title: General practitioners' adherence to work-up and referral recommendations in fertility care.
abstract: What is the current guideline adherence by general practitioners (GPs) for work-up and subsequent referral from primary to secondary care for patients suffering from infertility?
  
  
  
  Guideline adherence by GPs concerning infertility was 9.2% in couples referred.
  
  
  
  Adherence to recommendations can decrease unnecessary referral, diagnostics and treatments, and consequently result in lower expenditures. Moreover, patients can be saved from unnecessary hospital visits, emotional burden and out of pocket costs.
  
  
  
  A retrospective cohort study among 306 patients referred for basic fertility work-up between January 2011 and June 2013 from primary care to a secondary care teaching hospital or a tertiary hospital with IVF facilities.
  
  
  
  Couples were eligible to participate when there was no previous referral for fertility problems and the duration of the child wish was <2 years. Data to assess guideline adherence were collected from the referral letter and the medical records. A patient questionnaire was used to determine patients' general and fertility-related characteristics.
  
  
  
  The GP performed a Chlamydia Antibody Titre (CAT) testing and semen analysis as recommended in 15.9% and 42.2% of the referred patients, respectively. According to the guideline, 39% of the couples were under referred (i.e. not immediately referred as recommended), 8.8% were unnecessarily referred and the CAT and semen analysis were unnecessarily repeated in secondary care in 80.0% and 57.1% of cases, respectively.
  
  
  
  We could not include non-referred patients with expectant management in primary care, an unknown number of whom became pregnant in this period. This may have resulted in an underestimation of primary care performance.
  
  
  
  Our findings show that guideline adherence concerning work-up and subsequent referral for fertility problems is low. The influence of patient demands for referral remains largely unknown. Barriers and facilitators for guideline adherence should be determined to develop interventions to improve guideline adherence in the areas of work-up and referral for fertility care and to diminish duplicate tests in secondary care.
  
  
  
  Funded by CZ, a Dutch healthcare insurer (grant number AFVV 11-232). CZ had no role in designing the study, data collection, analysis and interpretation of data or writing of the report. Competing interests: None.
  
  
  
  Not applicable.
authors.affiliation: Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
authors.forename: H W
authors.initials: HW
authors.lastname: van der Pluijm-Schouten
authors.affiliation: Scientific Institute for Quality of Healthcare, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
authors.forename: R P M G
authors.initials: RPMG
authors.lastname: Hermens
authors.affiliation: Department of Obstetrics and Gynaecology, Canisius Wilhelmina Hospital, PO Box 9015, 6500 GS, Nijmegen, The Netherlands.
authors.forename: C F
authors.initials: CF
authors.lastname: van Heteren
authors.affiliation: Department of Primary and Community Care, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
authors.forename: H J
authors.initials: HJ
authors.lastname: Schers
authors.affiliation: Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
authors.forename: M J
authors.initials: MJ
authors.lastname: Schleedoorn
authors.affiliation: Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
authors.forename: M
authors.initials: M
authors.lastname: Arkenbout
authors.affiliation: Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
authors.forename: P W
authors.initials: PW
authors.lastname: Maassen
authors.affiliation: Scientific Institute for Quality of Healthcare, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
authors.forename: J A M
authors.initials: JAM
authors.lastname: Kremer
authors.affiliation: Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
authors.forename: W L D M
authors.initials: WLDM
authors.lastname: Nelen
mesh_terms: D000328:Adult; D000907:Antibodies, Bacterial / Q000032:analysis; D002689:Chlamydia / Q000276:immunology; D002690:Chlamydia Infections / Q000097:blood / Q000175:diagnosis / Q000276:immunology / Q000503:physiopathology; D015331:Cohort Studies; D005191:Family Characteristics; D005260:Female; D058005:General Practitioners; D006801:Humans; D007247:Infertility, Female / Q000175:diagnosis* / Q000453:epidemiology / Q000209:etiology / Q000628:therapy; D007248:Infertility, Male / Q000175:diagnosis* / Q000453:epidemiology / Q000503:physiopathology / Q000628:therapy; D008297:Male; D008499:Medical Records; D009426:Netherlands / Q000453:epidemiology; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care; D012017:Referral and Consultation; D012189:Retrospective Studies; D012307:Risk Factors; D055101:Semen Analysis
chemical_list: D000907:Antibodies, Bacterial
keywords: fertility work-up; guideline adherence; infertility; primary care; referral