Achieving early surgery for undescended testes: quality improvement through a multifaceted approach to guideline implementation.

BACKGROUND: Surgery for undescended testes is recommended before the age of 2 years. However, boys are still undergoing surgery for undescended testes at a much later age than recommended.
METHODS: An initial audit reviewed all orchidopexies performed at Northampton General Hospital between 1992 and 1994. This demonstrated that only 19% of boys had surgery by the age of 2 years, and the key reason for late surgery was late referral. Guidelines for referral of undescended testes were established in which referral to a surgeon was advised following the 8-month child health surveillance check if undescended testis was suspected. This would enable surgery before the age of 2 years. Audit results were disseminated and we implemented a package of measures based on evidence based change management techniques. These included written advice to general practitioners (GPs), a parent information leaflet and an amended personal child health record advising timing of referral. A reminder to the GP to refer following the 8-month check was generated using computer recall from the Child Health System records. Guideline implementation was monitored by annual audit and feedback.
RESULTS: The baseline audit for the years 1992-94 found a median age at surgery of 4 years. Implementation of the new policies in 1998 resulted in a reduction in median age at surgery to 2.0 years in the 12 months ending September 2001.
CONCLUSIONS: While concern about the age at orchidopexy has been highlighted in many previous studies, this is the first to show that improvement in the age at orchidopexy can be achieved. Implementing locally agreed guidelines with written information to GPs and parents combined with computerized recall from Child Health System records achieved the target within 3 years. Similar systems could be implemented nationally at minimal cost.