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Edwards HB, Redaniel MT, Sillero-Rejon C, Pithara-McKeown C, Margelyte R, Stone T, Peters TJ, Hollingworth W, McLeod H, Craggs P, Hill EM, Redwood S, Treloar E, Donovan JL, Opmeer BC, Luyt K. Quality improvement interventions to increase the uptake of magnesium sulphate in preterm deliveries for the prevention of cerebral palsy (PReCePT study): a cluster randomised controlled trial. BJOG 2024; 131:256-266. [PMID: 37691262 DOI: 10.1111/1471-0528.17651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 06/19/2023] [Accepted: 08/13/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVE To compare two quality improvement (QI) interventions to improve antenatal magnesium sulphate (MgSO4 ) uptake in preterm births for the prevention of cerebral palsy. DESIGN Unblinded cluster randomised controlled trial. SETTING Academic Health Sciences Network, England, 2018. SAMPLE Maternity units with ≥10 preterm deliveries annually and MgSO4 uptake of ≤70%; 40 (27 NPP, 13 enhanced support) were included (randomisation stratified by MgSO4 uptake). METHODS The National PReCePT Programme (NPP) gave maternity units QI materials (clinical guidance, training), regional support, and midwife backfill funding. Enhanced support units received this plus extra backfill funding and unit-level QI coaching. MAIN OUTCOME MEASURES MgSO4 uptake was compared using routine data and multivariable linear regression. Net monetary benefit was estimated, based on implementation costs, lifetime quality-adjusted life-years and societal costs. The implementation process was assessed through qualitative interviews. RESULTS MgSO4 uptake increased in all units, with no evidence of any difference between groups (0.84 percentage points lower uptake in the enhanced group, 95% CI -5.03 to 3.35). The probability of enhanced support being cost-effective was <30%. NPP midwives gave more than their funded hours for implementation. Units varied in their support needs. Enhanced support units reported better understanding, engagement and perinatal teamwork. CONCLUSIONS PReCePT improved MgSO4 uptake in all maternity units. Enhanced support did not further improve uptake but may improve teamwork, and more accurately represented the time needed for implementation. Targeted enhanced support, sustainability of improvements and the possible indirect benefits of stronger teamwork associated with enhanced support should be explored further.
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Affiliation(s)
- Hannah B Edwards
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Maria Theresa Redaniel
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Carlos Sillero-Rejon
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Christalla Pithara-McKeown
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Ruta Margelyte
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Tracey Stone
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Tim J Peters
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - William Hollingworth
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hugh McLeod
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Pippa Craggs
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Research and Innovation, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Elizabeth M Hill
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sabi Redwood
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Emma Treloar
- St Michael's Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Jenny L Donovan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Brent C Opmeer
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Karen Luyt
- St Michael's Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Hellström S, Jonsdotter A, Jonsson M, Pettersson K, Saltvedt S, Herbst A, Ågren J, Ådén U, Domellöf M, Hagberg H, Carlsson Y. A follow up on the feasibility after national implementation of magnesium sulfate for neuroprotection prior to preterm birth. Acta Obstet Gynecol Scand 2023; 102:1741-1748. [PMID: 37680134 PMCID: PMC10619608 DOI: 10.1111/aogs.14673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/16/2023] [Accepted: 08/18/2023] [Indexed: 09/09/2023]
Abstract
INTRODUCTION The risk for brain injury manifested as cerebral palsy is higher in very preterm born children than in term. Prenatal administration of magnesium sulfate (MgSO4 ) has been shown to be neuroprotective and reduces the proportion of very preterm born children later diagnosed with cerebral palsy. A Swedish national clinical practice guideline was implemented in March 2020, stipulating the administration of a single intravenous dose of 6 g MgSO4 1-24 h prior to delivery before gestational age 32+0, aiming for 90% treatment coverage. The aim of this study was to evaluate the feasibility of this new clinical practice guideline in the first year of its implementation. MATERIAL AND METHODS Data on MgSO4 treatment were collected by reviewing the medical charts of women who gave birth to live born children in gestational age 22+0-31+6 during the period of March 1, 2020 to February 28, 2021, at five Swedish university hospitals. Women with pre-eclampsia, eclampsia, or high elevated liver enzymes low platelets (HELLP) were excluded. RESULTS A total of 388 women were eligible and 79% received treatment with MgSO4 . Of the 21% not receiving treatment, 9% did not receive treatment due to lack of knowledge about the clinical practice guideline, 9% were not possible to treat and 3% had missing data. The proportion treated increased from 72% to 87% from the first to the last 3 months. Of those treated, 81% received the drug within the stipulated timeframe (mean 8.7 h, median 3.4 h). CONCLUSIONS There was a positive trend over time in the proportion of women receiving MgSO4 treatment, but the a priori target of 90% was not reached during the first year of implementation. Our findings indicate that this target could be reached with additional information to clinicians.
