Patients' preferences, experiences and expectations with wait time until surgery in gynaecological oncology: a mixed-methods study in two gynaecological oncological centres in the Netherlands

OBJECTIVES

Patient-centredness of care during wait time before surgery can be improved. In this study we aimed to assess (1) patients' experiences with and preferences regarding wait time before surgery; (2) the impact of wait time on quality of life (QoL) and (3) which factors influence patients' wait time experience.

DESIGN, SETTING, PARTICIPANTS

We performed an exploratory sequential mixed-methods study among women with gynaecological cancer in two tertiary hospitals. We conducted semistructured interviews and identified aspects of QoL and factors that influenced wait time acceptability through thematic analysis. We developed a questionnaire from this thematic analysis which was completed by 97 women. Descriptive statistics and univariate and multivariate regression analyses were performed.

RESULTS

Average ideal wait time was 3.5 weeks (±1.7 weeks), minimum and maximum acceptable wait times were 2.2 and 5.6 weeks. Many patients scored above the threshold of the Hospital Anxiety and Depression Scale for anxiety (48%) or depression (34%), had sleeping problems (56%) or experienced pain (54%). A number of factors were more common in patients who indicated that their wait time had been too long: low education level (OR 7.4, 95% CI 0.5 to 5.0, p=0.007), time to surgery >4 weeks (OR 7.0, 95% CI 0.8 to 4.4, p=0.002) and experienced sleep disturbance (OR 3.27, 95% CI 0.0 to 3.1, p=0.05). If patients expectation of wait time was >4 weeks (OR 0.20, 95% CI -4.0 to -0.5 p=0008) or if patients experienced pain (OR 0.26, 95% CI -3.6 to -0.3, p=0.03), they less frequently indicated that wait time had been too long.

CONCLUSION

To improve patient-centredness of care, healthcare providers should aim to reduce wait time to 3-4 weeks and ensure that patients are well informed about the length of wait time and are aware of high levels of anxiety, depression and pain during this time. Future studies should evaluate what interventions can improve QoL during wait time.

Improving IVF Utilization with Patient-Centric Artificial Intelligence-Machine Learning (AI/ML): A Retrospective Multicenter Experience

Objectives: In vitro fertilization (IVF) has the potential to give babies to millions more people globally, yet it continues to be underutilized. We established a globally applicable and locally adaptable IVF prognostics report and framework to support patient-provider counseling and enable validated, data-driven treatment decisions. This study investigates the IVF utilization rates associated with the usage of machine learning, center-specific (MLCS) prognostic reports (the Univfy® report) in provider-patient pre-treatment and IVF counseling. Methods: We used a retrospective cohort comprising 24,238 patients with new patient visits (NPV) from 2016 to 2022 across seven fertility centers in 17 locations in seven US states and Ontario, Canada. We tested the association of Univfy report usage and first intra-uterine insemination (IUI) and/or first IVF usage (a.k.a. conversion) within 180 days, 360 days, and "Ever" of NPV as primary outcomes. Results: Univfy report usage was associated with higher direct IVF conversion (without prior IUI), with odds ratios (OR) 3.13 (95% CI 2.83, 3.46), 2.89 (95% CI 2.63, 3.17), and 2.04 (95% CI 1.90, 2.20) and total IVF conversion (with or without prior IUI), OR 3.41 (95% CI 3.09, 3.75), 3.81 (95% CI 3.49, 4.16), and 2.78 (95% CI 2.59, 2.98) in 180-day, 360-day, and Ever analyses, respectively; p < 0.05. Among patients with Univfy report usage, after accounting for center as a factor, older age was a small yet independent predictor of IVF conversion. Conclusions: Usage of a patient-centric, MLCS-based prognostics report was associated with increased IVF conversion among new fertility patients. Further research to study factors influencing treatment decision making and real-world optimization of patient-centric workflows utilizing the MLCS reports is warranted.

What do women undergoing in vitro fertilization (IVF) understand about their chance of IVF success?

STUDY QUESTION

How well informed are Australian women who undergo IVF about their chances of having a baby?

SUMMARY ANSWER

Only one in four women estimated their individual chance of success with IVF accurately, with most women overestimating their chance.

WHAT IS KNOWN ALREADY

Limited knowledge about infertility and infertility treatment in the general population is well-documented. The few studies that have investigated patients' knowledge about the chance of IVF success suggest that while IVF patients are aware of average success rates, they tend to be unrealistic about their own chance of success.

STUDY DESIGN, SIZE, DURATION

We conducted an anonymous online survey of 217 women who had started IVF since 2018 in Australia. The survey was advertised on social media, enabling women from across Australia to participate. Responses were collected in June 2021.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The survey included questions on demographic characteristics and IVF history. It asked what participants thought their chance of having a baby from one IVF treatment cycle was, how they rated their knowledge about chance of success, and about their experience of receiving IVF-related information. Participants' estimations of their chance of success were compared with their chance as calculated by the Society for Assisted Reproductive Technology's (SART) online calculator. Responses to a free-text question about what information women wished they had been given when they started treatment were analysed thematically.

MAIN RESULTS AND THE ROLE OF CHANCE

Only about a quarter (58/217, 27%) of participants accurately estimated their chance of having a baby within 20% relative to their SART calculated chance, with more than half (118/217, 54%) overestimating their chance. Ninety percent of women indicated that their preferred source of treatment information was a consultation with their doctor, despite less than half (44%) reporting that doctors explained the probability of having a baby with IVF well (mean 5.9/10). In free-text responses, many women also reported that they wished they had been given more realistic information about IVF and their chance of success.

LIMITATIONS, REASONS FOR CAUTION

The dissemination method precludes calculation of response rate, and it is not possible to know if participants are representative of all women undergoing IVF. Additionally, we only surveyed women undergoing IVF, while those who decided not to have IVF were not included. Therefore, women who overestimated their chance may have been overrepresented. There is also inherent imprecision in the way understanding of chance of success was estimated. The potential impact of recall bias could neither be quantified nor excluded. It is difficult to determine to what extent women's lack of understanding of what is possible with IVF is due to poor information-provision by clinicians and the clinic, and how much can be explained by optimism bias.

WIDER IMPLICATIONS OF THE FINDINGS

The finding of poor understanding of personal chance of success amongst women undergoing IVF in Australia requires further investigation to determine potential reasons for this. The findings can be used by clinics to develop strategies for improvement in the information-provision process to ensure that women can make informed decisions about their fertility treatment.

STUDY FUNDING/COMPETING INTEREST(S)

This study received no external funding. S.L. is supported by a NHMRC Investigator Grant (APP1195189). R.W. is supported by a NHMRC Investigator Grant (APP2009767). B.W.M. is supported by a NHMRC Investigator Grant (GNT1176437). B.W.M. reports consultancy for Merck and ObsEva and has received research funding and travel funding from Merck. The other authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Evaluation of oncofertility care in childhood cancer patients: the EU-Horizon 2020 twinning project TREL initiative

Background

The 5-year survival rate of childhood cancer exceeds 80%, however, many survivors develop late effects including infertility. The aim of this study was to evaluate the current status of oncofertility care at Vilnius University Hospital Santaros Klinikos (VULSK) within the framework of the EU-Horizon 2020 TREL project.

Methods

All parents or patients aged 12-17.9 years treated from July 1, 2021 until July 1, 2022 were invited to complete an oncofertility-care-evaluation questionnaire. After completing the questionnaire, patients were triaged to low-risk (LR) or high-risk (HR) of gonadal damage using a risk stratification tool (triage). Data was assessed using descriptive statistics.

Results

Questionnaires were completed by 48 parents and 13 children triaged as 36 (59%) LR and 25 (41%) HR patients. Most HR respondents (21/25, 84%) were not counseled by a fertility specialist. Six boys (4 HR, 2 LR) were counseled, none of the girls was counseled. Three HR boys underwent sperm cryopreservation. Only 17 (27.9%, 9 HR, 8 LR) respondents correctly estimated their risk. All counseled boys (n = 6) agreed the risk for fertility impairment had been mentioned as compared to 49.1% (n = 27) of uncounseled. All counseled respondents agreed they knew enough about fertility (vs. 42%).

Conclusions

Respondents counseled by a fertility specialist were provided more information on fertility than uncounseled. HR patients were not sufficiently counseled by a fertility specialist. Based on the current experience oncofertility care at VULSK will be improved.

The PCQ-Infertility Revised: A New Digital Instrument to Measure Treatment Satisfaction of Fertility Patients

Background

One of the key dimensions of healthcare quality is patient-centeredness, which represents how well healthcare is geared towards patients' needs and wishes. Many questionnaires that measure the patient-centeredness are long and complicated, eliciting non-response or careless responding. Moreover, responses to some commonly used questionnaires are difficult to interpret. The Patient-Centeredness Questionnaire-Infertility (PCQ-Infertility) is used to measure the patient's experience of fertility healthcare quality. The aim of this study was to improve the PCQ-Infertility to allow large-scale clinical implementation.

