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Lehmann CU, Adams WG, Chaparro JD, Fiks AG, Grout RW, Leu MG, Mendonca EA, Michel JJ, Okechukwu K, Salmon J, Sharifi M, Downs SM. Better Guidelines and Policies: AAP's Partnership for Policy Implementation. Pediatrics 2024; 154:e2023061360. [PMID: 38864111 DOI: 10.1542/peds.2023-061360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 04/17/2024] [Accepted: 04/17/2024] [Indexed: 06/13/2024] Open
Abstract
OBJECTIVES In 2005, the American Academy of Pediatrics founded the Partnership for Policy Implementation (PPI). The PPI has collaborated with authors to improve the quality of clinical guidelines, technical reports, and policies that standardize care delivery, improve care quality and patient outcomes, and reduce variation and costs. METHODS In this article, we describe how the PPI trained informaticians apply a variety of tools and techniques to these guidance documents, eliminating ambiguity in clinical recommendations and allowing guideline recommendations to be implemented by practicing clinicians and electronic health record (EHR) developers more easily. RESULTS Since its inception, the PPI has participated in the development of 45 published and 27 in-progress clinical practice guidelines, policy statements, technical and clinical reports, and other projects endorsed by the American Academy of Pediatrics. The partnership has trained informaticians to apply a variety of tools and techniques to eliminate ambiguity or lack of decidability and can be implemented by practicing clinicians and EHR developers. CONCLUSIONS With the increasing use of EHRs in pediatrics, the need for medical societies to improve the clarity, decidability, and actionability of their guidelines has become more important than ever.
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Affiliation(s)
- Christoph U Lehmann
- Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas
| | - William G Adams
- Boston Medical Center/BU Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Juan D Chaparro
- Department of Pediatrics, The Ohio State University College of Medicine; Division of Clinical Informatics, Nationwide Children's Hospital, Columbus, Ohio
| | - Alexander G Fiks
- Clinical Futures (A Research Institute Center of Emphasis) and Department of Biomedical Informatics, Children's Hospital of Philadelphia; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Randall W Grout
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana Regenstrief Institute, Inc, Indianapolis, Indiana
| | - Michael G Leu
- Departments of Pediatrics and Biomedical Informatics and Medical Education and UW Medicine IT Services, University of Washington, Seattle, Washington Seattle Children's Hospital, Seattle, Washington
| | - Eneida A Mendonca
- Cincinnati Children's Hospital Medical Center, and Departments of Pediatrics and Biomedical Informatics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jeremy J Michel
- Department of Biomedical Informatics, Children's Hospital of Philadelphia; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania ECRI Guidelines Trust, ECRI, Plymouth Meeting, Pennsylvania
| | | | | | - Mona Sharifi
- Department of Pediatrics, Center for Medical Informatics, Center for Implementation Science, Yale University School of Medicine, New Haven, Connecticut
| | - Stephen M Downs
- Department of Pediatrics and Center for Biomedical Informatics, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Lin H, Li Y, Ou S, Jiao X, Wang W, Haahr T, Humaidan P, Zhang Q. The relationship of total progressive motile sperm count with the outcome of IUI? An analysis of 5171 cycles. Gynecol Endocrinol 2022; 38:954-959. [PMID: 36271782 DOI: 10.1080/09513590.2022.2126453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Background: The role of motile sperm count in intrauterine insemination (IUI) success rate is controversial. This retrospective cohort study performed among unselected infertile couples undergoing IUI was to explore the association between the total progressive motile sperm count (TPMSC) and the live birth rate (LBR) following IUI.Methods: The total cohort of 5363 cycles, 2666 infertile couples between January 2015 and December 2018 and finally 5171 cycles, 2647 couples were included for analysis in Sun Yat-sen memorial hospital of Sun Yat-sen University. The primary outcome was LBR per cycle. And the secondary outcome measure was clinical pregnancy rate (CPR) per cycle.Results: From the receiver operating characteristic (ROC) analysis of female age predicting live birth, female age cutoff was defined as 28 years. With a female age of ≤28 years, the CPRs were 11.5%, 14.9%, 16.1%, and 15.8% in quartile groups of pre-wash TPMSC, respectively. For the LBRs the values were 9.4%, 12.9%, 14.4%, and 11.3%, and there were also no significant differences in quartile groups of pre-wash TPMSC with ≤24 million (M), [24M-50M], [50M-97M], >97M. No statistically significant differences in the CPRs (p = .051) and LBRs (p = .088) were also observed in the quartiles groups of post-wash TPMSC. With a female age of >28 years, the CPR in couples with post-wash TPMSC ≤22.32 M was significantly lower than with post-wash TPMSC >81.0 M (p = .007). There was an obvious trend in which CPRs and LBRs increased with the post-wash TPMSC during the <81 M interval in women >28 years.Conclusions: The optimal female age cutoff for live birth was 28 years in IUI cycles. Pre-wash and post-wash TPMSC were not significantly associated with CPR and LBR per cycle. When female age >28 years, there was a better outcome with post-wash TPMSC >22.32 million.
