Interventions, outcomes and outcome measurement instruments in stillbirth care research: A systematic review to inform the development of a core outcome set

BACKGROUND

A core outcome set could address inconsistent outcome reporting and improve evidence for stillbirth care research, which have been identified as an important research priority.

OBJECTIVES

To identify outcomes and outcome measurement instruments reported by studies evaluating interventions after the diagnosis of a stillbirth.

SEARCH STRATEGY

Amed, BNI, CINAHL, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, MEDLINE, PsycINFO, and WHO ICTRP from 1998 to August 2021.

SELECTION CRITERIA

Randomised and non-randomised comparative or non-comparative studies reporting a stillbirth care intervention.

DATA COLLECTION AND ANALYSIS

Interventions, outcomes reported, definitions and outcome measurement tools were extracted.

MAIN RESULTS

Forty randomised and 200 non-randomised studies were included. Fifty-eight different interventions were reported, labour and birth care (52 studies), hospital bereavement care (28 studies), clinical investigations (116 studies), care in a multiple pregnancy (2 studies), psychosocial support (28 studies) and care in a subsequent pregnancy (14 studies). A total of 391 unique outcomes were reported and organised into 14 outcome domains: labour and birth; postpartum; delivery of care; investigations; multiple pregnancy; mental health; emotional functioning; grief and bereavement; social functioning; relationship; whole person; subsequent pregnancy; subsequent children and siblings and economic. A total of 242 outcome measurement instruments were used, with 0-22 tools per outcome.

CONCLUSIONS

Heterogeneity in outcome reporting, outcome definition and measurement tools in care after stillbirth exists. Considerable research gaps on specific intervention types in stillbirth care were identified. A core outcome set is needed to standardise outcome collection and reporting for stillbirth care research.

CT fractional flow reserve: an alternative to stress ECHO for gatekeeping to invasive coronary angiography

Funding Acknowledgements

Type of funding sources: None.

Introduction

Stress echocardiography (SE) can assess the significance of moderate/severe stenoses found on CT coronary angiography (CTCA), as a gatekeeper to invasive coronary angiography (ICA). In 2017, the UK National Institute for Health and Care Excellence (NICE), recommended CT fractional flow reserve (CTFFR) on all patients with coronary stenoses on CTCA to reduce downstream ICA and reduce costs.

Aim

We describe our experience of using CTFFR and compare this with previously accepted practice of judicious use of SE in patients with moderate/severe CTCA stenosis, and subsequent rate of ICA.

Method

An electronic patient record identified patients undergoing CTFFR between January 2019 and March 2020, and CTCA between January 2017 and June 2018, at our centre. We assessed downstream testing following CT evidence of moderate/severe stenoses and undertook a cost analysis per patient (PP) with the following NHS tariffs; CTCA=£220, CTFFR=£530, SE=£177, ICA=£1000.

Results

140 patients were referred for CTFFR with 125 analysed (rejection rate 11%) of which 81 had moderate/severe stenoses. The baseline audit comprised 652 patients undergoing CTCA of which 92 had moderate/severe stenoses.

Moderate CTCA stenosis: Baseline audit

58 had moderate stenosis, 18 (31%) underwent SE, with 1 positive and subsequent ICA. 36 (62%) were referred directly for ICA. In total 17 (46%) were revascularised. Cost of £1224 PP.

CTFFR audit

44 had moderate stenosis, with 35 negative and 9 positive CTFFR.  9 (26%) and 7 (78%) following negative and positive CTFFR respectively, were subsequently referred for ICA. In total 16 (36%) were referred for ICA, and 44% revascularised. Cost of £1425 PP.

Severe CTCA stenosis: Baseline audit

34 had severe stenosis, 1 (3%) underwent SE. 33 (97%) were referred directly for ICA. In total 18 (60%) were revascularised. Cost of £1418 PP.

CTFFR audit

37 had severe stenoses, with 10 negative CTFFR and 27 positive CTFFR.  5 (50%) and 22 (81%) following negative and positive CTFFR respectively were referred for ICA. In total 27 (73%) were referred for ICA and 70% revascularised. Cost of £1719 PP.

