Design: Retrospective review

Setting: Canada

Patients or Participants: Fellowship-trained surgeons who perform ≥2 endometriosis surgeries per month

Interventions: N/A

Measurements and Main Results:

Five consecutive deidentified surgical reports per surgeon were evaluated by two reviewers. Each dictation was assigned a quality score (between 0-28), with points given based on the number of components from the American Association of Gynecologic Laparoscopists (AAGL) classification system that were documented. The primary outcome was the proportion of dictations for which endometriosis stage could be assigned. Secondary outcomes included mean dictation quality scores expressed in percentages, individual score components, and quality score variation between surgeons, institutions, and dictation approaches. Proportions were compared with Kruskal-Wallis test, and quality score variation using ICC (Intraclass Correlation Coefficient).

52 dictations were reviewed from 11 surgeons across 5 sites. AAGL stage could be assigned in 28/52 (54%) of cases. The mean quality score was 53% (range 18-86%). Endometriosis was not documented most commonly for the small bowel/cecum (96%), right ureter (77%) and rectovaginal septum (73%). For a given surgeon, consistency between consecutive reports was poor (ICC 0.17, 95% CI -0.04 - 0.53). Quality scores did not significantly differ between surgeons, institutions, trainee vs. staff, template vs free-style dictation.

Conclusion:

There is significant variability and inconsistency in endometriosis surgery documentation, with accurate disease staging only possible in half of dictations. There is a need to standardize surgical documentation for endometriosis surgeries, enhancing communication and ultimately patient care.