Pulse oximetry as a screening test for congenital heart defects in newborn infants: a test accuracy study with evaluation of acceptability and cost-effectiveness

Cost-utility analysis of prenatal diagnosis of congenital cardiac diseases using deep learning

BACKGROUND

Deep learning (DL) is a new technology that can assist prenatal ultrasound (US) in the detection of congenital heart disease (CHD) at the prenatal stage. Hence, an economic-epidemiologic evaluation (aka Cost-Utility Analysis) is required to assist policymakers in deciding whether to adopt the new technology.

METHODS

The incremental cost-utility ratios (CUR), of adding DL assisted ultrasound (DL-US) to the current provision of US plus pulse oximetry (POX), was calculated by building a spreadsheet model that integrated demographic, economic epidemiological, health service utilization, screening performance, survival and lifetime quality of life data based on the standard formula: CUR = Increase in Intervention Costs - Decrease in Treatment costs Averted QALY losses of adding DL to US & POX US screening data were based on real-world operational routine reports (as opposed to research studies). The DL screening cost of 145 USD was based on Israeli US costs plus 20.54 USD for reading and recording screens.

RESULTS

The addition of DL assisted US, which is associated with increased sensitivity (95% vs 58.1%), resulted in far fewer undiagnosed infants (16 vs 102 [or 2.9% vs 15.4%] of the 560 and 659 births, respectively). Adoption of DL-US will add 1,204 QALYs. with increased screening costs 22.5 million USD largely offset by decreased treatment costs (20.4 million USD). Therefore, the new DL-US technology is considered "very cost-effective", costing only 1,720 USD per QALY. For most performance combinations (sensitivity > 80%, specificity > 90%), the adoption of DL-US is either cost effective or very cost effective. For specificities greater than 98% (with sensitivities above 94%), DL-US (& POX) is said to "dominate" US (& POX) by providing more QALYs at a lower cost.

CONCLUSION

Our exploratory CUA calculations indicate the feasibility of DL-US as being at least cost-effective.

Pulse Oximetry Screening for Critical Congenital Heart Defects in Newborn Babies

Pulse oximetry screening (POS) was first described over 20 years ago. However, in recent years, major clinical trials have demonstrated consistent test accuracy for the detection of critical congenital heart defects (CCHD). International uptake of POS has progressed well over the last 10 years with most major high-income countries now recommending screening. This review describes the evidence base which has led to this, the current debate regarding choice of screening algorithm, and the future areas for further research.

Newborn Pulse Oximetry Screening for Detecting Congenital Heart Disease: Experience at a Tertiary Care Center

Background

Congenital heart disease (CHD) remains the number one birth defect worldwide. Pulse oximetry screening (POS) is a widely used CHD screening modality effective in detecting critical lesions. This study is aimed at assessing the accuracy and cost-effectiveness of POS in a cohort of term well-babies admitted to a regular nursery in a tertiary care center.

Methods

We reviewed the charts of term babies admitted to our regular nursery over a period of one year. The results of POS and the findings of echocardiography were collected. Similarly, we explored the records of our fetal echocardiography program to identify the fetuses screened for CHD during the same period.

Results

900 term babies were born and admitted to newborn nursery at our center, and 69 fetuses were evaluated by our fetal cardiology team during the study period. None of our term babies had a positive POS at birth or 24 hours of age. However, 56 babies had a cardiac echo before hospital discharge due to suspicious findings on physical examination or a family history of CHD. A simple noncritical CHD was noted in 10 of them. Additionally, 53 babies underwent echocardiography within the first five years of life; a simple CHD was noted in 6 of them. In parallel, 21 of our fetuses were found to have CHD: 16 simple CHD and 5 critical CHD (CCHD).

Conclusion

Despite its cost-effectiveness and efficacy in screening for CCHD, POS is suboptimal for detecting simple CHD. In the absence of a proper prenatal screening and fetal echocardiography program, POS remains a cost-effective modality for detecting CCHD.

Pulse Oximetry Screening: Association of State Mandates with Emergency Hospitalizations

We evaluated the association between implementation of state-mandated pulse oximetry screening (POS) and rates of emergency hospitalizations among infants with Critical Congenital Heart Disease (CCHD) and assessed differences in that association across race/ethnicity. We hypothesized that emergency hospitalizations among infants with CCHD decreased after implementation of mandated POS and that the reduction was larger among racial and ethnic minorities compared to non-Hispanic Whites. We utilized statewide inpatient databases from Arizona, California, Kentucky, New Jersey, New York, and Washington State (2010-2014). A difference-in-differences model with negative binomial regression was used. We identified patients with CCHD whose hospitalizations between three days and three months of life were coded as "emergency" or "urgent" or occurred through the emergency department. Numbers of emergency hospitalizations aggregated by month and state were used as outcomes. The intervention variable was an implementation of state-mandated POS. Difference in association across race/ethnicity was evaluated with interaction terms between the binary variable indicating the mandatory policy period and each race/ethnicity group. The model was adjusted for state-specific variables, such as percent of female infants and percent of private insurance. We identified 9,147 CCHD emergency hospitalizations. Among non-Hispanic Whites, there was a 22% (Confidence Interval [CI] 6%-36%) decline in CCHD emergency hospitalizations after implementation of mandated POS, on average. This decline was 65% less among non-Hispanic Blacks compared to non-Hispanic Whites. Our study detected an attenuated association with decreased number of emergency hospitalizations among Black compared to White infants. Further research is needed to clarify this disparity.

Methods of assessing value for money of UK-based early childhood public health interventions: a systematic literature review

INTRODUCTION

Economic evaluation has an important role to play in the demonstration of value for money of early childhood public health interventions; however, concerns have been raised regarding their consistent application and relevance to commissioners. This systematic review of the literature therefore aims to collate the breadth of the existing economic evaluation evidence of these interventions and to identify the approaches adopted in the assessment of value.

SOURCE OF DATA

Recently published literature in Medline, EMBASE, EconLit, Health Management Information Consortium, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, Health Technology Assessment, NHS EED and Web of Science.

AREAS OF AGREEMENT

The importance of the early childhood period on future health and well-being as well as the potential to impact health inequalities making for a strong narrative case for expenditure in early childhood public health.

AREAS OF CONTROVERSY

The most appropriate approaches to evaluating value for money of such preventative interventions relevant for UK decision-makers given the evident challenges.

GROWING POINTS

The presented review considered inconsistencies across methodological approaches used to demonstrate value for money. The results showed a mixed picture in terms of demonstrating value for money.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future resource allocations decisions regarding early childhood public health interventions may benefit from consistency in the evaluative frameworks and health outcomes captured, as well as consistency in approaches to incorporating non-health costs and outcomes, incorporating equity concerns and the use of appropriate time horizons.

Peripheral Saturation and Perfusion Index on the First Day of Life Play a Role in Early Discharge of Healthy Term Newborns

INTRODUCTION

Pulse oximetry screening is a safe, feasible test, effective in identifying congenital heart diseases in otherwise well-appearing newborns. Uncertainties still persist on the most effective algorithm to be used and the timing of screening. The aim of this study was to evaluate the role of the pulse oximetry screening associated with the peripheral perfusion index performed in the first 24 hours of life for the early detection of congenital heart diseases and noncongenital heart diseases in the newborns.

MATERIALS AND METHODS

A prospective observational cohort study was conducted. The enrollment criteria were as follows: term newborns with an APGAR score >8 at 5 minutes. The exclusion criteria were as follows: clinical signs of prenatal/perinatal asphyxia or known congenital malformations. Four parameters of pulse oximetry screening were utilized: saturation less than 90% (screening 1), saturation of less than 95% in one or both limbs (screening 2), difference of more than 3% between the limbs (screening 3), and preductal peripheral perfusion index or postductal peripheral perfusion index below 0.70 (screening 4). The likelihood ratio, sensibility, specificity, and positive and negative predictive values for identification of congenital heart diseases or noncongenital heart diseases (suspicion of perinatal infection and any respiratory diseases) were evaluated.

