13 research outputs found
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OSHPD Postpartum Maternal Outcomes Validation Study
The California Hospital Outcomes Project is an initiative mandated by the State of California and conducted by the Office of Statewide Health Planning and Development (OSHPD), to develop public reports comparing hospital outcomes for selected medical conditions and surgical procedures for patients treated in hospitals throughout California. Over the last decade, CHOP has reported risk-adjusted hospital mortality rates for heart attack and community-acquired pneumonia. In 2005, OSHPD is releasing its first report on obstetric care.Delivery was selected as an important topic for public reporting because it is the most frequent single reason for hospitalization in California, and because complications of delivery are associated with substantial health care costs and impairment of function. In 2003, for example, there were 170,465 repairs of obstetric lacerations and 147,084 cesarean deliveries performed in California hospitals – more than any other surgical procedure. Although most women who require these procedures have excellent outcomes, a small minority experience complications that cause pain, weakness, impaired bonding with their new child, bowel or bladder problems, sexual dysfunction, rehospitalization, and even death.This technical report, prepared for OSHPD, summarizes the validation of multiple potential measures of inpatient obstetric quality of care. These measures include two that have been endorsed by OSHPD for public reporting: risk-adjusted postpartum maternal readmission rates and risk-adjusted perineal laceration rates. Other measures were also evaluated in this validation study, but are not recommended for public reporting, including risk-adjusted rates of endometritis, wound infection, hemorrhage, and urinary tract infection. This validation study was designed by the UC Davis research team in collaboration with OSHPD staff and the AB 524 Technical Advisory Committee. It was designed to address a variety of concerns, specified in detail later in this report, about the validity of using hospital-reported ICD-9-CM codes in the California Patient Discharge Data Set to report publicly on hospital performance.The original methodology for estimating and analyzing risk-adjusted postpartum maternal readmission rates was developed in 1996, using data on deliveries performed in 1992-1993. This developmental work is fully described in a report that was published by the OSHPD in December 1996 (Section 2, citation 19). We were subsequently asked by the OSHPD to validate the data and methodology used in this 1996 report. To simplify the task, we selected a subsample of the same records for this validation study. As described in detail in later sections of this report, we collected records from hospitals in 1998, recoded and abstracted them in 1999, and performed analyses in 2000-2001. Although some results from these analyses have already appeared in print elsewhere, this report compiles all relevant findings in a single document. We believe that the findings are still informative, despite their age, because there is no evidence of statewide improvement in the coding of obstetric records over the past decade. In addition, the mean postpartum length of stay and readmission rate have remained relatively stable over time (after some decrease in length of stay during the 1990s), suggesting that the clinical factors driving readmissions have also been relatively stable. This study remains the most comprehensive published analysis of the accuracy of ICD-9-CM coded inpatient obstetric data. However, if the OSHPD continues to use the same datasets in the same manner, it would be prudent to repeat this validation study in the future
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The Extended Fetal Cardiac Examination
The aims of this study were to demonstrate the feasibility of obtaining additional cardiac views as proposed on an extended fetal cardiac examination and to see if there was any variation in individual components of that examination stratified by sonographer training, patient body habitus, or equipment. We retrospectively reviewed 200 consecutive detailed second-trimester high-risk fetal obstetric sonograms that included additional extended cardiac views. We analyzed the percentage of the time individual views were obtained, with variation based on (1) a sonographer with greater than 3 years of training compared with a group with 6 to 12 months of training, (2) 2 different ultrasound units, and (3) different body mass indices. Overall, the highest rate of visualization was achieved with the 4-chamber view (98.2%), whereas the 3-vessel tracheal view had the lowest percentage of visualization (40.2%), among the less experienced sonographers. Differences in successful completion of the extended cardiac views were not statistically different between the sonographer with a level of training greater than 3 years as compared with those with 6 to 12 months' training except for the 3-vessel tracheal view (P < 0.001). There is no statistically significant difference in our ultrasound equipment, when considering only inexperienced sonographers. Increasing body mass index had an inverse relationship with obtaining the components of the detailed cardiac examination. Using state-of-the-art ultrasound equipment and with focused additional training of obstetric sonographers, the majority of extended cardiac views can be obtained. There are exceptions
TIMING AND MODE OF DELIVERY IN PRENATALLY DIAGNOSED CRITICAL CONGENITAL HEART DISEASE: AN ANALYSIS OF PRACTICES WITHIN THE UNIVERSITY OF CALIFORNIA FETAL CONSORTIUM
907: Multi-institutional practice patterns in fetal CHD following a standardized clinical assessment and management plan
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Multi-Institutional Practice-Patterns in Fetal Congenital Heart Disease Following Implementation of a Standardized Clinical Assessment and Management Plan.
