Nuchal Translucency Quality Review (NTQR) program: first one and half million results

Resistance to Change

Advances in medical technology do not follow a smooth process and are highly variable. Implementation can occasionally be rapid, but often faces varying degrees of resistance resulting at the very least in delayed implementation. Using qualitative comparative analysis, we have evaluated numerous technological advances from the perspective of how they were introduced, implemented, and opposed. Resistance varies from benign - often happening because of inertia or lack of resources to more active forms, including outright opposition using both appropriate and inappropriate methods to resist/delay changes in care. Today, even public health has become politicized, having nothing to do with the underlying science, but having catastrophic results. Two other corroding influences are marketing pressure from the private sector and vested interests in favor of one outcome or another. This also applies to governmental agencies. There are a number of ways in which papers have been buried including putting the thumb on the scale where reviewers can sabotage new ideas. Unless we learn to harness new technologies earlier in their life course and understand how to maneuver around the pillars of obstruction to their implementation, we will not be able to provide medical care at the forefront of technological capabilities.

United States' experience in nuchal translucency measurement: variation according to provider characteristics in over five million ultrasound examinations

OBJECTIVE

The Nuchal Translucency Quality Review (NTQR) program has provided standardized education, credentialing and epidemiological monitoring of nuchal translucency (NT) measurements since 2005. Our aim was to review the effect on NT measurement of provider characteristics since the program's inception.

METHODS

We evaluated the distribution of NT measurements performed between January 2005 and December 2019, for each of the three primary performance indicators of NT measurement (NT median multiples of the median (MoM), SD of log₁₀ NT MoM and slope of NT with respect to crown-rump length (CRL)) for all providers within the NTQR program with more than 30 paired NT/CRL results. Provider characteristics explored as potential sources of variability included: number of NT ultrasound examinations performed annually (annual scan volume of the provider), duration of participation in the NTQR program, initial credentialing by an alternative pathway, provider type (physician vs sonographer) and number of NT-credentialed providers within the practice (size of practice). Each of these provider characteristics was evaluated for its effect on NT median MoM and geometric mean of the NT median MoM weighted for the number of ultrasound scans, and multiple regression was performed across all variables to control for potential confounders.

RESULTS

Of 5 216 663 NT measurements from 9340 providers at 3319 sites, the majority (75%) of providers had an NT median MoM within the acceptable range of 0.9-1.1 and 85.5% had NT median MoM not statistically significantly outside this range. Provider characteristics associated with measurement within the expected range of performance included higher volume of NT scans performed annually, practice at a site with larger numbers of other NT-credentialed providers, longer duration of participation in the NTQR program and alternative initial credentialing pathway.

CONCLUSIONS

Annual scan volume, duration of participation in the NTQR program, alternative initial credentialing pathway and number of other NT-credentialed providers within the practice are all associated with outcome metrics indicating quality of performance. It is critical that providers participate in ongoing quality assessment of NT measurement to maintain consistency and precision. Ongoing assessment programs with continuous feedback and education are necessary to maintain quality care. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Quality control of ultrasonography markers for Down's syndrome screening: a retrospective study by the laboratory

OBJECTIVES

Quality control of ultrasonography markers is necessary to ensure greater efficacy of prenatal aneuploidy screening. The aim of this study was to assess the quality of the crown-rump length (CRL) and nuchal translucence (NT) measurement accuracy by the laboratory according to quality indicators.

METHODS

Retrospective observational study on 4,908 single-foetus pregnant women who underwent prenatal aneuploidy screening in the first trimester of pregnancy. Euploid foetuses with CRL between 45 and 84 mm were included, while those with NT≥3.5 mm were excluded. CRL measurement was considered to be accurate if the median multiples of the median (MoM) for pregnancy-associated plasma protein A (PAPP-A) was between 0.90 and 1.10. Fifteen sonographers participated in the study, six of whom comprised the control group. Systematic error for a sonographer was considered when CRL measurement was greater than ±2 mm with respect to the control group. Quality for NT was assured by means of the WHIRI method and each sonographer cumulative sum control chart (CUSUM).

RESULTS

For CRL accuracy, five sonographers underestimated the measurements, while another four overestimated them, with no statistical differences. For smaller sized foetuses, all sonographers met the established specifications. Regarding NT control, three sonographers did not meet the quality criteria for the median MoM. All sonographers met the specifications for the logarithmic standard deviation of the NT MoM levels. Thirteen sonographers met the CUSUM specifications.

CONCLUSIONS

Evaluation of a quality control of ultrasonography parameters by laboratory professionals is necessary to avoid under- or overestimation tendencies for CRL and NT measurements. CUSUM is a useful tool for the immediate correction of errors in NT measurements.

The impact of individual sonographer variation on the detection of small for gestational age fetuses using a third trimester growth scan

OBJECTIVES

Detection of small for gestational age (SGA) fetuses in a third trimester ultrasound could be affected by variation in sonographer performance.

