Improving management of the genitourinary syndrome of menopause: evaluation of a health system-based, cluster-randomized intervention.

Abstract Background Genitourinary symptoms are common in postmenopausal women and adversely impact quality of life. National surveys and data collected from our health care system demonstrate that postmenopausal women with the genitourinary syndrome of menopause often fail to receive appropriate diagnosis or treatment. Objective To promote greater detection and treatment of the genitourinary syndrome of menopause, we created and tested a clinician-focused, health system intervention that included clinician education sessions and a suite of evidence-based electronic health record tools. Study Design Using a cluster randomized design, we allocated primary care (16) and gynecology (6) clinics to intervention or control. From September–November 2014, we provided training about the diagnosis and treatment of genitourinary syndrome of menopause in face-to-face 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 education materials for the patient’s after visit summary. The tools aimed to facilitate accurate diagnostic coding and prescribing (SmartSet, SmartRx) along with relevant patient information (SmartText). Clinicians who only performed visits at control clinics received no training or notification about the tools. Our primary outcome was vulvovaginal diagnoses made at well visits for women aged 55 and older from 11/15/14 through 11/15/15. We also assessed urinary diagnoses, vaginal estrogen prescriptions and use of the electronic tools. There was departmental support for the intervention but no prioritization within the health care system to incentivize change. Results In the one-year period, 386 clinicians performed 14,921 well visits for women aged 55 and older. Among the 190 clinicians who performed well visits in the intervention clinics, 109 (57.4%) completed either in-person or online educational training. The proportion of visits that included a vulvovaginal (7.2% vs 5.8%; OR=1.27, 95% CI [0.65, 2.51]) or urinary diagnosis (2.5% vs. 3.1%; OR=0.79, 95% CI [0.55, 1.13]) or vaginal estrogen prescription (4.5% vs 3.7%; OR=1.24, 95% CI [0.63, 2.46]) did not differ between study arms. There was a significant interaction for primary care and gynecology, which revealed more vulvovaginal diagnoses by gynecology but not primary care intervention clinics (OR=1.63, 95% CI [1.15, 2.31]), but there was no significant interaction for prescriptions. Clinicians in the intervention clinics were more likely to use decision support tools compared to those in control clinics--SmartSet (22.2% vs.1.5%) OR=18.8, 95% CI [5.5, 63.8] and SmartText for patient information (38.0% vs. 24.4%) OR=1.91, 95% CI [1.10, 3.34]. A per protocol analysis showed similar findings. Conclusion Overall, the intervention did not lead to more diagnoses or prescription therapy for postmenopausal genitourinary symptoms but did result in greater distribution of patient information. Gynecology clinicians were more likely to address genitourinary symptoms generally and were more likely to make a vulvovaginal diagnosis after the intervention. Further efforts for improving care should consider ongoing clinician education beginning with enhanced menopause curricula in residency training. Additional interventions to consider include greater access for postmenopausal women to gynecologic care, addressing treatment barriers and development of national performance metrics.