Guideline adherence is worth the effort: a cost-effectiveness analysis in intrauterine insemination care.

STUDY QUESTION: Is optimal adherence to guideline recommendations in intrauterine insemination (IUI) care cost-effective from a societal perspective when compared with suboptimal adherence to guideline recommendations? SUMMARY ANSWER: Optimal guideline adherence in IUI care has substantial economic benefits when compared with suboptimal guideline adherence. WHAT IS KNOWN ALREADY: Fertility guidelines are tools to help health-care professionals, and patients make better decisions about clinically effective, safe and cost-effective care. Up to now, there has been limited published evidence about the association between guideline adherence and cost-effectiveness in fertility care. STUDY DESIGN, SIZE, DURATION: In a retrospective cohort study involving medical record analysis and a patient survey (n = 415), interviews with staff members (n = 13) and a review of hospitals' financial department reports and literature, data were obtained about patient characteristics, process aspects and clinical outcomes of IUI care and resources consumed. In the cost-effectiveness analyses, restricted to four relevant guideline recommendations, the ongoing pregnancy rate per couple (effectiveness), the average medical and non-medical costs of IUI care, possible additional IVF treatment, pregnancy, delivery and period from birth up to 6 weeks after birth for both mother and offspring per couple (costs) and the incremental net monetary benefits were calculated to investigate if optimal guideline adherence is cost-effective from a societal perspective when compared with suboptimal guideline adherence. PARTICIPANTS/MATERIALS, SETTING, METHODS: Seven hundred and sixty five of 1100 randomly selected infertile couples from the databases of the fertility laboratories of 10 Dutch hospitals, including 1 large university hospital providing tertiary care and 9 public hospitals providing secondary care, were willing to participate, but 350 couples were excluded because of ovulatory disorders or the use of donated spermatozoa (n = 184), still ongoing IUI treatment (n = 143) or no access to their medical records (n = 23). As a result, 415 infertile couples who started a total of 1803 IUI cycles were eligible for the cost-effectiveness analyses. MAIN RESULTS AND THE ROLE OF CHANCE: Optimal adherence to the guideline recommendations about sperm quality, the total number of IUI cycles and dose of human chorionic gonadotrophin was cost-effective with an incremental net monetary benefit between € 645 and over € 7500 per couple, depending on the recommendation and assuming a willingness to pay € 20 000 for an ongoing pregnancy. LIMITATIONS, REASONS FOR CAUTION: Because not all recommendations applied to all 415 included couples, smaller groups were left for some of the cost-effectiveness analyses, and one integrated analysis with all recommendations within one model was impossible. WIDER IMPLICATIONS OF THE FINDINGS: Optimal guideline adherence in IUI care has substantial economic benefits when compared with suboptimal guideline adherence. For Europe, where over 144,000 IUI cycles are initiated each year to treat ≈ 32 000 infertile couples, this could mean a possible cost saving of at least 20 million euro yearly. Therefore, it is valuable to make an effort to improve guideline development and implementation.

Monitoring reproductive health in Europe: what are the best indicators of reproductive health? A need for evidence-based quality indicators of reproductive health care.

Monitoring reproductive health by the Reprostat indicators in Europe will facilitate the transparency of reproductive health as well as comparisons over time and between countries. However, for the monitoring and improvement of reproductive health care, we suggest the systematic development of evidence-based quality indicators, especially process and structure indicators.

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

BACKGROUND: International collaboration could facilitate systematic development of guidelines to regulate and improve clinical practice. To promote European collaboration in guideline development in reproductive medicine, insight into existing subfertility guidelines in Europe is essential. The study aim was to explore the number and quality of clinical practice guidelines on homologous intrauterine insemination (IUI) in Europe. METHODS: To identify IUI guidelines in Europe, electronic databases and Internet were systematically searched and key experts on assisted reproduction in 25 European countries were questioned. The quality of IUI guidelines was systematically assessed with the internationally validated Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument. Qualitative methods were used to appraise IUI guideline recommendations and references. RESULTS: National guidelines on IUI are available in four of 25 European countries. The quality of IUI guidelines in Europe is moderate to high, but the recommendations and references differ considerably. CONCLUSIONS: The number of IUI guidelines in Europe is surprisingly small, and differences in their recommendations and references are considerable. To overcome these deficiencies in clinical guidance on IUI care in Europe, a central body with expertise in up-to-date guideline development methodology and sufficient resources could be established in Europe for central selection and international exchange of evidence to support guideline recommendations.

Barriers to physician adherence to a subfertility guideline.

BACKGROUND: Guidelines aim to improve clinical practice but are not self-implementing. Insight into barriers to physician guideline adherence is crucial for development of effective implementation strategies. The study aim was to identify barriers to physician adherence to an intrauterine insemination (IUI) guideline of the Dutch Society of Obstetrics and Gynaecology. METHODS: We conducted a cross-sectional survey among all Dutch gynaecologists, residents and fertility physicians (n = 860), using written questionnaires that were based on information obtained in focus group discussions. We investigated barriers related to physicians' knowledge and attitudes, and external barriers. RESULTS: The response rate was 65%. We used 344 questionnaires for analysis. Physicians' knowledge was adequate, with a median unfamiliarity rate with each of the 31 key guideline recommendations of 12%. Physicians' attitudes were generally positive, especially regarding guideline development and quality. Important attitude-related barriers included physicians' lack of self-efficacy regarding physician-patient communication and poor outcome expectancy. External barriers were mostly related to specific patient characteristics and associated with higher age of physicians and fewer consultations for fertility problems per week. CONCLUSIONS: Multiple barriers impede physician adherence to subfertility guidelines, mainly physicians' lack of self-efficacy and low outcome expectancy. Both physicians and patients play an important role in future implementation interventions to optimize subfertility care.

Current Internet use and preferences of IVF and ICSI patients.

BACKGROUND: Nowadays, the Internet has a tremendous impact on modern society, including healthcare practice. The study aim was to characterize current Internet use by IVF and ICSI patients and to identify their preferences regarding Internet applications in fertility care. METHODS: A total of 163 couples with fertility problems awaiting an IVF or ICSI procedure in the University Medical Centre Nijmegen, The Netherlands, was asked to complete a written questionnaire on Internet use in general, and also for fertility-related problems, preferences regarding Internet applications in fertility care and demographic characteristics. RESULTS: The response rate was 82%. In total, 81% of infertile couples used the Internet. Multivariate logistic regression analysis showed ethnic background and annual family income to be significant predictors of Internet use. Some 66% of Internet users and 54% of the total study population used the Internet for fertility-related problems. The female partners were the main Internet users with regard to fertility-related issues. In terms of preferences of the study participants, the majority favoured personal medical information online. CONCLUSIONS: Most infertile couples used the Internet with respect to fertility-related problems and were interested in implementation of Internet applications in fertility care. Healthcare providers should actively participate in the development and implementation of Internet applications in fertility care.