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Cockburn N, Osborne C, Withana S, Elsmore A, Nanjappa R, South M, Parry-Smith W, Taylor B, Chandan JS, Nirantharakumar K. Clinical decision support systems for maternity care: a systematic review and meta-analysis. EClinicalMedicine 2024; 76:102822. [PMID: 39296586 PMCID: PMC11408819 DOI: 10.1016/j.eclinm.2024.102822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 08/17/2024] [Accepted: 08/23/2024] [Indexed: 09/21/2024] Open
Abstract
Background The use of Clinical Decision Support Systems (CDSS) is increasing throughout healthcare and may be able to improve safety and outcomes in maternity care, but maternity care has key differences to other disciplines that complicate the use of CDSS. We aimed to identify evaluated CDSS and synthesise evidence of their impact on maternity care. Methods We conducted a systematic review for articles published before 24th May 2024 that described i) CDSS that ii) investigated the impact of their use iii) in maternity settings. Medline, CINAHL, CENTRAL and HMIC were searched for articles relating to evaluations of CDSS in maternity settings, with forward- and backward-citation tracing conducted for included articles. Risk of bias was assessed using the Mixed Methods Assessment Tool, and CDSS were described according to the clinical problem, purpose, design, and technical environment. Quantitative results from articles reporting appropriate data were meta-analysed to estimate odds of a CDSS achieving its desired outcome using a multi-level random effects model, first by individual CDSS and then across all CDSS. PROSPERO ID: CRD42022348157. Findings We screened 12,039 papers and included 87 articles describing 47 unique CDSS. 24 articles (28%) described randomised controlled trials, 30 (34%) described non-randomised interventional studies, 10 (11%) described mixed methods studies, 10 (11%) described qualitative studies, 7 (8%) described quantitative descriptive studies, and 7 (8%) described economic evaluations. 49 (56%) were in High-Income Countries and 38 (44%) in Low- and Middle-Income countries, with no CDSS trialled in both income categories. Meta-analysis of 35 included studies found an odds ratio for improved outcomes of 1.69 (95% confidence interval 1.24-2.30). There was substantial variation in effects, aims, CDSS types, context, study designs, and outcomes. Interpretation Most CDSS evaluations showed improvements in outcomes, but there was heterogeneity in all aspects of design and evaluation of systems. CDSS are increasingly important in delivering healthcare, and Electronic Health Records and mHealth will increase their availability, but traditional epidemiological methods may be limited in guiding design and demonstrating effectiveness due to rapid CDSS development lifecycles and the complex systems in which they are embedded. Development methods that are attentive to context, such as Human Centred Design, will help to meet this need. Funding None.
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Affiliation(s)
- Neil Cockburn
- Department of Applied Health Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Cristina Osborne
- Department of Applied Health Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Supun Withana
- Department of Applied Health Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Amy Elsmore
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom
| | - Ramya Nanjappa
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom
| | - Matthew South
- Department of Applied Health Sciences, University of Birmingham, Birmingham, United Kingdom
| | - William Parry-Smith
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom
- Keele University, Keele, United Kingdom
| | - Beck Taylor
- Warwick Medical School, Warwick University, Coventry, United Kingdom
| | - Joht Singh Chandan
- Department of Applied Health Sciences, University of Birmingham, Birmingham, United Kingdom
- Birmingham Health Partners, University of Birmingham, Birmingham, United Kingdom