RESULTS

The best predictive results for minor congenital heart disease were obtained combining screening 3 and screening 4 (χ ² (1) = 15,279; p < 0.05; OR = 57,900 (9,465-354,180)). Screening 2, screening 3, and screening 4 were predictive for noncongenital heart diseases (χ ² (1) = 11,550; p < 0.05; OR = 65,744 (10,413-415,097)). Combined screenings 2-4 were predictive for both congenital heart disease and noncongenital heart disease (χ ² (1) = 22,155; p < 0.05; OR = 117,685 (12,972-1067,648)).

CONCLUSIONS

Combining peripheral saturation with the peripheral perfusion index in the first 24 hours of life shows a predictive role in the detection of minor congenital heart diseases and neonatal clinical conditions whose care needs attention.

Impact of pulse oximetry screening to detect congenital heart defects: 5 years' experience in a UK regional neonatal unit

Pulse oximetry screening (POS) has been shown to be an effective, non-invasive investigation that can detect up to 50-70% of previously undiagnosed congenital heart defects (CHDs). The aims of this study were to assess the accuracy of POS in detection of CHDs and its impact on clinical practice. All eligible newborn infants born between 1 Jan 2015 and 31 Dec 2019 in a busy regional neonatal unit were included in this prospective observational study. A positive POS was classified as two separate measurements of oxygen saturation < 95%, or a difference of > 2% between pre- and post-ductal circulations. Overall, 23,614 infants had documented POS results. One hundred eighty nine (0.8%) infants had a true positive result: 6 had critical CHDs, 9 serious or significant CHDs, and a further 156/189 (83%) infants had significant non-cardiac conditions. Forty-three infants who had a normal POS were later diagnosed with the following categories of CHDs post-hospital discharge: 1 critical, 15 serious, 20 significant and 7 non-significant CHDs. POS sensitivity for detection of critical CHD was 85.7%, whereas sensitivity was only 33% for detection of major CHDs (critical and serious) needing surgery during infancy; specificity was 99.3%.Conclusion: Pulse oximetry screening showed moderate to high sensitivity in detection of undiagnosed critical CHDs; however, it failed to detect two-third of major CHDs. Our study further emphasises the significance of adopting routine POS to detect critical CHDs in the clinical practice. However, it also highlights the need to develop new, innovative methods, such as perfusion index, to detect other major CHDs missed by current screening tools. What is Known: • Pulse oximetry screening is cost effective, acceptable, easy to perform and has moderate sensitivity and high specificity in detection of critical congenital heart defects. • Pulse oximetry screening has been implemented many countries including USA for detection of critical congenital heart defects, but it is not currently recommended by the UK National Screening Committee. What is New: • To our knowledge, this is the first study describing postnatal detection and presentation of all the infants with congenital heart defects over a period of 5 years, including those not detected on the pulse oximetry screening, on the clinical practice. • It emphasises that further research required to detect critical congenital heart defects and other major CHDs which can be missed on the screening tools currently employed in clinical practice.

Major heart defects: the diagnostic evaluations of first-year-olds

Background

Severe or critical congenital heart defects (CHDs) constitute one third of the heart defect cases detected only after birth. These prenatally unrecognised defects usually manifest as cyanotic or acyanotic lesions and are diagnosed postnatally at various times. The aim of the study was to identify their clinical symptoms and determine individual risk periods for CHD manifestation.

Methods

Data were assessed retrospectively based on a cohort of patients born between 2009 and 2018 in a population of 175,153 live births. Occurrence of the first symptoms of CHD was classified into: early neonatal (0–7 days), late neonatal (8–28 days), early infancy (1–6 months), or late infancy (6–12 months). The first symptom for which the child was referred to a paediatric cardiologist was defined as a symptom of CHD.

Results

There were 598 major CHDs diagnosed in the studied region, 91% of which were isolated anomalies. A concomitant genetic disorder was diagnosed in 6% of the cases, while 3% presented extracardiac pathology with a normal karyotype. In total, 47% (282/598) of all CHDs were not identified prenatally. Of these, 74% (210/282) were diagnosed as early neonates, 16% (44/282) as late neonates, and 10% (28/282) as infants. The most common symptoms leading to the diagnosis of CHD were heart murmur (51%, 145/282) and cyanosis (26%, 73/282). Diagnosis after discharge from the hospital occurred in 12% (72/598) of all major CHDs. Ventricular septal defect and coarctation of the aorta constituted the majority of delayed diagnoses.

Conclusions

In conclusion, murmur and cyanosis are the most common manifestations of prenatally undetected CHDs. Although most children with major CHDs are diagnosed as neonates, some patients are still discharged from the maternity hospital with an unidentified defect.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02997-2.

New born pulse oximetry screening: A global perspective

The possibility of pulse oximetry screening (POS) for congenital heart defects was first described over 20 years ago. Since then, an accumulation of research evidence and clinical practice experience has established POS as an important test to detect critical congenital heart defects (CCHDs). POS meets the criteria for universal screening and professional bodies around the globe have recommended universal POS. Many countries have already adopted POS while several others are working towards its implementation. In low and low-middle-income countries (LLMIC), POS has the additional potential for reducing morbidity and mortality from neonatal sepsis. This review summarises the evidence for POS and looks at current global uptake and different approaches to the implementation of POS.

Newborn Pulse Oximetry Screening at a Community Hospital: An 8-Year Experience

OBJECTIVES

To evaluate newborn pulse oximetry screening (POS) outcomes at a large community hospital and the impact of the recommended revised POS algorithm.

METHODS

A retrospective cohort study was performed to evaluate the results of POS in the well-infant nursery between 2012 and 2020. The POS results were obtained from an electronic platform. Chart review was completed for newborns with failed screens. The recommended revision to POS, no second rescreen, was applied to the data to evaluate screening outcomes.

RESULTS

Of the total 65 414 infants admitted to the well-infant nursery during this 8-year period, >99% (n = 64 780) received POS. Thirty-one infants failed POS (4.6 per 10 000 screened). All infants who failed POS were found to have a disorder, with 12 (39%) having critical congenital heart disease (CCHD), 9 (29%) having non-CCHD requiring further follow-up, and 10 (32%) having noncardiac conditions. One false-negative screen result was identified through the Maryland Department of Health Newborn Screening Follow-up Program. The positive predictive value of POS for those screened was 39% for CCHD, with a specificity of 99.97%. Eliminating the second rescreen in the POS algorithm would have resulted in an additional 5 newborns without CCHD failing POS, increasing the false-positive rate from 0.03% to 0.04%.

CONCLUSIONS

POS is an effective tool for identifying CCHD and secondary conditions. POS was successfully implemented with few missed screens and was highly specific. Elimination of the second rescreen in the pulse oximetry algorithm would have resulted in a minimal increase in false-positive results and faster evaluation of newborns with CCHD.

Diagnostic value of pulse oximetry combined with cardiac auscultation in screening congenital heart disease in neonates

OBJECTIVE

This study aimed to investigate the feasibility and reliability of pulse oximetry combined with cardiac auscultation in screening neonatal congenital heart disease (CHD).

METHODS

This was a retrospective, observational, screening study. All newborns included in the study were at the Second Affiliated Hospital of Wenzhou Medical University from July 2019 to January 2020. Primary screening of CHD was conducted by pulse oximetry combined with cardiac auscultation assays. Indices, including sensitivity, specificity, the positive/negative predictive value, the positive/negative likelihood ratio, and the diagnostic odds ratio, were calculated. The area under the relative operating characteristic curve of the subjects was measured.

RESULTS

A total of 3327 neonates were enrolled, among whom 139 were diagnosed with CHD and the incidence of CHD was 4.2%. The sensitivity, specificity, diagnostic odds ratio, and area under the relative operating characteristic curve of pulse oximetry combined with cardiac auscultation were 89.9%, 94.7%, 169.0, and 0.923, respectively.

