1
|
Estañ-Capell J, Alarcón-Torres B, Miró-Pedro M, Martínez-Costa C. Differences When Classifying Small for Gestational Age Preterm Infants According to the Growth Chart Applied. Am J Perinatol 2024; 41:e1212-e1219. [PMID: 36709759 DOI: 10.1055/s-0043-1761297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Consensus around the ideal chart to classify preterm babies is scant. It is particularly relevant in small for gestational age (SGA) infants due to its clinical and therapeutic implications. The aim of the study was to compare Olsen, Intergrowth-21st, and Fenton growth charts, regarding the classification at birth and incidence of SGA preterm infants. STUDY DESIGN Retrospective study of 529 preterm infants ≤ 32 weeks of gestational age. Birth weight Z-score was calculated applying the three growth charts and ponderal index (PI) was also estimated. Incidence of SGA (birth weight < 10th percentile) and clinical outcome were compared according to the chart used. RESULTS Incidence of SGA was significantly higher (p < 0.001) with Olsen (101 cases, 19.1%) compared with Intergrowth-21st (75 cases, 14.2%) and Fenton (53 cases, 10%). Differences were also found with PI of SGA preterm infants, as those infants classified by Olsen were mostly symmetric (PI > 10th percentile), while Fenton and Intergrowth-21st identified less symmetric SGA infants. Kappa concordance between Intergrowth-21st and Fenton was 0.805, Intergrowth-21st versus Olsen 0.824, and Fenton versus Olsen 0.641. No differences were observed on neonatal morbidities or mortality. CONCLUSION Significant differences were detected when classifying very preterm infants at birth according to the growth chart, mainly among symmetric SGA. Concordance between Fenton and Olsen was poor, but Intergrowth-21st showed high concordance with Fenton and Olsen. However, further research is needed to select the ideal chart. Variability in the population selected to create the curves and the accuracy dating the pregnancy are factors that may have explained differences. KEY POINTS · Very preterm infants are differently classified at birth with various growth charts.. · Higher incidence of small for gestational age infants with Olsen compared with Fenton or Intergrowth.. · Variability in population selection and accuracy in dating pregnancy may have explained differences..
Collapse
Affiliation(s)
- Javier Estañ-Capell
- Neonatal Unit, Hospital Clínico Universitario, Valencia, Spain
- Department of Pediatrics, School of Medicine, University of Valencia, Valencia, Spain
| | | | | | | |
Collapse
|
2
|
Axelsson Fisk S, Alex-Petersen J, Rostila M, Liu C, Juárez SP. Social inequalities in the risk of giving birth to a small for gestational age child in Sweden 2010-16: a cross-sectional study adopting an intersectional approach. Eur J Public Health 2024; 34:22-28. [PMID: 37878824 PMCID: PMC10843954 DOI: 10.1093/eurpub/ckad184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Well-established associations exist between the risk of small for gestational age (SGA) and unidimensional sociodemographic factors. We investigated social inequalities in SGA risk and adopted an intersectional approach that simultaneously considers different social categories. By doing so, we could assess heterogeneities in SGA risk within unidimensional sociodemographic categories. METHODS We included all live 679 694 singleton births in Sweden between 2010 and 2016. The outcome was SGA, and the exposures were age, maternal educational level, dichotomous migration status and civil status. Thirty-six possible combinations of these factors constituted the exposure in an intersectional model. We present odds ratios (ORs) with 95% confidence intervals (95% CIs) and the area under the receiver operating characteristic curve (AUC)-a measurement of discriminatory accuracy (i.e. the ability to discriminate the babies born SGA from those who are not). RESULTS Women with low education and women born outside Sweden had ORs of 1.46 (95% CI 1.38-1.54) and 1.50 (95% CI 1.43-1.56) in unidimensional analyses, respectively. Among women aged under 25 with low education who were born outside Sweden and unmarried, the highest OR was 3.06 (2.59-3.63). The discriminatory accuracy was low for both the unidimensional model that included all sociodemographic factors (AUC 0. 563) and the intersectional model (AUC 0.571). CONCLUSIONS The intersectional approach revealed a complex sociodemographic pattern of SGA risk. Sociodemographic factors have a low accuracy in identifying SGA at the individual level, even when quantifying their multi-dimensional intersections. This cautions against interventions targeted to individuals belonging to socially defined groups to reduce social inequalities in SGA risk.
