162: How often do physicians follow national guidelines for the diagnosis of hypertensive diseases of pregnancy?

Abstract

The formulation of an accurate diagnosis influences delivery timing, and thus impacts pregnancy outcomes.It remains unclear how often physicians in clinical practice follow our national organization’s diagnostic criteria recommendations for hypertensive diseases of pregnancy (HDP). Our aim was to compare HDP diagnoses made by clinicians to those generated by experts who reviewed charts and adjudicated diagnoses.Further, we reviewed the clinical implications of the diagnoses made on timing of delivery. We conducted a secondary analysis of a multicenter prospective cohort study designed to evaluate serum PlGF in predicting adverse pregnancy outcome in women who presented with signs or symptoms of preeclampsia (PE). The study was performed in 24 centers in the US and Canada. The diagnosis and management criteria used were prior to the Hypertension in Pregnancy Task Force Guidelines publication. We reviewed patients who received the final diagnosis of preeclampsia (mild or severe), atypical preeclampsia, chronic hypertension, gestational hypertension (mild or severe), HELLP, eclampsia and those who remained non hypertensive.We then compared the diagnosis made by managing physicians to that adjudicated by experts who reviewed the charts. We also valuated the impact of asynchronous diagnosis on gestational age at delivery recommendations. 869 patients were included,of which 404 (46%) had a discordant diagnosis between investigator and adjudicators (figure 1). These differences in diagnoses would have affected delivery recommendations for 314 patients. All 31 patients undergoing immediate delivery per the investigator diagnosis, received diagnoses by the adjudicators that did not warrant immediate delivery (figure 2). On the other hand, all 25 patients that had a diagnosis consistent with expectant management by the investigators, would have been delivered earlier based on adjudicated diagnosis. Furthermore 65% of patients with a clinician diagnosis that recommended delivery at 37-39 weeks would have been delivered earlier by the expert adjudicator. The implications of lack of compliance with guideline recommendations for diagnosis and management of HDP amongst clinicians are concerning since they could lead to adverse pregnancy outcome. Future studies are needed to investigate the reasons for non-adherence with guideline recommendations in clinical practice.View Large Image Figure ViewerDownload Hi-res image Download (PPT)