Management and Outcomes of Congenital Anomalies in Low-, Middle- and High-Income Countries

Sponsor

King's College London (Other)

Overall Status

Completed

CT.gov ID

NCT03666767

Collaborator

(none)

3,850

Enrollment

Location

16.3

Actual Duration (Months)

236.3

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

This study is a multi-centre, international, prospective cohort study of congenital anomalies to compare outcomes between LMICs and high-income countries (HICs) globally.

Condition or Disease	Intervention/Treatment	Phase
Oesophageal Atresia Congenital Diaphragmatic Hernia Intestinal Atresia Gastroschisis Exomphalos Anorectal Malformation Hirschsprung Disease	Other: Comparisons will be made between LMICs and HICs

Detailed Description

Background: Congenital anomalies have risen to become the 5th leading cause of death in children under 5-years of age globally, yet limited literature exists, particularly from low- and middle-income countries (LMICs) where most of these deaths occur.

Aim: To undertake a multi-centre prospective cohort study of congenital anomalies to compare outcomes between LMICs and high-income countries (HICs) globally.

Methods: The Global PaedSurg Research Collaboration will be established consisting of children's surgical care providers from around the world to participate in the study; collaborators will be co-authors of resulting presentations and publication(s). Data will be collected on patients presenting primarily with seven congenital anomalies (oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation and Hirschsprung's disease) for a minimum of one month between Oct 2018 - April 2019. Anonymous data will be collected on patient demographics, clinical status, interventions and outcome. Data will be captured using the secure, online data collection tool REDCap.

The primary outcome will be all-cause in-hospital mortality and the secondary outcomes will be occurrence of post-operative complications. Chi-squared analysis will be used to compare mortality between LMICs and HICs. Multilevel, multivariate logistic regression analysis will be undertaken to identify patient level and hospital level factors affecting outcomes with adjustment for confounding factors. P<0.05 will be deemed significant. Study approval will be sought from all participating centres. Funding has been granted by the Wellcome Trust.

Outcomes: The study aims to be the first large-scale, geographically comprehensive, multi-centre prospective cohort study of a selection of common congenital anomalies to define current management and outcomes globally. Results will be used to aid advocacy and global health prioritisation and inform future interventional studies aimed at improving outcomes.

Study Design

Study Type:

Observational

Actual Enrollment :

3850 participants

Observational Model:

Cohort

Time Perspective:

Prospective

Official Title:

Management and Outcomes of Congenital Anomalies in Low-, Middle- and High-Income Countries: A Multi-Centre, International, Prospective Cohort Study

Actual Study Start Date :

Oct 1, 2018

Actual Primary Completion Date :

Jun 30, 2019

Actual Study Completion Date :

Feb 9, 2020

Arms and Interventions

Arm	Intervention/Treatment
Oesophageal atresia (OA) +/- tracheo-oesophageal fistula (TOF)	Other: Comparisons will be made between LMICs and HICs Countries will be defined as low, middle or high-income using the World Bank classification.
Congenital diaphragmatic hernia (CDH)	Other: Comparisons will be made between LMICs and HICs Countries will be defined as low, middle or high-income using the World Bank classification.
Intestinal atresia (IA)	Other: Comparisons will be made between LMICs and HICs Countries will be defined as low, middle or high-income using the World Bank classification.
Gastroschisis	Other: Comparisons will be made between LMICs and HICs Countries will be defined as low, middle or high-income using the World Bank classification.
Exomphalos	Other: Comparisons will be made between LMICs and HICs Countries will be defined as low, middle or high-income using the World Bank classification.
Anorectal malformation (ARM)	Other: Comparisons will be made between LMICs and HICs Countries will be defined as low, middle or high-income using the World Bank classification.
Hirschsprung's disease	Other: Comparisons will be made between LMICs and HICs Countries will be defined as low, middle or high-income using the World Bank classification.