Methods

The study was performed in three parts. First, shortcomings of the original PCQ-Infertility were identified by evaluation of expert opinions. Second, the number of items were reduced, and items were rescaled and rephrased. Third, 844 patients filled in the original PCQ-Infertility and 260 patients filled in the revised PCQ-Infertility and reliability analyses were performed. In addition, a confirmatory factor analysis was performed on the revised PCQ-Infertility.

Results

The number of items in the revised questionnaire was reduced by 24% (from 51 to 39 items), which increased the internal consistency and reliability. The reliability analyses and confirmatory factor analysis indicated high consistency and convergent validity in all seven dimensions (accessibility, information, communication, patient involvement, respect for patient's values, continuity and transition, and competence) of the revised PCQ-Infertility.

Conclusion

The revised PCQ-Infertility is a more valid and reliable instrument than the original PCQ-Infertility, easier to interpret and shorter. Therefore, large-scale clinical implementation and data analysis are now possible, giving the opportunity for fertility care professionals to evaluate and improve their healthcare.

Real-world assessment of the patient-centredness of endometriosis care: European countries benchmarked by patients

European patients cross the borders of their countries to receive more patient-centred healthcare. Benchmarking across European countries for the patient-centredness of endometriosis care had yet to be performed. This study proved the factorial structure and reliability of translation of the ENDOCARE questionnaire in nine different languages. Moreover, the benchmark potential of the ENDOCARE questionnaire was shown by the significant between-country variance for case-mix-adjusted overall and dimensional patient-centredness scores, explaining 3-9% of the total variance in patient-centredness assessed across 10 European countries. Compared with the least patient-centred country, endometriosis care was more patient-centred in Denmark, Italy and Belgium. 'Reaching a diagnosis quickly' and 'physicians demarcating the endometriosis complexity level which they can treat' were consistently rated of more-than-average importance and were experienced negatively by more than half of the European sample. National and European policymakers and specialized clinics are prompted to monitor their patient-centredness and set up improvement projects.

Web-based Guidance for Assisted Reproductive Technology With an Online App (myFertiCare): Quantitative Evaluation With the HOT-fit Framework

BACKGROUND

Assisted reproductive technologies (ARTs) are considered to be physically and mentally stressful. During their treatment trajectory, couples express high information and communication needs. They appreciate using the internet to obtain fertility-related information. In a previous study, we developed myFertiCare, an eHealth tool providing personalized information and interactive functionalities for infertile couples in order to improve patient-centered care. The app has already been successful in qualitative evaluations of usability.

OBJECTIVE

The aim of the current study is to quantitatively evaluate the implementation of myFertiCare by using the human, organizational, and technology-fit (HOT-fit) framework and to study the effects of using myFertiCare on couples' knowledge about infertility, their experience of the burden of infertility, and their experience of patient-centered care. With these results, implementation can be further improved, and patient-centered care can be enhanced.

METHODS

A quantitative study was performed based on the HOT-fit framework using validated questionnaires focusing on the human, organizational, and technology domains. Questions were added on the effect of using myFertiCare on couples' knowledge about infertility and treatment. Questions regarding the burden of infertility, the burden of infertility treatment, and the experience of patient-centeredness were based on the main items of the validated fertility quality of life (FertiQoL) and Patient-Centredness Questionnaire-Infertility questionnaires, respectively. Also, nonusers of the app were included to explore motivations for not using the app and identify opportunities for improvement. Finally, user data were analyzed to provide insight into multiple variables concerning app use.

RESULTS

In the human and technology domains, myFertiCare showed good system usability, high user satisfaction, and high information and interface quality. In the organizational domain, implementation was considered to be sufficient by both patients and staff. Use of the app increased knowledge about the treatment, improved coping with the treatment, and enhanced the experience of patient-centeredness. User data showed that women were the main app users and that use of the app gradually declined during the treatment trajectory.

CONCLUSIONS

A multi-faceted online app, myFertiCare, has been successfully evaluated quantitatively for implementation by using the HOT-fit framework. Use of the app increased knowledge about the treatment, improved coping with the treatment, and enhanced the experience of patient-centeredness. App use could be improved by creating more publicity. By providing myFertiCare, professionals in fertility care are supported in guiding patients through their treatment trajectory and in delivering patient-centered care.

Development of a questionnaire to evaluate female fertility care in pediatric oncology, a TREL initiative

Background

Currently the five-year survival of childhood cancer is up to 80% due to improved treatment modalities. However, the majority of childhood cancer survivors develop late effects including infertility. Survivors describe infertility as an important and life-altering late effect. Fertility preservation options are becoming available to pre- and postpubertal patients diagnosed with childhood cancer and fertility care is now an important aspect in cancer treatment. The use of fertility preservation options depends on the quality of counseling on this important and delicate issue. The aim of this manuscript is to present a questionnaire to determine the impact of fertility counseling in patients suffering from childhood cancer, to improve fertility care and evaluate what patients and their parents or guardians consider good fertility care.

Methods

Within the framework of the EU-Horizon 2020 TREL project, a fertility care evaluation questionnaire used in the Netherlands was made applicable for international multi-center use. The questionnaire to be used at least also in Lithuania, incorporates patients’ views on fertility care to further improve the quality of fertility care and counseling. Results evaluate fertility care and will be used to improve current fertility care in a national specialized pediatric oncology center in the Netherlands and a pediatric oncology center in Lithuania.

Conclusion

An oncofertility-care-evaluation questionnaire has been developed for pediatric oncology patients and their families specifically. Results of this questionnaire may contribute to enhancement of fertility care in pediatric oncology in wider settings and thus improve quality of life of childhood cancer patients and survivors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09450-2.

Fertility Workup With Video Consultation During the COVID-19 Pandemic: Pilot Quantitative and Qualitative Study

BACKGROUND

Due to the COVID-19 pandemic, major parts of elective health care in the Netherlands, such as reproductive medicine, were paused. When health care was resumed, video consultation was used as a new solution to continue consultations with the new governmental rules of social distancing. Prior to this COVID-19 situation, video consultation was not used extensively in the Netherlands; therefore, physicians and patients are not familiar with this way of consultation.

OBJECTIVE

The purpose of this study was to measure the level of patient centeredness and shared decision making in infertile couples who have undergone fertility workup through video consultation.

METHODS

This is a questionnaire study with an additional qualitative part for a more in depth understanding. Infertile couples (ie, male and female partners with an unfulfilled wish for a child after 1 year of unprotected intercourse) were referred to a fertility center and underwent fertility workup through video consultation. The fertility workup consisted of 2 separate video consultations, with diagnostic tests according to a protocol. After the last video consultation couples received a digital questionnaire, which consisted of a modified version of the Patient-Centered Questionnaire-Infertility (PCQ-I) and CollaboRATE questionnaire. Fifty-three eligible infertile couples were approached, and of these, 22 participated. Four women were approached for a semistructured interview.

RESULTS

The median score on the modified PCQ-I (scale of 0 to 3) was 2.64. The highest rating was for the subscale communication and information, and the lowest rating was for the subscale organization of care. The median score on the CollaboRATE questionnaire (scale of 1 to 9) was 8 for all 3 subquestions. Patients mentioned privacy, less travel time, and easy use of the program as possible benefits of video consultation. However, patients preferred the first consultation with their physician to be face-to-face consultation as video consultation was considered less personal.

CONCLUSIONS

The high levels of patient centeredness and shared decision making show that video consultation is a promising way of providing care remotely, although attention has to be payed to mitigate the more impersonal setting of video consultation when compared with face-to-face consultation.

Patient-centered infertility questionnaire for female clients (PCIQ-F): part I: questionnaire development

BACKGROUND

Patient-centered care is an essential component of health care quality. To achieve patient-centered care, health care authorities should have a clear definition and an applicable tool to measure the extent of its application. The real concept of patient centeredness should be developed by the patients themselves. We aimed to demonstrate a way to develop a draft Arabic patient-centered infertility care (PCIC) questionnaire for females clients following practical steps that address women with infertility.

METHODS

An iterative process of questionnaire development was undertaken by combining two approaches: the steps proposed by Robert F. DeVellis for scale development and the recommended practices for questionnaire development and testing in the European statistical system. We attempted to develop the draft questionnaire that involved conceptualization and operationalization, generation of an item pool, development of the questionnaire format, review of the initial item pool by experts, and consideration of validation items for inclusion.

RESULTS

We generated an item pool from in-depth interviews with 14 women who sought infertility care within 6 months before the interview time. We then added more items from a literature review. The item pool contained 123 items distributed through 10 domains. Ten women with infertility were included for face validation. Then, experts with backgrounds in Obstetrics and Gynecology, Family Medicine, and Public Health reviewed the item pool using content validation (n = 10 professors and/or specialists). The item pool was finally reduced to 57 items. We developed the draft Arabic patient-centered infertility care questionnaire for female clients (PCIQ-F) with three sections, including 66 items: background variables, PCIC experience variables, and a general question about the quality of infertility care in the health facility. The draft questionnaire was further reviewed and edited last by experts in preparation for part 2, which will test the questionnaire and prepare the final version.