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Affiliation(s)
- Haiyan Lin
- Reproductive Center, Department of Gynecology and Obstetrics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yu Li
- Reproductive Center, Department of Gynecology and Obstetrics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Songbang Ou
- Reproductive Center, Department of Gynecology and Obstetrics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xuedan Jiao
- Reproductive Center, Department of Gynecology and Obstetrics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wenjun Wang
- Reproductive Center, Department of Gynecology and Obstetrics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Thor Haahr
- The Fertility Clinic, Skive Regional Hospital, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Qingxue Zhang
- Reproductive Center, Department of Gynecology and Obstetrics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
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Smits R, D'Hauwers K, IntHout J, Braat D, Fleischer K. Impact of a nutritional supplement (Impryl) on male fertility: study protocol of a multicentre, randomised, double-blind, placebo-controlled clinical trial (SUppleMent Male fERtility, SUMMER trial). BMJ Open 2020; 10:e035069. [PMID: 32616489 PMCID: PMC7333867 DOI: 10.1136/bmjopen-2019-035069] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/23/2020] [Accepted: 05/13/2020] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Infertility is a worldwide problem and about 10%-15% of all couples will be affected by the inability to have children. In approximately 50% of infertile couples, a male factor is involved. Most of the male infertile cases are characterised as 'idiopathic', except for a small percentage of cases which are causative by a genetic aetiology. In the past decade, the role of oxidative stress related to sperm quality has been researched thoroughly and estimated to be the problem in 25%-87% of male infertility cases. Impryl is a nutritional supplement which works on the metabolic system and the regulation of oxidative stress by activating the 1-carbon cycle and therefore recycling of homocysteine. We hypothesise that the nutritional supplement Impryl in men of infertile couples might improve the ongoing pregnancy rate. METHODS AND ANALYSIS We designed a multicentre, randomised, double-blind, placebo-controlled clinical trial. We aimed to include 1200 male adults aged 18-50 years, part of a couple that is diagnosed with infertility. The couple will either start or has already been started with fertility treatment, that is, expectative management (duration of 6 months), intrauterine insemination (IUI) with or without mild ovarian stimulation or ovulation induction, either in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) treatment. Male participants will be randomised in either the Impryl or the placebo group, with identical appearance of the tablets to be distributed (doses: one tablet each day), for a total duration of maximal 6 months. Patients can start directly with fertility treatment and/or natural conception. The primary outcome is the number of ongoing pregnancies confirmed by ultrasound at ≥10 to 12 weeks, and conceived in the time window between randomisation up to and including month 6 of intervention use. Secondary outcomes are change in semen parameters between baseline and after 3 months of intervention in the IUI/IVF/ICSI group, based on (prewash) total motile sperm count. Furthermore the number of pregnancies conceived in the optimal intervention time window (after full spermatogenesis of 72 days), overall number of pregnancies, time to pregnancy, embryo fertilisation rate in IVF/ICSI, embryo-utilisation rate in IVF/ICSI, number of miscarriages, live birth rate and adverse events are documented within the study period of 15 months. ETHICS AND DISSEMINATION The protocol is approved by the local medical ethical review committee at the Radboud University Medical Centre and by the national Central Committee on Research Involving Human Subjects. Findings will be shared with the academic and medical community, funding and patient organisations in order to contribute to optimisation of medical care and quality of life for patients with infertility. TRIAL REGISTRATION NUMBERS NCT03337360 and NTR6551.