Importantly 14 patients underwent ICA following negative CTFFR with 29% revascularised.

Conclusion

CTFFR use in all patients with moderate/severe stenosis reduced the rate of downstream ICA compared with previous judicious use of SE, albeit at greater cost and similar revascularisation rates. A small number of patients underwent ICA despite negative CTFFR due to clinical concerns.

The NICE guidance recommending CTFFR on all patients with moderate/severe CTCA stenosis reduces ICA. However, assuming equal efficacy, based on the non-invasive arm of the Platform trial1, SE would achieve this at lower cost. Notably, CTFFR benefits from completing assessment within a single visit, which is pertinent in the COVID-19 era and negates inherent delays between multiple tests.

Resilience and vulnerability of maternity services in Zimbabwe: a comparative analysis of the effect of Covid-19 and lockdown control measures on maternal and perinatal outcomes, a single-centre cross-sectional study at Mpilo Central Hospital

BACKGROUND

On the 27th of March 2020 the Zimbabwean government declared the Covid-19 pandemic a 'national disaster'. Travel restrictions and emergency regulations have had significant impacts on maternity services, including resource stock-outs, and closure of antenatal clinics during the lockdown period. Estimates of the indirect impact of Covid-19 on maternal and perinatal mortality was expected it to be considerable, but little data was yet available. This study aimed to examine the impact of Covid-19 and lockdown control measures on non-Covid outcomes in a government tertiary level maternity unit in Bulawayo, Zimbabwe, by comparing maternal and perinatal morbidity and mortality before, and after the lockdown was implemented.

METHODS

This was a retrospective, observational study, using a cross-sectional design to compare routine monthly maternal and perinatal statistics three months before and after Covid-19 emergency measures were implemented at Mpilo Central Hospital.

RESULTS

Between January-March and April-June 2020, the mean monthly deliveries reduced from 747.3 (SD ± 61.3) in the first quarter of 2020 to 681.0 (SD ± 17.6) during lockdown, but this was not statistically significant, p = 0.20. The Caesarean section rates fell from a mean of 29.8% (SD ± 1.7) versus 28.0% (SD ± 1.7), which was also not statistically significant, p = 0.18. During lockdown, the percentage of women delivering at Mpilo Central Hospital who were booked at the hospital fell from a mean of 41.6% (SD ± 1.1) to 35.8% (SD ± 4.3) which was statistically significant, p = 0.03. There was no significant change, however, in maternal mortality or severe maternal morbidity (such as post-partum haemorrhage (PPH), uterine rupture, and severe preeclampsia/eclampsia), stillbirth rate or special care baby unit admission. There was an increase in the mean total number of early neonatal deaths (ENND) (mean 18.7 (SD ± 2.9) versus 24.0 (SD ± 4.6), but this was not statistically significant, p = 0.32.

CONCLUSIONS

Overall, maternity services at Mpilo showed resilience during the lockdown period, with no significant change in maternal and perinatal adverse outcomes, with the same number of man-hours worked before and during the lockdown Maternal and perinatal outcomes should continue to be monitored to assess the impact of Covid-19 and the lockdown measures as the pandemic in Zimbabwe unfolds. Further studies would be beneficial to explore women's experiences and understand how bookings and deliveries at local clinics changed during this time.

P1329 An unexpected finding in a patient wth previous coronary artery bypass grafts and atypical chest pain

