When evaluating clinical healthcare quality using a single indicator, a medical center may excel in one aspect while underperform in others. This "focus on a single point" evaluation method may not provide a comprehensive reflection of the overall healthcare services[11, 12, 20]. Therefore, it is essential to adopt a multidimensional assessment for surgical treatment. This composite evaluation approach was initially proposed by The Society for Thoracic Surgeons and further summarized by O'Brien et al[21], describing it as the "all-or-none" TO indicator[22, 23]. Our results indicated that 85.0% of patients with a CSP in our study achieved a TO. For patients with a CSP undergoing surgical treatment, safe surgery can be considered when there are few postoperative complications, the hospital stay is short, and there is no need for readmission. Surgery is deemed effective when the gestational sac is completely removed without intraoperative complications. The aforementioned target variables were included in the definition of a TO in this study. Our results indicate that severe postoperative complications and a postoperative hospital stay exceeding 7 days were the main obstacles in achieving a TO in patients with a CSP. Therefore, clinical practitioners should strive to reduce the occurrence of severe postoperative complications and shorten hospital stays.
Furthermore, a better understanding of the factors that lead to a TO may help healthcare providers enhance postoperative management, improve healthcare quality, and reduce hospital costs[24, 25]. A TO provides treatment feedback for healthcare providers and serves as a basis for improving healthcare services. This provides patients with more information to aid in making informed decisions when choosing healthcare services. Hospitals can utilize TO data to assess the success rate of treatments, potentially facilitating enhancements in quality standards. Incorporating TO data can guide selective decisions by consolidating metrics on patient safety, treatment effectiveness, and operational efficiency.
In this study, we found that both individual patient and surgical factors influenced the likelihood of achieving a TO in patients with a CSP. Specifically, patients with a history of cesarean section at a primary hospital and diagnosed with CSP type III often face increased surgical difficulties, such as an increased risk of intraoperative adhesions or bleeding. Excessive intraoperative blood loss can prolong postoperative recovery time and decrease the likelihood of achieving a TO. When treating high-risk patients, clinical practitioners should strive to develop minimally invasive and tailored treatments. For instance, HIFU is a highly safe and effective treatment for patients[26–28] with a CSP owing to its non-invasive, non-ionizing nature and minimal damage to other organs[29, 30]. Additionally, hysteroscopic evacuation can reduce damage to the normal uterine tissue and prevent blind curettage. Our results show that using these two methods together can minimize patient harm and aid patients with a CSP to more easily achieve a TO.
Although the recurrence rate for a CSP is relatively low, some patients opt out of future pregnancies because of fear of recurrence[31, 32]. However, our results indicate that patients who achieved a TO showed a significantly stronger desire for future pregnancies than those in the non-TO group. This could be attributed to receiving higher-quality healthcare services, faster postoperative recovery, and consequently, greater confidence in future pregnancies. However, these findings warrant further prospective studies.
To the best of our knowledge, this study is the first to comprehensively assess the treatment outcomes of CSP patients using the TO concept. This study has some limitations. First, it was a retrospective study conducted at a single center, with a relatively small sample size and incomplete data collection, which may introduce certain inherent biases that could not be entirely avoided. Second, the TO definition in this study primarily references from the field of oncology. In the future, we anticipate making adjustments and improvements to the definition of TO based on the specific characteristics of patients with a CSP in further large-sample studies. Finally, a TO is a composite index consisting of individual components without weighted comparisons between different outcome variables, thereby lacking clear data or reasons to demonstrate the usefulness and necessity of these weights. Therefore, adding any weight to the TO measurement is subjective and reduces its simplicity and usefulness. Nonetheless, the indicators included in this study for a TO are the clinical factors that patients are concerned about and those that doctors pay attention to, indicating that a TO, as a composite index composed of simple indicators, possesses good generalizability and strong reproducibility in the real world. Most importantly, we confirmed the potential of a TO as an evaluation tool for assessing the medical quality of patients with a CSP. We look forward to conducting prospective studies to validate our findings.