1
|
Vepa S, Alavi M, Wu W, Schmittdiel J, Herrinton LJ, Desai K. Prenatal detection rates for congenital heart disease using abnormal obstetrical screening ultrasound alone as indication for fetal echocardiography. Prenat Diagn 2024; 44:706-716. [PMID: 38489018 DOI: 10.1002/pd.6544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/20/2023] [Accepted: 02/11/2024] [Indexed: 03/17/2024]
Abstract
OBJECTIVE To determine the live born prenatal detection rate of significant congenital heart disease (CHD) in a large, integrated, multi-center community-based health system using a strategy of referral only of patients with significant cardiac abnormalities on obstetrical screening ultrasound for fetal echocardiography. Detection rates were assessed for screening in both radiology and maternal fetal medicine (MFM). The impact on fetal echocardiography utilization was also assessed. METHODS This was a retrospective cohort study using an electronic health record, outside claims databases and chart review to determine all live births between 2016 and 2020 with postnatally confirmed sCHD that were prenatally detectable and resulted in cardiac surgery, intervention, or death within 1 year. RESULTS There were 214,486 pregnancies resulting in live births. Prenatally detectable significant CHD was confirmed in 294 infants. Of those 183 were detected for an overall live-born detection rate of 62%. Detection rates in MFM were 75% and in radiology were 52%. The number of fetal echocardiograms needed to detect (NND) sCHD was 7. CONCLUSIONS A focus on quality and standardization of obstetrical screening ultrasound with referral to fetal echocardiography for cardiac abnormalities alone achieves benchmark targets for live-born detection of significant CHD requiring fewer fetal echocardiograms.
Collapse
Affiliation(s)
- Sanjay Vepa
- Department of Pediatric Cardiology, Kaiser Permanente, Oakland, California, USA
| | - Mubarika Alavi
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Weilu Wu
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Julie Schmittdiel
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Lisa J Herrinton
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Kavin Desai
- Department of Pediatric Cardiology, Kaiser Permanente, Oakland, California, USA
| |
Collapse
|
2
|
Rivero-Arias O, Png ME, White A, Yang M, Taylor-Phillips S, Hinton L, Boardman F, McNiven A, Fisher J, Thilaganathan B, Oddie S, Slowther AM, Ratushnyak S, Roberts N, Shilton Osborne J, Petrou S. Benefits and harms of antenatal and newborn screening programmes in health economic assessments: the VALENTIA systematic review and qualitative investigation. Health Technol Assess 2024; 28:1-180. [PMID: 38938110 PMCID: PMC11228689 DOI: 10.3310/pytk6591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024] Open
Abstract
Background Health economic assessments are used to determine whether the resources needed to generate net benefit from an antenatal or newborn screening programme, driven by multiple benefits and harms, are justifiable. It is not known what benefits and harms have been adopted by economic evaluations assessing these programmes and whether they omit benefits and harms considered important to relevant stakeholders. Objectives (1) To identify the benefits and harms adopted by health economic assessments in this area, and to assess how they have been measured and valued; (2) to identify attributes or relevance to stakeholders that ought to be considered in future economic assessments; and (3) to make recommendations about the benefits and harms that should be considered by these studies. Design Mixed methods combining systematic review and qualitative work. Systematic review methods We searched the published and grey literature from January 2000 to January 2021 using all major electronic databases. Economic evaluations of an antenatal or newborn screening programme in one or more Organisation for Economic Co-operation and Development countries were considered eligible. Reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist. We identified benefits and harms using an integrative descriptive analysis and constructed a thematic framework. Qualitative methods We conducted a meta-ethnography of the existing literature on newborn screening experiences, a secondary analysis of existing individual interviews related to antenatal or newborn screening or living with screened-for conditions, and a thematic analysis of primary data collected with stakeholders about their experiences with screening. Results The literature searches identified 52,244 articles and reports, and 336 unique studies were included. Thematic framework resulted in seven themes: (1) diagnosis of screened for condition, (2) life-years and health status adjustments, (3) treatment, (4) long-term costs, (5) overdiagnosis, (6) pregnancy loss and (7) spillover effects on family members. Diagnosis of screened-for condition (115, 47.5%), life-years and health status adjustments (90, 37.2%) and treatment (88, 36.4%) accounted for most of the benefits and harms evaluating antenatal screening. The same themes accounted for most of the benefits and harms included in studies assessing newborn screening. Long-term costs, overdiagnosis and spillover effects tended to be ignored. The wide-reaching family implications of screening were considered important to stakeholders. We observed good overlap between the thematic framework and the qualitative evidence. Limitations Dual data extraction within the systematic literature review was not feasible due to the large number of studies included. It was difficult to recruit healthcare professionals in the stakeholder's interviews. Conclusions There is no consistency in the selection of benefits and harms used in health economic assessments in this area, suggesting that additional methods guidance is needed. Our proposed thematic framework can be used to guide the development of future health economic assessments evaluating antenatal and newborn screening programmes. Study registration This study is registered as PROSPERO CRD42020165236. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127489) and is published in full in Health Technology Assessment; Vol. 28, No. 25. See the NIHR Funding and Awards website for further award information.
Collapse
Affiliation(s)
- Oliver Rivero-Arias
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - May Ee Png
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ashley White
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Miaoqing Yang
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Lisa Hinton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- THIS Institute, University of Cambridge, Cambridge, UK
| | | | - Abigail McNiven
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | - Sam Oddie
- Bradford Institute for Health Research, Bradford Children's Research, Bradford, UK
| | | | - Svetlana Ratushnyak
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Jenny Shilton Osborne
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
3
|
Londoño Trujillo D, Castro García PA, Rojas López KK, Moreno-Medina KJ, Dominguez Torres MT, Dennis Verano RJ, Sandoval Reyes NF. Cost-Effectiveness of the Prenatal Detection of Congenital Heart Diseases: A Systematic Literature Review. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2024; 11:141-148. [PMID: 38800495 PMCID: PMC11127739 DOI: 10.36469/001c.116147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 04/03/2024] [Indexed: 05/29/2024]
Abstract
Background: Congenital heart disease is the most common congenital condition worldwide, with a prevalence of 80 cases per 10 000 live births. In addition to perinatal morbidity and mortality, it entails long-term consequences such as multiple surgeries, prolonged hospitalizations, lifelong cardiac follow-up, reduced quality of life, risk of heart failure, and premature mortality in adulthood. This significant health and economic burden on healthcare systems and families highlights the relevance of evaluating the cost-effectiveness of methods for early detection of this condition. Objective: To conduct a systematic literature review (SLR) to identify and analyze existing economic evaluations on prenatal detection of congenital heart diseases through ultrasound, focusing on the reported cost-effectiveness results and the methodological quality of the evaluated studies according to established criteria. Methods: An SLR of economic evaluations was conducted following PRISMA guidelines. A quantitative synthesis of key methodological components of each economic evaluation was performed. The incremental medical costs, effectiveness measures, and cost-effectiveness ratios reported in each study were compiled and compared. The methodological quality was assessed according to compliance with the 24 CHEERS criteria. Results: We found 785 articles, of which only 7 met all inclusion criteria. Most were cost-effectiveness analyses, with the most common outcome being number of cases detected. Screening with only 4-chamber views interpreted by general practitioners or cardiologists were dominant strategies compared with screening with 4-chamber plus outflow views interpreted by a general practitioner. Fetal echocardiography was most effective but most expensive. Screening with 4-chamber and outflow view, followed by referral to a specialist, were recommended as the least expensive strategy per defect detected. On average, articles met 17 of the 24 CHEERS criteria. Discussion: While recent cost-effectiveness analyses demonstrated improved methodological quality, there was a lack of homogeneity due to differences in comparators and population subgroups analyzed. Despite this heterogeneity, fetal ultrasonography screening was consistently identified as a cost-effective strategy, with its cost-effectiveness heavily influenced by the expertise of the interpreting physician. Conclusion: Most studies recommend implementing obstetric ultrasonography screening, without routine fetal echocardiography, for detecting congenital heart diseases.
