Morrison J, Carroll L, Twaddle S, Cameron I, Grimshaw J, Leyland A, Baillie H, Watt G
Department of General Practice, University of Glasgow, Glasgow G12 0RR, UK.
BMJ. 2001 May 26;322(7297):1282-4. doi: 10.1136/bmj.322.7297.1282.
To investigate the effect of clinical guidelines on the management of infertility across the primary care-secondary care interface.
Cluster randomised controlled trial.
General practices and NHS hospitals accepting referrals for infertility in the Greater Glasgow Health Board area.
All 221 general practices in Glasgow; 214 completed the trial.
General practices in the intervention arm received clinical guidelines developed locally. Control practices received them one year later. Dissemination of the guidelines included educational meetings.
The time from presentation to referral, investigations completed in general practice, the number and content of visits as a hospital outpatient, the time to reach a management plan, and costs for referrals from the two groups.
Data on 689 referrals were collected. No significant difference was found in referral rates for infertility. Fewer than 1% of couples were referred inappropriately early. Referrals from intervention practices were significantly more likely to have all relevant investigations carried out (odds ratio 1.32, 95% confidence interval 1.00 to 1.75, P=0.025). 70% of measurements of serum progesterone concentrations during the midluteal phase and 34% of semen analyses were repeated at least once in hospital, despite having been recorded as normal when checked in general practice. No difference was found in the proportion of referrals in which a management plan was reached within one year or in the mean duration between first appointment and date of management plan. NHS costs were not significantly affected.
Dissemination of infertility guidelines by commonly used methods results in a modest increase in referrals having recommended investigations completed in general practice, but there are no detectable differences in outcome for patients or reduction in costs. Clinicians in secondary care tended to fail to respond to changes in referral practice by doctors. Guidelines that aim to improve the referral process need to be disseminated and implemented so as to lead to changes in both primary care and secondary care.
研究临床指南对跨越初级保健 - 二级保健界面的不孕症管理的影响。
整群随机对照试验。
大格拉斯哥健康委员会地区接受不孕症转诊的全科诊所和国民保健服务医院。
格拉斯哥的所有221家全科诊所；214家完成了试验。
干预组的全科诊所收到当地制定的临床指南。对照组诊所一年后收到。指南的传播包括教育会议。
从就诊到转诊的时间、全科诊所完成的检查、作为医院门诊患者的就诊次数和内容、达成管理计划的时间以及两组转诊的费用。
收集了689例转诊的数据。不孕症的转诊率没有显著差异。不到1%的夫妇被过早不恰当地转诊。干预组转诊的患者更有可能进行所有相关检查（优势比1.32，95%置信区间1.00至1.75，P = 0.025）。尽管在全科诊所检查时黄体中期血清孕酮浓度测量值和精液分析中有70%和34%被记录为正常，但在医院至少重复进行了一次。在一年内达成管理计划的转诊比例或首次预约到管理计划日期之间的平均持续时间方面没有发现差异。国民保健服务费用没有受到显著影响。
通过常用方法传播不孕症指南会使在全科诊所完成推荐检查的转诊略有增加，但在患者结局或费用降低方面没有可检测到的差异。二级保健的临床医生往往没有对医生转诊实践的变化做出反应。旨在改善转诊过程的指南需要进行传播和实施，以便在初级保健和二级保健中都能带来改变。
