An economic evaluation of universal and targeted case-finding strategies for identifying antenatal depression: a model-based analysis comparing common case-finding instruments.

Half of women with depression in the perinatal period are not identified in routine care, and missed cases reflect inequalities in other areas of maternity care. Case finding (screening) for depression in pregnant women may be a cost-effective strategy to improve identification, and targeted case finding directs finite resources towards the greatest need. We compared the cost-effectiveness of three case-finding strategies: no case finding, universal (all pregnant women), and targeted (only pregnant women with risk factors for antenatal depression, i.e. history of anxiety/depression, age < 20 years, and adverse life events). A decision tree model was developed to represent case finding (at around 20 weeks gestation) and subsequent treatment for antenatal depression (up to 40 weeks gestation). Costs include case finding and treatment. Health benefits are measured as quality-adjusted life years (QALYs). The sensitivity and specificity of case-finding instruments and prevalence and severity of antenatal depression were estimated from a cohort study of pregnant women. Other model parameters were derived from published literature and expert consultation. The most cost-effective case-finding strategy was a two-stage strategy comprising the Whooley questions followed by the PHQ-9. The mean costs were £52 (universal), £61 (no case finding), and £62 (targeted case finding). Both case-finding strategies improve health compared with no case finding. Universal case finding is cost-saving. Costs associated with targeted case finding are similar to no case finding, with greater health gains, although targeted case finding is not cost-effective compared with universal case finding. Universal case finding for antenatal depression is cost-saving compared to no case finding and more cost-effective than targeted case finding.

A survey of knowledge and use of telehealth among veterinarians.

BACKGROUND: As usage of digital information and communication technologies continues to grow, the incorporation of telehealth and telemedicine has become a topic of interest in the veterinary industry. Veterinary telemedicine presents the opportunity to expand veterinary medicine by increasing access to healthcare services for clients and patients and improving medical quality. The objective of this study was to assess veterinarians' knowledge and utilization of telehealth and telemedicine. RESULTS: Seventy-six veterinarians participated in the study and both qualitative and quantitative analyses were performed on the data collected. Several key themes emerged from the qualitative analysis of open-ended questions, including telecommunication, Doctor of Veterinary Medicine (DVM)-patient services, and remote interaction, among others. Through coding and qualitative analysis, researchers identified a lack of knowledge of the American Veterinary Medical Association (AVMA) definitions of telehealth and telemedicine. Specifically, a notable amount of participants were unaware of the distinction between the two practices per AVMA guidelines. Quantitative analyses revealed that the largest group of respondents reported sometimes utilizing telehealth and telemedicine in practice, with no distinct difference in utilization among the different age demographics of participants. CONCLUSIONS: These observations indicate a need for interventions both in veterinary school and continuing education programs with the purpose of increasing both knowledge and utilization of telehealth and telemedicine among veterinarians. While these recommendations serve as a starting point, future studies are needed to further enhance the understanding of veterinary telehealth and telemedicine in practice.

Pilot evaluation of a digital approach to occupational therapy home assessments: acceptability and efficiency compared with usual practice in a hospital.

INTRODUCTION: Pre-discharge home assessments by occupational therapists facilitate safe and timely discharge from hospital and are associated with better health outcomes. Digital technology offers the potential to reduce duplication of documentation and improve communication and sharing of home assessment findings. OBJECTIVE: This quality improvement project evaluated time-cost; clinician satisfaction and confidence; and acceptability of the use of a digital approach to home assessments. METHODS: A prospective, cross-sectional design was used to compare usual practice with the digital approach across two sub-acute wards in a large metropolitan hospital in Queensland, Australia. Time to document and conduct home assessments as well as clinician satisfaction and confidence were compared using descriptive statistics. Clinician perspectives about the home assessment approaches were collected through a survey and analyzed using content analysis. RESULTS: Home assessment and documentation time were significantly lower for the home assessments conducted using the digital approach compared with usual practice assessments. Clinician satisfaction with using digital technology was higher. CONCLUSIONS: The introduction of this simple technology reduced clinicians' time to conduct home assessments and document home assessment reports. The project was well received by occupational therapy clinicians. SPANISH ABSTRACT: http://links.lww.com/IJEBH/A187.

Generating EQ-5D-3L health utility scores from the Edinburgh Postnatal Depression Scale: a perinatal mapping study.