Collapse
|
4
|
Sakai-Bizmark R, Chang RKR, Martin GR, Hom LA, Marr EH, Ko J, Goff DA, Mena LA, von Kohler C, Bedel LEM, Murillo M, Estevez D, Hays RD. Current Postlaunch Implementation of State Mandates of Newborn Screening for Critical Congenital Heart Disease by Pulse Oximetry in U.S. States and Hospitals. Am J Perinatol 2024; 41:e550-e562. [PMID: 36580978 PMCID: PMC11105930 DOI: 10.1055/s-0042-1756327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/06/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Our objective was to gauge adherence to nationally endorsed protocols in implementation of pulse oximetry (POx) screening for critical congenital heart disease (CCHD) in infants after mandate by all states and to assess associated characteristics. STUDY DESIGN Between March and October 2019, an online questionnaire was administered to nurse supervisors who oversee personnel conducting POx screening. The questionnaire used eight questions regarding performance and interpretation of screening protocols to measure policy consistency, which is adherence to nationally endorsed protocols for POx screening developed by professional medical societies. Multilevel linear regression models evaluated associations between policy consistency and characteristics of hospitals and individuals, state of hospital location, early versus late mandate adopters, and state reporting requirements. RESULTS Responses from 189 nurse supervisors spanning 38 states were analyzed. Only 17% received maximum points indicating full policy consistency, and 24% selected all four options for potential hypoxia that require a repeat screen. Notably, 33% did not recognize ≤90% SpO2 as an immediate failed screen and 31% responded that an infant with SpO2 of 89% in one extremity will be rescreened by nurses in an hour rather than receiving an immediate physician referral. Lower policy consistency was associated with lack of state reporting mandates (beta = -1.23 p = 0.01) and early adoption by states (beta = -1.01, p < 0.01). CONCLUSION When presented with SpO2 screening values on a questionnaire, a low percentage of nurse supervisors selected responses that demonstrated adherence to nationally endorsed protocols for CCHD screening. Most notably, almost one-third of respondents did not recognize ≤90% SpO2 as a failed screen that requires immediate physician follow-up. In addition, states without reporting mandates and early adopter states were associated with low policy consistency. Implementing state reporting requirements might increase policy consistency, but some inconsistency may be the result of unique protocols in early adopter states that differ from nationally endorsed protocols. KEY POINTS · Low adherence to nationally endorsed protocols.. · Inconsistent physician follow-up to hypoxia.. · Reporting improved consistency with national policy..
Collapse
Affiliation(s)
- Rie Sakai-Bizmark
- Division of General Pediatrics, Lundquist Institute for Biomedical Innovation, Torrance, California
- Department of Pediatrics, Harbor-UCLA Medical Center and the David Geffen School of Medicine, University of California at Los Angeles, Torrance, California
| | - Ruey-Kang R. Chang
- Department of Pediatrics, Harbor-UCLA Medical Center and the David Geffen School of Medicine, University of California at Los Angeles, Torrance, California
- Division of Cardiology, Lundquist Institute for Biomedical Innovation, Torrance, California
| | - Gerard R. Martin
- Division of Cardiology, Lundquist Institute for Biomedical Innovation, Torrance, California
| | - Lisa A. Hom
- Division of Cardiology, Children's National Hospital, the George Washington University School of Medicine, Washington, District of Columbia
| | - Emily H. Marr
- Division of General Pediatrics, Lundquist Institute for Biomedical Innovation, Torrance, California
| | - Jamie Ko
- Department of Pediatrics, Harbor-UCLA Medical Center and the David Geffen School of Medicine, University of California at Los Angeles, Torrance, California
- Division of Pediatric Hospital Medicine, Lundquist Institute for Biomedical Innovation, Torrance, California
| | - Donna A. Goff
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Laurie A. Mena
- Division of General Pediatrics, Lundquist Institute for Biomedical Innovation, Torrance, California
| | - Connie von Kohler
- Miller Children's and Women's Hospital Long Beach, MemorialCare Health System, Long Beach, California
| | - Lauren E. M. Bedel
- Division of General Pediatrics, Lundquist Institute for Biomedical Innovation, Torrance, California
| | - Mary Murillo
- Division of General Pediatrics, Lundquist Institute for Biomedical Innovation, Torrance, California
| | - Dennys Estevez
- Division of General Pediatrics, Lundquist Institute for Biomedical Innovation, Torrance, California
| | - Ron D. Hays
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
- Department of Health Policy and Management, Fielding School of Public Health, University of California at Los Angeles, Los Angeles, California
| |
Collapse
|
5
|
Rakha S. Initiating a Fetal Cardiac Program from Scratch in Low- and Middle-Income Countries: Structure, Challenges, and Hopes for Solutions. Pediatr Cardiol 2024:10.1007/s00246-024-03479-9. [PMID: 38639814 DOI: 10.1007/s00246-024-03479-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/19/2024] [Indexed: 04/20/2024]
Abstract
Although fetal cardiac programs are well established in developed countries, establishing an efficient program in low- and middle-income countries (LMICs) is still considered a significant challenge. Substantial obstacles usually face the initiation of fetal cardiac service from scratch in LMICs. The primary structural frame of a successful fetal cardiac program is described in detail, emphasizing the required team members. The potential challenges for starting fetal cardiac services in LMICs include financial, awareness-related, prenatal obstetric screening, sociocultural, psychosocial, and social support factors. These challenges could be solved by addressing these barriers, such as collecting funds for financial support, raising awareness among families and health care providers, telemedicine, building international health partnerships, modifying training protocols for fetal cardiologists and sonographers, and initiating support groups and social services for families with confirmed fetal cardiac disease. Initiating a successful fetal cardiac program requires multi-aspect structural planning. The challenges for program initiation require diverse efforts, from modified training and promoting awareness of care providers and the community to governmental and nonprofit organizations' collaborations for proper building and utilization of program resources.
Collapse
Affiliation(s)
- Shaimaa Rakha
- Pediatric Cardiology Unit, Department of Pediatrics, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
| |
Collapse
|
6
|
Savitsky LM, Hamilton C, Sterrett M, Olerich K, Ma K, Albright CM. Universal Fetal Echocardiography for Pregestational Diabetes Mellitus: A Cost-Effectiveness Analysis. Obstet Gynecol 2024:00006250-990000000-01035. [PMID: 38422504 DOI: 10.1097/aog.0000000000005538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/18/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVE To evaluate the cost effectiveness of universal fetal echocardiogram for patients with pregestational diabetes mellitus by first-trimester hemoglobin A1c (Hb A1c) level. METHODS We developed a cost-effectiveness model comparing two strategies of screening for critical fetal congenital heart disease among patients with diabetes: universal fetal echocardiogram and fetal echocardiogram only after abnormal findings on detailed anatomy ultrasonogram. We excluded ventricular septal defect, atrial septal defects, and bicuspid aortic valve from the definition of critical fetal congenital heart disease. Probabilities and costs were derived from the literature. We used individual models to evaluate different scenarios: first-trimester Hb A1c lower than 6.5%, Hb A1c 6.5-9.0%, and Hb A1c higher than 9.0%. Primary outcomes included fetal death, neonatal death, and false-positive and false-negative results. A cost-effectiveness threshold was set at $100,000 per quality-adjusted life-year. Univariable sensitivity analyses were performed to investigate the drivers of the model. RESULTS Universal fetal echocardiogram is not cost effective except for when first-trimester Hb A1c level is higher than 9.0% (incremental cost-effectiveness ratio $638,100, $223,693, and $67,697 for Hb A1c lower than 6.5%, 6.5-9.0%, and higher than 9.0%, respectively). The models are sensitive to changes in the probability of congenital heart disease at a given Hb A1c level, as well as the cost of neonatal transfer to a higher level of care. Universal fetal echocardiogram became both cost saving and more effective when the probability of congenital heart disease reached 14.48% (15.4 times the baseline risk). In the Monte Carlo simulation, universal fetal echocardiogram is cost effective in 22.7%, 48.6%, and 62.3% of scenarios for each of the three models, respectively. CONCLUSION For pregnant patients with first-trimester Hb A1c levels lower than 6.5%, universal fetal echocardiogram was not cost effective, whereas, for those with first-trimester Hb A1c levels higher than 9.0%, universal fetal echocardiogram was cost effective. For those with intermediate Hb A1c levels, universal fetal echocardiogram was cost effective in about 50% of cases; therefore, clinical judgment based on individual patient values, willingness to pay to detect congenital heart disease, and resource availability needs to be considered.
