Metzemaekers J, Haazebroek P, Smeets M J G H, English J, Blikkendaal M D, Twijnstra A R H, Adamson G D, Keckstein J, Jansen F W
Department of Gynaecology, Leiden University Medical Center, Leiden, the Netherlands.
Institute of Psychology, Leiden University, Leiden, the Netherlands.
Hum Reprod Open. 2020 Dec 30;2020(4):hoaa053. doi: 10.1093/hropen/hoaa053. eCollection 2020.
Is electronic digital classification/staging of endometriosis by the EQUSUM application more accurate in calculating the scores/stages and is it easier to use compared to non-digital classification?
We developed the first digital visual classification system in endometriosis (EQUSUM). This merges the three currently most frequently used separate endometriosis classification/scoring systems (i.e. revised American Society for Reproductive Medicine (rASRM), Enzian and Endometriosis Fertility Index (EFI)) to allow uniform and adequate classification and registration, which is easy to use. The EQUSUM showed significant improvement in correctly classifying/scoring endometriosis and is more user-friendly compared to non-digital classification.
Endometriosis classification is complex and until better classification systems are developed and validated, ideally all women with endometriosis undergoing surgery should have a correct rASRM score and stage, while women with deep endometriosis (DE) should have an Enzian classification and if there is a fertility wish, the EFI score should be calculated.
A prospective endometriosis classification proof of concept study under experts in deep endometriosis was conducted. A comparison was made between currently used non-digital classification formats for endometriosis versus a newly developed digital classification application (EQUSUM).
PARTICIPANTS/MATERIALS SETTING METHODS: A hypothetical operative endometriosis case was created and summarized in both non-digital and digital form. During European endometriosis expert meetings, 45 DE experts were randomly assigned to the classic group versus the digital group to provide a proper classification of this DE case. Each expert was asked to provide the rASRM score and stage, Enzian and EFI score. Twenty classic forms and 20 digital forms were analysed. Questions about the user-friendliness (system usability scale (SUS) and subjective mental effort questionnaire (SMEQ)) of both systems were collected.
The rASRM stage was scored completely correctly by 10% of the experts in the classic group compared to 75% in the EQUSUM group (<0. 01). The rASRM numerical score was calculated correctly by none of the experts in the classic group compared with 70% in the EQUSUM group (<0.01). The Enzian score was correct in 60% of the classic group compared to 90% in the EQUSUM group (=0.03). EFI scores were calculated correctly in 25% of the classic group versus 85% in the EQUSUM group (<0.01). Finally, the usability measured with the SUS was significantly better in the EQUSUM group compared to the classic group: 80.8 ± 11.4 and 61.3 ± 20.5 (<0.01). Also the mental effort measured with the SMEQ was significant lower in the EQUSUM group compared to the classic group: 52.1 ± 18.7 and 71.0 ± 29.1 (=0.04). Future research should further develop and confirm these initial findings by conducting similar studies with larger study groups, to limit the possible role of chance.
These first results are promising, however it is important to note that this is a preliminary result of experts in DE and needs further testing in daily practice with different types (complex and easy) of endometriosis cases and less experienced gynaecologists in endometriosis surgery.
This is the first time that the rASRM, Enzian and EFI are combined in one web-based application to simplify correct and automatic endometriosis classification/scoring and surgical registration through infographics. Collection of standardized data with the EQUSUM could improve endometriosis reporting and increase the uniformity of scientific output. However, this requires a broad implementation.
STUDY FUNDING/COMPETING INTERESTS: To launch the EQUSUM application, a one-time financial support was provided by Medtronic to cover the implementation cost. No competing interests were declared.
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与非数字分类相比，EQUSUM应用程序对子宫内膜异位症进行电子数字分类/分期在计算评分/分期方面是否更准确，且使用起来是否更便捷？
我们开发了首个用于子宫内膜异位症的数字视觉分类系统（EQUSUM）。该系统融合了目前最常用的三种独立的子宫内膜异位症分类/评分系统（即修订后的美国生殖医学学会（rASRM）、恩齐安和子宫内膜异位症生育指数（EFI）），以实现统一且充分的分类与记录，且易于使用。与非数字分类相比，EQUSUM在正确分类/评分子宫内膜异位症方面有显著改进，并且用户友好性更高。
子宫内膜异位症的分类很复杂，在开发并验证出更好的分类系统之前，理想情况下，所有接受手术的子宫内膜异位症女性都应获得正确的rASRM评分和分期，而深部子宫内膜异位症（DE）女性应进行恩齐安分类，若有生育意愿，则应计算EFI评分。
研究设计、规模、持续时间：在深部子宫内膜异位症专家的参与下进行了一项前瞻性子宫内膜异位症分类概念验证研究。对目前使用的子宫内膜异位症非数字分类格式与新开发的数字分类应用程序（EQUSUM）进行了比较。
参与者/材料、设置、方法：创建了一个假设的手术子宫内膜异位症病例，并以非数字和数字形式进行总结。在欧洲子宫内膜异位症专家会议期间，45名DE专家被随机分配到经典组和数字组，以对该DE病例进行恰当分类。要求每位专家提供rASRM评分和分期、恩齐安和EFI评分。分析了20份经典表格和20份数字表格。收集了关于两个系统用户友好性（系统可用性量表（SUS）和主观心理努力问卷（SMEQ））的问题。
经典组中10%的专家完全正确地给出了rASRM分期，而EQUSUM组为75%（<0.01）。经典组中没有专家正确计算出rASRM数值评分，而EQUSUM组为70%（<0.01）。恩齐安评分在经典组中的正确率为60%，而EQUSUM组为90%（=0.03）。EFI评分在经典组中的正确计算率为25%，而EQUSUM组为85%（<0.01）。最后，与经典组相比，EQUSUM组用SUS测量的可用性显著更好：分别为80.8±11.4和61.3±20.5（<0.01）。同样，与经典组相比，EQUSUM组用SMEQ测量的心理努力也显著更低：分别为52.1±18.7和71.0±29.1（=0.04）。未来的研究应通过对更大的研究群体进行类似研究来进一步发展并证实这些初步发现，以限制机遇可能产生的作用。
局限性、谨慎的原因：这些初步结果很有前景，但需要注意的是，这是DE专家的初步结果，需要在日常实践中对不同类型（复杂和简单）的子宫内膜异位症病例以及经验较少的子宫内膜异位症手术妇科医生进行进一步测试。
这是首次将rASRM、恩齐安和EFI整合到一个基于网络的应用程序中，通过信息图表简化正确且自动的子宫内膜异位症分类/评分及手术记录。使用EQUSUM收集标准化数据可以改善子宫内膜异位症报告，并提高科学产出的一致性。然而，这需要广泛实施。
研究资金/利益冲突：为推出EQUSUM应用程序，美敦力提供了一次性资金支持以支付实施成本。未申报利益冲突。
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