Implementation of national guidelines on antenatal magnesium sulfate for neonatal neuroprotection: extended evaluation of the effectiveness and cost-effectiveness of the National PReCePT Programme in England.

Abstract

Since 2015, the National Institute for Health and Care Excellence (NICE) guidelines have recommended antenatal magnesium sulfate (MgSO₄) for mothers in preterm labour (<30 weeks' gestation) to reduce the risk of cerebral palsy (CP) in the preterm baby. However, the implementation of this guideline in clinical practice was slow, and MgSO₄ use varied between maternity units. In 2018, the PRrevention of Cerebral palsy in PreTerm labour (PReCePT) programme, an evidence-based quality improvement (QI) intervention to improve use of MgSO₄, was rolled out across England. Earlier evaluation found this programme to be effective and cost-effective over the first 12 months. We extended the original evaluation to determine the programme's longer-term impact over 4 years, its impact in later preterm births, the impact of the COVID-19 pandemic, and to compare MgSO₄ use in England (where PReCePT was implemented) to Scotland and Wales (where it was not). Quasi-experimental longitudinal study using data from the National Neonatal Research Database on babies born <30 weeks' gestation and admitted to a National Health Service neonatal unit. Primary outcome was the percentage of eligible mothers receiving MgSO₄, aggregated to the national level. Impact of PReCePT on MgSO₄ use was estimated using multivariable linear regression. The net monetary benefit (NMB) of the programme was estimated. MgSO₄ administration rose from 65.8% in 2017 to 85.5% in 2022 in England. PReCePT was associated with a 5.8 percentage points improvement in uptake (95% CI 2.69 to 8.86, p<0.001). Improvement was greater when including older preterm births (<34 weeks' gestation, 8.67 percentage points, 95% CI 6.38 to 10.96, p<0.001). Most gains occurred in the first 2 years following implementation. PReCePT had a NMB of £597 000 with 89% probability of being cost-effective. Following implementation, English uptake appeared to accelerate compared with Scotland and Wales. There was some decline in use coinciding with the onset of the pandemic. The PReCePT QI programme cost-effectively improved use of antenatal MgSO₄, with anticipated benefits to the babies who have been protected from CP.