Collapse
Affiliation(s)
- Sten Axelsson Fisk
- Department of Clinical Sciences Lund, Obstetrics and Gynaecology, Lund University, Lund, BMC C14. Lund, 22185, Sweden
- Department of Obstetrics and Gynaecology, Ystad Hospital, Ystad, Sweden
| | | | - Mikael Rostila
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden
- Centre for Health Equity Studies (CHESS), Stockholm University/Karolinska Institutet, Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society (NVS), Aging Research Center (ARC), Karolinska Institutet/Stockholm University, Stockholm, Sweden
| | - Can Liu
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden
- Centre for Health Equity Studies (CHESS), Stockholm University/Karolinska Institutet, Stockholm, Sweden
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Sol Pia Juárez
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden
- Centre for Health Equity Studies (CHESS), Stockholm University/Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
3
|
Relph S, Vieira MC, Copas A, Alagna A, Page L, Winsloe C, Shennan A, Briley A, Johnson M, Lees C, Lawlor DA, Sandall J, Khalil A, Pasupathy D. Characteristics associated with antenatally unidentified small-for-gestational-age fetuses: prospective cohort study nested within DESiGN randomized controlled trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:356-366. [PMID: 36206546 PMCID: PMC7616055 DOI: 10.1002/uog.26091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/26/2022] [Accepted: 09/30/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To identify the clinical characteristics and patterns of ultrasound use amongst pregnancies with an antenatally unidentified small-for-gestational-age (SGA) fetus, compared with those in which SGA is identified, to understand how to design interventions that improve antenatal SGA identification. METHODS This was a prospective cohort study of singleton, non-anomalous SGA (birth weight < 10th centile) neonates born after 24 + 0 gestational weeks at 13 UK sites, recruited for the baseline period and control arm of the DESiGN trial. Pregnancy with antenatally unidentified SGA was defined if there was no scan or if the final scan showed estimated fetal weight (EFW) at the 10th centile or above. Identified SGA was defined if EFW was below the 10th centile at the last scan. Maternal and fetal sociodemographic and clinical characteristics were studied for associations with unidentified SGA using unadjusted and adjusted logistic regression models. Ultrasound parameters (gestational age at first growth scan, number and frequency of ultrasound scans) were described, stratified by presence of indication for serial ultrasound. Associations of unidentified SGA with absolute centile and percentage weight difference between the last scan and birth were also studied on unadjusted and adjusted logistic regression, according to time between the last scan and birth. RESULTS Of the 15 784 SGA babies included, SGA was not identified antenatally in 78.7% of cases. Of pregnancies with unidentified SGA, 47.1% had no recorded growth scan. Amongst 9410 pregnancies with complete data on key maternal comorbidities and antenatal complications, the risk of unidentified SGA was lower for women with any indication for serial scans (adjusted odds ratio (aOR), 0.56 (95% CI, 0.49-0.64)), for Asian compared with white women (aOR, 0.80 (95% CI, 0.69-0.93)) and for those with non-cephalic presentation at birth (aOR, 0.58 (95% CI, 0.46-0.73)). The risk of unidentified SGA was highest among women with a body mass index (BMI) of 25.0-29.9 kg/m2 (aOR, 1.15 (95% CI, 1.01-1.32)) and lowest in those with underweight BMI (aOR, 0.61 (95% CI, 0.48-0.76)) compared to women with BMI of 18.5-24.9 kg/m2 . Compared to women with identified SGA, those with unidentified SGA had fetuses of higher SGA birth-weight centile (adjusted odds for unidentified SGA increased by 1.21 (95% CI, 1.18-1.23) per one-centile increase between the 0th and 10th centiles). Duration between the last scan and birth increased with advancing gestation in pregnancies with unidentified SGA. SGA babies born within a week of the last growth scan had a mean difference between EFW and birth-weight centiles of 19.5 (SD, 13.8) centiles for the unidentified-SGA group and 0.2 (SD, 3.3) centiles for the identified-SGA group (adjusted mean difference between groups, 19.0 (95% CI, 17.8-20.1) centiles). CONCLUSIONS Unidentified SGA was more common amongst women without an indication for serial ultrasound, and in those with cephalic presentation at birth, BMI of 25.0-29.9 kg/m2 and less severe SGA. Ultrasound EFW was overestimated in women with unidentified SGA. This demonstrates the importance of improving the accuracy of SGA screening strategies in low-risk populations and continuing performance of ultrasound scans for term pregnancies. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- S. Relph
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - M. C. Vieira
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
- Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - A. Copas
- Centre for Pragmatic Global Health Trials, Institute for Global Health, University College London, London, UK
| | - A. Alagna
- Guy’s & St Thomas’ Charity, London, UK
| | - L. Page
- West Middlesex University Hospital, Chelsea & Westminster Hospital NHS Foundation Trust, Isleworth, UK
| | - C. Winsloe
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
- Centre for Pragmatic Global Health Trials, Institute for Global Health, University College London, London, UK
| | - A. Shennan
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - A. Briley
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
- Caring Futures Institute, Flinders University and North Adelaide Local Health Network, Adelaide, Australia
| | - M. Johnson
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - C. Lees
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - D. A. Lawlor
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol NIHR Biomedical Research Centre, Bristol, UK
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
| | - J. Sandall
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - A. Khalil
- Fetal Medicine Unit, St George’s University Hospitals NHS Foundation Trust, London, UK
- Molecular & Clinical Sciences Research Institute, St George’s University of London, London, UK
| | - D. Pasupathy
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
- Reproduction and Perinatal Centre, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - on behalf of the DESiGN Trial Team and DESiGN Collaborative Group
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
- Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil
- Centre for Pragmatic Global Health Trials, Institute for Global Health, University College London, London, UK
- Guy’s & St Thomas’ Charity, London, UK
- West Middlesex University Hospital, Chelsea & Westminster Hospital NHS Foundation Trust, Isleworth, UK
- Caring Futures Institute, Flinders University and North Adelaide Local Health Network, Adelaide, Australia
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol NIHR Biomedical Research Centre, Bristol, UK
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Fetal Medicine Unit, St George’s University Hospitals NHS Foundation Trust, London, UK
- Molecular & Clinical Sciences Research Institute, St George’s University of London, London, UK
- Reproduction and Perinatal Centre, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| |
Collapse
|
4
|
Implementation of Uterine Artery Doppler Scanning: Improving the Care of Women and Babies High Risk for Fetal Growth Restriction. J Pregnancy 2023; 2023:1506447. [PMID: 36726451 PMCID: PMC9886456 DOI: 10.1155/2023/1506447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/17/2022] [Accepted: 01/03/2023] [Indexed: 01/24/2023] Open
Abstract
Introduction While stillbirth rates have declined in many countries, these declines are less marked in the UK. Fetal growth restriction (FGR) affects about 3% to 7% of all pregnancies and is by far the single strongest risk factor for stillbirth. FGR implies a pathological restriction of the genetic growth potential and is not synonymous with small-for-gestational age (SGA). The Royal College of Obstetricians and Gynaecologists (RCOG) defines SGA as an estimated fetal weight (EFW) or abdominal circumference (AC) less than the 10th centile. The likelihood of FGR is higher in severe SGA defined as an EFW or AC less than the 3rd centile. The second version of Saving Babies' Lives Care Bundle (SBLCBv2) recommends the second trimester uterine artery Doppler (UtAD) pulsatility index (PI) screening for pregnancies at high risk of FGR. This study was aimed at determining the prevalence of FGR and assess pregnancy outcomes following the implementation of UtAD at the United Lincolnshire Hospitals NHS Trust (ULHT). Methods One-year retrospective cohort study (1st September 2020-31st August 2021) was conducted across both ULHT hospitals in the UK (Lincoln County Hospital in Lincoln and Pilgrim Hospital in Boston). Results During the study period, 5197 women were booked at ULHT. Of 5197, 349 were identified as high risk for FGR. When numbers were compared for the two hospitals, FGR rate was higher in Lincoln 8.10% vs. 4.51% in Boston. In addition, an increased proportion of abnormal UtAD scans was observed in Lincoln (35.7%) vs. in Boston (22%) (P = 0.014). Of the 349 UtAD scans, 237 were normal (67.9%), 41 showed unilateral notching (11.7%), 43 bilateral notching (12.3%), and 28 raised PI (8%). Babies in the bilateral notching group exhibited the lowest birth weight (P = 0.005), born at an earlier gestation (P = 0.029), and with low Apgar scores at 1 (P = 0.007) and 5 minutes (P < 0.001). Discussion. UtAD is a useful second trimester screening tool for women identified as high risk for FGR and helps stratify the intensity of surveillance. However, the findings call into question a focus solely on the UtAD PI for improving FGR detection without taking into account bilateral notching.
