Implementation of a cost-effective strategy to prevent neonatal early-onset group B haemolytic streptococcus disease in the Netherlands

Abstract

BackgroundEarly-onset Group B haemolytic streptococcus infection (EOGBS) is an important cause of neonatal morbidity and mortality in the first week of life. Primary prevention of EOGBS is possible with intra-partum antibiotic prophylaxis (IAP.) Different prevention strategies are used internationally based on identifying pregnant women at risk, either by screening for GBS colonisation and/or by identifying risk factors for EOGBS in pregnancy or labour. A theoretical cost-effectiveness study has shown that a strategy with IAP based on five risk factors (risk-based strategy) or based on a positive screening test in combination with one or more risk factors (combination strategy) was the most cost-effective approach in the Netherlands. IAP for all pregnant women with a positive culture in pregnancy (screening strategy) and treatment in line with the current Dutch guideline (IAP after establishing a positive culture in case of pre-labour rupture of membranes or preterm birth and immediate IAP in case of intra-partum fever, previous sibling with EOGBS or GBS bacteriuria), were not cost-effective. Cost-effectiveness was based on the assumption of 100% adherence to each strategy. However, adherence in daily practice will be lower and therefore have an effect on cost-effectiveness.Method/DesignThe aims are to: a.) implement the current Dutch guideline, the risk-based strategy and the combination strategy in three pilot regions and b.) study the effects of these strategies in daily practice. Regions where all the care providers in maternity care implement the allocated strategy will be randomised. Before the introduction of the strategy, there will be a pre-test (use of the current guideline) involving 105 pregnant women per region. This will be followed by a post-test (use of the allocated strategy) involving 315 women per region. The outcome measures are: 1.) adherence to the specific prevention strategy and the determinants of adherence among care providers and pregnant women, 2.) outcomes in pregnant women and their babies and 3.) the costs of each strategy in relation to the effects.DiscussionThis study will provide recommendations for the implementation of the most cost-effective prevention strategy for EOGBS in the Netherlands on the basis of feasibility in daily practice.Trial registrationDutch Trial Register, NTR3965

A systematic approach to implementing and evaluating clinical guidelines: The results of fifteen years of Preventive Child Health Care guidelines in the Netherlands

“…The framework has been used for the introduction of innovations in a wide range of settings in Dutch health care (Crone et al, 2006;de Veer et al, 2011;M. A. Fleuren et al, 2012;Kolkman et al, 2013;Vlemmix et al, 2010). Fig.…”

Barriers and facilitators related to the uptake of four strategies to prevent neonatal early-onset group B haemolytic streptococcus disease: a qualitative study

“…procedural clarity). Since the study is part of a larger study with the aim to examine the most cost-effective prevention strategy on the basis of both efficacy and feasibility in daily practice [22], the next step is to accommodate these determinants into implementation strategies. Looking at the determinants that are associated with the preventive strategies, we must first clarify some recommendations and provide answers to assumed incorrectness of other recommendations.…”

“…A detailed understanding of these determinants can guide the process of designing implementation strategies that will have the potential to produce actual change [18][19][20]. The aim of this study (part of a larger study that examines the most cost-effective prevention strategy on the basis of efficacy and feasibility in daily practice) is to assess the determinants that will influence the implementation of four preventive strategies for EOGBS among care providers and women [22].…”

Risk‐based approach versus culture‐based screening for identification of group B streptococci among women in labor

“…Guidelines outline two strategies for the identification of women in labor who should be offered intrapartum antibiotic prophylaxis (IAP): the risk‐based approach and the culture‐based screening approach . The Royal College of Obstetricians and Gynaecologists (RCOG) recommend IAP only to women in labor with a risk factor (previous neonate with EOGBS, GBS bacteriuria during the current pregnancy, temperature >38°C, rupture of membranes [ROM] for more than 18 hours, or delivery at less than 37 weeks of pregnancy) claiming that 66% of EOGBS neonates are born to mothers with one or more of these risk factors .…”