Disparities between perceived and true outcomes of infants born at 23-25 weeks' gestation

Improving accuracy of outcome prediction for infants born extremely preterm using a digital tool: Translating 'NIC-PREDICT' into clinical practice, the first steps

BACKGROUND

Many clinicians overestimate mortality and disability rates in infants born extremely preterm. We developed a digital tool ('NIC-PREDICT') that predicts infant mortality and survival with and without major disability in infants born 23-27 weeks' gestation.

AIMS

To determine if clinicians could use NIC-PREDICT accurately, and if their perceptions of infant outcomes improved after its release in 2021.

MATERIALS AND METHODS

Midwives, nurses, obstetricians, neonatologists and paediatricians working in tertiary and non-tertiary hospitals in Victoria were asked to use NIC-PREDICT to estimate three mutually exclusive outcomes: (i) mortality; (ii) survival free of major disability; and (iii) survival with major disability for six different scenarios where a liveborn infant was offered survival-focused care after birth. The proportions who completed the survey (responded to all six scenarios) and the proportions able to provide 100% accurate results for all scenarios were determined. Estimates of the three outcomes were compared with true rates.

RESULTS

A total of 85 clinicians responded: 70 (82%) completed the survey, with an overall accuracy of 76%. Overall, predictions of mortality were accurate (mean difference from true value 0.7% (95% confidence interval (CI) -0.7, 2.1) P = 0.33), as were predictions of survival without major disability (mean difference - 0.7 (95% CI -3.0, 1.7) P = 0.58). However, survival with major disability was overestimated by 4.9% ((95% CI 1.7, 8.0) P = 0.003).

CONCLUSIONS

Most perinatal clinicians who responded used NIC-PREDICT correctly to estimate expected outcomes in infants born extremely preterm who are offered intensive care. Undue pessimism about survival with major disability remains an ongoing concern.

Neonatal and Obstetric Provider Perceptions and Management at 22 Weeks' Gestation

OBJECTIVE

Active treatment for periviable infants may be influenced by neonatal and obstetric provider perceptions of prognosis. The two aims of this study are to (1) quantify prognostic discordance between provider and data-driven survival estimates and (2) evaluate if prognostic discordance is associated with the threshold probability of survival at which neonatal providers recommend active treatment or obstetric providers recommend antenatal corticosteroids.

STUDY DESIGN

Provider survival estimates and threshold probabilities of survival for active treatment and antenatal steroid use were obtained from a case-based survey for an infant or pregnancy at 22 weeks' gestation that was administered at two Atlanta hospitals. Data-driven survival estimates, including ranges, were acquired through the National Institute of Child Health and Human Development Extremely Preterm Birth Outcomes Tool. Prognostic discordance was calculated as the difference between a provider and data-driven estimates and classified as pessimistic (provider estimate below data-driven estimate range), accurate (within range), or optimistic (above range). The association between prognostic discordance and the threshold probability of survival was evaluated using nonparametric tests.

RESULTS

We had 137 neonatal respondents (51% response rate) and 57 obstetric responses (23% response rate). The overall median prognostic discordance was 1.5% (interquartile range: 17, 13) and 52 (27%) of all respondents were pessimistic, 100 (52%) were accurate, and 42 (22%) were optimistic. The survival threshold above which neonatal and obstetric providers recommended active treatment or antenatal corticosteroids was 30% (20-45%) and 10% (0-20%), respectively. Thresholds did not significantly differ among the three prognostic discordance groups (p = 0.45 for neonatal and p = 0.53 for obstetric providers). There was also no significant correlation between the magnitude of prognostic discordance and thresholds.

CONCLUSION

Prognostic discordance exists among both neonatal and obstetric providers. However, this discordance is not associated with the threshold probability of survival at which providers recommend active treatment or antenatal corticosteroids at 22 weeks' gestation.

KEY POINTS

· Prognostic discordance at 22 weeks' gestation exists for neonatal and obstetric providers.. · Prognostic discordance is not associated with survival thresholds for neonatal active treatment.. · Prognostic discordance is not associated with survival thresholds for the use of antenatal corticosteroids..

An e-Delphi study on mode of delivery and extremely preterm breech singletons

OBJECTIVES

To understand clinicians' consensus on mode of delivery in extremely preterm breech infants; assess knowledge on neonatal outcomes and its impact on consensus.

STUDY DESIGN

A two-round Delphi of obstetrical or neonatal care providers, recruited from national conferences and investigator networks. Round one assessed decision-making (vignettes), and knowledge; the second round reassessed vignettes after presenting outcome data.

RESULTS

In round one (102 respondents), consensus (a priori, ≥75% agreement) was achieved in 4/13 vignettes: two when likely/very likely to offer Cesarean (26 and 27 weeks) and two for unlikely/very unlikely (23 weeks growth restriction, ± adverse features). Clinicians generally underestimated neonatal outcomes. In round two (87 respondents), three scenarios achieved consensus (likely/very likely to offer Cesarean at 25-27 weeks); in five other vignettes, not offering Cesarean was reduced in ≥15% of respondents.

CONCLUSION

Limited consensus exists on extremely preterm breech mode of delivery, partly associated with neonatal outcome underestimation.

GESTATIONAL AGE NOTATION

The authors follow the World Health Organization's notation on gestational age. Under this notation, the first day of the last menstrual period (LMP) is day 0 of week 0. Therefore, days 0-6 represent completed week 0, days 7-13 represent completed week 1 and so on.

Conversations About End-of-Life Decisions in Neonatology: Do Doctors and Parents Implement Shared Decision-Making?

INTRODUCTION

Advances in perinatal medicine have contributed to significantly improved survival of newborns. While some infants die despite extensive medical treatment, a larger proportion dies following medical decision-making (MDM). International guidelines about end-of-life (EOL) MDM for neonates unify in their recommendation for shared decision-making (SDM) between doctors and parents. Yet, we do not know to what extent SDM is realized in neonatal practice.

OBJECTIVE

We aim at examining to which extent SDM is implemented in the NICU setting.

METHODS

By means of Qualitative Content Analysis, audio-recorded conversations between neonatologists and parents were analyzed. We used a framework by de Vos that was used to analyze similar conversations on the PICU.

RESULTS

In total we analyzed 17 conversations with 23 parents of 12 NICU patients. SDM was adopted only to a small extent in neonatal EOL-MDM conversations. The extent of sharing decreased considerably over the stages of SDM. The neonatologists suggested finding a decision together with parents, while at the same time seeking parents' agreement for the intended decision to forgo life-sustaining treatment.

CONCLUSIONS

Since SDM was only realized to a small extent in the NICU under study, we propose evaluating how parents in this unit experience the EOL-MDM process and whether they feel their involvement in the process acceptable and beneficial. If parents evaluate their involvement in the current approach beneficial, the need for implementation of SDM to the full extent, as suggested in the guidelines, may need to be critically re-assessed.