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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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Edwards HB, Redaniel MT, Sillero-Rejon C, Margelyte R, Peters TJ, Tilling K, Hollingworth W, McLeod H, Craggs P, Hill E, Redwood S, Donovan J, Treloar E, Wetz E, Swinscoe N, Ford GA, Macleod J, Luyt K. National PReCePT Programme: a before-and-after evaluation of the implementation of a national quality improvement programme to increase the uptake of magnesium sulfate in preterm deliveries. Arch Dis Child Fetal Neonatal Ed 2023:archdischild-2022-324579. [PMID: 36617442 DOI: 10.1136/archdischild-2022-324579] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 11/26/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To evaluate the effectiveness and cost-effectiveness of the National PReCePT Programme (NPP) in increasing use of magnesium sulfate (MgSO4) in preterm births. DESIGN Before-and-after study. SETTING Maternity units (N=137) within NHS England and the Academic Health Science Network (AHSN) in 2018. PARTICIPANTS Babies born ≤30 weeks' gestation admitted to neonatal units in England. INTERVENTIONS The NPP was a quality improvement (QI) intervention including the PReCePT (Preventing Cerebral Palsy in Pre Term labour) QI toolkit and materials (preterm labour proforma, staff training presentations, parent leaflet, posters for the unit and learning log), regional AHSN-level support, and up to 90 hours funded backfill for a midwife 'champion' to lead implementation. MAIN OUTCOME MEASURES MgSO4 uptake post implementation was compared with pre-NPP implementation uptake. Implementation and lifetime costs were estimated. RESULTS Compared with pre-implementation estimates, the average MgSO4 uptake for babies born ≤30 weeks' gestation, in 137 maternity units in England, increased by 6.3 percentage points (95% CI 2.6 to 10.0 percentage points) to 83.1% post implementation, accounting for unit size, maternal, baby and maternity unit factors, time trends, and AHSN. Further adjustment for early/late initiation of NPP activities increased the estimate to 9.5 percentage points (95% CI 4.3 to 14.7 percentage points). From a societal and lifetime perspective, the health gains and cost savings associated with the NPP effectiveness generated a net monetary benefit of £866 per preterm baby and the probability of the NPP being cost-effective was greater than 95%. CONCLUSION This national QI programme was effective and cost-effective. National programmes delivered via coordinated regional clinical networks can accelerate uptake of evidence-based therapies in perinatal care.
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Affiliation(s)
- Hannah B Edwards
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Applied Research Collaboration (ARC) West, Bristol, UK
| | - Maria Theresa Redaniel
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Applied Research Collaboration (ARC) West, Bristol, UK
| | - Carlos Sillero-Rejon
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Applied Research Collaboration (ARC) West, Bristol, UK
| | - Ruta Margelyte
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Applied Research Collaboration (ARC) West, Bristol, UK
| | - Tim J Peters
- Bristol Dental School, University of Bristol, Bristol, UK
| | - Kate Tilling
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Applied Research Collaboration (ARC) West, Bristol, UK
| | - William Hollingworth
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Applied Research Collaboration (ARC) West, Bristol, UK
| | - Hugh McLeod
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Applied Research Collaboration (ARC) West, Bristol, UK
| | - Pippa Craggs
- NIHR Applied Research Collaboration (ARC) West, Bristol, UK
- Research and Innovation, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Elizabeth Hill
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Applied Research Collaboration (ARC) West, Bristol, UK
| | - Sabi Redwood
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Applied Research Collaboration (ARC) West, Bristol, UK
| | - Jenny Donovan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Emma Treloar
- Obstetrics, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Ellie Wetz
- West of England Academic Health Science Network, Bristol, UK
| | | | - Gary A Ford
- Medical Sciences Division, University of Oxford, Oxford, UK
| | - John Macleod
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Applied Research Collaboration (ARC) West, Bristol, UK
| | - Karen Luyt
- Translational Health Sciences, University of Bristol Medical School, Bristol, UK
