Toolkit-Based Approach to Improving Primary Care Provider (PCP) Confidence in Vasomotor Symptom (VMS) Management: A Quality Improvement Initiative

Vasomotor symptoms (VMS), including hot flashes and night sweats, affect a significant proportion of midlife women and can severely impact their quality of life. Despite their prevalence, many primary care providers lack confidence in identifying and managing VMS, leading to gaps in care. Targeted education has been shown to improve provider competency in menopause management. This quality improvement initiative aimed to enhance provider confidence in VMS management through structured educational interventions. A primary care clinic affiliated with a large academic health system identified a gap in provider confidence in VMS management. Pre-intervention data indicated that while 81% of providers felt somewhat confident in identifying VMS, only 76% reported confidence in managing it, with substantial reliance on external resources. Given the increasing demand for menopause care, this project sought to address these knowledge gaps and improve clinical preparedness. A Plan-Do-Study-Act (PDSA) framework guided the implementation of an educational intervention. A pre- and post-intervention survey assessed provider confidence in identifying and managing VMS. The study included 26 participants from various clinical backgrounds, including nurse practitioners, midwives, and physicians. Confidence levels were measured on a Likert scale, and statistical analysis was conducted using the Wilcoxon signed-rank test. Interventions: The intervention consisted of an evidence-based educational session on VMS pathophysiology, management strategies, and clinical guidelines. Participants received a decision-support toolkit and attended interactive discussions to reinforce learning. Results: Among the 12 participants who completed both pre- and post-surveys, confidence in identifying VMS improved but did not reach statistical significance (p = 0.084). Pre-intervention, 50% of providers agreed they were confident in determining when VMS should be treated; postintervention, this increased to 58%. Those reporting neutral or low confidence declined from 33% to 0%. Confidence in managing VMS showed a statistically significant improvement (p = 0.041). Pre-intervention, only 25% of providers agreed they were confident in managing VMS; post-intervention, this increased to 42%, with 58% reporting they were somewhat confident. Those with neutral or low confidence dropped from 33% to 0%. The intervention successfully elevated provider comfort with VMS management, a key step toward improving clinical decision-making. Screening practices and resource utilization also varied. While 43% of providers always screened for menopause-related symptoms pre-intervention, this increased post-intervention. All participants used external resources to some degree, with 33% relying on them all the time, highlighting an ongoing need for accessible clinical tools. Conclusion: This project successfully improved provider confidence in managing VMS, with statistically significant gains in management confidence and a positive trend in identification confidence. The intervention provided a cost-effective, structured educational approach to addressing menopause-related knowledge gaps. Future initiatives should focus on integrating menopause education into continuing medical education (CME) and providing ongoing clinical support to sustain practice improvements.

1 Toolkit-Based Approach to Improving Primary Care Provider Confidence in Vasomotor Symptom Management: A Quality Improvement Initiative Tammy Dunklebarger, Micaela Besser, Lisa Taylor-Swanson College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III April 14, 2025 2 Abstract Background Vasomotor symptoms (VMS), including hot flashes and night sweats, affect a significant proportion of midlife women and can severely impact their quality of life. Despite their prevalence, many primary care providers lack confidence in identifying and managing VMS, leading to gaps in care. Targeted education has been shown to improve provider competency in menopause management. This quality improvement initiative aimed to enhance provider confidence in VMS management through structured educational interventions. Local Problem A primary care clinic affiliated with a large academic health system identified a gap in provider confidence in VMS management. Pre-intervention data indicated that while 81% of providers felt somewhat confident in identifying VMS, only 76% reported confidence in managing it, with substantial reliance on external resources. Given the increasing demand for menopause care, this project sought to address these knowledge gaps and improve clinical preparedness. Methods A Plan-Do-Study-Act (PDSA) framework guided the implementation of an educational intervention. A pre- and post-intervention survey assessed provider confidence in identifying and managing VMS. The study included 26 participants from various clinical backgrounds, including nurse practitioners, midwives, and physicians. Confidence levels were measured on a Likert scale, and statistical analysis was conducted using the Wilcoxon signed-rank test. Interventions 3 The intervention consisted of an evidence-based educational session on VMS pathophysiology, management strategies, and clinical guidelines. Participants received a decision-support toolkit and attended interactive discussions to reinforce learning. Results Among the 12 participants who completed both pre- and post-surveys, confidence in identifying VMS improved but did not reach statistical significance (p = 0.084). Pre-intervention, 50% of providers agreed they were confident in determining when VMS should be treated; postintervention, this increased to 58%. Those reporting neutral or low confidence declined from 33% to 0%. Confidence in managing VMS showed a statistically significant improvement (p = 0.041). Pre-intervention, only 25% of providers agreed they were confident in managing VMS; post-intervention, this increased to 42%, with 58% reporting they were somewhat confident. Those with neutral or low confidence dropped from 33% to 0%. The intervention successfully elevated provider comfort with VMS management, a key step toward improving clinical decision-making. Screening practices and resource utilization also varied. While 43% of providers always screened for menopause-related symptoms pre-intervention, this increased post-intervention. All participants used external resources to some degree, with 33% relying on them all the time, highlighting an ongoing need for accessible clinical