Usability, accuracy, and cost-effectiveness of a medical software for early pregnancies: a retrospective study

STUDY QUESTION

Can early pregnancies be accurately and cost-effectively diagnosed and managed using a new medical computerized tool?

SUMMARY ANSWER

Compared to the standard clinical approach, retrospective implementation of the new medical software in a gynaecological emergency unit was correlated with more accurate diagnosis and more cost-effective management.

WHAT IS KNOWN ALREADY

Early pregnancy complications are responsible for a large percentage of consultations, mostly in emergency units, with guidelines becoming complex and poorly known/misunderstood by practitioners.

STUDY DESIGN, SIZE, DURATION

A total of 780 gynaecological emergency consultations (446 patients), recorded between November 2018 and June 2019 in a tertiary university hospital, were retrospectively encoded in a new medical computerized tool. The inclusion criteria were a positive hCG test result, ultrasonographical visualization of gestational sac, and/or embryo corresponding to a gestational age of 14 weeks or less. Diagnosis and management suggested by the new computerized tool are named eDiagnoses, while those provided by a gynaecologist member of the emergency department staff are called medDiagnoses.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Usability was the primary endpoint, with accuracy and cost reduction, respectively, as secondary and tertiary endpoints. Identical eDiagnoses/medDiagnoses were considered as accurate. During follow-up visits, if the updated eDiagnoses and medDiagnoses became both identical to a previously discrepant eDiagnosis or medDiagnosis, this previous eDiagnosis or medDiagnosis was also considered as correct. Four double-blinded experts reviewed persistent discrepancies, determining the accurate diagnoses. eDiagnoses/medDiagnoses accuracies were compared using McNemar's Chi square test, sensitivity, specificity, and predictive values.

MAIN RESULTS AND THE ROLE OF CHANCE

Only 1 (0.1%) from 780 registered medical records lacked data for full encoding. Out of the 779 remaining consultations, 675 eDiagnoses were identical to the medDiagnoses (86.6%) and 104 were discrepant (13.4%). From these 104, 60 reached an agreement during follow-up consultations, with 59 medDiagnoses ultimately changing into the initial eDiagnoses (98%) and only one discrepant eDiagnosis turning later into the initial medDiagnosis (2%). Finally, 24 remained discrepant at all subsequent checks and 20 were not re-evaluated. Out of these 44, the majority of experts agreed on 38 eDiagnoses (86%) and 5 medDiagnoses (11%, including four twin pregnancies whose twinness was the only discrepancy). No majority was reached for one discrepant eDiagnosis/medDiagnosis (2%). In total, the accuracy of eDiagnoses was 99.1% (675 + 59 + 38 = 772 eDiagnoses out of 779), versus 87.4% (675 + 1 + 5 = 681) for medDiagnoses (P < 0.0001). Calculating all basic costs of extra consultations, extra-medications, extra-surgeries, and extra-hospitalizations induced by incorrect medDiagnoses versus eDiagnoses, the new medical computerized tool would have saved 3623.75 Euros per month. Retrospectively, the medical computerized tool was usable in almost all the recorded cases (99.9%), globally more accurate (99.1% versus 87.4%), and for all diagnoses except twinning reports, and it was more cost-effective than the standard clinical approach.

LIMITATIONS, REASONS FOR CAUTION

The retrospective study design is a limitation. Some observed improvements with the medical software could derive from the encoding by a rested and/or more experienced physician who had a better ultrasound interpretation. This software cannot replace clinical and ultrasonographical skills but may improve the compliance to published guidelines.

WIDER IMPLICATIONS OF THE FINDINGS

This medical computerized tool is improving. A new version considers diagnosis and management of multiple pregnancies with their specificities (potentially multiple locations, chorioamnionicity). Prospective evaluations will be required. Further developmental steps are planned, including software incorporation into ultrasound devices and integration of previously published predictive/prognostic factors (e.g. serum progesterone, corpus luteum scoring).

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was obtained for this study. F.B. and D.G. created the new medical software.

TRIAL REGISTRATION NUMBER

NCT03993015.

P-404 Usability, accuracy and cost-effectiveness of “eDiagEPU”, a medical software for early pregnancies: a retrospective study

Study question

Can early pregnancies be accurately and cost-effectively diagnosed and managed using a new medical computerised tool, named “eDiagEPU”?

Summary answer

Compared to the standard clinical approach, the retrospective implementation of “eDiagEPU” in a gynaecological emergency unit was correlated with sharper diagnoses and more cost-effective managements.

What is known already

Early pregnancies complications are responsible for a large percentage of consultations, mostly in emergency units. Moreover, clinical guidelines updates for the management of Intrauterine Pregnancies of Uncertain Viability (IPUV) have become increasingly complex and seem to be unknown or misunderstood by several practitioners. Specifically, a recently published prospective multinational survey revealed a limited knowledge regarding early pregnancy guidelines, with 69.0% of the participants reporting incorrect managements of IPUV and 86.6% misinterpreting the evolution of serum human chorionic gonadotropin (hCG).

