Extent, regional variation and impact of gynecologist payment models in routine pelvic examinations: a nationwide cross-sectional study

Abstract

BackgroundBased on moderate quality evidence, routine pelvic examination is strongly recommended against in asymptomatic women. The aims of this study was to quantify the extent of routine pelvic examinations within specialized health care in Norway, to assess if the use of these services differs across hospital referral regions and to assess if the use of colposcopy and ultrasound differs with gynecologists’ payment models.MethodsNationwide cross-sectional study including all women aged 18 years and older in Norway in the years 2014–16 (2,038,747). Data was extracted from the Norwegian Patient Registry and Statistics Norway. The main outcome measures were 1. The number of appointments per 1000 women with a primary diagnosis of “Encounter for gynecological examination without complaint, suspected or reported diagnosis.” 2. The age-standardized number of these appointments per 1000 women in the 21 different hospital referral regions of Norway. 3. The use of colposcopy and ultrasound in routine pelvic examinations, provided by gynecologists with fixed salaries and gynecologists paid by a fee-for-service model.ResultsAnnually 22.2 out of every 1000 women in Norway had a routine pelvic examination, with variation across regions from 6.6 to 43.9 per 1000. Gynecologists with fixed salaries performed colposcopy in 1.6% and ultrasound in 74.5% of appointments. Corresponding numbers for fee-for-service gynecologists were 49.2% and 96.2%, respectively.ConclusionsRoutine pelvic examinations are widely performed in Norway. The variation across regions is extensive. Our results strongly indicate that fee-for-service payments for gynecologists skyrocket the use of colposcopy and increase the use of ultrasound in pelvic examinations of asymptomatic women.Electronic supplementary materialThe online version of this article (10.1186/s12905-017-0471-2) contains supplementary material, which is available to authorized users.

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The Use, Quality and Effectiveness of Pelvic Examination in Primary Care for the Detection of Gynaecological Cancer

“…The study period spanned the years 2014 to 2016, encompassing an estimated adult female population of 2,038,747 in Norway. 8 During this period, the national rate stood at 22.2 pelvic examinations per 1000 women. A majority of women (88.9%) who underwent pelvic examinations had only one such exam.…”

“…Annually, 2.6% (38,065) of women aged 25-69 years received routine pelvic examinations, while the percentages were 0.97% (2231) for younger women and 0.96% (3143) for those aged 70 years or older. 8 Variation in pelvic examinations per 1000 women was observed across hospital referral regions, ranging from 6.6 to 43.9. Fee-for-service gynecologists conducted approximately two-thirds (29,324) of pelvic examinations, with the mean age of examined women slightly higher compared to those attended by fixed-salary gynecologists (47.8 vs. 46.7 years).…”

“…For instance, colposcopy was used in 1.6% (249) of appointments at fixed-salary gynecologists, while it was employed in 49.2% (14,427) of appointments by fee-for-service gynecologists. 8 Moreover, approximately 87.3% (29,324) of appointments in private practice indicated a procedural code for "complete examination performed by a specialist." Further analysis revealed that annually, there were 2013 appointments for cervical screening within publicly funded specialized healthcare, constituting 4.3% of the combined appointments for cervical screening and routine pelvic examinations.…”