tools. Conclusion This project successfully improved provider confidence in managing VMS, with statistically significant gains in management confidence and a positive trend in identification confidence. The intervention provided a cost-effective, structured educational approach to 4 addressing menopause-related knowledge gaps. Future initiatives should focus on integrating menopause education into continuing medical education (CME) and providing ongoing clinical support to sustain practice improvements. Keywords: Vasomotor symptoms, menopause, primary care, provider confidence, quality improvement, medical education, hormone therapy, women's health 5 Toolkit-Based Approach to Improving Primary Care Provider Confidence in Vasomotor Symptom Management: A Quality Improvement Initiative Problem Description Vasomotor symptoms (VMS), such as hot flashes and night sweats, significantly impact the quality of life for menopausal women. These symptoms affect approximately 80% of menopausal women and typically persist for 7 to 9 years (The Menopause Society [TMS], 2023). Despite their prevalence, there is a notable lack of comprehensive menopausal education among primary care providers (PCPs) (Allen et al., 2023; Aninye et al., 2021; Kling et al., 2019; Vesco et al., 2024). Provider confidence is often hindered by limited menopause-specific education across medical training programs, concerns about hormone therapy safety, and time constraints within clinical practice (Allen et al., 2023; Brown et al., 2024). This knowledge gap impedes effective diagnosis and management of VMS, often resulting in inadequate treatment and prolonged patient discomfort (Aninye et al., 2021; Brown et al., 2024). Menopausal vasomotor symptoms extend beyond temporary discomfort; they are linked to a heightened risk of chronic conditions such as metabolic syndrome, type 2 diabetes, cardiovascular diseases, non-alcoholic fatty liver disease, and osteoporosis in perimenopausal and postmenopausal women (Ryu et al., 2020). Untreated VMS not only diminishes affected women's quality of life but also strains healthcare systems through increased service demand and resource utilization (Sarrel et al., 2015). In Utah, with only 37 menopause-certified providers for approximately 683,000 women aged 45-64, the patient-to-provider ratio is about 18,432 women per provider (United States Census Bureau, 2022). This limited number of providers exacerbates the issue, and places increased reliance on PCPs to provide adequate care and support for menopausal patients. 6 Available Knowledge The current landscape of menopause education among healthcare providers reveals a concerning deficit that spans various specialties, including obstetrics and gynecology (OB/GYN), primary care, family medicine, and internal medicine. Within OB/GYN— traditionally considered the specialty most knowledgeable about menopause—Allen et al. (2023) found that only 31.3% of residency programs include a menopause curriculum, and just 29.3% of residents have dedicated time at a menopause clinic. This lack of structured training contributes to a significant gap in provider confidence regarding menopause management. Kling et al. (2019) reported that 20.3% of residents across various specialties received no menopause education during their training, and only 6.8% felt adequately prepared to care for midlife women. This limited understanding of menopause management leads to delays in recognizing transitions and addressing early symptoms (Aninye et al., 2021), highlighting that both OB/GYNs and other medical specialists do not feel sufficiently prepared to manage menopause effectively. Research has estimated that the direct and indirect costs associated with untreated vasomotor symptoms (VMS) in the United States are substantial. Women with untreated VMS had significantly higher healthcare resource utilization compared to those without, with an 82% increase in all-cause outpatient visits and a 121% increase in VMS-related outpatient visits during a 12-month follow-up (Sarrel et al., 2015). The mean direct costs per patient per year were $1,346 higher for those with untreated VMS, and they also experienced an incremental indirect cost of $770 per patient per year due to increased work productivity loss (Sarrel et al., 2015). Overall, this translates to an estimated $14 billion annually when considering the total population affected by untreated VMS (Sarrel et al., 2015). This highlights the economic 7 advantages of improved VMS management through PCP education and standardized care protocols. Research indicates that targeted education and training can significantly enhance primary care providers' ability to diagnose and treat vasomotor symptoms effectively. A study by Reed et al. (2016) demonstrated that a targeted educational intervention improved clinicians' knowledge and confidence in managing menopause-related issues. Similarly, Aggarwal (2022) found that structured training programs for PCPs resulted in better patient outcomes and increased satisfaction in menopausal care. Additionally, implementing toolkits that provide resources and promote professional guidelines can empower providers to deliver more effective and protective care for their patients, fostering improved experiences and feelings toward menopause treatment (Vesco et al., 2024). Rationale The management of vasomotor symptoms in midlife women represents an important area for improvement in primary care, where gaps in provider confidence and knowledge can significantly impact patient outcomes. This project utilized the Johns Hopkins Evidence-Based Practice (JHEBP) model to address this, as it provides a structured, systematic approach to enhancing clinical practices through evidence synthesis and implementation. This model includes several key phases: identifying the problem, appraising and synthesizing evidence, implementing interventions, and evaluating outcomes. Initially, the project assessed the current confidence levels of family medicine providers in managing VMS, pinpointing specific needs and barriers in practice. Subsequently, an expert-reviewed reference toolkit was developed and tailored to enhance provider knowledge and confidence, all aligned with the most recent evidence-based guidelines. 