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1. QA of screening for downs

This document discusses standardizing marker values in first trimester screening to account for factors like gestational age, weight, and ethnicity. It explains that marker levels depend on various characteristics, so converting to multiples of the median (MoM) removes these effects. Any biases or errors in determining gestational age from crown-rump length can significantly impact the standardized MoM values and affect screening accuracy, leading to changes in detection and false positive rates. Precise measurement of crown-rump length is important for obtaining accurate gestational dating and standardizing marker levels.

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WHAT, WHY AND HOW?
WHAT: Some background
Probability Model Age risk model Risk MoM values Marker values (PAPP-A, free  hCG, NT) Gestational age (from CRL) Maternal weight Smoking Ethnicity The process Standardisation
Standardisation Ideally markers should be independent of other variables such as gestation, weight, ethnicity, .. so that interpretation is easy The reality is that marker levels depend, to various degrees, on: • Gestation • Maternal weight • Ethnicity • Smoking status • Multiple pregnancy • IVF • Machine • Laboratory • Reagent lot • etc. We standardise into MoM values to remove the effects of these characteristics. 4
PAPP-A 0 5 10 15 PAPP-A 0 5 10 15 PAPP-A 0 5 10 15 Illustration PAPP-A 11w+3d 12w+3d 13w+3d
PAPP-A 0 5 10 15 PAPP-A 0 5 10 15 PAPP-A 0 5 10 15 11w+3d 12w+3d 13w+3d
PAPP-A 0 5 10 15 0.5 1.0 2.0 PAPP-A 0 5 10 15 0.5 1.0 2.0 PAPP-A 0 5 10 15 0.5 1.0 2.0 11w+3d 12w+3d 13w+3d
PAPP-A MoM 0 1 2 3 4 5 PAPP-A MoM 0 1 2 3 4 5 PAPP-A MoM 0 1 2 3 4 5 MoMs 11w+3d 12w+3d 13w+3d
PAPP-A MoM - log scale 0.1 0.5 1.0 2.0 10.0 PAPP-A MoM - log scale 0.1 0.5 1.0 2.0 10.0 PAPP-A MoM - log scale 0.1 0.5 1.0 2.0 10.0 Log (MoMs) 11w+3d 12w+3d 13w+3d
11w+3d 12w+3d 13w+3d PAPP-A MoM - log scale 0.1 0.5 1.0 2.0 10.0 PAPP-A MoM - log scale 0.1 0.5 1.0 2.0 10.0 PAPP-A MoM - log scale 0.1 0.5 1.0 2.0 10.0
PAPP-A Gestation (days) PAPP-A(iU/l) 50 60 70 80 90 100 0.1 0.2 0.5 1.0 2.0 5.0 Wk 7 Wk 8 Wk 9 Wk 10 Wk 11 Wk 12 Wk 13 Weight (kg) PAPP-AMoM 40 50 60 70 80 90 100 110 120 130 140 150 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 11
Effects on PAPP-A MoM PAPP-A 0.1 0.5 1.0 1.5 2.0 3.0 Trisomy 21 - Wk 11-13 Trisomy 18 Trisomy 13 Afro-Caribbean Asian Oriental Smoking 11 12 13 PAPP-A 12
Free β-hCG (T1) Gestation (days) hCGbeta 50 60 70 80 90 100 5 10 20 30 40 50 60 80 100 150 200 250 Wk 7 Wk 8 Wk 9 Wk 10 Wk 11 Wk 12 Wk 13 Gestation (days) FreebetahCG 100 110 120 130 140 150 5 10 15 20 25 30 Wk 15 Wk 16 Wk 17 Wk 18 Wk 19 Wk 20 Weight (kg) FreebetaMoM 40 50 60 70 80 90 100 110 120 130 140 150 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 Gestation (days) FreebetahCG 100 110 120 130 140 150 5 10 15 20 25 30 Wk 15 Wk 16 Wk 17 Wk 18 Wk 19 Wk 20 13