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Kayode G, Howell A, Burden C, Margelyte R, Cheng V, Viner M, Sandall J, Carter J, Brigante L, Winter C, Carroll F, Thilaganathan B, Anumba D, Judge A, Lenguerrand E. Socioeconomic and ethnic disparities in preterm births in an English maternity setting: a population-based study of 1.3 million births. BMC Med 2024; 22:371. [PMID: 39300558 PMCID: PMC11414185 DOI: 10.1186/s12916-024-03493-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 06/17/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND Preterm birth is a major cause of infant mortality and morbidity and accounts for 7-8% of births in the UK. It is more common in women from socially deprived areas and from minority ethnic groups, but the reasons for this disparity are poorly understood. To inform interventions to improve child survival and their quality of life, this study examined the socioeconomic and ethnic inequalities in preterm births (< 37 weeks of gestation at birth) within Health Trusts in England. METHODS This study investigated socioeconomic and ethnic inequalities in preterm birth rates across the National Health Service (NHS) in England. The NHS in England can be split into different units known as Trusts. We visualised between-Trust differences in preterm birth rates. Health Trusts were classified into five groups based on their standard deviation (SD) variation from the average national preterm birth rate. We used modified Poisson regression to compute risk ratios (RR) and 95% confidence intervals (95% CI) with generalised estimating equations. RESULTS The preterm birth rate ranged from 6.8/100 births for women living in the least deprived areas to 8.8/100 births for those living in the most deprived areas. Similarly, the preterm birth rate ranged from 7.8/100 births for white women, up to 8.6/100 births for black women. Some Health Trusts had lower than average preterm birth rates in white women whilst concurrently having higher than average preterm birth rates in black and Asian women. The risk of preterm birth was higher for women living in the most deprived areas and ethnicity (Asian). CONCLUSIONS There was evidence of variation in rates of preterm birth by ethnic group, with some Trusts reporting below average rates in white ethnic groups whilst concurrently reporting well above average rates for women from Asian or black ethnic groups. The risk of preterm birth varied substantially at the intersectionality of maternal ethnicity and the level of socioeconomic deprivation of their residency. In the absence of other explanations, these findings suggest that even within the same Health Trust, maternity care may vary depending on the women's ethnicity and/or whether she lives in an area of high socioeconomic deprivation. Thus, social factors are likely key determinants of inequality in preterm birth rather than provision of maternity care alone.
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Affiliation(s)
- G Kayode
- Translational Health Science, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol, BS105NB, UK
| | - A Howell
- Translational Health Science, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol, BS105NB, UK
| | - C Burden
- Translational Health Science, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol, BS105NB, UK
| | - R Margelyte
- Translational Health Science, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol, BS105NB, UK
| | - V Cheng
- Translational Health Science, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol, BS105NB, UK
| | - M Viner
- Department of Women and Children's Health, School of Life Course & Population Sciences, King's College London, London, UK
| | - J Sandall
- Department of Women and Children's Health, School of Life Course & Population Sciences, King's College London, London, UK
| | - J Carter
- Department of Women and Children's Health, School of Life Course & Population Sciences, King's College London, London, UK
| | | | - C Winter
- Department of Women's Health, The PROMPT Maternity Foundation, Southmead Hospital, Bristol, UK
| | - F Carroll
- Royal College of Obstetricians and Gynaecologists, London, UK
| | - B Thilaganathan
- Tommy's National Centre for Maternity Improvement, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - D Anumba
- Academic Unit of Reproductive and Developmental Medicine, University of Sheffield, Sheffield, UK
| | - A Judge
- Translational Health Science, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol, BS105NB, UK
| | - E Lenguerrand
- Translational Health Science, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol, BS105NB, UK.