CONCLUSION

The PCIQ-F questionnaire development is a multi-step iterative process started and ended by the target users as experts. Experts' participation in infertility care and in questionnaire format development had a great impact on questionnaire development and conflict resolution. We recommend this transparent and replicable approach for new instrument developers; it is likely to generate a questionnaire that is valid and acceptable to target users. The draft PCIQ-F questionnaire is ready for testing of its psychometric properties before the final version to measure the PCIC level in health facilities.

Web-Based Guidance Through Assisted Reproductive Technology (myFertiCare): Patient-Centered App Development and Qualitative Evaluation

BACKGROUND

Providing patient-centered fertility care is known to improve quality of life and can reduce anxiety and depression. In a previous study, we established the need for a web-based app providing personalized information and interactive functionalities among couples undergoing intracytoplasmic sperm injection with surgically retrieved sperm.

OBJECTIVE

This study aimed to design, develop, and qualitatively evaluate a multifaceted web-based app for infertile couples undergoing intracytoplasmic sperm injection with surgically retrieved sperm during their treatment trajectory.

METHODS

The web-based app was developed in three phases: (1) we established a patient-centered functional design, (2) developed the app in collaboration with medical and technical professionals, and (3) qualitatively evaluated the app among couples using a think-aloud method.

RESULTS

The basis of the app is the couple's visualized treatment trajectory. The app provides personalized and interactive functionalities; for example, customized information and communication options. During qualitative evaluation, myFertiCare was highly appreciated and received a median score of 8 out of 10. The main improvements made upon conclusion of the think-aloud sessions were related to faster login and easier app navigation.

CONCLUSIONS

A patient-centered web-based app aimed at guiding couples through their fertility treatment course was systematically designed, developed, and positively evaluated by patients and medical and technical professionals.

Educational needs of fertility healthcare professionals using ART: a multi-country mixed-methods study

RESEARCH QUESTION

What are the most pressing educational needs of fertility healthcare professionals using assisted reproductive technologies (ART)?

DESIGN

This mixed-methods study combined qualitative interviews with quantitative surveys. Participants included physicians and nurses specialized in reproductive endocrinology or in obstetrics/gynaecology, and laboratory specialists, with a minimum of 3 years of experience, practising in Australia, Brazil, Canada, China, France, Germany, India, Italy, Japan, Mexico, Spain or the UK. Maximum variation purposive sampling was used to ensure a mix of experience and settings. Interviews were transcribed and coded through thematic analysis. Quantitative data were analysed using frequency tables, cross-tabulations and chi-squared tests to compare results by reimbursement context.

RESULTS

A total of 535 participants were included (273 physicians, 145 nurses and 117 laboratory specialists). Knowledge gaps, skills gaps and attitude issues were identified in relation to: (i) ovarian stimulation (e.g. knowledge of treatments and instruction protocols for ovarian stimulation), (ii) embryo culture and cryopreservation/vitrification (e.g. diverging opinions on embryo freezing, (iii) embryo assessment (e.g. performing genetic testing), (iv) support of luteal phase and optimizing pregnancy outcomes (e.g. knowledge of assessment methods for endometrial receptivity), and (v) communication with patients (e.g. reluctance to address emotional distress).

CONCLUSIONS

This descriptive, exploratory study corroborates previously reported gaps in fertility care and identifies potential causes of these gaps. Findings provide evidence to inform educational programmes for healthcare professionals who use ART in their practice and calls for the development of case-based education and interprofessional training programmes to improve care for patients with fertility issues.

Patient-centred infertility care among Arab women experiencing infertility: a qualitative study

OBJECTIVE

The current study aims to define patient-centred infertility care (PCIC) from the perspective of Arab women with infertility.

DESIGN

Semistructured in-depth telephone interviews.

SETTING

Hospitals providing infertility care, Jeddah, Saudi Arabia.

PARTICIPANTS

Arab women who received infertility treatment during the 6 months preceding the interview at any hospital in Jeddah, Saudi Arabia. Interviews were conducted with Arab women experiencing infertility from January 2017 to December 2018. A purposive sample of 14 women were included in the final analysis with maximum variation.

RESULTS

Participants highlighted nine important PCIC dimensions. Of these, four were agreed on by all participants: accessibility, minimising cost, information and education, and staff attitudes and communication. The remaining five dimensions were staff competence, physical comfort, privacy, psychological and emotional support, and continuity and coordination of care. The concept of PCIC was related to three major contributors: participants' demographics, patient experience with infertility care and health-seeking behaviour.

CONCLUSIONS

The current study provided nine PCIC dimensions and items, which can guide efforts to improve the quality of infertility care in Arab countries in two ways: first, by raising infertility care providers' awareness of their patients' needs, and second, by developing a validated tool based on the dimensions for measuring PCIC from Arab patients' perspective. Clear differences between the Arab and the European PCIC model were found. Our findings concluded that women continued to exhibit basic unmet needs.

A systematic review and secondary analysis of two studies identifying demographic and medical characteristics determining patient-centeredness in endometriosis care as experienced by patients

STUDY QUESTION

What are the patient-specific determinants associated with patient-centered endometriosis care as measured by the ENDOCARE questionnaire (ECQ)?

SUMMARY ANSWER

‘Overall grade for endometriosis care’, ‘educational level’, ‘membership of a patient organization’ and ‘having seen other specialists for endometriosis complaints’ are correlated with overall patient-centeredness scores (PCS).

WHAT IS KNOWN ALREADY

Patient-centeredness of endometriosis care can be evaluated using the validated ECQ. The ECQ leads to an overall PCS and separate PCS for 10 dimensions of endometriosis care. Previously, educational level and quality of life scores were found to be associated with ECQ results.

STUDY DESIGN, SIZE, DURATION

First, a systematic literature review was performed (PROSPERO registration number: CRD42020169872). MEDLINE, Cochrane CENTRAL and EMBASE databases were searched from inception to May 2020 for studies in any language reporting on the results of the ECQ in patients with endometriosis. Two studies were identified. From the two studies, all original data were merged. In total, data from 546 patients were available for analysis. Second, univariate and multivariate regression analyses were performed to identify determinants for patient-centeredness of endometriosis care.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The two included studies evaluated patient-centeredness in four endometriosis care centers in Belgium and the Netherlands. All participants had surgically proven endometriosis. Possible patient-specific determinants were selected from the demographic and medical questions from the first part of the ECQ. These determinants were evaluated using linear regression analysis and all possible determinants with a P > 0.2 in the univariate analysis were selected for stepwise multivariate analysis. Separate analyses were performed for overall PCS and each of the 10 dimensions.

MAIN RESULTS AND THE ROLE OF CHANCE

The two included studies provided data from 546 patients. After adjustment for care center, multivariate analysis showed that a higher ‘grade for endometriosis care’ (B = 0.66), a ‘lower educational level’ (B = 0.50), ‘being member of a patient organization’ (B = 0.49) and ‘having seen other specialists for endometriosis complaints’ (B = 0.34) were independently associated with higher overall PCS (R² = 0.41). ‘Grade for endometriosis care’ was a determinant for all dimensions of endometriosis care. ‘Having seen other specialists for endometriosis complaints’ was positively associated with the care dimensions ‘respect for patients’ values, preferences and expressed needs’, ‘continuity and transition’ and ‘technical skills’. Members of a patient organization showed higher scores on the care dimensions ‘emotional support and alleviation of fear and anxiety’, ‘continuity and transition’ and ‘endometriosis clinic staff’. Furthermore, we found that having a higher level of education is associated with lower scores in the care dimensions ‘physical comfort’, ‘emotional support and alleviation of fear and anxiety’ and ‘involvement of significant other’.

LIMITATIONS, REASONS FOR CAUTION

These results delineate the patient-specific determinants of patient-centered care as measured using the Dutch ECQ. Whether results are generalizable to other countries should be investigated in an international study. This requires the ECQ to be validated in other languages first.

WIDER IMPLICATIONS OF THE FINDINGS

The aforementioned determinants of patient-centered care are of value for studies benchmarking clinics for their patient-centeredness. In addition, they help clinicians to determine how to tailor their care to individual patients. At every visit, patients could be asked to grade the endometriosis care (on a scale of 0–10) to easily investigate patient-centeredness. When there is more time, women with endometriosis should be asked to complete the entire ECQ to investigate patient-centeredness in depth.

STUDY FUNDING/COMPETING INTEREST(S)

The department of reproductive medicine (involving C.B.L. and V.M.) of the Amsterdam UMC, Vrije Universiteit Amsterdam has received several research and educational grants from Guerbet, Merck and Ferring. The authors have no conflict of interest related to this manuscript.

Patient-centered care in Israeli IVF units: divergent perceptions of patients and providers

Background

Patient-centered care is particularly important for patients undergoing fertility treatment because of their emotional involvement and their constant contact with providers. To the best of our knowledge, to date, there have been no rigorous studies of the discrepancies between the patients’ perceptions of the care they received and the providers’ perceptions of the care that they provided, in specific dimensions and elements of patient-centered care.