CONCLUSIONS

Pulse oximetry combined with cardiac auscultation is a novel screening method with acceptable accuracy and feasibility for neonatal CHD. This combination method is worth promoting widely.

Pulse oximetry screening to detect critical congenital heart diseases in asymptomatic neonates

Background

Critical congenital heart diseases (CCHDs), 10% to 25% of all CHD, are duct-dependent defects that are life threatening without intervention in the neonatal period or infancy. One third of neonates with CCHDs are discharged home undetected and have a poorer outcome. Pulse oximetry screening before discharge is increasingly being used to diagnose CCHDs in developed countries.

Methods

This prospective observational study conducted at a tertiary care hospital from September 2016 to March 2019 screened all asymptomatic intramural neonates after 24 hours of life using a Masimo pulse oximeter with signal extraction technology using the standard American Academy of Pediatrics algorithm. A positive screen was followed by a confirmatory echocardiography (gold standard) and a negative screen by clinical examination at 6, 10 and 14 weeks and identification of readmissions during the study period.

Results

A total of 1855 neonates (82.99% of the eligible 2235 neonates) underwent screening at a mean (SD) age at screening of 32.4 (6.8) hours and took a mean (SD) time of 3.5 (1.2) minutes. The sensitivity, specificity, positive and negative predictive value of pulse oximetry screening for detection of CCHDs in asymptomatic neonates was 75% (95% CI: 28.91% to 96.59%), 99.29% (95% CI: 98.79% to 99.60%), 18.75% (95% CI: 5.80% to 43.80%) and 99.94% (95% CI: 99.66 to 99.99%), respectively.

Conclusion

Pulse oximetry screening of asymptomatic neonates between 24 and 48 hours of life improved the detection of CCHDs with high specificity and negative predictive value, moderate sensitivity and a reasonably low false positivity rate.

The Methodological Quality and Challenges in Conducting Economic Evaluations of Newborn Screening: A Scoping Review

INTRODUCTION

Cost-effectiveness (CEA) and cost-utility analyses (CUA) have become popular types of economic evaluations (EE) used for evidence-based decision-making in healthcare resource allocation. Newborn screening programs (NBS) can have significant clinical benefits for society, and cost-effectiveness analysis may help to select the optimal strategy among different screening programs, including the no-screening option, on different conditions. These economic analyses of NBS, however, are hindered by several methodological challenges. This study explored the methodological quality in recent NBS economic evaluations and analyzed the main challenges and strategies adopted by researchers to deal with them.

METHODS

A scoping review was conducted according to PRISMA methodology to identify CEAs and CUAs of NBS. The methodological quality of the retrieved studies was assessed quantitatively using a specific guideline for the quality assessment of NBS economic evaluations, by calculating a general score for each EE. Challenges in the studies were then explored using thematic analysis as a qualitative synthesis approach.

RESULTS

Thirty-five studies met the inclusion criteria. The quantitative analysis showed that the methodological quality of NBS economic evaluations was heterogeneous. Lack of clear description of items related to results, discussion, and discounting were the most frequent flaws. Methodological challenges in performing EEs of neonatal screenings include the adoption of a long time horizon, the use of quality-adjusted life years as health outcome measure, and the assessment of costs beyond the screening interventions.

CONCLUSIONS

The results of this review can support future economic evaluation research, aiding researchers to develop a methodological guidance to perform EEs aimed at producing solid results to inform decisions for resource allocation in neonatal screening.

Pulse oximetry screening for critical congenital heart defects in Ontario, Canada: a cost-effectiveness analysis

OBJECTIVE

Previously conducted cost-effectiveness analyses of pulse oximetry screening (POS) for critical congenital heart defects (CCHDs) have shown it to be a cost-effective endeavour, but the geographical setting of Ontario in relation to its vast yet sparsely populated regions presents unique challenges. The objective of this study was to estimate the cost-effectiveness of POS for CCHD in Ontario, Canada.

METHODS

A cost-effectiveness analysis, comparing POS to no POS, was conducted from the Ontario healthcare payer perspective using a Markov model. The base case was defined as a well-appearing newborn at 24 h of age. Outcome measures, including quality-adjusted life months (QALMs), lifetime costs, and incremental cost-effectiveness ratios (ICER) [ΔCost/ΔQALMs], were calculated over a lifetime horizon. All outcomes were discounted at 1.5% per year. Cost-effectiveness was assessed using an a priori ICER threshold of CAD$4166.67 per QALM (equivalent to CAD$50,000 per quality-adjusted life year). Deterministic and probabilistic sensitivity analyses were conducted to assess parameter uncertainty.

RESULTS

Implementation of POS is expected to lead to timely diagnosis of 51 CCHD cases annually. The incremental cost of performing POS was estimated to be $27.27 per screened individual, with a gain of 0.02455 QALMs. This yielded an ICER of CAD$1110.79 per QALM, well below the pre-determined threshold. The probabilistic sensitivity analysis estimated a 92.3% chance of routine implementation of POS being cost-effective.

CONCLUSION

Routine implementation of POS for CCHD in Ontario is expected to be cost-effective.

Cost-Effectiveness Analysis of Pulse Oximetry Screening in the Full-Term Neonates for Diagnosis of Congenital Heart Disease: A Systematic Review

Context: Congenital heart disease (CHD) is a leading cause of mortality by birth defects with significant social and economic burden. Pulse oximetry as a safe and non-invasive screening method, and with its potential for early detection of CHD has improved neonatal health outcomes. Objectives: The aim of this study was to systematically review economic evaluation studies that compared pulse oximetry with current programs to diagnose early detection of CHD in full-term newborns. Data Sources: A systematic review was conducted according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, and related articles published from 1995 up to March 2020 were searched in different databases (MEDLINE, EMBASE, PubMed, Science Direct, Google Scholar, Scopus, NHS EED, Science Citation Index, MagIran, Cochrane Library, EconLit and SID). The articles were selected based on inclusion and exclusion criteria. Consolidated health economic evaluation reporting standards (CHEERS) statement checklist was used to qualitatively evaluate the papers. Overall, 7 articles were included in the study. Results: Timely diagnosis was considered as main effectiveness health outcome in most studies. The highest and lowest values of incremental cost-effectiveness ratio (in two-phase studies) were €139,000 and $100 per infant in the Netherlands and Colombia respectively; and (in one-phase studies) were £24,000 and £1,489 per infant both belonging to the UK. Implementing pulse oximetry method concurrent with the clinical examination is more cost-effective. The reviewed studies had been conducted in high-income and upper middle-income countries; therefore, when the results are generalizing by policy makers in different health systems, a substantial precaution approach is needed.

Universal Screening for CCHD in Saudi Arabia: The Road to a 'State of the Art' Program

Critical congenital heart disease (CCHD) has been defined as structural heart defects that are usually associated with hypoxia in the newborn period and have potential for significant morbidity and mortality early in life. CCHD has been estimated to be present in ∼3 in 1000 live births, including Saudi Arabia. Pulse Oximetry Screening (POS) is a highly specific and moderately sensitive test for detecting CCHD with very low false-positive rates. The Kingdom of Saudi Arabia is among high-income countries with a population of more than 33 million and more than 600,000 annual live births. In 2015, the Universal Screening Program for CCHD using Pulse Oximetry was approved in Saudi Arabia. It is expected that any new national program will undergo a learning curve and face many challenges. We believe that developing countries may face different challenges during implementation of such national projects, but the success achieved by Saudi Arabia in implementing the program was mainly due to good preparation before launching the project and advancements in the use of the technology involved in this project. Since starting the universal CCHD screening in 2016, more than 900,000 babies have been screened in Saudi Arabia and many lives have been saved using this safe, non-invasive, inexpensive, and reasonably sensitive test.

Health professionals' views of newborn pulse oximetry screening in a midwifery-led maternity setting. "It's a good thing to do, but fund it!"