Free β-hCG (T1) Effects on Free ß-hCG (T1) MoM Free ß-hCG (T1) 0.1 0.5 1.0 1.5 2.0 3.0 Trisomy 21 Trisomy 18 Trisomy 13 Afro-Caribbean Asian Oriental Smoking 11 12 13 14
AFP Weight (kg) AFPMoM 40 50 60 70 80 90 100 120 140 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 Gestation (days) AFP 100 110 120 130 140 150 20 30 40 50 60 70 80 Wk 15 Wk 16 Wk 17 Wk 18 Wk 19 Wk 20 15
AFP Effects on AFP MoM AFP 0.1 0.5 1.0 1.5 2.0 3.0 Trisomy 21 Trisomy 18 Trisomy 13 African Caribbean Chinese Oriental Asian Bangladeshi Indian Pakistani Smoking 16
uE3 Weight (kg) uE3MoM 40 50 60 70 80 90 110 130 150 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 Gestation (days) uE3 100 110 120 130 140 150 1 2 3 4 5 6 7 8 10 15 20 Wk 15 Wk 16 Wk 17 Wk 18 Wk 19 Wk 20 17
Effects on uE3 MoM uE3 0.1 0.5 1.0 1.5 2.0 3.0 Trisomy 21 Trisomy 18 Trisomy 13 African Caribbean Chinese Oriental Asian Bangladeshi Indian Pakistani Smoking uE3 18
hCG Weight (kg) hCGMoM 40 50 60 70 80 90 100 120 140 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 Gestation (days) hCG 100 110 120 130 140 150 10 20 30 40 50 Wk 15 Wk 16 Wk 17 Wk 18 Wk 19 Wk 20 19
hCG Effects on hCG MoM hCG 0.1 0.5 1.0 1.5 2.0 3.0 Trisomy 21 Trisomy 18 Trisomy 13 African Caribbean Chinese Asian Indian Pakistani Smoking 20
Free β-hCG (T2) Weight (kg) FreebetahCGMoM 40 50 60 70 80 90 100 120 140 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 Gestation (days) FreebetahCG 100 110 120 130 140 150 5 10 15 20 25 30 Wk 15 Wk 16 Wk 17 Wk 18 Wk 19 Wk 20 21
Free β-hCG (T2) Effects on Free ß-hCG (T2) MoM Free ß-hCG (T2) 0.1 0.5 1.0 1.5 2.0 3.0 Trisomy 21 African Caribbean Black Other Asian Bangladeshi Indian Pakistani Other Asian Chinese Oriental Smoking 22
Gestation (days) Inhibin 100 110 120 130 140 150 100 150 200 250 300 Weight (kg) InhibinMoM 40 50 60 70 80 90 100 120 140 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 Inhibin 23
Effects on Inhibin MoM Inhibin 0.1 0.5 1.0 1.5 2.0 3.0 Trisomy 21 Asian Caribbean Smoking Inhibin 24
Nuchal Translucency
NT Crown-rump length (mm) Nuchaltranslucency(mm) 45 50 55 60 65 70 75 80 85 0.5 1 2 3 4 5 6 7 8
WHY : the effect of errors on the screening program
Standardisation • MoM values should be centred on 1.0 when viewed together, by gestation, by weight, by smoking status, by ethnicity … • What if this is not true? 28
Inputs and parameter estimates Risk DR/FPR/SPR Process Amplification of errors
Effects of bias – biochemistry (NT and biochemistry at 12 weeks risk cut-off 1 in 150 at term) A 27% increase in SPR with 70 more ‘positive’ results per 10,000 screening tests than expected. PAPP-A hCG β 1 1 2.6% 85% 0.9 1 3.3% 87% 1 0.9 2.0% 83% 1.1 1 2.0% 83% 1 1.1 3.1% 86% 0.9 0.9 2.7% 85% 1.1 1.1 2.4% 84% 0.9 1.1 4.0% 88% 1.1 0.9 1.7% 81% Median MoM FPR (%) DR (%)
The importance of crown rump length
