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.

Evaluation of an effective multifaceted implementation strategy for elective single-embryo transfer after in vitro fertilization.

STUDY QUESTION: What is the relationship between the rate of elective single-embryo transfer (eSET) and couples' exposure to different elements of a multifaceted implementation strategy? SUMMARY ANSWER: Additional elements in a multifaceted implementation strategy do not result in an increased eSET rate. WHAT IS KNOWN ALREADY: A multifaceted eSET implementation strategy with four different elements is effective in increasing the eSET rate by 11%. It is unclear whether every strategy element contributes equally to the strategy's effectiveness. STUDY DESIGN AND SIZE: An observational study was performed among 222 subfertile couples included in a previously performed randomized controlled trial. PARTICIPANTS, SETTINGS AND METHODS: Of the 222 subfertile couples included, 109 couples received the implementation strategy and 113 couples received standard IVF care. A multivariate regression analysis assessed the effectiveness of four different strategy elements on the decision about the number embryos to be transferred. Questionnaires evaluated the experiences of couples with the different elements. MAIN RESULTS AND ROLE OF CHANCE: Of the couples who received the implementation strategy, almost 50% (52/109) were exposed to all the four elements of the strategy. The remaining 57 couples who received two or three elements of the strategy could be divided into two further classes of exposure. Our analysis demonstrated that additional elements do not result in an increased eSET rate. In addition to the physician's advice, couples rated a decision aid and a counselling session as more important for their decision to transfer one or two embryos, compared with a phone call and a reimbursement offer (P < 0.001). LIMITATIONS AND REASONS FOR CAUTION: The differences in eSET rate between exposure groups failed to reach significance, probably because of the small numbers of couples in each exposure group. WIDER IMPLICATIONS OF THE FINDINGS: Adding more elements to an implementation strategy does not always result in an increased effectiveness, which is in concordance with recent literature. This in-depth evaluation of a multifaceted intervention strategy could therefore help to modify strategies, by making them more effective and less expensive.

A review of strategies to stimulate dental professionals to integrate smoking cessation interventions into primary care.

OBJECTIVE: To summarise evidence regarding the effectiveness of various implementation strategies to stimulate the delivery of smoking cessation advice and support during daily dental care. BASIC RESEARCH DESIGN: Search of online medical and psychological databases, correspondence with authors and checking of reference lists. Only studies were selected which examined a support strategy to promote tobacco use cessation having a component to be delivered by a dentist, dental hygienist or dental assistant in the daily practice setting. Furthermore only controlled studies and systematic reviews were included. Methodological quality and outcomes were independently summarised and checked by two reviewers. RESULTS: Eight studies met the inclusion criteria: 4 addressed strategies aimed at the dental professional and 4 addressed strategies aimed at both professional and patient. Only 4 of the studies were of a good quality. The 8 studies used combinations of implementation strategies, which made it difficult to evaluate the effectiveness of distinct components. Professional education appeared to enhance motivation for smoking cessation activities and advice giving. Organisational interventions (e.g., protocols, involvement of the whole team, referral possibilities) and incorporation of patient-oriented tools also contributed to the delivery of smoking cessation interventions. CONCLUSIONS: Multifaceted support strategies positively influence dental professionals' knowledge of smoking and smoking cessation, their motivation to give advice and their performance. As only 4 studies were of good methodological quality, it was not possible to draw firm conclusions about specific components. Additional research is needed to unravel which strategies best stimulate the provision of smoking cessation advice and support during daily dental practice.

Experienced barriers and facilitators for integrating smoking cessation advice and support into daily dental practice. A short report.

In a controlled study, primary care dental professionals in the intervention group were encouraged to provide smoking cessation advice and support for all smoking patients with the help of a stage-based motivational protocol. The barriers and facilitators reported by the dental professionals on two occasions for their efforts to incorporate smoking cessation advice and counselling into daily patient care are summarised here. Lack of practice time and anticipated resistance on the part of the patient were cited as barriers by over 50% of the dental professionals in the first interviews. Periodontal treatment and the presence of smoking-related diseases were mentioned as the most important stimuli. The experience-based interviews revealed key points for the implementation of smoking cessation advice and support in daily dental care. Education on the associations between smoking and oral health, vocational training on motivational interviewing and the offering of structured advice protocols were identified as promising components for an implementation strategy to promote the involvement of dental professionals in the primary and secondary prevention of tobacco addiction.

