Design and Implementation of a Clinician-Focused Intervention to Improve Diagnosis and Management of Symptomatic Vulvovaginal Atrophy in a Large Health System

Background/Aims: Nearly 50% of postmenopausal women experience symptoms related to vulvovaginal atrophy (VVA). However, despite the availability of effective treatment options, studies show that few women seek treatment for, and few providers ask women about, these symptoms. Our paired abstract describes clinician-reported barriers to diagnosis and management. Here we describe the prevalence of VVA diagnoses among women seen for well care within Kaiser Permanente Northwest (KPNW). We also describe the design of a clinician-focused intervention to improve diagnosis and management of symptomatic VVA. Methods: Using electronic medical record (EMR) data, we identified well visits among women 55 years or older occurring within 17 KPNW primary care and OB/GYN clinics between June 2013 and May 2014. We computed the proportion of women who received a VVA-related diagnosis at the index visit. We then stratified the clinics based on visit volume and randomized them to an immediate versus delayed clinician-focused intervention. The intervention includes online and in-person education for clinicians regarding: 1) diagnosis and management of symptomatic VVA, and 2) new EMR-based clinical support tools (Smartsets and Smarttexts). Results: We identified 14,274 unique well visits over the 1-year period of time. Of these, 80.5% (11,500/14,274) occurred in primary care. Only 5.7% (769/13,544) of visits by women not already using vaginal estrogen contained a VVA-related diagnosis. There are 371 clinicians; education for those in the intervention clinics is ongoing (Fall 2014). After the education period, we’ll prospectively collect EMR data to compare groups on the following outcomes: 1) proportion of well visits with VVA diagnoses; 2) proportion of women receiving vaginal estrogen prescriptions; and 3) proportion of visits that used the clinical support tools. We will also conduct an online survey of patients to determine if women in the intervention clinics are more likely than those in the control clinics to discuss VVA symptoms with their providers and to receive education and treatment options if symptomatic. Discussion: The proportion of postmenopausal women with a VVA-related diagnosis was lower than expected. The purpose of our ongoing study is to evaluate whether active outreach to providers with education and clinical support tools leads to improved diagnosis and management of VVA

Design, Implementation, and Response Rates From an Online Patient Survey to Assess Genitourinary Symptoms and Related Health Care Experiences of Postmenopausal Women

Background/Aims: Nearly 50% of postmenopausal women experience symptoms related to genitourinary syndrome of menopause (GSM), including vulvovaginal dryness and irritation, painful intercourse and urinary incontinence. As part of a clinician-focused intervention to improve diagnosis and management of GSM at Kaiser Permanente Northwest, we conducted an online survey of women with a well-woman visit to primary care and obstetrics/gynecology (OB/GYN) to assess patient vulvovaginal, urinary and sexual symptoms and related health care experiences. Our goal was to maximize patient participation while minimizing staffing requirements. Methods: Electronic communication was used for all contact with patients, including recruitment, consent, eligibility screening, survey and thank you gift cards. REDCap was used for everything except e-gift card ($5) delivery, which required a separate system. We sent an email invitation to all women ≥ 55 years old with a well-woman visit to primary care or OB/GYN during the previous week and an email address on file. Eligible patients were identified from the electronic medical record and uploaded to REDCap weekly. An initial recruitment email, which included a link to the survey, was sent each Tuesday morning. Patients who did not respond were re-sent the email the next Monday afternoon. Patients who clicked the survey link were taken to the REDCap site, which explained the study and contained the IRB-required consent language. Participants who actively agreed to participate then completed an eligibility screening page and, finally, the survey. For security, only one-time access was allowed to the survey. E-gift cards were sent weekly to all new respondents. REDCap and SAS software reports were run weekly to track recruitment patterns and watch for data anomalies. Results: Email addresses were found for 80% of eligible women (5,961/7,483). The overall response rate was 25% (1,483/5,961) and varied across the 18 randomized clinics from 19% to 34%. The response rate was lower for women ≥ 75 years old (18% vs. 26% for \u3c 75). The active refusal rate was 2%. Conclusion: Electronic surveys can successfully be used at relatively low cost, even for topics that are sensitive in nature. Lessons learned and copies of recruitment, consent, screening and survey materials as well as recruitment reports will be presented

Design, Implementation, and Response Rates From an Online Patient Survey to Assess Genitourinary Symptoms and Related Health Care Experiences of Postmenopausal Women