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Affiliation(s)
- Roos Smits
- Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
| | | | - Joanna IntHout
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Didi Braat
- Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
| | - Kathrin Fleischer
- Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
- MVZ VivaNeo Kinderwunschzentrum, Dusseldorf, Germany
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Which key performance indicators are most effective in evaluating and managing an in vitro fertilization laboratory? Fertil Steril 2020; 114:9-15. [PMID: 32532495 DOI: 10.1016/j.fertnstert.2020.04.054] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 04/28/2020] [Indexed: 02/09/2023]
Abstract
The laboratory is the heart of an in vitro fertilization (IVF) clinic, and a quality management system is critical for its administration. We review the main structural, process, and outcome key performance indicators (KPIs) to provide laboratory managers with concrete tools aimed at enhancing the quality of their work. Three concepts must be stressed when dealing with KPIs in IVF: [1] always consider the three types of indicators (structural, process, and outcome related), [2] carefully adapt the control chart to either promptly identify issues and adopt corrective measures, or redefine the control limits in a process called "progress building," [3] consider that achieving a healthy live birth is a multidisciplinary effort that is subject to several confounders, which must be recognized and accounted for in the analyses. In this regard, future KPIs shared among clinicians and embryologists are desirable to enhance the quality of infertility care for IVF patients.
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Lemmens L, Kos S, Beijer C, Braat DDM, Jonker MA, Nelen WLDM, Wetzels AMM. Optimization of laboratory procedures for intrauterine insemination: survey of methods in relation to clinical outcome. Andrology 2018; 6:707-713. [PMID: 29959833 DOI: 10.1111/andr.12510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 05/14/2018] [Accepted: 05/16/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is a wide practice variation of used methods and outcomes in IUI in fertility laboratories. Standardization of the IUI procedure is important for reducing inconsistency among laboratories in counseling infertile couples and in pregnancy results. The aim of the study was to evaluate the currently used laboratory procedures of IUI in Dutch fertility laboratories and their effect on IUI pregnancy results. Additionally, the methods for semen analysis (SA) were evaluated, as SA is related to IUI in terms of inseminated sperm number and IUI counseling. MATERIAL AND METHODS This questionnaire survey study was sent to laboratories participating in the Dutch external quality control program for semen analysis (SKML) and consisted of 46 questions concerning laboratory management, methods for semen analysis and IUI, and clinical results. The results were analyzed using univariable and multivariable logistic regression models. RESULTS A total of 52 laboratories (out of 99) provided information on used methodologies for SA or laboratory procedures of IUI and the organization of the laboratory. A wide variability was confirmed in used methods for both SA and IUI. Evaluation of pregnancy results obtained during 3 years (2013-2015) showed that specific used laboratory methods have a significant effect on the probability of becoming pregnant. DISCUSSION AND CONCLUSION Important to remark is that in this survey study cycle-specific data, including variables of the individual couples (age, stimulation protocol, etc), were not included and may have effects on the results. The reported results provide an overview of the current practice performance; however, the organization of fertility laboratories is changing rapidly. The use of standardized methods in IUI is important for optimizing the performance of care and improving pregnancy results. The knowledge on used procedures, however, is limited, and further research on factors involving SA and the IUI procedure is necessary.