The (near) perfect world of biochemistry Cyprus Gestation (weeks) PAPP-AMoM 7 8 9 10 11 12 13 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 n= 812 n= 4787 n= 4231 n= 1426 n= 311 n= 72 n= 2 Median Standard The median MoM value for any sub- population defined by time period, gestational age, maternal weight, smoking status and ethnicity should lie within 5% of the target value of 1. Median MoM by gestation
Operator hCGbetaMoM ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 0.8 1.0 1.2 n = 2 7 n = 2 9 n = 3 3n = 3 4 n = 3 5 n = 3 7 n = 3 8 n = 4 7 n = 6 6 n = 6 8 n = 7 0 n = 7 5 n = 7 7 n = 7 9 n = 8 0 n = 9 9 n = 1 0 4 n = 1 0 4 n = 1 0 9 n = 1 5 3 n = 1 8 6 OperatorPAPP-AMoM ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 0.8 1.0 1.2 n = 2 7 n = 2 9 n = 3 3 n = 3 4 n = 3 5 n = 3 7 n = 3 8 n = 4 7 n = 6 6 n = 6 8 n = 7 0 n = 7 5 n = 7 7 n = 7 9 n = 8 0 n = 9 9 n = 1 0 4 n = 1 0 4 n = 1 0 9 n = 1 5 3 n = 1 8 6 PAPP-AMoMhCGβMoM Operator Operator
Why operator effects on biochemistry? • Causes include – case mix – sample preparation – storage – transportation – CRL measurement
PAPP-A by gestation Gestation (days) PAPP-A 50 60 70 80 90 100 0.1 0.2 0.5 1.0 2.0 5.0 Wk 7 Wk 8 Wk 9 Wk 10 Wk 11 Wk 12 Wk 13
PAPP-A by gestation Gestation (days) PAPP-A 50 60 70 80 90 100 0.1 0.2 0.5 1.0 2.0 5.0 Wk 7 Wk 8 Wk 9 Wk 10 Wk 11 Wk 12 Wk 13  MoM = 1
PAPP-A by gestation Gestation (days) PAPP-A 50 60 70 80 90 100 0.1 0.2 0.5 1.0 2.0 5.0 Wk 7 Wk 8 Wk 9 Wk 10 Wk 11 Wk 12 Wk 13  MoM = 1  MoM = 0.57
Free β-hCG by gestation Gestation (days) hCGbeta 50 60 70 80 90 100 5 10 20 30 40 50 60 80 100 150 200 250 Wk 7 Wk 8 Wk 9 Wk 10 Wk 11 Wk 12 Wk 13  MoM = 1 MoM =1.2 
Effects of Crown Rump Length (CRL) biases on biochemistry MoM values (NT and biochemistry at 12 weeks risk cut-off 1 in 150 at term) CRL Error Error in GA Median MoM (mm) (days) PAPP-A hCG beta DR FPR -5 -2.7 1.17 0.93 80% 1.4% -4 -2.2 1.13 0.94 81% 1.6% -3 -1.6 1.10 0.96 82% 1.9% -2 -1.1 1.06 0.97 83% 2.0% -1 -0.5 1.03 0.99 84% 2.4% 0 0.0 1.00 1.00 85% 2.7% 1 0.5 0.97 1.01 86% 3.1% 2 1.0 0.94 1.03 86% 3.7% 3 1.6 0.92 1.04 87% 4.1% 4 2.1 0.89 1.06 88% 4.8% 5 2.6 0.87 1.07 89% 5.5% Down’s syndrome presents as biochemical immaturity so effects of errors on PAPP-A and free β-hCG combine.
Crown-rump length (mm) Nuchaltranslucency(mm) 45 50 55 60 65 70 75 80 85 0.5 1 2 3 4 5 6 7 8 Impact of NT on risks
Crown-rump length (mm) Nuchaltranslucency(mm) 45 50 55 60 65 70 75 80 85 0.5 1 2 3 4 5 6 7 8 Impact of NT on risks
Impact of NT on risks Crown-rump length (mm) Nuchaltranslucency(mm) 45 50 55 60 65 70 75 80 85 0.5 1 2 3 4 5 6 7 8
How : DQASS
DQASS • The aim is to monitor and support the quality and effectiveness of screening • Provide feedback on all aspects of the test to laboratories, ultrasound departments and commercial suppliers. • Through meta-analyses DQASS provides information on effects of factors such a smoking that can be used to improve screening performance.
