Geographic variation in antenatal steroid use for late preterm births

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A recent study revealed varied adoption rates of antenatal steroids for late preterm births across US regions, despite promising trial results.

Geographic variation in antenatal steroid use for late preterm births | Image Credit: © Tryfonov - © Tryfonov - stock.adobe.com.

Geographic variation in antenatal steroid use for late preterm births | Image Credit: © Tryfonov - © Tryfonov - stock.adobe.com.

There is significant variation in the use of antenatal steroid administration for late preterm births based on geographic location, according to a recent study published in JAMA Network Open.

Takeaways

  1. The study reveals significant regional variation in the use of antenatal steroid administration for late preterm births in the United States.
  2. The Antenatal Late Preterm Steroids (ALPS) trial, conducted in February 2016, resulted in a substantial increase (over 200%) in steroid exposure among US infants born late preterm. However, the practice did not uniformly adopt nationwide.
  3. The study utilized cross-sectional data from the National Center for Health Statistics, focusing on births between November 15, 2022, and January 13, 2023. The analysis was done on a hospital referral region (HRR) level.
  4. Approximately 48.2% of HRRs exhibited fast adoption of late preterm steroid use, while 51.8% were slow adopters. Fast adopters saw a higher increase in steroid use (from 5.9% to 18%) compared to slow adopters (from 3.7% to 9.2%).
  5. Faster adopters tended to have a lower median proportion of patients with postsecondary education, a higher proportion covered by private insurance, and a higher mean rate of patients with a prior preterm birth, suggesting potential socioeconomic influences on adoption rates.

In February 2016, the Antenatal Late Preterm Steroids (ALPS) trial displayed a decreased risk in neonatal respiratory morbidity among high-risk individuals after late preterm administration of antenatal. This led to an over 200% increase in steroid exposure among US infants born late preterm, but it is unclear if this practice was adopted nationwide.

To determine antenatal steroid administration patterns regionally, investigators conducted a cross-sectional study between November 15, 2022, and January 13, 2023. The National Center for Health Statistics provided county-identified US birth certificate data for use in the analysis. 

US birth certificate data included antenatal steroid exposure. This was reported as a binary variable, without specification about the gestational age at administration. 

The period of evidence dissemination was from February to October 2016, the time from when the ALPS trial was published online to when it was included in updated clinical guidance by the American College of Obstetricians and Gynecologists. To analyze variation in late preterm steroid use, data from a 12-month period before and after the dissemination period was also included.

Geographic evaluation occurred on a hospital referral region (HRR) level, with HRR defined by the Dartmouth Atlas Project and regional health care markets. HRR eligibility criteria included over 100 eligible late preterm births in the preperiod and available steroid exposure data for all eligible births.

Eligible births were defined by study authors as, “liveborn, nonanomalous singleton neonates born between 34 and 36 completed weeks of gestation to individuals without pregestational diabetes.” Exclusion criteria included unknown antenatal steroid exposure, no reliable reporting of data elements, and unknown federal information processing system code for location of delivery.

There were 666,097 late preterm births across 282 HRRs included in the final analysis, of which 35.9% were in the preperiod, 27.4% in the dissemination period, and 36.7% in the postperiod. Mothers were aged a mean 27.9 years.

A range from 0% to 47.4% was reported for late preterm steroid use across HRs following publication of the ALPS trial. Significant differences between the expected and reported steroid rate in the postperiod were reported, ranging from 94.8% less than expected to 33.8% more than expected.

Fast adoption was reported in 48.2% of HRRs, while the remaining 51.8% were slow adopters. Steroid use increased from 5.9% in the preperiod to 18% in the postperiod among fast adopters. Among slow adopters, this change was from 3.7% in the preperiod to 9.2% in the postperiod. These increases were 12.1% and 5.5%, respectively.

Among faster adopters, a lower median proportion of patients with postsecondary education experience, a higher proportion of deliveries covered by private insurance, and a higher mean rate of patients with a prior preterm birth were reported.

These results indicated significant variation in late preterm steroid use following publication of the ALPS trial across HRRs. Investigators concluded antenatal steroid exposure in the late preterm period has not been adopted nationwide, and that this information should inform future research on barriers to access.

Reference

Freret TS, Cohen JL, Gyamfi-Bannerman C, et al. Regional variation in antenatal late preterm steroid use following the ALPS trial. JAMA Netw Open. 2024;7(1):e2350830. doi:10.1001/jamanetworkopen.2023.50830

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