In an attempt to aid practitioners with the diagnosis and management of early pregnancies, a software, named “eDiagEPU”, was developed.

Study design, size, duration

A total of 780 consultations, recorded between November 2018 and June 2019 in the gynaecological emergency unit of a tertiary university hospital, were retrospectively encoded in eDiagEPU. Positive hCG, ultrasonographical visualisation of gestational sac or/and embryo corresponding to a gestational age of 14 weeks gestation or less were the inclusion criteria.

Diagnoses and managements suggested by eDiagEPU are named “eDiagnoses”. The ones provided by a gynaecologist member of the emergency department staff are called “medDiagnoses”.

Participants/materials, setting, methods

Identical eDiagnosis and medDiagnosis were considered as correct (gold standard). During follow-up examinations, if they became both identical to a previous discrepant eDiagnosis or medDiagnosis, this previous eDiagnosis/medDiagnosis was considered as correct. Persistent discrepancies were reviewed by four double-blinded experts whose majority defined the correct eDiagnosis/medDiagnosis.

The accuracies of eDiagnoses/medDiagnoses were compared using McNemar’s Chi square test, computing diagnostic values (Sensitivity, Specificity, and predictive values) and 95% Confidence Intervals (CI). Cost reduction was also analysed.

Main results and the role of chance

Only one datum (0.1%) from 780 registered medical records was missing to process using “eDiagEPU”. Out of the 779 consultations that could be fully encoded until obtaining an eDiagnosis, 675 eDiagnoses were identical to the medDiagnoses (86.6%) and 104 discrepant (13.4%). From these 104, 60 reached an agreement during follow-up controls with 59 medDiagnoses finally changing into the initial eDiagnoses (98%) while only one discrepant eDiagnosis turning later into the initial medDiagnosis (2%). Finally, 24 remained discrepant at all subsequent checks and 20 were not reevaluated. Out of these 44 discrepancies without identical diagnoses/managements during follow-up controls, the double-blinded experts majority chose 38 eDiagnoses (86%) and 5 medDiagnoses (11%) including 4 twin pregnancies whose twinness was the only discrepancy. One discrepant eDiagnosis/medDiagnosis reached no majority (2%).

In total, eDiagnoses accuracy was 99.1% (675 + 59 + 38=772 eDiagnoses out of 779 final diagnoses), vs 87.4% (675 + 1 + 5=681) for medDiagnoses accuracy (p &lt; 0.0001). Calculating all basic costs of consultations, medications, surgeries and hospitalisations induced by medDiagnoses versus eDiagnoses, “eDiagEPU” would have saved 3 623.75 € per month.

Retrospectively, “eDiaEPU” was usable (99.9%), more accurate for each diagnosis except twinning report and more cost-effective than standard clinical approach.

Limitations, reasons for caution

The retrospective design is a limitation, as well as the quality of ultrasound interpretation. Some improvements could not derive exclusively from “eDiagEPU” but also from the encoding by a rested or more experienced physician. This software cannot replace clinical and ultrasonographical skills but can improve the diagnostic and therapeutic reasoning.

Wider implications of the findings

An improved “eDiagEPU” version, considering the diagnosis and management of multiple pregnancies with their specificities (potentially multiple locations, chorioamnionicity) has been developed. Prospective evaluations will be required. Further development steps are considered, including software incorporation into ultrasound devices and integration of previously published predictive/prognostic factors (serum progesterone, corpus luteum scoring...).

Trial registration number

NCT03993015

Influence of cervical cerclage interventions upon the incidence of neonatal death: a retrospective study comparing prophylactic versus rescue cerclages

OBJECTIVE

The purpose of this study was to compare the efficacy of prophylactic and rescue cervical cerclages for pregnant patients with an incompetent cervix, and to assess the neonatal outcomes of both clinical conditions.

METHODS

This was a retrospective observational study of all women who had an elective or rescue cerclage between January 2008 and December 2016 in our institution. Prophylactic cerclage was defined as a cerclage before 16 weeks of gestation, while rescue cerclages were performed between 16 and 23 weeks of gestation.

RESULTS

In total, we analyzed the outcomes of 212 cervical interventions; 71% of the recruited patients experienced prophylactic cerclage, while 29% underwent rescue cerclage. Most of the patients delivered vaginally (70%) and were able to leave the hospital with a healthy newborn (78%). The mean pregnancy prolongation time after cerclage in the prophylactic and rescue groups were 21 weeks and 10 weeks, respectively.

CONCLUSION

Prophylactic cerclage interventions are most likely to be associated with a reduction of fetal demise because of the correlation between fetal prognosis and the gestational age at which cerclage is performed. Once the diagnosis of cervical insufficiency is confirmed, cerclage should be recommended as this will help to prolong the pregnancy.

