R.P.M.G. Hermens

The effect of a multifaceted empowerment strategy on decision making about the number of embryos transferred in in vitro fertilisation: randomised controlled trial

Objective To evaluate the effects of a multifaceted empowerment strategy on the actual use of single embryo transfer after in vitro fertilisation. Design Randomised controlled trial. Setting Five in vitro fertilisation clinics in the Netherlands. Participants 308 couples (women aged <40) on the waiting list for a first in vitro fertilisation cycle. Interventions The multifaceted strategy aimed to empower couples in deciding how many embryos should be transferred. The strategy consisted of a decision aid, support of a nurse specialising in in vitro fertilisation, and the offer of reimbursement by way of an extra treatment cycle. The control group received standard care for in vitro fertilisation. Main outcome measures Use of single embryo transfer in the first and second treatment cycles as well as decision making variables and costs of the empowerment strategy. Results After the first treatment cycle, single embryo transfer was used by 43% (65/152) of couples in the intervention group and 32% (50/156) in the control group (difference 11%, 95% confidence interval 0% to 22%; P=0.05). After the second treatment cycle, single embryo transfer was used by 26% (14/154) of couples in the intervention group compared with 16% (8/51) in the control group (difference 10%, −6% to 26%; P=0.20). Compared with couples receiving standard care, those receiving the empowerment strategy had significantly higher empowerment and knowledge levels but no differences in anxiety levels. Mean total savings per couple in the intervention group were calculated to be €169.75 (£146.77;

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

219.12). Conclusions A multifaceted empowerment strategy encouraged use of single embryo transfer, increased patients’ knowledge, reduced costs, and had no effect on levels of anxiety or depression. This strategy could therefore be an important tool to reduce the twin pregnancy rate after in vitro fertilisation. This trial did not, however, demonstrate the anticipated 25% difference in use of single embryo transfer of the power calculation. Trial registration ClinicalTrials.gov NCT00315029.

Development of indicators for patient-centred cancer care

BACKGROUNDnElective 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.nnnMETHODSnWe 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.nnnRESULTSnWe 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.nnnCONCLUSIONSnThis 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.

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

PurposeAssessment of current practice with a valid set of indicators is the key to successfully improving the quality of patient-centred care. For improvement purposes, we developed indicators of patient-centred cancer care and tested them on a population of patients with non-small cell lung cancer (NSCLC).MethodsRecommendations for patient-centred care were extracted from clinical guidelines, and patients were interviewed to develop indicators for assessing the patient-centredness of cancer care. These indicators were tested with regard to psychometric characteristics (room for improvement, applicability, discriminating capacity and reliability) on 132 patients with NSCLC treated in six hospitals in the east Netherlands. Data were collected from patients by means of questionnaires.ResultsEight domains of patient-centred cancer care were extracted from 61 oncology guidelines and 37 patient interviews and were translated into 56 indicators. The practice test amongst patients with NSCLC showed the most room for improvement within the domains ‘emotional and psychosocial support’, ‘physical support’ and ‘information supply’. Overall, 26 of the 56 indicators had good psychometric characteristics.ConclusionsDeveloping a valid set of patient-centred indicators is a first step towards improving the patient centredness of cancer care. Indicators can be based on recommendations from guidelines, but adding patient opinions leads to a more complete picture of patient centredness. The practice test on patients with NSCLC showed that the patient centredness of cancer care can be improved. Our set of indicators may also be useful for future quality assessments for other patients with cancers or chronic diseases.

Information provision in fertility care: a call for improvement

BACKGROUNDnAfter 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.nnnMETHODSnA 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.nnnRESULTSnIn 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%.nnnCONCLUSIONSnThis 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

BACKGROUNDnAdequate 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.nnnMETHODSnAll 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 professionals 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.nnnRESULTSnA 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.nnnCONCLUSIONSnDespite 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.

