NUMBER OF OPERATIVE ACTIONS AND REFERRALS TO GYNECOLOGY CASES AT MALINGPING HOSPITAL 2020-2022

William Halim

RSUD Malingping

Keywords

Abstract

Malingping Regional Hospital, Referral System, Gynecology Cases, Patient Welfare, Equal distribution of doctors

Almost every woman has experienced a gynecological condition in her life. Access to quality and adequate health services for women is one of the Indonesian government's national programs. The main aim of this study is to assess the number of procedures and referrals for gynecological cases at the Malingping Regional General Hospital (RSUD) from 2020 to 2022. This research is a retrospective descriptive study. The target population includes all gynecology patients in outpatient clinics. In contrast, the accessible population is all gynecology patients undergoing outpatient treatment at Malingping District Hospital during that period. Research shows that ovarian tumors dominate with 45% of a total of 140 cases, with various treatments such as surgery and referral, especially in cases of suspected malignancy. Malingping District General Hospital faces significant obstacles in patient referral, particularly in cancer cases involving long travel and long waiting times, which have the potential to worsen patient morbidity and mortality. Challenges such as limited anatomical pathology facilities, distance to referral hospitals, and the uneven distribution of specialist doctors underscore the need to improve infrastructure, services, and health policies to ensure better access for regional patients. Cases with gynecological problems can be managed observationally, medically, and operatively. Correct diagnosis is essential for successful treatment. Hospitals must have a unified system, human resources, facilities, and infrastructure to support this. The current problem at Malingping Regional Hospital is supporting examinations, the availability of which depends on the hospital's spending capacity.

Corresponding Author: William Halim

E-mail: [email protected]

INTRODUCTION

Women's health has a vital role in preserving healthy future generations. Almost every woman has experienced a gynecological condition in her life. Access to quality and adequate health services for women is one of the national programs of the Indonesian government (Susiloningtyas, 2020). In this case, the availability of adequate facilities and human resources plays a vital role in its success.

Malingping Regional Hospital is a regional government general hospital in South Banten province. The Malingping work area covers 11 sub-districts with a population of 413,675 people. Currently, the Malingping area is still categorized as a remote area with difficult access to transportation and long distances for cases requiring referral (Rahayu et al., 2019). The primary referrals for Malingping Regional Hospital are Adjidarmo Regional Hospital, Serang Regional Hospital and Tangerang Regional Hospital. The distance that must be traveled to reach the referral hospital is 75 km to 155 km, with access to mountain roads, which are pretty narrow and winding. This will significantly impact services that could be more optimal for the community in terms of economy and time (Epstein, 2018). Gynecological cases with benign characteristics can generally be treated at Malingping District Hospital; however, in cases with the possibility of malignancy, the patient must be referred to a referral hospital. With limited transportation and living costs for the referring family, some Malingping Regional Hospital patients still choose to avoid being referred while the patient is being referred. This will have a significant impact on optimizing service to patients.

The most common gynecological cases that undergo surgery at Malingping District Hospital include Uterine myoma, Ovarian Cyst, Adenomyosis, pelvic organ prolapse, abnormal uterine bleeding, and Bartholin's Cyst (Boitano et al., 2022). Cases that generally require referral are cases of ovarian cysts that may be malignant, endometrial cancer, and cervical cancer (Song et al., 2022). Limited supporting examinations will also impact the need for patient referrals.

Some gynecological cases generally do not cause significant symptoms (Yudianti & Nurhayati, 2018). Characteristics of patients in the Malingping area, in general, will go for a check-up if they experience pretty severe symptoms such as bleeding and a large enough mass (DAERAH, 2019). The delay in getting checked can be caused by a lack of knowledge in the community or the role of shamans or Taraji who are still angry in the Malingping area.

Ultrasonography is the best initial modality to differentiate between malignant and benign ovarian tumors (Mahyenda et al., 2022). Physical examination and examination of tumor markers (CA-125) are also critical in diagnosis (Gopireddy et al., 2020). If malignant characteristics are found on examination, the case must be referred for further treatment by an oncology consultant. This research can become a reference and illustration for improving Malingping Regional Hospital services to the surrounding community.