Collapse
Affiliation(s)
- Leah M Savitsky
- Department of Obstetrics and Gynecology, University of Washington, and the Department of Maternal-Fetal Medicine, Providence Swedish Hospital, Seattle, Washington; and the Department of Maternal-Fetal Medicine, Kaiser San Diego, San Diego, California
| | | | | | | | | | | |
Collapse
|
7
|
Moon-Grady AJ, Donofrio MT, Gelehrter S, Hornberger L, Kreeger J, Lee W, Michelfelder E, Morris SA, Peyvandi S, Pinto NM, Pruetz J, Sethi N, Simpson J, Srivastava S, Tian Z. Guidelines and Recommendations for Performance of the Fetal Echocardiogram: An Update from the American Society of Echocardiography. J Am Soc Echocardiogr 2023; 36:679-723. [PMID: 37227365 DOI: 10.1016/j.echo.2023.04.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
| | - Mary T Donofrio
- Children's National Hospital, Washington, District of Columbia
| | | | | | - Joe Kreeger
- Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Wesley Lee
- Baylor College of Medicine, Houston, Texas
| | | | - Shaine A Morris
- Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Houston, Texas
| | - Shabnam Peyvandi
- University of California, San Francisco, San Francisco, California
| | | | - Jay Pruetz
- Children's Hospital of Los Angeles, Los Angeles, California
| | | | - John Simpson
- Evelina London Children's Hospital, London, United Kingdom
| | | | - Zhiyun Tian
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| |
Collapse
|
8
|
Mires S, Reddy S, Skerritt C, Caputo M, Eastwood K. Maternal metabolomic profiling and congenital heart disease risk in offspring: A systematic review of observational studies. Prenat Diagn 2023; 43:647-660. [PMID: 36617630 PMCID: PMC10946495 DOI: 10.1002/pd.6301] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/19/2022] [Accepted: 01/02/2023] [Indexed: 01/10/2023]
Abstract
Aetiological understanding and screening methods for congenital heart disease (CHD) are limited. Maternal metabolomic assessment offers the potential to identify risk factors and biomarkers. We performed a systematic review (PROSPERO CRD42022308452) investigating the association between fetal/childhood CHD and endogenous maternal metabolites. Ovid-MEDLINE, Ovid-EMBASE and Cochrane Library were searched between inception and 06/09/2022. Case control studies included analysing maternal blood or urine metabolites in pregnancy or postpartum where there was foetal/childhood CHD. Risk of bias assessment utilised the Scottish Intercollegiate Guidelines Network methodology checklist and narrative synthesis was performed. A total of 134 records were screened with eight eligible studies (n = 3242 pregnancies, n = 842 CHD-affected offspring). Five studies performed metabolomic analysis in pregnancy. Metabolites distinguishing case and control groups spanned lipid, glucose and amino-acid pathways, with the development of sensitive risk prediction models. No single metabolite consistently distinguished cases and controls across studies. Three studies performed targeted analysis postnatally with altered lipid and amino acid metabolites and raised homocysteine and markers of oxidative stress identified in cases. Included studies reported small sample sizes, analysing different biosamples at variable time points using differing techniques. At present, there is not enough evidence to confidently associate maternal metabolomic profiles with offspring CHD risk. However, several identified pathways warrant further investigation.
Collapse
Affiliation(s)
- Stuart Mires
- University of BristolBristolUK
- University Hospitals Bristol and Weston NHS Foundation TrustBristolUK
| | - Snigdha Reddy
- Birmingham Women's and Children's NHS Foundation TrustBirminghamUK
| | - Clare Skerritt
- University Hospitals Bristol and Weston NHS Foundation TrustBristolUK
| | - Massimo Caputo
- University of BristolBristolUK
- University Hospitals Bristol and Weston NHS Foundation TrustBristolUK
| | - Kelly‐Ann Eastwood
- University of BristolBristolUK
- University Hospitals Bristol and Weston NHS Foundation TrustBristolUK
| |
Collapse
|
9
|
Prenatal diagnosis lowers neonatal cardiac care costs in resource-limited settings. Cardiol Young 2022; 32:1754-1760. [PMID: 35000657 DOI: 10.1017/s104795112100487x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Prenatal diagnosis of critical CHDs and planned peripartum care is an emerging concept in resource-limited settings. OBJECTIVE To report the impact of prenatal diagnosis and planned peripartum care on costs of neonatal cardiac care in a resource-limited setting. METHODS Prospective study (October 2019 to October 2020). Consecutive neonates undergoing surgery or catheter-based interventions included. Patients were divided into prenatal (prenatal diagnosis) and post-natal (diagnosis after birth) groups. Costs of cardiac care (total, direct, and indirect) and health expenses to income ratio were compared between study groups; factors impacting costs were analysed. RESULTS A total of 105 neonates were included, including 33 in prenatal group. Seventy-seven neonates (73.3%) underwent surgical procedures while the rest needed catheter-based interventions. Total costs were 16.2% lower in the prenatal group (p = 0.008). Direct costs were significantly lower in the prenatal group (18%; p = 0.02), especially in neonates undergoing surgery (20.4% lower; p = 0.001). Health expenses to income ratio was also significantly lower in the prenatal group (2.04 (1.03-2.66) versus post-natal:2.58 (1.55-5.63), p = 0.01);, particularly in patients undergoing surgery (prenatal: 1.58 (1.03-2.66) vs. post-natal: 2.99 (1.91-6.02); p = 0.002). Prenatal diagnosis emerged as the only modifiable factor impacting costs on multivariate analysis. CONCLUSION Prenatal diagnosis and planned peripartum care of critical CHD is feasible in resource-limited settings and is associated with significantly lower costs of neonatal cardiac care. The dual benefit of improved clinical outcomes and lower costs of cardiac care should encourage policymakers in resource-limited settings towards developing more prenatal cardiac services.
Collapse
|
10
|
Yitbarek K, Tuji A, Alemayehu YK, Tadesse D, Tadele A, Tsegaye S, Abera Y, Abrar M, Ibrahim A, Esmael S, Belete M, Mohammed A, Shekabdulahi M, Olani H, Selamu A, Medhin G, Gerbaba MJ. Effect of USAID-funded obstetric ultrasound service interventions on maternal and perinatal health outcomes at primary healthcare facilities in Ethiopia: a propensity score matching analysis. BMJ Open 2022; 12:e065351. [PMID: 36220324 PMCID: PMC9558785 DOI: 10.1136/bmjopen-2022-065351] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE A dimensional shift in the health service delivery in the primary healthcare setting is required to raise maternal and child well-being. This study aimed to evaluate the effect of US Agency for International Development-funded obstetric ultrasound service on maternal and perinatal health outcomes at Ethiopia's primary healthcare facilities. DESIGN We employed a quasi-experimental study design. SETTING The study was conducted in primary health centres located in four regions of Ethiopia. PARTICIPANTS We used 2 years' data of 1568 mothers from 13 intervention and 13 control primary health centres. Data were obtained from Vscan, antenatal care (ANC), delivery and postnatal care registers. INTERVENTION Use of portable obstetric ultrasound service during pregnancy. OUTCOME MEASURES The primary outcome variables include complete four ANC visits, referral during ANC, delivery in a health facility and having postnatal care and continuum of care. The secondary outcome variable was perinatal death. RESULTS With the kernel matching approach, we have found that having four or more ANC visits was decreased after the intervention (average treatment effect (ATE): -0.20; 95% CI: -0.23 to -0.09), and the rest of the indicators, including referral during ANC (ATE: 0.01; 95% CI: 0.15 to 0.34), institutional delivery (ATE: 0.24; 95% CI: 0.15 to 0.34) and postnatal care (ATE: 0.26; 95% CI: 0.10 to 0.37), were significantly raised because of the intervention. Similarly, we have found that perinatal death dropped considerably due to the intervention. CONCLUSION The findings show a consistent increase in maternal health service use because of the introduction of obstetric ultrasound services at the primary health centre level. Furthermore, early detection of complications and following referral for specialty care were found to be high. The consistent rise in maternal health service use indicators calls for additional trial to test the effect of obstetric ultrasound service in other locations of the country. Furthermore, evaluating the predictive values, sensitivity and specificity of the obstetric ultrasound service is important.
Collapse
Affiliation(s)
- Kiddus Yitbarek
- Department of Health Policy and Management, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Alemu Tuji
- USAID Transform Health in Developing Regions, Amref Health Africa, Addis Ababa, Ethiopia
| | - Yibeltal Kiflie Alemayehu
- Department of Health Policy and Management, Faculty of Public Health, Jimma University, Jimma, Ethiopia
- MERQ Consultancy PLC, Addis Ababa, Ethiopia
| | - Derebe Tadesse
- USAID Transform Health in Developing Regions, Amref Health Africa, Addis Ababa, Ethiopia
| | - Afework Tadele
- Department of Population and Family Health, Jimma University, Jimma, Ethiopia
| | - Sentayehu Tsegaye
- USAID Transform Health in Developing Regions, Amref Health Africa, Addis Ababa, Ethiopia
| | - Yared Abera
- USAID Transform Health in Developing Regions, Amref Health Africa, Addis Ababa, Ethiopia
| | - Mohammed Abrar
- USAID Transform Health in Developing Regions, Amref Health Africa, Semera, Afar, Ethiopia
| | - Ahmed Ibrahim
- USAID Transform Health in Developing Regions, Amref Health Africa, Jigjiga, Somali, Ethiopia
| | - Salah Esmael
- USAID Transform Health in Developing Regions, Amref Health Africa, Asosa, Benishangul-gumuz, Ethiopia
| | - Mebrie Belete
- USAID Transform Health in Developing Regions, Amref Health Africa, Gambela, Ethiopia
| | - Abdella Mohammed
- USAID Transform Health in Developing Regions, Amref Health Africa, Semera, Afar, Ethiopia
| | - Muktar Shekabdulahi
- USAID Transform Health in Developing Regions, Amref Health Africa, Jigjiga, Somali, Ethiopia
| | - Hundessa Olani
- USAID Transform Health in Developing Regions, Amref Health Africa, Asosa, Benishangul-gumuz, Ethiopia
| | - Arab Selamu
- USAID Transform Health in Developing Regions, Amref Health Africa, Gambela, Ethiopia
| | - Girmay Medhin
- Aklilu Lemma Institute of Pathology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Mulusew J Gerbaba
- Department of Epidemiology, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| |
Collapse
|
11
|
Martin GR, Schwartz BN, Hom LA, Donofrio MT. Lessons Learned from Infants with Late Detection of Critical Congenital Heart Disease. Pediatr Cardiol 2022; 43:580-585. [PMID: 34709442 DOI: 10.1007/s00246-021-02760-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 10/15/2021] [Indexed: 11/25/2022]
Abstract
Late detection of critical congenital heart disease (CCHD) is multifactorial and ill defined. We investigated the results of pulse oximetry screening (POS) and points in the care chain that contribute to delayed detection of CCHD. The medical records of 13 infants with delayed detection at a single pediatric cardiac center between 2013 and 2016 were identified and reviewed. Left heart obstructive lesions were the most common diagnosis (n = 8; 62%) and included coarctation of the aorta (n = 6), interrupted aortic arch with ventricular septal defect (n = 1), and critical aortic stenosis (n = 1). Tetralogy of Fallot (TOF) (n = 2), truncus arteriosus (n = 1), pulmonary atresia with ventricular septal defect (n = 1), and total anomalous pulmonary venous drainage (n = 1) made up the remainder of the conditions. Routine prenatal care was reported in most infants (10/13). Infants with late detection had either a true negative POS (10/13 infants) or no POS performed (3/13 infants). At the time of detection, 5/6 (83%) infants with coarctation had normal pulse oximetry values, whereas 6/7 (86%) infants with other CCHD developed abnormal pulse oximetry values. At diagnosis, 11/13 (85%) infants had significant signs or symptoms of clinical deterioration; only 2 infants were completely asymptomatic. Late detection of CCHD is uncommon and multifactorial. Eliminating late detection is dependent upon improving detection on screening obstetrical ultrasounds, enforcement of universal POS, and attention to the neonatal physical exam.
