title: Variation in subfertility care measured by guideline-based performance indicators.
abstract: BACKGROUND
  About 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.
  
  
  METHODS
  A 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.
  
  
  RESULTS
  One 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%).
  
  
  CONCLUSIONS
  This 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.
authors.affiliation: Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
authors.forename: S M
authors.initials: SM
authors.lastname: Mourad
authors.forename: W L D M
authors.initials: WL
authors.lastname: Nelen
authors.forename: R P M G
authors.initials: RP
authors.lastname: Hermens
authors.forename: L F
authors.initials: LF
authors.lastname: Bancsi
authors.forename: D D M
authors.initials: DD
authors.lastname: Braat
authors.forename: G A
authors.initials: GA
authors.lastname: Zielhuis
authors.forename: R P T M
authors.initials: RP
authors.lastname: Grol
authors.forename: J A M
authors.initials: JA
authors.lastname: Kremer
mesh_terms: D000328:Adult; D015331:Cohort Studies; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007246:Infertility / Q000628:therapy*; D008297:Male; D017410:Practice Guidelines as Topic; D011785:Quality Assurance, Health Care; D011786:Quality Control; D019984:Quality Indicators, Health Care; D015203:Reproducibility of Results; D034121:Reproductive Health Services / Q000458:organization & administration* / Q000592:standards*; D012189:Retrospective Studies; D016896:Treatment Outcome