METHODS

Retrospective analysis of all singleton, non-anomalous ultrasound examinations between 35⁺⁰ -36⁺⁶ weeks gestation, in a single institution where a universal 36-week scan is offered. Screen positive was defined as estimated fetal weight (EFW) <10th centile; SGA was birthweight <10th centile. Individual sonographers' distributions of head circumference (HC), abdominal circumference (AC) and femur length (FL) were used to assess sonographers' screen positive rate (SPR), detection rate (DR) and true positive rate (TPR). Univariate and multivariate regression analysis was performed to assess the association between the sonographers' mean and SD (SD) for HC, AC, FL and their SPR, DR and TPR.

RESULTS

There were 27 sonographers performing more than 50 examinations per year, a total of 5691 scans. The mean incidence of SGA was 10.0%. For an overall SPR of 9.4%, the overall DR was 43.8% (95% CI: 39.6% - 48.1%) and the overall TPR was 46.5% (95% CI: 42.9% - 50.2%). Higher AC scatter (SD difference up to 11.6 mm) was associated with higher SPR (P = 0.001). Lower mean FL (difference up to 3.6 mm) was associated with higher SPR (P = 0.003) and higher DR (P = 0.002). As a result, DR varied amongst different sonographers between 14.3% and 85.7% and TPR varied between 8.3% and 100.0%.

CONCLUSIONS

Monitoring of individual AC and FL distributions is a simple and effective tool for institutional quality assurance.

ACR Appropriateness Criteria® Nuchal Translucency Evaluation at 11 to 14 Weeks of Gestation

A fetus with an increased nuchal translucency at 11 to 14 weeks gestation is at risk for aneuploidy, genetic syndromes, structural anomalies, and intrauterine fetal demise in both single and twin gestations. In addition to referral to genetics for counseling and consideration of diagnostic genetic testing, a detailed anatomic survey and fetal echocardiogram are indicated in the second trimester to screen for congenital malformations and major heart defects. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

First-Trimester Ultrasound

Since the 1980s, development of high-resolution transvaginal ultrasound transducers has significantly improved ultrasound evaluation at earlier gestational ages. Although many indications exist for first-trimester ultrasound in pregnancy, more emphasis has been placed on assessment of fetal anatomy recently. In turn, congenital diagnoses can also be made earlier in pregnancy, raising the question of whether anatomic assessment in the first trimester is one of choice or obligation. Combining transvaginal and transabdominal approach yields the highest detection rate overall. Some studies have shown that more than half of all anomalies and almost all severe anomalies can be detected on early scans.

Sonologist's characteristics related to a higher quality in fetal nuchal translucency measured in primary antenatal care centers

OBJECTIVE

To assess the quality of nuchal translucency (NT) measurements in primary care and the sonologist's characteristics related with a higher quality.

METHODS

The median NT expressed in multiples of the median (MoM) was calculated for each sonologist of 14 participating antenatal primary care centers of the Catalan Institute of Health. A survey to the sonologists was used to establish variables related to higher-quality measurements.

RESULTS

The median NT MoM obtained in 16 448 NT measurements, performed by 102 sonologists, was 0.94 MoM. NT underestimation was observed in 46% of the sonologists. Underestimation were less frequent among professionals who performed more than 230 ultrasounds per year (26% vs 53%;p = .022), those who completed the online Fetal Medicine Foundation (FMF) course (22% vs 54%; p = .021), and those who were subject to periodic audits (24% vs 56%; p = .021). Underestimation rate decreased from 60%, to 33% and 14% with the increase of the years of experience from less than 5 years, to 6 to 15 years and more than 15 years of experience, respectively (p = .029).

CONCLUSIONS

Higher-quality measurements were demonstrated in sonologists who performed more ultrasounds per year, those with more years of scanning experience, those who completed the online FMF course, and those periodically audited.

Impact of a shift in nuchal translucency measurements on the detection rate of first-trimester Down syndrome screening: A population-based study

OBJECTIVE

To assess the distribution of nuchal translucency (NT) measurements following a national policy without credentialing and its impact on first-trimester Down syndrome screening (DSS) detection rate.

METHOD

All first-trimester DSS data recorded in France (2010-2014) were collected by the laboratories in charge via an Internet database (https://www.bionuqual.org/echo.php). There was no minimal requirement for image quality to allow sonographers to enter the screening process. A subgroup of DSS with complete DS follow-up corresponded to 1614 sonographers. Based on the distribution of maternal age, DS detection rate was calculated and split as a function of the distribution of NT multiple of the median (MoM).

RESULTS

Four thousand nine hundred forty-three sonographers performed 2,337,372 NT measurements. Median NT expressed in MoM was 0.83. Screenings with complete follow-up consisted of 197,417 screenings, in which DSS detection rates were respectively 70.4%, 70.9%, 79.4%, 87.7%, and 79.5% for the following median NT MoM ranges: <0.7, 0.70 to 0.79, 0.80 to 0.89, 0.90 to 0.99, and >0.99 (trend χ = 12.21; P = .0158).

CONCLUSION

In France, following a policy of quality assessment without standardized credentialing, the distribution of NT measurements did not fit the expected distribution. Down syndrome detection rate was 10% lower in screenings by sonographers with a median NT < 0.80 MoM.