Collapse
Affiliation(s)
- Gerard R Martin
- Division of Cardiology and The Children's National Heart Institute, Children's National Hospital, 111 Michigan Avenue, N.W., Washington, D.C., 20010, USA.
- The George Washington School of Medicine, Washington, D.C., USA.
| | - Bryanna N Schwartz
- Division of Cardiology and The Children's National Heart Institute, Children's National Hospital, 111 Michigan Avenue, N.W., Washington, D.C., 20010, USA
- The George Washington School of Medicine, Washington, D.C., USA
| | - Lisa A Hom
- Division of Cardiology and The Children's National Heart Institute, Children's National Hospital, 111 Michigan Avenue, N.W., Washington, D.C., 20010, USA
- The George Washington School of Medicine, Washington, D.C., USA
| | - Mary T Donofrio
- Division of Cardiology and The Children's National Heart Institute, Children's National Hospital, 111 Michigan Avenue, N.W., Washington, D.C., 20010, USA
- The George Washington School of Medicine, Washington, D.C., USA
| |
Collapse
|
12
|
Matsui H, Hirata Y, Inuzuka R, Hayashi T, Nagamine H, Ueda T, Nakayama T. Initial national investigation of the prenatal diagnosis of congenital heart malformations in Japan-Regional Detection Rate and Emergency Transfer from 2013 to 2017. J Cardiol 2021; 78:480-486. [PMID: 34454809 DOI: 10.1016/j.jjcc.2021.08.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/11/2021] [Accepted: 08/04/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Investigation into the detection rate (DR) of congenital heart diseases (CHDs) in fetuses is important for the assessment of fetal cardiac screening systems. OBJECTIVES We highlight issues of fetal cardiac screening in Japan. METHODS We performed an initial national survey of fetal diagnosis of CHDs from the data of the national registry for congenital heart surgery from 2013 to 2017. Subjects were neonates and infants with moderate or severe CHDs. We investigated DR in each prefecture in Japan and emergency transfer (ET) for neonates by analyzing distance and admission day of ET with or without fetal diagnoses. RESULTS The overall average DR in Japan was 0.41 (0.02 increase every year). No regional significant relationship was found between DR and population in each prefecture. ET was performed in 12% of neonates with prenatal diagnosis and in 63% of neonates without resulting in significant risk for ET in fetuses without a fetal diagnosis [OR 13.3 (11.6-15.3), p<0.001]. The distance of ET was shorter and admission was earlier in the neonates with a prenatal diagnosis than in those without [median 6.6 km (IQR: 4.1-25.7) vs 17.0 km (IQR: 7.4-35.3), median 0.0 day (IQR: 0.0-0.0) vs 0.0 day (IQR: 0.0-1.0), p<0.001, p<0.001, respectively] CONCLUSIONS: Prenatal cardiac diagnosis reduces geographic and chronological risks of ET for moderate to severe CHDs. DR is still developing and periodic official surveillance is required for improving prenatal cardiac diagnosis in Japan.
Collapse
Affiliation(s)
- Hikoro Matsui
- Department of Pediatrics, School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Yasutaka Hirata
- Department of Cardiac Surgery, School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryo Inuzuka
- Department of Pediatrics, School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Taiyu Hayashi
- Department of Pediatrics Cardiology, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroki Nagamine
- Department of Pediatrics Cardiology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Tomomi Ueda
- Department of Pediatrics Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Toshio Nakayama
- Department of Obstetrics, School of Medicine, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
13
|
Hu WY, Yu YC, Dai LY, Li SY, Zhao BW. Reliability of Sonography-based Volume Computer Aided Diagnosis in the Normal Fetal Heart. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:953-962. [PMID: 32856729 DOI: 10.1002/jum.15469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/25/2020] [Accepted: 07/13/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To explore the inter- and intra-observer reliability of Sonography-based Volume Computer Aided Diagnosis (SonoVCAD) in the display of 8 diagnostic planes of fetal echocardiography and to evaluate its efficiency. METHODS Three-dimensional volume data sets of the 56 normal singleton fetuses were acquired from a 4-chamber view by using a volume probe. After processing the data sets by using SonoVCAD, 8 cardiac diagnostic planes were displayed automatically. Three doctors with different experiences of performing fetal echocardiography evaluated each diagnostic plane and the success rates of 8 diagnostic planes were calculated. Inter-observer and intra-observer reliabilities were estimated by Cohen's kappa statistics. RESULTS A total of 276 volume data sets acquired from the 56 normal fetuses were used for SonoVCAD analysis and display. The success rate of each diagnostic section was more than 90%, ranging from 90.6% to 99.6%. Among 276 volumes, 81.5% (225/276) of volumes were able to generate all 8 diagnostic views successfully. Moderate to substantial agreement (kappa, 0.509-0.794) was found between 2 less experienced operators. Moderate to near-perfect agreement (kappa, 0.439-0.933) was found between an expert and 2 less experienced sonographers. Intra-observer reliability was substantial to near-perfect (kappa, 0.602-0.903). The efficiency of SonoVCAD was assessed. The expert spent less time than 2 less experienced examiners (P < 0.001) but no significant difference was found between 2 less experienced examiners (P = 0.176). Besides, SonoVCAD consumed significantly less time than 2-dimensional ultrasound (P < 0.001). CONCLUSIONS SonoVCAD can significantly improve the success rates of 8 diagnostic planes in fetal echocardiography with low operator dependency, good reproducibility and high efficiency.
Collapse
Affiliation(s)
- Wan Yu Hu
- Department of Diagnostic Ultrasound & Echocardiography, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
| | - Yan Cheng Yu
- Department of Ultrasonography, Affiliated Hospital of Hangzhou Normal University, Hangzhou, People's Republic of China
| | - Li Ya Dai
- Department of Ultrasonography, Lishui Central Hospital, Lishui, People's Republic of China
| | - Shi Yan Li
- Department of Diagnostic Ultrasound & Echocardiography, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
| | - Bo Wen Zhao
- Department of Diagnostic Ultrasound & Echocardiography, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
| |
Collapse
|
14
|
Fazekas-Pongor V, Csáky-Szunyogh M, Fekete M, Mészáros Á, Cseh K, Pénzes M. Congenital heart diseases and parental occupational exposure in a Hungarian case-control study in 1997 to 2002. Congenit Anom (Kyoto) 2021; 61:55-62. [PMID: 33140474 DOI: 10.1111/cga.12401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 10/21/2020] [Accepted: 10/28/2020] [Indexed: 12/01/2022]
Abstract
The etiology of congenital heart diseases is not fully understood yet, however, endocrine disrupting chemicals may have a causative role in their development. The purpose of our study was to examine the association between congenital heart diseases and periconceptional parental occupational exposure to endocrine disrupting chemicals. In our Hungarian population-based case-control study, we examined 2263 live born cases with any congenital heart disease and 6789 matched controls selected between years 1997 to 2002. Occupational exposure was assessed with a job-exposure matrix developed for endocrine disrupting chemicals. Conditional multiple logistic regression analyses were performed to test associations between parental occupational exposure to endocrine disrupting chemicals and congenital heart diseases of the offspring as a whole and by congenital heart disease subtypes. The prevalence of exposure to endocrine disrupting chemicals was 4.5% for both case and control mothers and 19.1% and 19.4% for case and control fathers, respectively. We found a positive association between paternal pesticide (adjusted odds ratio = 1.66, 95% confidence interval: 1.03-2.69) and alkylphenolic compound exposure (adjusted odds ratio = 1.95, 95% confidence interval: 1.30-2.93) and the development of patent ductus arteriosus in the offspring. Alkylphenolic compound exposure occurred among painters, famers, and those working in the food service industry, while pesticide exposure occurred predominantly among farm workers. We identified that certain occupations may increase the occurrence of certain congenital heart disease phenotypes in the offspring. By paying closer attention to those working in these areas, antenatal detection rates of congenital heart diseases may be improved.