Background/Aims: Nearly 50% of postmenopausal women experience symptoms related to genitourinary syndrome of menopause (GSM), including vulvovaginal dryness and irritation, painful intercourse and urinary incontinence. As part of a clinician-focused intervention to improve diagnosis and management of GSM at Kaiser Permanente Northwest, we conducted an online survey of women with a well-woman visit to primary care and obstetrics/gynecology (OB/GYN) to assess patient vulvovaginal, urinary and sexual symptoms and related health care experiences. Our goal was to maximize patient participation while minimizing staffing requirements. Methods: Electronic communication was used for all contact with patients, including recruitment, consent, eligibility screening, survey and thank you gift cards. REDCap was used for everything except e-gift card ($5) delivery, which required a separate system. We sent an email invitation to all women ≥ 55 years old with a well-woman visit to primary care or OB/GYN during the previous week and an email address on file. Eligible patients were identified from the electronic medical record and uploaded to REDCap weekly. An initial recruitment email, which included a link to the survey, was sent each Tuesday morning. Patients who did not respond were re-sent the email the next Monday afternoon. Patients who clicked the survey link were taken to the REDCap site, which explained the study and contained the IRB-required consent language. Participants who actively agreed to participate then completed an eligibility screening page and, finally, the survey. For security, only one-time access was allowed to the survey. E-gift cards were sent weekly to all new respondents. REDCap and SAS software reports were run weekly to track recruitment patterns and watch for data anomalies. Results: Email addresses were found for 80% of eligible women (5,961/7,483). The overall response rate was 25% (1,483/5,961) and varied across the 18 randomized clinics from 19% to 34%. The response rate was lower for women ≥ 75 years old (18% vs. 26% for \u3c 75). The active refusal rate was 2%. Conclusion: Electronic surveys can successfully be used at relatively low cost, even for topics that are sensitive in nature. Lessons learned and copies of recruitment, consent, screening and survey materials as well as recruitment reports will be presented

Design and Implementation of a Clinician-Focused Intervention to Improve Diagnosis and Management of Symptomatic Vulvovaginal Atrophy: Clinician-Reported Barriers

Background/Aims: Nearly 50% of postmenopausal women experience symptoms related to vulvovaginal atrophy (VVA) including vulvovaginal dryness and irritation, painful intercourse, dysuria, urinary urgency and incontinence, and recurrent urinary tract infection. Effective treatment options are available, however few women seek treatment for these symptoms and few providers ask women if they are symptomatic. As part of the development of a clinician-focused intervention to improve diagnosis and management of symptomatic VVA among Kaiser Permanente Northwest patients, we conducted a survey of primary care and OB/GYN clinicians to assess provider knowledge about VVA and barriers to its diagnosis and treatment. Methods: We sent an email invitation to take a short online survey to all 353 Kaiser Permanente Northwest primary care and OB/GYN clinicians with valid email addresses. The survey included VVA knowledge questions related to symptoms, diagnosis and treatment, and practice assessment questions. We asked clinicians to report all potential barriers to VVA diagnosis and treatment in their practice. A list of potential barriers and an open-ended response option were provided. Results: The response rate was 34% (120/353). Knowledge about VVA was good; 67% (641/953) of responses were correct. Only 39.5% (47/119) of clinicians were likely to assess VVA in a postmenopausal patient if she did not mention symptoms. Most clinicians rated their confidence in counseling their patients as medium or less regarding menopause-related vaginal discomfort (56.1%; 67/118) and the risks/benefits of vaginal estrogen therapy (58%; 69/119). Commonly reported barriers were lack of time during the visit (75.4%; 86/114), lack of patient education materials (45.6%; 52/114) and clinical tools (18.4%; 21/114), patient discomfort with discussing vulvovaginal concerns (41.2%; 47/114), warnings about risks of estrogen medication in elderly women (36.8%; 42/114), and the clinicians’ lack of knowledge about VVA (32.5%; 37/114). Discussion: Provider knowledge about VVA symptoms and treatment is generally good. Barriers to patient care such as time, lack of clinical support tools, and patient-provider discomfort with discussion of VVA may explain why this easily treated condition is frequently underdiagnosed and undertreated. Our second abstract describes the intervention phase of our study, which includes the design and implementation of a clinician-focused intervention to improve diagnosis and management of symptomatic VVA