Proceedings: Beyond Ultrasound First Forum on Improving the Quality of Ultrasound Imaging in Obstetrics and Gynecology

The Beyond Ultrasound First Forum was conceived to increase awareness that the quality of obstetric and gynecologic ultrasound can be improved, and is inconsistent throughout the country, likely due to multiple factors, including the lack of a standardized curriculum and competency assessment in ultrasound teaching. The forum brought together representatives from many professional associations; the imaging community including radiology, obstetrics and gynecology, and emergency medicine among others; in addition to government agencies, insurers, industry, and others with common interest in obstetric and gynecologic ultrasound. This group worked together in focus sessions aimed at developing solutions on how to standardize and improve ultrasound training at the resident level and beyond. A new curriculum and competency assessment program for teaching residents (obstetrics and gynecology, radiology, and any other specialty doing obstetrics and gynecology ultrasound) was presented, and performance measures of ultrasound quality in clinical practice were discussed. The aim of this forum was to increase and unify the quality of ultrasound examinations in obstetrics and gynecology with the ultimate goal of improving patient safety and quality of clinical care. This report describes the proceedings of this conference including possible approaches to resident teaching and means to improve the inconsistent quality of ultrasound examinations performed today.

Proceedings: Beyond Ultrasound First Forum on improving the quality of ultrasound imaging in obstetrics and gynecology

The Beyond Ultrasound First Forum was conceived to increase awareness that the quality of obstetric and gynecologic ultrasound can be improved, and is inconsistent throughout the country, likely due to multiple factors, including the lack of a standardized curriculum and competency assessment in ultrasound teaching. The forum brought together representatives from many professional associations; the imaging community including radiology, obstetrics and gynecology, and emergency medicine among others; in addition to government agencies, insurers, industry, and others with common interest in obstetric and gynecologic ultrasound. This group worked together in focus sessions aimed at developing solutions on how to standardize and improve ultrasound training at the resident level and beyond. A new curriculum and competency assessment program for teaching residents (obstetrics and gynecology, radiology, and any other specialty doing obstetrics and gynecology ultrasound) was presented, and performance measures of ultrasound quality in clinical practice were discussed. The aim of this forum was to increase and unify the quality of ultrasound examinations in obstetrics and gynecology with the ultimate goal of improving patient safety and quality of clinical care. This report describes the proceedings of this conference including possible approaches to resident teaching and means to improve the inconsistent quality of ultrasound examinations performed today.

Evaluating first trimester maternal serum screening combinations for Down syndrome suitable for use with reflexive secondary screening via sequencing of cell free DNA: high detection with low rates of invasive procedures

OBJECTIVES

Examine primary Down syndrome screening using combinations of first trimester serum markers, with and without sequencing of cell free DNA as a secondary reflexive test.

METHODS

Samples from 40 Down syndrome cases were matched with five control samples and tested for PAPP-A, free β, AFP, inhibin-A and PlGF. Results were converted to weight-adjusted multiples of the median (MoM) and population parameters computed. Monte Carlo simulation modeled Down syndrome detection and false positive rates for various marker combinations. After reflexive DNA testing, the revised detection and false positive rates were also computed.

RESULTS

At a primary false positive rate of 20%, the baseline combination (maternal age, PAPP-A and free β) detected 86.9%. Adding AFP or PlGF increased detection to 89.8% and 89.5%, respectively. Adding AFP and PlGF, AFP and inhibin-A, or all three markers, detected 93.7%, 94.1% and 95.5%, respectively. Modeling reflexive cf DNA testing results in little loss in detection (1%), but false positive rates fall to 0.2%.

CONCLUSION

First trimester reflexive testing does not require nuchal translucency measurements, and has high detection and very low rates of invasive procedures. However, timing of DNA sample collection and the costs of sample collection and DNA testing need to be considered before implementation.

Is there any relationship between adverse pregnancy outcome and first trimester nuchal translucency measurements in normal karyotype fetuses?

AIM

This study aims to research whether there is a relationship between first trimester nuchal translucency (NT) measurements and pregnancy complications such as gestational diabetes mellitus (GDM), gestational hypertension (GHT), intrauterine growth restriction (IUGR) and oligohydramnios.

METHOD

This study included 225 singleton pregnancies attending Canakkale Onsekiz Mart University Obstetrics and Gynecology clinic for all monitoring and examinations, and gave birth at our clinic between January 2011 and December 2012. Data sources were clinical records and the hospital's automation system, and the study was planned as retrospective cohort. NT measurement was made between 10 weeks 3 days and 13 weeks 6 days gestation. For data analysis, the chi-square, Mann-Whitney U test and Spearman correlation were used.

RESULTS

Of pregnancies, in the study, 5 (2.2%) developed GDM, 6 (2.6%) developed GHT, 2 (0.89%) developed IUGR and 10 (4.4%) developed oligohydramnios. There was no correlation identified between NT measurements and development of GDM, GHT, IUGR and oligohydramnios.

CONCLUSION

There was no relationship found between first trimester NT measurements and complications that could develop in pregnancy. For the first time in the literature, NT and oligohydramnios were studied and no relationship was observed.