BACKGROUND: Perinatal depression (PND) describes depression experienced by parents during pregnancy or in the first year after a baby is born. The EQ-5D instrument (a generic measure of health status) is not often collected in perinatal research, however disease-specific measures, such as the Edinburgh Postnatal Depression Scale (EPDS) are widely used. Mapping can be used to estimate generic health utility index values from disease-specific measures like the EPDS. OBJECTIVE: To develop a mapping algorithm to estimate EQ-5D utility index values from the EPDS. METHODS: Patient-level data from the BaBY PaNDA study (English observational cohort study) provided 1068 observations with paired EPDS and EQ-5D (3-level version; EQ-5D-3L) responses. We compared the performance of six alternative regression model types, each with four specifications of covariates (EPDS score and age: base, squared, and cubed). Model performance (ability to predict utility values) was assessed by ranking mean error, mean absolute error, and root mean square error. Algorithm performance in 3 external datasets was also evaluated. RESULTS: There was moderate correlation between EPDS score and utility values (coefficient: - 0.42). The best performing model type was a two-part model, followed by ordinary least squared. Inclusion of squared and cubed covariates improved model performance. Based on graphs of observed and predicted utility values, the algorithm performed better when utility was above 0.6. CONCLUSIONS: This direct mapping algorithm allows the estimation of health utility values from EPDS scores. The algorithm has good external validity but is likely to perform better in samples with higher health status.

Application of the multi-theory model to explain veterinarians' intentions to use telehealth/telemedicine.

BACKGROUND: Telehealth adoption is being fueled by both technological breakthroughs and societal demands; however, veterinarians have yet to fully embrace the concept of telemedicine, limiting its use and potential benefits. The goal of this study was to evaluate how effective the multi-theory model (MTM) of health behaviour change explains the initiation and sustenance of telehealth use among veterinarians. METHODS: For this cross-sectional study, a research company was contracted to disseminate the MTM-based online survey to veterinarians currently engaged in clinical practice within the United States. RESULTS: A total of 243 veterinarians participated in this study. The most frequently reported age group among participants was 31-40 years (33.7%, n = 82). It was also noted that the majority of participants were female (70.0%, n = 170) and white (76.5%, n = 186). Hierarchical multiple regression showed that participatory dialogue (p = 0.037), species (p = 0.013) and previous monthly telehealth use (p = 0.040) were significant explanatory variables of initiation of telehealth use. Moreover, emotional transformation (p < 0.001) and previous monthly telehealth use (p = 0.035) were significant explanatory variables of sustenance of telehealth use. LIMITATIONS: The data were collected in July 2020, during a global pandemic, in which telehealth use surged across a variety of professions. As a result, the findings of the study may not be relevant in periods when there is no pandemic. CONCLUSIONS: Based on the findings of this study, researchers, educators and veterinary professionals should consider using MTM as theoretical framework to develop interventions to enhance telehealth use.

An economic evaluation of targeted case-finding strategies for identifying postnatal depression: A model-based analysis comparing common case-finding instruments.

BACKGROUND: Half of women with postnatal depression (PND) are not identified in routine care. We aimed to estimate the cost-effectiveness of PND case-finding in women with risk factors for PND. METHODS: A decision tree was developed to represent the one-year costs and health outcomes associated with case-finding and treatment for PND. The sensitivity and specificity of case-finding instruments, and prevalence and severity of PND, for women with ≥1 PND risk factor were estimated from a cohort of postnatal women. Risk factors were history of anxiety/depression, age < 20 years, and adverse life events. Other model parameters were derived from published literature and expert consultation. Case-finding for high-risk women only was compared with no case-finding and universal case-finding. RESULTS: More than half of the cohort had one or more PND risk factor (57.8 %; 95 % CI 52.7 %-62.7 %). The most cost-effective case-finding strategy was the Edinburgh Postnatal Depression Scale with a cut-off of ≥10 (EPDS-10). Among high-risk women, there is a high probability that EPDS-10 case-finding for PND is cost-effective compared to no case-finding (78.5 % at a threshold of £20,000/QALY), with an ICER of £8146/QALY gained. Universal case-finding is even more cost-effective at £2945/QALY gained (versus no case-finding). There is a greater health improvement with universal rather than targeted case-finding. LIMITATIONS: The model includes costs and health benefits for mothers in the first year postpartum, the broader (e.g. families, societal) and long-term impacts are also important. CONCLUSIONS: Universal PND case-finding is more cost-effective than targeted case-finding which itself is more cost-effective than not case-finding.

Experiences and outcomes on the use of telemetry to monitor the fetal heart during labour: findings from a mixed methods study.