Collapse
Affiliation(s)
- Vince Fazekas-Pongor
- Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Melinda Csáky-Szunyogh
- Hungarian Congenital Abnormalities Registry, National Public Health Center, Budapest, Hungary
| | - Mónika Fekete
- Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Ágota Mészáros
- Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Károly Cseh
- Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Melinda Pénzes
- Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| |
Collapse
|
15
|
Fazekas-Pongor V, Fekete M, Csáky-Szunyogh M, Cseh K, Pénzes M. Parental occupational exposure and congenital heart diseases in a Hungarian case-control study. Int Arch Occup Environ Health 2020; 94:515-527. [PMID: 33170344 PMCID: PMC8032570 DOI: 10.1007/s00420-020-01589-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 10/06/2020] [Indexed: 11/10/2022]
Abstract
Purpose Our study aimed to explore the effect of parental occupational exposure to endocrine disrupting chemicals (EDCs) on the development of congenital heart diseases (CHDs) in the offspring, and to compare job-exposure matrix (JEM)-assessed and self-reported occupational exposures with each other. Methods Live-born infants born in 2007–2008 were selected from the population-based Hungarian Case–Control Surveillance of Congenital Abnormalities Study. 577 cases with any CHDs were compared to 1731 matched controls. Parental periconceptional occupational exposure to EDCs was assessed by a JEM and by questionnaire-based self-reporting of parents. Multivariate conditional logistic regression analyses were conducted to explore associations between parental occupational exposure to EDCs and the entire spectrum of CHDs and by CHD subtypes in the offspring. Kappa statistics were also performed to determine the consistency among JEM-assessed and self-reported occupational exposure of parents. Results JEM-assessed paternal exposure to polychlorinated organic substances, phthalates, biphenolic compounds, and solvents were significantly associated with the entire spectrum of CHDs. Ventricular septal defects were significantly associated with paternal self-reported exposure to pesticides, while atrial septal defects were significantly associated to paternal JEM-assessed phthalate exposure. Paternal solvent exposure was significantly associated with atrial septal defects and right ventricle outflow tract obstructions. JEM-assessed and self-reported exposures to pesticides, heavy metals, and solvents exhibited poor agreement for mothers and slight agreement for fathers. Conclusion Even though parental occupational exposure to EDCs seems to have a minor impact on the occurrence of CHDs, the results of biological and environmental monitoring should be taken into consideration as well.
Collapse
Affiliation(s)
- Vince Fazekas-Pongor
- Department of Public Health, Faculty of Medicine, Semmelweis University Budapest, Üllői út 26, Budapest, 1085, Hungary.
| | - Mónika Fekete
- Department of Public Health, Faculty of Medicine, Semmelweis University Budapest, Üllői út 26, Budapest, 1085, Hungary
| | - Melinda Csáky-Szunyogh
- Hungarian Congenital Abnormalities Registry, National Public Health Center, Albert Flórián út 2-6, Budapest, 1097, Hungary
| | - Károly Cseh
- Department of Public Health, Faculty of Medicine, Semmelweis University Budapest, Üllői út 26, Budapest, 1085, Hungary
| | - Melinda Pénzes
- Department of Public Health, Faculty of Medicine, Semmelweis University Budapest, Üllői út 26, Budapest, 1085, Hungary
| |
Collapse
|
16
|
Bak GS, Shaffer BL, Madriago E, Allen A, Kelly B, Caughey AB, Pereira L. Impact of maternal obesity on fetal cardiac screening: which follow-up strategy is cost-effective? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:705-716. [PMID: 31614030 DOI: 10.1002/uog.21895] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 09/30/2019] [Accepted: 10/02/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To perform a cost-effectiveness analysis of different follow-up strategies for non-obese and obese women who had incomplete fetal cardiac screening for major congenital heart disease (CHD). METHODS Three decision-analytic models, one each for non-obese, obese and Class-III-obese women, were developed to compare five follow-up strategies for initial suboptimal fetal cardiac screening. The five strategies were: (1) no follow-up ultrasound (US) examination but direct referral to fetal echocardiography (FE); (2) one follow-up US, then FE if fetal cardiac views were still suboptimal; (3) up to two follow-up US, then FE if fetal cardiac views were still suboptimal; (4) one follow-up US and no FE; and (5) up to two follow-up US and no FE. The models were designed to identify fetuses with major CHD in a theoretical cohort of 4 000 000 births in the USA. Outcomes related to neonatal mortality and neurodevelopmental disability were evaluated. A cost-effectiveness willingness-to-pay threshold was set at US$100 000 per quality-adjusted life year (QALY). Base-case and sensitivity analysis and Monte-Carlo simulation were performed. RESULTS In our base-case models for all body mass index (BMI) groups, no follow-up US, but direct referral to FE led to the best outcomes, detecting 7%, 25% and 82% more fetuses with CHD in non-obese, obese and Class-III-obese women, respectively, compared with the baseline strategy of one follow-up US and no FE. However, no follow-up US, but direct referral to FE was above the US$100 000/QALY threshold and therefore not cost-effective. The cost-effective strategy for all BMI groups was one follow-up US and no FE. Both up to two follow-up US with no FE and up to two follow-up US with FE were dominated (being more costly and less effective), while one follow-up US with FE was over the cost-effectiveness threshold. One follow-up US and no FE was the optimal strategy in 97%, 93% and 86% of trials in Monte-Carlo simulation for non-obese, obese and Class-III-obese models, respectively. CONCLUSION For both non-obese and obese women with incomplete fetal cardiac screening, the optimal CHD follow-up screening strategy is no further US and immediate referral to FE; however, this strategy is not cost-effective. Considering costs, one follow-up US and no FE is the preferred strategy. For both obese and non-obese women, Monte-Carlo simulations showed clearly that one follow-up US and no FE was the optimal strategy. Both non-obese and obese women with initial incomplete cardiac screening examination should therefore be offered one follow-up US. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- G S Bak
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
| | - B L Shaffer
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - E Madriago
- Department of Pediatrics, Division of Pediatric Cardiology, Oregon Health & Science University, Portland, OR, USA
| | - A Allen
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - B Kelly
- Department of Pediatrics, Division of Pediatric Cardiology, Oregon Health & Science University, Portland, OR, USA
| | - A B Caughey
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - L Pereira
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Oregon Health & Science University, Portland, OR, USA
| |
Collapse
|
17
|
Bhambhani A, Mathew A, Varunya M, Uligada S, Kala P. Role of routine fetal echocardiography in an unselected group of pregnant women for prenatal detection of cardiac malformations. Indian Heart J 2020; 72:427-430. [PMID: 33189206 PMCID: PMC7670276 DOI: 10.1016/j.ihj.2020.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/13/2020] [Accepted: 08/04/2020] [Indexed: 11/05/2022] Open
Abstract
Objectives We investigated the potential for improvement in prenatal detection of congenital heart disease (CHD) by routinely performing detailed fetal echocardiography (FE) in all pregnant women. Methods Following routine obstetric sonography, 1445 unselected pregnant women were prospectively subjected to FE at gestational ages between 16 and 24 weeks, or at first visit, if they presented later. Maternal or fetal factors, conventionally known to be associated with risk of CHD, were noted. The prevalence and detection rates of cardiac abnormalities were determined, and confirmation of findings by postnatal follow-up was done to ensure accuracy of FE. Prevalence of CHD was compared in pregnancies with or without conventional risk factors. Results The overall prevalence of CHD was 8.3 per 1000; only 2 CHD cases belonged to the high maternal risk group, while 10 cases were observed without maternal risk factors. Cardiac malformations were suspected in 14 fetuses during obstetric scan; but, only 5 of them had CHD, remaining 9 had structurally normal hearts. 50% of CHD cases occurred in pregnancies not associate with any (fetal or maternal) risk factor. The sensitivity, and specificity for prenatal CHD detection were 91.7% and 100% respectively. Conclusions Our study indicates that a substantial proportion of CHD cases occur in women not having high risk of giving birth to children with CHD. FE is a highly sensitive and specific test with strong predictive values. We recommend that FE should be done in every pregnancy.
