Haags Endometriose in Balans-centrum eerste stap in de goede richting
Centralisatie tilt endometriose zorg naar hoger plan
Gezien de complexiteit van endometriose is het raadzaam de zorg rond deze aandoening te concentreren in expertcentra, stellen hoogleraar Frank Willem Jansen en collega’s. In Den Haag is de eerste aanzet hiertoe gedaan.
Jeroen Metzemaekers
arts-onderzoeker, Leids Universitair Medisch Centrum
Maddy Smeets
gynaecoloog, Haaglanden Medisch Centrum
Frank Willem Jansen
hoogleraar gynaecologie, Leids Universitair Medisch Centrum
Centralisatie van zorg, voor complexe (chirurgische) procedures met een laag volume en hoog risico, resulteert in een hoog niveau van zorg en creëert wetenschap. In Nederland is de oncologische zorg al op deze manier georganiseerd, in zogenaamde expertcentra voor borst-, prostaat-, colorectale en pancreaschirurgie. Maar de (chirurgische) behandeling van Diepe Endometriose (DE), eveneens een laagvolume-hoogrisicoprocedure, nog niet. In naburige landen, zoals Engeland, Oostenrijk, Duitsland en Denemarken, is dit wel het geval en controleren de British Society for Gynaecological Endoscopy (BSGE) en de European Endometriosis League (EEL) het medisch handelen. In Nederland zijn gesprekken hierover gaande binnen de werkgroep endometriose van de Nederlandse Vereniging voor Obstetrie en Gynaecologie (NVOG) en de werkgroep coloproctologie (WCP) van de Nederlandse Vereniging voor Heelkunde (NVvH).
Het idee voor centralisatie wordt breed omarmd, maar de impact op de professionele autonomie en mogelijke negatieve financiële consequenties moeten nog verder worden uitgediept. Verder is het de vraag of centralisatie financiële voordelen gaat opleveren, wat echter niet eenvoudig te beantwoorden is. Een systematische review hierover komt tot wisselende uitkomsten, echter een recent artikel over centralisatie in Denemarken (waaronder ook de endometriose) laat een verhoging van de productiviteit zien, waarbij de kosten stabiel blijven.1 2 Het belangrijkste argument om te centraliseren blijft verbetering van zorg voor de patiënt, waarbij mogelijk ook nog financiële voordelen te behalen zijn.
Complexe ziekte
Endometriose is een complexe ziekte waarvan de etiologie en pathogenese nog onvoldoende zijn opgehelderd. Mede hierdoor bestaat er nog geen causale behandeling, terwijl de morbiditeit die deze ziekte veroorzaakt enorme impact kan hebben op alle facetten van de kwaliteit van leven. De prevalentie van endometriose bij vrouwen in de vruchtbare leeftijd is naar schatting 10-15 procent, in de groep subfertiele vrouwen kan dit oplopen tot 30 procent. Ongeveer 10 procent zou DE hebben. Er bestaat veelal een delay in de diagnostiek van gemiddeld 7,4 jaar. De chirurgische behandeling van DE kent vele uitdagingen, met inherent de kans op ernstige complicaties zoals naadlekkage en fistelvorming. Met de introductie van de minimaal invasieve chirurgie is de mogelijkheid om deze ziekte ook laparoscopisch te behandelen toegenomen en wordt dit ook breder toegepast. Gezien de complexiteit van deze chirurgie vergt dit een multidisciplinair dedicated team met kennis van de aandoening, dat de operatieve valkuilen herkent en daarop kan acteren.
Er zijn inmiddels internationale criteria voor zo’n team. Naast een gynaecoloog als hoofdbehandelaar moet het bestaan uit een uroloog, chirurg en radioloog. Tevens is ondersteuning door een psycholoog, fysiotherapeut en diëtist een voorwaarde.
