Study evaluates quality indicators for hormone therapy in menopausal women

Improvements are needed in VA's prescribing of hormone therapy for menopausal women veterans, concludes a study in the (JHQ), the peer-reviewed journal of the National Association for Healthcare Quality (NAHQ).

"Our findings underscore the need to develop and implement innovations for providing practitioners with point-of care information and decision support to ensure patients are receiving guideline-adherent care in health care settings, including VA," comments lead author Kristina M. Cordasco, MD, MPH, of VA Greater Los Angeles Health System.

Quality Indicators Show Need for Improvement in Hormone Therapy for Women Veterans

The researchers developed a set of seven quality indicators to assess how well hormone therapy prescribed for women veterans met accepted, evidence-based guidelines. Recommendations for systemic (oral) hormone therapy in menopausal women can be complex. Estrogen therapy is effective for menopausal symptoms, especially hot flashes, and can reduce the risk of fractures in women with osteoporosis.

However, hormone therapy can increase the risk of certain cancers, blood clots, and other health problems. It should not be used for other types of menopausal symptoms, such as sexual dysfunction or depression; or in women with certain health issues (contraindications), such as breast cancer or heart disease. In addition, in women with a uterus (those who haven't had a hysterectomy), the hormone progesterone should always be given with estrogen to protect against endometrial cancer.

Dr. Cordasco and colleagues used their quality indicators to assess adherence to guidelines for hormone therapy in women veterans. The analysis included a total of 355 systemic hormone prescriptions provided to 266 women at four VA centers.

Across the seven quality indicators, average adherence to systemic hormone therapy guidelines was 58 percent, with similar rates for new and renewal prescriptions. About three-fourths of new prescriptions documented a specific indication for hormone therapy consistent with current guidelines. However, in more than one-fourth of cases, there was no documentation of the absence of contraindications.

In more than half of new prescriptions, the initial prescription for estrogen was higher than the generally recommended starting dose, without documented reasons for this high dose . Most renewal prescriptions stayed at this high dose, or escalated it without a documented reason. In eight out of 116 cases, progesterone was not initially prescribed along with estrogen in women with an intact uterus, potentially transiently increasing their risk of endometrial cancer.

Women's health issues can pose a challenge in the VA system, where only about ten percent of patients are women. To address this challenge, VA channels patients into panels of Designated Women's Health Providers (DWHPs). Most hormone therapy prescriptions were written by DWHPs, but their performance in following guidelines was similar to that of other providers.

The study suggests that nearly 40 percent of prescriptions for systemic hormone therapy for menopausal women in the VA system aren't consistent with evidence-based guidelines. It is unknown how this finding compares to guideline adherence in healthcare settings outside VA, as such studies have not been conducted. However, this finding is "unfortunately consistent with prior work in other conditions and populations," the researchers write.

The quality indicators developed for the study should be used to assess prescriptions in other patient populations and other healthcare systems, Dr. Cordasco and colleagues believe. They write, "Our findings lay important foundation for interventions for improving guideline adherence." The researchers call for further studies of the underlying reasons for variations in care, along with evaluation of computerized decision support or other tools to ensure safe use of hormone therapy in women veterans.