In-training assessment using direct observation of single-patient encounters: a literature review.

We reviewed the literature on instruments for work-based assessment in single clinical encounters, such as the mini-clinical evaluation exercise (mini-CEX), and examined differences between these instruments in characteristics and feasibility, reliability, validity and educational effect. A PubMed search of the literature published before 8 January 2009 yielded 39 articles dealing with 18 different assessment instruments. One researcher extracted data on the characteristics of the instruments and two researchers extracted data on feasibility, reliability, validity and educational effect. Instruments are predominantly formative. Feasibility is generally deemed good and assessor training occurs sparsely but is considered crucial for successful implementation. Acceptable reliability can be achieved with 10 encounters. The validity of many instruments is not investigated, but the validity of the mini-CEX and the 'clinical evaluation exercise' is supported by strong and significant correlations with other valid assessment instruments. The evidence from the few studies on educational effects is not very convincing. The reports on clinical assessment instruments for single work-based encounters are generally positive, but supporting evidence is sparse. Feasibility of instruments seems to be good and reliability requires a minimum of 10 encounters, but no clear conclusions emerge on other aspects. Studies on assessor and learner training and studies examining effects beyond 'happiness data' are badly needed.

Are oral health complaints related to smoking cessation intentions?

OBJECTIVE: Smoking influences oral health in several ways (such as the occurrence of periodontitis, teeth discolouration and oral cancer); therefore, smoking behaviour should be addressed in dental care. Dentists can play a role in primary and secondary prevention of tobacco dependence. They see their patients repeatedly over time. This study investigates whether oral health complaints can be seized as an opportunity to start smoking cessation counselling. METHODS: A structured patient questionnaire in a sample of 1101 smokers (52.1% women, mean age 40.4 years) in a convenience sample of 87 primary care dental practices. The I-change model was used to describe factors influencing behavioural change. Dependent factors such as intention to quit smoking and related factors (attitude, social support and self-efficacy) were analysed in relation to independent factors such as oral health complaints (gingiva problems, gingiva inflammation, oral cancer and discoloured teeth) using a general linear model (univariate analysis), multinomial logistic regression analysis and multiple linear regression analysis. RESULTS: A total of 56.3% had discoloured teeth, 27% of the smokers had a problem with their gums and 15.7% had gingiva inflammation. We found no direct relation between oral health complaints and the intention to quit smoking. However, teeth discolouration was positively related to attitudes towards smoking cessation [ß, Confidential interval (95%); 1.92 (1.45-2.40 for advantages and -0.86(-1.18 to -0.53) for disadvantages] and negatively to self-efficacy regarding quitting [-2.69 (-3.49 to 1.88)]. CONCLUSIONS: We found no direct relation between oral health complaints and the intention to quit smoking, but oral health complaints and especially teeth discolouration were related to factors influencing the quit intention. Patients with discoloured teeth are more likely to have a positive attitude towards smoking cessation but are uncertain to persist smoking cessation. It is suggested that teeth discolouration can be a good entrance for addressing smoking cessation in daily dental practice.

Three methods of multi-source feedback compared: a plea for narrative comments and coworkers' perspectives.

BACKGROUND: Doctor performance assessments based on multi-source feedback (MSF) are increasingly central in professional self-regulation. Research has shown that simple MSF is often unproductive. It has been suggested that MSF should be delivered by a facilitator and combined with a portfolio. AIMS: To compare three methods of MSF for consultants in the Netherlands and evaluate the feasibility, topics addressed and perceived impact upon clinical practice. METHOD: In 2007, 38 facilitators and 109 consultants participated in the study. The performance assessment system was composed of (i) one of the three MSF methods, namely, Violato's Physician Achievement Review (PAR), the method developed by Ramsey et al. for the American Board of Internal Medicine (ABIM), or the Dutch Appraisal and Assessment Instrument (AAI), (ii) portfolio, (iii) assessment interview with a facilitator and (iv) personal development plan. The evaluation consisted of a postal survey for facilitators and consultants. Generalized estimating equations were used to assess the association between MSF method used and perceived impact. RESULTS: It takes on average 8 hours to conduct one assessment. The CanMEDS roles 'collaborator', 'communicator' and 'manager' were discussed in, respectively, 79, 74 and 71% of the assessment interviews. The 'health advocate role' was the subject of conversation in 35% of the interviews. Consultants are more satisfied with feedback that contains narrative comments. The perceived impact of MSF that includes coworkers' perspectives significantly exceeds the perceived impact of methods not including this perspective. CONCLUSIONS: Performance assessments based on MSF combined with a portfolio and a facilitator-led interview seem to be feasible in hospital settings. The perceived impact of MSF increases when it contains coworkers' perspectives.

