Methods to Encourage the Use of Antenatal Corticosteroid Therapy for Fetal Maturation

Abstract

Context Antenatal corticosteroids for fetal maturation have been underused, despite evidence for their benefits in cases of preterm birth. Objective To evaluate dissemination strategies aimed at increasing appropriate use of this therapy. Design and Setting Twenty-seven tertiary care institutions were randomly assigned to either usual dissemination of practice recommendations (n = 14) or usual dissemination plus an active, focused dissemination effort (n = 13). Subjects Obstetricians and their preterm delivery cases at participating hospitals. Intervention Recommendations by a National Institutes of Health (NIH) Consensus Conference held in late February-early March 1994 were disseminated in early May 1994. Usual dissemination was publication of the recommendations and endorsement by the American College of Obstetricians and Gynecologists. Active dissemination was a year-long educational effort led by an influential physician and a nurse coordinator at each facility, consisting of grand rounds, a chart reminder system, group discussion of case scenarios, monitoring, and feedback. Main Outcome Measure Use or nonuse of antenatal corticosteroids was abstracted from medical records of eligible women delivering at the participating hospitals in the 12 months immediately prior to release of the NIH recommendations (average number of records abstracted, 130) and in the 12 months following their release (average number of records abstracted, 122). Results Active dissemination significantly increased the odds of corticosteroid use after the conference. Use increased from 33.0% of eligible patients receiving corticosteroids to 57.6%, or by 75% over baseline, in usual dissemination hospitals. Use increased from 32.9% to 68.3%, or an 108% increase, in active dissemination hospitals. Gestational age and maternal diagnosis affected use of the therapy in complex ways. Conclusion An active, focused dissemination effort increased the effectiveness of usual dissemination methods when combined with key principles to change physician practices.

Promoting antenatal steroid use for fetal maturation: Results from the California Perinatal Quality Care Collaborative

“…To increase antenatal steroid use, these neonatologists acted as change agents within their individual hospitals. Although hospital-based targeting of obstetricians has been shown to improve antenatal steroid use rates, 6,23,24 our study suggests that improvement also can also be accomplished by targeting neonatologists.…”

“…4,5 Two recent trials addressed methods to facilitate translation of perinatal research findings into practice. Leviton et al 6 reported that an active, focused dissemination effort to promote antenatal steroid use significantly increased the effectiveness of usual dissemination methods, but noted "radically" variable initial and response rates. Horbar et al 7 successfully promoted early use of surfactants for preterm infants using a multifaceted QI intervention that included attendance at a 2-day workshop.…”

“…Two previous perinatalneonatal randomized controlled trials reported that "active" dissemination methods were more effective than "usual" (ie, continuing medical education lectures and unfocused diffusion of recommendations, publications, and discussion) methods in changing processes. 6,27 Ferguson et al 28 reported that a low-intensity QI effort consisting of (1) identification of a local opinion leader, (2) notification by call-to-action letters, (3) an evidence basis for the desired practice, (4) comparison of site-specific performance data between regional/national benchmarks, (5) an action plan for QI, and (6) establishment of contact information was effective in raising process measures in coronary artery bypass patients nationally over a range of process use rates that approximates those observed in our trial. The CPQCC strategy represents a composite of program techniques that have been shown to successfully and efficiently influence physician behavior.…”

“…In their antenatal steroid intervention study of 6798 births in 27 tertiary care centers, Leviton et al 6 reported that the rate of clinical chorioamnionitis was approximately 13% to 14% and the rate of imminent delivery (defined as within 2 hours of admission) was 2%, suggesting a theoretic maximum of approximately 85% in 24 -to 34-week pregnancies. Our postintervention average of 86.2% approximates this maximum, and our upper-quartile hospitals all exceeded 90%.…”

The Prevention of Preterm Labour - Corticotropin Releasing Hormone Type 1 Receptors as a Target for Drug Design and Development

“…1,2 Even though tocolytic and corticosteroid techniques have been used to inhibit labour and reduce the consequences of prematurity on the foetus, they have not reduced the rate of preterm birth.…”