Subfertility guidelines in Europe: the quantity and quality of intrauterine insemination guidelines

BACKGROUND

International collaboration could facilitate systematic development of guidelines to regulate and improve clinical practice. To promote European collaboration in guideline development in reproductive medicine, insight into existing subfertility guidelines in Europe is essential. The study aim was to explore the number and quality of clinical practice guidelines on homologous intrauterine insemination (IUI) in Europe.

METHODS

To identify IUI guidelines in Europe, electronic databases and Internet were systematically searched and key experts on assisted reproduction in 25 European countries were questioned. The quality of IUI guidelines was systematically assessed with the internationally validated Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument. Qualitative methods were used to appraise IUI guideline recommendations and references.

RESULTS

National guidelines on IUI are available in four of 25 European countries. The quality of IUI guidelines in Europe is moderate to high, but the recommendations and references differ considerably.

CONCLUSIONS

The number of IUI guidelines in Europe is surprisingly small, and differences in their recommendations and references are considerable. To overcome these deficiencies in clinical guidance on IUI care in Europe, a central body with expertise in up-to-date guideline development methodology and sufficient resources could be established in Europe for central selection and international exchange of evidence to support guideline recommendations.

Loss to follow-up of cervical smears without endocervical columnar cells is not disturbing

OBJECTIVE

To investigate the six-month recommended follow-up after mass screening of Pap smears because of the absence of endocervical columnar cells (ECC-) or ECC+ smears with atypical squamous or glandular cells of undetermined origin (ASCUS/AGUS) or low-grade squamous or glandular intraepithelial lesions (LSIL/LGIL) in a Dutch mass screening cervical cancer programme.

METHODS

Data were extracted from computerised medical records of national representative Dutch general practices. We have studied the attendance at and the outcome of the subsequent Pap smears after a 6-month recommendation.

RESULTS

The six-month follow-up was linked to 8.7% of the Pap smears (n = 1,002); 77.6% were without endocervical columnar cells (ECC-). Clear differences were found between the follow-up of ECC+ and ECC- smears; after 36 weeks of follow-up of 43.5% the women had an ECC- smear and 66.9% had other conditions. For initial ECC- Pap smears, 84.1% had no abnormalities in the subsequent Pap smear; for initial ECC+ Pap smears, in about 64% of the cases no abnormalities were found (p < 0.0001).

CONCLUSIONS

Repeating ECC- smears has a low follow-up rate but also lacks evidence-based necessity. However, for the other 6-month recommended Pap smears, one in five women had still not responded within one year, so improvement is necessary.

Follow-up of abnormal or inadequate cervical smears using two guidance systems: RCT on effectiveness

BACKGROUND

To improve follow-up compliance after an initial inadequate or abnormal cervical smear, two follow-up guidance systems were tested for effectiveness. A comprehensive system (cytopathology laboratory monitored the follow-up of all abnormal and inadequate smears) was compared to a selective system (monitoring was left to the smear taker; laboratory acted as a safety net).

METHODS

In an RCT on all family practices (N = 171) in the catchment areas of two cytopathology laboratories (Nijmegen region, The Netherlands, 1998-2000), practices were allocated at random to one of the follow-up guidance systems. All women included were registered at the practices, invited to the national screening program and had abnormal or inadequate smears. Measurements comprised of (1) follow-up compliance at baseline and 1 year after the initial smear and (2) diagnostic outcome of the follow-up smear.

RESULTS

During the study period, 132 practices sent their cervical smears to the laboratories. The comprehensive system covered 1226 women, the selective 1034. In the comprehensive system, the increase in follow-up compliance for initial inadequate and slightly abnormal smears was significantly higher (8.9%) than in the selective one, which implied an extra detection of eleven, more serious, abnormalities per 1000 women.

CONCLUSION

The comprehensive system was more effective than the selective and is suitable for use on a larger scale.

Barriers to physician adherence to a subfertility guideline

BACKGROUND

Guidelines aim to improve clinical practice but are not self-implementing. Insight into barriers to physician guideline adherence is crucial for development of effective implementation strategies. The study aim was to identify barriers to physician adherence to an intrauterine insemination (IUI) guideline of the Dutch Society of Obstetrics and Gynaecology.

METHODS

We conducted a cross-sectional survey among all Dutch gynaecologists, residents and fertility physicians (n = 860), using written questionnaires that were based on information obtained in focus group discussions. We investigated barriers related to physicians' knowledge and attitudes, and external barriers.