8 Implementing the toolkit involved rapid cycle changes, allowing iterative adjustments based on feedback and emerging data. This adaptive approach facilitated real-time improvements and supported the initiative’s long-term success. By evaluating changes in provider confidence and identifying quality improvement opportunities, this project aimed to ensure that the toolkit was practical, functional, and meets user satisfaction criteria. Ultimately, the structured methodology of the Johns Hopkins EBP model aligns with our objectives and positions our project to create lasting improvements in the care of midlife women experiencing VMS in primary care settings. Specific Aims This Doctor of Nursing Practice Quality Improvement initiative aims to develop, implement, and evaluate the impact of an evidence-based menopausal vasomotor symptoms management toolkit tailored for primary care providers. This initiative aims to increase PCPs' confidence in effectively managing menopausal VMS for midlife women, thereby improving care delivery and promoting better health outcomes within this population. Methods Context The VMS Management Toolkit was implemented at two clinical sites within a large academic system: a women’s health/midwifery APRN practice and a family medicine practice located in urban Salt Lake City, Utah. The women’s health/midwifery APRN practice operates across multiple clinics throughout the Salt Lake Valley and is staffed by 21 providers, including certified nurse midwives (CNMs) and women’s health nurse practitioners (WHNPs). This practice primarily serves women from adolescence through older adulthood, providing a range of services including prenatal care, labor and delivery, postpartum care, and general gynecologic 9 care. The family medicine practice is staffed by 24 providers, including 21 medical doctors (MDs), one doctor of osteopathic medicine (DO), one family nurse practitioner (FNP), and one physician assistant (PA). This practice provides comprehensive care for patients of all ages and genders, addressing a broad spectrum of health concerns within the family medicine model. The toolkit aims to address health equity by improving menopause management for midlife women, a historically underserved population, while also equipping providers with essential education and resources. Additionally, providers across medical specialties often have limited education in menopause care, making them another underserved group in this area. Leadership for the project included a physician lead at the family medicine practice and an advanced practice nurse at the women’s health/midwifery APRN practice. At the time of implementation, neither clinic had a structured educational program focused on menopause, highlighting the importance of this initiative in advancing clinical care. Intervention A vasomotor symptom management toolkit was designed to provide evidence-based resources for patients and healthcare providers. The toolkit was created based on current literature, expert feedback, and clinical best practices to standardize and improve the management of VMS, focusing on increasing provider confidence and patient engagement. Patient Folder The patient folder contains several educational documents to empower patients with information on managing VMS. These materials include: • A guide on how to find a local Menopause Society Certified Provider (MSCP). • An educational document explaining the physiology of VMS. 10 • A comprehensive overview of VMS treatment options, including hormonal and nonhormonal therapies. • Two patient handouts from The Menopause Society (TMS) (formerly the North American Menopause Society, NAMS) that detail hormonal and non-hormonal therapies for VMS. Provider Folder The provider folder is designed to support healthcare professionals with a comprehensive approach to diagnosing and treating VMS. The materials in this folder include: • An overview of VMS, including its physiology and screening recommendations. • A summary of estimated drug costs for common VMS treatments. • Order sets for both hormonal and non-hormonal prescription therapies. • A document comparing the effectiveness of treatment options for VMS. • Information on common drug formulations, including detailed dot phrases for easy documentation. • Algorithms and decision-making tools to guide clinicians in managing VMS more effectively. The toolkit is intended to serve as a practical, user-friendly resource to help providers confidently manage VMS in diverse patient populations. The VMS Management Toolkit was designed based on evidence-based guidelines and resources with the help of an additional Women’s Health Nurse Practitioner (WHNP) student. Prior to its finalization and implementation, the toolkit was thoroughly reviewed by an interdisciplinary group of healthcare professionals to ensure its accuracy, clinical relevance, and usability. This review team included a Medical Doctor (MD) and Family Nurse Practitioner 11 (FNP) from the Family Medicine department, as well as a Certified Nurse Midwife (CNM)/Doctor of Nursing Practice (DNP), CNM/Master of Science in Nursing (MSN), and Doctor of Osteopathic Medicine (DO) from the Obstetrics & Gynecology (OB/GYN) department. Study of the Intervention The implementation strategy for the VMS Management Toolkit began with initial provider training through a presentation supplemented with handouts and an interactive discussion to encourage engagement and address potential concerns. Providers were encouraged to reference the toolkit in their daily practice, particularly when managing patients with vasomotor symptoms, and to provide biweekly feedback to facilitate real-time modifications. Data collection involved pre- and post-implementation surveys designed to assess provider confidence in identifying and managing VMS, screening frequency for menopause symptoms, and overall toolkit usability (Appendix A). Surveys also explored participants' roles and training backgrounds to evaluate differences in knowledge and confidence across provider types. Following implementation, providers responded to additional survey questions regarding their usage of the toolkit, ease of use of its components, and suggestions for enhancements. A post-survey was administered eight weeks after implementation to assess long-term impact, provider satisfaction, and opportunities for future improvements (Appendix B). The primary expected outcome was a measurable increase in provider confidence, anticipated to enhance the quality of menopause care for midlife women. Secondary expected outcomes included toolkit’s usability, provider satisfaction, and practical application in clinical settings. Qualitative feedback collected throughout the study provided further insight into barriers and facilitators to implementation, informing future iterations of the toolkit. 