OBJECTIVE

To understand from health professionals who care for newborns their views on the introduction of pulse oximetry screening for the detection of hypoxaemia in a midwifery-led maternity setting. Although oximetry screening for newborns is internationally accepted, national screening is not yet introduced in New Zealand. In this context, we drew on maternity carers' reflections during a feasibility study of oximetry screening to provide perspectives on barriers and enablers to universal screening.

METHODS

Data were generated from nine focus groups during five months of 2018 in two north island regions of New Zealand. Participants' (n = 45) opinions about the use of oximetry screening in newborns were analysed thematically using an inductive approach.

FINDINGS

Overall, participants stated pulse oximetry screening was easy to do, non-invasive, and worthwhile. Midwives were reassured by screening that provided evidence of either a healthy baby or a need for urgent review. From participants' reports, we identified three themes: (1) oximetry screening for newborns is reassuring, practical and worthwhile; (2) midwifery services workload expectations and under-resourcing will hinder universal screening, and (3) location of the baby at the time of screening could impede universal access.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

Midwives viewed implementing a national pulse oximetry screening programme as sensible but problematic unless resourced and funded appropriately. Policymakers should view the concerns of midwives about human and physical resources as significant and account for the need to resource this screening programme appropriately as a priority before implementation.

Oximetry and neonatal examination for the detection of critical congenital heart disease: a systematic review and meta-analysis

Background: Undiagnosed congenital heart disease in the prenatal stage can occur in approximately 5 to 15 out of 1000 live births; more than a quarter of these will have critical congenital heart disease (CCHD). Late postnatal diagnosis is associated with a worse prognosis during childhood, and there is evidence that a standardized measurement of oxygen saturation in the newborn by cutaneous oximetry is an optimal method for the detection of CCHD. We conducted a systematic review of the literature and meta-analysis comparing the operational characteristics of oximetry and physical examination for the detection of CCHD. Methods: A systematic review of the literature was conducted on the following databases including published studies between 2002 and 2017, with no language restrictions: Pubmed, Science Direct, Ovid, Scopus and EBSCO, with the following keywords: oximetry screening, critical congenital heart disease, newborn OR oximetry screening heart defects, congenital, specificity, sensitivity, physical examination. Results: A total of 419 articles were found, from which 69 were selected based on their titles and abstracts. After quality assessment, five articles were chosen for extraction of data according to inclusion criteria; data were analyzed on a sample of 404,735 newborns in the five included studies. The following values were found, corresponding to the operational characteristics of oximetry in combination with the physical examination: sensitivity: 0.92 (CI 95%, 0.87-0.95), specificity: 0.98 (CI 95%, 0.89-1.00), for physical examination alone sensitivity: 0.53 (CI 95%, 0.28-0.78) and specificity: 0.99 (CI 95%, 0.97-1.00). Conclusions: Evidence found in different articles suggests that pulse oximetry in addition to neonatal physical examination presents optimal operative characteristics that make it an adequate screening test for detection of CCHD in newborns, above all this is essential in low and middle-income settings where technology medical support is not entirely available.

Pulse Oximetry Screening for Critical Congenital Heart Defects: A Life-Saving Test for All Newborn Babies

Congenital heart defects (CHD) are the commonest congenital malformations and remain a major cause of neonatal mortality and morbidity in the developed world[...]

Pulse oximetry screening for critical congenital heart disease: a comparative study of cohorts over 11 years

Background: Pulse oximetry (POS) has been proposed as a screening tool for CCHD in newborn. The aim was to identify the effect of POS on the rate of diagnosis after discharge and survival to one year in cases with CCHD.Material and Methods: All cases of CCHD from three tertiary level hospitals in the Northern region of UK between 1st January 2001 and 31st December 2011 were identified from the Northern Congenital Abnormality Survey (NorCAS). A retrospective cohort study comparing screened and unscreened population for CCHD was undertaken. The main outcome was post discharge diagnosis rate and mortality at one year between the cohorts.Results: Total number of births during the 11 years was 138,176. A total of 147 cases had CCHD, 59 diagnosed postnatally. Five and eight cases were diagnosed after discharge in the screened and the unscreened cohort respectively. The rate of post-discharge diagnosis in the screened population was 7/100,000 and 13/100,000 in the unscreened population with a relative risk of 0.52 (CI 0.2 to 1.42). Mortality at one year in postnatally diagnosed cases was five and one in the screened and unscreened cohorts respectively.Conclusion: With good antenatal detection rates, POS did not have a statistically significant impact in identifying cases of CCHD, when added to the present screening process of antenatal ultrasound and postnatal examination. The same conclusion cannot be made for regions with lower antenatal detection rates; perhaps it may be more appropriate to consider pulse oximetry as a screening tool for hypoxemia of any cause.Brief rationaleThis is the first study evaluating the contemporaneous post-discharge diagnosis rate between screened and unscreened populations. The rate of post-discharge diagnosis was 7/100,000 in the screened and 13/100,000 in the unscreened populations. However, this did not achieve statistical significance and in a setting with high antenatal diagnosis a very large study would be required to demonstrate efficacy of POS.

Cost-effectiveness analysis of pulse oximetry screening for critical congenital heart defects following homebirth and early discharge

Pulse oximetry (PO) screening is used to screen newborns for critical congenital heart defects (CCHD). Analyses performed in hospital settings suggest that PO screening is cost-effective. We assessed the costs and cost-effectiveness of PO screening in the Dutch perinatal care setting, with home births and early postnatal discharge, compared to a situation without PO screening. Data from a prospective accuracy study with 23,959 infants in the Netherlands were combined with a time and motion study and supplemented data. Costs and effects of the situations with and without PO screening were compared for a cohort of 100,000 newborns. Mean screening time per newborn was 4.9 min per measurement and 3.8 min for informing parents. The additional costs of screening were in total €14.71 per screened newborn (€11.00 personnel, €3.71 equipment costs). Total additional costs of screening and referral were €1,670,000 per 100,000 infants. This resulted in an incremental cost-effectiveness ratio of €139,000 per additional newborn with CCHD detected with PO, when compared to a situation without PO screening. A willingness-to-pay threshold of €20,000 per gained QALY for screening in the Netherlands makes the screening likely to be cost-effective.Conclusion: PO screening in the Dutch care setting is likely to be cost-effective. What is Known: • Pulse oximetry is increasingly implemented as a screening tool for critical congenital heart defects in newborns. • Previous studies suggest that the screening in cost-effective and in the USA a reduction in infant mortality from critical congenital heart defects was demonstrated. What is New: • This is the first cost-effectiveness analysis for pulse oximetry screening in a setting with screening after home births, with screening at two moments. • Costs of pulse oximetry screening in a setting with hospital and homebirth deliveries were €14.71 and is likely to be cost-effective accordint to Dutch standards.

Can echocardiographic screening in the early days of life detect critical congenital heart disease among apparently healthy newborns?

BACKGROUND

Delayed diagnosis of critical congenital heart disease (CCHD) carries a serious risk of mortality, morbidity, and handicap. As echocardiography is commonly used to diagnose congenital heart disease (CHD), echocardiographic investigations in newborns may be helpful in detecting CCHD earlier and with higher sensitivity than when using other screening methods. The present study aimed to evaluate the effectiveness of echocardiographic screening for CCHD in a tertiary care center.

METHODS

A retrospective chart review was conducted among newborns delivered at Hamamatsu University Hospital between June 2009 and May 2016. The study included consecutive newborns who underwent early echocardiographic screening (within the first 5 days of life) performed by pediatric cardiologists, were born at ≥36 weeks of gestation, had a birthweight ≥2300 g, and were cared for in the well-baby nursery. Newborns admitted to the neonatal intensive care unit, as well as those with prenatal diagnosis of CHD and/or clinical symptoms or signs of CHD were excluded. Four CHD outcome categories were defined: critical, serious, clinically significant, and clinically non-significant.