Collapse
Affiliation(s)
- Anupam Bhambhani
- Department of Cardiology, Vydehi Institute of Medical Sciences and Research Centre, Whitefield, Bangalore, India.
| | - Amalu Mathew
- Department of Cardiology, Vydehi Institute of Medical Sciences and Research Centre, Whitefield, Bangalore, India
| | - Mary Varunya
- Department of Radiodiagnosis, Vydehi Institute of Medical Sciences and Research Centre, Whitefield, Bangalore, India
| | - Seema Uligada
- Department of Radiodiagnosis, Vydehi Institute of Medical Sciences and Research Centre, Whitefield, Bangalore, India
| | - Prachi Kala
- Department of Radiodiagnosis, Vydehi Institute of Medical Sciences and Research Centre, Whitefield, Bangalore, India
| |
Collapse
|
18
|
Bak GS, Shaffer BL, Madriago E, Allen A, Kelly B, Caughey AB, Pereira L. Detection of fetal cardiac anomalies: cost-effectiveness of increased number of cardiac views. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:758-767. [PMID: 31945242 DOI: 10.1002/uog.21977] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 12/22/2019] [Accepted: 12/31/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To compare the recommended three-view fetal heart screening method to detect major congenital heart disease (CHD) with more elaborate screening strategies to determine the cost-effective strategy in unselected (low-risk) pregnancies. METHODS A decision-analytic model was designed to compare four screening strategies to identify fetuses with major CHD in a theoretical cohort of 4 000 000 births in the USA. The four strategies were: (1) three views: four-chamber view (4CV) and views of the left (LVOT) and right (RVOT) ventricular outflow tracts; (2) five views: 4CV, LVOT, RVOT and longitudinal views of the ductal arch and aortic arch; (3) five axial views: 4CV, LVOT, RVOT, three-vessel (3V) view and three-vessels-and-trachea view; and (4) six views: 4CV, LVOT, RVOT and 3V views and longitudinal views of the ductal arch and aortic arch. Outcomes related to neonatal mortality and neurodevelopmental disability were evaluated. The analysis was performed from a healthcare-system perspective, with a cost-effectiveness willingness-to-pay threshold set at $100 000 per quality-adjusted life year (QALY). Baseline analysis, one-way sensitivity analysis and Monte-Carlo simulation were performed. RESULTS In our baseline model, screening with five axial views was the optimal strategy, detecting 3520 more CHDs, and resulting in 259 fewer children with neurodevelopmental disability, 40 fewer neonatal deaths and only slightly higher costs, compared with screening with the currently recommended three views. Screening with six views was more effective, but also cost considerably more, compared with screening with five axial views, and had an incremental cost of $490 023/QALY, which was over the willingness-to-pay threshold. The five-view strategy was dominated by the other three strategies, i.e. it was more costly and less effective in comparison. The data were robust when tested with Monte-Carlo and one-way sensitivity analysis. CONCLUSION Although current guidelines recommend a minimum of three views for detecting CHD during the mid-trimester anatomy scan, screening with five axial views is a cost-effective strategy that may lead to improved outcome compared with three-view screening. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- G S Bak
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
| | - B L Shaffer
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - E Madriago
- Department of Pediatrics, Division of Pediatric Cardiology, Oregon Health & Science University, Portland, OR, USA
| | - A Allen
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - B Kelly
- Department of Pediatrics, Division of Pediatric Cardiology, Oregon Health & Science University, Portland, OR, USA
| | - A B Caughey
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - L Pereira
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Oregon Health & Science University, Portland, OR, USA
| |
Collapse
|
19
|
Cawyer CR, Kuper SG, Ausbeck E, Sinkey RG, Owen J. The added value of screening fetal echocardiography after normal cardiac views on a detailed ultrasound. Prenat Diagn 2019; 39:1148-1154. [PMID: 31499581 DOI: 10.1002/pd.5557] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 08/19/2019] [Accepted: 08/23/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Evaluate fetal echocardiography's ability to detect critical (lesions requiring immediate neonatal intensive care) congenital heart disease (CHD) after normal anatomic cardiac views on detailed ultrasound. METHODS Singletons with both a detailed ultrasound at 18 + 0 to 22 + 6 weeks and echocardiogram performed at least 14 days later and at 20 + 0 to 24 + 6 weeks. Cases with cardiac pathology on detailed ultrasound were excluded. Different combinations of cardiac views were described: Basic (four-chamber, outflow tracts), Expanded (plus three-vessel view), and Complete (plus ductal/aortic arches). "Normal" was defined on either 2D gray scale or color Doppler. Primary outcome was rates of critical CHD missed on ultrasound but seen on fetal echocardiogram. RESULTS One thousand two hundred twenty-three women had normal Basic cardiac views. One thousand one hundred ninety (97.3%) were confirmed normal on echocardiogram. Twenty-one (1.71%) total CHDs were missed, and three were critical (0.25%; 95% CI, 0.03%-0.53%). Of the 1,223 women, 763 had Complete views. Ten (1.31%) total CHDs were missed and one (0.13%; 95% CI, 0.13%-0.36%) was confirmed critical. CONCLUSION Fetal echocardiography can increase CHD detection despite normal cardiac anatomy on detailed ultrasound; however, CHDs missed are rarely critical. Approximately 750 fetal echocardiograms need to be performed to detect one critical CHD with Complete normal cardiac views on detailed ultrasound.
Collapse
Affiliation(s)
- Chase R Cawyer
- Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Spencer G Kuper
- Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elizabeth Ausbeck
- Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Rachel G Sinkey
- Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - John Owen
- Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama
| |
Collapse
|
20
|
Noël C, Gagnon MH, Cardinal MP, Guertin O, Déry A, Têtu C, Vanasse A, Roy-Lacroix MÈ, Poder TG, Marelli AJ, Cavallé-Garrido T, Vaujois L, Bigras JL, Dallaire F. Rationale and Design of the FREQUENCY Study: The Fetal Cardiac Registry of Québec to Improve Resource Utilization in Fetal Cardiology. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 41:459-465.e12. [PMID: 30591407 DOI: 10.1016/j.jogc.2018.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 10/05/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Prenatal detection of congenital heart diseases (CHD) decreases morbidity and cost. To improve detections rates, most physicians refer pregnant women with high-risk pregnancies to fetal cardiologists even when there is no suspicion of CHD at the second trimester screening. This paper presents the rationale and detailed method of the Fetal Cardiac Registry of Québec to Improve Resource Utilization in Fetal Cardiology (FREQUENCY) study. The overall objective is to assess the impact of second trimester ultrasound screening (U/S) and referral pattern in fetal cardiology on detection rates, health care costs, and resource utilization, as well as perinatal morbidity and mortality. METHODS This multicentre retrospective population-based cohort study will link fetal echocardiography data from all centres performing fetal echocardiography in Québec with administrative health care data. This data linking will allow the determination of a true denominator (all women in Québec who underwent second trimester U/S) with complete follow-up of up to 2 years for offspring. This protocol meets Canadian Task Force Classification II-2. RESULTS The study investigators have collected and cleaned fetal echocardiography data for 24 259 eligible pregnancies referred to fetal cardiology. These data will be matched to approximately 860 000 pregnancies between 2007 and 2015. CONCLUSION The results of the FREQUENCY study will shed light on the impact of the current prenatal CHD screening strategy in Canada.
Collapse
Affiliation(s)
- Camille Noël
- Division of Pediatric and Fetal Cardiology, Department of Pediatrics, Faculty of Medicine and Heath Sciences, Université de Sherbrooke, Sherbrooke, QC; Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC
| | - Marie-Hélène Gagnon
- Department of Pediatrics, Montréal Children's Hospital, McGill University, Montréal, QC
| | - Mikhail-Paul Cardinal
- Division of Pediatric and Fetal Cardiology, Department of Pediatrics, Faculty of Medicine and Heath Sciences, Université de Sherbrooke, Sherbrooke, QC; Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC
| | - Olivier Guertin
- Division of Pediatric and Fetal Cardiology, Department of Pediatrics, Faculty of Medicine and Heath Sciences, Université de Sherbrooke, Sherbrooke, QC; Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC
| | - Antoine Déry
- Division of Pediatric and Fetal Cardiology, Department of Pediatrics, Faculty of Medicine and Heath Sciences, Université de Sherbrooke, Sherbrooke, QC; Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC
| | - Cassandre Têtu
- Department of Pediatrics, Montréal Children's Hospital, McGill University, Montréal, QC
| | - Alain Vanasse
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC; Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Heath Sciences, Université de Sherbrooke, Sherbrooke, QC
| | - Marie-Ève Roy-Lacroix
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC; Division of Fetal-Maternal Medicine, Department of Obstetrics and Gynecology, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, QC
| | - Thomas G Poder
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC; Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Heath Sciences, Université de Sherbrooke, Sherbrooke, QC; Unité D'évaluation des Technologies et des Modes d'Intervention en Santé, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke Sherbrooke, QC
| | - Ariane J Marelli
- MAUDE Unit (McGill Adult Unit for Congenital Heart Disease Excellence), McGill University, Montréal, QC
| | - Tiscar Cavallé-Garrido
- Division of Pediatric Cardiology, Montréal Children's Hospital, McGill University, Montréal, QC
| | - Laurence Vaujois
- Division of Pediatric and Congenital Cardiology, Department of Pediatrics, Laval University Hospital, Faculty of Medicine, Laval University, Québec City, QC
| | - Jean-Luc Bigras
- Department of Pediatric Cardiology, University Hospital Sainte-Justine, University of Montréal, Montréal, QC
| | - Frédéric Dallaire
- Division of Pediatric and Fetal Cardiology, Department of Pediatrics, Faculty of Medicine and Heath Sciences, Université de Sherbrooke, Sherbrooke, QC; Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC.