BACKGROUND: Wireless continuous electronic fetal monitoring (CEFM) using telemetry offers potential for increased mobility during labour. United Kingdom national recommendations are that telemetry should be offered to all women having CEFM during labour. There is limited contemporary evidence on experiences of telemetry use or impacts it may have. AIM: To gather in-depth knowledge about the experiences of women and midwives using telemetry, and to assess any impact that its use may have on clinical outcomes, mobility in labour, control or satisfaction. METHODS: A convergent parallel mixed-methods study was employed. Grounded theory was adopted for interviews and analysis of 13 midwives, 10 women and 2 partners. Satisfaction, positions during labour and clinical outcome data was analysed from a cohort comparing telemetry (n = 64) with wired CEFM (n = 64). Qualitative and quantitative data were synthesised to give deeper understanding. FINDINGS: Women using telemetry were more mobile and adopted more upright positions during labour. The core category A Sense of Normality encompassed themes of 'Being Free, Being in Control', 'Enabling and Facilitating' and 'Maternity Unit Culture'. Greater mobility resulted in increased feelings of internal and external control and increased perceptions of autonomy, normality and dignity. There was no difference in control or satisfaction between cohort groups. CONCLUSIONS: When CEFM is used during labour, telemetry provides an opportunity to improve experience and support physiological capability. The use of telemetry during labour contributes to humanising birth for women who have CEFM and its use places them at the centre and in control of their birth experience.

Role of ethnicity in high-level obstetric clinical incidents: a review of cases from a large UK NHS maternity unit.

INTRODUCTION: Women from ethnic minority groups are at more risk of adverse outcomes in pregnancy compared with those from white British groups; suboptimal care may contribute to this increased risk. This study aimed to examine serious clinical incidents at two maternity units to explore causative factors for women from ethnic minorities and determine whether these differed from white women. METHODS: A retrospective review was conducted of all serious incidents (n=36) occurring in a large National Health Service maternity provider (~14 000 births per annum) between 2018 and 2020. Data were collected from case records for variables which could mediate the association between ethnicity and adverse outcome. The incident reviews were blinded and reviewed by two independent investigators and data regarding root causes and contributory factors were extracted. RESULTS: Fourteen of the 36 incidents (39%) occurred in women from minority ethnic groups, which is comparable to the maternity population. Women involved in serious clinical incidents frequently had pre-existing medical or obstetric complications. Booking after 12 weeks' gestation occurred more frequently in women from minority ethnic groups than in the background population. There were differences in root causes of serious incidents between groups, a lack of situational awareness was the most frequent cause in white women and staff workload was most frequent in women from minority ethnic groups. Communication issues and detection of deterioration were similar between the two groups. DISCUSSION: Although there was no difference in the proportion of serious incidents between the groups, there were differences in medical and pregnancy-related risk factors between groups and in the root causes identified. Efforts are needed to ensure equity of early access to antenatal care and to ensure that there is adequate staffing to ensure that women's needs are met; this is particularly cogent when there are complex medical or social needs.

The use of continuous foetal monitoring technologies that enable mobility in labour for women with complex pregnancies: A survey of Australian and New Zealand hospitals.

OBJECTIVE: Freedom of movement and choice of positioning in labour and birth is known to enhance physiological processes and positive experiences for women during childbirth. Continuous foetal monitoring technologies that enable mobility in labour for women with complex pregnancies, such as wireless CTG, have been marketed for clinical use in most high resource settings since 2003 but there is a paucity of midwifery literature about its clinical use. The aim of this survey was to determine how often, and for whom, wireless and beltless technologies are being used in maternity settings across Australia and New Zealand and to identify any barriers to their uptake. DESIGN: A survey tool developed by Watson et al. (2018) for use in the United Kingdom was adapted for the Australian/New Zealand context. One Maternity Unit Manager or key midwifery clinician from each of 208 public and private hospitals across Australia and New Zealand was invited by email to participate in an online survey between October 2019 and January 2020. Descriptive statistics were used to describe the characteristics of the facilities and the frequency of availability of the monitors. Free text responses were thematically analysed. FINDINGS: The survey received a high (71%) response rate from a range of public and private hospitals in urban and rural settings. Women's freedom of movement and sense of choice and control in labour were seen by most respondents to be positively influenced by wireless monitoring technology. Most facilities reported having at least one wireless or beltless foetal monitor available, however, results suggest that many women consenting to continuous monitoring still do not have access to technology that enables freedom of movement. KEYCONCLUSIONS: Further research is required to explore the barriers and facilitators to enabling freedom of movement and positioning to all women in childbirth, including those women with complex pregnancies who may consent to continuous foetal monitoring.