12 Measures The toolkit integrated multiple evidence-based tools, including standardized documentation templates, educational materials, treatment order sets, and clinical algorithms. Providers initially received training through a presentation followed by electronic handouts and a discussion forum. The effectiveness of the toolkit was assessed through survey responses collected two months post-training. The primary outcome measure was a change in provider confidence, with a target of at least a 20% increase in the percentage of providers agreeing with the statement, "I am confident in managing VMS." Secondary measures included changes in provider screening practices, barriers and facilitators to implementation, frequency of toolkit use, and overall usability (Table 1). A total of 45 providers were contacted for participation, with 21 from the women’s health/midwifery APRN practice and 24 from the family medicine practice. While participation was encouraged, engagement varied among providers. Data were collected through REDCap (Research Electronic Data Capture), a secure web-based application for survey administration and data management. To facilitate ongoing improvement, frequent communication was maintained with providers to ensure necessary adjustments to the toolkit in line with the JHEBP model, allowing for continuous refinement based on provider feedback and clinical applicability. Analysis A mixed-methods approach was used to evaluate the toolkit’s impact. Descriptive statistics characterized provider demographics and practice backgrounds, while the Wilcoxon signed-rank test was used to determine the statistical significance of changes in provider confidence. Qualitative data were obtained through biweekly provider emails, team discussions, and open-ended survey responses. These responses were analyzed for themes related to 13 feasibility, usability, and provider satisfaction. Feedback was categorized to identify key facilitators and barriers to implementation, providing insight into how the toolkit functioned in clinical practice and informing future iterations. This comprehensive approach allowed for both quantitative assessment of changes in provider confidence and qualitative evaluation of realworld implementation challenges. Ethical Considerations This project was classified as a Quality Improvement initiative and therefore, did not require oversight from the Institutional Review Board (IRB) at the University of Utah. Additionally, no conflicts of interest were associated with the project. Results A total of 26 providers participated in the study. Of these, 21 completed the pre-survey, and 17 completed the post-survey, and 12 paired participants who completed both surveys. The data were used to assess the impact of the toolkit on provider confidence in identifying and managing vasomotor symptoms, as well as the feasibility, usability, and satisfaction with the intervention. Descriptive statistics were used to summarize provider characteristics and baseline confidence levels, while the Wilcoxon signed-rank test was applied to evaluate changes in confidence among paired participant data. Qualitative feedback was analyzed thematically to identify common facilitators and barriers to implementation. Variability in response rates between the pre- and post-surveys was noted, which may influence the generalizability of findings. Despite this limitation, the results provide valuable insight into the effectiveness of the toolkit in clinical practice and highlight areas for future refinement. Demographics 14 The study included 26 participants from various clinical backgrounds. The majority were nurse practitioners or certified nurse midwives (67%), followed by medical doctors (24%) and other healthcare professionals (10%). The participants had diverse training backgrounds, with the highest representation from women’s health (48%), followed by family medicine (29%) and obstetrics/gynecology (24%). Most participants had some level of menopause-related training during their prior clinical education, with 57% having attended at least one session, 14% having attended two sessions, and 24% having completed three or more sessions. Screening practices varied, with 43% of participants reporting that they always screen for menopause-related symptoms, while 24% did so often, 24% sometimes, and 10% never. In terms of reference material usage, 33% reported using references all the time, 29% most of the time, and 38% some of the time (Table 2). Among the 26 respondents, 38.1% reported consulting resources some of the time, while 28.6% indicated they do so most of the time. Notably, 33.3% stated that they consult resources all of the time, highlighting a substantial reliance on external guidelines for VMS management. No respondents reported that they never consult resources. These findings suggest that while a majority of providers (100%) use external references to some extent, the level of reliance varies, with about one-third utilizing them consistently. This variation may reflect differences in confidence, familiarity with VMS management, or institutional support for clinical decisionmaking. Confidence in Identifying VMS Among the 12 participants who completed both pre- and post-surveys, confidence in identifying VMS showed improvement, though the change was not statistically significant (p=0.084). Pre-intervention, 67% of participants reported confidence levels of 4 ("somewhat 15 agree") or 5 ("agree") on a Likert scale (1 = "disagree" to 5 = "agree"). Two participants (17%) reported low confidence, while two (17%) were neutral. Post-intervention, all participants (100%) reported confidence levels of 4 or 5, with 58% selecting "agree" (5) and 42% selecting "somewhat agree" (4). Notably, two participants increased their confidence scores by 3 points, and 50% of participants demonstrated a positive shift in confidence. However, those who were already confident pre-intervention (scoring 4 or 5) largely maintained stable scores. A Wilcoxon signed-rank test revealed no statistically significant change (N = 6, W = 2.5, p=0.084), suggesting that while the intervention contributed to an upward trend in confidence, the impact was not strong enough to reach statistical significance (Table 3). Despite this, the practical impact remains notable. The toolkit supported individual improvements in confidence and served as a readily available, cost-effective resource for VMS identification. Even if it does not significantly alter confidence levels across all providers, it may still enhance clinical awareness and reinforce best practices in the management of VMS. Confidence in Managing VMS The intervention led to a statistically significant improvement (N = 6, W = 0, p =0.041) in provider confidence in managing VMS, highlighting its impact on clinical preparedness (Table 3). Pre-intervention confidence levels