Document Type
Dissertation
Date of Degree
12-2024
Primary Advisor
Lisa Schwartz, EdD, MS, CGC
Keywords
Recurrent Pregnancy Loss (RPL), Consolidated Framework for Implementation Research (CFIR), Theoretical Domains Framework (TDF), Laboratory Test Utilization
Abstract
Background: More than 50% of patients with recurrent pregnancy loss (RPL) are left without explanations for their losses. However, current research suggests that up to 90% of these individuals could receive explanations through evidence-based laboratory testing. Professional guidelines vary in their recommendations for laboratory testing and RPL evaluation, which can contribute to delayed or fragmented care and untreated maternal disease. Inequities in access to genetic testing further complicate the diagnostic landscape of RPL since payor policies often determine which tests are covered, leaving many patients without access due to financial constraints.
Objective: This study aimed to evaluate current practices of Obstetrician Gynecologist Clinical Providers (OBCPs) in assessing RPL patients, explore factors influencing their behavior regarding laboratory testing, and identify barriers and facilitators in RPL evaluation to inform future care improvements.
Methods: This study was conducted using an explanatory sequential mixed methods design, which included retrospective chart review and semi-structured interviews with OBCPs. The quantitative phase included a retrospective chart review of RPL patients, which were defined as patients with two or more tests for chromosomal analysis of a product of conception (POC), OBCPs were recruited through purposeful and snowball sampling to participate in interviews, which were recorded and transcribed via Microsoft Teams and thematically analyzed via Dedoose software. The Consolidated Framework for Implementation Research (CFIR) and the Theoretical Domains Framework (TDF) served as the foundational conceptual frameworks guiding the interview protocol and thematic analysis.
Results: Charts of 224 RPL patients, were reviewed for the number of RPL-related laboratory tests ordered and categorized as low (one to two tests), medium (three to four tests), and high (five to six tests) evaluations. Most evaluations (113 [50.4%]) fell into the “low” category, 30 (13.4%) fell into the “medium”, and 81 (36.1%) fell into the “high” category. Fifteen interviews with OBCPs provided rich descriptions of their experience in RPL evaluations and revealed that differences in provider specialty and training, guideline preferences, patient influence, and access to laboratory results contributed to the variation in RPL evaluations. The evaluations were subsequently assessed for appropriate utilization; inappropriate utilization accounted for 47.3% (106) of the 224 evaluations, with overutilization (70 [31.3%]) being more prevalent than underutilization (36 [16.1%]).
Discussion: Laboratory testing for RPL evaluation is complex and impacted by the specialization of the provider, practice setting factors, patient influence, laboratory test ordering, access to test results, and laboratory test interpretation. Interventions to improve this process should include implementing protocols for POC collection and RPL laboratory testing and improved coordination among a multidisciplinary team of specialists including clinical laboratory providers. Future research should include the patient experience of this process to understand the barriers and facilitators from their perspective.
Recommended Citation
Grant, Emelia, "Evaluation of the Etiology of Recurrent Pregnancy Loss (RPL): An Explanatory Mixed Methods Study Exploring Obstetrician Gynecologist Clinical Provider Behaviors and Factors Contributing to Incomplete Evaluations" (2024). Doctor of Philosophy in Translational Health Sciences Dissertations. Paper 34.
https://hsrc.himmelfarb.gwu.edu/smhs_crl_dissertations/34
Open Access
1
Comments
©2024 by Emelia Grant. All rights reserved.