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Ayed M, Ahmed J, More K, Ayed A, Husain H, AlQurashi A, Alrajaan N. Antenatal Magnesium Sulfate for Preterm Neuroprotection: A Single-Center Experience from Kuwait Tertiary NICU. Biomed Hub 2022; 7:80-87. [PMID: 35950015 PMCID: PMC9294943 DOI: 10.1159/000525431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/08/2022] [Indexed: 11/19/2022] Open
Abstract
Objectives The study aimed to evaluate the impact of antenatal exposure of magnesium sulfate (MgSO<sub>4</sub>) on short- and long-term outcomes in preterm neonates born less than 32 weeks gestation. Methods Single-center retrospective cohort study of 229 neonates born between 24 and 32 weeks gestation was conducted from January 2018 through December 2018 in a level III neonatal care unit in Kuwait. Antenatal MgSO<sub>4</sub> exposure was collected from the medical records, and the indication was for neuroprotection effect. Brain MRI was done on 212 neonates (median gestational age 36 weeks), and brain injury was assessed using the Miller's score. Neurodevelopmental outcome was assessed by Bayley-III scales of infant development at 36 months corrected age (N = 146). The association of exposure to MgSO4 with brain injury and neurodevelopmental outcomes was examined using multivariable regression analysis adjusting for gestational age at MRI and variables with p value <0.05 on univariate analysis. Results Among the 229 neonates, 47 received antenatal MgSO<sub>4</sub>. There were no differences between the groups in gestational age and birth weight. MgSO<sub>4</sub> exposure was not associated with an increased risk of necrotizing enterocolitis, chronic lung disease, retinopathy of prematurity, and mortality. The incidence of cerebellar hemorrhage was significantly less in the MgSO<sub>4</sub> group (0% vs. 16%, p value = 0.002). Neonates who received MgSO<sub>4</sub> had lower risks of grade 3–4 intraventricular hemorrhage (IVH) adjusted OR 0.248 (95% CI: 0.092, 0.66), p = 0.006; moderate-severe white matter injury (WMI) adjusted odd ratio 0.208 (95% CI: 0.044, 0.96), p = 0.046; and grade 3–4 IVH and/or moderate-severe WMI adjusted OR 0.23 (95% CI: 0.06, 0.84), p = 0.027. Neurodevelopmental assessment at 36 months corrected age showed better motor (adjusted beta coefficient 1.08 [95% CI: 0.099, 2.06]; p = 0.031) and cognitive composite scores (adjusted beta coefficient 1.29 [95% CI: 0.36, 2.22]; p = 0.007) in the MgSO<sub>4</sub> group. Conclusion Antenatal exposure to MgSO<sub>4</sub> in preterm neonates less than 32 weeks was independently associated with lower risks of brain injury and better motor and cognitive outcomes.
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Affiliation(s)
- Mariam Ayed
- Department of Neonatology, Farwaniya Hospital, Ministry of Health of Kuwait, Kuwait City, Kuwait
- *Mariam Ayed,
| | - Javed Ahmed
- Division of Neonatology, Women's Wellness, and Research Centre, Hamad Medical Corporation, Doha, Qatar
| | - Kiran More
- Division of Neonatology, Sidra Medicine, Doha, Qatar
- Weill Cornell Medicine, Doha, Qatar
| | - Amal Ayed
- Department of Obstetrics and Gynaecology, Farwaniya Hospital, Ministry of Health of Kuwait, Kuwait City, Kuwait
| | - Hamid Husain
- Department of Pediatrics, Adan Hospital, Ministry of Health of Kuwait, Hadiya, Kuwait
| | - Ammar AlQurashi
- Department of Pediatrics, Adan Hospital, Ministry of Health of Kuwait, Hadiya, Kuwait
| | - Najla Alrajaan
- Department of Pediatrics, Farwaniya Hospital, Ministry of Health of Kuwait, Kuwait City, Kuwait
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Keir AK, Shepherd E, McIntyre S, Rumbold A, Groves C, Crowther C, Callander EJ. Antenatal magnesium sulfate to prevent cerebral palsy. Arch Dis Child Fetal Neonatal Ed 2022; 107:225-227. [PMID: 34233908 DOI: 10.1136/archdischild-2021-321817] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 06/17/2021] [Indexed: 11/04/2022]
Abstract
Magnesium sulfate given to women before birth at <30 weeks' gestation reduces the risk of cerebral palsy in their children. Our study aimed to assess the impact of a local quality improvement programme, primarily using plan-do-study-act cycles, to increase the use of antenatal magnesium sulfate. After implementing our quality improvement programme, an average of 86% of babies delivered at <30 weeks' gestation were exposed to antenatal magnesium sulfate compared with a historical baseline rate of 63%. Our study strengthens the case for embedding quality improvement programmes in maternal perinatal care to reduce the impact of cerebral palsy on families and society.
