title: Pragmatic randomised controlled trial to evaluate guidelines for the management of infertility across the primary care-secondary care interface.
abstract: OBJECTIVE
  To investigate the effect of clinical guidelines on the management of infertility across the primary care-secondary care interface.
  
  
  METHODS
  Cluster randomised controlled trial.
  
  
  METHODS
  General practices and NHS hospitals accepting referrals for infertility in the Greater Glasgow Health Board area.
  
  
  METHODS
  All 221 general practices in Glasgow; 214 completed the trial.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of General Practice, University of Glasgow, Glasgow G12 0RR, UK.
authors.forename: J
authors.initials: J
authors.lastname: Morrison
authors.forename: L
authors.initials: L
authors.lastname: Carroll
authors.forename: S
authors.initials: S
authors.lastname: Twaddle
authors.forename: I
authors.initials: I
authors.lastname: Cameron
authors.forename: J
authors.initials: J
authors.lastname: Grimshaw
authors.forename: A
authors.initials: A
authors.lastname: Leyland
authors.forename: H
authors.initials: H
authors.lastname: Baillie
authors.forename: G
authors.initials: G
authors.lastname: Watt
mesh_terms: D003362:Cost-Benefit Analysis; D005194:Family Practice / Q000592:standards*; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D007246:Infertility / Q000628:therapy*; D007255:Information Services; D008297:Male; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D013997:Time Factors; D016896:Treatment Outcome; D006113:United Kingdom