Collapse
|
5
|
Relph S, Vieira MC, Copas A, Coxon K, Alagna A, Briley A, Johnson M, Page L, Peebles D, Shennan A, Thilaganathan B, Marlow N, Lees C, Lawlor DA, Khalil A, Sandall J, Pasupathy D, Healey A. Improving antenatal detection of small-for-gestational-age fetus: economic evaluation of Growth Assessment Protocol. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:620-631. [PMID: 35797108 PMCID: PMC9828078 DOI: 10.1002/uog.26022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/19/2022] [Accepted: 06/23/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To determine whether the Growth Assessment Protocol (GAP), as implemented in the DESiGN trial, is cost-effective in terms of antenatal detection of small-for-gestational-age (SGA) neonate, when compared with standard care. METHODS This was an incremental cost-effectiveness analysis undertaken from the perspective of a UK National Health Service hospital provider. Thirteen maternity units from England, UK, were recruited to the DESiGN (DEtection of Small for GestatioNal age fetus) trial, a cluster randomized controlled trial. Singleton, non-anomalous pregnancies which delivered after 24 + 0 gestational weeks between November 2015 and February 2019 were analyzed. Probabilistic decision modeling using clinical trial data was undertaken. The main outcomes of the study were the expected incremental cost, the additional number of SGA neonates identified antenatally and the incremental cost-effectiveness ratio (ICER) (cost per additional SGA neonate identified) of implementing GAP. Secondary analysis focused on the ICER per infant quality-adjusted life year (QALY) gained. RESULTS The expected incremental cost (including hospital care and implementation costs) of GAP over standard care was £34 559 per 1000 births, with a 68% probability that implementation of GAP would be associated with increased costs to sustain program delivery. GAP identified an additional 1.77 SGA neonates per 1000 births (55% probability of it being more clinically effective). The ICER for GAP was £19 525 per additional SGA neonate identified, with a 44% probability that GAP would both increase cost and identify more SGA neonates compared with standard care. The probability of GAP being the dominant clinical strategy was low (11%). The expected incremental cost per infant QALY gained ranged from £68 242 to £545 940, depending on assumptions regarding the QALY value of detection of SGA. CONCLUSION The economic case for replacing standard care with GAP is weak based on the analysis reported in our study. However, this conclusion should be viewed taking into account that cost-effectiveness analyses are always limited by the assumptions made. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- S. Relph
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and MedicineKing's College LondonLondonUK
| | - M. C. Vieira
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and MedicineKing's College LondonLondonUK
- Department of Obstetrics and GynaecologyUniversity of Campinas (UNICAMP), School of Medical SciencesSão PauloBrazil
| | - A. Copas
- Centre for Pragmatic Global Health TrialsInstitute for Global Health, University College LondonLondonUK
| | - K. Coxon
- Faculty of Health, Social Care and EducationKingston and St George's UniversityLondonUK
| | - A. Alagna
- The Guy's & St Thomas' CharityLondonUK
| | - A. Briley
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and MedicineKing's College LondonLondonUK
- Caring Futures InstituteCollege of Nursing and Health Sciences, Flinders UniversityAdelaideAustralia
| | - M. Johnson
- Department of Surgery and CancerImperial College LondonLondonUK
| | - L. Page
- West Middlesex University Hospital, Chelsea & Westminster Hospital NHS Foundation TrustLondonUK
| | - D. Peebles
- UCL Institute for Women's HealthUniversity College LondonLondonUK
| | - A. Shennan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and MedicineKing's College LondonLondonUK
| | - B. Thilaganathan
- Fetal Medicine UnitSt George's University Hospitals NHS Foundation TrustLondonUK
- Molecular & Clinical Sciences Research InstituteSt George's, University of LondonLondonUK
| | - N. Marlow
- UCL Institute for Women's HealthUniversity College LondonLondonUK
| | - C. Lees
- Department of Surgery and CancerImperial College LondonLondonUK
| | - D. A. Lawlor
- Population Health ScienceBristol Medical School, University of BristolBristolUK
- Bristol NIHR Biomedical Research CentreBristolUK
| | - A. Khalil
- Fetal Medicine UnitSt George's University Hospitals NHS Foundation TrustLondonUK
- Molecular & Clinical Sciences Research InstituteSt George's, University of LondonLondonUK
| | - J. Sandall
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and MedicineKing's College LondonLondonUK
| | - D. Pasupathy
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and MedicineKing's College LondonLondonUK
- Reproduction and Perinatal Centre, Faculty of Medicine and HealthUniversity of SydneySydneyAustralia
| | - A. Healey
- Department of Health Service and Population ResearchDavid Goldberg Centre, King's College LondonLondonUK
| | | |
Collapse
|
6
|
Relph S, Coxon K, Vieira MC, Copas A, Healey A, Alagna A, Briley A, Johnson M, Lawlor DA, Lees C, Marlow N, McCowan L, McMicking J, Page L, Peebles D, Shennan A, Thilaganathan B, Khalil A, Pasupathy D, Sandall J. Effect of the Growth Assessment Protocol on the DEtection of Small for GestatioNal age fetus: process evaluation from the DESiGN cluster randomised trial. Implement Sci 2022; 17:60. [PMID: 36064428 PMCID: PMC9446790 DOI: 10.1186/s13012-022-01228-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 07/27/2022] [Indexed: 11/21/2022] Open
Abstract
Background Reducing the rate of stillbirth is an international priority. At least half of babies stillborn in high-income countries are small for gestational-age (SGA). The Growth Assessment Protocol (GAP), a complex antenatal intervention that aims to increase the rate of antenatal detection of SGA, was evaluated in the DESiGN type 2 hybrid effectiveness-implementation cluster randomised trial (n = 13 clusters). In this paper, we present the trial process evaluation. Methods A mixed-methods process evaluation was conducted. Clinical leads and frontline healthcare professionals were interviewed to inform understanding of context (implementing and standard care sites) and GAP implementation (implementing sites). Thematic analysis of interview text used the context and implementation of complex interventions framework to understand acceptability, feasibility, and the impact of context. A review of implementing cluster clinical guidelines, training and maternity records was conducted to assess fidelity, dose