Impact of guideline implementation on patient care: a cluster RCT.

In Western European countries, dentists use standardized procedures, rather than individualized risk assessment, for routine oral examinations. The predictive hypothesis was that guideline implementation strategies based on multifaceted interventions would be more effective in patient care than the dissemination of guidelines only. A cluster-randomized trial was conducted, with groups of general dental practitioners (GDPs) as the unit of randomization. Patients were clustered within practices and prospectively enrolled in the trial. Patient data were collected from registration forms. The primary outcome measure was guideline-adherent recall assignment, and a secondary outcome measure was guideline-adherent bitewing frequency. The interventions consisted of online training, guideline dissemination, and educational sessions. For low-risk patients, guideline-adherent recall increased in the intervention group (+8%), which differed from the control group (-6.1%) (p = 0.01). Guideline-adherent bitewings showed mixed results. We conclude that multifaceted intervention had a moderate but relevant effect on the performance of GDPs, which is consistent with other findings in primary care.

What determines the provision of smoking cessation advice and counselling by dental care teams?

OBJECTIVE: To investigate determinants of the provision of smoking cessation advice and counselling by various dental professionals in the dental team (dentists, dental hygienists and prevention auxiliaries). DESIGN: Cross-sectional design. SETTING: Sixty-two general dental practices in the Netherlands. METHODS: Multivariate logistic analyses of self-reported counselling behaviour collected from questionnaires for dentists (n = 72), dental hygienists (n = 31) and prevention auxiliaries (n = 50) in general dental practices. MAIN OUTCOME MEASURES: Stimuli and barriers for smoking cessation counselling and advice behaviour to patients with or without oral health problems. RESULTS: Dental hygienists provided more general cessation advice and counselling than dentists. However, when patients had oral complaints, dentists counselled more often compared to prevention auxiliaries. The support from experienced colleagues positively influenced the provision of advice and counselling as well as the perceived self-efficacy for all kinds of dental professionals. CONCLUSIONS: The provision of general smoking cessation advice to patients with no acute oral complaints can be improved by more involvement of the dentist and/or task delegation to prevention auxiliaries and dental hygienists. Social support is important in encouraging more smoking cessation advice and counselling. Implementation strategies for support of smoking cessation in dental care should focus on creating a positive advice culture among colleagues.

Information provision in fertility care: a call for improvement.

BACKGROUND: Adequate information provision is a crucial dimension of high-quality fertility care. Clinical practice guidelines containing consensus-based recommendations may standardize practice between settings. This study was designed for three purposes: (i) to assess actual adherence to recommendations on information provision, (ii) to measure patient satisfaction with current practice and (iii) to analyse how variation in adherence relates to the characteristics of patients and clinics. METHODS: All recommendations concerning patient information were extracted from 10 national fertility guidelines and edited into a patient questionnaire. Additional questions concerning patient satisfaction and potential determinants of information provision at patient level were included. A total of 2698 couples from 16 clinics were invited to participate. A professional's questionnaire was sent to all gynaecologists to gather potential determinants at clinic level. Multilevel regression analysis was performed to identify the determinants of information provision. RESULTS: A total of 1499 couples (56%) participated. The percentage of couples who reported to have received complete information varied between recommendations from 10 to 96% (mean 57%). Overall, 94% of couples were satisfied with fertility services. The use of checklists for information provision, the presence of obstetrics/gynaecology residents and specialized nursing personnel, and higher patient anxiety scores were significantly associated (P < 0.05) with higher levels of information received. CONCLUSIONS: Despite the possibility of recall bias in questionnaire studies and observed high patient satisfaction with fertility services, we conclude that information provision for infertile couples is currently poor and in need of improvement. This could easily be procured by, for example, the use of information checklists.

Patient-oriented intervention in addition to centrally organised checkups improves diabetic patient outcome in primary care.

