ABSTRACT
ABSTRACT Objective To investigate the impact of an enhanced QI support programme (ESP) in further improving the magnesium sulphate (MgSO 4 ) uptake compared to the National PReCePT Programme (NPP) model. Design An unblinded cluster randomised controlled trial. Setting NHS England and the AHSN network in 2018. Participants Maternity units with ≥10 pre-term deliveries annually and MgSO 4 uptake ≤70%. 40 maternity units (27 NPP, 13 ESP) were included. Randomisation was stratified by MgSO 4 uptake. Interventions MgSO 4 reduces the risk of cerebral palsy by 30%. NHS England commissioned the AHSN network in 2018 to deliver the NPP to increase MgSO 4 uptake in all maternity units in England. NPP units received PReCePT QI materials, regional support, and midwife backfill funding. ESP units received NPP plus backfill funding, unit-level QI coaching, and tablet computer Main outcome measures MgSO 4 uptake post-implementation was compared between trial groups. Implementation and lifetime costs, and quality-adjusted life-years were estimated. The implementation process, fidelity, and local adaptations were assessed through a qualitative process evaluation. Results Using routine data and multivariable linear regression, both ESP and NPP units increased uptake between pre- and post-implementation. Post-implementation uptake increase in ESP units was similar to NPP units (−0.84 percentage points difference, 95% Confidence Interval -5.03 to 3.35 percentage points). Decision tree and probabilistic analyses were used to estimate cost-effectiveness and the probability ESP cost-effective was < 30%. Midwives implementing the NPP allocated more than their funded hours. Implementers of the ESP had better overall understanding of and collective engagement in PReCePT QI and made more use of QI methods. Units varied in amount and kind of support required to successfully implement the intervention. Conclusion This trial did not find additional benefit from the ESP compared with the NPP. Units with low uptake of MgSO 4 were found to experience a range of local challenges and targeted enhanced support may improve performance and represent good value. Trial registration ISRCTN 40938673 ( https://www.isrctn.com/ISRCTN40938673 ) WHAT IS ALREADY KNOWN ON THIS TOPIC Since 2009 there has been strong evidence for the fetal neuroprotective benefits of antenatal MgSO 4 in women at risk of pre-term birth. This took a further 6 years to become a NICE recommended intervention. By 2017, only two-thirds of all eligible women in England were being given MgSO 4 , with wide regional variations. The PReCePT pilot study in 2015 demonstrated that uptake could be increased significantly using a Quality Improvement (QI) intervention to increase maternity staff awareness of MgSO 4 , and investment in staff time for training. In 2018, NHS England funded the National PReCePT Programme (NPP) in maternity units nationally, which provided a QI toolkit, backfill funding for a unit-level support for a midwife ‘champion’ and regional-level clinical champion. WHAT THIS STUDY ADDS The study has shown that national quality improvement programmes are effective in increasing MgSO 4 across maternity units in England. While overall uptake increased in both groups between baseline and follow-up, the study did not demonstrate additional benefit of the ESP compared to the NPP. Enhanced support can be delivered to units who are struggling or those with low improvement capability. Instead of delivering enhanced support to all units, a targeted intervention might be valuable for units who have low MgSO 4 implementation rates despite the national QI programme. Assessing individual organisations’ support needs based on factors including their readiness to change may help focus support to local needs.
Subject(s)
Cerebral PalsyABSTRACT
Objectives To evaluate the impact of a new clinic-based rapid STI testing, diagnosis and treatment service on healthcare delivery and resource needs in a sexual health service. Design Controlled interrupted time series study. Setting Two sexual health services in UK: Unity Sexual Health in Bristol, UK (main site) and Croydon Sexual Health in London (control site). Participants Electronic patient records for all attendances during the period one year before and one year after the intervention. Intervention Introduction: of an in-clinic rapid testing system for gonorrhoea and chlamydia in combination with revised treatment pathways. Outcome measures Time-to-test notification, staff capacity, cost per episode of care and overall service costs. We also assessed rates of gonorrhoea culture swabs, follow-up attendances, and examinations. Results Time-to-notification and the rate of gonorrhoea swabs significantly decreased following implementation of the new system. There was no evidence of change in follow-up visits or examination rates for patients seen in clinic related to the new system. Staff capacity in clinics appeared to be maintained across the study period. Overall, the number of episodes per week was unchanged in the Unity SHS, and the mean cost per episode decreased by 7.5% (95%CI 5.7%, 9.3%). Conclusions: The clear improvement in time-to-notification, while maintaining activity at a lower overall cost, suggests that the implementation of clinic-based testing in parallel to postal testing kits had the intended impact, which bolsters the case for more widespread rollout in SHS. Strengths and limitations of this study We used controlled interrupted time series models with confounder adjustment to estimate the effect of the intervention distinct from any background changes and independent of other time varying factors. Model validity was bolstered by using a relatively long time series with good temporal resolution. Data from both the main and control sites was derived from the same electronic patient record system. There was a general consensus between main and sensitivity analyses. Our study was limited by being non-randomised, having only one control site, and the follow up period for females being truncated by the impact of the Covid-19 pandemic.