Three‐dimensional model for improvement of endometriosis care (3D‐E)

Endometriosis affects approximately 10% of women of reproductive age and leads to significant morbidity and financial burden. Consequently, countries such as France and Germany are formulating strategies to combat endometriosis. In this study, we propose the implementation of our three‐dimensional model (3D‐E) to raise awareness about endometriosis and enhance timely diagnosis, treatment, and long‐term care for affected patients.


| INTRODUC TI ON
5][6] Based on the knowledge of its chronicity, deterioration of QoL, and consequences, there are calls to action to improve the diagnostic delay and treatment and raise awareness concerning endometriosis in the general population coming from medical and political leaders. 7Therefore, national strategies have been implemented in Australia and European countries such as France to improve the care of patients with endometriosis. 8,9These require political power and financial investment to be implanted, which is not be available in all countries around the world.Hence, we focused on the development of an easily implantable, low-cost three-dimensional model (3D-E) for the improvement of endometriosis care available for health care providers worldwide.

| MATERIAL S AND ME THODS
The methodology of our work was based on the adapted Six Sigma Principle (SSP) and on the modified recommendation of Sales et al.   for implementing evidence-based findings into a clinical routine and establishing models, strategies, and tools. 10,11The model development was divided into five steps according to the SSP.In the first part (Define) the goal was specificized to improve timely care for patients with endometriosis by reducing the delays.
In the second step (Measure), the published literature was reviewed in MEDLINE, the Web of Science, and EBSCO.The abovementioned publications concerning factors leading to diagnostic delay were researched in terms of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol.
Inputted items were: "endometriosis" and "diagnostic delay", with the condition that these items must be included in the title of the study or in the abstract, occurring together in the same article.The original research articles written in English that considered the time of diagnostic delay and risk factors since 2008 (past 15 years) were included.Reviews, comments, and articles were excluded in case they lacked focus on the time factor of the delay or factors contributing to it.In addition, articles reporting diagnostic delay in their background only were not considered.
Risk factors identified by the primary literature were extracted by group according to the provided definitions.An overview is provided in Table 1.In the third step (Analyze) the factors that could be improved by health care providers were identified.Applicable options were selected based on integrability in the clinical routine, cost-effectiveness, and evidence-based principle.
In the fourth step (Implement), the feasible tools for the medical professionals compatible with the daily routine were integrated into the model and incorporated.Furthermore, implemented parts of the model were evaluated in terms of available tools for the particular item (Control).The article was assessed based on the number of downloads and the elective considering the feedback of the students.

| Step 1: Risk factors for diagnostic delay
The initial research found 67 articles mentioning endometriosis and diagnostic delay.Of these, 50 were excluded because they did not meet the inclusion criteria, with 14 being reviews, 20 discussing endometriosis and diagnostic delay only as background and not the goal of the study, one being a corrigendum, one being a case report, and 11 mentioning only one of either endometriosis or diagnostic delay.In addition, one study reporting awareness of general practitioners and two studies not reporting risk factors was excluded, thus 17 papers were selected for the final analysis (Table 1).

| Step 2: Selection of improvable factors by the gynecologist
Taken together, the most discussed diagnostic problem included menstrual cramps being considered normal, especially if started with menarche or presenting at a young age.Targets to combat diagnostic delay were defined as low awareness of endometriosis and not accessible expertise.
Based on SSP, the tool was suggested to improve awareness by providing easily accessible information for and from health care providers on the evidence-based principle that is useful in their clinical routine.Specifically, cost-effective methods were identified using resources already available and simultaneously reaching a broad spectrum of "the decision-makers", i.e. physicians.In addition, nurses and other health care personnel's special abilities, knowledge, and skills above their typical routine could be involved in order to improve the management of patients with endometriosis.

First dimension: Physicians in the system
There were approximately 421 300 physicians providing health care in Germany in the year 2022.The most of them, independently of the specialization, receive weekly the official medical journal of the German Medical Chamber Deutsches Ärzteblatt (Impact Factor in 2022: 8.251; circulation of 392 000 copies weekly).To raise awareness, especially of extragenital endometriosis, which is commonly presented to nongynecological physicians, we wrote a review describing the urogenital, bowel, thoracic, neural, and skin endometriosis; its diagnostics and differential diagnostics; and possible treatment options and published it in the mentioned journal. 25cond dimension: Medical students (physicians to be) There were more than 100 000 medical students of general medicine in 2022 in Germany, from which 2935 attended the Medical Faculty of Ulm University.As a part of the curriculum, the lectures from general gynecology and obstetrics are already integrated.In addition, the students need to collect their credits in the electives as well.In order to deepen their knowledge of endometriosis, we TA B L E 1 Overview of studies discussing diagnostic delay in endometriosis from the past 15 years.started an elective in the winter term of 2022 focused on the significance, medical and social impact of endometriosis, its diagnostics, surgical and hormonal treatment, and the care regarding infertility of patients with endometriosis.The curriculum of our elective is shown in Table 2.