BACKGROUND: Logistic support to general practitioners improves the care processes for patients with diabetes but is not sufficient to meet all criteria. AIM: To introduce patient-oriented interventions by a practice nurse in general practices which already use logistic support to improve the care processes for patients with diabetes. DESIGN OF STUDY: A controlled before-after study with delayed intervention in the control group. SETTING: 51 practices (n = 23 for the intervention and n = 28 for the control group) in the south of The Netherlands and 900 of their patients with type 2 diabetes. METHODS: Data were collected on the results of the checkups (fasting blood glucose, glycosylated haemoglobin (HbA1C), cholesterol, cholesterol/high-density lipoprotein ratio, triglycerides, creatinine, blood pressure, fundus photo, foot exam and body mass index), smoking status, physical activity and medication use. The effect of the patient-oriented intervention was analysed in a mixed model with repeated measurement covariance structure. RESULTS: The HbA1C improved in the intervention group (from 7.3 to 7.1), while that of the control group deteriorated (from 7.2 to 7.3). The percentage of patients with an HbA1C >or=8.5 was halved after the intervention (from 13 to 6). Patients in the intervention group started to exercise more besides their daily activities compared with the control group. The need for medication increased more in the control group than in the intervention group (more changes to insulin and more defined daily dose (DDD) oral medication). CONCLUSION: Patient-oriented interventions in addition to logistic support have a positive effect on diabetic patient outcomes.

Perceived barriers to elective single embryo transfer among IVF professionals: a national survey.

BACKGROUND: After initial years of improvement, the multiple pregnancy rate after in vitro fertilization (IVF) in Europe now remains stable at 23% with single embryo transfer (SET) constituting 19% of all IVF cycles. Although elective SET prevents multiple pregnancies after IVF, couples and professionals apparently often decide to transfer more embryos. Previous qualitative research has identified factors that impede the use of elective SET. The aim of this study was to quantify those barriers among IVF professionals and to identify predictors of professionals' willingness to perform elective SET. METHODS: A national survey among all Dutch IVF professionals quantified the barriers suggested by a previous qualitative study and assessed characteristics of the professionals and clinics. Multivariate analysis identified predictors related to the willingness of IVF professionals to perform elective SET. RESULTS: In total, 107 professionals participated. The most frequently mentioned barriers to elective SET use were suboptimal success rates associated with cryopreservation (96%), not seeing twin pregnancies as a complication (79%) and lack of a SET protocol (78%). Two variables seem to predict the professionals' willingness to perform elective SET: university hospital of the initial fertility training (P< 0.01) and high scores of perceived barriers, e.g. professionals' attitudes and skills (P < 0.01). The explained variance of these two variables was 25%. CONCLUSIONS: This study has identified the main barriers to elective SET use and predictors for willingness of professionals to perform elective SET. This insight into the decision-making process could be critical in terms of increasing the use of elective SET.

Variation in subfertility care measured by guideline-based performance indicators.

BACKGROUND: About 30-40% of patients do not receive care based on available scientific evidence. For subfertility, this may imply unnecessary and expensive diagnostic tests and treatments. It is therefore important to identify gaps in performance by monitoring current subfertility care. A set of 39 guideline-based performance indicators was previously developed for this purpose. This study aimed to assess several quality criteria of the indicator-set and to use the set to assess current subfertility care. METHODS: A historic cohort study was performed in 16 Dutch subfertility clinics; 2698 couples were invited to participate. Indicator data were gathered by medical record extraction, and patient and professional questionnaires. Quality criteria for each indicator (measurability, reliability, applicability, improvement potential, discriminatory capacity, complexity and case-mix stability) were assessed. Current practice was measured as adherence to the separate indicators. RESULTS: One thousand four-hundred and ninety-nine (56%) couples participated. All indicators were measurable, but the results for the other quality criteria varied. In total, 14 of the 39 indicators scored <50% adherence. Variation in performance between the clinics was up to 100%. The highest median adherence (86%) is found within the guideline 'indications for IVF-treatment'. The lowest median adherence is found within the guideline 'initial assessment of fertility' (43%), followed closely by the guideline 'anovulation' (44%). CONCLUSIONS: This study shows the quality of the developed indicator-set for monitoring clinical subfertility care. A first assessment in the Netherlands reveals large variation between clinics and ample room for improvement of care.