Objective

To compare provider and patient perceptions of the extent to which care in Israeli IVF units is patient-centered.

Methods

A previously validated survey instrument was used to assess the patient and provider perceptions of ten dimensions of patient-centered care: accessibility of providers, provision of information and of explanations, communication skills of providers, patient involvement in the treatment, respect for patient values and needs, continuity and transition in treatment, professional competence, care organization, physical comfort, and emotional support. The patient survey and the provider survey were conducted in 2016–2017; both surveys were carried out in 8 of 25 hospital-based IVF units in Israel. Seventy-six providers and 524 patients (response rate 79%) participated in the surveys.

Findings

The perceptions of patients and providers were similar regarding seven of the ten dimensions of patient-centered care, although there were some differences in patient vs. provider scores by unit. There were three dimensions with substantial provider-patient score differences: Moderate-sized gaps were found relative to the provision of information and explanations (1.96 vs. 2.38, on a 0–3 scale) and respect for patient values and needs (1.92 vs. 2.47). A large gap was observed relative to emotional support (0.96 vs. 2.54).

Conclusions

Providers appear to underestimate the needs of fertility treatment patients for information, respect, and emotional support. The observed differences between what patients feel about their care and what providers assume they provide, especially regarding emotional support, indicates a need for ongoing, specific feedback to providers as to the patient-centeredness of the care they provide. The particularly large patient – provider gap relative to the provision of emotional support highlights the importance of increasing the attention paid to the psychological impact of fertility treatment and of giving patients an opportunity to consult a counselor who is familiar with problems associated with fertility treatments.

Policy recommendations

Efforts to improve the patient-centeredness in FT should begin by establishing a national ongoing feedback mechanism, involving all 25 IVF units operating in Israel working in collaboration with the Ministry of Health. The findings from this joint effort should be shared with the public. In addition, we recommended appointing one professional in each IVF unit to be in charge of promoting improvements in the patient-centered care for that unit. Assigning a mental health professional (psychologist or social worker) to each and every IVF unit is also of crucial importance.

Infertility Management and Pharmacotherapy: What Every Pharmacist Should Know

Infertility is a significant public health concern in the United States. As such, utilization of infertility services, including pharmacotherapeutic treatments, is prevalent, and the role of the pharmacist as part of the health care team is essential. Pharmacists can assist patients by providing education on infertility causes, risk factor mitigation, referrals, nonpharmacologic and pharmacologic management options, navigation of the prescription process, and resource availability for the significant financial burden accompanying infertility treatment. In-depth pharmacotherapeutic information may not be readily available to pharmacists dispensing and counseling on these medications, and infertility management regimens are often varied and complicated requiring more in-depth counseling on use and administration. Given the complexity of infertility management, pharmacists are a valuable patient support and education resource. This article provides an in-depth review of infertility management strategies, both nonpharmacologic and pharmacologic.

Communication and Respect for Patient Value as Significant Factors in Patient-Centered Infertility Care: A Survey of Patients' Experiences in Two Infertility Centers

Context:

The patient-centered infertility care (PCIC) approach emphasizes the patient's role in choosing the most appropriate clinical approach in infertility care. The concept can improve the patient satisfaction with care performed as well as the efficacy of the treatment. In addition, this concept can also lead to improve collaboration between patient and care provider, ultimately supporting a more cost-effective health-care scheme.

Aims:

This study was developed in order to determine patients' experience in their PCIC.

Settings and Design:

This is a descriptive study. We conducted the study in two fertility care clinics, Clinic A and Clinic B.

Subjects and Methods:

The Patient-Centeredness Questionnaire-Infertility (PCQ-I) was used, consisting of 7 essential themes. The questionnaire was completed by consenting patients in two infertility clinics.

Statistical Analysis Used:

The questionnaire was analyzed using the Statistical Package for the Social Sciences 21 version statistical software.

Results:

Eighty-eight Clinic A patients who completed the questionnaire responded that the best element of their treatment received was communication (correlation with global score [CGS]: 0.747), whereas the least acceptable aspect was the low accessibility (CGS: 0.211). A total of 20 Clinic B patients responded that the best element of their treatment received was respect for the patient's value (CGS: 0.866), whereas the least acceptable aspect was also the low level of accessibility (CGS: 0.193).

Conclusions:

The PCQ-I can be used to evaluate patients' experience during treatment and may help the health-care provider to improve their performance.

A mental health program for infertile couples undergoing oocyte donation: protocol for a mixed methods study

Background

The psychological consequences of infertility in couples undergoing oocyte donation differ culturally, racially, religiously, and legally from other infertile couples undergoing assisted reproductive treatments. Therefore, the inclusion of a mental health program in assisted reproductive services is essential for these couples. As such, the aim of this study is to develop a program for improving the mental health of these couples.

Methods

This study is designed using an exploratory mixed method and the program based on Talbot and Verrinder model. Different steps of this research include determination of a specific topic for planning (needs assessment), initial design of the program, finalization of the program (using the views of experts in this area), implementation of the program, monitoring of the implementation of the program and evaluation of the program. To perform the first step of Talbot’s program, the first phase of the study will be conducted. At first, through a qualitative study, the items of the questionnaire are designed and then its psychometric steps will be performed by a cross-sectional study. In the second and third steps, the classic Delphi technique will be used in four-round for initiation and finalization of the program, and the second phase will be completed. The fourth, fifth and sixth steps of the program including implementation, monitoring of the implementation and evaluation of the program in the future will be performed.

Discussion

Designing an appropriate program based on the documentations of the qualitative study and evidence can improve the mental health and quality of life of the couples undergoing oocyte donation. The program, based on the measurement of needs, will be implemented using a tool designed specifically for the target population and can be useful in the processes of treatment, education, policymaking and legislation as well as research.

Preferred problem solving and decision-making role in fertility treatment among women following an unsuccessful in vitro fertilization cycle

Background

While the literature on healthcare decision-making has long focused on doctor-patient interaction, fertility treatment is an exception, characterized by a triangular interplay between the doctor, the woman and her partner. This study examined treatment decision-making preferences of women undergoing in vitro fertilization (IVF) treatment, following an unsuccessful IVF cycle, especially their preferred level of doctor and spousal involvement.

Methods

A cross-sectional survey was conducted with 246 Chinese women undergoing IVF recruited from an assisted reproduction clinic of a university-affiliated hospital in Hong Kong. Data collection was conducted between January 2014 and August 2015.

Results

Most participants preferred sharing the decision-making tasks with their doctors (92%). In the doctor-patient relationship, passive roles were associated with higher marital satisfaction, presence of religious affiliation and secondary infertility, while autonomous roles were related to female-factor infertility. Fifty-two percent of participants anticipated sharing decision-making, while 46% preferred handing over the decision to their husbands. Preference for a passive rather than a shared role in the spousal relationship was related to a higher husband’s age, greater marital satisfaction and higher anxiety.

Conclusions

In brief, women tended to prefer sharing decision-making tasks with their doctor as well as actively engaging their partner in making decisions about fertility treatment. This study adds to our understanding of women’s role preference and level of involvement in infertility treatment decision-making by providing quantitative evidence from women’s experience. It highlights the importance of healthcare professionals in facilitating shared decision-making among couples.

Validation of the Rainbow Model of Integrated Care Measurement Tools (RMIC-MTs) in renal care for patient and care providers

INTRODUCTION

Integrated service delivery is considered to be an essential condition for improving the management and health outcomes of people with chronic kidney disease (CKD). However, research on the assessment of integrated care by patients and care providers is hindered by the absence of brief, reliable, and valid measurement tools.

OBJECTIVE

The aim of this study was to develop survey instruments for healthcare professionals and patients based on the Rainbow Model of Integrated Care (RMIC), and to evaluate their psychometric properties.

DESIGN

The development process was based on the US Food and Drug Administration guidelines. This included item generation from systematic reviews of existing tools and expert opinion on clarity and content validity, involving renal care providers and chronic kidney patients. A cross-sectional, multi-centre design was used to test for internal consistency and construct validity.

SETTING

Outpatient clinics in a large renal network.

PARTICIPANTS

A sample of 30.788 CKD patients, and 8.914 renal care providers.

METHODS AND ANALYSIS

Both survey instruments were developed using previous qualitative work and published literature. A multidisciplinary expert panel assessed the face and content validity of both instruments and following a pilot study, the psychometric properties of both instruments were explored. Exploratory factor analysis with principal axis factoring and with promax rotation was used to assess the underlying dimensions of both instruments; Cronbach's alpha was used to determine the internal constancy reliability.

