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Update neonatal decision tree table with RDS data inputs #1584

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Jan 28, 2025
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Update neonatal decision tree table with RDS data inputs #1584

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03019ce
Update neonatal decision tree inputs with RDS placeholders
Jan 16, 2025
1062750
Make edits based on reviewer feedback
Jan 21, 2025
8657256
Merge branch 'main' into mncnh_neonatal_decision_tree_data
Jan 21, 2025
1c00c51
Update RDS mortality fractions for all 3 locations
Jan 24, 2025
e9a2b14
Merge branch 'main' into mncnh_neonatal_decision_tree_data
pletale Jan 24, 2025
ef99409
Add note about Pakistan RDS paper
Jan 24, 2025
eeb7f06
Merge branch 'mncnh_neonatal_decision_tree_data' of https://github.co…
Jan 24, 2025
f100588
Merge branch 'main' into mncnh_neonatal_decision_tree_data
pletale Jan 27, 2025
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Merge branch 'main' into mncnh_neonatal_decision_tree_data
pletale Jan 28, 2025
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25 changes: 18 additions & 7 deletions docs/source/models/concept_models/vivarium_mncnh_portfolio/concept_model.rst
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Expand Up @@ -380,15 +380,26 @@ V&V Checks:
- XX relative risk on incidence of encephalopathy if birthing parent experiences obstructed labor
- Need to determine how neonatal mortality in general will be modeled and how we will handle overlaps with preterm and LBWSG RR's on all cause mortality
* - 7
- XX% of each type of facility have CPAP or NICU capabilities
-
- Percentage of each facility type that have CPAP capabilities: CMONC - 39.3% and BMONC - 7.5%
- These values are from the 2016 EmONC Final Report and are therefore only reflective of Ethiopian health systems. Please use these as a placeholder for now while we
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try to find reliable values for Nigeria and Pakistan.
* - 8
- XX relative risk on RDS mortality of facility having CPAP or NICU capabilities vs. not
- Need to confirm this will impact mortality not incidence. Also need to determine how neonatal mortality in general will be modeled and how we will handle overlaps with preterm and LBWSG RR's on all cause mortality
- 0.64 (95% CI 0.50-0.82) relative risk on RDS mortality of facility having CPAP capabilities
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@NathanielBlairStahn NathanielBlairStahn Jan 20, 2025 •
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Are you sure 0.64 is the right number? Checking the source, it looks like this was the effect size for reducing "death or use of additional ventilatory support," whereas the RR for "mortality" was 0.53
(95% CI 0.34 to 0.83). Does that look right?

Also, is this the relative risk of "the facility having CPAP capabilities," or is it the relative risk of the neonate actually getting the CPAP intervention? My reading of the Cochrane review was that it's the latter (actually getting the intervention) -- does that seem right? We could potentially model these as different things in our simulation (i.e. a neonate born in a facility with CPAP, but they didn't actually get it), so we want to make sure we know what the number is measuring.

Also, it would be good to know what population this effect size applies to. E.g., was CPAP given to all preterm babies, or just those with RDS? According to the methods section, it says the type of participants were "preterm infants (less than 37 weeks of gestation) with respiratory failure becoming evident soon after birth," so I think it's the latter. We should probably note that somewhere, maybe in the notes column.

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Are you sure 0.64 is the right number? Checking the source, it looks like this was the effect size for reducing "death or use of additional ventilatory support," whereas the RR for "mortality" was 0.53
(95% CI 0.34 to 0.83). Does that look right?

I see also that "Three out of five of these trials were conducted in the 1970s. Therefore, the applicability of these results to current practice is unclear. Further studies in resource‐poor settings should be considered and research to determine the most appropriate pressure level needs to be considered," which make me think all of this is less solid than I would like.

