Developing guideline-based key performance indicators for recurrent miscarriage care: lessons from a multi-stage consensus process with a diverse stakeholder group

Factors that shape recurrent miscarriage care experiences: findings from a national survey

BACKGROUND

Learning what matters to women/couples with recurrent miscarriage (RM) is essential to inform service improvement efforts and future RM care practices. Previous national and international surveys have examined inpatient stays, maternity care, and care experiences around pregnancy loss, but there is little focus on RM care. We aimed to explore the experiences of women and men who have received RM care and identify patient-centred care items linked to overall RM care experience.

METHODS

Between September and November 2021, we invited people who had experienced two or more consecutive first trimester miscarriages and received care for RM in Ireland in the ten-year period prior to participate in a cross-sectional web-based national survey. The survey was purposefully designed and administered via Qualtrics. It included questions on sociodemographics, pregnancy and pregnancy loss history, investigation and treatment for RM, overall RM care experience, and patient-centred care items at various stages of the RM care pathway such as respect for patients' preferences, information and support, the environment, and involvement of partners/family. We analysed data using Stata.

RESULTS

We included 139 participants (97% women, n = 135) in our analysis. Of the 135 women, 79% were aged 35-44 years (n = 106), 24% rated their overall RM care experience as poor (n = 32), 36% said the care they received was much worse than expected (n = 48), and 60% stated health care professionals in different places did not work well together (n = 81). Women were more likely to rate a good care experience if they had a healthcare professional to talk to about their worries/fears for RM investigations (RRR 6.11 [95% CI: 1.41-26.41]), received a treatment plan (n = 70) (RRR 3.71 [95% CI: 1.28-10.71]), and received answers they could understand in a subsequent pregnancy (n = 97) (RRR 8 [95% CI: 0.95-67.13]).

CONCLUSIONS

While overall experience of RM care was poor, we identified areas that could potentially improve people's RM care experiences - which have international relevance - such as information provision, supportive care, communication between healthcare professionals and people with RM, and care coordination between healthcare professionals across care settings.

An examination of care received by women with recurrent miscarriage and infertility against guideline-based key performance indicators

OBJECTIVES

International guidelines for the management of recurrent miscarriage (RM) do not provide detailed guidance for the care of women/couples with concurrent infertility. Research studies concerning the investigation and treatment of RM frequently omit this cohort. The aim of this study was to assess the care of women/couples with infertility attending a RM clinic in a large tertiary unit in the Republic of Ireland.

STUDY DESIGN

We conducted an audit of women with RM and infertility attending our RM clinic from 2008 to 2020 against 110 established guideline-based key performance indicators (KPIs) for RM care, encompassing five categories: structure of care, counselling/supportive care, investigation, treatment and outcomes. Information was gathered from documentation from the RM clinic, hospital laboratory and electronic health records.

RESULTS

We identified 128 women with infertility and RM. Information provision in RM clinics regarding modifiable risk factors (71 %; 91/128) and unexplained RM (53 %; 69/128) could be improved. Most women were investigated in line with KPIs, except for pelvic ultrasound (40 %; 51/128), cytogenetic analysis (27 %; 34/128) and 3D ultrasound (2 %; 2/128). Immunotherapies were seldom prescribed (<1%); however, 98 % (125/128) of women received aspirin, 48 % LMWH (62/128) and 16 % corticosteroids (21/128). Surgical interventions were uncommon (5 %; 6/128)). The subsequent pregnancy rate was 70 % (89/128), with 36 % undergoing artificial reproductive technology (32/89). The livebirth rate was 63 % (56/89); 37 % had a further pregnancy loss (33/89), of which two were second-trimester miscarriages.

CONCLUSIONS

Women with RM and infertility received care largely in line with RM guideline-based KPIs. However, we identified areas for improvement, including the quality of information provision, and access to certain investigations. While guideline-based KPIs allow for internationally applicable and reproducible audit that can direct service improvements, the experiences and needs of service-users are not captured, meriting further qualitative research.

Estimating the costs associated with the implementation of a best practice model of care for recurrent miscarriage clinics in Ireland: a cost analysis

Background  Recurrent miscarriage (RM) affects 1%-5% of the reproductive age population. Given increasing calls for dedicated recurrent miscarriage clinics (RMC), decision makers will require data on the resultant budgetary implications. The aim of this study was to identify the potential costs to the Irish healthcare system of implementing a best practice RMC model of care.  Methods  A ‘best practice’ RMC was developed as part of the RE:CURRENT Project. A micro-costing approach was employed by identifying, measuring, and valuing resource usage by unit costs for the RMC for ≥2 consecutive losses. Per patient costs were estimated using two care pathway scenarios: typical and complex. Per patient costs were extrapolated, using population data and published prevalence rates for RM, to estimate the total cost to the Irish health system. A sensitivity analysis was also performed.     Results   The cost for a RM patient who has another pregnancy after receiving investigations, treatment and reassurance scans ranges between €1,634 (typical) and €4,818 (complex). For a RM patient who does not conceive again, costs range from €1,384 (typical) to €4,318 (complex). Using population estimates for ≥2 losses, the total cost to the Irish health service ranges from €20,336,229 (complex) to €61,927,630 (typical) for those who progress to pregnancy, and from €7,789,437 (complex) to €22,480,630 (typical) for those who do not progress to another pregnancy. Together, the total cost of the proposed best practice RMC is €112,533,926 with an average cost per patient €1,871.   Conclusions  This study advocates for a new model of care for RMCs in Ireland and provides a set of cost estimates at the patient and healthcare system level. While future studies should explicitly consider the cost effectiveness of this or similar models of care, this analysis provides a valuable first step in providing a detailed breakdown of the associated costs and budget implications.