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Affiliation(s)
- Amy K 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, Adelaide, North Adelaide, South Australia, Australia
| | - Emily Shepherd
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Sarah McIntyre
- Cerebral Palsy Alliance Research Institute, The University of Sydney, Sydney, New South Wales, 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
| | - Charlotte Groves
- Women's and Babies' Division, Women's and Children's Hospital, Adelaide, North Adelaide, South Australia, Australia
| | - Caroline Crowther
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Emily Joy Callander
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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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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Lapinsky SC, Wee WB, Penner M. Timing of antenatal corticosteroids for optimal neonatal outcomes: A Markov decision analysis model. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 44:482-489. [PMID: 34749025 DOI: 10.1016/j.jogc.2021.10.016] [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: 08/09/2021] [Revised: 10/21/2021] [Accepted: 10/21/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Antenatal corticosteroids (ACSs) are administered to pregnant individuals at high risk of preterm delivery to reduce neonatal morbidity and mortality. ACSs have a limited timeframe of effectiveness, and timing of administration can be difficult because of uncertainty surrounding the likelihood of preterm delivery. The objective of the current study was to design a decision analysis model to optimize the timing of ACS administration and identify important model variables that impact administration timing preference. METHODS We created a Markov decision analysis model with a base case of a patient at 240 weeks gestation with antepartum hemorrhage. Decision strategies included immediate, delayed, and no ACS administration. Outcomes were based on the neonatal perspective and consisted of lifetime quality adjusted life years (QALYs). Data for model inputs were derived from current literature and clinical recommendations. RESULTS Our base case analysis revealed a preferred strategy of delaying ACSs for 2 weeks, which maximized QALYs (39.18 lifetime discounted), driven by reduced neonatal morbidity at the expense of 0.1% more neonatal deaths, when compared with immediate ACS administration. Sensitivity analyses identified that, if the probability of delivery within the next week was >6.19%, then immediate steroids were preferred. Other important variables included gestational age, ACS effectiveness, and ACS adverse effects. CONCLUSION ACS timing involves a trade-off between morbidity and mortality, and optimal timing depends on probability of delivery, gestational age, and risks and benefits of ACSs. Clinicians should carefully consider these factors prior to ACS administration.
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Affiliation(s)
- Stephanie C Lapinsky
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.
| | - Wallace B Wee
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON; Department of Pediatrics, Division of Respiratory Medicine, Hospital for Sick Children, Toronto, ON
| | - Melanie Penner
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON; Bloorview Research Institute, Toronto, ON; Department of Paediatrics, University of Toronto, Toronto, ON; Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON
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Edwards H, Redaniel MT, Opmeer B, Peters T, Margelyte R, Sillero Rejon C, Hollingworth W, Craggs P, Hill E, Redwood S, Donovan J, Luyt K. Evaluating an enhanced quality improvement intervention in maternity units: PReCePT trial protocol. BMJ Open Qual 2021; 10:e001204. [PMID: 34031151 PMCID: PMC8149440 DOI: 10.1136/bmjoq-2020-001204] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 05/10/2021] [Indexed: 11/25/2022] Open
Abstract
The UK's National Institute for Health and Care Excellence Preterm labour and birth guideline recommends use of magnesium sulfate (MgSO4) in deliveries below 30 weeks' gestation to prevent cerebral palsy and other neurological problems associated with preterm delivery. Despite national guidance, the uptake of MgSO4 administration in eligible women has been slow. National Health Service England has rolled out the PReCePT (PRevention of Cerebral Palsy in Pre-Term labour) quality improvement (QI) toolkit to increase uptake of MgSO4 in preterm deliveries. The toolkit is designed to increase maternity staff knowledge about MgSO4 and provides training and practical tools to help staff consider use in eligible women. The PReCePT trial compares the effectiveness of two different methods of implementing the QI toolkit (standard versus enhanced support). The standard support arm (control) receives the QI toolkit and regional-level support for a midwife/obstetric 'champion'. The enhanced support arm (intervention) receives this plus additional clinical backfill funding and unit-level QI microcoaching. It is funded by The Health Foundation. This is a cluster randomised controlled trial designed to include 48 maternity units randomised (2:1 ratio) to standard or enhanced support. Units are eligible for inclusion if they have 10 or more preterm (<30 weeks' gestation) deliveries annually and MgSO4 uptake of 70% or less. Randomisation is stratified by previous level of MgSO4 uptake. The QI intervention is implemented over 9 months. All units are followed up for a further 9 months. Blinding is not possible due to the nature of the intervention. The primary outcome is the proportion of MgSO4 uptake among eligible women at follow-up, adjusting for uptake before implementation of the toolkit. The effectiveness of the intervention will be assessed using weighted linear regression on data from the National Neonatal Research Database. Semistructured qualitative staff interviews will inform understanding of the process and outcomes. Economic evaluation will describe total costs and cost-effectiveness.Trial registration number SRCTN 40938673.
