Page 103 - Diagnostic delay of endometriosis

observed causative factors for the delay, which mainly focus on improving knowledge and adequate use of diagnostics. They are however in line with the relatively low adherence to the guideline recommendations regarding the radiologic assessment of patients with a suspicion of deep endometriosis and referral of these patients to a centre of expertise which offers multidisciplinary treatment. Interestingly, the opinion of the respondents about centralisation seems contradictory as 61% of respondents were in favour of centralisation and 39% state they oppose to it. However, when asked about their motivation, those who claim to reject centralisation mainly point out that centralised care is not necessary for all patients, but only for women with severe endometriosis who may need complex surgery. This suggests that they may not be opposed to the concept of centralisation, but wish to preserve the opportunity to practice low-complex endometriosis care in all hospitals. A model with designated levels of expertise, as introduced in Belgium by D’Hooghe et al,13 may correspond to the suggestions regarding both directing endometriosis care according to the complexity of individual cases, as well as improving collaboration between gynaecologists in different hospitals and with other medical specialists. Another important observation was the advice to improve the collaboration between gynaecologists and GPs.
There are some limitations to this study. Although the response rate is high, only one gynaecologist from each hospital was invited to complete the questionnaire. Therefore, we may have missed relevant suggestions from other gynaecologists. Moreover, as our respondents are the gynaecologists most responsible for endometriosis care in their hospital, they may not be representative of the general-care gynaecologist. These gynaecologists with special interest in endometriosis are more likely to be familiar with the ESHRE guideline and have implemented it in their daily practice. The sample may be biased as those who are not familiar with the guideline, were probably less likely to respond. The questionnaire was not completed by any gynaecologist in 18 hospitals. The non-responding hospitals included all types of hospitals, such as academic, teaching and community hospitals. It should be noted that over estimation of guideline adherence by response bias is a well-known phenomenon. A review from Adams et al. has shown a median over-estimation of guideline adherence of 27% when self-reported measures are compared with objective measures.19 Another noteworthy point is the questionnaire was not validated because this is the first study to assess the opinion of gynaecologists on diagnostic delay and the use of the ESHRE guideline. Furthermore, we only quantitatively explored the guideline
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