RESULTS

The response rate was 65%. We used 344 questionnaires for analysis. Physicians' knowledge was adequate, with a median unfamiliarity rate with each of the 31 key guideline recommendations of 12%. Physicians' attitudes were generally positive, especially regarding guideline development and quality. Important attitude-related barriers included physicians' lack of self-efficacy regarding physician-patient communication and poor outcome expectancy. External barriers were mostly related to specific patient characteristics and associated with higher age of physicians and fewer consultations for fertility problems per week.

CONCLUSIONS

Multiple barriers impede physician adherence to subfertility guidelines, mainly physicians' lack of self-efficacy and low outcome expectancy. Both physicians and patients play an important role in future implementation interventions to optimize subfertility care.

How should preconceptional cystic fibrosis carrier screening be provided? Opinions of potential providers and the target population

BACKGROUND

Since the identification of the cystic fibrosis (CF) gene, large-scale CF carrier screening has become possible. One possible target group is couples planning a pregnancy (preconceptional screening), providing a maximum number of reproductive options and a minimum of time constraints.

OBJECTIVES

To identify obstacles in the implementation of a preconceptional CF carrier screening programme, to find out how potential providers and the target population think the screening should be implemented, and to determine whether potential providers think they are able to provide the screening programme.

METHODS

A survey was conducted among 200 general practitioners (GPs), 134 Municipal Health Service (MHS) workers and 303 recently married couples.

RESULTS

52% (102/197) of the eligible GPs participated, 84% (113/134) of the MHS workers and 70% (380/544) of the individuals planning a pregnancy. In general, potential providers and the target population had a positive attitude towards CF screening. Preferred methods of informing the target population were: in leaflets, during a GP consultation for those people seeking advice before pregnancy, and sending a personal invitation to all people of reproductive age. Potential providers believed that they would be able to provide the screening programme. Important perceived obstacles were the absence of a preconceptional care setting, high workload, and lack of financial resources.

CONCLUSION

Different intervention strategies will be necessary to overcome the obstacles in the implementation. The positive attitude towards CF carrier screening in combination with the willingness of the potential providers to participate in the screening programme will make it easier to overcome the obstacles.

Preconceptional Cystic Fibrosis Carrier Screening: Attitudes and Intentions of the Target Population

The aim of this study was to assess the attitudes and intentions of individuals planning a pregnancy with regard to preconceptional cystic fibrosis (CF) carrier screening and to determine factors associated with a positive and negative/neutral intention to have the test. A survey, based on a questionnaire, was conducted among a stratified random sample of 303 recently married couples (606 individuals). Of the eligible individuals, 70% (n = 380) participated. Of the respondents, 73% had a positive attitude toward a routine offer of preconceptional CF carrier screening, and 56% had the intention to participate in a screening program. A positive intention to have the test was associated with high perceived anticipation of regret, intended preconceptional behavior, high perceived pressure from experts, high perceived consequences of the test results, low perceived barriers, and low perceived negative consequences for family members. These results suggest that the offer of routine preconceptional CF carrier screening would lead to substantial acceptance among couples planning a pregnancy. Several variables related with intention were identified.

Impact of nurse practitioners on workload of general practitioners: randomised controlled trial

OBJECTIVE

To examine the impact on general practitioners' workload of adding nurse practitioners to the general practice team.

DESIGN

Randomised controlled trial with measurements before and after the introduction of nurse practitioners.

SETTING

34 general practices in a southern region of the Netherlands.

PARTICIPANTS

48 general practitioners.

INTERVENTION

Five nurses were randomly allocated to general practitioners to undertake specific elements of care according to agreed guidelines. The control group received no nurse.

MAIN OUTCOME MEASURES

Objective workload, derived from 28 day diaries, included the number of contacts per day for each of three conditions (chronic obstructive pulmonary disease or asthma, dementia, cancer), by type of consultation (in practice, telephone, home visit), and by time of day (surgery hours, out of hours). Subjective workload was measured by using a validated questionnaire. Outcomes were measured six months before and 18 months after the intervention.

RESULTS

The number of contacts during surgery hours increased in the intervention group compared with the control group (P < 0.06), particularly for patients with chronic obstructive pulmonary disease or asthma (P < 0.01). The number of consultations out of hours declined slightly in the intervention group compared with the control group, but this difference did not reach significance. No significant changes became apparent in subjective workload.

CONCLUSION

Adding nurse practitioners to general practice teams did not reduce the workload of general practitioners, at least in the short term. This implies that nurse practitioners are used as supplements, rather than substitutes, for care given by general practitioners.