- Need to confirm this will impact mortality not incidence. Also need to determine how neonatal mortality in general will be modeled
and how we will handle overlaps with preterm and LBWSG RR's on all cause mortality. Note that we might want RR for NICU, but this value
is for CPAP capabilities. Source: `2020 Cochrane review <https://pmc.ncbi.nlm.nih.gov/articles/PMC8094155/>`_
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* - 9
- XX relative risk for RDS incidence based on birthing parent receiving antenatal corticosteroids
- Need to confirm this will impact incidence not mortality. Also need to determine how neonatal mortality in general will be modeled and how we will handle overlaps with preterm and LBWSG RR's on all cause mortality

- 0.66 (95% CI 0.56-0.77) relative risk for RDS incidence based on birthing parent receiving antenatal corticosteroids
- This value is for incidence of RDS, however there is also an RR on RDS mortality (0.69, 95% CI 0.59-0.81). Also need to determine how neonatal mortality
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in general will be modeled and how we will handle overlaps with preterm and LBWSG RR's on all cause mortality.
Source: `2017 Cochrane review <https://pubmed.ncbi.nlm.nih.gov/28321847/>`_
* - 10
- Percentage of preterm deaths caused by RDS: Ethiopia - 45.3%; Nigeria - 52.4%; Pakistan - 35.6%
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@NathanielBlairStahn NathanielBlairStahn Jan 21, 2025 •
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I think we have to be careful with these numbers because of how GBD models things. Specifically, I think the percentages listed here tell us

Among all babies who were born preterm and died, what fraction died of RDS?

But what we need for the model is

Among all babies who were born preterm and died of preterm birth complications as defined by GBD, what fraction died of RDS?"

For example, in Table 4 in the Ethiopia paper, I divided the causes of death into two groups:

  • Causes explicitly modeled by GBD (% of deaths):

    • sepsis (26.1%)
    • pneumonia (3.0%, presumed to be captured in the cause "Lower respiratory infections")
    • meningitis (0.8%)
    • congenital anomalies (3.4%)
    • asphyxia (13.6%, presumed to be captured in the cause "Neonatal encephalopathy due to birth asphyxia and trauma)
    • Intraventricular haemorrhage (1.1%, presumed to be captured in GBD's intracerebral and subarachnoid hemorrhage causes, but we should double check that)

  • Causes not explicitly modeled by GBD (% of deaths):

    • respiratory distress syndrome (45.3%)
    • apnoea (1.4%)
    • necrotising enterocolitis (0.8%)
    • others (4.5%)

Assuming the causes in the second category are included in GBD's "Neonatal preterm birth" cause (which we should double-check) and the ones in the first category aren't (which we should also double-check), the fraction of RDS deaths among GBD's preterm birth deaths would be 45.3 / (45.3 + 1.4 + 0.8 + 4.5) = 87.1%. (I think previously I had included intraventricular hemorrhage in the preterm birth cause, which would give 85.3%.)

@aflaxman and @pletale does that seem right?

If so, I think we'll have to do something similar for the other sources.

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Also, would it be better to put these numbers on the preterm birth cause page instead, so that we don't have to duplicate the data?

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Also, would it be better to put these numbers on the preterm birth cause page instead, so that we don't have to duplicate the data?

I think both the numbers and the reasoning behind them (i.e. this calculation that Nathiel wrote out, once Alix has double checked it) should be on the preterm page. I think there is a place in the table for the number already.

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@pletale pletale Jan 24, 2025 •
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I'm struggling to find confirmation of what is included in GBD's neonatal preterm birth complications cause. The neonatal disorders methods appendix doesn't go into those details. Do either of you know where we might be able to confirm what is included? For now, I'll add a note that we need to confirm this.

- Ethiopia source: `Major causes of death in preterm infants in selected hospitals in Ethiopia <https://www.sciencedirect.com/science/article/pii/S2214109X19302207>`_
Nigeria source: `Current Trends in Neonatal Morbidity and Mortality - Experiences from a Tertiary Center in Lagos, Nigeria <https://pmc.ncbi.nlm.nih.gov/articles/PMC9490664/>`_
Pakistan source: `Birth asphyxia is under-rated as a cause of preterm neonatal mortality in low- and middle-income countries <https://obgyn.onlinelibrary.wiley.com/doi/10.1111/1471-0528.17220>`_


.. _inputs_to_neonatal_decision_tree_table:

.. list-table:: Inputs to Neonatal Decision Tree
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