Report production Feedback & advice Improvements Data submissions Lab reports ~40 per year Cycle reports A Two Day Workshop Thursday 17 and Friday 18 January 2008 DQASS Workshop on Standardisation, Monitoring and Updating Medians: Why, When and How? Presented by: Amy Baker Barry Nix Dave Worthington Dave Wright Workshops Individualised feedback to all sonographers on all scan measurements ~20002 (from April 2010) NuchalTranslucency(mm) ID: 49057 (n = 184) Crown-rump length (mm) Cycle 5 From: 16/05/2008 To: 31/10/2008 40 45 50 55 60 65 70 75 80 85 90 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 68(37%) 116(63%) Bias =0.08mm 4NTvalues greaterthan4mmshownas 4mm NuchalTranslucency(mm) ID: 49057 (n = 184) Crown-rump length (mm) Cycle 5 From: 16/05/2008 To: 31/10/2008 40 45 50 55 60 65 70 75 80 85 90 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 68(37%) 116(63%) Bias =0.08mm 4NTvalues greaterthan4mmshownas 4mm NuchalTranslucency(mm) ID: 49057 (n = 184) Crown-rump length (mm) Cycle 5 From: 16/05/2008 To: 31/10/2008 40 45 50 55 60 65 70 75 80 85 90 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 68(37%) 116(63%) Bias =0.08mm 4NTvalues greaterthan4mmshownas 4mm NuchalTranslucency(mm) ID: 49057 (n = 184) Crown-rump length (mm) Cycle 5 From: 16/05/2008 To: 31/10/2008 40 45 50 55 60 65 70 75 80 85 90 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 68(37%) 116(63%) Bias =0.08mm 4NTvalues greaterthan4mmshownas 4mm DQASS
Monitoring SPR
DQASS diagnostics for biochemistry • MoM values should be centred on 1.0 when viewed together, by gestation, by weight, by smoking status, by ethnicity … • Small deviations from this target can have important implications for screening
Gestational age Gestation (weeks) MoMPAPP-A 10 11 12 13 14 0.7 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 n= 28 n= 227 n= 1137 n= 3710 n= 2539 n= 11 Gestation (weeks) MoMPAPP-A 10 11 12 13 14 0.7 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 n= 2066 n= 6793 n= 3234 n= 25 Cycle 2 Cycle 7 48
Maternal weight Weight group MoMFreebeta-hCG <50kg 50-60kg 60-70kg 70-80kg 80-90kg 90-100kg 100-110kg 110-120kg >120kg 0.7 0.8 0.9 1.0 1.1 1.2 1.3 n= 368 n= 1818 n= 2404 n= 1409 n= 706 n= 385 n= 170 n= 88 n= 46 Weight group MoMFreebeta-hCG <50kg 50-60kg 60-70kg 70-80kg 80-90kg 90-100kg 100-110kg 110-120kg >120kg 0.7 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 n=638 n=3043 n=3870 n=2326 n=1211 n=614 n=273 n=136 n=88 Cycle 2 Cycle 7 49
Smoking status Cycle 2 Cycle 7 Smoking status MoMInhibin No Yes 0.7 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 n= 4729 n= 1119 Smoking status MoMInhibin Non-Smoker Smoker 0.7 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 n= 2821 n= 563 50