varied, with some providers reporting lower scores, but post-intervention 100% of participants reported feeling somewhat confident (64.7%) or confident (35.3%) in managing VMS. Importantly, all participants who initially had low confidence exhibited substantial improvement, with increases of 2–3 points in their self-reported scores. Additionally, 50% of participants experienced a positive change in their confidence level, reinforcing the intervention's impact. The Wilcoxon signed-rank test confirmed that these gains were statistically significant, 16 indicating that the structured support and educational resources provided were effective in improving provider confidence in managing VMS. Beyond statistical significance, these findings highlight clinical relevance, as increased confidence in VMS management can lead to more proactive and evidence-based patient care. The intervention's ability to elevate provider comfort suggests that similar resources could be integrated into other clinical settings to enhance menopause-related care and decision-making. Feasibility and Usability In terms of feasibility, 65% of participants found the toolkit easy to implement into their clinical practice (Table 4). This indicates that the toolkit was both accessible and straightforward for providers to use. Regarding usability, 24% of participants used the toolkit “most/all” of the time, 35% used it “some of the time,” and 41% did not utilize it at all during patient care (Table 5). These findings highlight some variability in adoption but also suggest that there is potential for increased engagement with continued use. Participants found certain components of the toolkit particularly useful. Sixty-five percent of participants identified the algorithms as the most accessible feature, while 41% found the smart phrases and patient handouts to be helpful. In comparison, provider handouts (24%) and order sets (18%) were used less frequently. Barriers to Integration Several barriers to using the toolkit were identified through the post-survey responses. A substantial portion of participants, 29%, reported that they perceived no clinical need for the toolkit, which may have contributed to underutilization. In addition, 24% of participants mentioned they forgot the toolkit was available, indicating that even when the toolkit was accessible, it wasn't always top of mind during patient care. Furthermore, 12% of participants 17 faced access difficulties, which could have been related to logistical challenges in obtaining or using the toolkit effectively in their clinical environments. These factors suggest that while the toolkit was feasible to implement, its utilization was hampered by both a lack of perceived need and practical barriers to consistent use. Toolkit Strengths User feedback highlighted several key strengths of the VMS toolkit, particularly its clarity, comprehensiveness, and practical utility (Table 6). Many participants found the medication dosage guidance particularly useful, with one provider noting, “Clear charts with details on dosing.” This structured approach helped streamline clinical decision-making and ensure accurate prescribing. The dot phrases were another widely appreciated feature, as they facilitated efficient documentation and enhanced patient education. One participant shared, “Loved the dot phrases and all the education available for me to give the patient.” Similarly, the organization and layout of the toolkit stood out as a major benefit, with users describing it as “excellent and comprehensive” and another stating, “Loved all the resources and how clearly they were laid out.” Additionally, the clinical algorithms were seen as particularly valuable in a busy clinical setting, guiding providers through patient risk assessment and treatment pathways. One user remarked, “I appreciate the algorithms, which would be so helpful in a busy clinic.” The inclusion of patient handouts further enhanced the toolkit’s utility, ensuring that providers had accessible, evidence-based materials to share with patients. Lastly, newer providers found the order sets especially beneficial, with one participant emphasizing that they were “incredibly helpful as a new provider.” 18 Overall, the feedback suggests that the toolkit was well-received and provided actionable, structured guidance that supported both efficient clinical workflows and enhanced patient care. Satisfaction and Long-Term Viability Satisfaction with the toolkit was high, with 76% of participants indicating they would incorporate at least some components into their future practice. The most valued elements included clinical algorithms (59%), followed by patient handouts and smart phrases (53% each), provider handouts (47%), and order sets (41%). These findings suggest that the toolkit’s structured guidance and clinical decision support were particularly beneficial to providers. To ensure long-term viability, a cloud-based digital platform could be developed to facilitate real-time updates, integrating automated literature scanning mechanisms to align with emerging clinical guidelines. Additionally, expanding the toolkit to address a broader range of menopause-related symptoms, providing multi-language versions, and incorporating patient education and self-management tools would enhance its accessibility and utility. These adaptations could help sustain its impact and support a broader adoption across diverse clinical settings. Discussion Summary This QI project sought to enhance primary care providers’ confidence in identifying and managing VMS in midlife women. Our findings suggest that while the majority of providers initially reported some confidence in VMS identification, there was still a substantial gap in management confidence. Following the intervention, we observed a measurable improvement in provider-reported confidence levels, indicating that targeted educational interventions can positively impact clinical practice. 