Stephen Thung

Impact of a comprehensive patient safety strategy on obstetric adverse events

OBJECTIVE We implemented a comprehensive strategy to track and reduce adverse events. STUDY DESIGN We incrementally introduced multiple patient safety interventions from September 2004 through November 2006 at a university-based obstetrics service. This initiative included outside expert review, protocol standardization, the creation of a patient safety nurse position and patient safety committee, and training in team skills and fetal heart monitoring interpretation. We prospectively tracked 10 obstetrics-specific outcome. The Adverse Outcome Index, an expression of the number of deliveries with at least 1 of the 10 adverse outcomes per total deliveries, was analyzed for trend. RESULTS Our interventions significantly reduced the Adverse Outcome Index (linear regression, r(2) = 0.50; P = .01) (overall mean, 2.50%). Concurrent with these improvements, we saw clinically significant improvements in safety climate as measured by validated safety attitude surveys. CONCLUSION A systematic strategy to decrease obstetric adverse events can have a significant impact on patient safety.

Estrogen Receptor-β, Estrogen Receptor-α, and Progesterone Resistance in Endometriosis

Loss of progesterone signaling in the endometrium may be a causal factor in the development of endometriosis, and progesterone resistance is commonly observed in women with this disease. In endometriotic stromal cells, the levels of progesterone receptor (PR), particularly the PR-B isoform, are significantly decreased, leading to a loss of paracrine signaling. PR deficiency likely underlies the development of progesterone resistance in women with endometriosis who no longer respond to progestin therapy. Here we review the complex epigenetic and transcriptional mechanisms leading to PR deficiency. The initial event may involve deficient methylation of the estrogen receptor (ER)beta promoter resulting in pathologic overexpression of ERbeta in endometriotic stromal cells. We speculate that alterations in the relative levels of ERbeta and ERalpha in endometrial tissue dictate E2-regulated PR expression, such that a decreased ERalpha-tauomicron-ERbeta ratio may result in suppression of PR. In this review, we propose a molecular model that may be responsible for changes in ERbeta and ERalpha leading to PR loss and progesterone resistance in endometriosis.

Universal cervical-length screening to prevent preterm birth: a cost-effectiveness analysis.

To determine whether routine measurement of second‐trimester transvaginal cervical length by ultrasound in low‐risk singleton pregnancies is a cost‐effective strategy.

Screening for Gestational Diabetes Mellitus: Are the Criteria Proposed by the International Association of the Diabetes and Pregnancy Study Groups Cost-Effective?

OBJECTIVE The International Association of the Diabetes and Pregnancy Study Groups (IADPSG) recently recommended new criteria for diagnosing gestational diabetes mellitus (GDM). This study was undertaken to determine whether adopting the IADPSG criteria would be cost-effective, compared with the current standard of care. RESEARCH DESIGN AND METHODS We developed a decision analysis model comparing the cost-utility of three strategies to identify GDM: 1) no screening, 2) current screening practice (1-h 50-g glucose challenge test between 24 and 28 weeks followed by 3-h 100-g glucose tolerance test when indicated), or 3) screening practice proposed by the IADPSG. Assumptions included that 1) women diagnosed with GDM received additional prenatal monitoring, mitigating the risks of preeclampsia, shoulder dystocia, and birth injury; and 2) GDM women had opportunity for intensive postdelivery counseling and behavior modification to reduce future diabetes risks. The primary outcome measure was the incremental cost-effectiveness ratio (ICER). RESULTS Our model demonstrates that the IADPSG recommendations are cost-effective only when postdelivery care reduces diabetes incidence. For every 100,000 women screened, 6,178 quality-adjusted life-years (QALYs) are gained, at a cost of

The cost-effectiveness of universal screening in pregnancy for subclinical hypothyroidism

125,633,826. The ICER for the IADPSG strategy compared with the current standard was

Proteomic Biomarkers of Intra-amniotic Inflammation: Relationship with Funisitis and Early-onset Sepsis in the Premature Neonate

20,336 per QALY gained. When postdelivery care was not accomplished, the IADPSG strategy was no longer cost-effective. These results were robust in sensitivity analyses. CONCLUSIONS The IADPSG recommendation for glucose screening in pregnancy is cost-effective. The model is most sensitive to the likelihood of preventing future diabetes in patients identified with GDM using postdelivery counseling and intervention.

A comprehensive obstetrics patient safety program improves safety climate and culture

OBJECTIVE The purpose of this study was to determine whether routine screening for subclinical hypothyroidism during pregnancy would be cost-effective. STUDY DESIGN We developed a decision analysis model to compare the cost-effectiveness of 2 screening strategies during pregnancy for subclinical hypothyroidism: (1) no routine screening of serum thyroid-stimulating hormone (TSH) levels (standard) and (2) routine screening of TSH levels. In the latter, women with subclinical hypothyroidism received thyroid hormone replacement. We assumed that thyroid hormone replacement could reduce the incidence of an offspring IQ < 85 for pregnancies with subclinical hypothyroidism. The main outcome measure was marginal cost per quality-adjusted life year (QALY) gained. RESULTS Our model predicts that universal screening is the dominant strategy. For every 100,000 pregnant women who were screened,

Multidimensional Proteomics Analysis of Amniotic Fluid to Provide Insight into the Mechanisms of Idiopathic Preterm Birth

8,356,383 are saved, and 589.3 QALYs are gained. When subclinical hypothyroidism prevalence is reduced to 0.25%, screening remains cost-effective at

Accreta complicating complete placenta previa is characterized by reduced systemic levels of vascular endothelial growth factor and by epithelial-to-mesenchymal transition of the invasive trophoblast

21,664/QALY gained. CONCLUSION Screening for subclinical hypothyroidism in pregnancy will be a cost-effective strategy under a wide range of circumstances.

Timing of postpartum intrauterine device placement: a cost-effectiveness analysis

Our goal was to determine the relationship between 4 amniotic fluid (AF) proteomic biomarkers (human neutrophil defensins 2 and 1, calgranulins C and A) characteristic of intra-amniotic inflammation, and funisitis and early-onset sepsis in premature neonates. The mass restricted (MR) score was generated from AF obtained from women in preterm labor (n = 123). The MR score ranged from 0–4 (none to all biomarkers present). Funisitis was graded histologically and interpreted in relation to the MR scores. Neonates (n = 97) were evaluated for early-onset sepsis. There was significant correlation between the severity of AF inflammation and the presence (53/123) and grades of funisitis (p < 0.001). Funisitis occurred independently of the amniocentesis-to-delivery interval or status of the membranes and was best predicted by an MR score 3–4 and an earlier gestational age (GA) at delivery. Neonates born to women with an MR score 3–4 had an increased incidence of suspected/confirmed sepsis, even after adjusting for GA at birth. Calgranulin C had the highest association with clinically significant funisitis, while calgranulin A had the strongest association with early-onset sepsis. To conclude, AF proteomic analysis shows that women with MR scores 3–4 are more likely to have histologic funisitis, and deliver neonates with early-onset sepsis.