The benefits of this research are diverse and cover several significant areas. In the academic field, the results of this research can provide a general overview of the characteristics of gynecological cases in outpatients at Malingping District Hospital. Apart from that, the experience of carrying out research in Obstetrics and Gynecology can improve the academic aspects at Malingping Regional Hospital. This research will provide important information regarding the number of patients treated and referred from the obstetrics and gynecology outpatient clinic at Malingping District Hospital. This information can be the basis for more effective and targeted health policies. Furthermore, in the service sector, this research can be a crucial consideration for improving health facilities and Human Resources (HR) in the Malingping area. The practical implications of this research can support efforts to improve the quality of health services at Malingping District Hospital, thereby providing direct benefits to the local community.

The main objective of this research is to assess the number of procedures and referrals for gynecological cases at Malingping Regional General Hospital (RSUD) from 2020 to 2022. Specifically, this research aims to determine the number of gynecological cases treated at Malingping Regional General Hospital and the number of cases referred outside. The second objective was to identify the characteristics of gynecological cases undergoing surgical procedures at Malingping District Hospital. Through this research, an in-depth understanding of the dynamics of gynecological services at Malingping Regional Hospital during the specified period can be obtained.

RESEARCH METHODS

This retrospective descriptive study aims to determine the number of gynecology patients who underwent surgery and the number of patients referred from the outpatient clinic at Malingping Regional General Hospital, Lebak, from July 2020 to December 2022. The target population includes all gynecology patients at the clinic outpatient care. In contrast, the accessible population is all gynecology patients who underwent outpatient care at Malingping District Hospital during that period. Research subjects will be selected based on inclusion criteria, namely patients with gynecological cases who require action or must be referred. In contrast, the exclusion criteria involve incomplete primary patient data.

RESULTS AND DISCUSSION

One hundred forty patients were enrolled in this study for gynecological cases from July 2020 to June 2022 in the outpatient department at Malingping General Hospital. These cases include ovarian tumors, ovarian cancer, uterine myoma, adenomyosis, and abnormal uterine bleeding (PUA) (Charkhchi et al., 2020). Cervical cancer, endometrial cancer, Mullerian anomaly, Bartholin's abscess, malignant trophoblastic disease (PTG), pelvic organ prolapse (POP), tuba ovarian abscess, hydrosalpinx, and imperforate hymen (Table 1).

Table 1 Types of Cases and Management

	Action	Refer	Medicamentosa	Amount
Ovarian Tumor	28	30	5	63
PUAs			15	15
Uterine Myoma	16		2	18
Adenomyosis	9	2	1	12
Cervical Cancer		7		7
Ovarian Cancer		1		1
Endometrial Cancer		1		1
Mullerian anomaly		7		7
Bartholin's abscess	5			5
POP	1	1	4	6
Tuboovarian Abscess	2			2
Imperforate Hymen	1			1
PTG		1		1
Hydrosalpinx		1		1

Ovarian tumors have the most significant number of cases, with 45% of the total. Ovarian tumors are divided into suspected malignant and benign based on the results of the examination carried out. The second most common case is uterine myoma.

Diagram 1 Case Percentage

Cancer cases and Mullerian anomalies have a 100% percentage of being referred to referral hospitals because subspecialty competency is required for subsequent treatment. In other cases, referrals can be made based on the level of difficulty of the case, the confidence of the doctor in charge, the competence of the doctor, or the availability of facilities and infrastructure.

Table 2 Types of Ovarian Tumors and Treatment

Ovarian Tumor	Operative Actions	Reference	Medicamentosa
Benign Suspicion	34	10	5
Malignant Suspicion	0	14	0

Malingping Regional General Hospital is a type C hospital that has been operating in the South Lebak area since 2005 and is still trying to improve services to patients in the area. The distance between referral hospitals is still one of the reasons why patients are reluctant to continue treatment at referral hospitals. Even though patient financing at Malingping District Hospital already uses BPJS, the cost of living for the delivery family and the situation of each family are generally inhibiting factors for patients' continued therapy at referral hospitals. Cases where treatment is stopped will cause deterioration to the point of death.