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Affiliation(s)
- Hannah Edwards
- Applied Research Collaboration West (NIHR ARC West), National Institute for Health Research, Bristol, UK
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Maria Theresa Redaniel
- Applied Research Collaboration West (NIHR ARC West), National Institute for Health Research, Bristol, UK
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Brent Opmeer
- Applied Research Collaboration West (NIHR ARC West), National Institute for Health Research, Bristol, UK
| | - Tim Peters
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Ruta Margelyte
- Applied Research Collaboration West (NIHR ARC West), National Institute for Health Research, Bristol, UK
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Carlos Sillero Rejon
- Applied Research Collaboration West (NIHR ARC West), National Institute for Health Research, Bristol, UK
- Population Health Sciences, University of Bristol, Bristol, UK
| | - William Hollingworth
- Applied Research Collaboration West (NIHR ARC West), National Institute for Health Research, Bristol, UK
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Pippa Craggs
- Research and Innovation, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Elizabeth Hill
- Applied Research Collaboration West (NIHR ARC West), National Institute for Health Research, Bristol, UK
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Sabi Redwood
- Applied Research Collaboration West (NIHR ARC West), National Institute for Health Research, Bristol, UK
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Jenny Donovan
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Karen Luyt
- Translational Health Sciences, University of Bristol, Bristol, UK
- Neonatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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Abstract
OBJECTIVE The objective is to provide guidelines for the use of antenatal magnesium sulphate for fetal neuroprotection of the preterm infant. OPTIONS Antenatal magnesium sulphate administration should be considered for fetal neuroprotection when women present at ≤33 + 6 weeks with imminent preterm birth, defined as a high likelihood of birth because of active labour with cervical dilatation ≥4 cm, with or without preterm pre-labour rupture of membranes, and/or planned preterm birth for fetal or maternal indications. There are no other known fetal neuroprotective agents. OUTCOMES The outcomes measured are the incidence of cerebral palsy (CP) and neonatal death. EVIDENCE Published literature was retrieved through searches of PubMed or Medline, CINAHL, and the Cochrane Library in December 2017, using appropriate controlled vocabulary and key words (magnesium sulphate, cerebral palsy, preterm birth). Results were restricted to systematic reviews, randomized controlled trials, and relevant observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to December 2017. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS Antenatal magnesium sulphate for fetal neuroprotection reduces the risk of "death or CP" (relative risk [RR] 0.85; 95% confidence interval [CI] 0.74-0.98; 4 trials, 4446 infants), "death or moderate-severe CP" (RR 0.85; 95% CI 0.73-0.99; 3 trials, 4250 infants), "any CP" (RR 0.71; 95% CI 0.55-0.91; 4, trials, 4446 infants), "moderate-to-severe CP" (RR 0.60; 95% CI 0.43-0.84; 3 trials, 4250 infants), and "substantial gross motor dysfunction" (inability to walk without assistance) (RR 0.60; 95% CI 0.43-0.83; 3 trials, 4287 women) at 2 years of age. Results were consistent between trials and across the meta-analyses. There is no anticipated significant increase in health care-related costs because women eligible to receive antenatal magnesium sulphate will be judged to have imminent preterm birth. VALIDATION Australian National Clinical Practice Guidelines were published in March 2010 by the Antenatal Magnesium Sulphate for Neuroprotection Guideline Development Panel. Antenatal magnesium sulphate was recommended for fetal neuroprotection in the same dosage as recommended in these guidelines. However, magnesium sulphate was recommended only at <30 weeks gestation, based on 2 considerations. First, no single gestational age subgroup was considered to show a clear benefit. Second, in the face of uncertainty, the committee felt it was prudent to limit the impact of their clinical practice guidelines on resource allocation. In March 2010, the American College of Obstetricians and Gynecologists issued a Committee Opinion on magnesium sulphate for fetal neuroprotection. It stated that "the available evidence suggests that magnesium sulfate given before anticipated early preterm birth reduces the risk of cerebral palsy in surviving infants." No official opinion was given on a gestational age cut-off, but it was recommended that physicians develop specific guidelines around the issues of inclusion criteria, dosage, concurrent tocolysis, and monitoring in accordance with 1 of the larger trials. Similarly, the World Health Organization also strongly recommends use of magnesium sulphate for fetal neuroprotection in its 2015 recommendations on interventions to improve preterm birth outcomes but cites further researching on dosing regimen and re-treatment. SPONSORS Canadian Institutes of Health Research (CIHR). SUMMARY STATEMENT RECOMMENDATIONS.