| |
Collapse
|
21
|
Kosinski P, Dobrowolski P, Lipa M, Luterek K, Wielgos M. Remarkable Hypermobility of the Ventricular Septum Diagnosed Prenatally. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:2959-2960. [PMID: 29672892 DOI: 10.1002/jum.14649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 02/09/2018] [Accepted: 03/01/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Przemyslaw Kosinski
- First Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Dobrowolski
- Department of Congenital Heart Disease, Institute of Cardiology, Warsaw, Poland
| | - Michal Lipa
- First Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Luterek
- First Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Miroslaw Wielgos
- First Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| |
Collapse
|
22
|
Ferrier C, Dhombres F, Guilbaud L, Durand-Zaleski I, Jouannic JM. [Ultrasound screening for birth defects: A medico-economic review]. ACTA ACUST UNITED AC 2017; 45:408-415. [PMID: 28720225 DOI: 10.1016/j.gofs.2017.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 06/14/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The systematic use of ultrasound during pregnancy aims at birth defect detection. Our objective was to assess the economic efficiency of prenatal ultrasound screening for fetal malformations. METHODS We carried out a literature review on Medline via PubMed between 1985 and 2015, from the economic perspective of the prenatal ultrasound screening for fetal malformations. RESULTS The literature on this subject was sparse and we selected only twelve articles presenting relevant economic data, of which only eight were proper medico-economic studies. We found arguments for the economic effectiveness of ultrasound screening for fetal malformation detection, which is largely linked to the terminations of pregnancies and to the cost of the handicaps "avoided". However, none of the reviewed articles could reach medico-economic conclusions. Additionally, we highlighted various elements making economic analyses more complex in this field: the choice of the method, the uncertainty around two essential parameters (the efficiency of ultrasound and the costs of procedures) and the difficulties to compare or to generalize results. We also noticed important methodological heterogeneity among the studies and the absence of French study. CONCLUSIONS Previously published data are insufficient to assess the economic efficiency of prenatal ultrasound screening for fetal malformations.
Collapse
Affiliation(s)
- C Ferrier
- Service de médecine fœtale, pôle de périnatalité, hôpital Armand-Trousseau, AP-HP, UPMC, Paris 6, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France; Unité de recherche clinique en économie de la santé d'Île-de-France, Hôtel-Dieu de Paris, 1, place du parvis de Notre-Dame, 75004 Paris, France
| | - F Dhombres
- Service de médecine fœtale, pôle de périnatalité, hôpital Armand-Trousseau, AP-HP, UPMC, Paris 6, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France.
| | - L Guilbaud
- Service de médecine fœtale, pôle de périnatalité, hôpital Armand-Trousseau, AP-HP, UPMC, Paris 6, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France
| | - I Durand-Zaleski
- Unité de recherche clinique en économie de la santé d'Île-de-France, Hôtel-Dieu de Paris, 1, place du parvis de Notre-Dame, 75004 Paris, France
| | - J-M Jouannic
- Service de médecine fœtale, pôle de périnatalité, hôpital Armand-Trousseau, AP-HP, UPMC, Paris 6, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France
| |
Collapse
|
23
|
Evers PD, Ranade D, Lewin M, Arya B. Diagnostic Approach in Fetal Coarctation of the Aorta: A Cost-Utility Analysis. J Am Soc Echocardiogr 2017; 30:589-594. [PMID: 28410945 DOI: 10.1016/j.echo.2017.01.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Coarctation of the aorta (CoA) is difficult to diagnose by fetal echocardiogram (F-Echo), often requiring multiple F-Echos during gestation and neonatal echocardiograms (N-Echos) after birth. Furthermore, CoA is the most common ductal-dependent lesion missed on routine physical exam. OBJECTIVES We sought to determine the most cost-effective diagnostic approach in caring for infants in whom an initial F-Echo is concerning for CoA. METHODS Four paradigms for management after initial F-Echo could not rule out CoA were compared, with a single paradigm involving additional F-Echos: (1) multiple F-Echos for diagnostic clarity and performance of N-Echo on neonates with remaining high suspicion for CoA on F-Echos (prenatal-multiple), (2) no further F-Echo and performance of N-Echo on neonates with high suspicion for CoA on initial F-Echo (postnatal-selective), (3) no further F-Echo and performance of N-Echo on all neonates (postnatal-all), and (4) no further F-Echo or N-Echo with reliance on routine physical exam to identify afflicted infants (postnatal-none). Decision analysis models were constructed. Probabilities dictating clinical course and costs were calculated using our institution's study population. The utility-state values were derived from existing literature. The measure of effectiveness was quality-adjusted life years. To represent societal perspectives, cost was defined as hospital reimbursement payments. RESULTS From 2007 to 2014 at our institution, 92 patients were diagnosed with CoA and met the inclusion criteria for this study. These patients presented to care either through prenatal diagnosis (n = 31), postnatal examination findings while clinically well (n = 41), or after clinical deterioration in extremis (n = 20), with one patient subsequently dying. Presenting in extremis was associated with a 20% increase in the cost of their subsequent care and with a 51% increase in length of hospital stay. Postnatal-none was the least effective paradigm but also the least costly, thus forming the baseline model. Of the three other diagnostic approaches modeled, Postnatal-all was the cost-effective paradigm, maximizing utility due to avoidance of high-cost/low-utility disease states such as presentation in extremis and death. Prenatal-multiple was the next most effective but was also the most expensive. CONCLUSIONS Echocardiography is the screening gold standard in avoiding the devastating clinical manifestations of a missed CoA. When a diagnosis of CoA cannot be ruled out on initial F-Echo, the most cost-effective approach is performance of N-Echo on all neonates with no further prenatal evaluation.
Collapse
Affiliation(s)
- Patrick D Evers
- Division of Cardiology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington
| | - Daksha Ranade
- Department of Research Informatics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington
| | - Mark Lewin
- Division of Cardiology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington
| | - Bhawna Arya
- Division of Cardiology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington.
| |
Collapse
|
24
|
Komisar J, Srivastava S, Geiger M, Doucette J, Ko H, Shenoy J, Shenoy R. Impact of changing indications and increased utilization of fetal echocardiography on prenatal detection of congenital heart disease. CONGENIT HEART DIS 2016; 12:67-73. [PMID: 27561699 DOI: 10.1111/chd.12405] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 07/11/2016] [Accepted: 07/21/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND Antenatal diagnosis of congenital heart defects (CHD) can impact outcomes in neonates with severe CHD. Obstetric screening guidelines and the indications for fetal echocardiography (FE) have evolved in an attempt to improve the early prenatal detection of CHD. Analyzing yield for specific indications will help clinicians better stratify at-risk pregnancies. METHODS Retrospective cohort study of all FE performed between 2000 and 2010 at a single tertiary care academic medical center in New York City. A total of 9878 FE met inclusion criteria for our study. In cases of multiple gestations (MG), each fetus was counted as a separate study. RESULTS The number of new diagnosis of fetal CHD by FEs increased 200%. There was a statistically significant increase in those referred for suspected CHD, increased nuchal translucency (NT), MG, and suboptimal imaging (P < .001). The indication of "suboptimal imaging" (SO) not only accounted for 5.23% of all referrals from 2000 to 2002, compared to 22.26% of all referrals from 2008 to 2010 (P < .0001), but also had the lowest yield for diagnoses of CHD (P < .02). CONCLUSIONS Over the past decade, there has been an increase in utilization of FE with a proportional increase in prenatally diagnosed CHD. For indications such as suspected CHD, NT and MG increases in referrals have led to a proportionate increase in fetal diagnosis of CHD. SO as an indication has the lowest yield of fetal diagnosis of CHD. Antenatal detection of CHD may be improved by a change in obstetric imaging protocols to ensure appropriate referrals.