19 Key strengths of this project include its focus on a well-documented gap in provider education, the integration of evidence-based training resources, and the use of a structured quality improvement model to guide implementation. Additionally, the project benefited from strong institutional support and alignment with broader initiatives aimed at improving midlife women’s health. The findings support the primary target that structured educational interventions would enhance provider confidence in managing VMS. However, some unexpected challenges emerged, particularly regarding provider engagement with external resources and time constraints in clinical practice. These insights highlight the need for ongoing education, reinforcement, and systemic support to sustain improvements in provider competency. Interpretation The observed improvement in provider confidence suggests a positive association between the intervention and the outcome. Compared to existing literature, which highlights a pervasive lack of menopause-related education among healthcare providers, our results align with previous studies demonstrating that structured training can bridge this gap. However, the extent to which these improvements translate into sustained practice change remains an area for future exploration. This project had a meaningful impact on both individuals and systems. On an individual level, providers reported feeling more prepared to discuss and manage VMS, potentially leading to improved patient outcomes. At a systemic level, the initiative aligns with broader efforts to standardize menopause management in primary care settings, addressing an important gap in women’s health equity. 20 Several factors influenced the difference between observed and anticipated outcomes. While confidence improved, some providers still reported reliance on external resources, indicating that a single educational intervention may not be sufficient to create long-term practice change. Contextual factors, such as time constraints and competing clinical priorities, also played a role in shaping outcomes. The intervention was cost-effective, requiring minimal financial investment beyond time allocation for training and resource dissemination. However, strategic trade-offs included provider workload and competing educational priorities. Future iterations of this initiative may benefit from integrating VMS education into routine continuing medical education (CME) or leveraging digital platforms for greater accessibility and sustainability. Overall, the project was feasible and well-received, though ongoing efforts will be necessary to ensure lasting improvements. Future research should explore additional strategies to reinforce learning, such as follow-up assessments, mentorship programs, or clinical decision support tools. By addressing these areas, we can continue to enhance provider confidence and ultimately improve menopause care for midlife women. Limitations While 26 out of 45 invited participants (49%) completed the intervention, the small sample size may limit the generalizability of findings. The study included providers from two clinical settings representing family medicine and midwifery/women’s health clinics. However, these findings may not fully reflect provider confidence levels across other primary care and specialty settings. Additionally, because all participants in the midwifery/women’s health group were women and the majority were white, there may be demographic limitations in how these results translate to more diverse provider populations. However, the sample did include a range 21 of clinical experience levels, which strengthens the applicability of findings across different career stages. Another limitation is the reliance on self-reported confidence scores, which may not directly correlate with clinical competence or patient outcomes. Future research incorporating objective measures of competency, such as patient outcomes or standardized assessments, could provide further validation of the toolkit’s impact. The intervention was implemented over an eight-week period, which may not have been sufficient to observe long-term behavior changes or sustained toolkit usage. A longer implementation period could provide greater insight into how providers integrate the toolkit into routine practice and whether confidence gains persist over time. Additionally, participant selfselection may have introduced bias, as those who engaged with the toolkit may have already had an interest in menopause management. Future studies should consider longitudinal assessments and broader recruitment strategies to capture a more representative provider sample. Conclusion This QI initiative demonstrated that a structured VMS toolkit can enhance provider confidence, particularly in managing vasomotor symptoms, where a statistically significant improvement (p =0.041) was observed. While confidence in identifying VMS showed an upward trend, it did not reach statistical significance. Participant feedback indicated that the toolkit was well-received, with 76% of providers expressing intent to incorporate at least some components into their practice. The toolkit’s strengths—including clinical algorithms, dot phrases, and patient handouts—provided valuable decision-making support and improved documentation efficiency. However, barriers such as time constraints, lack of relevant patients, and existing provider preferences limited broader adoption. 22 To enhance sustainability, future efforts should focus on integrating the toolkit into provider training programs and identifying clinical champions to support its ongoing use. Regular follow-ups and continued education on menopause management may also reinforce its utility. Additionally, the toolkit’s structure could be adapted for other aspects of menopause care, such as genitourinary syndrome of menopause, bone health, and weight management. Exploring its application in other primary care and specialty settings could further expand its impact. Future research should examine the long-term effects of toolkit implementation on provider confidence, clinical outcomes, and patient satisfaction. A larger, more diverse provider sample and extended study duration would allow for a more comprehensive evaluation of its effectiveness. These next steps will be critical in refining the toolkit and ensuring its broader adoption across various clinical settings. 