Outcome Measures

Primary Outcome Measures

All-cause, in-hospital mortality [Mortality whilst in hospital during primary admission, up to a maximum of 30-days following primary intervention or 30-days following presentation for those who do not receive an intervention and are still in hospital.]
This will include all patients in the study, both those who did not receive an intervention and those that did. For patient's hospitalised for over 30-days following primary intervention, a 30-day post-primary intervention mortality rate will be utilised. For patients who do not receive a primary intervention (conservative generic ward care only) but remain alive and hospitalised at 30-days following primary admission will have this time point used for recording their mortality status for the primary outcome.

Secondary Outcome Measures

Surgical site-infection [Occurring within 30-days of primary intervention]
This is defined by the Centre for Disease Control as including one or more of the following within 30-days of surgery: 1) purulent drainage from the superficial or deep (fascia or muscle) incision, but not within the organ/ space component of the surgical site OR 2) at least two of: pain or tenderness; localised swelling; redness; heat; fever; AND the incision is opened deliberately to manage infection, spontaneously dehisces or the clinician diagnoses a SSI (negative culture swab excludes this criterion) OR 3) there is an abscess within the wound (clinically or radiologically detected).
Wound dehiscence [Occurring within 30-days of primary intervention]
All layers of the wound open post-operatively
Need for re-intervention [Occurring within 30-days of primary intervention]
Need for a second unplanned intervention within 30-days of the primary intervention.
Condition specific complications [Occurring within 30-days of primary intervention]
OA: pneumonia, mediastinitis, pneumothorax, chylothorax, haemothorax, anastomotic leak, anastomotic stricture, recurrent TOF, other. CDH: air leak, chylothorax, recurrence, adhesional obstruction. IA: anastomotic leak/ stenosis, short-gut, missed additional atresia, adhesive bowel obstruction. Gastroschisis: ischaemic bowel, abdominal compartment syndrome, necrotising enterocolitis. Exomphalos: ruptured sac. ARM: electrolyte disturbance, high stoma output (over 20mls/kg/day), stoma prolapse/ retraction/ herniation, peri-stoma skin breakdown (or perianal if primary reconstruction was undertaken without a covering stoma), anal stenosis. Hirschsprung's disease: enterocolitis, electrolyte disturbance, high stoma output (over 20mls/kg/day), stoma prolapse/ retraction/ herniation, peri-stoma skin breakdown (or perianal if primary pull-through was undertaken without covering stoma), anal stenosis, post-operative obstruction, anastomotic leak.
Condition specific outcome variables [Occurring within 30-days of primary intervention]
Oesophageal atresia: time to first oral feed (in days) and time to full oral feeds (in days)
Length of hospital stay [Maximum 30-days post-intervention or following presentation for those who do not receive an intervention]
In days, including the first and last day. Time from admission to death in patients who do not survive.
30-day post primary intervention mortality [Death within 30-days of primary intervention or 30-days of presentation in those who do not receive an intervention]
Ventilation requirement [Occurring within 30-days of primary intervention or admission for those not receiving an intervention]
Need for any ventilation (excluding during anaesthetic for interventions) and duration of ventilation in days
Time to first enteral feed [Occurring within 30-days of primary intervention or admission for those not receiving an intervention]
In days, including the day of the primary intervention and the day when enteral feeds were started.
Time to full enteral feeds [Occurring within 30-days of primary intervention or admission for those not receiving an intervention]
In days, including the day of the primary intervention and the day when full enteral feeds were achieved.
Parenteral nutrition requirement [Occurring within 30-days of primary intervention or admission for those not receiving an intervention]
Need for any parenteral nutrition and total duration of parenteral nutrition in days for those who receive it.

Eligibility Criteria

Criteria

Ages Eligible for Study:

N/A to 16 Years

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

Inclusion Criteria:

Any neonate, infant or child under the age of 16-years, presenting for the first time, with one of the study conditions can be included in the study.
Children who have NOT previously received any surgery for their condition.
Children who have received basic resuscitative and supportive care for their condition at a different healthcare facility and then been transferred to the study centre.
Patients presenting primarily with one of the study conditions who receive palliative care or no care must be included within the study to reflect true outcomes.

Exclusion Criteria:

Any neonate, infant or child with one of the study conditions who has previously received surgery (including a stoma) for their condition
If they have recently received surgery for their condition, were discharged and then represented with a complication of the surgery during the study period they should NOT be included in the study.