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Affiliation(s)
- L Lemmens
- Fertility Laboratory, Department of Obstetrics and Gynaecology, Radboud university medical center, Nijmegen, The Netherlands
| | - S Kos
- Department of Clinical Chemistry, Maasstad Hospital, Rotterdam, The Netherlands
| | - C Beijer
- Department of Clinical Chemistry, Atalmedial, Medical Diagnostic Centre, Amsterdam, The Netherlands
| | - D D M Braat
- Department of Obstetrics and Gynaecology, Radboud university medical center, Nijmegen, The Netherlands
| | - M A Jonker
- Department for Health Evidence, Radboud university medical center, Nijmegen, The Netherlands
| | - W L D M Nelen
- Department of Obstetrics and Gynaecology, Radboud university medical center, Nijmegen, The Netherlands
| | - A M M Wetzels
- Fertility Laboratory, Department of Obstetrics and Gynaecology, Radboud university medical center, Nijmegen, The Netherlands
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Lemmens L, Kos S, Beijer C, Braat DDM, Nelen WLDM, Wetzels AMM. Techniques used for IUI: is it time for a change? Hum Reprod 2018; 32:1835-1845. [PMID: 28854719 DOI: 10.1093/humrep/dex223] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 06/04/2017] [Indexed: 12/29/2022] Open
Abstract
STUDY QUESTION Are the guidelines for the technical aspects of IUI (WHO, 2010) still in accordance with the current literature? SUMMARY ANSWER In general, the laboratory guidelines of the World Health Organization (WHO) are a suitable protocol, although the evidence is not always conclusive and some changes are advisable. WHAT IS KNOWN ALREADY Lack of standardization of the technical procedures required for IUI might result in inter-laboratory variation in pregnancy rates. Most centers still use their own materials and methods even though some guidelines are available. STUDY DESIGN, SIZE, DURATION A structural review focusing on the association between pregnancy rates and the procedures of semen collection (e.g. ejaculatory abstinence, collection place), semen processing (e.g. preparation method, temperature during centrifugation/storage), insemination (e.g. timing of IUI, bed rest after IUI) and the equipment used. PARTICIPANTS/MATERIALS, SETTING, METHODS A literature search was performed in Medline and the Cochrane library. When no adequate studies of the impact of a parameter on pregnancy results were found, its association with sperm parameters was reviewed. MAIN RESULTS AND THE ROLE OF CHANCE For most variables, the literature review revealed a low level of evidence, a limited number of studies and/or an inadequate outcome measure. Moreover, the comparison of procedures (i.e. semen preparation technique, time interval between semen, collection, processing and IUI) revealed no consensus about their results. It was not possible to develop an evidence-based, optimal IUI treatment protocol. LIMITATIONS, REASONS FOR CAUTION The included studies exhibited a lack of standardization in inclusion criteria and methods used. WIDER IMPLICATIONS OF THE FINDINGS This review emphasizes the need for more knowledge about and standardization of assisted reproduction technologies. Our literature search indicates that some of the recommendations in the laboratory guidelines could be adapted to improve standardization, comfort, quality control and to cut costs. STUDY FUNDING/COMPETING INTEREST(S) The Dutch Foundation for Quality Assessment in Medical Laboratories (SKML), Nijmegen, The Netherlands. S.K. and W.N. have no conflicts of interest to disclose. C.B. and A.W. are members of the board of the SKML. With a grant from SKML, L.L. was paid for her time to perform the research and write the publication. D.B. received grants from Merck Serono, Ferring and MSD, outside the submitted work. REGISTRATION NUMBER N/A.
