Am J Obstet Gynecol. 2020 Feb 27. pii: S0002-9378(20)30228-3. [Epub ahead of print]
Patient Safety and Quality Committee, Society for Maternal-Fetal Medicine
Congenital heart defects (CHD) are a leading cause of neonatal morbidity and mortality. Accurate prenatal diagnosis of CHD can reduce morbidity and mortality by improving prenatal care, facilitating predelivery pediatric cardiology consultation, and directing delivery to facilities with resources to manage the complex medical and surgical needs of newborns with CHD. Unfortunately, less than one-half of CHD cases are detected prenatally, resulting in lost opportunities for counseling, shared decision-making, and delivery at an appropriate facility. Quality improvement initiatives to improve prenatal CHD detection depend on the ability to measure the rate of detection at the level of providers, facilities, or populations, but no standard metric exists for measuring the detection of CHD at any level. The need for such a metric was recognized at a Cooperative Workshop held at the 2016 Annual Meeting of the Society for Maternal-Fetal Medicine, which recommended the development of a quality metric to assess the rate of prenatal detection of clinically significant CHD. In this paper, we propose potential quality metrics to measure prenatal detection of "critical" CHD, defined as defects with a high rate of morbidity or mortality or that require surgery or tertiary follow-up. One metric is based on a retrospective approach, assessing whether postnatally diagnosed CHD had been identified prenatally. Other metrics are based on a prospective approach, assessing the sensitivity and specificity of prenatal diagnosis of CHD by comparing prenatal ultrasound findings with newborn findings. Potential applications, limitations, challenges, barriers, and value for both approaches are discussed. We conclude that future development of these metrics will depend on an expansion of the International Classification of Diseases (ICD) system to include specific codes that distinguish fetal CHD from newborn CHD and on the development of record systems that facilitate the linkage of fetal records (in the maternal chart) with newborn records.