Implementation guideline of recurrent miscarriage (Alert-study)

Introduction Recurrent miscarriage (RM) is a complex clinical problem, concerning a heterogeneous group of women trying to conceive. Patients often do not receive evidence-based care, which in daily practice results in unnecessary and expensive diagnostic tests and treatment. In 2007, the Dutch guideline on RM was thoroughly revised. Unfortunately guidelines are not self-implementing and during measurement of the quality of care, guideline adherence appeared to be poor. Based on this measurement and on identified barriers for guideline adherence in RM, a strategy for implementation of the new guideline was developed and applied in two hospitals. The aim of this thesis is to investigate adherence to the revised guideline on RM, after introduction of the implementation strategy in the two participating hospitals. Methods A retrospective cohort study was performed in two Departments of Obstetrics and Gynaecology (AMC and OLVG), after introduction of the implementation strategy. All RM patients that visited the two participating hospitals between March 2009 and December 2009 were included. Data about the care they received were acquired from their medical records. The quality of care was measured with the guideline-based quality indicators for RM. Guideline adherence after the introduction of the strategy was compared to the guideline adherence in the two hospitals prior to introduction of the strategy. Results 140 women with RM were included. Selective karyotyping showed an improvement from 57.2% to 79.1% (p=0.000) and selective thrombophilia screening showed an improved from 38.9% to 78.4% (p=0.000). The quality indicators “perform anti-phospholipid antibody screening in all patients” and “determine random homocystein in all patients” showed an increase in adherence of 11.9% (p=0.064) and 12.4% (p=0.005) respectively. Overall, improvement of care was better at the AMC than at the OLVG. None of the indicators showed a significantly lower adherence after the strategy was introduced. Conclusion Introduction of the implementation package has contributed to a higher adherence of the guideline RM. Further measurement will take place in other hospitals where the strategy was introduced. A process evaluation will take place to determine which parts of the strategy are most effective. The results so far are promising for future dissemination and use of the strategy to improve care in RM.