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Affiliation(s)
- L Lemmens
- Fertility Laboratory, Department of Obstetrics and Gynaecology, Radboud University Medical Center Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - S Kos
- Department of Clinical Chemistry, Maasstad Hospital Rotterdam, PO Box 9100, 3007 AC Rotterdam, The Netherlands
| | - C Beijer
- Department of Clinical Chemistry, Atalmedial, Medical Diagnostic Centre, PO Box 69641, 1060 CR Amsterdam, The Netherlands
| | - D D M Braat
- Department of Obstetrics and Gynaecology, Radboud University Medical Center Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - W L D M Nelen
- Department of Obstetrics and Gynaecology, Radboud University Medical Center Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - A M M Wetzels
- Fertility Laboratory, Department of Obstetrics and Gynaecology, Radboud University Medical Center Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands
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Peeraer K, Luyten J, Tomassetti C, Verschueren S, Spiessens C, Tanghe A, Meuleman C, Debrock S, Dancet E, D'Hooghe T. Cost-effectiveness of ovarian stimulation with gonadotrophin and clomiphene citrate in an intrauterine insemination programme for subfertile couples. Reprod Biomed Online 2018; 36:302-310. [DOI: 10.1016/j.rbmo.2017.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 11/29/2017] [Accepted: 12/08/2017] [Indexed: 11/17/2022]
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van den Boogaard E, Hermens RPMG, Franssen AMHW, Doornbos JPR, Kremer JAM, van der Veen F, Goddijn M. Recurrent miscarriage: do professionals adhere to their guidelines. Hum Reprod 2013; 28:2898-904. [DOI: 10.1093/humrep/det329] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Dancet EAF, D'Hooghe TM, Spiessens C, Sermeus W, De Neubourg D, Karel N, Kremer JAM, Nelen WLDM. Quality indicators for all dimensions of infertility care quality: consensus between professionals and patients. Hum Reprod 2013; 28:1584-97. [PMID: 23508250 DOI: 10.1093/humrep/det056] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
STUDY QUESTION What is the relative importance of the six dimensions of quality of care according to different stakeholders and can a quality indicator set address all six quality dimensions and incorporate the views from professionals working in different disciplines and from patients? SUMMARY ANSWER Safety, effectiveness and patient centeredness were the most important quality dimensions. All six quality dimensions can be assessed with a set of 24 quality indicators, which is face valid and acceptable according to both professionals from different disciplines and patients. WHAT IS KNOWN ALREADY To our knowledge, no study has weighted the relative importance of all quality dimensions to infertility care. Additionally, there are very few infertility care-specific quality indicators and no quality indicator set covers all six quality dimensions and incorporated the views of professionals and patients. STUDY DESIGN, SIZE AND DURATION A three-round iterative Delphi survey including patients and professionals from four different fields, conducted in two European countries over the course of 2011 and 2012. PARTICIPANTS/MATERIALS, SETTINGS AND METHODS Dutch and Belgian gynaecologists, embryologists, counsellors, nurses/midwifes and patients took part (n = 43 in round 1 and finally 30 in round 3). Respondents ranked the six quality dimensions twice for importance and their agreement was evaluated. Furthermore, in round 1, respondents gave suggestions, which were subsequently uniformly formulated as quality indicators. In rounds 2 and 3, respondents rated the quality indicators for preparedness to measure and for importance (relation to quality and prioritization for benchmarking). Providing feedback allowed selecting indicators based on consensus between stakeholder groups. Measurable indicators, important to all stakeholder groups, were selected for each quality dimension. MAIN RESULTS All stakeholder groups and most individuals agreed that safety, effectiveness and patient centeredness were the most important quality dimensions. A total of 498 suggestions led to the development of 298 indicators. Professionals were sufficiently prepared to measure 204 of these indicators. Based on importance, 52 (7-15 per dimension; round 2) and finally 24 (4 per dimension; round 3) quality indicators were selected. LIMITATIONS, REASONS FOR CAUTION The final quality indicator set does not cover the entire care process, but rather takes a 'sample' of each quality dimension. Although the quality indicators are face valid and acceptable, their psychometric characteristics need to be tested by further research. WIDER IMPLICATIONS OF THE FINDINGS Quality management should focus on safety, effectiveness and patient centeredness of care. Clinics can use the quality indicator set to assess all quality dimensions of their care.