Why don't we perform elective single embryo transfer? A qualitative study among IVF patients and professionals.

BACKGROUND: Elective single embryo transfer (eSET) enables the prevention of multiple pregnancies after in vitro fertilization (IVF). However, in Europe, the multiple pregnancy rate after IVF remains stable at approximately 23%, with SET occurring in 15% of all IVF cycles. In most European clinics, the decision for the number of embryos transferred is established through a form of shared decision-making between patients and professionals. The aim of this study is to explore factors influencing this decision, in particular factors preventing eSET use. METHODS: We performed explorative, semi-structured, in-depth interviews, based on two theoretical models. The interviews were performed among 19 Dutch IVF professionals and 20 patients who had just undergone IVF or were on the waiting list for IVF. The interviews were fully transcribed and two researchers independently scored the factors according to the models. RESULTS: We identified a wide variety of factors, potentially influencing eSET use: 37 with the professionals and 26 among the patients. Examples of factors mentioned by both patients and professionals were: uncertainty about the eSET technique, couples' lack of knowledge about essential eSET aspects, absence of a reimbursement system which favours eSET, inadequate options to select couples suitable for eSET and inferior cryopreservation success rates. CONCLUSIONS: This study demonstrates that both IVF professionals and patients identify numerous factors preventing eSET use in clinical practice. To estimate the impact of these factors identified, a quantitative confirmation and assessment of the magnitude of the effect is necessary.

The methodological quality of clinical guidelines of the European Society of Human Reproduction and Embryology (ESHRE).

BACKGROUND: Clinical practice guidelines bridge the gap between the evidence from literature and clinical practice, and they may provide guidance in ethical, legal and societal dilemmas. To explore the potentials for future international guideline development within the field of human reproduction and embryology, we assessed the quality of existing guidelines produced by the European Society of Human Reproduction and Embryology (ESHRE). METHODS: We systematically searched for the ESHRE guidelines produced after 1996 in electronic databases and on the Internet. Subsequently, we assessed the methodological quality of these guidelines using the validated Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument. RESULTS: The overall methodological quality of most of the 11 selected ESHRE guidelines was poor. Most of the guidelines scored <30% in the domains of 'stakeholder involvement', 'rigour of development', 'applicability' and 'editorial independence'. Only one guideline was rated 'strongly recommended'. CONCLUSIONS: The methodological quality of the guidelines produced under the auspices of ESHRE can be improved. We suggest a systematic, up-to-date methodology, investment in guideline development specialists, systematic quality control and the incorporation of indicator development. Furthermore, attention should be paid to the document nomenclature, and an ESHRE guidelines' summary on a special part of the ESHRE website would be a good initiative.

Possibilities for transborder cooperation in breast cancer care in Europe: a comparative analysis regarding the content, quality and evidence use of breast cancer guidelines.

To encourage transborder cooperation in breast cancer care in Europe, we explored possibilities with the German-Dutch border area as an example. Evidence-based breast cancer guidelines were searched and compared on the: (1) methodological quality (with AGREE (Appraisal of Guidelines for Research and Evaluation)), (2) content of recommendations and (3) evidence use. The methodological quality of the German (n=2) and Dutch guidelines (n=2) was generally sufficient and comparable, although the applicability and the editorial independence were not clearly documented in the Dutch guidelines. Regarding the content analysis, German recommendations were taken as a reference point, because of the highest AGREE scores. Twenty-one of 25 recommendations discussed in both guidelines were corresponding and 4 were different, 32 were not mentioned in the Dutch guideline. The guidelines shared little evidence (< or =11%). We conclude that there are possibilities to encourage transborder cooperation. The clinical context of our results should be examined by measuring the actual care in both countries preferably with quality indicators.

Determinants of the choice for single or double embryo transfer in twin prone couples.