RESULTS

17.512 patients (response rate: 56.9%) and 8.849 care providers (response rate: 69.5%) responded to the questionnaires. Factor analysis of the patient questionnaire yielded three internally consistent (Cronbach's alpha > 0.7) factors: person-centeredness, clinical coordination, and professional coordination. Factor analysis of the provider questionnaire produced eight internally consistent (Cronbach's alpha > 0.7) factors: person-centeredness, community centeredness, clinical coordination, professional coordination, organisational coordination, system coordination, technical and cultural competence. As hypothesised, care coordination patient and providers scores significantly correlated with questions about quality of care, treatment involvement, reported health, clinics' organisational readiness, and external care coordination capacity.

CONCLUSION

This study provides evidence for the reliability and validity of the RMIC patient and provider questionnaires as generic tools to assess the experience with or perception of integrated renal care delivery. The instruments are recommended in future applications testing test-retest reliability, convergent and predictive validity, and responsiveness.

Independent and Web-Based Advice for Infertile Patients Using Fertility Consult: Pilot Study

Background

Patient-centered care—that is, care tailored to personal wishes and needs of patients—has become increasingly important. It is especially relevant in health care areas where patients suffer from a high burden of disease, such as fertility care. At present, both diagnosis and treatment for infertile couples is provided at a single hospital. As a consequence, patients are not likely to receive optimal, independent advice regarding their fertility problems. Internet-based, independent advice could be feasible for large groups of patients because it is not limited by travel distance and overhead costs.

Objective

The aim of this study was to explore the experiences of both patients and professionals with an online platform using video consultations for patients with infertility seeking independent advice for their fertility problem.

Methods

This pilot study evaluated an online platform, Fertility Consult, where patients with infertility can get independent advice by a gynecologist through a video consultation, thus eliminating the need of meeting the doctor physically. Semistructured interviews were performed with 2 gynecologists and the chairman of the Dutch patients association. This information was used for a patients’ questionnaire about their first experiences with Fertility Consult, including questions about the level of patient-centeredness and shared decision making, using the Patient-Centered Questionnaire-Infertility (PCQ-Infertility) and the CollaboRATE questionnaire, respectively.

Results

Of the first 27 patients enrolled at Fertility Consult, 22 responded (82%). Most patients (82%) visited Fertility Consult for a second opinion, seeking more personal attention and independent advice. The mean level of patient-centeredness on the PCQ-Infertility questionnaire was 2.78 (SD 0.58) on a scale of 0 to 3. For the CollaboRATE questionnaire (scale 0-9), patients provided a median score of 8.0 (range 7-9) on all 3 questions about shared decision making.

Conclusions

Patients were satisfied with independent, well-prepared, Web-based advice; health care professionals felt they were able to provide patients with proper advice in a manner befitting patients’ needs, without any loss of quality. Future studies should focus more on the separation of advice and treatment and on Web-based consultations compared with face-to-face consultations to ascertain the possibility of increased patient involvement in the process to improve the level of patient-centered care.

Patient-centered elective egg freezing: a binational qualitative study of best practices for women's quality of care

PURPOSE

How can elective egg freezing (EEF) be made patient centered? This study asked women to reflect on their experiences of EEF, which included their insights and recommendations on the optimal delivery of patient-centered care.

METHODS

In this binational, qualitative study, 150 women (114 in the USA, 36 in Israel) who had completed at least one cycle of EEF were recruited from four American IVF clinics (two academic, two private) and three in Israel (one academic, two private) over a two-year period (June 2014-August 2016). Women who volunteered for the study were interviewed by two medical anthropologists. Interviews were audio recorded, transcribed, and entered into a qualitative data management program (Dedoose) for analysis.

RESULTS

The majority (85%) of women were without partners at the time of EEF, and thus were undertaking EEF alone in mostly couples-oriented IVF clinics. Following the conceptual framework known as "patient-centered infertility care," we identified two broad categories and eleven specific dimensions of patient-centered EEF care, including (1) system factors: information, competence of clinic and staff, coordination and integration, accessibility, physical comfort, continuity and transition, and cost and (2) human factors: attitude and relationship with staff, communication, patient involvement and privacy, and emotional support. Cost was a unique factor of importance in both countries, despite their different healthcare delivery systems.

CONCLUSIONS

Single women who are pursuing EEF alone in the mostly couples-oriented world of IVF have distinct and multifaceted needs. IVF clinics should strive to make best practices for patient-centered EEF care a high priority.

Patient-centered communication, patient satisfaction, and retention in care in assisted reproductive technology visits

PURPOSE

To explore the association between patient-centered communication, patients' satisfaction, and retention in care in assisted reproductive technology (ART) visits.

METHODS

ART visits at eight Italian clinics were videotaped and coded using the Roter Interaction Analysis System, which includes a Patient-Centered Index (PCI), a summary "patient-centered communication" ratio. After the visit, patients completed a satisfaction questionnaire (SATQ). After 3 months, patients were asked about their retention in care. Spearman correlations and Mann-Whitney tests were used to test associations between the study variables; the open-ended item of SATQ was analyzed through content analysis.

RESULTS

Eighty-five visits were videotaped (involving 28 gynecologists and 160 patients). PCI score (μ = 0.51 ± 0.28) revealed a more disease-oriented communication during the visit. Patients reported high levels of satisfaction with the visit and identified in the information provision or in the doctor's humanity or kindness the main reasons of satisfaction. At the follow-up, the majority of the couples declared to have followed the clinicians' recommendations and to have remained related to the ART center. No associations were found among the study variables, except for a lower male satisfaction among couples who declared to have changed ART clinic.

CONCLUSIONS

Contrary to what was expected, the style of physician-patient communication was not found to be associated with patient satisfaction and retention in care. However, patients were highly satisfied and engaged. The actual meaning of a communication that is "patient-centered" in the ART context might be wider, including the couples' need for information, as suggested by qualitative findings.

Hormonal medication in medically assisted reproduction: a systematic review of assessments from patients

Several hormonal fertility medications have comparable effectiveness. A literature review was conducted into patients' assessments regarding seven medication characteristics including 'side effects' and 'ease of use'. Medline, CINAHL and PsycINFO were searched for female fertility patients' written assessments of a hormonal medication. The tools used were appraised and common (i.e. ≥10%) unpleasant consequences were distinguished from rare ones. The 35 eligible studies did not rely on valid and reliable tools and did not provide patient assessments regarding all seven medication characteristics for any of the globally used medications. Evidence on medications for oocyte triggering was absent and for induction of pituitary quiescence it was scarce. Regarding medications for ovarian stimulation and luteal support, evidence on general side effects (mostly headache), local side effects (mostly pain), 'interference with home life' and 'impact on psychological wellbeing' was found. Evidence on 'ease of use' and 'required education' was only identified for medication for ovarian stimulation. Evidence on 'interference with work life' and 'compliance worry' was absent. This review calls for randomized controlled trials questioning patients with valid and reliable tools. In the meantime, this review's summary of the best available evidence can be integrated in decision aids facilitating personalized and informed medication choices.

Societal preferences for fertility treatment in Australia: a stated preference discrete choice experiment

Objective: To investigate preferences for fertility treatment from the Australian general population with the aims of calculating the willingness to pay in tax contribution for attributes (characteristics) that make up treatment and for an "ideal" fertility treatment program. We also assessed whether willingness-to-pay varies by the relationship status or sexual orientation of the patient.Methods: A stated preference discrete choice experiment was administered to a panel of 801 individuals representative of the Australian general population. Seven attributes of fertility treatment under three broad categories were included: outcome, process, and cost. Attributes were identified through published literature, focus group discussions, expert knowledge, and a pilot study. A Bayesian fractional experimental design was used, and data analysis was performed using a generalized multinomial logit model. Further analyses included interaction terms and latent class modeling.Results: Six of the seven attributes influenced the choice of a treatment program. Under process attributes, individuals preferred: continuity of care of clinic staff, where patients are seen by the same doctor but different nurses at each visit; "alternative" treatments being offered to all patients; and onsite clinic counseling and peer-support groups. Personalization and tailoring of the treatment journey were not important. Among outcome attributes, the improved success rate of having a baby per cycle and significant side-effects were considered important. Cost of treatment also influenced the choice of treatment program. Individual preferences for fertility treatment were not associated with patients' relationship status or sexual orientation. Latent class modeling revealed sub-groups with distinct fertility treatment preferences.Conclusion: This study provides important insights into the attributes that influence the preferences of fertility treatment in Australia. It also estimates socially-inclusive willingness-to-pay values in tax contributions for an "ideal" package of treatment. The results can inform economic evaluations of fertility treatment programs.

Measuring patient-centredness in publicly funded fertility care: A New Zealand validation and international comparison of the Patient-Centred Questionnaire-Infertility

BACKGROUND

The Patient-Centred Questionnaire-Infertility (PCQ-Infertility) has proven to be a reliable instrument to assess the extent of patient-centredness of fertility care in European countries.

AIMS

To validate the PCQ-Infertility in New Zealand (NZ) and to compare results with international experience.