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Affiliation(s)
- E A F Dancet
- Leuven University Hospital, Leuven University Fertility Centre, Herestraat 49, Leuven 3000, Belgium
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den Breejen EME, Nelen WLDM, Schol SFE, Kremer JAM, Hermens RPMG. Development of guideline-based indicators for patient-centredness in fertility care: what patients add. Hum Reprod 2013; 28:987-96. [DOI: 10.1093/humrep/det010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Haagen EC, Nelen WLDM, Adang EM, Grol RPTM, Hermens RPMG, Kremer JAM. Guideline adherence is worth the effort: a cost-effectiveness analysis in intrauterine insemination care. Hum Reprod 2012. [PMID: 23202990 DOI: 10.1093/humrep/des408] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
STUDY QUESTION Is optimal adherence to guideline recommendations in intrauterine insemination (IUI) care cost-effective from a societal perspective when compared with suboptimal adherence to guideline recommendations? SUMMARY ANSWER Optimal guideline adherence in IUI care has substantial economic benefits when compared with suboptimal guideline adherence. WHAT IS KNOWN ALREADY Fertility guidelines are tools to help health-care professionals, and patients make better decisions about clinically effective, safe and cost-effective care. Up to now, there has been limited published evidence about the association between guideline adherence and cost-effectiveness in fertility care. STUDY DESIGN, SIZE, DURATION In a retrospective cohort study involving medical record analysis and a patient survey (n = 415), interviews with staff members (n = 13) and a review of hospitals' financial department reports and literature, data were obtained about patient characteristics, process aspects and clinical outcomes of IUI care and resources consumed. In the cost-effectiveness analyses, restricted to four relevant guideline recommendations, the ongoing pregnancy rate per couple (effectiveness), the average medical and non-medical costs of IUI care, possible additional IVF treatment, pregnancy, delivery and period from birth up to 6 weeks after birth for both mother and offspring per couple (costs) and the incremental net monetary benefits were calculated to investigate if optimal guideline adherence is cost-effective from a societal perspective when compared with suboptimal guideline adherence. PARTICIPANTS/MATERIALS, SETTING, METHODS Seven hundred and sixty five of 1100 randomly selected infertile couples from the databases of the fertility laboratories of 10 Dutch hospitals, including 1 large university hospital providing tertiary care and 9 public hospitals providing secondary care, were willing to participate, but 350 couples were excluded because of ovulatory disorders or the use of donated spermatozoa (n = 184), still ongoing IUI treatment (n = 143) or no access to their medical records (n = 23). As a result, 415 infertile couples who started a total of 1803 IUI cycles were eligible for the cost-effectiveness analyses. MAIN RESULTS AND THE ROLE OF CHANCE Optimal adherence to the guideline recommendations about sperm quality, the total number of IUI cycles and dose of human chorionic gonadotrophin was cost-effective with an incremental net monetary benefit between € 645 and over € 7500 per couple, depending on the recommendation and assuming a willingness to pay € 20 000 for an ongoing pregnancy. LIMITATIONS, REASONS FOR CAUTION Because not all recommendations applied to all 415 included couples, smaller groups were left for some of the cost-effectiveness analyses, and one integrated analysis with all recommendations within one model was impossible. WIDER IMPLICATIONS OF THE FINDINGS Optimal guideline adherence in IUI care has substantial economic benefits when compared with suboptimal guideline adherence. For Europe, where over 144,000 IUI cycles are initiated each year to treat ≈ 32 000 infertile couples, this could mean a possible cost saving of at least 20 million euro yearly. Therefore, it is valuable to make an effort to improve guideline development and implementation.