Collapse
Affiliation(s)
- Jonathan Komisar
- Department of Medical Education, Icahn School of Medicine, New York, New York
| | - Shubhika Srivastava
- Division of Pediatric Cardiology, Mount Sinai Medical Center, New York, New York
| | - Miwa Geiger
- Division of Pediatric Cardiology, Mount Sinai Medical Center, New York, New York
| | - John Doucette
- Department of Preventive Medicine, Icahn School of Medicine, New York, New York
| | - Helen Ko
- Division of Pediatric Cardiology, Mount Sinai Medical Center, New York, New York
| | - Jay Shenoy
- Division of Pediatric Cardiology, Mount Sinai Medical Center, New York, New York
| | - Rajesh Shenoy
- Division of Pediatric Cardiology, Mount Sinai Medical Center, New York, New York
| |
Collapse
|
25
|
Almeida LFG, Araujo Júnior E, Crott GC, Okido MM, Berezowski AT, Duarte G, Marcolin AC. Epidemiological Risk Factors and Perinatal Outcomes of Congenital Anomalies. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2016; 38:348-55. [PMID: 27459392 PMCID: PMC10374240 DOI: 10.1055/s-0036-1586160] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 06/10/2016] [Indexed: 10/21/2022] Open
Abstract
Objectives To identify the epidemiological risk factors for congenital anomalies (CAs) and the impact of these fetal malformations on the perinatal outcomes. Methods This prospective cohort study comprised 275 women whose fetuses had CAs. Maternal variables to establish potential risk factors for each group of CA and perinatal outcomes were evaluated. The primary outcome was CA. Secondary outcomes included: fetal growth restriction (FGR); fetal distress (FD); premature rupture of membranes (PROM); oligohydramnios or polyhydramnios; preterm delivery (PTD); stillbirth; cesarean section; low birth weight; Apgar score < 7 at the 1st and 5th minutes; need for assisted ventilation at birth; neonatal infection; need for surgical treatment; early neonatal death; and hospitalization time. Chi-square (χ(2)) test and multilevel regression analysis were applied to compare the groups and determine the effects of maternal characteristics on the incidence of CAs. Results The general prevalence of CAs was of 2.4%. Several maternal characteristics were associated to CAs, such as: age; skin color; level of education; parity; folic acid supplementation; tobacco use; and history of previous miscarriage. There were no significant differences among the CA groups in relation to FGR, FD, PROM, 1-minute Apgar score > 7, and need for assisted ventilation at birth. On the other hand, the prevalence of the other considered outcomes varied significantly among groups. Preterm delivery was significantly more frequent in gastrointestinal tract/abdominal wall defects. The stillbirth rate was increased in all CAs, mainly in isolated fetal hydrops (odds ratio [OR]: 27.13; 95% confidence interval [95%CI]: 2.90-253.47). Hospitalization time was higher for the urinary tract and congenital heart disease groups (p < 0.01). Neonatal death was significantly less frequent in the central nervous system anomalies group. Conclusion It was possible to identify several risk factors for CAs. Adverse perinatal outcomes were presented in all CA groups, and may differ according to the type of CA considered.
Collapse
Affiliation(s)
- Lissa Fernandes Garcia Almeida
- Department of Gynecology and Obstetrics, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Gerson Claudio Crott
- Department of Gynecology and Obstetrics, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Marcos Masaru Okido
- Department of Gynecology and Obstetrics, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Aderson Tadeu Berezowski
- Department of Gynecology and Obstetrics, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Geraldo Duarte
- Department of Gynecology and Obstetrics, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Alessandra Cristina Marcolin
- Department of Gynecology and Obstetrics, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
| |
Collapse
|
26
|
Yeo L, Romero R. How to Acquire Cardiac Volumes for Sonographic Examination of the Fetal Heart: Part 2. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:1043-66. [PMID: 27091912 PMCID: PMC8475629 DOI: 10.7863/ultra.16.01082] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 03/13/2016] [Indexed: 05/04/2023]
Abstract
The effective performance of fetal cardiac examination using spatiotemporal image correlation (STIC) technology requires 2 essential steps: volume acquisition and postprocessing. An important prerequisite is training sonologists to acquire high-quality volume data sets so that when analyzed, such volumes are informative. This article is part 2 of a series on 4-dimensional sonography with STIC. Part 1 focused on STIC technology and its features, the importance of operator training/experience and acquisition of high-quality STIC volumes, factors that affect STIC volume acquisition rates, and general recommendations on performing 4D sonography with STIC. In part 2, we discuss a detailed and practical stepwise approach for STIC volume acquisition, along with methods to determine whether such volumes are appropriate for analysis.
Collapse
Affiliation(s)
- Lami Yeo
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI, USA
- Detroit Medical Center, Hutzel Women’s Hospital, Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Roberto Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, USA
| |
Collapse
|
27
|
Yeo L, Romero R. How to Acquire Cardiac Volumes for Sonographic Examination of the Fetal Heart: Part 1. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:1021-42. [PMID: 27091914 PMCID: PMC8475630 DOI: 10.7863/ultra.16.01081] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 02/29/2016] [Indexed: 05/13/2023]
Abstract
Four-dimensional sonography with spatiotemporal image correlation (STIC) technology allows acquisition of a fetal cardiac volume data set and displays a cine loop of a complete single cardiac cycle in motion. Part 1 of this 2-part article reviews STIC technology and its features, the importance of operator training/experience, and acquisition of high-quality STIC volumes, as well as factors that affect STIC volume acquisition rates. We also propose a detailed and practical stepwise approach to performing 4-dimensional sonography with STIC and begin herein by providing general recommendations. Part 2 will discuss specifics of the approach, along with how to determine whether such volumes are appropriate for analysis.
Collapse
Affiliation(s)
- Lami Yeo
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI, USA
- Detroit Medical Center, Hutzel Women’s Hospital, Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Roberto Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA
- Department of Molecular Obstetrics and Genetics, Wayne State University, Detroit, MI, USA
| |
Collapse
|
28
|
Sinkey RG, Odibo AO. Cost-Effectiveness of Old and New Technologies for Aneuploidy Screening. Clin Lab Med 2016; 36:237-48. [PMID: 27235909 DOI: 10.1016/j.cll.2016.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Cost-effectiveness analyses allow assessment of whether marginal gains from new technology are worth increased costs. Several studies have examined cost-effectiveness of Down syndrome (DS) screening and found it to be cost-effective. Noninvasive prenatal screening also appears to be cost-effective among high-risk women with respect to DS screening, but not for the general population. Chromosomal microarray (CMA) is a genetic sequencing method superior to but more expensive than karyotype. In light of CMAs greater ability to detect genetic abnormalities, it is cost-effective when used for prenatal diagnosis of an anomalous fetus. This article covers methodology and salient issues of cost-effectiveness.
Collapse
Affiliation(s)
- Rachel G Sinkey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida, 2 Tampa General Circle, Tampa, FL 33606, USA.
| | - Anthony O Odibo
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida, 2 Tampa General Circle, Tampa, FL 33606, USA
| |
Collapse
|
29
|
Abstract
Patients and providers are faced with a wide array of choices to screen for structural abnormalities, aneuploidy, and genetic diseases in the prenatal period. It is important to consider the features of the diseases being screened for, the characteristics of the screening tests used, and the population being screened when evaluating prenatal screening techniques.
Collapse
Affiliation(s)
- Lorene A Temming
- Department of Obstetrics and Gynecology, School of Medicine, Washington University in St. Louis, St. Louis, MO.
| | - George A Macones
- Department of Obstetrics and Gynecology, School of Medicine, Washington University in St. Louis, St. Louis, MO
| |
Collapse
|
30
|
The Ultrasonic Microsurgical Anatomical Comparative Study of the CHD Fetuses and Their Clinical Significance. BIOMED RESEARCH INTERNATIONAL 2015; 2015:520394. [PMID: 26640788 PMCID: PMC4657069 DOI: 10.1155/2015/520394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 06/03/2015] [Accepted: 06/07/2015] [Indexed: 12/03/2022]
Abstract
The aim of our study was to increase the detection rate of fetal cardiac malformations for congenital heart disease (CHD). The ultrasonic and microanatomical methods were combined to study the CHD cases firstly, which could provide the microsurgical anatomical basis to the prenatal ultrasonic diagnosis which was used in suspected CHD and help the sonographer to improve the quality of fetal cardiac diagnosis. We established the ultrasonic standard section of the 175 complex CHD cases and collected the fetal echocardiography image files. The induced/aborted fetuses were fixed by 4% paraformaldehyde and dissected by the ultrasonic microsurgical anatomy. This research could obtain the fetal cardiac anatomic cross-sectional images which was consistent with the ultrasonic standard section and could clearly show the internal structure of the vascular malformation that optimized the ultrasound examination individually. This method could directly display the variation of the CHD fetal heart clearly and comprehensively help us to understand the complex fetal cardiac malformation from the internal structure of the vascular malformation which was consolidated by the anatomical basis of the fetal heart. This study could improve the integrity and accuracy of the prenatal cardiac ultrasound examination tremendously.
Collapse
|