PReCePT Devolved Nations Evaluation Report

Executive Summary: This study set out to evaluate the longer term sustainability, effectiveness, and cost effectiveness of the National PReCePT Programme (NPP) in England, and explore trends and MgSO4 guidance implementation practices in the devolved nations, Scotland and Wales. We found that the majority of improvement in MgSO4 use seemed to take place in the first year or two following the NPP. Benefits were largely sustained over the 4 years of follow-up, with an overall appearance of plateau in recent years. There was some indication of a slight declining trend in use coinciding with the COVID-19 pandemic, that continued to the end of 2022 (the end of the currently available data). Regional disparities in use of MgSO4 reduced since the NPP was launched. We estimated that the NPP was associated with around 597,000 GBP net monetary benefit (NMB) from a lifetime societal perspective, with an 89% probability of being cost-effective for babies with less than 30 weeks gestation. This NMB increased to 4.2M GBP when including babies up to 32 weeks gestation. By 2022, MgSO4 use in Wales had caught up with levels in England, with levels in Scotland not far behind. The NMB of implementing MgSO4 for babies up to 32 weeks gestation in the three nations has increased over time, generating approximately 125M GBP in England, 8M GPB in Scotland and 5M GBP in Wales in 2022. Consequently, the benefit forgone for not achieving optimal MgSO4 uptake has also reduced over time, although there remains considerable scope for improving performance in each nation. The improvements in implementing MgSO4 have generated health gains and cost savings associated with CP prevention. Investing additional resources in implementing MgSO4 further would be likely to be cost-effective in all three nations. Our analysis highlighted how devolved nation activities were (directly or indirectly) shaped by PReCePT methodology. Qualitative interviews with clinical leads involved in implementing MgSO4 in Scotland and Wales, where the NPP was not implemented, shed light on the separate but similar initiatives implemented there, explaining the increasing trends also observed in the devolved nations (e.g. the Maternity and Children Quality Improvement Collaborative (MCQIC) Preterm Perinatal Wellbeing Package (PPWP) in Scotland, improvement interventions mirroring PERIPrem in Wales, and British Association for Perinatal Medicine Toolkits in both nations). Challenges and enablers were linked to perinatal team relationships; local leadership with protected time and funding; access to national performance data; staff clarity and confidence on guidance and administration of treatment; opportunities for and commitment to co-creating meaning around the intervention; skills, competencies and resources available to adopters; and engagement in continuous improvement activities (e.g. audit and feedback, benchmarking and missed case reviews). Findings reiterate the need for local champions with backfill funding and protected time, and regional and national capacity building and support structures. These reflect findings from the corresponding interviews with English teams. The essential next step in this quality improvement journey is to better quantify, in this same population, the health and societal benefits associated with cases of cerebral palsy prevented from the improvements achieved in use of MgSO4. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was jointly funded by The Health Foundation (funders reference 557668), the National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West, core NIHR infrastructure funded: NIHR200181), and Health Innovation West of England (formerly the West of England Academic Health Science Network). The views expressed are those of the authors and not necessarily those of NHS England, NHS Improvement, the NIHR or the Department of Health and Social Care. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The PReCePT Programme Evaluation was granted a favourable ethical opinion by the UK National Health Service Health Research Authority (HRA project ID: 260504) and the University of Bristol Faculty of Health Sciences Research Ethics Committee (FREC Ref: 84582). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Anonymised individual-level data for this study are from the NNRD. Our data sharing agreement with the NNRD prohibits sharing data extracts outside of the University of Bristol research team.