23 References Aggarwal, N., Meeta, M., & Chawla, N. (2022). Menopause management: A manual for primary care practitioners and nurse practitioners. Journal of Mid-Life Health, 13(Suppl 1), S2– S51. https://doi.org/10.4103/jmh.jmh_85_22 Allen, N. E., et al. (2023). Needs assessment of menopause education in United States obstetrics and gynecology residency training programs. Menopause, 30(5), 540-546. https://doi.org/10.1097/GME.0000000000002200 Aninye, I. O., Laitner, M. H., & Chinnappan, S. (2021). Menopause preparedness: Perspectives for patient, provider, and policymaker consideration. Menopause, 28(10), 1186-1191. https://doi.org/10.1097/GME.0000000000001819 Brown, L., Hunter, M. S., Chen, R., Crandall, C. J., Gordon, J. L., Mishra, G. D., Rother, V., Joffe, H., & Hickey, M. (2024). Promoting good mental health over the menopause transition. The Lancet, 403(10430), 969–983. https://doi.org/10.1016/S01406736(23)02801-5 Kling, J. M., MacLaughlin, K. L., Schnatz, P. F., Crandall, C. J., Skinner, L. J., Stuenkel, C. A., Kaunitz, A. M., Bitner, D. L., Mara, K., Fohmader Hilsaca, K. S., & Faubion, S. S. (2019). Menopause management knowledge in postgraduate family medicine, internal medicine, and obstetrics and gynecology residents: A cross-sectional survey. Mayo Clinic Proceedings, 94(2), 242–253. https://doi.org/10.1016/j.mayocp.2018.08.033 Reed, S. D., et al. (2016). The effect of a targeted educational intervention on clinician knowledge and confidence in managing menopause-related issues. Menopause, 23(1), 4550. https://doi.org/10.1097/GME.0000000000000487 24 Ryu, K. J., Park, H., Park, J. S., Lee, Y. W., Kim, S. Y., Kim, H., Jeong, Y., Kim, Y. J., Yi, K. W., Shin, J. H., Hur, J. Y., & Kim, T. (2020). Vasomotor Symptoms: More Than Temporary Menopausal Symptoms. Journal of menopausal medicine, 26(3), 147–153. https://doi.org/10.6118/jmm.20030 Sarrel, P., Portman, D., Lefebvre, P., Lafeuille, M. H., Grittner, A. M., Fortier, J., Gravel, J., Duh, M. S., & Aupperle, P. M. (2015). Incremental direct and indirect costs of untreated vasomotor symptoms. Menopause, 22(3), 260-266. https://doi.org/10.1097/GME.0000000000000320 The Menopause Society. (2015). Nonhormonal management of menopause-associated vasomotor symptoms. Menopause, 22(11), 1155–1174. https://doi.org/10.1097/GME.0000000000000546 United States Census Bureau. (2022). Utah population and people: Population by age and sex. https://data.census.gov/profile/Utah?g=040XX00US49#populations-and-people Vesco, K. K., Brooks, N. B., Francisco, M. C., Leo, M. C., Anderson, T. M., Kalter, M., & Clark, A. L. (2024). Resident training to optimize patient-focused menopause management: A multispecialty menopause curriculum to enhance knowledge and preparedness. Menopause, 31(1), 11-19. https://doi.org/10.1097/GME.0000000000002291 25 Table 1 Outcome Measures Measure Pre-Intervention Post-Intervention Demographic Data X Confidence in Identifying X X Confidence in Managing X X Qualitative Toolkit Review X Ease of Use by Components X Continue to Use by Components X 26 Table 2 Participant Demographics of Medical Professionals (N=21) at Study Sites Variable Frequency Percentage (%) NP/CNM 14 67% PA 0 0% MD 5 24% DO 0 0% Other 2 10% Family Medicine 6 29% Internal Medicine 0 0% OB/GYN 5 24% Women’s Health 10 48% Other 0 0% None 1 5% 1 Training Session 12 57% 2 Training Sessions 3 14% 3+ Training Sessions 5 24% Role Training Background Menopause Training Screening Frequency 27 Always 9 43% Often 5 24% Sometimes 5 24% Never 2 10% None 0 0% Some of the Time 8 38% Most of the Time 6 29% All of the Time 7 33% Reference Use Frequency 28 Table 3 Toolkit Usability and Adoption Metrics (N=12) Usability Measure Pre-Intervention Post- Intervention “I am confident in identifying when VMS should be treated. “ Agree 6 (50%) 7 (58%) Somewhat agree 2 (17%) 5 (42%) Neither agree nor disagree 2 (17%) 0 (0%) Somewhat disagree 1 (8%) 0 (0%) Disagree 1 (8%) 0 (0%) “I am confident in managing VMS. “ Agree 3 (25%) 5 (42%) Somewhat agree 5 (42%) 7 (58%) Neither agree nor disagree 1 (8%) 0 (0%) Somewhat disagree 2 (17%) 0 (0%) Disagree 1 (8%) 0 (0%) p-value Statistical Significance 0.084 Not statistically significant 0.041 Statistically significant 29 Table 4 Which of the following toolkit components will you continue to use in the future? N= 17 Algorithms Order Sets Smart Phrases Provider Handouts Patient Handouts 10 (59%) 7 (41%) 9 (53%) 8 (47%) 9 (53%) Table 5 Which of the following toolkit components did you find easy to use? N= 17 Algorithms Order Sets Smart Phrases Provider Handouts Patient Handouts 11 (65%) 3 (18%) 7 (41%) 4 (24%) 7 (41%) 30 Table 6 Qualitative Toolkit Review: User Feedback on Toolkit Features (N=17) User Feedback on Toolkit Features Quotes Frequency (%) Biggest Barriers to Using the Toolkit Not needed; no relevant “I rarely see/tx pts with VMS” patients encountered “I didn’t need it for the patients I saw” 5 (29%) “Didn’t have any relevant patients” Not needed; already have “It's an extra step, I generally know my treatment preferred resources preferences” Forgot about the toolkit “Forgot to use, forgetting there were dot phrases I 1 (6%) 4 (24%) can use” “Forgetting it was there or being actively in the patient visit” Too time-consuming or too “Looking up info that is not online is challenging in much effort to access clinic. For example, the toolkit info is saved to my 2 (12%) work laptop which I don’t use in clinic” “Getting Teams up on the computer at work – I wish it lived on Pulse instead” N/A; no barriers --- 2 (12%) “It is a lot of documents to manage. I wonder if they 3 (18%) Areas for Improvement Toolkit is too large could be grouped into sub-folders” “It was big! Took a minute to navigate” “So much information to get through” 31 Prefer existing resources “I have my own toolkit / ideas / options that I already 2 (12%) use” Exclude internal guidelines “I don’t think we should have internal guidelines at 1 (6%) all” Improve phrasing of dot “Some of the wordiness of the dot phrases” 1 (6%) “I would like it if it were embedded into our charts so 1 (6%) phrases Integrate into EPIC system that I don't have to remember to put in the dot phrase.” NA; no suggested --- 5 (29%) “Clear charts with details on dosing” 2 (12%) improvements Effective Components of the Toolkit Medication dosage guidance “Medications! And links to patient handouts” Dot phrases “Loved the dot phrases and all the education 5 (29%) available for me to give the patient” “I liked that you had made dot phrases” “Easy to access dot phrases” Algorithms “I like that it helps identify patients who are high 5 (29%) risk” “I appreciate the algorithms, which would be so helpful in a busy clinic” Well-organized format “Loved all the resources and how clearly they were laid out” “The clarity of the sections” 2 (12%) 32 Patient education resources “The patient handouts are excellent. And thank you 3 (18%) so much for all the dot-phrases!!” Order sets “Incredibly helpful as a new provider” 1 (6%) 33 Figure 1 Provider Confidence in Identifying and Managing VMS: Pre- and Post-Intervention Outcomes 34 Appendix A Pre-Implementation Survey Questions 1. What is your role? a. NP / CNM b. PA c. MD d. DO e. Other 2. What is your training background? Select all that apply. a. Family Medicine b. Internal Medicine c. OBGYN d. Women’s Health e. Other 3. How many times did you receive specific training on menopause during your training? a. 0 b. 1 c. 2 d. 3+ 4. How often, if ever, do you screen for menopause symptoms among midlife women? a. Always b. Often c. Sometimes d. Never 5. I am confident in identifying