Ethnicity Cycle 2 Cycle 7 Ethnic origin MoMPAPP-A Caucasian Afro-Caribbean Asian Mixed Oriental 0.7 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 n= 7907 n= 2054 n= 563 n= 373 n= 176 Ethnic origin MoMPAPP-A Caucasian Afro-Caribbean Asian Oriental Other 0.7 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 n=7881 n=1979 n=1608 n=263 n=469 51
CUSUM 52 Time 1 2 3 4 5 6 7 8 9 10 Deviation from target 0 0 0 0 0.5 0.5 0.5 0.5 0.5 0.5 Cumulative sum 0 0 0 0 0.5 1 1.5 2 2.5 3 0 0.5 1 1.5 2 2.5 3 3.5 0 2 4 6 8 10 12 CUSUM Time
Change points A change of -10% was introduced around the middle of September. This is detected relatively quickly. A change of -5% was introduced around the middle of September. This takes longer to detect. 53
CUSUM charts for detecting change points
Diagnostics for NT
NuchalTranslucency(mm) ID: 49057 (n = 184) Crown-rump length (mm) 40 45 50 55 60 65 70 75 80 85 90 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 68 (37%) 116 (63%) 4 NTvalues greaterthan 4mmshownas 4mm Expected relationship with CRL Expected degree of scatter about the curve DQASS Diagnostics: Nuchal Translucency
NuchalTranslucency(mm) ID: Sample (n = 300) Crown-rump length (mm) Cycle From: NA To: NA 40 45 50 55 60 65 70 75 80 85 90 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 152 (51%) 148 (49%) Bias = 0mm
NuchalTranslucency(mm) ID: Sample (n = 300) Crown-rump length (mm) Cycle From: NA To: NA 40 45 50 55 60 65 70 75 80 85 90 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 152 (51%) 148 (49%) Bias = 0mm NuchalTranslucency(mm) ID: Sample (n = 300) Crown-rump length (mm) Cycle From: NA To: NA 40 45 50 55 60 65 70 75 80 85 90 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 287 (96%) 13 (4%) Bias = -0.58mm Bias
NuchalTranslucency(mm) ID: Sample (n = 300) Crown-rump length (mm) Cycle From: NA To: NA 40 45 50 55 60 65 70 75 80 85 90 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 152 (51%) 148 (49%) Bias = 0mm Bias NuchalTranslucency(mm) ID: Sample (n = 300) Crown-rump length (mm) Cycle From: NA To: NA 40 45 50 55 60 65 70 75 80 85 90 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 12 (4%) 288 (96%) Bias = 0.55mm 1 NT value greater than 4mm shown as 4mm
Cycle Reports
Pareto Charts
Sonography
0.0 0.1 0.2 0.3 0.4 0.5 0.6 020406080100 Bias (mm) Proportionoftests 10% of all scans, bias of 0.60mm Illustration (n = 4 sonographers)
0.0 0.1 0.2 0.3 0.4 0.5 0.6 Bias (mm) Proportionoftests Illustration (n = 4 sonographers) 30% of all scans, bias of 0.34mm 020406080100
0.0 0.1 0.2 0.3 0.4 0.5 0.6 020406080100 Bias (mm) Proportionoftests Area = Average bias Illustration (n = 4 sonographers)
0.0 0.1 0.2 0.3 0.4 0.5 0.6 Bias (mm) Proportionoftests Illustration (n = 4 sonographers) 020406080100
0.0 0.1 0.2 0.3 0.4 0.5 0.6 020406080100 Bias (mm) Proportionoftests Illustration (n = 4 sonographers)
Cycle 18
Other outputs from DQASS Parameter estimates for configuring the screening program. Example: Twin effect for Inhibin-A. MoM 1.4 1.6 1.8 2 2.2 2.4 2.6 2.8 3 3.2 3.4 Cycle 18 Cycle 19 Pooled
Thank you!