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Affiliation(s)
- E C Haagen
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
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Hermens RPMG, Haagen EC, Nelen WLDM, Tepe EM, Akkermans R, Kremer JAM, Grol RPTM. Patient and hospital characteristics associated with variation in guideline adherence in intrauterine insemination care. Int J Qual Health Care 2011; 23:574-82. [PMID: 21676961 DOI: 10.1093/intqhc/mzr027] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To assess the association of patient and hospital characteristics with adherence to guidelines for intrauterine insemination (IUI) care. DESIGN Retrospective cohort study using multilevel regression analysis. Characteristics studied at the patient level were female age, type and duration of subfertility, diagnosis and number of started IUI cycles. At the hospital level, the characteristics studied were hospital size, teaching hospital, in vitro fertilization (IVF) licence and number of physicians involved in the IUI programme. Data were obtained from medical records and questionnaires for gynaecologists. SETTING AND PARTICIPANTS Five hundred and fifty-eight subfertile couples who underwent IUI treatment at 10 Dutch hospitals. MAIN OUTCOME MEASURES Adherence to systematically developed guideline-based performance indicators describing 20 processes of IUI care. RESULTS A total of 558 couples who started 2,334 IUI cycles participated. Guideline adherence in IUI care was often substandard and varied considerably between hospitals. Variation in guideline adherence in IUI care was associated with the patient characteristics 'diagnosis' and 'female age'. Only adherence to the guideline recommendation regarding 'screening for tubal occlusion' was associated with hospital characteristics ('hospital size' and 'IVF licence'). Large explained variances up to 39% were found for the different models. CONCLUSIONS A number of patient and hospital characteristics were associated with variation in guideline adherence in IUI care, particularly the patient characteristics 'diagnosis' and 'female age'. The identification of different subgroups in the patient population and different types of hospitals with regard to the extent of guideline adherence in IUI care is important for the tailoring of interventions to improve IUI care.
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Affiliation(s)
- Rosella P M G Hermens
- 1Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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van den Boogaard E, Hermens RPMG, Verhoeve HR, Kremer JAM, van der Veen F, Knegt AC, Goddijn M. Selective karyotyping in recurrent miscarriage: are recommended guidelines adopted in daily clinical practice? Hum Reprod 2011; 26:1965-70. [DOI: 10.1093/humrep/der179] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Brandes M, Hamilton CJCM, van der Steen JOM, de Bruin JP, Bots RSGM, Nelen WLDM, Kremer JAM. Severity of oligo-asteno-teratozoospermia no longer determines overall success rate in male subfertility. ACTA ACUST UNITED AC 2011; 34:614-23. [PMID: 21449983 DOI: 10.1111/j.1365-2605.2010.01128.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In this longitudinal multicentre cohort study, the overall ongoing pregnancy rate after current evidence-based management in male subfertility was studied. All subfertile couples who visited the fertility clinic for the first time between 2002 and 2006, and had male subfertility as a single diagnosis (n = 762 of 2476 couples), were included in this study. Couples were grouped by the severity of male factor. Group I (n = 541) had a total motile sperm count (TMSC) 1-20 × 10(6). Group II (n = 161) had a TMSC <1 × 10(6). Group III (n = 60) had azoospermia. The overall ongoing pregnancy rate was 65.5% (500/762). The overall ongoing pregnancy rates in group I (69.3%) and group II (61.5%) were comparable (p = 0.06). However, group I and group II conceived significantly more frequently than group III (43.3%) (group I vs. group III p < 0.001 and group II vs. group III p = 0.02, respectively). Moreover, the spontaneous ongoing pregnancy rate in group I was 35.3%, in group II 22.4% and in group III, 1.7% (group I vs. group II p = 0.002; group I vs. group III p < 0.001; group II vs. group III p < 0.001). Thus, despite a significant difference in spontaneous ongoing pregnancy rates, except for azoospermia, the overall ongoing pregnancy rates, regardless of the severity of the male factor, were comparable. Couples with poorer sperm parameters, however, have to undergo more invasive treatment to reach the same goal.
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Affiliation(s)
- M Brandes
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands.
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Brandes M, Hamilton CJCM, van der Steen JOM, de Bruin JP, Bots RSGM, Nelen WLDM, Kremer JAM. Unexplained infertility: overall ongoing pregnancy rate and mode of conception. Hum Reprod 2010; 26:360-8. [DOI: 10.1093/humrep/deq349] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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