Veterans Health Administration Primary Care Provider Adherence to Prescribing Guidelines for Systemic Hormone Therapy in Menopausal Women.

BACKGROUND: Systemic hormone therapy (HT) is effective for treating menopausal symptoms but also confers risks. Therefore, experts have developed clinical guidelines for its use. PURPOSE: We assessed primary care guideline adherence in prescribing systemic HT, and associations between adherence and provider characteristics, in four Veterans Health Administration (VA) facilities. METHODS: We abstracted medical records associated with new and renewal systemic HT prescriptions examining adherence to guidelines for documenting indications and contraindications; prescribing appropriate dosages; and prescribing progesterone. RESULTS: Average guideline adherence was 58%. Among new prescriptions, 74% documented a guideline-adherent indication and 28% documented absence of contraindications. Among renewals, 39% documented a guideline-adherent indication. In prescribing an appropriate dose, 45% of new prescriptions were guideline-adherent. Among renewal prescriptions with conjugated equine estrogen doses ≥0.625 mg or equivalent, 16% documented the dosing rationale. Among 116 prescriptions for systemic estrogen in women with a uterus, progesterone was not prescribed in 8. CONCLUSIONS: Guideline adherence in prescribing systemic HT was low among VA primary care providers. Failures to coprescribe progesterone put women at increased risk for endometrial cancer. IMPLICATIONS: Intervention development is urgently needed to improve guideline adherence among primary care prescribers of systemic HT for menopause. Similar assessments should be conducted in community settings.

Guideline Adherence of Veterans Health Administration Primary Care for Abnormal Uterine Bleeding.

BACKGROUND: Abnormal uterine bleeding (AUB) is common among primary care patients. We assessed the extent to which Veterans Health Administration (VA) primary care patients with AUB are receiving guideline-adherent primary care. METHODS: We identified women with AUB presenting to primary care providers across four VA health care systems from June 2013 to September 2015. We performed a structured abstraction of electronic medical record data for 15 indicators of guideline-adherent AUB care. We determined whether documented care was guideline-adherent and compared adherence of care by primary care providers by VA Designated Women's Health Provider status and by volume of clinical encounters with women veterans. RESULTS: Across 305 episodes of AUB, 53% of the care was guideline adherent. There was high adherence with documenting menopausal status (98%), ordering diagnostic studies and referrals for postmenopausal women (92%), and documenting bleeding patterns (87%). There was lower adherence with documenting whether there was active bleeding (55%), performing thyroid testing (47%), performing a pelvic examination (42%), ordering diagnostic studies and referrals in younger women with increased endometrial cancer risk (40%), assessing for pregnancy (32%), assessing for cervical motion, uterine, or adnexal tenderness in patients with intrauterine devices (30%), and assessing for elevated endometrial cancer risk (6%). There were no significant differences in overall guideline adherence between primary care providers who were, versus were not, VA Designated Women's Health Providers, or by provider volume of encounters with women veterans. CONCLUSIONS: VA primary care has high guideline adherence when caring for postmenopausal women with AUB. Quality improvement and educational initiatives are needed to improve primary care for AUB in younger women veterans.