Background Prenatal diagnosis of congenital heart disease has been associated with early-term delivery and cesarean delivery (CD). We implemented a multi-institutional standardized clinical assessment and management plan (SCAMP) through the University of California Fetal-Maternal Consortium. Our objective was to decrease early-term (37-39 weeks) delivery and CD in pregnancies complicated by fetal congenital heart disease using a SCAMP methodology to improve practice in a high-risk and clinically complex setting. Methods and Results University of California Fetal-Maternal Consortium site-specific management decisions were queried following SCAMP implementation. This contemporary intervention group was compared with a University of California Fetal-Maternal Consortium historical cohort. Primary outcomes were early-term delivery and CD. A total of 496 maternal-fetal dyads with prenatally diagnosed congenital heart disease were identified, 185 and 311 in the historical and intervention cohorts, respectively. Recommendation for later delivery resulted in a later gestational age at delivery (38.9 versus 38.1 weeks, P=0.01). After adjusting for maternal age and site, historical controls were more likely to have a CD (odds ratio [OR],1.8; 95% CI, 2.1-2.8; P=0.004) and more likely (OR, 2.1; 95% CI, 1.4-3.3) to have an early-term delivery than the intervention group. Vaginal delivery was recommended in 77% of the cohort, resulting in 61% vaginal deliveries versus 50% in the control cohort (P=0.03). Among pregnancies with major cardiac lesions (n=373), vaginal birth increased from 51% to 64% (P=0.008) and deliveries ≥39 weeks increased from 33% to 48% (P=0.004). Conclusions Implementation of a SCAMP decreased the rate of early-term deliveries and CD for prenatal congenital heart disease. Development of clinical pathways may help standardize care, decrease maternal risk secondary to CD, improve neonatal outcomes, and reduce healthcare costs
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Multi-Institutional Practice-Patterns in Fetal Congenital Heart Disease Following Implementation of a Standardized Clinical Assessment and Management Plan.
Background Prenatal diagnosis of congenital heart disease has been associated with early-term delivery and cesarean delivery (CD). We implemented a multi-institutional standardized clinical assessment and management plan (SCAMP) through the University of California Fetal-Maternal Consortium. Our objective was to decrease early-term (37-39 weeks) delivery and CD in pregnancies complicated by fetal congenital heart disease using a SCAMP methodology to improve practice in a high-risk and clinically complex setting. Methods and Results University of California Fetal-Maternal Consortium site-specific management decisions were queried following SCAMP implementation. This contemporary intervention group was compared with a University of California Fetal-Maternal Consortium historical cohort. Primary outcomes were early-term delivery and CD. A total of 496 maternal-fetal dyads with prenatally diagnosed congenital heart disease were identified, 185 and 311 in the historical and intervention cohorts, respectively. Recommendation for later delivery resulted in a later gestational age at delivery (38.9 versus 38.1 weeks, P=0.01). After adjusting for maternal age and site, historical controls were more likely to have a CD (odds ratio [OR],1.8; 95% CI, 2.1-2.8; P=0.004) and more likely (OR, 2.1; 95% CI, 1.4-3.3) to have an early-term delivery than the intervention group. Vaginal delivery was recommended in 77% of the cohort, resulting in 61% vaginal deliveries versus 50% in the control cohort (P=0.03). Among pregnancies with major cardiac lesions (n=373), vaginal birth increased from 51% to 64% (P=0.008) and deliveries ≥39 weeks increased from 33% to 48% (P=0.004). Conclusions Implementation of a SCAMP decreased the rate of early-term deliveries and CD for prenatal congenital heart disease. Development of clinical pathways may help standardize care, decrease maternal risk secondary to CD, improve neonatal outcomes, and reduce healthcare costs
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Exome Sequencing for Prenatal Diagnosis in Nonimmune Hydrops Fetalis
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Nonimmune hydrops fetalis: identifying the underlying genetic etiology.