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Creswell L, Rolnik DL, Lindow SW, O’Gorman N. Preterm Birth: Screening and Prediction. Int J Womens Health 2023; 15:1981-1997. [PMID: 38146587 PMCID: PMC10749552 DOI: 10.2147/ijwh.s436624] [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: 08/24/2023] [Accepted: 12/13/2023] [Indexed: 12/27/2023] Open
Abstract
Preterm birth (PTB) affects approximately 10% of births globally each year and is the most significant direct cause of neonatal death and of long-term disability worldwide. Early identification of women at high risk of PTB is important, given the availability of evidence-based, effective screening modalities, which facilitate decision-making on preventative strategies, particularly transvaginal sonographic cervical length (CL) measurement. There is growing evidence that combining CL with quantitative fetal fibronectin (qfFN) and maternal risk factors in the extensively peer-reviewed and validated QUanititative Innovation in Predicting Preterm birth (QUiPP) application can aid both the triage of patients who present as emergencies with symptoms of preterm labor and high-risk asymptomatic women attending PTB surveillance clinics. The QUiPP app risk of delivery thus supports shared decision-making with patients on the need for increased outpatient surveillance, in-patient treatment for preterm labor or simply reassurance for those unlikely to deliver preterm. Effective triage of patients at preterm gestations is an obstetric clinical priority as correctly timed administration of antenatal corticosteroids will maximise their neonatal benefits. This review explores the predictive capacity of existing predictive tests for PTB in both singleton and multiple pregnancies, including the QUiPP app v.2. and discusses promising new research areas, which aim to predict PTB through cervical stiffness and elastography measurements, metabolomics, extracellular vesicles and artificial intelligence.
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Affiliation(s)
- Lyndsay Creswell
- Department of Obstetrics and Gynecology, The Coombe Hospital, Dublin, Ireland
| | - Daniel Lorber Rolnik
- Department of Obstetrics and Gynecology, Monash University, Melbourne, VIC, Australia
| | - Stephen W Lindow
- Department of Obstetrics and Gynecology, The Coombe Hospital, Dublin, Ireland
| | - Neil O’Gorman
- Department of Obstetrics and Gynecology, The Coombe Hospital, Dublin, Ireland
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Carter J, Carlisle N, David A, Sandall J, Seed P, Shennan A, Tribe R, Watson H. Re.The web-based application "QUiPP v.2" for the prediction of preterm birth in symptomatic women is not yet ready for worldwide clinical use: ten reflections on development, validation and use.". Arch Gynecol Obstet 2023; 307:641. [PMID: 35394199 DOI: 10.1007/s00404-022-06500-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 02/26/2022] [Indexed: 11/26/2022]
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Coutinho CM, Sotiriadis A, Odibo A, Khalil A, D'Antonio F, Feltovich H, Salomon LJ, Sheehan P, Napolitano R, Berghella V, da Silva Costa F. ISUOG Practice Guidelines: role of ultrasound in the prediction of spontaneous preterm birth. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:435-456. [PMID: 35904371 DOI: 10.1002/uog.26020] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/22/2022] [Indexed: 05/15/2023]
Affiliation(s)
- C M Coutinho
- Department of Gynecology and Obstetrics, Clinics Hospital, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - A Sotiriadis
- Second Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - A Odibo
- Washington University School of Medicine, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, St Louis, MO, USA
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - F D'Antonio
- Center for Fetal Care and High Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - H Feltovich
- Fetal Ultrasound, Intermountain Healthcare, Salt Lake City, UT, USA
| | - L J Salomon
- Department of Obstetrics and Fetal Medicine, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris Cité University, Paris, France
| | - P Sheehan
- Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
| | - R Napolitano
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - V Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - F da Silva Costa
- Maternal Fetal Medicine Unit, Gold Coast University Hospital and School of Medicine, Griffith University, Gold Coast, Queensland, Australia
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Dehaene I, Steen J, Vandewiele G, Roelens K, Decruyenaere J. The web-based application "QUiPP v.2" for the prediction of preterm birth in symptomatic women is not yet ready for worldwide clinical use: ten reflections on development, validation and use. Arch Gynecol Obstet 2022; 306:571-575. [PMID: 35106643 PMCID: PMC8807143 DOI: 10.1007/s00404-022-06418-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 01/24/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE In this correspondence, we highlight general and domain-specific caveats in the development and validation of prediction models. METHODS Development and use of the "QUiPP" application, a tool for preterm birth prediction which is supported by the United Kingdom National Health Service, is scrutinised and commented on. RESULTS We highlight and elaborate ten points which may be perceived to be unclear or potentially misleading. CONCLUSION While the QUiPP application has high potential, it lacks transparency (on certain aspects related to model development) and proper validation. This precludes transportability to settings with other treatment policies and to other countries where the app has been made publicly available.
