Guidelines in gynaecology: evaluation in menorrhagia and in urinary incontinence

Objective To evaluate the effectiveness of national guidelines and local protocols in improving hospital care (process and outcome) for women with menorrhagia and for women with urinary incontinence. Design 2 x 2 balanced incomplete block controlled before and after study. Setting Gynaecology units in four district general hospitals across Scotland. Intervention National guidelines were adapted locally to protocols, which were disseminated at specific local educational meetings and implemented by placing a copy of the appropriate protocol in women's hospital casenotes prior to consultation. Population Four hundred and ninety-seven women with menorrhagia and 449 women with urinary incontinence. Main outcome measures Process of care within six key areas of clinical practice: initial hospital assessment; appropriate use of hospital investigations; inappropriate use of hospital investigations; appropriate first line treatments; appropriate pre-surgery assessment; and use of surgical treatments. Outcome of care using condition-specific outcome measures and four domains of SF-36 at zero, six and twelve months following intervention. Results There were significant improvements with the introduction of guidelines and protocols in two (initial hospital assessment and appropriate pre-surgery assessment) of the six key areas of clinical practice assessed. In the other areas there were no significant improvements or deteriorations observed. There was no evidence of effect of guidelines and protocols on the condition-specific outcome measures or on the four domains of the SF-36. Conclusions There were only very modest benefits observed from the introduction of guidelines and protocols on the hospital management of the two conditions. The reasons for this lack of impact of the guidelines is unclear. Experience of this study raises important methodological issues for future research in this area.