RESULTS

A total of 4082 live newborns were delivered during the study period. Of 3434 newborns who met the inclusion criteria and had complete echocardiography data, 104 (3.0%) were diagnosed as having CHD. Among these, none was initially diagnosed as having critical or serious CHD. Of the 95 newborns who continued follow-up with a cardiologist, 61 (64%) were determined to have non-significant CHDs that resolved within 6 months of life. Review of excluded newborns revealed nine cases of critical or serious CHD; among these newborns, six were diagnosed prenatally and three had some clinical signs of CHD prior to hospital discharge.

CONCLUSIONS

In our tertiary care center, echocardiography screening within the first 5 days of life did not help improve CCHD detection rate in newborns without prenatal diagnosis or clinical signs of CHD. Echocardiographic screening may be associated with increased rate of false-positives (defects resulting in clinically non-significant CHDs) in newborns without prenatal diagnosis or suspicion of CHD.

Neonatal echocardiogram in duodenal obstruction is unnecessary after normal fetal cardiac imaging

BACKGROUND

Duodenal obstruction (DO) is associated with congenital cardiac anomalies that may complicate the delivery of anesthesia during surgical repair. As most infants undergo fetal ultrasounds that identify cardiac anomalies, our aim was to determine the utility of obtaining preoperative neonatal echocardiograms in all DO patients.

METHODS

We conducted a retrospective cohort study of all DO patients treated at two tertiary care children's hospitals between January 2005 and February 2016. Prenatal ultrasounds were compared to neonatal echocardiograms to determine concordance. Binomial exact analyses were used to estimate the negative predictive value (NPV) of prenatal imaging.

RESULTS

We identified 65 infants with DO. The majority of patients (93.8%) had prenatal ultrasounds, including twenty patients that underwent fetal echocardiogram. Fourteen (21.5%) were diagnosed with cardiac lesions in utero, and neonatal echocardiograms confirmed 12 lesions, without identifying any new lesions. No changes to anesthetic management were made because of cardiac lesions. The NPV of prenatal imaging was 100% (95% Confidence Interval: 91.0-100.0).

CONCLUSIONS

Neonatal echocardiogram is unlikely to identify new cardiac lesions in DO patients with negative fetal imaging and delays in surgical care are unwarranted.

LEVELS OF EVIDENCE

Study of Diagnostic Test-Level II.

Is pulse oximetry helpful for the early detection of critical congenital heart disease at high altitude?

OBJECTIVE

To assess the pulse oximetry as a method for screening critical congenital heart disease (CHD) in newborns.

STUDY DESIGN

This is an observational, transversal, descriptive simple study. The pre-ductal and postductal saturation were taken in term newborns that fulfilled the criteria of inclusion and exclusion in the Hospital Gineco-Obstetrico Isidro Ayora (HGOIA) in Quito. These measurements were performed between the 24 and 48 h after birth. Those newborns that saturated less than 90% on initial pulse oxìmetry underwent 3 successive measurements at 1-h intervals. Those who saturate less than 90% after 3 measurements or have a difference higher than 3% in preductal saturation and postductal saturation (positive screening) underwent transthoracic echocardiography evaluate for CHD.

RESULTS

Pulse oximetry from 963 newborns was evaluated. In Quito, at an altitude of 2820 meters above sea level (9252 feet), the mean preductal saturation was 92.76% (SD ± 3) and the postductal saturation, 93.76% (SD ± 4.7). Pulse oximetry in 53 patients (5.5%) was classified as a positive screening. No critical congenital heart diseases were found. Atrial septal defect (ASD) was the most common finding in a 46.94% (n = 23), followed by the association of patent ductus arteriosus (PDA) and ASD with a 12.24% (n = 6).

CONCLUSION

In this cohort of patients who underwent screening pulse oximetry, no critical congenital heart diseases (CHD) were observed. However, identifying those with oxygen saturation less than 90% after 3 successive measurements or a pre- and postductal oxygen difference of > 3% resulted in successful identification of ASD and PDA. It is necessary to implement new cutoff points in saturation values to identify critical cardiac anomalies in cities placed at a high altitude. The use of pulse oximetry should be recommended in all the newborns.

Accuracy of Pulse Oximetry Screening for Critical Congenital Heart Defects after Home Birth and Early Postnatal Discharge

OBJECTIVE

To assess the accuracy of pulse oximetry screening for critical congenital heart defects (CCHDs) in a setting with home births and early discharge after hospital deliveries, by using an adapted protocol fitting the work patterns of community midwives.

STUDY DESIGN

Pre- and postductal oxygen saturations (SpO₂) were measured ≥1 hour after birth and on day 2 or 3. Screenings were positive if the SpO₂ measurement was <90% or if 2 independent measures of pre- and postductal SpO₂ were <95% and/or the pre-/postductal difference was >3%. Positive screenings were referred for pediatric assessment. Primary outcomes were sensitivity, specificity, and false-positive rate of pulse oximetry screening for CCHD. Secondary outcome was detection of noncardiac illnesses.

RESULTS

The prenatal detection rate of CCHDs was 73%. After we excluded these cases and symptomatic CCHDs presenting immediately after birth, 23 959 newborns were screened. Pulse oximetry screening sensitivity in the remaining cohort was 50.0% (95% CI 23.7-76.3) and specificity was 99.1% (95% CI 99.0-99.2). Pulse oximetry screening was false positive for CCHDs in 221 infants, of whom 61% (134) had noncardiac illnesses, including infections (31) and respiratory pathology (88). Pulse oximetry screening did not detect left-heart obstructive CCHDs. Including cases with prenatally detected CCHDs increased the sensitivity to 70.2% (95% CI 56.0-81.4).

CONCLUSION

Pulse oximetry screening adapted for perinatal care in home births and early postdelivery hospital discharge assisted the diagnosis of CCHDs before signs of cardiovascular collapse. High prenatal detection led to a moderate sensitivity of pulse oximetry screening. The screening also detected noncardiac illnesses in 0.6% of all infants, including infections and respiratory morbidity, which led to early recognition and referral for treatment.

Pulse Oximetry Screening Adapted to a System with Home Births: The Dutch Experience

Neonatal screening for critical congenital heart defects is proven to be safe, accurate, and cost-effective. The screening has been implemented in many countries across all continents in the world. However, screening for critical congenital heart defects after home births had not been studied widely yet. The Netherlands is known for its unique perinatal care system with a high rate of home births (18%) and early discharge after an uncomplicated delivery in hospital. We report a feasibility, accuracy, and acceptability study performed in the Dutch perinatal care system. Screening newborns for critical congenital heart defects using pulse oximetry is feasible after home births and early discharge, and acceptable to mothers. The accuracy of the test is comparable to other early-screening settings, with a moderate sensitivity and high specificity.

Pulse oximetry screening for critical congenital heart defects

BACKGROUND

Health outcomes are improved when newborn babies with critical congenital heart defects (CCHDs) are detected before acute cardiovascular collapse. The main screening tests used to identify these babies include prenatal ultrasonography and postnatal clinical examination; however, even though both of these methods are available, a significant proportion of babies are still missed. Routine pulse oximetry has been reported as an additional screening test that can potentially improve detection of CCHD.

OBJECTIVES

• To determine the diagnostic accuracy of pulse oximetry as a screening method for detection of CCHD in asymptomatic newborn infants• To assess potential sources of heterogeneity, including:○ characteristics of the population: inclusion or exclusion of antenatally detected congenital heart defects;○ timing of testing: < 24 hours versus ≥ 24 hours after birth;○ site of testing: right hand and foot (pre-ductal and post-ductal) versus foot only (post-ductal);○ oxygen saturation: functional versus fractional;○ study design: retrospective versus prospective design, consecutive versus non-consecutive series; and○ risk of bias for the "flow and timing" domain of QUADAS-2.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2) in the Cochrane Library and the following databases: MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Health Services Research Projects in Progress (HSRProj), up to March 2017. We searched the reference lists of all included articles and relevant systematic reviews to identify additional studies not found through the electronic search. We applied no language restrictions.