END OF PRESENTATION
NuchalTranslucency(mm) ID: Sample (n = 300) Crown-rump length (mm) Cycle From: NA To: NA 40 45 50 55 60 65 70 75 80 85 90 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 152 (51%) 148 (49%) Bias = 0mm Spread NuchalTranslucency(mm) ID: Sample (n = 300) Crown-rump length (mm) Cycle From: NA To: NA 40 45 50 55 60 65 70 75 80 85 90 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 159(53%) 141(47%) Bias =-0.01mm Spreaddecreased: 0.43
NuchalTranslucency(mm) ID: Sample (n = 300) Crown-rump length (mm) Cycle From: NA To: NA 40 45 50 55 60 65 70 75 80 85 90 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 152 (51%) 148 (49%) Bias = 0mm Trend NuchalTranslucency(mm) ID: Sample (n = 300) Crown-rump length (mm) Cycle From: NA To: NA 40 45 50 55 60 65 70 75 80 85 90 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 130(43%) 170(57%) Bias =0.09mm Trenddeviation 2NTvalues greaterthan4mmshownas 4mm
NuchalTranslucency(mm) ID: Sample (n = 300) Crown-rump length (mm) Cycle From: NA To: NA 40 45 50 55 60 65 70 75 80 85 90 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 152 (51%) 148 (49%) Bias = 0mm Trend NuchalTranslucency(mm) ID: Sample (n = 300) Crown-rump length (mm) Cycle From: NA To: NA 40 45 50 55 60 65 70 75 80 85 90 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 168 (56%) 132 (44%) Bias = -0.07mm Trend deviation 1 NT value greater than 4mm shown as 4mm
Hospital Summary Report
Hospital Summary Report ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### ##### #####
Hospital Summary Report
Cycle reports
End of cycle reports Cycle 14 report April 2013 to September 2013
Cycle reports for biochemistry- PAPP-A Estimated proportion of median MoMs outside 5% Best Worst DQASS 88 DQASS 99
Cycle reports for NT - National
Cycle reports for NT - Region x
Laboratory throughput
Rationale • Need for sufficient precision to estimate performance (standardised SPR) • To enable monitoring of laboratory medians and early detection of change points • For proficiency/expertise
log(MoM) -50 -40 -30 -20 -10 0 10 20 log(MoM) -50 -40 -30 -20 -10 0 10 20 log(MoM) -50 -40 -30 -20 -10 0 10 20 log(MoM) -50 -40 -30 -20 -10 0 10 20 Sample log(MoM) -50 -40 -30 -20 -10 0 10 20 0 200 400 600 800 1000 Sample log(MoM) -250 -200 -150 -100 -50 0 50 0 2500 5000 5 labs 1,000 samples 1 lab5,000 samples
DQASS • Feedback and support to sonographers laboratories, hospitals and suppliers • Monitoring at the local and national level • A national database: evidence on screening parameters, effects of smoking ethnicity etc
Thank you!
MONITORING PROGRESS REGIONALLY AND NATIONALLY
Laboratory
Cycle by cycle feedback to individual laboratories 0 10 20 30 40 50 60 AFP hCG uE3 Inhibin Estimatedproportion(%)ofMoMvalues outside5% Cycle 1 Cycle 2 Cycle 3
Sonography
0.0 0.1 0.2 0.3 0.4 0.5 0.6 020406080100 Bias (mm) Proportionoftests 10% of all scans, bias of 0.60mm Illustration (n = 4 sonographers)
0.0 0.1 0.2 0.3 0.4 0.5 0.6 Bias (mm) Proportionoftests Illustration (n = 4 sonographers) 30% of all scans, bias of 0.34mm 020406080100
0.0 0.1 0.2 0.3 0.4 0.5 0.6 020406080100 Bias (mm) Proportionoftests Area = Average bias Illustration (n = 4 sonographers)
0.0 0.1 0.2 0.3 0.4 0.5 0.6 Bias (mm) Proportionoftests Illustration (n = 4 sonographers) 020406080100
0.0 0.1 0.2 0.3 0.4 0.5 0.6 020406080100 Bias (mm) Proportionoftests Illustration (n = 4 sonographers)
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0 10 20 30 40 50 60 70 80 90 100 Bias (mm) ProportionofWomenScreened National Cycle 8: Reference Cycle 12: Cycle 11: Cycle 10: Cycle 12: 1841 Sonographers 203601 Scans 1.24% < 25 scans Cycle 11: 1759 Sonographers 188472 Scans 1.37% < 25 scans Cycle 10: 1599 Sonographers 167944 Scans 1.91% < 25 scans 46.92% 42.38% 6.91% 3.79% 57.55% 38.40% 3.29% 0.77% 60.94% 36.39% 2.08% 0.59% DQASS NT-QA
Highlights • Consistency of provision • Evidenced improvement is quality • Improved outcomes
Consistent provision March 2007: SPR 5.9% September 2012: SPR 2.5% Combined 15% Quadruple 9% Triple 48% Double 27% Integrated 1% Combined Quadruple Triple Double Integrated Combined 80% Quadruple 19% Integrated 1%
Cycle Scans (000,s) Sonograhers (n) Green (%) 8 (Apr-Sep 2010) 102 884 35 9 128 1,160 39 10 168 1,599 47 11 188 1,759 58 12 (Apr-Sep 2012) 204 1,841 61 Improving Quality