MATERIALS AND METHODS

A cross-sectional 46-item questionnaire study among 409 women undergoing publicly funded fertility care (intrauterine insemination or in vitro fertilisation / intracytoplasmic sperm injection) in three fertility clinics in the Northern Auckland region was performed between October 2015 and September 2016. Inclusion of eligible participants was both retro- and prospective. The questionnaire was distributed by email link and women were asked to complete it with their partner. Internal consistency and construct validity were determined and correction for case mix was performed. Mean dimension scores, adjusted for 'current pregnancy', 'educational level' and 'treatment type', were calculated for each dimension of the PCQ-Infertility. NZ results were compared with PCQ-Infertility results from five countries.

RESULTS

Of 409 invited women, 255 questionnaires were submitted (response rate 62%), of which 216 (53%) were analysable. The dimension 'Care organization' had poor internal consistency, but overall the questionnaire had high internal consistency (Cronbach's α = 0.93). Construct validity was also good. International comparison showed NZ to have the second highest overall score. In New Zealand, the lowest scoring domain was 'Continuity and transition'.

CONCLUSIONS

The NZ version of the PCQ-infertility proved a valid instrument for the assessment of patient-centredness of publicly funded fertility care. Future research should focus on international inequities in patient-centred fertility care and use of the tool for quality improvement. Local use of the PCQ-Infertility is encouraged.

Assessment of the societal and individual preferences for fertility treatment in Australia: study protocol for stated preference discrete choice experiments

INTRODUCTION

In Australia, societal and individual preferences for funding fertility treatment remain largely unknown. This has resulted in a lack of evidence about willingness to pay (WTP) for fertility treatment by either the general population (the funders) or infertile individuals (who directly benefit). Using a stated preference discrete choice experiment (SPDCE) approach has been suggested as a more appropriate method to inform economic evaluations of fertility treatment. We outline the protocol for an ongoing study which aims to assess fertility treatment preferences of both the general population and infertile individuals, and indirectly estimate their WTP for fertility treatment.

METHODS AND ANALYSIS

Two separate but related SPDCEs will be conducted for two population samples-the general population and infertile individuals-to elicit preferences for fertility treatment to indirectly estimate WTP. We describe the qualitative work to be undertaken to design the SPDCEs. We will use D-efficient fractional experimental designs informed by prior coefficients from the pilot surveys. The mode of administration for the SPDCE is also discussed. The final results will be analysed using mixed logit or latent class model.

ETHICS AND DISSEMINATION

This study is being funded by the Australian National Health and Medical Research Council (NHMRC) project grant AP1104543 and has been approved by the University of New South Wales Human Research Ethics Committee (HEC 17255) and a fertility clinic's ethics committee. Findings of the study will be disseminated in peer-reviewed journals and presented at various conferences. A lay summary of the results will be made publicly available on the University of New South Wales National Perinatal Epidemiology and Statistics Unit website. Our results will contribute to the development of an evidence-based policy framework for the provision of cost-effective and patient-centred fertility treatment in Australia.

Medical egg freezing: the importance of a patient-centered approach to fertility preservation

PURPOSE

This binational qualitative study of medical egg freezing (MEF) examined women's motivations and experiences, including their perceived needs for patient-centered care in the midst of fertility- and life-threatening diagnoses.

METHODS

Forty-five women who had undertaken MEF were interviewed in the USA (33 women) and in Israel (12 women) between June 2014 and August 2016. Interviews lasted approximately 1 h and were conducted by two senior medical anthropologists, one in each country. Women were recruited from four American IVF clinics (two academic, two private) and two Israeli clinics (both academic) where MEF is being offered to cancer patients and women with other fertility-threatening medical conditions.

RESULTS

Women who undertake MEF view their fertility and future motherhood as important components of their identities and recovery and, thus, are grateful for the opportunity to pursue fertility preservation. However, women who undergo MEF have special needs, given that they tend to be a "vulnerable" population of young (age < 30), unmarried, resource-constrained women, who are facing not only fertility loss but also the "double jeopardy" of cancer. Through in-depth, qualitative interviews, these women's MEF stories reveal 10 dimensions of care important to fertility preservation, including five "system factors" (information, coordination and integration, accessibility, physical comfort, cost) and five "human factors" (adolescent issues, male partner involvement, family involvement, egg disposition decisions, emotional support). Together, these dimensions of care constitute an important framework that can be best described as "patient-centered MEF."

CONCLUSIONS

Women pursuing MEF have special medical needs and concerns, which require particular forms of patient-centered care. This study outlines 10 dimensions of patient-centered fertility preservation that are appropriate for MEF patients. This approach may help IVF clinics to be better prepared for delivering top-quality care to mostly young, single women facing the daunting prospect of fertility loss and life-threatening medical diagnoses.

Shared agenda making for quality improvement; towards more synergy in maternity care

OBJECTIVES

Professionals in maternity care have started working in a network approach. To further enhance the efficacy of this multidisciplinary maternity network, the identification of priorities for improvement is warranted. The aim of this study was to create key recommendations for the improvement agenda, in co-production with patients and professionals.

STUDY DESIGN

We conducted a Delphi study to inventory (round 1), prioritize (round 2) and eventually approve (round 3) the improvement agenda for the maternity network. Both patients and professionals joined this study. Initial input for the study consisted of experiences from 397 patients, collected using the ReproQ questionnaire. In round 1, the expert panel, gave improvement recommendations, based on the ReproQ results. This resulted in 11 recommendations. In the second round, the expert panel prioritised these recommendations. In the consensus meeting then finally the concrete improvement agenda was composed.

RESULTS

Priority scores differed considerably between patients and professionals in seven items, while four items received similar priority scores from both groups. The four most important improvement activities were: Realise more single bedrooms in hospitals; Create more opportunities for the continued presence of the community midwife during labour; Initiate a digital patient record view system for the network with a view function for patients; and Introduce a case manager for pregnant woman.

CONCLUSION

Based on patient experience and the active involvement of patients and professionals, we were able to compose the shared agenda for quality improvement in maternity care.

A conceptual framework for patient-centered fertility treatment

BACKGROUND

Patient-centered care is a pillar of quality health care and is important to patients experiencing infertility. In this study we used empirical, in-depth data on couples' experiences of infertility treatment decision making to inform and revise a conceptual framework for patient-centered fertility treatment that was developed based on health care professionals' conceptualizations of fertility treatment, covering effectiveness, burden, safety, and costs.

METHODS

In this prospective, longitudinal mixed methods study, we collected data from both members (separately) of 37 couples who scheduled an initial consult with a reproductive specialist. Data collection occurred 1 week before the initial consultation, 1 week after the initial consultation, and then roughly 2, 4, 8, and 12 months later. Data collection included semi-structured qualitative interviews, self-reported questionnaires, and medical record review. Interviews were recorded, transcribed, and content analyzed in NVivo. A single coder analyzed all transcripts, with > 25% of transcripts coded by a second coder to ensure quality control and consistency.

RESULTS

Content analysis of the interview transcripts revealed 6 treatment dimensions: effectiveness, physical and emotional burden, time, cost, potential risks, and genetic parentage. Thus, the revised framework for patient-centered fertility treatment retains much from the original framework, with modification to one dimension (from safety to potential risks) and the addition of two dimensions (time and genetic parentage). For patients and their partners making fertility treatment decisions, tradeoffs are explicitly considered across dimensions as opposed to each dimension being considered on its own.

CONCLUSIONS

Patient-centered fertility treatment should account for the dimensions of treatment that patients and their partners weigh when making decisions about how to add a child to their family. Based on the lived experiences of couples seeking specialist medical care for infertility, this revised conceptual framework can be used to inform patient-centered treatment and research on infertility and to develop decision support tools for patients and providers.

Implementing targeted expectant management in fertility care using prognostic modelling: a cluster randomized trial with a multifaceted strategy

STUDY QUESTION

What is the effectiveness of a multifaceted implementation strategy compared to usual care on improving the adherence to guideline recommendations on expectant management for couples with unexplained infertility?

SUMMARY ANSWER

The multifaceted implementation strategy did not significantly increase adherence to guideline recommendations on expectant management compared to care as usual.

WHAT IS KNOWN ALREADY

Intrauterine insemination (IUI) with or without ovarian hyperstimulation has no beneficial effect compared to no treatment for 6 months after the fertility work-up for couples with unexplained infertility and a good prognosis of natural conception. Therefore, various professionals and policy makers have advocated the use of prognostic profiles and expectant management in guideline recommendations.

STUDY DESIGN, SIZE, DURATION

A cluster randomized controlled trial in 25 clinics in the Netherlands was conducted between March 2013 and May 2014. Clinics were randomized between the implementation strategy (intervention, n = 13) and care as usual (control, n = 12). The effect of the implementation strategy was evaluated by comparing baseline and effect measurement data. Data collection was retrospective and obtained from medical record research and a patient questionnaire.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 544 couples were included at baseline and 485 at the effect measurement (247 intervention group/238 control group).