Feasibility of a Wiki as a Participatory Tool for Patients in Clinical Guideline Development

BACKGROUNDnAbout 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.nnnMETHODSnA 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.nnnRESULTSnOne 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%).nnnCONCLUSIONSnThis 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.

Organizational determinants of patient-centered fertility care: a multilevel analysis

Background Patient participation is essential in developing high-quality guidelines but faces practical challenges. Evidence on timing, methods, evaluations, and outcomes of methodologies for patient participation in guideline development is lacking. Objective To assess the feasibility of a wiki as a participatory tool for patients in the development of a guideline on infertility determined by (1) use of the wiki (number of page views and visitors), (2) benefits of the wiki (ie, number, content, and eligibility of the recommendations to be integrated into the guideline), and (3) patients’ facilitators of and barriers to adoption, and the potential challenges to be overcome in improving this wiki. Methods To obtain initial content for the wiki, we conducted in-depth interviews (n = 12) with infertile patients. Transcripts from the interviews were translated into 90 draft recommendations. These were presented on a wiki. Over 7 months, infertile patients were invited through advertisements or mailings to formulate new or modify existing recommendations. After modifying the recommendations, we asked patients to select their top 5 or top 3 recommendations for each of 5 sections on fertility care. Finally, the guideline development group assessed the eligibility of the final set of recommendations within the scope of the guideline. We used a multimethod evaluation strategy to assess the feasibility of the wiki as a participatory tool for patients in guideline development. Results The wiki attracted 298 unique visitors, yielding 289 recommendations. We assessed the 21 recommendations ranked as the top 5 or top 3 for their eligibility for being integrated into the clinical practice guideline. The evaluation identified some challenges needed to be met to improve the wiki tool, concerning its ease of use, website content and layout, and characteristics of the wiki tool. Conclusions The wiki is a promising and feasible participatory tool for patients in guideline development. A modified version of this tool including new modalities (eg, automatically limiting the number and length of recommendations, using a fixed format for recommendations, including a motivation page, and adding a continuous prioritization system) should be developed and evaluated in a patient-centered design.

Coming soon to your clinic: high-quality ART.

OBJECTIVEnTo identify organizational determinants of positive patient experiences with fertility care, with the goal of improving patient centeredness of care.nnnDESIGNnCross-sectional survey.nnnSETTINGnOne large university clinic and 12 medium-sized fertility clinics in the Netherlands.nnnPATIENT(S)nThree hundred and sixty-nine couples receiving medically assisted reproduction in one of the participating clinics between March and May 2008.nnnINTERVENTION(S)nNone.nnnMAIN OUTCOME MEASURE(S)nOrganizational determinants of patients experiences with patient centeredness in fertility care.nnnRESULT(S)nOf the patients during the relevant period, 78% of the women and 76% of their partners participated in the study. Infertile couples who have a lead physician, have access to an electronic personal health record, or see trained fertility nurses have more positive experiences with aspects of patient-centered care, like continuity of care and partner involvement. Moreover, receiving a treatment other than in vitro fertilization was negatively associated with the perceived patient centeredness of care. The identified determinants explained 5.1% to 22.4% of the total variance.nnnCONCLUSION(S)nThis study provides organizational determinants of patients experiences with fertility care on numerous facets of patient centeredness. These organizational determinants can be used as valuable tools to enable clinics to provide a more positive patient experience.

Development of guideline-based indicators for patient-centredness in fertility care: what patients add.

The concept of patient-friendly medically assisted reproduction includes a robust set of clinical practice principles, to improve the quality of subfertility care. This concept is an important move away from the sole focus on effectiveness and high pregnancy rates in assisted reproduction technology (ART). Although the concept of patient-friendly ART has several strong points, we feel it is incomplete. For achieving true high-quality ART, the concept should be extended to two more dimensions: timeliness and patient centredness. Moreover, we propose a change in the concepts name to the less ambiguous high-quality ART.