and reach. Results Interviews were conducted with 28 clinical leads and 27 frontline healthcare professionals across 11 sites. Staff at implementing sites generally found GAP to be acceptable but raised issues of feasibility, caused by conflicting demands on resource, and variable beliefs among clinical leaders regarding the intervention value. GAP was implemented with variable fidelity (concordance of local guidelines to GAP was high at two sites, moderate at two and low at one site), all sites achieved the target to train > 75% staff using face-to-face methods, but only one site trained > 75% staff using e-learning methods; a median of 84% (range 78–87%) of women were correctly risk stratified at the five implementing sites. Most sites achieved high scores for reach (median 94%, range 62–98% of women had a customised growth chart), but generally, low scores for dose (median 31%, range 8–53% of low-risk women and median 5%, range 0–17% of high-risk women) were monitored for SGA as recommended. Conclusions Implementation of GAP was generally acceptable to staff but with issues of feasibility that are likely to have contributed to variation in implementation strength. Leadership and resourcing are fundamental to effective implementation of clinical service changes, even when such changes are well aligned to policy mandated service-change priorities. Trial registration Primary registry and trial identifying number: ISRCTN 67698474. Registered 02/11/16. 10.1186/ISRCTN67698474. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01228-1.
Collapse
Affiliation(s)
- Sophie Relph
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, School of Life Course Sciences, Women's Health Academic Centre KHP, King's College London, 10th Floor North Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Kirstie Coxon
- Department of Midwifery, Faculty of Health, Social Care and Education, Kingston and St. George's Universities, Kenry House, Kingston Hill, London, KT2 7LB, UK
| | - Matias C Vieira
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, School of Life Course Sciences, Women's Health Academic Centre KHP, King's College London, 10th Floor North Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.,Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, 13083-881, Brazil
| | - Andrew Copas
- Centre for Pragmatic Global Health Trials, Institute for Global Health, University College London, Gower Street, London, WC1E 6BT, UK
| | - Andrew Healey
- Centre for Implementation Science and King's Health Economics, Health Services and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience at King's College London, The David Goldberg Centre, London, SE5 8AF, UK
| | - Alessandro Alagna
- The Guy's & St Thomas' Charity, 9 King's Head Yard, London, SE1 1NA, UK
| | - Annette Briley
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, School of Life Course Sciences, Women's Health Academic Centre KHP, King's College London, 10th Floor North Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.,Caring Futures Institute Flinders University and North Adelaide Local Health Network, Adelaide, SA, 5042, Australia
| | - Mark Johnson
- Department of Surgery and Cancer, Imperial College London, Kensington, London, SW7 2AZ, UK
| | - Deborah A Lawlor
- Bristol NIHR Biomedical Research Centre, Bristol, BS8 2BL, UK.,Medical Research Council Integrative Epidemiology Unit at the University of Bristol, Bristol, BS8 2BL, UK.,Population Health Science, Bristol Medical School, University of Bristol, Bristol, BS8 2BL, UK
| | - Christoph Lees
- Department of Surgery and Cancer, Imperial College London, Kensington, London, SW7 2AZ, UK
| | - Neil Marlow
- UCL Institute for Women's Health, University College London, Gower Street, London, WC1E 6BT, UK
| | - Lesley McCowan
- Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Jessica McMicking
- Guy's and St Thomas' NHS Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Louise Page
- West Middlesex University Hospital, Chelsea & Westminster Hospital NHS Foundation Trust, Twickenham Road, Isleworth, TW7 6AF, UK
| | - Donald Peebles
- UCL Institute for Women's Health, University College London, Gower Street, London, WC1E 6BT, UK
| | - Andrew Shennan
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, School of Life Course Sciences, Women's Health Academic Centre KHP, King's College London, 10th Floor North Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Baskaran Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK.,Molecular & Clinical Sciences Research Institute, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK.,Molecular & Clinical Sciences Research Institute, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Dharmintra Pasupathy
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, School of Life Course Sciences, Women's Health Academic Centre KHP, King's College London, 10th Floor North Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.,Reproduction and Perinatal Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2145, Australia
| | - Jane Sandall
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, School of Life Course Sciences, Women's Health Academic Centre KHP, King's College London, 10th Floor North Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | | |
Collapse
|
7
|
Butler E, Hugh O, Gardosi J. Evaluating the Growth Assessment Protocol for stillbirth prevention: progress and challenges. J Perinat Med 2022; 50:737-747. [PMID: 35618671 DOI: 10.1515/jpm-2022-0209] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2022] [Indexed: 11/15/2022]
Abstract
Many stillbirths are associated with fetal growth restriction, and are hence potentially avoidable. The Growth Assessment Protocol (GAP) is a multidisciplinary program with an evidence based care pathway, training in risk assessment, fetal growth surveillance with customised charts and rolling audit. Antenatal detection of small for gestational age (SGA) has become an indicator of quality of care. Evaluation is essential to understand the impact of such a prevention program. Randomised trials will not be effective if they cannot ensure proper implementation before assessment. Observational studies have allowed realistic evaluation in practice, with other factors excluded that may have influenced the outcome. An award winning 10 year study of stillbirth data in England has been able to assess the effect of GAP in isolation, and found a strong, causal association with improved antenatal detection of SGA babies, and the sustained decline in national stillbirth rates. The challenge now is to apply this program more widely in low and middle income settings where the main global burden of stillbirth is, and to adapt it to local needs and resources.