Ovarian tumors were the most common cases from the data taken. Ovarian tumors can lead to malignant tumors or benign tumors. 80% of all ovarian tumors are benign. Ovarian tumor cases caused the deaths of 13,900 patients in Indonesia in 2015, and this is because most patients came for treatment at a late stage. The correct diagnosis can be made by taking a history, examination, and appropriate supporting examinations (Talley & Oï¿½connor, 2014). The simplest supporting examination currently is an ultrasound examination available at Malingping Regional Hospital. The most common follow-up examination is a tumor marker examination Ca-125. The Ca-125 examination is not always available at Malingping District Hospital; this is also one of the reasons why patients have to undergo an examination in another city, which is around 150 km away. Operative treatment was carried out in 34 patients, and 5 patients received medical or observational therapy (Colomina et al., 2021). 14 patients out of 63 cases of ovarian tumors were referred due to suspicion of malignancy, in which case these cases required further management by a gynecological oncology subspecialist (Olawaiye & Zhao, 2022). Ten cases of benign tumors were referred due to several complicating factors to prevent morbidity in inpatient treatment. Some cases of ovarian tumor treatment require an examination by the anatomical pathology department on-site to carry out a frozen section; this also plays a role in whether or not the patient needs to be referred (Aidos et al., 2018). Currently, Malingping District Hospital has 2 obstetrics and gynecology specialists who practice not on the same day, so the doctor in charge only carries out operative procedures with a nurse assistant and an instrument nurse. Currently, for biopsy examinations, patients must bring their specimens to be examined in the nearest city, a distance of around 100 km, at their own expense. This is because there is no anatomical pathology department available at Malingping District Hospital.

Most of the benign gynecological cases of uterine myoma and adenomyosis were handled at Malingping District Hospital, 28 out of 30 cases. 2 cases of adenomyosis were referred because of the suspected high level of difficulty in handling these cases to avoid morbidity. The operator's competency and experience will be essential in the management flow. Referrals of 7 out of 7 patients with Mullerian anomaly cases were directed to the Fertility and Endocrinology Consultant subspecialist department for further consultation and management. Cases with hydrosalpinx are also referred to because they are associated with infertility.

Patients diagnosed with cancer are referred to a gynecological oncology subspecialist (Dewald & Khan, 2022). There were 7 cases of cervical cancer and 1 case each of ovarian cancer and endometrial cancer. The situation of patients with cancer or cases that have the potential to be cancer is quite varied. Some patients come to the hospital only when they experience severe symptoms. This condition will also make it difficult for patients to continue referrals, so some patients continue traditional or alternative therapy. This situation will increase the level of patient morbidity and mortality.

Patients who continue referrals with BPJS guarantees also complain of several obstacles. The patient will make an appointment at the destination hospital to continue this referral. With limited hospitals providing subspecialty services, patients queue for quite a long time. Further treatment, such as further examinations or surgery, also requires varying waiting times. Patients and accompanying families must stay overnight in the destination area because the journey is quite far and dangerous, around 3-5 hours, and passes through mountainous areas. If the next service requires a long waiting time, the patient will travel home and go back; this will have an impact on economic factors, family readiness, and the patient's condition.

Currently, the distribution of specialist doctors still needs to be improved in Indonesia. The Indonesian government is working to accelerate the Specialist and Subspecialist Study Program to increase public access to health services. Alignment between the government and doctors' organizations will play an essential role in increasing access for doctors to increase their competency in specialist and subspecialty fields.

CONCLUSION

Cases with gynecological problems can be managed observationally, medically, and operatively. Correct diagnosis is essential for successful treatment. Hospitals must have a unified system, human resources, facilities, and infrastructure to support this. The current problem at Malingping Regional Hospital is supporting examinations, the availability of which depends on the hospital's spending capacity. The success of operative management depends on several factors: diagnosis, communication, operator competency, infrastructure, and teamwork. In general, obstetricians and gynecologists can treat gynecological cases benignly. Some complications in cases of benign tumors, especially endometriosis and adenomyosis, are the tendency for tumor adhesions to surrounding organs. Supporting examinations such as CT Scans and MRIs will be very useful for detecting these adhesions. Increasing competency and supporting equipment will contribute to successful management and reduce the risk of morbidity. Delays in diagnosis or delays in treatment will have an impact on the success rate of patient treatment. By competence, the gynecological oncology subspecialty department will handle cases diagnosed with malignancy or malignant tendencies. The provision of subspecialty services at Malingping District Hospital needs to be considered to improve community health services geographically. The government should also increase the number of hospitals in the surrounding area.

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