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Affiliation(s)
- Sara Hellström
- Department of Obstetrics and Gynecology, Region Västra GötalandSahlgrenska University HospitalGothenburgSweden
- Division of Neonatology, Department of Pediatrics, The Queen Silvia Children's HospitalSahlgrenska University HospitalGothenburgSweden
| | - Andrea Jonsdotter
- Department of Obstetrics and Gynecology, Region Västra GötalandSahlgrenska University HospitalGothenburgSweden
- Center of Perinatal Medicine and HealthInstitute of Clinical Sciences, Sahlgrenska Academy, University of GothenburgGothenburgSweden
| | - Maria Jonsson
- Department of Women's and Children's HealthUppsala UniversityUppsalaSweden
| | - Karin Pettersson
- Clinical Intervention Science and Technology, CLINTECKarolinska InstituteStockholmSweden
| | - Sissel Saltvedt
- Department of Women's and Children's HealthKarolinska Institutet, Karolinska University HospitalStockholmSweden
| | - Andreas Herbst
- Department of Obstetrics and Gynecology, Skåne University HospitalInstitution for Clinical Sciences Lund, Lund UniversityLundSweden
| | - Johan Ågren
- Department of Women's and Children's HealthUppsala UniversityUppsalaSweden
| | - Ulrika Ådén
- Department of Women's and Children's HealthKarolinska Institutet, Karolinska University HospitalStockholmSweden
- Department of Biomedical and Clinical SCIENCESLinköping UniversityLinköpingSweden
| | - Magnus Domellöf
- Department of Clinical Sciences, PediatricsUmeå UniversityUmeåSweden
| | - Henrik Hagberg
- Department of Obstetrics and Gynecology, Region Västra GötalandSahlgrenska University HospitalGothenburgSweden
- Center of Perinatal Medicine and HealthInstitute of Clinical Sciences, Sahlgrenska Academy, University of GothenburgGothenburgSweden
| | - Ylva Carlsson
- Department of Obstetrics and Gynecology, Region Västra GötalandSahlgrenska University HospitalGothenburgSweden
- Center of Perinatal Medicine and HealthInstitute of Clinical Sciences, Sahlgrenska Academy, University of GothenburgGothenburgSweden
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Keir A, Rumbold A, Shepherd E, Mcintyre S, Groves C, Cavallaro A, Crowther C, Callander E. Antenatal magnesium sulphate for preventing cerebral palsy: An economic evaluation of the impact of a quality improvement program. Aust N Z J Obstet Gynaecol 2021; 62:168-171. [PMID: 34843629 DOI: 10.1111/ajo.13459] [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] [Received: 06/29/2021] [Revised: 10/11/2021] [Accepted: 10/31/2021] [Indexed: 11/26/2022]
Abstract
Previous work demonstrated that implementing a quality improvement (QI) program improves the uptake of guideline-recommended antenatal magnesium sulphate, a critical intervention known to reduce cerebral palsy risk. Here we estimate potential cost savings attributable to the improved uptake. By expanding coverage from 63 to 83% of eligible women, we estimated that five children potentially would not have received a diagnosis of cerebral palsy, a potential cost saving of $AU4.8 million in lifetime healthcare costs. Our findings strengthen the case for embedding QI approaches in perinatal care to reduce the incidence of cerebral palsy.
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Affiliation(s)
- Amy Keir
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School and the Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
- Women's and Babies Division, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Alice Rumbold
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School and the Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Emily Shepherd
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School and the Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Sarah Mcintyre
- Cerebral Palsy Alliance Research Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Charlotte Groves
- Women's and Babies Division, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Angela Cavallaro
- Women's and Babies Division, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | | | - Emily Callander
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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