Clinical audit to improve the management of infertile couples in Scotland
Aims were (1) to review the literature on clinical audit; its history, methodology and role in the current National Health Service (NHS) Clinical Effectiveness initiative; and (2) to describe and discuss one national clinical audit exercise, the Gynaecology Audit Project in Scotland (GAPS) audit of the investigation and initial management of infertility. Care by general practitioners: The review of referral letters revealed that less than half of couples have basic tests of confirmation of ovulation and semen analysis performed in primary care. Conversely, up to a fifth of women with regular menses undergo unnecessary and expensive endocrine investigations. Between the two audit periods, significant, but modest, improvements occurred in the proportion of couples where the male partner was examined and had semen analysis performed and where the women's rubella status was checked. Care by gynaecologists: Between the two audit periods, significant changes in line with nine of the agreed audit criteria were demonstrated. two significant changes contrary to the agreed criteria also occurred. Patient satisfaction and experience: The patient survey indicated that 87% of women were satisfied with their care. However, over a third (39%) had never been asked to bring their partner to the clinic; 86% felt they had not been given enough help with emotional aspects of infertility; only a third had been given any written information and 78% expressed a wish for more written information. Conclusions: Clinical audit remains a cornerstone of national strategies to promote more uniform standards of high quality, evidence-based care. The GAPS Infertility Audit demonstrated the feasibility of conducting a national audit exercise encompassing patient management in both primary and secondary care settings. Modest changes in the process of care and in patients' experience were demonstrable. The modest extent of change confirms the view that audit and feedback may not be the most effective means of promoting improvements in practice. Further research is needed to determine obstacles to change and the most effective ways of overcoming them.