Recurrent cleft lip and palate in siblings of a patient with malabsorption syndrome, probably caused by hypovitaminosis a associated with folic acid and vitamin B(2) deficiencies

We present a woman with metabolic disorders secondary to malabsorption and renal disease who gave birth to a stillborn male fetus with left unilateral cleft lip and palate and a live born infant with left unilateral cleft lip and palate. We discuss potential cofactors that could be implicated in the abnormal embryonic process.

First sickle cell crisis triggered by induction of labor in a primigravida

Sickle cell anemia is a severe disorder that rarely spares affected adults. We describe here a 32-year-old pregnant woman who presented her first lifetime symptoms of her disease during induction of labor at term. We therefore discuss the possible causes that may have triggered this inaugural crisis.

Prediction of preterm delivery by fetal fibronectin: a meta-analysis

OBJECTIVE

To assess the cervicovaginal fetal fibronectin test to predict preterm delivery.

DATA SOURCES

We searched MEDLINE, Current Contents, Index Medicus, and proceedings of meetings for studies published between 1991 and June 1997.

METHODS OF STUDY SELECTION

Inclusion criteria were prospective cohort study; test performed between 20 and 36 weeks' gestation; fetal fibronectin measured by a previously described assay, with a cutoff level set at 50 ng/mL; test results not disclosed to women or physicians; and fewer than 20% of study participants excluded from the analysis.

TABULATION, INTEGRATION, AND RESULTS

Twenty-nine relevant studies were stratified according to the prevalence of preterm delivery, the number of tests performed, and delivery before 34, 35, or 37 weeks. Sensitivities, specificities, and likelihood ratios were calculated in each study. The summary estimates of the likelihood ratio for tests yielding positive results or tests yielding negative results along with their 95% confidence intervals (CIs) were computed in each stratum according to a random-effects model. All summary likelihood ratios for a test yielding positive results indicated a significant association with preterm delivery. The strongest association was found between a single test with positive results and delivery before 37 weeks in a low-risk population (likelihood ratio 7.5; 95% CI 4.6, 12.3). This association also was found in high-risk women (likelihood ratio 3.5; 95% CI 2.6, 4.6). In high-risk women, a test yielding negative results was associated with a reduction in risk of preterm delivery (likelihood ratio 0.4; 95% CI 0.3, 0.5).

CONCLUSION

Fetal fibronectin in cervicovaginal secretions is associated with preterm delivery in both high-risk and low-risk women.

Trial of labour after caesarean section in sub-Saharan Africa: a meta-analysis

OBJECTIVE

To evaluate the safety and effectiveness of a policy of trial of labour for women with a previous caesarean section, delivering in hospitals in sub-Saharan Africa.

DESIGN

A meta-analysis of 17 published reports.

SETTING

Hospitals located in sub-Saharan Africa.

MAIN OUTCOME MEASURES

The probability of vaginal delivery, the risk of mortality and morbidity, and the risk difference for specific obstetrical conditions were computed using an approach equivalent to a random effects model.

RESULTS

The proportion of women who were allowed a trial of labour ranged from 37% to 97% across reports. The probability of a vaginal delivery among these women was 69% (95% CI 63-75%). Maternal mortality among all women with a previous caesarean section was 1.9/1000 (95% CI 0-4.3). Uterine rupture and scar dehiscence occurred in 2.1% (95% CI 1.0-3.2). Criteria used to select women for a trial of labour appeared to have a limited impact on the probability of vaginal delivery.

CONCLUSIONS

In hospitals in sub-Saharan Africa a selective policy of trial of labour after a previous caesarean section has a success rate comparable to that observed in developed countries. The policy appears to be relatively safe and applicable in this context.

A single cervical fetal fibronectin screening test in a population at low risk for preterm delivery: an improvement on clinical indicators?

OBJECTIVE

To assess the accuracy of a single cervical fetal fibronectin test to predict spontaneous preterm delivery in an unselected antenatal population.

DESIGN

A prospective blind cohort study.

SETTING

Antenatal clinic of a teaching hospital in a Brussels semiurban area.

PARTICIPANTS

An unselected group of 170 women followed at the antenatal clinic.

METHODS

A single cervical sample was obtained between 24 and 33 completed weeks of pregnancy. The fibronectin test was compared with clinical evaluation and their predictive properties were assessed.

RESULTS

Fifteen women were excluded from the analysis because of elective preterm delivery for medical indications or loss to follow up. Of the 155 remaining women, nine (7%) had a spontaneous preterm delivery. For a single fetal fibronectin test, the sensitivity was 26.7%, the specificity 95.7%, and the positive and negative predictive values 40.0% and 92.4%, respectively. The likelihood ratio of a positive was similar to that of clinical predictors of preterm birth (LR = 6.2; 95% CI 2.0-19.6). Sensitivities were low for both clinical criteria and the fetal fibronectin test.

CONCLUSIONS

Because of low sensitivity in a low risk population, screening for preterm delivery should not be based on the result of a single fetal fibronectin test alone. However, due to its high specificity the test might be useful in avoiding unnecessary medical intervention.