Eerste stappen
In het Endometriose in Balans-centrum (EiB) te Den Haag zijn de eerste stappen gezet om een dergelijk expertisecentrum te realiseren. Het centrum hanteert een hybride zorgstroom met invloeden van value-based health care- en patient centered care-principes. Dit vertaalt zich in de praktijk naar zorg georganiseerd rondom de patiënt, regie terug bij de patiënt en op maat geformuleerde zorg met shared decision making als uitgangspunt. Bij het eerste bezoek wordt de patiënt door het multidisciplinaire team gezien, wat meerdere consultaties bespaart. Daarnaast is er een hechte band met het Leids Universitair Medisch Centrum, dat onder andere de wetenschappelijke input levert. Recentelijk heeft het centrum het predicaat focuskliniek met STZ-status gekregen en als eerste in Nederland het hoogste predicaat van de European Endometriosis League. De toestroom van nieuwe patiënten was in 2018 verdubbeld ten opzichte van het jaar ervoor. Van de 674 aanmeldingen was 71 procent supraregionaal verwezen en had 58 procent DE (rASRM-graad III-IV). Patiënten met een rASRM-graad I-II werden nadrukkelijk teruggewezen naar initiële verwijzers.
Verder is het gehele ok-team speciaal toegerust voor endometrioseoperaties en is er wekelijks operatiekamertijd gereserveerd. Dit houdt in dat er training zijn specifiek gericht op endometriose operaties en een vast en dedicated OK team (gynaecoloog, chirurg, uroloog, omloop, assisterende, anesthesist en medewerker) dat specifiek is aangenomen/aangesteld om bij endometriose operaties te assisteren.
Niveaus van expertise
Hoewel vergelijkende studies nog ontbreken, geven de cijfers van recent patiënt tevredenheidsonderzoek (quality consumer index) en het jaarverslag (o.a. complicatieregistratie) aan dat patiënten de geleverde zorg in het EiB-centrum waarderen en dat de (chirurgische) resultaten goed zijn.
Endometriose centra kunnen volgens Duits model worden ingedeeld op drie niveaus van expertise. Niveau 1 (laagcomplex, basiszorg): gespecialiseerde gynaecologen die de basisendometriosezorg kunnen leveren. Niveau 2 (complex, differentiatiezorg): centra die naast de basiszorg ook de chirurgische behandeling kunnen inzetten. Niveau 3 (hoogcomplex): endometriosecentra die complexe hooggespecialiseerde zorg leveren, met name de chirurgische behandeling van DE. In Engeland is daarbij, om aan de kwaliteitseisen te voldoen, de voorwaarde gesteld dat op het hoogste niveau minimaal twaalf operaties (met rectovaginale betrokkenheid) per gynaecoloog per jaar moeten worden verricht. In Nederland is de werkgroep Endometriose van de NVOG bezig met het formulieren van minimumvereisten voor dergelijke centra. Hier wordt gesproken over twee zorgniveaus in plaats van drie, waarbij niveau 1 de basisendometriosezorg levert en niveau 2 de complexere endometriosezorg met ook DE.
Om de zorg rond DE op een goede manier te centraliseren, is het zaak visitaties uit te voeren en de kwaliteit te monitoren. Nadrukkelijk zullen daarbij centra op niveau 1(Nederlandse indeling) de regie houden over de patiënten met milde endometriose. Echter een zeer belangrijke voorwaarde om centralisatie te kunnen verwezenlijken is classificatie (rASRM, Enzian en EFI) en eenduidige registratie. Door inzichtelijk te krijgen wie welke zorg levert is het mogelijk om dergelijke centra aan te kunnen stellen. Dit inzicht en uniformiteit in registratie kan verkregen worden met het gebruik van de EQUSUM. Dit is een web-based applicatie voor endometriose classificatie en registratie op basis van wetenschappelijke consensus (www.equsum.org). Deze applicatie is door het LUMC in samenwerking met het EiB-centrum ontwikkeld.
Zes tot acht centra
Kortom, gezien de complexiteit van het diagnosticeren en behandelen van DE zijn expertisecentra op zijn plaats. Mede door definiëring van de inhoud en het aanwijzen van dergelijke centra, door onder andere te werken met correcte registratie en classificatie, kan endometriose zorg naar een hoger plan worden getild. De eerste initiatieven voor deze centralisatie, in de vorm van het opstellen van een richtlijn onder leiding van de werkgroep Endometriose van de NVOG, zijn in de maak. Ook de recente samenspraak met de werkgroep coloproctologie van de NVvH geeft hiertoe een goede impuls. Uitgaande van Deense criteria over de endometriose zorg zou er in Nederland plaats zijn voor zes tot acht van deze gespecialiseerde centra.
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