The first contraception consult in general practice: how can we improve the quality for adolescents?
L. Peremans1, JJ Rethans2, V. Verhoeven1, L. Debaene1, P. Van Royen1, J. Denekens1
1Department of General Practice, University of Antwerp, Belgium,
2Skills Lab University of Maastricht, The Netherlands
Introduction: During the consultation the general practitioner GP has and should use the opportunity to counsel and to give correct information about different possibilities for contraception. A high quality contraception consultation with an adolescent is a challenge for every general practitioner and requires adequate knowledge and communication skills for adolescents.
Objectives: To evaluate the effectiveness of two implementation strategies (empowered patients and a computer software programme) for a clinical guideline on oral contraceptives in daily general practice.
Method: In 2002 an evidence-based clinical guideline for oral contraceptive use was developed and distributed to all Flemish GPs. To assess the basic performance of GPs we used incognito standardized patients in a randomised before and after study. On basis of a validated checklist the three standardized patients score their visits to the GPs and they register the circumstances and the duration of the consultation. One hundred fifty GPs, using the same electronic record software system, were invited to participate in the study. Based on GP’s mean score on the checklist of 24.01/48 (SD=7.01) in a pilot study in 2003, we calculated that a sample of 45 GPs (with á= 0.05 and 1-â = 80%) for the intervention. The at random selected GPs received a first visit by a standardized patient.
Five months after the basic assessment of performance one control and two interventions groups are planned. Both patients and GPs are blinded for the intervention. One group is visited by an ‘empowered’ patient and a second group l uses a new update of their computer software, with a ‘contraceptive consult’ tool included. The third group is a control group.
Results: Forty-three consults could be analysed. Before the intervention, GPs’ mean score on the checklist was 26.16 (SD=5.76). None of the GPs took a personal history to exclude sexual transmitted infections and only one third asked for contra-indications as high blood pressure and cancer. Less than one fourth asked for use of medication (9/43), diabetes (4/43), migraine (11/43) and liver disease (10/43). None of the physicians did a technical examination. The students got enough information about the correct pill use but hardly on factors associated with pill failure and interactions with other medication. For 8 GPs the pill prescription corresponded with the guidelines. In August we will measure GPs’ performance after the intervention and we will have the results of the intervention.
Conclusion: Developing and distributing guidelines are not enough to change GPs’ behaviour. For quality improvement of the contraception consult other interventions, on patients’ and doctors’ side, should be performed and evaluated.