Quality of Nuchal Translucency Measurements Correlates with Broader Aspects of Program Rigor and Culture of Excellence

Abstract

Introduction: To determine if nuchal translucency (NT) quality correlates with the extent to which clinics vary in rigor and quality control. Methods: We correlated NT performance quality (bias and precision) of 246,000 patients with two alternative measures of clinic culture - % of cases for whom nasal bone (NB) measurements were performed and % of requisitions correctly filled for race-ethnicity and weight. Results: When requisition errors occurred in <5% of cases, the average MoM (multiple of the median) was 0.97. When >5% (33%), the curve lowered to 0.93 MoM (p < 0.001) with both bias and precision of measurements impaired. Likewise, for centers with NB >90%, MoM was 0.99 compared to those <10% at 0.93 (p < 0.001). Precision and bias were highly correlated (p < 0.001). Conclusions: Rigor in NT measurements has improved, but the discussion has been confined to individuals. Progressive educational and remediation strategies need to expand to a second dimension - clinics themselves. Cross-clinic variation in NT quality exists independent of individual variation in NT quality, and two divergent indices of program rigor are associated with NT quality. Quality control must be program wide, and to effect continued improvement in the quality of NT results across time, the cultures of clinics must become a target for intervention.

United States' experience in nuchal translucency measurement: variation according to provider characteristics in over five million ultrasound examinations

“…The NTQR data have been able to provide a robust, detailed NT referent curve for the majority of the USA population that underwent NT screening over the 15-year period from January 2005 to December 2019, and these data confirm that ongoing assessment of accuracy through a national registry and feedback program has resulted in significant improvement and consistency within this single measured analyte for first-trimester screening, with more than 85% of physicians and sonologists providing consistent measurements within appropriate ranges 9,11,19,24 . Our prior data were limited in terms of our ability to review provider characteristics, but the current, larger dataset shows that those providers with longer duration within the NTQR program, those with a higher annual volume of scans, and those with more NT-credentialed providers at their practice site had greater accuracy of measurement (higher NT median MoM) and greater consistency of measurement (lower SD of log 10 NT MoM).…”

“…This study has provided clear evidence that ongoing quality assessment programs, such as NTQR, can hold large, heterogeneous groups of providers to a tight standard. These programs, therefore, should be considered not just as a model for the maintenance of optimal NT measurement but, in the broader context, as a means of assuring obstetric quality performance and care 24 . While outcome measures of quality (e.g.…”

Resistance to Change

“…We ran the FMF's US program. Multiple papers documented the teaching process, examinations of data to prove quality improvements over time leading to certification, and increasing statistical performance metrics of screening [53][54][55]. Later, the SMFM established its own program.…”

“…Many American physicians and organizations simply refused to accept that any specific training was necessary [45,[53][54][55]. Both ACOG and the Society for Maternal-Fetal Medicine (SMFM) were largely silent for several years.…”