Collapse
|
8
|
Vieira MC, Relph S, Muruet-Gutierrez W, Elstad M, Coker B, Moitt N, Delaney L, Winsloe C, Healey A, Coxon K, Alagna A, Briley A, Johnson M, Page LM, Peebles D, Shennan A, Thilaganathan B, Marlow N, McCowan L, Lees C, Lawlor DA, Khalil A, Sandall J, Copas A, Pasupathy D. Evaluation of the Growth Assessment Protocol (GAP) for antenatal detection of small for gestational age: The DESiGN cluster randomised trial. PLoS Med 2022; 19:e1004004. [PMID: 35727800 PMCID: PMC9212153 DOI: 10.1371/journal.pmed.1004004] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 04/29/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Antenatal detection and management of small for gestational age (SGA) is a strategy to reduce stillbirth. Large observational studies provide conflicting results on the effect of the Growth Assessment Protocol (GAP) in relation to detection of SGA and reduction of stillbirth; to the best of our knowledge, there are no reported randomised control trials. Our aim was to determine if GAP improves antenatal detection of SGA compared to standard care. METHODS AND FINDINGS This was a pragmatic, superiority, 2-arm, parallel group, open, cluster randomised control trial. Maternity units in England were eligible to participate in the study, except if they had already implemented GAP. All women who gave birth in participating clusters (maternity units) during the year prior to randomisation and during the trial (November 2016 to February 2019) were included. Multiple pregnancies, fetal abnormalities or births before 24+1 weeks were excluded. Clusters were randomised to immediate implementation of GAP, an antenatal care package aimed at improving detection of SGA as a means to reduce the rate of stillbirth, or to standard care. Randomisation by random permutation was stratified by time of study inclusion and cluster size. Data were obtained from hospital electronic records for 12 months prerandomisation, the washout period (interval between randomisation and data collection of outcomes), and the outcome period (last 6 months of the study). The primary outcome was ultrasound detection of SGA (estimated fetal weight <10th centile using customised centiles (intervention) or Hadlock centiles (standard care)) confirmed at birth (birthweight <10th centile by both customised and population centiles). Secondary outcomes were maternal and neonatal outcomes, including induction of labour, gestational age at delivery, mode of birth, neonatal morbidity, and stillbirth/perinatal mortality. A 2-stage cluster-summary statistical approach calculated the absolute difference (intervention minus standard care arm) adjusted using the prerandomisation estimate, maternal age, ethnicity, parity, and randomisation strata. Intervention arm clusters that made no attempt to implement GAP were excluded in modified intention to treat (mITT) analysis; full ITT was also reported. Process evaluation assessed implementation fidelity, reach, dose, acceptability, and feasibility. Seven clusters were randomised to GAP and 6 to standard care. Following exclusions, there were 11,096 births exposed to the intervention (5 clusters) and 13,810 exposed to standard care (6 clusters) during the outcome period (mITT analysis). Age, height, and weight were broadly similar between arms, but there were fewer women: of white ethnicity (56.2% versus 62.7%), and in the least deprived quintile of the Index of Multiple Deprivation (7.5% versus 16.5%) in the intervention arm during the outcome period. Antenatal detection of SGA was 25.9% in the intervention and 27.7% in the standard care arm (adjusted difference 2.2%, 95% confidence interval (CI) -6.4% to 10.7%; p = 0.62). Findings were consistent in full ITT analysis. Fidelity and dose of GAP implementation were variable, while a high proportion (88.7%) of women were reached. Use of routinely collected data is both a strength (cost-efficient) and a limitation (occurrence of missing data); the modest number of clusters limits our ability to study small effect sizes. CONCLUSIONS In this study, we observed no effect of GAP on antenatal detection of SGA compared to standard care. Given variable implementation observed, future studies should incorporate standardised implementation outcomes such as those reported here to determine generalisability of our findings. TRIAL REGISTRATION This trial is registered with the ISRCTN registry, ISRCTN67698474.