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Affiliation(s)
- Isabelle Dehaene
- Obstetrics and Gynaecology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - Johan Steen
- Department of Internal Medicine and Paediatrics, Renal Division, Ghent University, Ghent, Belgium ,Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Kristien Roelens
- Obstetrics and Gynaecology, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Johan Decruyenaere
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
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Carlisle N, Watson HA, Carter J, Kuhrt K, Seed PT, Tribe RM, Sandall J, Shennan AH. Clinicians' experiences of using and implementing a medical mobile phone app (QUiPP V2) designed to predict the risk of preterm birth and aid clinical decision making. BMC Med Inform Decis Mak 2021; 21:320. [PMID: 34794405 PMCID: PMC8600728 DOI: 10.1186/s12911-021-01681-w] [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: 10/09/2020] [Accepted: 11/03/2021] [Indexed: 11/23/2022] Open
Abstract
Background As the vast majority of women who present in threatened preterm labour (TPTL) will not deliver early, clinicians need to balance the risks of over-medicalising the majority of women, against the potential risk of preterm delivery for those discharged home. The QUiPP app is a free, validated app which can support clinical decision-making as it produces individualised risks of delivery within relevant timeframes. Recent evidence has highlighted that clinicians would welcome a decision-support tool that accurately predicts preterm birth. Methods Qualitative interviews were undertaken as part of the EQUIPTT study (The Evaluation of the QUiPP app for Triage and Transfer) (REC: 17/LO/1802) which aimed to evaluate the impact of the QUiPP app on management of TPTL. Individual semi-structured telephone interviews were used to explore clinicians’ (obstetricians’ and midwives’) experiences of using the QUiPP app and how it was implemented at their hospital sites. Thematic analysis was chosen to explore the meaning of the data, through a framework approach. Results Nineteen participants from 10 hospital sites in England took part. Data analysis revealed three overarching themes which were: ‘experience of using the app’, ‘how QUiPP risk changes practice’ and ‘successfully adopting QUiPP: context is everything’. With these final themes we appeared to have achieved our aim of exploring the clinicians’ experiences of using and implementing the QUiPP app. Conclusion This study explored different clinician’s experiences of implementing the app. The organizational and cultural context at different sites appeared to have a large impact on how well the QUiPP app was implemented. Future work needs to be undertaken to understand how best to embed the intervention within different settings. This will inform scale up of QUiPP app use across the UK and ensure that clinicians have access to this free, easy-to-use tool which can positively aid clinical decision making when caring for women in TPTL. Clinical trial registry and registration number ISRCTN 17846337, registered 08th January 2018, https://doi.org/10.1186/ISRCTN17846337.
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Affiliation(s)
- N Carlisle
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, St Thomas' Hospital, 10th Floor North Wing, Westminster Bridge Road, London, SE1 7EH, UK.
| | - H A Watson
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, St Thomas' Hospital, 10th Floor North Wing, Westminster Bridge Road, London, SE1 7EH, UK.
| | - J Carter
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, St Thomas' Hospital, 10th Floor North Wing, Westminster Bridge Road, London, SE1 7EH, UK
| | - K Kuhrt
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, St Thomas' Hospital, 10th Floor North Wing, Westminster Bridge Road, London, SE1 7EH, UK
| | - P T Seed
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, St Thomas' Hospital, 10th Floor North Wing, Westminster Bridge Road, London, SE1 7EH, UK
| | - R M Tribe
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, St Thomas' Hospital, 10th Floor North Wing, Westminster Bridge Road, London, SE1 7EH, UK
| | - J Sandall
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, St Thomas' Hospital, 10th Floor North Wing, Westminster Bridge Road, London, SE1 7EH, UK
| | - A H Shennan
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, St Thomas' Hospital, 10th Floor North Wing, Westminster Bridge Road, London, SE1 7EH, UK
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