SELECTION CRITERIA

We selected studies that met predefined criteria for design, population, tests, and outcomes. We included cross-sectional and cohort studies assessing the diagnostic accuracy of pulse oximetry screening for diagnosis of CCHD in term and late preterm asymptomatic newborn infants. We considered all protocols of pulse oximetry screening (eg, different saturation thresholds to define abnormality, post-ductal only or pre-ductal and post-ductal measurements, test timing less than or greater than 24 hours). Reference standards were diagnostic echocardiography (echocardiogram) and clinical follow-up, including postmortem findings, mortality, and congenital anomaly databases.

DATA COLLECTION AND ANALYSIS

We extracted accuracy data for the threshold used in primary studies. We explored between-study variability and correlation between indices visually through use of forest and receiver operating characteristic (ROC) plots. We assessed risk of bias in included studies using the QUADAS-2 tool. We used the bivariate model to calculate random-effects pooled sensitivity and specificity values. We investigated sources of heterogeneity using subgroup analyses and meta-regression.

MAIN RESULTS

Twenty-one studies met our inclusion criteria (N = 457,202 participants). Nineteen studies provided data for the primary analysis (oxygen saturation threshold < 95% or ≤ 95%; N = 436,758 participants). The overall sensitivity of pulse oximetry for detection of CCHD was 76.3% (95% confidence interval [CI] 69.5 to 82.0) (low certainty of the evidence). Specificity was 99.9% (95% CI 99.7 to 99.9), with a false-positive rate of 0.14% (95% CI 0.07 to 0.22) (high certainty of the evidence). Summary positive and negative likelihood ratios were 535.6 (95% CI 280.3 to 1023.4) and 0.24 (95% CI 0.18 to 0.31), respectively. These results showed that out of 10,000 apparently healthy late preterm or full-term newborn infants, six will have CCHD (median prevalence in our review). Screening by pulse oximetry will detect five of these infants as having CCHD and will miss one case. In addition, screening by pulse oximetry will falsely identify another 14 infants out of the 10,000 as having suspected CCHD when they do not have it.The false-positive rate for detection of CCHD was lower when newborn pulse oximetry was performed longer than 24 hours after birth than when it was performed within 24 hours (0.06%, 95% CI 0.03 to 0.13, vs 0.42%, 95% CI 0.20 to 0.89; P = 0.027).Forest and ROC plots showed greater variability in estimated sensitivity than specificity across studies. We explored heterogeneity by conducting subgroup analyses and meta-regression of inclusion or exclusion of antenatally detected congenital heart defects, timing of testing, and risk of bias for the "flow and timing" domain of QUADAS-2, and we did not find an explanation for the heterogeneity in sensitivity.

AUTHORS' CONCLUSIONS

Pulse oximetry is a highly specific and moderately sensitive test for detection of CCHD with very low false-positive rates. Current evidence supports the introduction of routine screening for CCHD in asymptomatic newborns before discharge from the well-baby nursery.

Early Detection with Pulse Oximetry of Hypoxemic Neonatal Conditions. Development of the IX Clinical Consensus Statement of the Ibero-American Society of Neonatology (SIBEN)

This article reviews the development of the Ninth Clinical Consensus Statement by SIBEN (the Ibero-American of Neonatology) on "Early Detection with Pulse Oximetry (SpO₂) of Hypoxemic Neonatal Conditions". It describes the process of the consensus, and the conclusions and recommendations for screening newborns with pulse oximetry.

Parental preference and perspectives on continuous pulse oximetry in infants and children with bronchiolitis

OBJECTIVE

The purpose of the study was to investigate parental preference of continuous pulse oximetry in infants and children with bronchiolitis.

MATERIALS AND METHODS

A cross-sectional prospective study was conducted at Hamad Medical Corporation in Qatar. Parents of infants and children <24 months old and hospitalized with bronchiolitis were offered an interview survey.

RESULTS

A total of 132 questionnaires were completed (response rate 100%). Approximately 90% of participants were 20-40 years of age, and 85% were females. The mean age of children was 7.2±5.8 months. Approximately eight in ten parents supported the idea of continuous pulse oximetry in children with bronchiolitis. Almost 43% of parents believed that continuous pulse-oximetry monitoring would delay their children's hospital discharge. Interestingly, approximately 85% of caregivers agreed that continuous pulse oximetry had a good impact on their children's health. In addition, around one in two of the participants stated that good bedside examinations can obviate the need for continuous pulse oximetry. Furthermore, 80% of parents believed that continuous pulse-oximetry monitoring would give the health-care provider a good sense of security regarding the child's health. Finally, being a male parent was associated with significantly increased risk of reporting unnecessary fatigue, attributed to the sound of continuous pulse oximetry (P=0.031).

CONCLUSION

Continuous pulse-oximetry monitoring in children with bronchiolitis was perceived as reassuring for parents. Involving parents in decision-making is considered essential in the better management of children with bronchiolitis or any other disease. The first step to decrease continuous pulse oximetry will require provider education and change as well. Furthermore, we recommend proper counseling for parents, emphasizing that medical technology is not always essential, but is a complementary mode of managing a disease.

Perfusion index in healthy newborns during critical congenital heart disease screening at 24 hours: retrospective observational study from the USA

OBJECTIVE

To describe the distribution of perfusion index (PI) in asymptomatic newborns at 24 hours of life when screening for critical congenital heart disease (CCHD) using an automated data selection method.

DESIGN

This is a retrospective observational study.

SETTING

Newborn nursery in a California public hospital with ~3500 deliveries annually.

METHODS

We developed an automated programme to select the PI values from CCHD screens. Included were term and late preterm infants who were screened for CCHD from November 2013 to January 2014 and from May 2015 to July 2015. PI measurements were downloaded every 2 s from the pulse oximeter and median PI were calculated for each oxygen saturation screen in our cohort.

RESULTS

We included data from 2768 oxygen saturation screens. Each screen had a median of 29 data points (IQR 17 to 49). The median PI in our study cohort was 1.8 (95% CI 1.8 to 1.9) with IQR 1.2 to 2.7. The median preductal PI was significantly higher than the median postductal (1.9 vs 1.8, p=0.03) although this difference may not be clinically significant.

CONCLUSION

Using an automated data selection method, the median PI in asymptomatic newborns at 24 hours of life is 1.8 with a narrow IQR of 1.2 to 2.7. This automated data selection method may improve accuracy and precision compared with manual data collection method. Further studies are needed to establish external validity of this automated data selection method and its clinical application for CCHD screening.

A Meta-Analysis about the Screening Role of Pulse Oximetry for Congenital Heart Disease

OBJECTIVE

The opinions about the application of pulse oximetry in diagnosis of congenital heart disease (CHD) were debatable. We performed this meta-analysis to confirm the diagnostic role of pulse oximetry screening for CHD.

METHODS

Relevant articles were searched in the databases of Pubmed, Embase, Google Scholar, and Chinese National Knowledge Infrastructure (CNKI) up to April 2017. Data was processed in the MetaDiSc 1.4 software. Pooled sensitivity and specificity with 95% confidence interval (95% CI) were calculated to explain the diagnostic role of pulse oximetry screening for CHD. I2⩾50% or p < 0.05 indicated significant heterogeneity. Area under curve (AUC) of summary receiver operating characteristics (SROC) was calculated to assess its diagnostic accuracy. The robustness of overall results was evaluated by sensitivity analysis. Publication bias was evaluated by Deek's funnel plot.

RESULTS

22 eligible articles were selected. Pooled sensitivity and specificity were 0.69 (0.67-0.72) and 0.99 (0.99-0.99), respectively. The corresponding AUC was 0.9407, suggesting high diagnostic accuracy of pulse oximetry screening for CHD. Sensitivity analysis demonstrated that the pooled results were robust. Deek's funnel plot seemed to be symmetrical.

CONCLUSIONS

Pulse oximetry screening could be used to diagnose CHD. It shows high diagnosis specificity and accuracy.