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Magee LA, De Silva DA, Sawchuck D, Synnes A, von Dadelszen P. No 376 - Recours au sulfate de magnésium aux fins de neuroprotection fœtale. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:523-542. [DOI: 10.1016/j.jogc.2018.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Shih STF, Tonmukayakul U, Imms C, Reddihough D, Graham HK, Cox L, Carter R. Economic evaluation and cost of interventions for cerebral palsy: a systematic review. Dev Med Child Neurol 2018; 60:543-558. [PMID: 29319155 DOI: 10.1111/dmcn.13653] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2017] [Indexed: 11/30/2022]
Abstract
AIM Economic appraisal can help guide policy-making for purchasing decisions, and treatment and management algorithms for health interventions. We conducted a systematic review of economic studies in cerebral palsy (CP) to inform future research. METHOD Economic studies published since 1970 were identified from seven databases. Two reviewers independently screened abstracts and extracted data following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Any discrepancies were resolved by discussion. RESULTS Of 980 identified references, 115 were included for full-text assessment. Thirteen articles met standard criteria for a full economic evaluation, two as partial economic evaluations, and 18 as cost studies. Six were full economic evaluations alongside clinical studies or randomized controlled trials, whereas seven involved modelling simulations. The economic case for administration of magnesium sulfate for imminent preterm birth is compelling, achieving both health gain and cost savings. Current literature suggests intrathecal baclofen therapy and botulinum toxin injection are cost-effective, but stronger evidence for long-term effects is needed. Lifestyle and web-based interventions are inexpensive, but broader measurement of outcomes is required. INTERPRETATION Prevention of CP would avoid significant economic burden. Some treatments and interventions have been shown to be cost-effective, although stronger evidence of clinical effectiveness is needed. What this paper adds Cost-effectiveness evidence shows prevention is the most significant strategy. Some treatments are cost-effective, but stronger evidence for long-term effectiveness is required. Comparison of treatment costs is challenging owing to variations in methodologies and varying clinical indications.
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Affiliation(s)
- Sophy T F Shih
- Deakin Health Economics, Centre for Population Health Research, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Utsana Tonmukayakul
- Deakin Health Economics, Centre for Population Health Research, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Christine Imms
- Centre for Disability and Development Research, Australian Catholic University, Fitzroy, Victoria, Australia
| | - Dinah Reddihough
- Murdoch Children's Research Institute, Parkville, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia
| | - H Kerr Graham
- Royal Children's Hospital, Parkville, Victoria, Australia
| | - Liz Cox
- Victorian Managed Insurance Authority, Melbourne, Victoria, Australia
| | - Rob Carter
- Deakin Health Economics, Centre for Population Health Research, Faculty of Health, Deakin University, Geelong, Victoria, Australia
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Chollat C, Marret S. Magnesium sulfate and fetal neuroprotection: overview of clinical evidence. Neural Regen Res 2018; 13:2044-2049. [PMID: 30323118 PMCID: PMC6199933 DOI: 10.4103/1673-5374.241441] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Antenatal administration of magnesium sulfate is an important part of the neuroprotective strategy for preterm infants. Strong evidence from five randomized controlled trials and five meta-analyses has demonstrated that magnesium sulfate, when administered before preterm delivery, significantly reduces the risk of cerebral palsy at two years. Through secondary analyses of randomized controlled trials and other original clinical studies, this state-of-the-art review highlights the absence of serious adverse effects in both pregnant women and neonates, as well as the impact of maternal body mass index and preeclamptic status on the maternal and neonatal magnesium levels, which could influence the magnitude of the neuroprotective effect. Although antenatal magnesium sulfate is a cost-effective strategy, some practice surveys have demonstrated that the use of magnesium sulfate is not sufficient and that its use is heterogeneous, differing among different maternity wards. Since 2010, an increasing number of obstetrical societies have recommended its use to improve the neurological outcomes of preterm infants, especially the International Federation of Gynecology and Obstetrics and World Health Organization in 2015, and France in 2017. Considering the neuroprotective impact of magnesium sulfate when administered before delivery, postnatal administration should be considered, and its effects should be assessed using randomized controlled trials.