when VMS should be treated. a. Agree b. Somewhat Agree c. Neither Agree nor Disagree d. Somewhat Disagree e. Disagree 6. I am confident in managing VMS. a. Agree b. Somewhat Agree c. Neither Agree nor Disagree d. Somewhat Disagree e. Disagree 7. On a weekly basis, how many patients do you care for experiencing VMS symptoms? a. 0 b. 1-2 patients 35 c. 3-4 patients d. 4-5 patients e. 6+ patients 8. How important do you believe it is to be trained to manage VMS? a. Important b. Somewhat Important c. Neutral d. Somewhat Unimportant e. Unimportant 9. How frequently do you need to consult resources (such as UpToDate, position statements, etc.) for management details when caring for a woman with VMS? a. None of the Time b. Some of the Time c. Most of the Time d. All of the Time 36 Appendix B Post-Implementation Survey Questions 1. I am confident in identifying when VMS should be treated. a. Agree b. Somewhat Agree c. Neither Agree nor Disagree d. Somewhat Disagree e. Disagree 2. I am confident in managing VMS. a. Agree b. Somewhat Agree c. Neither Agree nor Disagree d. Somewhat Disagree e. Disagree 3. How often did you reference our toolkit when caring for women with VMS? a. None of the Time b. Some of the Time c. Most of the Time d. All of the Time Follow-up: a. If they answered, “none or some”, ask “Why did you not reference the toolkit? What were the biggest barriers?” 4. What did you like about the toolkit? 5. What didn’t you like about the toolkit? 6. Which of the following toolkit components did you find easy to use? Select all that apply a. Algorithms b. Order Sets c. Smart Phrases d. Provider Handouts e. Patient Handouts 7. Which of the following toolkit components will you continue to use? Select all that apply a. Algorithms b. Order Sets c. Smart Phrases d. Provider Handouts e. Patient Handouts 8. Do you feel there’s anything missing from the toolkit? 9. Is there anything you would like to add to the toolkit? 37 Appendix C Executive Summary Toolkit-Based Approach to Improving Primary Care Provider (PCP) Confidence in Vasomotor Symptom (VMS) Management: A Quality Improvement Initiative Background & Problem Statement Vasomotor symptoms (VMS), including hot flashes and night sweats, significantly impact midlife women’s health and quality of life. Despite their prevalence, many primary care providers (PCPs) lack confidence in VMS management, leading to inconsistent screening and treatment practices. Pre-intervention data from 12 participants revealed that 67% reported some level of confidence in identifying VMS, while 25% felt fully confident in managing it. Additionally, 100% of providers relied on external resources to some extent, with 33% consulting them all the time, highlighting the need for structured clinical support. Given these gaps, this project aimed to increase provider confidence in identifying and managing VMS through structured education and decision-support tools. Intervention & Implementation A targeted educational intervention was implemented, including: • Training session covering VMS pathophysiology, guideline-based treatments, and clinical strategies. • Clinical decision-support toolkit with quick-reference materials. • Interactive discussion to reinforce learning and address provider concerns. The intervention was guided by the Plan-Do-Study-Act (PDSA) cycle for continuous improvement. Key Findings • Confidence in identifying VMS: Increased post-intervention, though not statistically significant (p = 0.084). • Confidence in managing VMS: Statistically significant improvement (p = 0.041), with 100% of participants reporting some level of confidence. • Screening practices: Post-intervention, more providers consistently screened for menopause-related symptoms. Toolkit Utilization & Usability: Among the 17 providers who used the toolkit, 59% planned to continue using algorithms, 53% smart phrases, and 47% provider handouts. The most user-friendly components included algorithms (65%) and smart phrases (41%), while order sets (18%) were found to be less intuitive. Impact & Recommendations • Clinical Impact: Improved provider confidence may lead to more proactive and consistent menopause care. • System-Level Change: Demonstrates feasibility of integrating menopause education into routine training. • Sustainability: Future efforts should focus on embedding menopause education into continuing medical education (CME) and expanding access to decision-support tools. Cost Analysis & Financial Considerations The intervention was cost-effective with minimal financial burden. The main costs involved time investment for training, while the benefits included improved provider competency and potential long-term cost savings from reduced unnecessary referrals, improved patient care, and the reduction of healthcare resource utilization associated with untreated VMS. Women with untreated VMS had significantly higher healthcare resource utilization compared to those without, with an 82% increase in all-cause outpatient visits and a 121% increase in VMS-related outpatient visits during a 12-month follow-up (Sarrel et al., 2015). The mean direct costs per patient per year were $1,346 higher for those with untreated VMS, and they also experienced an incremental indirect cost of $770 per patient per year due to increased work productivity loss (Sarrel et al., 2015). Estimated Costs & Benefits Expense Provider Training Time Cost Estimate Notes $50-$100 per provider Estimated based on hourly wage 38 • Expense Printed Materials Cost Estimate $50 Notes If physical copies were needed Digital Resource Hosting Minimal ($0-$100) Use of existing institutional platforms Total Estimated Cost $100-250 Initial investment Potential Benefits: Increased provider confidence, improved patient outcomes, reduced referrals Sustainability Institutional support through policy recommendations or clinic-wide protocols can help standardize menopause care. Partnering with organizations like The Menopause Society can enhance adoption, while expanding digital access via mobile-friendly resources or an online portal will support long-term use. Embedding menopause education into CME and integrating decision-support tools into electronic health records (EHR) systems can further ensure sustained provider engagement. Conclusion This initiative effectively improved provider confidence in managing VMS, with statistically significant gains in management confidence. The intervention was low-cost, high-impact, and easily scalable. Future recommendations include expanding the program to more providers, integrating VMS education into CME, and maintaining access to clinical support tools for sustained improvements.