Background
Genitourinary symptoms are common in postmenopausal women and negatively affect quality of life. National surveys and data collected from our health system indicate that postmenopausal women with genitourinary syndrome of menopause often do not receive appropriate diagnosis or treatment.
Aim
To promote increased detection and treatment of genitourinary syndrome of menopause, we created and tested a physician-centered health system intervention that included physician education sessions and a suite of evidence-based electronic health record tools.
Study design
Using a cluster-randomized design, we assigned primary care and gynecology clinics to the intervention or control group. From September to November 2014, we conducted training on the diagnosis and treatment of genitourinary syndrome of menopause in in-person presentations at each intervention clinic and in an online video.
We developed clinical decision support tools in the electronic health record that contained an evidence-based point-of-care knowledge resource, a standardized order set, and a checklist of patient educational materials for post-care summary. the patient’s visit.
The tools aimed to facilitate accurate diagnostic coding and prescription (SmartSet, SmartRx) along with relevant patient information (SmartText). Physicians who only made visits to control clinics received no training or notification about the tools.
Our primary outcome was vulvovaginal diagnoses made at follow-up visits for women aged 55 years or older from November 15, 2014 to November 15, 2015.
We also evaluated urinary diagnoses , vaginal estrogen prescriptions, and use of electronic tools. There was departmental support for the intervention but no prioritization within the health system to encourage change.
Results
In the 1-year period, 386 physicians performed 14,921 routine visits for women aged 55 years and older. Among the 190 physicians who completed good visits at the intervention clinics, 109 (57.4%) completed in-person or online educational training.
The proportion of visits that included a vulvovaginal diagnosis (7.2% vs 5.8%; odds ratio, 1.27; 95% confidence interval, 0.65-2.51) or urinary diagnosis (2.5% vs 3.1%; odds ratio, 0.79; 95% confidence interval, 0.55-1.13) or the prescription of vaginal estrogens (4.5% vs 3.7%; odds ratio, 1.24; 95% confidence interval, 0.63–2.46) did not differ between study arms.
There was a significant interaction for primary care and gynecology, revealing more vulvovaginal diagnoses by gynecology but not by primary care intervention clinics (odds ratio, 1.63; 95% confidence interval, 1.15-2). 31), but there was no significant interaction for prescriptions.
Physicians in intervention clinics were more likely to use decision support tools than those in control clinics: SmartSet (22.2% vs. 1.5%; odds ratio, 18.8; range 95% confidence interval, 5.5-63.8) and SmartText for patient information (38.0% vs. 24.4%; odds ratio, 1.91; 95% confidence interval, 1. 10-3,34). A per-protocol analysis revealed similar findings.
Conclusion Overall, the intervention did not result in more diagnoses or prescription of treatment for postmenopausal genitourinary symptoms, but it did result in greater sharing of patient information. Gynecologic physicians were more likely to address genitourinary symptoms overall and were more likely to make a vulvovaginal diagnosis postintervention. Additional efforts to improve care should consider continuing clinical education beginning with enhanced menopause curricula in residency training. Additional interventions to consider include increasing postmenopausal women’s access to gynecological care, addressing treatment barriers, and developing national performance metrics. |
