Post-Policy Implementation Review of Rapid Fetal Fibronectin (fFN) Testing for Preterm Labour in Alberta.

OBJECTIVES: In 2006, the Alberta Ministry of Health issued a policy to implement fetal fibronectin (fFN) testing as a publicly funded service for pregnant women. The goals were to reduce maternity health care utilization and unnecessary treatment, which would result in cost-savings for the health system by more accurately diagnosing false preterm labour. We conducted a post-policy implementation review to determine whether the policy implementation achieved its goals. METHODS: We assessed the impacts of fFN testing on clinical decision-making for ambulance transfer, hospital admission, and length of hospital stay by comparing these variables between the tested and untested patients. This post-implementation analysis was conducted separately for inpatients and outpatients and for true and false preterm labour, using multilevel regressions with episodes or visits being nested within patients. We then assessed the impact of fFN testing on costs to the health system by using decision-tree models populated with actual data and results from the regressions. RESULTS: The additional information, provided by fFN testing, influenced clinical decision-making. However, physicians placed a greater significance on positive test results than on negative results, which resulted in an inadvertent increase in health care utilization. After including the costs of fFN testing, the total cost to the system increased by $4.2 million (in 2014 Canadian dollars) between 2008 and 2013, with contributions of $700 000 for false labour and $3.5 million for true preterm labour. CONCLUSION: The policy to adopt fFN testing in Alberta did not achieve the intended aims of reducing unnecessary health care utilization to achieve cost-savings for the health system. There was an inherent tendency to err on the side of caution, and physicians were influenced more by positive test results.

An integrated web-based mental health intervention of assessment-referral-care to reduce stress, anxiety, and depression in hospitalized pregnant women with medically high-risk pregnancies: a feasibility study protocol of hospital-based implementation.

BACKGROUND: At prevalence rates of up to 40%, rates of depression and anxiety among women with medically complex pregnancies are 3 times greater than those in community-based samples of pregnant women. However, mental health care is not a component of routine hospital-based antenatal care for medically high-risk pregnant women. OBJECTIVE: The purpose of this study is to evaluate the effectiveness and feasibility of the hospital-based implementation of a Web-based integrated mental health intervention comprising psychosocial assessment, referral, and cognitive behavioral therapy (CBT) for antenatal inpatients. METHODS: This study is a quasi-experimental design. Pregnant women are eligible to participate if they are (1) <37 weeks gestation, (2) admitted to the antenatal inpatient unit for >72 hours, (3) able to speak and read English or be willing to use a translation service to assist with completion of the questionnaires and intervention, (4) able to complete follow-up email questionnaires, (5) >16 years of age, and (6) not actively suicidal. Women admitted to the unit for induction (eg, <72-hour length of stay) are excluded. A minimum sample of 54 women will be recruited from the antenatal high-risk unit of a large, urban tertiary care hospital. All women will complete a Web-based psychosocial assessment and 6 Web-based CBT modules. Results of the psychosocial assessment will be used by a Web-based clinical decision support system to generate a clinical risk score and clinician prompts to provide recommendations for the best treatment and referral options. The primary outcome is self-reported prenatal depression, anxiety, and stress symptoms at 6-8 weeks postrecruitment. Secondary outcomes are postpartum depression, anxiety, and stress symptoms; self-efficacy; mastery; self-esteem; sleep; relationship quality; coping; resilience; Apgar score; gestational age; birth weight; maternal-infant attachment; infant behavior and development; parenting stress/competence at 3-months postpartum; and intervention cost-effectiveness, efficiency, feasibility, and acceptability. All women will complete email questionnaires at 6-8 weeks postrecruitment and 3-months postpartum. Qualitative interviews with 10-15 health care providers and 15-30 women will provide data on feasibility and acceptability of the intervention. RESULTS: The study was funded in September, 2014 and ethics was approved in November, 2014. Subject recruitment will begin January, 2015 and results are expected in December, 2015. Results of this study will determine (1) the effectiveness of an integrated Web-based prenatal mental health intervention on maternal and infant outcomes and (2) the feasibility of implementation of the intervention on a high-risk antenatal unit. CONCLUSIONS: This study will provide evidence and guidance regarding the implementation of a Web-based mental health program into routine hospital-based care for women with medically high-risk pregnancies.

Automated patient assessments after outpatient surgery using an interactive voice response system.

OBJECTIVE: To test the feasibility and utility of an interactive voice response system (IVRS) for monitoring patients after outpatient surgery. METHODS: We studied consecutive patients undergoing gynecologic day surgery. The IVRS called patients on the first postoperative day and asked them if they were experiencing new problems. Feasibility was assessed in terms of call responses and acceptance by patients. Utility was measured in terms of the ability of the IVRS to identify adverse events (AEs), defined as procedure-related symptoms requiring a physician or hospital visit. We contacted patients 30 days later to elicit their perceptions of the IVRS and determine AE status. RESULTS: Follow-up was complete for 249 of 270 enrolled patients (92%). The IVRS successfully contacted 130 patients (52%). Of the 22 patients (17%) who required a follow-up phone call, 9 had a new problem related to surgery, 7 had new or worsening symptoms, 6 wanted to speak with a nurse, and 1 had a medication-related problem. Patients remembering the automated call (n = 96) reported the system easy to use (82%) and comprehend (86%). Most patients (68%) preferred the IVRS to a personal follow-up call (probability greater than 50%, P <.001). AEs occurred in 40 patients (16%; 95% confidence interval = 12%, 21%). The IVRS did not identify any AEs because 90% of these occurred after the automated call. CONCLUSION: An IVRS-based method of monitoring outpatient surgery patients is feasible. To improve utility, calls must occur later than first postoperative day.