 

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

Premenopausal Ovarian Masses (514)

Warning

Please report any inaccuracies or issues with this guideline using our online form

This guideline has been produced to assist clinicians with the initial assessment and appropriate management of suspected benign ovarian masses in premenopausal women. Up to 10% of women will have some form of surgery during their lifetime for the presence of an ovarian mass. In pre-menopausal women almost all ovarian masses and cysts are benign. The overall incidence of a symptomatic ovarian cyst in a pre-menopausal female being malignant is approximately 1:1000, increasing to 3:1000 at the age of 50. Pre-operative differentiation between the benign and the malignant ovarian mass in the pre-menopausal woman can be problematic with no specific tests. Exceptions are germ cell tumours with elevations of specific tumour markers such as alphafetoprotein (α-FP) and human chorionic gonadotrophin (hCG).

For the purposes of this guideline, simple cysts of 3cm or less should be considered physiological and do not merit further investigation.

The aim should be to minimise patient morbidity by conservative management where possible, use of laparoscopic techniques where appropriate, and referral to the gynaecological oncologists where appropriate.

History

A thorough medical history should be taken from the woman with specific attention to risk factors or protective factors for ovarian malignancy and a family history of ovarian or breast cancer.

Symptoms suggestive of endometriosis should be specifically considered along with any symptoms suggesting possible ovarian malignancy: persistent abdominal distension, appetite change including increased satiety, pelvic or abdominal pain, increased urinary urgency and/or frequency.

Examination and Investigations

A careful physical examination of the woman is essential and should include abdominal and vaginal examination, and examination to determine the presence or absence of local lymphadenopathy. Although clinical examination has poor sensitivity in the detection of ovarian masses, its importance lies in the evaluation of mass tenderness, mobility, nodularity and ascites.

In the acute presentation with pain the diagnosis of accident to the ovarian cyst should be considered (torsion, rupture, haemorrhage).

Imaging

A pelvic ultrasound is the single most effective way of evaluating a pelvic mass with transvaginal ultrasonography being preferable due to its increased sensitivity over transabdominal ultrasound. Routine use of CT or MRI is not indicated but where clinical or ultrasound suspicion exists, refer to Guidelines for Imaging of Gynaecological Malignancy (West of Scotland Cancer Network Guideline). CT of the abdomen and pelvis should be performed for masses with RMI >200 or in those with RMI <200 where clinical or ultrasound suspicion exists. MRI pelvis / lower abdomen should be performed in those with a complex mass which is difficult to characterise clinically or on ultrasound, or in young women (<30yrs) with suspected malignant tumour or a complex pelvic mass.

Blood tests

  1. CA125 – a serum CA125 assay does not need to be undertaken in all premenopausal women when an ultrasonographic diagnosis of a simple ovarian cyst has been made, but should be performed in all other circumstances. However it must be recognised that it is unreliable in determining whether ovarian lesions are benign or malignant as CA125 is also raised in conditions such as fibroids, endometriosis, adenomyosis and pelvic infection. Note also that CA125 is primarily a marker for epithelial ovarian tumours but is only elevated in around 50% of early stage disease.
  2.  LDH, αFP and hCG should be measured in all women under the age of 40 with a complex ovarian mass to exclude germ cell tumours.
  3. Calculate RMI – see below.

Calculation of the RMI

RMI combines three presurgical features: serum CA125 (CA125); menopausal status (M); and ultrasound score (U).
The RMI is a product of the ultrasound scan score, the menopausal status and the serum CA125 level (IU/ml) as follows:     RMI = U x M x CA125

  • The ultrasound result is scored 1 point for each of the following characteristics: multilocular cysts, solid areas, metastases, ascites and bilateral lesions. U = 0 (for an ultrasound score of 0), U=1 (for an ultrasound score of 1, U=3 (for an ultrasound score of 2-5).
  • The menopausal status is scored as 1=premenopausal and 3=postmenopausal.
  • Postmenopausal can be defined as women who have not had a period for more than one year or women over the age of 50 who have had a hysterectomy.
  • Serum CA125 is measured in IU/ml and can vary between zero to hundreds or even thousands of units.

Management

  • Women with an RMI of more than 200 should be discussed with the gynaecological oncology team and presented to the managed clinical network for gynaecological oncology after appropriate imaging as per WOSCAN Guidelines.
  • Women with small (less than 50mm diameter) ovarian cysts generally do not require follow-up as these cysts are very likely to be physiological and almost all resolve within 3 menstrual cycles.
  • Women with simple ovarian cysts of 50-70mm in diameter should have yearly ultrasound follow-up and those with larger simple cysts should be considered for either further imaging or surgical intervention.
  • Ovarian cysts that persist or increase in size are unlikely to be functional and may warrant surgical management.
  • The use of the combined oral contraceptive pill does not promote the resolution of ovarian cysts.

Surgery

  • A laparoscopic approach should be used whenever possible.
  • Aspiration of ovarian cysts, either vaginally or laparoscopically, is less effective and is associated with a high rate of recurrence.
  • Spillage of cyst contents should be avoided where possible as pre-operative and intra-operative assessment cannot absolutely preclude malignancy.
  • Where minimal access surgery is employed, consideration should be given to the use of a tissue bag to avoid peritoneal spill of cystic contents, bearing in mind the likely pre-operative diagnosis.
  • The possibility of oophorectomy must be discussed prior to surgery, documented in the notes and included in the consent form.

Editorial Information

Last reviewed: 14/12/2016

Next review date: 30/04/2023

Author(s): Morton Hair.

Approved By: Gynaecology Clinical Governance Group

Document Id: 514

References

RCOG. Management of Suspected Ovarian Masses in Premenopausal Women (Greentop Guideline No. 62). November 2011

Guidelines for Imaging of Gynaecological Malignancy. West of Scotland Cancer Network. 2014