MAIN RESULTS AND THE ROLE OF CHANCE

Guideline adherence increased from 49 to 69% (OR 2.66; 95% CI 1.45-4.89) in the intervention group, and from 49 to 61% (OR 2.03; 95% CI 1.38-3.00) in the control group. Multilevel analysis with case-mix adjustment showed that the difference of 8% was not statistically significant (OR 1.31; 95% CI 0.67-2.59). The ongoing pregnancy rate within six months after fertility work-up did not significantly differ between intervention and control group (25% versus 27%: OR 0.72; 95% CI 0.40-1.27).

LIMITATIONS REASONS FOR CAUTION

There is a possible selection bias, couples included in the study had a higher socio-economic status than non-responders. How this affects guideline adherence is unclear. Furthermore, when powering for this study we did not take into account the unexpected improvement of adherence in the control group.

WIDER IMPLICATIONS OF THE FINDINGS

Generalization of our results to other countries with recommendations on expectant management might be questionable because barriers for expectant management can be very different in other countries. Furthermore, due to a large variation in improved adherence rate in the intervention group it will be interesting to further analyse the process of implementation in each clinic with a process evaluation on professionals and couples' exposure to and experiences with the strategy.

STUDY FUNDING/COMPETING INTEREST(S)

Supported by Netherlands Organisation for Health Research and Development (ZonMW, project number 171203005). No competing interests.

TRIAL REGISTRATION NUMBER

Dutch trial Register, www.trialregister.nl NTR3405.

TRIAL REGISTRATION DATE

19 April 2012.

DATE OF FIRST PATIENT'S ENROLMENT

10 July 2012.

Couples' discontinuation of fertility treatments: a longitudinal study on demographic, biomedical, and psychosocial risk factors

PURPOSE

This study aims to explore the role of infertility-psychosocial variables on treatment discontinuation after controlling for demographic and biomedical variables in couples seeking reimbursed fertility treatment.

METHODS

A prospective study was conducted in 139 couples seeking fertility treatment. Between February 2010 and March 2011, participants completed measures of anxiety (STAI-State), depression (BDI-II), infertility-stress (FPI), and infertility coping strategies (COMPI-CSS). Medical data related to diagnosis, treatment, and discontinuation were collected in December 2013. A multiple logistic regression was performed to identify the predictors of discontinuation.

RESULTS

The discontinuation rate was 29.5%. Female education level, engagement in ART procedures, and female causation decreased the likelihood of treatment discontinuation, whereas female age and depression increased the likelihood of discontinuation. Female depression was the strongest predictor in this model. The model correctly identified 75.5% of cases.

CONCLUSIONS

Female age and female depression are associated with a higher likelihood of treatment discontinuation in couples seeking treatment. Reproductive health professionals should therefore inform couples about the link between the fertility treatment discontinuation and both female age and female depression. Couples in which female partners present clinically relevant depression should be referred to a mental health professional to prevent premature abandonment of fertility treatments and thus increase success rates.

Communication at an online infertility expert forum: provider responses to patients' emotional and informational cues

Online patient-provider communication has become increasingly popular in fertility care. However, it is not known to what extent patients express cues or concerns and how providers respond. In this study, we investigated cues and responses that occur in online patient-provider communication at an infertility-specific expert forum. We extracted 106 threads from the multidisciplinary expert forum of two Dutch IVF clinics. We performed the following analyses: (1) thematic analysis of patients' questions; and (2) rating patients' emotional and informational cues and subsequent professionals' responses using an adaptation of the validated Medical Interview Aural Rating Scale. Frequencies of themes, frequencies of cues and responses, and sequences (what cue is followed by what response) were extracted. Sixty-five infertile patients and 19 providers participated. The most common themes included medication and lifestyle. Patients gave more informational than emotional cues (106 versus 64). Responses to informational cues were mostly adequate (61%). The most common response to emotional cues was empathic acknowledgment (72%). Results indicate that an online expert forum could have a positive effect on patient outcomes, which should guide future research. Offering infertile patients an expert forum to communicate with providers can be a promising supplement to usual care in both providing information and addressing patients' concerns.

Satisfaction with in vitro fertilization treatment: patients' experiences and professionals' perceptions

BACKGROUND

This paper investigates patients' satisfaction with various aspects of fertility care and seeks to determine to what extent fertility specialists are able to assess patient satisfaction. Patients' experiences with in-vitro fertilization (IVF) services and facilities have been compiled and examined in order to discover whether patients' satisfaction is correlated to psychological factors and demographic, socio-economic, and health characteristics, and whether patients' satisfaction has an influence on the willingness to pay (WTP) for IVF treatment.

METHODS

The study was carried out on 204 patients and 19 fertility professionals from 8 public IVF units in Israel.

RESULTS

The study found that, overall, infertile patients are satisfied with the care they received. Several demographic variables (age; education; income; number of fertility treatments) and psychological factors ('Pessimism' and 'Activeness'), were found to be significantly correlated with patient satisfaction with IVF. The results yielded a negative correlation between the WTP for IVF treatment and the satisfaction with access to care and physical conditions.

CONCLUSIONS

Patient satisfaction is an important component in the evaluation of fertility treatments as well as other medical interventions. Insights into the quality of care as seen from the patients' perspective may help healthcare staff better meet patients' needs, wishes, and priorities.

Added value of involving patients in the first step of multidisciplinary guideline development: a qualitative interview study among infertile patients

BACKGROUND

Patient involvement in scoping the guideline is emphasized, but published initiatives actively involving patients are generally limited to the writing and reviewing phase.

OBJECTIVE

To assess patients' added value to the scoping phase of a multidisciplinary guideline on infertility.

DESIGN

Qualitative interview study.

SETTING AND PARTICIPANTS

We conducted interviews among 12 infertile couples and 17 professionals.

INTERVENTION

We listed and compared the couples' and professionals' key clinical issues (=care aspects that need improvement) to be addressed in the guideline according to four domains: current guidelines, professionals, patients and organization of care.

MAIN OUTCOME MEASURES

Main key clinical issues suggested by more than three quarters of the infertile couples and/or at least two professionals were identified and compared.

RESULTS

Overall, we identified 32 key clinical issues among infertile couples and 23 among professionals. Of the defined main key clinical issues, infertile couples mentioned eight issues that were not mentioned by the professionals. These main key clinical issues mainly concerned patient-centred (e.g. poor information provision and poor alignment of care) aspects of care on the professional and organizational domain. Both groups mentioned two main key clinical issues collectively that were interpreted differently: the lack of emotional support and respect for patients' values.

CONCLUSIONS

Including patients from the first phase of the guideline development process leads to valuable additional main key clinical issues for the next step of a multidisciplinary guideline development process and broadens the scope of the guideline, particularly regarding patient-centredness and organizational issues from a patients' perspective.

Tailored expectant management in couples with unexplained infertility does not influence their experiences with the quality of fertility care

STUDY QUESTION

Do couples who were eligible for tailored expectant management (TEM) and did not start treatment within 6 months after the fertility work-up, have different experiences with the quality of care than couples that were also eligible for TEM but started treatment right after the fertility work-up?

SUMMARY ANSWER

Tailored expectant management of at least 6 months in couples with unexplained infertility is not associated with the experiences with quality of care or trust in their physician.

WHAT IS KNOWN ALREADY

In couples with unexplained infertility and a good prognosis of natural conception within 1 year, expectant management for 6-12 months does not compromise ongoing birth rates and is equally as effective as starting medically assisted reproduction immediately. Therefore, TEM is recommended by various international clinical guidelines. Implementation of TEM is still not optimal because of existing barriers on both patient and professional level. An important barrier is the hesitance of professionals to counsel their patients for TEM because they fear that patients will be dissatisfied with care. However, if and how adherence to TEM actually affects the couples' experience with care is unknown. Experiences with the quality care can be measured by evaluating the patient-centredness of care and the patients' trust in their physician.

STUDY DESIGN, SIZE, DURATION

This is a retrospective cross-sectional study. A survey with written questionnaires was performed among all couples who participated in the retrospective audit of guideline adherence on TEM in 25 Dutch clinics.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Couples were eligible to participate if they were diagnosed with unexplained infertility and had a good prognosis (>30%) of natural conception within 1 year based on the Hunault prediction model. We used patient's questionnaires to collect data on the couples' experience with the quality of care and possible confounders for their experiences other than having undergone TEM or not. Multilevel regression analyses were performed to investigate case-mix adjusted association of TEM with the patient-centredness of care (PCQ-Infertility) and the patients' trust in their physician (Wake Forest Trust Scale).

MAIN RESULTS AND THE ROLE OF CHANCE

Couples who adhered to TEM experienced the quality of care on the same level as couples who were exposed to early treatment, i.e. started fertility treatment within 6 months after fertility work-up. There were no associations between adherence to TEM and the patient-centredness of care or the patients' trust in their physician.

LIMITATIONS, REASONS FOR CAUTION

Because this study is retrospective, recall bias might occur. Furthermore, we were unable to measure the difference in experience with care over time. Therefore, our results have to be interpreted carefully.