Cost-effectiveness analysis of neonatal screening of critical congenital heart defects in China

BACKGROUND

Pulse oximetry screening is a highly accurate tool for the early detection of critical congenital heart disease (CCHD) in newborn infants. As the technique is simple, noninvasive, and inexpensive, it has potentially significant benefits for developing countries. The aim of this study is to provide information for future clinical and health policy decisions by assessing the cost-effectiveness of CCHD screening in China.

METHODS AND FINDINGS

We developed a cohort model to evaluate the cost-effectiveness of screening all Chinese newborns annually using 3 possible screening options compared to no intervention: pulse oximetry alone, clinical assessment alone, and pulse oximetry as an adjunct to clinical assessment. We calculated the incremental cost per averted disability-adjusted life years (DALYs) in 2015 international dollars to measure cost-effectiveness. One-way sensitivity analysis and multivariate probabilistic sensitivity analysis were performed to test the robustness of the model. Of the three screening options, we found that clinical assessment is the most cost-effective strategy compared to no intervention with an incremental cost-effectiveness ratio (ICER) of Int$5,728/DALY, while pulse oximetry plus clinical assessment with the highest ICER yielded the best health outcomes. Sensitivity analysis showed that when the treatment rate increased up to 57.5%, pulse oximetry plus clinical assessment showed the best expected values among the three screening options.

CONCLUSION

In China, for neonatal screening for CCHD at the national level, clinical assessment was a very cost-effective preliminary choice and pulse oximetry plus clinical assessment was worth considering for the long term. Improvement in accessibility to treatment is crucial to expand the potential health benefits of screening.

A comparison of the incidence of undiagnosed congenital heart disease in hospital born and home born children

OBJECTIVE

To evaluate the incidence of otherwise undiagnosed congenital heart disease (CHD) in a population of children born in a hospital with routine pulse oximetry (RPO) screening compared to children born at home.

METHODS

We reviewed 15 years of births at 2 hospitals for incidence of undiagnosed CHD with RPO. The Health Department reviewed the same data for out of hospital births.

RESULTS

A total of 50,545 hospital births were screened and 1,274 children were born outside the hospital. There were 28 hospital-born babies diagnosed with cyanotic CHD prior to nursery discharge. Only one of these babies would not have been diagnosed without RPO. Three children were missed and there were 3 false positives. Sensitivity and positive predictive value of RPO was 25%, specificity and negative predictive value of RPO exceed 99%. The incidence of CHD requiring RPO diagnosis was roughly one birth per 50,000. Two children born at home with undiagnosed CHD were missed. One of these children presented with neonatal demise.

CONCLUSION

RPO screening is still valuable in diagnosing CHD only diagnosable with RPO. However, the incidence of CHD requiring RPO to diagnose is similar to other congenital diseases which are not mandated national screening tests. In our limited experience a patient is roughly 25 times more likely to have undiagnosed CHD if they are born outside of a hospital.

Newborn pulse oximetry screening in practice

The concept of using pulse oximetry (PO) as a screening test to identify newborn babies with critical congenital heart defects (CCHD) before life-threatening collapse occurs has been debated for some time now. Several recent large studies have consistently shown that PO screening adds value to existing screening techniques with over 90% of CCHDs detected. It can also help identify newborn babies with low oxygen saturations due to infection, respiratory disease and non-critical CCHD. Many countries have now introduced PO screening as routine practice, and as screening gains more widespread acceptance in the UK, we have focused more on the practical aspects of screening in this article. This includes case reports to demonstrate how the different screening modalities for CCHD work together and the experience of hospitals that have already introduced PO screening programmes (Birmingham Women's Hospital and others). Issues discussed include how and when to screen babies in hospital, what to do with a positive screen and how to screen babies born at home. The UK National Screening Committee is currently investigating the potential feasibility of routine PO screening in the UK, and so it is perhaps a suitable time for individual hospitals to consider the possibility of introducing such screening in their maternity units.

Toward a Framework for Benefit-Risk Assessment in Diagnostic Imaging: Identifying Scenario-specific Criteria

RATIONALE AND OBJECTIVES

Diagnostic imaging has many effects and there is no common definition of value in diagnostic radiology. As benefit-risk trade-offs are rarely made explicit, it is not clear which framework is used in clinical guideline development. We describe initial steps toward the creation of a benefit-risk framework for diagnostic radiology.

MATERIALS AND METHODS

We performed a literature search and an online survey of physicians to identify and collect benefit-risk criteria (BRC) relevant to diagnostic imaging tests. We operationalized a process for selection of BRC with the use of four clinical use case scenarios that vary by diagnostic alternatives and clinical indication. Respondent BRC selections were compared across clinical scenarios and between radiologists and nonradiologists.

RESULTS

Thirty-six BRC were identified and organized into three domains: (1) those that account for differences attributable only to the test or device (n = 17); (2) those that account for clinical management and provider experiences (n = 12); and (3) those that capture patient experience (n = 7). Forty-eight survey participants selected 22 criteria from the initial list in the survey (9-11 per case). Engaging ordering physicians increased the number of criteria selected in each of the four clinical scenarios presented. We developed a process for standardizing selection of BRC in guideline development.

CONCLUSION

These results suggest that a process relying on elements of comparative effectiveness and the use of standardized BRC may ensure consistent examination of differences among alternatives by way of making explicit implicit trade-offs that otherwise enter the decision-making space and detract from consistency and transparency. These findings also highlight the need for multidisciplinary teams that include input from ordering physicians.

A novel, more efficient, staged approach for critical congenital heart disease screening

OBJECTIVE

Screening for critical congenital heart disease (CCHD) using pulse oximetry has been endorsed by the American Academy of Pediatrics and the American Heart Association. The recommended screening requires two saturation readings. We sought to determine the incidence of undetected CCHD in Tennessee for the 2 years following implementation of an algorithm that assigned an immediate pass to a single lower extremity saturation of 97% or higher.

STUDY DESIGN

State Genetic Screening records and reports of missed cases from the Tennessee Initiative for Perinatal Quality Care were used to determine if CCHD cases were missed by the new screening algorithm.

RESULT

During the study, 232 infants failed the screen with 51 or 22% true positives, 13 infants had undetected CCHD (10 coarctations, 2 anomalous veins and 1 Tetralogy of Fallot).

CONCLUSION

This approach eliminated over 150 000 pulse oximetry determinations in Tennessee without affecting the ability of pulse oximetry to detect CCHD before discharge.

Pulse Oximetry During the First 24 Hours as a Screening Tool for Congenital Heart Defects

Introduction

Although screening for congenital heart defects (CHD) relies mainly on antenatal ultrasonography and clinical examination after birth, life-threatening cardiac malformations are often not diagnosed before the patient is discharged.

Aim

To assess the use of routine pulse oximetry in the delivery room and at 24 hours postpartum, and to study its feasibility as a screening test for CHD.

Material and Methods

In this prospective study, all infants born in “Cuza Voda” Maternity Hospital, Iasi, Romania, were enrolled over a thirteen-month period. Preductal oximetry was assessed during the first hour, and postductal oximetry was evaluated at twenty-four hours postpartum. Data were then analyzed to establish the sensitivity and specificity of pulse oximetry, as a screening test for CHD.

Results

5406 infants were included in the study, with a mean gestational age of 38.2 weeks and a mean birth weight of 3175 grams. During the first minute, blood oxygen saturation varied between 40% and 90% and at 24 hours of life, it ranged between 90% and 100%. Following oximetry assessment, 14 infants with critical CHD were identified. Blood oxygen saturation values in infants with CHD were lower throughout the entire period of evaluation. Pulse oximetry had good sensitivity and specificity at 1 hour (Se=87.5%, Sp=95.5%) and 24 hours (Se=92.5%, Sp=97.4%) for the diagnosis of CHD. Blood oxygen saturation values at one minute, 1 hour and 24 hours are strong discriminative parameters for the early diagnosis of CHD.