Collapse
Affiliation(s)
- Matias C. Vieira
- Department of Women and Children’s Health, King’s College London, London, United Kingdom
- Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP), Campinas, Brazil
| | - Sophie Relph
- Department of Women and Children’s Health, King’s College London, London, United Kingdom
| | - Walter Muruet-Gutierrez
- Department of Women and Children’s Health, King’s College London, London, United Kingdom
- School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom
| | - Maria Elstad
- School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom
| | - Bolaji Coker
- School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom
- NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, United Kingdom
| | - Natalie Moitt
- Department of Women and Children’s Health, King’s College London, London, United Kingdom
| | - Louisa Delaney
- Department of Women and Children’s Health, King’s College London, London, United Kingdom
| | - Chivon Winsloe
- Department of Women and Children’s Health, King’s College London, London, United Kingdom
- Centre for Pragmatic Global Health Trials, University College London, London, United Kingdom
| | - Andrew Healey
- Centre for Implementation Science and King’s Health Economics, King’s College London, London, United Kingdom
| | - Kirstie Coxon
- Faculty of Health, Social Care and Education, Kingston University and St. George’s, University of London, London, United Kingdom
| | - Alessandro Alagna
- London Perinatal Morbidity and Mortality Working Group (NHS), London, United Kingdom
| | - Annette Briley
- Department of Women and Children’s Health, King’s College London, London, United Kingdom
- Caring Futures Institute Flinders University and North Adelaide Local Health Network, Adelaide, Australia
| | - Mark Johnson
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Louise M. Page
- West Middlesex University Hospital, Chelsea & Westminster Hospital NHS Foundation Trust, Isleworth, United Kingdom
| | - Donald Peebles
- UCL Institute for Women’s Health, University College London, London, United Kingdom
| | - Andrew Shennan
- Department of Women and Children’s Health, King’s College London, London, United Kingdom
| | - Baskaran Thilaganathan
- Fetal Medicine Unit, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
- Molecular & Clinical Sciences Research Institute, St George’s, University of London, London, United Kingdom
| | - Neil Marlow
- UCL Institute for Women’s Health, University College London, London, United Kingdom
| | - Lesley McCowan
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Christoph Lees
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Deborah A. Lawlor
- Bristol NIHR Biomedical Research Centre, Bristol, United Kingdom
- Medical Research Council Integrative Epidemiology Unit at the University of Bristol, Bristol, United Kingdom
- Population Health Science, University of Bristol, Bristol, United Kingdom
| | - Asma Khalil
- Fetal Medicine Unit, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
- Molecular & Clinical Sciences Research Institute, St George’s, University of London, London, United Kingdom
| | - Jane Sandall
- Department of Women and Children’s Health, King’s College London, London, United Kingdom
| | - Andrew Copas
- Centre for Pragmatic Global Health Trials, University College London, London, United Kingdom
| | - Dharmintra Pasupathy
- Department of Women and Children’s Health, King’s College London, London, United Kingdom
- Reproduction and Perinatal Centre, University of Sydney, Sydney, Australia
- * E-mail:
| | | |
Collapse
|
9
|
Jardine J, Harris T, Khalil A, van der Meulen J. Adverse pregnancy outcomes: biological essentialism versus embodied biology - Authors' reply. Lancet 2022; 399:2014. [PMID: 35644153 DOI: 10.1016/s0140-6736(22)00171-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 01/25/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Jennifer Jardine
- Royal College of Obstetricians and Gynaecologists, London SE1 1SZ, UK; Department of Health Services Research, London School of Hygiene & Tropical Medicine, London, UK.
| | - Tina Harris
- Centre for Reproduction Research, Faculty of Health and Life Sciences, De Montfort University, Leicester, UK
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, London, UK; Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Jan van der Meulen
- Department of Health Services Research, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
10
|
Atallah A, Butin M, Moret S, Claris O, Gaucherand P, Doret-Dion M. Fetal growth restriction: underdiagnosed condition with non-optimal screening. J Matern Fetal Neonatal Med 2021; 35:8237-8244. [PMID: 34420493 DOI: 10.1080/14767058.2021.1967924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Fetal Growth restriction (FGR) is the pathological failure of a fetus to reach its biologically determined growth potential. Detection of FGR fetuses is a universally agreed key objective of antenatal care. Antenatal detection of FGR has undeniable benefits, juggling between intensive fetal surveillance and optimized timing of delivery; it reduces adverse perinatal outcomes by up to four-fold. However, FGR is still widely underdiagnosed. We aimed to identify the prevalence of FGR diagnosis in our wards and study the impact of the 2013 published French guidelines on the detection rate of FGR. The secondary objective aimed to highlight the factors of suboptimal screening in the population of non-diagnosed FGR fetuses and emphasize the screening method that led to antenatal diagnosis of FGR. MATERIALS AND METHODS We conducted a retrospective study at a single tertiary maternity center in Lyon-France, the Femme Mère Enfant Hospital, including the exhaustive population of FGR born after 24 + 0 weeks of gestation from 1 January 2011 to 31 December 2017. FGR was defined combining the neonatal and antenatal consensus-based definitions for early and late FGR in absence of congenital anomalies, excluding small for gestational age fetuses. For all FGR fetuses, we compared the antenatal detection rate of FGR during 2011-2013 to 2015-2017, since the French guidelines were published in December 2013. When FGR fetuses underwent an antenatal diagnosis of FGR, we retrospectively collected the characteristics that led to the diagnosis. When fetuses were not diagnosed as FGR, we retrospectively reviewed the implementation of the recommended screening method, enabling to evaluate whether screening was optimal or not. Statistical analysis was performed in July 2018, and statistical significance was regarded as a p-value <.05. RESULTS Over the seven-year period, and among 31,052 newborns, 1020 (3.3%) infants were identified as FGR and met the inclusion criteria. The detection rate of FGR was similar before and after publication of the French Guidelines related to FGR in 2013. Indeed, 50.8% (201/395) FGR were diagnosed between 2011 and 2013 versus 52.6% (245/465) between 2015 and 2017 (p = .59). In the population of non-diagnosed FGR infants, screening was suboptimal in 80%. Symphysis-fundal height (SFH) was not measured in 10.7%, with no difference before and after 2014 (7.3 versus 11.8% p = .11). Ultrasound examination for fetal biometry had not been prescribed in spite of abnormal SFH in 47.7% of undiagnosed FGR infants. Diagnosis has been missed in 11.5% of infants because of misinterpretation of the estimated fetal weight's centile. CONCLUSION FGR is widely underdiagnosed. However, the limited performances can partially be explained by the regular misuse of screening method in clinical practice. Despite the systematic third trimester ultrasound screening, the detection rate of FGR was similar to the one reported in the medical literature. The timing of routine third trimester ultrasound in low-risk women may be rethought.