WIDER IMPLICATIONS OF THE FINDINGS

Prospective research on couples undergoing TEM have to be performed to provide more detailed insight in the patients' experiences with the decision making process and subsequently the expectant period. Tackling the barriers surrounding TEM, i.e. better counselling and more patient information material, could further improve patient experiences with the quality of care for couples who are advised TEM.

STUDY FUNDING/COMPETING INTERESTS

Supported by Netherlands Organisation for Health Research and Development (ZonMW). ZonMW had no role in designing the study, data collection, analysis and interpretation of data or writing of the report. Competing interests: none.

TRIAL REGISTRATION NUMBER

www.trialregister.nl NTR3405.

ESHRE guideline: routine psychosocial care in infertility and medically assisted reproduction-a guide for fertility staff

STUDY QUESTION

Based on the best available evidence in the literature, what is the optimal management of routine psychosocial care at infertility and medically assisted reproduction (MAR) clinics?

SUMMARY ANSWER

Using the structured methodology of the Manual for the European Society of Human Reproduction and Embryology (ESHRE) Guideline Development, 120 recommendations were formulated that answered the 12 key questions on optimal management of routine psychosocial care by all fertility staff.

WHAT IS ALREADY KNOWN

The 2002 ESHRE Guidelines for counselling in infertility has been a reference point for best psychosocial care in infertility for years, but this guideline needed updating and did not focus on routine psychosocial care that can be delivered by all fertility staff.

STUDY, DESIGN, SIZE, DURATION

This guideline was produced by a group of experts in the field according to the 12-step process described in the ESHRE Manual for Guideline Development. After scoping the guideline and listing a set of 12 key questions in PICO (Patient, Intervention, Comparison and Outcome) format, thorough systematic searches of the literature were conducted; evidence from papers published until April 2014 was collected, evaluated for quality and analysed. A summary of evidence was written in a reply to each of the key questions and used as the basis for recommendations, which were defined by consensus within the guideline development group (GDG). Patient and additional clinical input was collected during the scoping and the review phase of the guideline development.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The guideline group, comprising psychologists, two medical doctors, a midwife, a patient representative and a methodological expert, met three times to discuss evidence and reach consensus on the recommendations.

MAIN RESULTS AND THE ROLE OF CHANCE THE GUIDELINE PROVIDES

120 recommendations that aim at guiding fertility clinic staff in providing optimal evidence-based routine psychosocial care to patients dealing with infertility and MAR. The guideline is written in two sections. The first section describes patients' preferences regarding the psychosocial care they would like to receive at clinics and how this care is associated with their well-being. The second section of the guideline provides information about the psychosocial needs patients experience across their treatment pathway (before, during and after treatment) and how fertility clinic staff can detect and address these. Needs refer to conditions assumed necessary for patients to have a healthy experience of the fertility treatment. Needs can be behavioural (lifestyle, exercise, nutrition and compliance), relational (relationship with partner if there is one, family friends and larger network, and work), emotional (well-being, e.g. anxiety, depression and quality of life) and cognitive (treatment concerns and knowledge).

LIMITATIONS, REASONS FOR CAUTION

We identified many areas in care for which robust evidence was lacking. Gaps in evidence were addressed by formulating good practice points, based on the expert opinion of the GDG, but it is critical for such recommendations to be empirically validated.

WIDER IMPLICATIONS OF THE FINDINGS

The evidence presented in this guideline shows that providing routine psychosocial care is associated with or has potential to reduce stress and concerns about medical procedures and improve lifestyle outcomes, fertility-related knowledge, patient well-being and compliance with treatment. As only 45 (36.0%) of the 125 recommendations were based on high-quality evidence, the guideline group formulated recommendations to guide future research with the aim of increasing the body of evidence.

Evolution of psychology and counseling in infertility

Five key paradigm shifts are described to illustrate the evolution of psychology and counseling in infertility. The first paradigm shift was in the 1930s when psychosomatic concepts were introduced in obstetrics and gynecology as causal factors to explain why some couples could not conceive despite the absence of organic pathology. In the second shift, the nurse advocacy movement of the 1970s stimulated the investigation of the psychosocial consequences of infertility and promoted counseling to help couples grieve childlessness when medical treatments often could not help them conceive. The third shift occurred with the advent of IVF, which created a demand for mental health professionals in fertility clinics. Mental health professionals assessed the ability of couples to withstand the demands of this new high technology treatment as well as their suitability as potential parents. The fourth shift, in the 1990s, saw reproductive medicine embrace the principles of evidence-based medicine, which introduced a much more rigorous approach to medical practice (effectiveness and safety) that extended to psychosocial interventions. The most recent paradigm shift, in the new millennium, occurred with the realization that compliance with protracted fertility treatment depended on the adoption of an integrated approach to fertility care. An integrated approach could reduce treatment burden arising from multiple sources (i.e., patient, clinic, and treatment). This review describes these paradigm shifts and reflects on future clinical and research directions for mental health professionals.

Performance of the measures of processes of care for adults and service providers in rehabilitation settings

Introduction

In recent years, client-centered care has been embraced as a new philosophy of care by many organizations around the world. Clinicians and researchers have identified the need for valid and reliable outcome measures that are easy to use to evaluate success of implementation of new concepts.

Objective

The current study was developed to complete adaptation and field testing of the companion patient-reported measures of processes of care for adults (MPOC-A) and the service provider self-reflection measure of processes of care for service providers working with adult clients (MPOC-SP(A)).

Design

A validation study

Settings

In-patient rehabilitation facilities.

Main outcome measures

MPOC-A and measure of processes of care for service providers working with adult clients (MPOC-SP(A)).

Results

Three hundred and eighty-four health care providers, 61 patients, and 16 family members completed the questionnaires. Good to excellent internal consistency (0.71–0.88 for health care professionals, 0.82–0.90 for patients, and 0.87–0.94 for family members), as well as moderate to good correlations between domains (0.40–0.78 for health care professionals and 0.52–0.84 for clients) supported internal reliability of the tools. Exploratory factor analysis of the MPOC-SP(A) responses supported the multidimensionality of the questionnaire.

Conclusion

MPOC-A and MPOC-SP(A) are valid and reliable tools to assess patient and service-provider accounts, respectively, of the extent to which they experience, or are able to provide, client-centered service. Research should now be undertaken to explore in more detail the relationships between client experience and provider reports of their own behavior.

Patient-centred quality of care in an IVF programme evaluated by men and women

STUDY QUESTION

Do men and women value the same aspects of quality of care during IVF treatment when measuring rates of importance by the validated instrument, quality from the patient's perspective of in vitro fertilization (QPP-IVF)?

SUMMARY ANSWER

Women valued most aspects of care as significantly more important than their partner although men and women evaluated the importance of the different care factors in a similar pattern.

WHAT IS KNOWN ALREADY

A few validated tools measuring patient-centred quality of care during IVF have been developed. Few studies of gender differences concerning experiences of patient-centred quality of care have been reported in the literature to date.

STUDY DESIGN, SIZE AND DURATION

A two-centre study was conducted between September 2011 and May 2012. Heterosexual couples (n = 497) undergoing IVF were invited to complete a questionnaire before receiving the result of the pregnancy test.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In all, 363 women and 292 men evaluated quality of care by answering the QPP-IVF questionnaire. The measurements consisted of two kinds of evaluations: the rating of the importance of various aspects of treatment (subjective importance) and the rating of perceived quality of care (perceived reality). Comparisons between men and women on importance ratings and perceived reality ratings were performed both on factor (subscale) and single item levels by intra-couple analyses and corrected for age. A stepwise multiple logistic regression analysis was performed in order to select baseline variables independently predicting evaluation at factor level.

MAIN RESULTS AND THE ROLE OF CHANCE

The response rate was 67.5%, with 363 women (74.2%) and 292 men (60.6%) completing the study. Both the woman and man responded in 251 couples. Women rated the different care aspects as significantly more important than their partner in all factors except the factor, 'Responsibility/continuity'. Both genders gave the factors, 'Medical care' and 'Information after treatment', the highest scores. At item level women rated the majority of items as significantly more important than men. Perceived reality for the majority of factors and items was similarly rated by men and women in the couples. For women, receiving embryo transfer, short duration of infertility, IVF as a method and number of previous cycles were independently correlated to the highest score of importance of certain factors.

LIMITATIONS, REASON FOR CAUTION

The lower response rate of men compared with women (60.6 versus 74.2%, respectively) might have influenced the results through selection bias. Only patients who had adequate fluency in the Swedish language participated.

WIDER IMPLICATIONS OF THE FINDINGS

This study is an important contribution in comparing the needs of men and women undergoing IVF treatments. The QPP-IVF instrument is a suitable instrument for revealing important care aspects identified by both men and women and a useful tool for stimulating patient-centred quality improvements within and between clinics.

STUDY FUNDING/COMPETING INTEREST

The study was supported by the LUA/ALF agreement at Sahlgrenska University Hospital, Gothenburg, Sweden, and by Hjalmar Svensson's Research Foundation. None of the authors declared any conflict of interests.