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Affiliation(s)
- Clément Chollat
- Institut National de la Santé et de la Recherche Médicale U1245, Genetics and Pathophysiology of Neurodevelopmental Disorders, Team 4 Neovasc, Institute of Research and Innovation in Biomedicine, Rouen School of Medicine, Normandy University, Caen; Department of Neonatal Intensive Care, Port Royal University Hospital, Paris, France
| | - Stéphane Marret
- Department of Neonatal Intensive Care, Port Royal University Hospital, Paris; Department of Neonatal Pediatrics and Intensive Care and Neuropediatrics, Charles-Nicolle University Hospital, Rouen, France
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12
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Marret S, Ancel PY. Protection cérébrale de l’enfant né prématuré par le sulfate de magnésium. ACTA ACUST UNITED AC 2016; 45:1418-1433. [DOI: 10.1016/j.jgyn.2016.09.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 09/21/2016] [Accepted: 09/21/2016] [Indexed: 12/15/2022]
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Gano D, Ho ML, Partridge JC, Glass HC, Xu D, Barkovich AJ, Ferriero DM. Antenatal Exposure to Magnesium Sulfate Is Associated with Reduced Cerebellar Hemorrhage in Preterm Newborns. J Pediatr 2016; 178:68-74. [PMID: 27453378 PMCID: PMC5085851 DOI: 10.1016/j.jpeds.2016.06.053] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 05/09/2016] [Accepted: 06/15/2016] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To determine the association of antenatal magnesium sulfate with cerebellar hemorrhage in a prospective cohort of premature newborns evaluated by magnetic resonance imaging (MRI). STUDY DESIGN Cross-sectional analysis of baseline characteristics from a prospective cohort of preterm newborns (<33 weeks gestation) evaluated with 3T-MRI shortly after birth. Exclusion criteria were clinical evidence of a congenital syndrome, congenital infection, or clinical status too unstable for transport to MRI. Antenatal magnesium sulfate exposure was abstracted from the medical records and the indication was classified as obstetric or neuroprotection. Two pediatric neuroradiologists, blinded to the clinical history, scored axial T2-weighted and iron susceptibility MRI sequences for cerebellar hemorrhage. The association of antenatal magnesium sulfate with cerebellar hemorrhage was evaluated using multivariable logistic regression, adjusting for postmenstrual age at MRI and known predictors of cerebellar hemorrhage. RESULTS Cerebellar hemorrhage was present in 27 of 73 newborns (37%) imaged at a mean ± SD postmenstrual age of 32.4 ± 2 weeks. Antenatal magnesium sulfate exposure was associated with a significantly reduced risk of cerebellar hemorrhage. Adjusting for postmenstrual age at MRI, and predictors of cerebellar hemorrhage, antenatal magnesium sulfate was independently associated in our cohort with decreased cerebellar hemorrhage (OR, 0.18; 95% CI, 0.049-0.65; P = .009). CONCLUSION Antenatal magnesium sulfate exposure is independently associated with a decreased risk of MRI-detected cerebellar hemorrhage in premature newborns, which could explain some of the reported neuroprotective effects of magnesium sulfate.
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Affiliation(s)
- Dawn Gano
- Department of Neurology, University of California, San Francisco, San Francisco, CA; Department of Pediatrics, University of California, San Francisco, San Francisco, CA.
