Variation in guideline adherence in intrauterine insemination care

Abstract

Health-care delivery according to clinical practice guidelines is thought to be critical in achieving optimal outcomes. This study aimed to assess the extent to which practice performance in intrauterine insemination (IUI) care is consistent with guideline recommendations and to evaluate the association between guideline adherence and outcome of IUI care. In a retrospective cohort study, 1100 infertile couples who underwent IUI treatment at 10 Dutch hospitals were asked to grant access to their medical record for assessment of guideline adherence using 25 systematically developed guideline-based performance indicators. A total of 558 couples who started 2334 IUI cycles participated. Guideline adherence regarding 20 process and five structure aspects of IUI care was often substandard and varied considerably between hospitals. Out of 10 possible associations investigated, guideline adherence regarding sperm quality and guideline adherence regarding the total number of IUI cycles were associated with improved ongoing pregnancy rates after IUI. Thus, guideline adherence in IUI care is far from optimal and varies substantially between hospitals. As associations between guideline adherence and ongoing pregnancy after IUI were mainly non-significant, further research is needed to evaluate associations between guideline adherence and other outcomes of IUI care besides ongoing pregnancy, such as patient safety and cost effectiveness.

Introduction

Infertility is common. As one in six couples fails to conceive within 1 year of regular unprotected sexual intercourse, approximately 72.4 million couples around the world are currently infertile (Boivin et al., 2007, Taylor, 2003). Roughly half of these couples seek medical care for their fertility problems (Boivin et al., 2007, Nachtigall, 2006). The clinical investigation and treatment of infertility has considerable physical and psychosocial implications for couples (Cousineau and Domar, 2007, Greil, 1997, Hughes, 2003, Verhaak et al., 2005). In addition, fertility treatment often carries a risk of multiple pregnancy which is associated with substantially higher rates of maternal and perinatal morbidity and mortality compared with singletons (Dickey et al., 2005, Fauser et al., 2005). The assessment and treatment of infertility is also expensive and the increased rates of adverse pregnancy outcomes add further to the resources used in health care (Goverde et al., 2000, Lukassen et al., 2004).

It is widely recognized that the quality of health care is often inadequate (Grol and Grimshaw, 2003, McGlynn et al., 2003). As infertility is a major health issue worldwide and its management is associated with health risks and high costs, there is great concern about the impact of substandard infertility care on health and health-care resources (Balen and Rutherford, 2007, Rawal et al., 2008). This prompted several professional societies in the fields of obstetrics and gynaecology, and reproductive medicine as well as governmental agencies to develop clinical practice guidelines for infertility care. These guidelines are tools to help physicians and patients to make better decisions about clinically effective, safe and cost-effective care and reduce inappropriate practice variation in infertility care. Essentially, these guidelines describe ‘the best thing to do’ and aim to improve the outcome of infertility care.

One of the most commonly used fertility treatments is homologous intrauterine insemination (IUI) (Nyboe Andersen et al., 2009). The overall success rate of IUI remains controversial. On average, reported clinical pregnancy rates are only 5–13% per IUI cycle (Bensdorp et al., 2007, Goverde et al., 2000, Guzick et al., 1999, Nyboe Andersen et al., 2009, Steures et al., 2004, Steures et al., 2007, The ESHRE Capri Workshop Group, 2009, Tummon et al., 1997, Verhulst et al., 2006). Poor guideline adherence and a high degree of inappropriate practice variation in IUI care may be responsible for these low pregnancy rates. However, up until now, there has been limited published evidence about guideline adherence in IUI care and the link between guideline adherence and outcome of IUI care. Therefore, the objective of this study was to assess the extent to which practice performance in IUI care is consistent with guideline recommendations and to evaluate the association between guideline adherence and outcome of IUI care.