Third dimension: EndoNurse and other medical professionals
The planning and monitoring of the therapeutical process in chronic conditions such as endometriosis as well as consulting requires a central planner.As the workload, not only in the gynecological departments, increases from year to year, a secondary cause of the diagnostic delay could be the time from referral to first meeting in the center.The concept of the patient's managers is already well established, e.g. in breast cancer as Breast Care Nurse.Therefore, the concept of an Endometriosis Care Nurse (EndoNurse) was considered to be integrated into management of the patients.The tasks of the EndoNurse could be to: • perform an initial consultation to evaluate QoL of the patients • provide general evidence-based information about endometriosis In an advanced setting, the EndoNurse could eventually: • oversee adherence to the hormonal treatment, discuss side effects, and check the correct administration • consult individual occasions in the treatment strategy • control the quality of pain management of patients with endometriosis In the consultations in the advanced setting, the high expertise of the EndoNurse would be required, accompanied by close interaction with the endometriosis specialist (physician).In this third dimension is an integrated collaboration with other medical professionals such as physiotherapists, nutritional specialists, sexual therapists, psychologists, and others (Figure 2).The content of our 3D-E model is summarized in Figure 3.

| DISCUSS ION
The global burden of endometriosis is displayed by the deteriorated QoL of affected patients, commonly missed days of work, reduced life-course potential, and high treatment costs. 4,2621]27 Nevertheless, patients with endometriosis must overcome two barriers: first, to be diagnosed, ideally on time; and second, to access effective symptom management throughout an interdisciplinary approach. 8The diagnostic delay in endometriosis has been discussed many times, but since then very little has changed, although there are political activities that are currently targeting combating endometriosis. 8,9terestingly, gynecologists state that even in the 21st century there is a lack of knowledge and awareness in both patients and medical professionals. 15r results show that the adapted information for the needs of medical specialists in their daily routine, which are easily accessible, is welcomed.It can be seen in the regular downloads of our review since the publication, not only in German but in English.We think that within that dimension more could be done.
The event where patients can meet with medical professionals to share needs, possibilities, and limitations on both sides could be beneficial as well.Indeed, patients with endometriosis state that their highest priority on the way to improve endometriosis care is to train health care professionals in order to improve their knowledge about endometriosis. 28This is the target in the first and second dimensions of our model.Focusing on medical students in the electives has shown its benefits in other medical topics. 29 the feedback of our students show, there is much appreciation

F I G U R E 3
The 3D-E model for improvement of endometriosis care and its dimensions with the patient in the middle.
of them for the elective on endometriosis.This easily accessible method to educate students requires planning and time investment of gynecologists teaching at universities or medical schools.
The experience-based learning, and connecting practical and theoretical knowledge in real-life situations are factors that improve students' motivation and learning effect. 30In our case, we offered experience to our students by meeting directly with the patients with endometriosis to hear about their symptoms and participate in their therapeutic planning in the outpatient department as well as advanced endometriosis surgery.
The complexity of the disease requires expertise and resources such as time, as patients wish to have better pain control, to be taken seriously, and to be listened to more. 28The implementation of breast care nurses has already demonstrated the improvement in patients' satisfaction and adherence to therapy in patients with breast cancer. 31similar model could be proposed for endometriosis care that is currently available in the United Kingdom. 32The roles and especially the requirements of the EndoNurse need further specification in order to be certificated and acknowledged as part of the endometriosis care system and provide evidence-based knowledge to the patients.
The limitations of our project is that the real-life impact is difficult to measure, albeit indirectly possible.The students have better knowledge of endometriosis than their peers after intensive participation in our elective, but how it would affect their future medical perspectives is open.The same could be discussed about our paper, in which many doctors were and are still interested.Nevertheless, the EndoNurse project directly targets patients, and its effect will hopefully be seen soon.

| CON CLUS IONS
Furthermore, low awareness led to delay commonly caused by late referral to a specialist, as the patients with endometriosis were seeing a median of five doctors before diagnosis.Other factors discussed were misdiagnosis or covering the diagnosis with the treatment prescribed by general practitioners.Last, the patient factors included body mass index, marital status, age, and number/complexity of symptoms.Identified factors are divided into categories as patients' factors, health-care providers' factors, and mutual factors (Figure 1).

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discuss lifestyle intervention to improve QoL of the patients • provide information about complementary medicine, dietary, and physiotherapeutic interventions, and refer the patients to the specialists in these fields if needed.
Due to information provided by Deutsches Ärzteblatt, our article is regularly downloaded.In 2022 it was accessed 9895 times in German and 163 times in English and between January and May 2023 already 4319 times in German and 135 times in English in addition to the print version.The students showed an extraordinary interest in our elective as its capacity as an elective has since been full and many are waiting to get on the list.In the feedback survey on why they decided to participate, students stated that awareness is very low and the topics about endometriosis are underrepresented in the curriculum in relation to its incidence.Responses of the students in German are found in the Appendix A. The concept of the EndoNurse is currently under development so feedback is not yet available.

F I G U R E 1 TA B L E 2 •
Categories of the factors leading to diagnostic delay in endometriosis.Curriculum of the elective focused on endometriosis in the Medical Faculty of Ulm University, Germany.Medical therapy and treatmenf of infertility Exam: Case-presentation and discussion Diagnostic delay is caused by different factors and has many negative consequences in the life of patients with endometriosis.The 3D-E model could be a low-cost, easily applicable, worldwide tool to work on the rising awareness of endometriosis, providing evidencebased information useful in daily routine for medical professionals and facilitating accessibility of appropriate care for patients with endometriosis.
Components of multidisciplinary care of patients with endometriosis.