A 79-year-old male with a previous history of ischaemic heart disease and previous coronary artery bypass grafting (CABG) in 2005 presented with atypical chest pain. He also had past medical history of hypertension, hyperlipidaemia and bladder diverticulum which has been previously investigated by an abdominal CT. The latter had showed an incidental finding of what was reported to be a large pericardial cyst. Despite poor acoustic window, transthoracic echocardiography revealed a spherical echo–free structure in the area of the right atrioventricular groove (Figure 1, panel A white arrow). As the patient was too claustrophobic to undergo cardiac MRI, he was subsequently referred for a cardiac CT in order to further investigate the cystic mass and assess graft patency. The CT revealed an occluded left internal mammary artery (LIMA) to the LAD, severe left main (LM) and proximal LAD disease, a patent vein graft to an obtuse marginal (OM) branch and identified a largely thrombosed giant aneurysm (62x65x89 mm) of an otherwise patent vein graft to the RCA (Figure 1, panels B–E, white arrows point to the thrombosed and yellow arrows point to the non-thrombosed segments of the vein graft aneurysm). Coronary angiography confirmed occlusion of the LIMA, patency of the OM vein graft and identified only the non-thrombosed segment of the RCA vein graft aneurysm (Figure 1, panel F). The case was discussed at an MDT meeting and it was decided to proceed with LM and LAD stenting, and initially conservative management and close surveillance of the RCA vein graft aneurysm as the patient was high–risk for repeat CABG due to age, frailty and other comorbidities.

Abstract P1329 Figure 1

Parents' and healthcare professionals' experiences of care after stillbirth in low- and middle-income countries: a systematic review and meta-summary

BACKGROUND

Stillbirth has a profound impact on women, families, and healthcare workers. The burden is highest in low- and middle-income countries (LMICs). There is need for respectful and supportive care for women, partners, and families after bereavement.

OBJECTIVE

To perform a qualitative meta-summary of parents' and healthcare professionals' experiences of care after stillbirth in LMICs.

SEARCH STRATEGY

Search terms were formulated by identifying all synonyms, thesaurus terms, and variations for stillbirth. Databases searched were AMED, EMBASE, MEDLINE, PsychINFO, BNI, CINAHL.

SELECTION CRITERIA

Qualitative, quantitative, and mixed method studies that addressed parents' or healthcare professionals' experience of care after stillbirth in LMICs.

DATA COLLECTION AND ANALYSIS

Studies were screened, and data extracted in duplicate. Data were analysed using the Sandelowski meta-summary technique that calculates frequency and intensity effect sizes (FES/IES).

MAIN RESULTS

In all, 118 full texts were screened, and 34 studies from 17 countries were included. FES range was 15-68%. Most studies had IES 1.5-4.5. Women experience a broad range of manifestations of grief following stillbirth, which may not be recognised by healthcare workers or in their communities. Lack of recognition exacerbates negative experiences of stigmatisation, blame, devaluation, and loss of social status. Adequately developed health systems, with trained and supported staff, are best equipped to provide the support and information that women want after stillbirth.

CONCLUSIONS

Basic interventions could have an immediate impact on the experiences of women and their families after stillbirth. Examples include public education to reduce stigma, promoting the respectful maternity care agenda, and investigating stillbirth appropriately.

TWEETABLE ABSTRACT

Reducing stigma, promoting respectful care and investigating stillbirth have a positive impact after stillbirth for women and families in LMICs.

Using guided self-help to treat common mental health problems: The Westminster Primary Care Psychology Service

We describe a new service offering cognitive behavioural therapy in the form of guided self-help to patients experiencing mild mental health problems. The referral pathway is outlined and the various treatment options are illustrated with case descriptions of depression and panic disorder. Patients' responses to this new service are reported and discussed.

Transoesophageal echocardiography: its role in the management of patients in a district general hospital

The aim of this study was to assess the value of a transoesophageal echocardiography (TOE) service in a district general hospital (DGH). A series of 151 consecutive cases was analysed retrospectively to determine the relative additional benefit of TOE over transthoracic echocardiography (TTE) in establishing diagnoses and making therapeutic decisions. Of the 151 cases, 140 were suitable for the two procedures to be compared. In 56%, TOE provided useful information for patient management. This consisted of the detection of new major findings (33%) and the exclusion of significant abnormalities (23%), suspected either clinically or by TTE. TOE made a minor clinical contribution in 8% of cases, while in 30% there was concordance between the two studies. Finally, in 6% both examinations were inconclusive. We conclude that TOE has a significant complementary role to TTE in terms of clinical diagnosis and patient management in the DGH setting.