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Managing menorrhagia in primary care

 

Menorrhagia is an important health care problem for women of reproductive age: a high proportion of referrals to gynaecology departments is for menstrual problems. There is sound research evidence about effective treatments but rates of inappropriate prescribing are high. Ways to improve the management of menorrhagia in primary care are needed. The question is what is the best way to tackle the issue. A recent study [1] was designed to use what is known about educational methods to improve the treatment of and referral for menorrhagia in East Anglia.

Reference:

GRK Fender et al. Randomised controlled trial of educational package on management of menorrhagia in primary care: the Anglia menorrhagia education study. BMJ 1999; 318: 1246-50.

How was the question tackled?

The aim was to test an educational package that included many of the features of academic detailing through a randomised controlled trial. The educational package consisted of four elements: a presentation of the evidence about effective treatment and current variations, a printed reference summary, a flow-chart for the management of menorrhagia and a follow-up visit at six months.

All 305 general practices in East Anglia were invited to take part. After the initial letter of invitation, a telephone call was made to check whether the practice intended to take part. There were no financial incentives to join the study. 100 practices agreed to take part and were then randomised to an intervention or control group. A member of the research team visited the 54 practices in the intervention group to meet the partners as an informal group. An interactive style was used in the meeting to encourage participation as the meeting went through the educational package. The summary and flow-chart acted as an aid-memoire. The 46 control practices received a visit to explain the purpose of the study and a follow-up visit.

All practices identified women complaining of menstrual problems. Data sheets were used to record symptoms, therapeutic choices, visits and referral outcomes. All consultations were recorded on a separate sheet. Doctors in the intervention group were asked keep the pad of data sheets in their consulting room and to place the flow chart prominently as an aide-memoire. Copies of the data sheets were sent to the research team on completion.

What did the study find?

95 practices (52 intervention and 43 control) returned at least one data sheet of which 74 practices (40/34) had patients with regular heavy menstruation (menorrhagia). 16 of the 100 practices withdrew from data gathering and five practices failed to return any sheets - but still participated in them meetings. The reasons were pressure of work, staff shortages, illness and break up of the partnership. In total 1001 data sheets were returned from the 95 practices, of these 563 were for regular heavy periods (377 intervention and 186 control). This was noticeably (60%) less than expected.

Analysis of the data sheets was at practice level and showed that:

The status of the practice (for example as fund-holding or as a branch surgery) appeared to have no impact on treatment or on referral rates. However, there seemed to be a link between training practices and higher use of norethisterone. Significant links were also noted between dispensing practices and the proscription of mefenamic acid and between urban practices and the prescription of tranexamic acid and mefenamic acid.

What has the review told us?

This is another helpful study that shows that carefully planned initiatives can be successful - if proven techniques are used. In this case the concept of academic detailing see Box 1. Its interesting that as the study was being launched an Effective Health Care Bulletin about menorrhagia was published nationally. The 'literature' would argue that such publications do not change behaviour but it may have helped to raise interest in the issue and thus reinforce the messages in the educational package.

Box 1: Principles of academic detailing

Conducting interviews to investigate baseline knowledge and motivations for current prescribing patterns.

Focusing on specific categories of physicians as well as on their opinion leaders

Defining clear educational and behavioural objectives.

Establishing credibility through a respected organisational identity, using authoritative sources information and presenting both sides of controversial issues

Stimulating active participation

Using graphic educational material

Repeating messages

Providing reinforcement and follow-up

Nevertheless, the study did demonstrate that use of a well-designed educational package could increase the level of appropriate prescribing and lower the level of hospital referral. Again it would be good to know how long the improvement lasted - or has treatment lapsed back to the previous levels. As we've said before, ways to reinforce changes when a study has ended are important. It's a way to guarantee better value for the effort put into implementing change.