Editorial: Two cheers for clinical practice guidelines: the hopes and headaches of quality improvement in reproductive healthcare

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Ed Hughes*

Professor of Obstetrics and Gynecology, McMaster University, 1200 Main Street West, Hamilton, ON, Canada L8N 3Z5*Correspondence address. E-mail: hughese{at}mcmaster.caReceived January 12, 2011. Revision received January 12, 2011. Accepted January 14, 2011. Effective and timely knowledge transfer is the engine of evidence-based medicine. ESHRE and other professional societies are key players in the process of knowledge transfer. They facilitate scientific dialogue in many different ways and provide frameworks for the generation of clinical practice guidelines (CPGs). While enormous thought and effort goes into the execution of clinical trials and the subsequent development of CPGs based on them, little is known about the effectiveness of guideline uptake in the field of reproductive medicine. How successful are guidelines in improving quality of care? What strategies beyond simple guideline publication, most effectively lead to change in practice? The study by Mourad et al. ( 2010) takes a bold and pragmatic look at these questions, on behalf of fertility care-givers and patients.

Based in Holland, this group used a relatively new and increasingly common design platform: cluster randomization. This means that the unit of allocation was not, as is usual, the individual patient, but instead a group of patients, in this case those attending a particular fertility clinic. The main reason for using cluster randomization is to avoid the risk of contamination: to keep separate the influences of the two strategies under study. Here, it would have been impossible to provide two types of CPG reinforcement strategy to the same physicians and expect them to apply them separately to individual patients within their practices. Important limitations of cluster randomization stem from the correlation that exists between patients within …

This ArticleHum. Reprod. (2011) 26 (4): 815-816. doi: 10.1093/humrep/der023 First published online: February 2, 2011

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A multi-faceted strategy to improve the use of national fertility guidelines; a cluster-randomized controlled trial

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Selma M. Mourad1,2, Rosella P.M.G. Hermens2, Janine Liefers2, Reinier P. Akkermans2, G.A. Zielhuis3, E. Adang3, Richard P.T.M. Grol2, Willianne L.D.M. Nelen1 and Jan A.M. Kremer1,*

1Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands

2Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands

3Department of Epidemiology, Biostatistics and Health Technology Assessment, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands *Correspondence address. E-mail: j.kremer{at}obgyn.umcn.nlReceived February 2, 2010. Revision received August 9, 2010. Accepted September 30, 2010. BACKGROUND Proper use of clinical practice guidelines can decrease variation in care between settings. However, actual use of fertility guidelines is suboptimal and in need of improvement. Hence, a cluster-randomized controlled trial was designed to study the effects of two strategies to implement national Dutch guidelines on comprehensive fertility care.

METHODS Sixteen fertility clinics participated in the trial. A minimal, professional-oriented implementation strategy of audit and feedback was tested versus a maximal multi-faceted strategy that was both professional and patient oriented. The extent of adherence to guideline recommendations, reflected in quality indicator scores, was the primary outcome measure. To gain an insight into unwanted side effects, patient anxiety and depression scores were gathered as secondary outcomes. Data collection encompassed medical record search, patient and professional questionnaires.

RESULTS A total of 1499 couples were included at baseline and 1396 at the after-measurement. No overall significant improvement in indicator scores was found for either strategy [odds ratios ranging from 0.23 (95% confidence interval (CI): 0.06–0.95) to 6.66 (95% CI: 0.33–132.8]. Secondary outcomes did not differ significantly for both groups, although selected anxiety scores appeared lower in the maximal intervention group. Process evaluation of the trial revealed positive patient experiences with the intervention material [e.g. an increased understanding of their doctor's treatment policy (61%), an increased ability to ask questions about the treatment (61%)]. Professionals’ appreciation of intervention elements varied, and execution of the multi-faceted strategy appeared incomplete.

DISCUSSION Absence of an intervention effect may be due to the nature of the strategies, incomplete execution or flaws in study design. Process evaluation data raise the question of whether professionals should be the only stakeholder responsible for guideline implementation. This study therefore contributes to an increased understanding of fertility guideline implementation in general, and the role of patients in particular.

Clinical Trials.gov: NCT00119925.

© The Author 2010. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org This ArticleHum. Reprod. (2011) 26 (4): 817-826. doi: 10.1093/humrep/deq299 First published online: December 6, 2010

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