| | - Mai-Lan Ho
- Department of Radiology, Mayo Clinic, Rochester, MN
| | - John Colin Partridge
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Hannah C. Glass
- Department of Neurology, University of California, San Francisco, San Francisco, CA,Department of Pediatrics, University of California, San Francisco, San Francisco, CA,Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Duan Xu
- Department of Radiology, University of California, San Francisco, San Francisco, CA
| | - A. James Barkovich
- Department of Neurology, University of California, San Francisco, San Francisco, CA,Department of Pediatrics, University of California, San Francisco, San Francisco, CA,Department of Radiology, University of California, San Francisco, San Francisco, CA
| | - Donna M. Ferriero
- Department of Neurology, University of California, San Francisco, San Francisco, CA,Department of Pediatrics, University of California, San Francisco, San Francisco, CA
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von Dadelszen P, Magee LA. Preventing deaths due to the hypertensive disorders of pregnancy. Best Pract Res Clin Obstet Gynaecol 2016; 36:83-102. [PMID: 27531686 PMCID: PMC5096310 DOI: 10.1016/j.bpobgyn.2016.05.005] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 05/25/2016] [Accepted: 05/29/2016] [Indexed: 02/08/2023]
Abstract
In this chapter, taking a life cycle and both civil society and medically oriented approach, we will discuss the contribution of the hypertensive disorders of pregnancy (HDPs) to maternal, perinatal and newborn mortality and morbidity. Here we review various interventions and approaches to preventing deaths due to HDPs and discuss effectiveness, resource needs and long-term sustainability of the different approaches. Societal approaches, addressing sustainable development goals (SDGs) 2.2 (malnutrition), 3.7 (access to sexual and reproductive care), 3.8 (universal health coverage) and 3c (health workforce strengthening), are required to achieve SDGs 3.1 (maternal survival), 3.2 (perinatal survival) and 3.4 (reduced impact of non-communicable diseases (NCDs)). Medical solutions require greater clarity around the classification of the HDPs, increased frequency of effective antenatal visits, mandatory responses to the HDPs when encountered, prompt provision of life-saving interventions and sustained surveillance for NCD risk for women with a history of the HDPs.
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Affiliation(s)
- Peter von Dadelszen
- Institute of Cardiovascular and Cell Sciences, St George's University of London, UK; Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK.
| | - Laura A Magee
- Institute of Cardiovascular and Cell Sciences, St George's University of London, UK; Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
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Could EEG Monitoring in Critically Ill Children Be a Cost-effective Neuroprotective Strategy? J Clin Neurophysiol 2016; 32:486-94. [PMID: 26057408 DOI: 10.1097/wnp.0000000000000198] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE Electrographic status epilepticus (ESE) in critically ill children is associated with unfavorable functional outcomes, but identifying candidates for ESE management requires resource-intense EEG monitoring. A cost-effectiveness analysis was performed to estimate how much ESE identification and management would need to improve patient outcomes to make EEG monitoring strategies a good value. METHODS A decision tree was created to examine the relationships among variables important to deciding whether to perform EEG monitoring. Variable costs were estimated from their component parts, outcomes were estimated in quality-adjusted life-years, and incremental cost-effectiveness ratios were calculated to compare the relative values using four alternative EEG monitoring strategies that varied by monitoring duration. RESULTS Forty-eight hours of EEG monitoring would be worth its cost if ESE identification and management improved patient outcomes by ≥7%. If ESE identification and management improved patient outcomes by 3% to 6%, then 24 or 48 hours of EEG monitoring would be worth the cost depending on how much decision makers were willing to pay per quality-adjusted life-year gained. If ESE identification and management improved outcomes by as little as 3%, then 24 hours of EEG monitoring would be worth the cost. CONCLUSIONS EEG monitoring has the potential to be cost-effective if ESE identification and management improves patient outcomes by as little as 3%.
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Abstract
Pre-eclampsia remains the second leading direct cause of maternal death, >99 % of which occurs in less developed countries. Over 90 percent of the observed reduction in pre-eclampsia-related maternal deaths in the UK (1952-2008) occurred with antenatal surveillance and timed delivery. In this review, we discuss the pathogenesis, diagnostic criteria, disease prediction models, prevention and management of pre-eclampsia. The Pre-eclampsia Integrated Estimate of RiSk (PIERS) models and markers of angiogenic imbalance identify women at incremental risk for severe pre-eclampsia complications. For women at high risk of developing pre-eclampsia, low doses of aspirin (especially if started <17 weeks) and calcium are evidence-based preventative strategies; heparin is less so. Severe hypertension must be treated and the Control of Hypertension In Pregnancy (CHIPS) Trial (reporting: 2014) will guide non-severe hypertension management. Magnesium sulfate prevents and treats eclampsia; there is insufficient evidence to support alternative regimens. Pre-eclampsia predicts later cardiovascular disease; however, at this time we do not know what to do about it.
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Affiliation(s)
- Peter von Dadelszen
- Department of Obstetrics and Gynaecology, University of British Columbia, Rm V3-339, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada,
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