PurposeNumerous etiologies may lead to nonimmune hydrops fetalis (NIHF), and the underlying cause often remains unclear. We aimed to determine the proportion of NIHF cases in which the etiology was clearly determined in a large, contemporary, and diverse cohort, as well as to describe the etiologies with a focus on genetic causes.MethodsRetrospective review of NIHF cases between 2015 and 2017 from the five University of California Fetal-Maternal Consortium sites. Singleton pregnancies with prenatally diagnosed NIHF were included, and cases with maternal alloimmunization were excluded. Cases were categorized as being of confirmed, suspected, or unknown etiology.ResultsSixty-five NIHF cases were identified. Forty-six percent (30/65) remained of unknown etiology, while 9.2% (6/65) had a suspected etiology and 44.6% (29/65) were of confirmed etiology. Among confirmed cases, 11 resulted from aneuploidy; 7 from fetal structural anomalies; 2 each from fetal arrhythmia, Noonan syndrome, and generalized lymphatic dysplasia; and 1 each from arthrogryposis, parvovirus, neonatal alloimmune thrombocytopenia, fetal goiter, and Kasabach-Merritt syndrome.ConclusionIn this contemporary, multicenter study, the cause of prenatally diagnosed NIHF was confirmed in only 44% of cases, and a genetic etiology was found in only 25% of those that received standard of care genetic testing
Exome Sequencing for Prenatal Diagnosis in Nonimmune Hydrops Fetalis
BackgroundThe cause of most fetal anomalies is not determined prenatally. Exome sequencing has transformed genetic diagnosis after birth, but its usefulness for prenatal diagnosis is still emerging. Nonimmune hydrops fetalis (NIHF), a fetal abnormality that is often lethal, has numerous genetic causes; the extent to which exome sequencing can aid in its diagnosis is unclear.MethodsWe evaluated a series of 127 consecutive unexplained cases of NIHF that were defined by the presence of fetal ascites, pleural or pericardial effusions, skin edema, cystic hygroma, increased nuchal translucency, or a combination of these conditions. The primary outcome was the diagnostic yield of exome sequencing for detecting genetic variants that were classified as either pathogenic or likely pathogenic according to the criteria of the American College of Medical Genetics and Genomics. Secondary outcomes were the percentage of cases associated with specific genetic disorders and the proportion of variants that were inherited.ResultsIn 37 of the 127 cases (29%), we identified diagnostic genetic variants, including those for disorders affecting the RAS-MAPK cell-signaling pathway (known as RASopathies) (30% of the genetic diagnoses); inborn errors of metabolism and musculoskeletal disorders (11% each); lymphatic, neurodevelopmental, cardiovascular, and hematologic disorders (8% each); and others. Prognoses ranged from a relatively mild outcome to death during the perinatal period. Overall, 68% of the cases (25 of 37) with diagnostic variants were autosomal dominant (of which 12% were inherited and 88% were de novo), 27% (10 of 37) were autosomal recessive (of which 95% were inherited and 5% were de novo), 1 was inherited X-linked recessive, and 1 was of uncertain inheritance. We identified potentially diagnostic variants in an additional 12 cases.ConclusionsIn this large case series of 127 fetuses with unexplained NIHF, we identified a diagnostic genetic variant in approximately one third of the cases. (Funded by the UCSF Center for Maternal-Fetal Precision Medicine and others; ClinicalTrials.gov number, NCT03412760.)