Associations among Stress, Anxiety, Depression, and Emotional Intelligence among Veterinary Medicine Students.

Background: Veterinary students are faced with immense pressures and rigors during school. These pressures have contributed to elevated levels of stress, anxiety, and depression (SAD) among veterinary students relative to the general population. One proposed concept to help students combat SAD is that of emotional intelligence (EI). We explored the relationship between EI and SAD among veterinary students at a college in the Southeast United States. Methods: A cross-sectional study design was implemented among a convenience sample of 182 veterinary medical students. The survey instrument contained 56 items that elicited information about students' demographics, perceived stress, anxiety, and depression, and emotional intelligence levels. Data analysis included univariate statistics, Pearson's correlations, and multiple regression and independent samples t-tests. Results: The study revealed a statistically significant, negative correlation between EI levels and stress, anxiety, and depression. Additionally, a statistically significant, positive correlation was found between stress and anxiety as well as both stress and anxiety and depression. Multiple linear regression showed that EI was a statistically significant predictor of stress (b = -0.239, p < 0.001), anxiety (b = -0.044, p < 0.001), and depression (b = -0.063, p < 0.001), after controlling for sociodemographic variables. Students' t-test results revealed a statistically significant mean difference in EI scores among students screening positive versus negative for depression, with students screening negative having a mean EI score of 10.81 points higher than students who screened positive for depression. Conclusion: There is a scientifically supported need for interventions in veterinary school to integrate EI into the veterinary medical curriculum and consider the EI levels of veterinary student candidates.

Value of a modified early obstetric warning system (MEOWS) in managing maternal complications in the peripartum period: an ethnographic study.

OBJECTIVE: To explore implementation of the modified early obstetric warning system (MEOWS) in practice to further understanding about the influence of contextual factors. METHODS: An ethnographic study using observations (>120 h), semi-structured interviews (n=45) and documentary review was performed in the maternity services in two UK hospitals over a 7-month period. Doctors, midwives and managers participated in the study and data were analysed thematically. RESULTS: For women admitted to hospital in the antenatal and postnatal period with an established risk of morbidity, the MEOWS enabled communication about vital signs from junior to senior midwives and obstetricians. The trigger prompts helped shape shared understandings of maternal complications. However, midwifery and obstetric staff questioned the added value of an extra chart in the postnatal period given the low incidence of maternal complications and the resulting increase in workload. In an effort to prioritise workload demands and respond to the immediate needs of both women and their babies, midwives exercised professional discretion regarding its use. However, discretionary use of MEOWS meant the loss of a potential universal safety net for detection of deterioration. CONCLUSIONS: Despite a decade of use in acute settings, research into the effectiveness of early warning systems still yields conflicting results. Widespread policy support for the MEOWS is based on its intuitive appeal and no validated system for use in the maternity population currently exists. Our findings suggest that, while the MEOWS has value in structuring the surveillance of hospitalised women with an established risk of morbidity, the complexities of managing risk and safety within the maternity pathway, the associated opportunity costs of MEOWS and variation in implementation currently call into question its role for routine use.

Women's safety alerts in maternity care: is speaking up enough?

Patients' contributions to safety include speaking up about their perceptions of being at risk. Previous studies have found that dismissive responses from staff discouraged patients from speaking up. A Care Quality Commission investigation of a maternity service where serious incidents occurred found evidence that women had routinely been ignored and left alone in labour. Women using antenatal services hesitated to raise concerns that they felt staff might consider irrelevant. The Birthplace in England programme, which investigated the quality and safety of different places of birth for 'low-risk' women, included a qualitative organisational case study in four NHS Trusts. The authors collected documentary, observational and interview data from March to December 2010 including interviews with 58 postnatal women. A framework approach was combined with inductive analysis using NVivo8 software. Speaking up, defined as insistent and vehement communication when faced with failure by staff to listen and respond, was an unexpected finding mentioned in half the women's interviews. Fourteen women reported raising alerts about safety issues they felt to be urgent. The presence of a partner or relative was a facilitating factor for speaking up. Several women described distress and harm that ensued from staff failing to listen. Women are speaking up, but this is not enough: organisation-focused efforts are required to improve staff response. Further research is needed in maternity services and in acute and general healthcare on the effectiveness of safety-promoting interventions, including real-time patient feedback, patient toolkits and patient-activated rapid response calls.