BACKGROUND: Some 84% of all European in vitro fertilisation (IVF) and intracytoplasmatic sperm injection (ICSI) cycles is performed with the transfer of more than 1 embryo, with 22% resulting in twin pregnancies. At many centres, the choice for one or more embryos is made through a shared decision-making process. To reduce the twin rate in a twin prone population by increasing the use of elective single embryo transfer (eSET), it is important to identify which objective patient factors are related to the choice for double embryo transfer (DET) and eSET. Therefore, the aim of this study was to identify determinants related to the choice for the transfer of eSET or DET in a twin prone population. METHODS: A retrospective study was performed on 477 twin prone couples at 2 Dutch IVF centres. We collected data on possible objective patient determinants, and a multivariate logistic regression analysis was performed to determine the impact of these determinants on the decision for DET. RESULTS: Of the twin prone couples, 61% opted for DET in their first IVF/ICSI cycle. Within the multivariate analysis, two objective patient determinants acted as a risk factor for the choice of DET - a lower number of available embryos (p=0.03) and a previous ongoing pregnancy after IVF/ICSI (p=0.04). The explained variance of the determinants was 3%. CONCLUSIONS: In twin prone couples, 61% still opted for DET in their first IVF/ICSI cycle. We identified 2 objective patient determinants for DET, but with an explained variance of only 3%. Therefore, further research is necessary to identify barriers and facilitators for eSET at both the level of the couples and clinicians.

Guideline-based development of quality indicators for subfertility care.

BACKGROUND: Internationally, several organizations have developed clinical guidelines for subfertility care to supply patients with the best possible care. However, to improve the implementation of such guidelines, we first need to gain insight into the application of clinical guidelines in daily practice. Valid quality indicators are necessary to estimate actual guideline adherence. However, none of the existing subfertility guideline programmes is accompanied by a satisfactory set of quality indicators. In this study, we develop a set of valid guideline-based quality indicators for subfertility care. METHODS: A systematic RAND-modified Delphi method was used to develop a set of key recommendations based on 10 national Dutch subfertility guidelines, international literature and existing international indicators. Experts' opinions were used to appraise recommendations regarding specific criteria such as efficacy, level of health gain, applicability and potential for care improvement. RESULTS: A representative set of 39 key recommendations was selected from 303 initial recommendations. The recommendations covered two structural and 37 procedural aspects, the latter encompassing 'indications for treatment', 'diagnostic procedures', 'treatment procedures' and 'patient information'. CONCLUSIONS: This study describes the systematic, stepwise method used to develop 39 process and structure indicators that can be used to monitor subfertility care.

Antibiotic prescribing in primary care: first choice and restrictive prescribing are two different traits.

OBJECTIVE: To investigate the quality of antibiotic prescribing in primary care using quality indicators and the relatedness of these indicators. To determine the influence of general practice and practice population characteristics on the indicator scores. METHODS: Data on performance were collected during the Second National Survey of General Practice over 1 year between May 2000 and April 2002 in The Netherlands. The study was carried out in 104 computerised general practices, comprising 195 general practitioners and about 400,000 patients. From a preliminary set of quality indicators on antibiotic prescribing (n = 15), eight were selected covering various medical conditions. Indicator scores were derived. A factor analysis was performed to examine the relatedness of these indicators. Composite scores were calculated for the indicators loading on the same factor. The influence of general practice and practice population characteristics on the quality of antibiotic prescribing was investigated. RESULTS: Considerable variation was found between indicator scores (32.8-94.2%) and between practices. The factor analysis discovered two interpretable factors-namely, "first choice prescribing" and "restrictive prescribing". The composite scores were 64% and 68%, respectively. No significant correlation was found between the two composite scores. Practice and population characteristics explained only a small proportion of the variance between practices. CONCLUSIONS: Although different quality indicators on antibiotic prescribing are grouped together over several medical conditions, there is large variation between those indicators. General practices performing well on first choice prescribing do not automatically perform well on restrictive prescribing. There is room for improvement on both aspects of prescribing. The variation between practices is clearly present and should be further investigated.

[Practice guidelines and accreditation: highlights from 50 years of quality management by the Dutch College of General Practitioners]. / Standaarden en praktijkaccreditering: hoogtepunten van 50 jaar kwaliteitsbeleid van het Nederlands Huisartsen Genootschap.

The Dutch College of General Practitioners (NHG) was established 50 years ago in response to the threatened position of general practitioners in The Netherlands. The NHG promotes quality care in general practice by aiding in the translation of scientific evidence into daily practice. The NHG practice guidelines form the core of its quality improvement programme, which comprises a cohesive package of continuing educational materials that support adoption in daily practice. The NHG practice accreditation programme is a new method for measuring and improving practice quality. This programme provides the basis for granting stamps of quality to general practices.