Conclusion

Routine pulse oximetry during the first 24 hours postpartum represents an early indicator of CHD to facilitate timely intervention. Pulse oximetry provides excellent sensitivity and specificity and has tremendous potential as a standard screening test for CHD during the first 24 hours of life.

Cost and Cost-Effectiveness Assessments of Newborn Screening for Critical Congenital Heart Disease Using Pulse Oximetry: A Review

Screening newborns for critical congenital heart disease (CCHD) using pulse oximetry is recommended to allow for the prompt diagnosis and prevention of life-threatening crises. The present review summarizes and critiques six previously published estimates of the costs or cost-effectiveness of CCHD screening from the United Kingdom, United States, and China. Several elements that affect CCHD screening costs were assessed in varying numbers of studies, including screening staff time, instrumentation, and consumables, as well as costs of diagnosis and treatment. A previous US study that used conservative assumptions suggested that CCHD screening is likely to be considered cost-effective from the healthcare sector perspective. Newly available estimates of avoided infant CCHD deaths in several US states that implemented mandatory CCHD screening policies during 2011-2013 suggest a substantially larger reduction in deaths than was projected in the previous US cost-effectiveness analysis. Taking into account these new estimates, we estimate that cost per life-year gained could be as low as USD 12,000. However, that estimate does not take into account future costs of health care and education for surviving children with CCHD nor the costs incurred by health departments to support and monitor CCHD screening policies and programs.

Maternal acceptability of pulse oximetry screening at home after home birth or very early discharge

The Netherlands has a unique perinatal healthcare system with a high rate of home births and very early discharge after delivery in hospital. Although we demonstrated that pulse oximetry (PO) screening for critical congenital heart disease is feasible in the Netherlands, it is unknown whether parents find the screening acceptable when performed in home birth setting. We assessed the acceptability of PO screening to mothers after screening in home setting. A questionnaire was sent electronically to mothers who gave birth and/or had postnatal care under supervision of a community midwife participating in the Pulse Oximetry Leiden Screening (POLS) study, a feasibility study of PO screening in the Dutch care system, performed in the Leiden region, the Netherlands. The questionnaire included questions based on satisfaction, general feelings, and perceptions of PO screening. A total of 1172/1521 (77%) mothers completed the questionnaire. Overall, mothers were happy with the performance of the test (95%), thought their baby was comfortable during the screening (90%) and did not feel stressed while the screening was performed (92%). Most mothers would recommend the test to others (93%) and considered the test important for all babies (93%).

CONCLUSION

Mothers of newborns participating in the study found the PO screening acceptable when performed at home. What is Known: • Pulse oximetry screening for critical congenital heart defects is (cost)effective and acceptable to mothers when performed in hospital. What is New: • Pulse oximetry screening for critical congenital heart defects is also acceptable for mothers when the screening is performed at home.

The impact and efficacy of routine pulse oximetry screening for CHD in a local hospital

OBJECTIVES

The objective of this study was to evaluate the impact and efficacy of pulse oximetry screening for CHD in a level-two neonatal unit without on-site access to paediatric echocardiography.

METHODS

All neonatal unit admissions between 1 September, 2011 and 31 August, 2013 were reviewed to determine the outcomes of newborns identified by pulse oximetry screening. Record linkage with the National Congenital Heart Disease Audit allowed follow-up of newborns with a negative screening result.

RESULTS

There were 11,233 live births during the study period, with 973 neonatal unit admissions unrelated to pulse oximetry screening. From the remaining screening population of 10,260 newborns, 23 were admitted on the basis of a screen-positive result; three of the 23 patients went on to have urgent echocardiograms, and two were found to have critical CHD. In the 21 newborns without critical CHD, an alternative diagnosis was made in 16 cases. Record linkage with the National Congenital Heart Disease Audit indicated that no newborns born in the hospital during the study period received surgery for critical CHD following negative screening. The estimated sensitivity of screening was 100% (95% confidence interval 15.81-100%) and specificity was 99.80% (95% confidence interval 99.69-99.87%), with a false-positive rate of 0.20% (95% confidence interval 0.13-0.31%).

CONCLUSION

The introduction of pulse oximetry screening to a hospital where paediatric echocardiography services are not available is practical, results in very few referrals to the regional paediatric cardiology centre, and detects cases of CHD that would otherwise go undiagnosed. Record linkage with a national CHD database provides a straightforward method for tracking cases of CHD that may have been missed by screening.

Feasibility of pulse oximetry screening for critical congenital heart defects in homebirths

BACKGROUND

Pulse oximetry has been shown to be a valuable additional screening test for detecting critical congenital heart defects in newborns. The feasibility of homebirth screening by the attending midwife has not been reported previously.

AIM

Routine pulse oximetry screening of homebirths at 2 h of age was introduced in a UK tertiary maternity service in January 2014. The process and outcomes were evaluated.

METHODS

Retrospective review of the clinical record of all babies undergoing pulse oximetry screening performed following homebirths over a 16-month period was undertaken. The acceptability of screening among the home care team (n=11) was also evaluated.

RESULTS

Ninety babies underwent routine pulse oximetry screening within 2 h following homebirth; two had a positive result and were admitted to the neonatal unit with significant respiratory illness. Screening was acceptable and reassuring to midwives enabling prompt postnatal decision making and confirming normal transition without significantly increasing workload.

CONCLUSIONS

Early pulse oximetry screening for homebirths is both feasible and acceptable.

The impact of the National Institute for Health Research Health Technology Assessment programme, 2003-13: a multimethod evaluation

BACKGROUND

The National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme supports research tailored to the needs of NHS decision-makers, patients and clinicians. This study reviewed the impact of the programme, from 2003 to 2013, on health, clinical practice, health policy, the economy and academia. It also considered how HTA could maintain and increase its impact.

METHODS

Interviews (n = 20): senior stakeholders from academia, policy-making organisations and the HTA programme. Bibliometric analysis: citation analysis of publications arising from HTA programme-funded research. Researchfish survey: electronic survey of all HTA grant holders. Payback case studies (n = 12): in-depth case studies of HTA programme-funded research.

RESULTS

We make the following observations about the impact, and routes to impact, of the HTA programme: it has had an impact on patients, primarily through changes in guidelines, but also directly (e.g. changing clinical practice); it has had an impact on UK health policy, through providing high-quality scientific evidence - its close relationships with the National Institute for Health and Care Excellence (NICE) and the National Screening Committee (NSC) contributed to the observed impact on health policy, although in some instances other organisations may better facilitate impact; HTA research is used outside the UK by other HTA organisations and systematic reviewers - the programme has an impact on HTA practice internationally as a leader in HTA research methods and the funding of HTA research; the work of the programme is of high academic quality - the Health Technology Assessment journal ensures that the vast majority of HTA programme-funded research is published in full, while the HTA programme still encourages publication in other peer-reviewed journals; academics agree that the programme has played an important role in building and retaining HTA research capacity in the UK; the HTA programme has played a role in increasing the focus on effectiveness and cost-effectiveness in medicine - it has also contributed to increasingly positive attitudes towards HTA research both within the research community and the NHS; and the HTA focuses resources on research that is of value to patients and the UK NHS, which would not otherwise be funded (e.g. where there is no commercial incentive to undertake research). The programme should consider the following to maintain and increase its impact: providing targeted support for dissemination, focusing resources when important results are unlikely to be implemented by other stakeholders, particularly when findings challenge vested interests; maintaining close relationships with NICE and the NSC, but also considering other potential users of HTA research; maintaining flexibility and good relationships with researchers, giving particular consideration to the Technology Assessment Report (TAR) programme and the potential for learning between TAR centres; maintaining the academic quality of the work and the focus on NHS need; considering funding research on the short-term costs of the implementation of new health technologies; improving the monitoring and evaluation of whether or not patient and public involvement influences research; improve the transparency of the priority-setting process; and continuing to monitor the impact and value of the programme to inform its future scientific and administrative development.