Collapse
Affiliation(s)
- Anthony Atallah
- Department of Obstetrics and Gynecology, Femme Mère Enfant Hospital, Hospices Civils de Lyon, University Hospital Center, Bron, France.,University of Lyon, University Claude Bernard Lyon 1, University of Saint-Étienne, Saint-Etienne, France.,University Hospital Centre Sainte Justine, Department of Maternal Fetal Medicine, University of Montreal, Canada
| | - Marine Butin
- Department of Neonatalogy, Femme Mère Enfant Hospital, Hospices Civils de Lyon, University Hospital Center, Bron, France.,International Center for Research in Infectiology, INSERM U1111, CNRS UMR5308, University of Lyon 1, Lyon, France
| | - Stéphanie Moret
- Department of Obstetrics and Gynecology, Femme Mère Enfant Hospital, Hospices Civils de Lyon, University Hospital Center, Bron, France
| | - Olivier Claris
- University Hospital Centre Sainte Justine, Department of Maternal Fetal Medicine, University of Montreal, Canada.,University of Lyon, Lyon, EA, France
| | - Pascal Gaucherand
- Department of Obstetrics and Gynecology, Femme Mère Enfant Hospital, Hospices Civils de Lyon, University Hospital Center, Bron, France.,University of Lyon, University Claude Bernard Lyon 1, University of Saint-Étienne, Saint-Etienne, France
| | - Muriel Doret-Dion
- Department of Obstetrics and Gynecology, Femme Mère Enfant Hospital, Hospices Civils de Lyon, University Hospital Center, Bron, France.,University of Lyon, University Claude Bernard Lyon 1, University of Saint-Étienne, Saint-Etienne, France
| |
Collapse
|
11
|
Widdows K, Roberts SA, Camacho EM, Heazell AEP. Stillbirth rates, service outcomes and costs of implementing NHS England's Saving Babies' Lives care bundle in maternity units in England: A cohort study. PLoS One 2021; 16:e0250150. [PMID: 33872334 PMCID: PMC8055032 DOI: 10.1371/journal.pone.0250150] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 04/01/2021] [Indexed: 11/30/2022] Open
Abstract
Objective To assess implementation of the Saving Babies Lives (SBL) Care Bundle, a collection of practice recommendations in four key areas, to reduce stillbirth in England. Design A retrospective cohort study of 463,630 births in 19 NHS Trusts in England using routinely collected electronic data supplemented with case note audit (n = 1,658), and surveys of service users (n = 2,085) and health care professionals (n = 1,064). The primary outcome was stillbirth rate. Outcome rates two years before and after the nominal SBL implementation date were derived as a measure of change over the implementation period. Data were collected on secondary outcomes and process outcomes which reflected implementation of the SBL care bundle. Results The total stillbirth rate, declined from 4.2 to 3.4 per 1,000 births between the two time points (adjusted Relative Risk (aRR) 0.80, 95% Confidence Interval (95% CI) 0.70 to 0.91, P<0.001). There was a contemporaneous increase in induction of labour (aRR 1.20 (95%CI 1.18–1.21), p<0.001) and emergency Caesarean section (aRR 1.10 (95%CI 1.07–1.12), p<0.001). The number of ultrasound scans performed (aRR 1.25 (95%CI 1.21–1.28), p<0.001) and the proportion of small for gestational age infants detected (aRR 1.59 (95%CI 1.32–1.92), p<0.001) also increased. Organisations reporting higher levels of implementation had improvements in process measures in all elements of the care bundle. An economic analysis estimated the cost of implementing the care bundle at ~£140 per birth. However, neither the costs nor changes in outcomes could be definitively attributed to implementation of the SBL care bundle. Conclusions Implementation of the SBL care bundle increased over time in the majority of sites. Implementation was associated with improvements in process outcomes. The reduction in stillbirth rates in participating sites exceeded that reported nationally in the same timeframe. The intervention should be refined to identify women who are most likely to benefit and minimise unwarranted intervention. Trial registration The study was registered on (NCT03231007); www.clinicaltrials.gov.
Collapse
Affiliation(s)
- Kate Widdows
- Faculty of Biological, Medical and Health, Maternal and Fetal Health Research Centre, School of Medical Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Stephen A. Roberts
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Elizabeth M. Camacho
- Manchester Centre for Health Economics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Alexander E. P. Heazell
- Faculty of Biological, Medical and Health, Maternal and Fetal Health Research Centre, School of Medical Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- St. Mary’s Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- * E-mail:
| |
Collapse
|
12
|
Relph S, Elstad M, Coker B, Vieira MC, Moitt N, Gutierrez WM, Khalil A, Sandall J, Copas A, Lawlor DA, Pasupathy D. Using electronic patient records to assess the effect of a complex antenatal intervention in a cluster randomised controlled trial-data management experience from the DESiGN Trial team. Trials 2021; 22:195. [PMID: 33685512 PMCID: PMC7941939 DOI: 10.1186/s13063-021-05141-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 02/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of electronic patient records for assessing outcomes in clinical trials is a methodological strategy intended to drive faster and more cost-efficient acquisition of results. The aim of this manuscript was to outline the data collection and management considerations of a maternity and perinatal clinical trial using data from electronic patient records, exemplifying the DESiGN Trial as a case study. METHODS The DESiGN Trial is a cluster randomised control trial assessing the effect of a complex intervention versus standard care for identifying small for gestational age foetuses. Data on maternal/perinatal characteristics and outcomes including infants admitted to neonatal care, parameters from foetal ultrasound and details of hospital activity for health-economic evaluation were collected at two time points from four types of electronic patient records held in 22 different electronic record systems at the 13 research clusters. Data were pseudonymised on site using a bespoke Microsoft Excel macro and securely transferred to the central data store. Data quality checks were undertaken. Rules for data harmonisation of the raw data were developed and a data dictionary produced, along with rules and assumptions for data linkage of the datasets. The dictionary included descriptions of the rationale and assumptions for data harmonisation and quality checks. RESULTS Data were collected on 182,052 babies from 178,350 pregnancies in 165,397 unique women. Data availability and completeness varied across research sites; each of eight variables which were key to calculation of the primary outcome were completely missing in median 3 (range 1-4) clusters at the time of the first data download. This improved by the second data download following clarification of instructions to the research sites (each of the eight key variables were completely missing in median 1 (range 0-1) cluster at the second time point). Common data management challenges were harmonising a single variable from multiple sources and categorising free-text data, solutions were developed for this trial. CONCLUSIONS Conduct of clinical trials which use electronic patient records for the assessment of outcomes can be time and cost-effective but still requires appropriate time and resources to maximise data quality. A difficulty for pregnancy and perinatal research in the UK is the wide variety of different systems used to collect patient data across maternity units. In this manuscript, we describe how we managed this and provide a detailed data dictionary covering the harmonisation of variable names and values that will be helpful for other researchers working with these data. TRIAL REGISTRATION Primary registry and trial identifying number: ISRCTN 67698474 . Registered on 02/11/16.
Collapse
Affiliation(s)
- Sophie Relph
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, 10th Floor North Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Maria Elstad
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, 4th Floor, Addison House, Guy's Campus, London, SE1 1UL, UK
| | - Bolaji Coker
- Division of Health and Social Care Research, King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, Guy's Hospital, London, UK
| | - Matias C Vieira
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, 10th Floor North Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.,Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP), School of Medical Sciences, 101 Alexander Fleming St, Cidade Universitaria, Campinas, SP, Brazil
| | - Natalie Moitt
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, 10th Floor North Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Walter Muruet Gutierrez
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, 10th Floor North Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK.,Molecular & Clinical Sciences Research Institute, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Jane Sandall
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, 10th Floor North Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Andrew Copas
- Centre for Pragmatic Global Health Trials, Institute for Global Health, University College London, Gower Street, London, WC1E 6BT, UK
| | - Deborah A Lawlor
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, BS8 2BL, UK.,Bristol NIHR Biomedical Research Centre, Bristol, BS8 2BL, UK.,MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, BS8 2BL, UK
| | - Dharmintra Pasupathy
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, 10th Floor North Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.,Speciality of Obstetrics, Gynaecology and Neonatology, Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | | |
Collapse
|
13
|
Relph S, Delaney L, Melaugh A, Vieira MC, Sandall J, Khalil A, Pasupathy D, Healey A. Costing the impact of interventions during pregnancy in the UK: a systematic review of economic evaluations. BMJ Open 2020; 10:e040022. [PMID: 33127635 PMCID: PMC7604861 DOI: 10.1136/bmjopen-2020-040022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The aim of this review was to summarise the current evidence on the costing of resource use within UK maternity care, in order to facilitate the estimation of incremental resource and cost impacts potentially attributable to maternity care interventions. METHODS A systematic review of economic evaluations was conducted by searching Medline, the Health Management Information Consortium, the National Health Service (NHS) Economic Evaluations Database, CINAHL and National Institute for Health and Care Excellence (NICE) guidelines for economic evaluations within UK maternity care, published between January 2010 and August 2019 in the English language. Unit costs for healthcare activities provided to women within the antenatal, intrapartum and postnatal period were inflated to 2018-2019 prices. Assessment of study quality was performed using the Quality of Health Economic Analyses checklist. RESULTS Of 5084 titles or full texts screened, 37 papers were included in the final review (27 primary research articles, 7 review articles and 3 economic evaluations from NICE guidelines). Of the 27 primary research articles, 21 were scored as high quality, 3 as medium quality and 3 were low quality. Variation was noted in cost estimates for healthcare activities throughout the maternity care pathway: for midwife-led outpatient appointment, the range was £27.34-£146.25 (mean £81.78), emergency caesarean section, range was £1056.44-£4982.21 (mean £3508.93) and postnatal admission, range was £103.00-£870.10 per day (mean £469.55). CONCLUSIONS Wide variation exists in costs applied to maternity healthcare activities, resulting in challenges in attributing cost to maternity activities. The level of variation in cost calculations is likely to reflect the uncertainty within the system and must be dealt with by conducting sensitivity analyses. Nationally agreed prices for granular unit costs are needed to standardise cost-effectiveness evaluations of new interventions within maternity care, to be used either for research purposes or decisions regarding national intervention uptake. PROSPERO REGISTRATION NUMBER CRD42019145309.
Collapse
Affiliation(s)
- Sophie Relph
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, London, UK
| | - Louisa Delaney
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, London, UK
| | - Alexandra Melaugh
- Health Improvement: Alcohol, Drugs, Tobacco and Justice Division, Public Health England, London, UK
| | - Matias C Vieira
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, London, UK
- Department of Obstetrics and Gynaecology, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Jane Sandall
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, London, UK
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Molecular & Clinical Sciences Research Institute, St George's, University of London, Cranmer Terrace, London, UK
| | - Dharmintra Pasupathy
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, London, UK
- Discipline of Obstetrics, Gynaecology & Neonatology, Westmead Clinical School, Faculty of Medicineand Health, University of Sydney, Sydney, New South Wales, Australia
| | - Andy Healey
- Health Service and Population Research, King's College London, De Crespigny Park, London, UK
| |
Collapse
|