Guidance

Antenatal and newborn blood spot screening: KPI data submission

Published 17 August 2020

Timescales

Q1 (1 April to 30 June)

Time for sense checking and return: 1 September to 30 September

Q2 (1 July to 30 September)

Time for sense checking and return: 1 December to 31 December

Q3 (1 October to 31 December)

Time for sense checking and return: 1 March to 31 March

Q4 (1 January to 31 March)

Time for sense checking and return: 1 June to 30 June

Key performance indicator (KPI) data is submitted one quarter in arrears, except the fetal anomaly screening KPI for ultrasound coverage (FA2) which is 2 quarters in arrears. Data collection must allow for sense checking, sign-off and submission by the deadline. Submissions received after the deadline will appear as a non-submission for that quarter.

Screening commissioners and regional screening quality assurance services (SQAS) work with local screening providers to review KPI data in accordance with locally agreed arrangements prior to submission. Local organisations can contact SQAS (regions) for advice on data collection and submission.

Completing the KPI template

Updated templates are provided every quarter for the submission of KPI data from maternity service providers, child health information services (CHIS) and screening laboratories. The templates ask for the numerator, denominator and commentary for each KPI. The templates for coverage KPIs contain additional fields for:

• exclusion categories
• declines
• individuals to follow up (those eligible who were not screened and did not decline)

By entering the exclusion information, the eligible population (the denominator) is accurately identified so that the calculation of coverage is correct. The declines are not excluded as they are individuals who are eligible for screening, so they are in the denominator but not the numerator. We ask for them separately because they provide important intelligence about the screening pathway and help to identify the remaining individuals to be accounted for.

Screening providers and screening commissioners or SQAS (regions) should use ‘sense checking’ to make sure data is correct according to the national definitions.

Data submissions are reviewed by the national screening data and information team. Data that does not meet the standard definition is not accepted. Data published as a ‘No return’ indicates that a submission was:

• not made
• not complete
• submitted but did not meet the definition of the KPI
• withdrawn by the service

Local commissioners and public health professionals are encouraged to talk to screening services to resolve any data submission issues.

Data sense checking

Generic

1. The template ‘submitted by’ and ‘signed off by’ sections are completed.
2. All numerators are a subset of the denominators. This means there are no performance percentages that are over 100%.
3. The correct maternity, clinical commissioning group (CCG) or laboratory service name from the dropdown list is used.

Antenatal screening coverage KPIs for infectious diseases and sickle cell and thalassemia

1. Data is matched cohort.
2. Exclusions and inclusions are accurately applied.
3. Denominators are the same or, if different, the difference can be explained.
4. Additional commentary is provided where relevant. This usually only applies to women in the ‘left to follow up’ category.
5. Unaccounted women are followed up and the screening safety incident guidance is applied where appropriate.

Timely assessment of women with hepatitis B (KPI ID2)

1. Only includes newly diagnosed hepatitis B positive women or those previously known with high infectivity markers detected in the current pregnancy.
2. Additional commentary is provided where women were not seen within the timeframe.
3. If zero cases in the quarter, the commentary should state ‘no cases’.

Antenatal screening coverage of the fetal anomaly ultrasound (FA2)

1. Data is matched cohort.
2. Exclusions and inclusions are accurately applied, for example women presenting to service after 23 weeks are excluded.
3. Women who had 2 attempts to complete the 18+0 to 20+6 screening scan and the scan is still incomplete should not be counted in the numerator (tested women); these women should appear in the left to follow up category.
4. Additional commentary is provided where relevant. This usually only applies to women in the ‘left to follow up’ category.
5. Unaccounted women are followed up and the screening safety incident guidance is applied where appropriate.

Antenatal screening coverage for T21/T18/T13 (FA3)

1. Data is matched cohort.
2. Exclusions and inclusions are accurately applied, for example women presenting to service ≥ 14+2 weeks (crown rump lengths (CRL) >84.0mm) are excluded. Some women may book and are thought to be < 14+2 weeks by last menstrual period (LMP) but when scanned they are found to be ≥ 14+2 weeks; these women can be excluded if there were no delays in the usual process of booking the dating scan.
3. Additional commentary is provided where relevant. This usually only applies to women in the ‘left to follow up’ category.
4. Unaccounted women are followed up and the screening safety incident guidance is applied where appropriate.

Newborn blood spot screening coverage (KPIs NB1 and NB4)

1. Data is matched cohort.
2. Additional commentary needs to account for all babies who do not have a recorded result at 17 days (NB1) or who do not have a recorded result at 21 calendar days of notifying the CHIS of movement in (NB4).
3. NB1 is based on only babies for whom the CCG was responsible at birth and on the last day of the reporting period. Responsible CCG refers to all babies registered with a GP within the CCG.
4. NB4 is based on the babies who have changed responsible CCG or have moved in from another UK country or abroad, in the reporting period. Responsible CCG refers to all babies registered with a GP within the CCG.
5. For NB4, does the number of babies moving in correlate with what you know about the local population?
6. Unaccounted babies are followed up and the screening safety incident guidance is applied where appropriate.

Quality of the newborn blood spot sample (NB2)

1. The data submitted relates to the maternity service.
2. This indicator is calculated from a low numerator (the number of repeat or further samples requested) and a high denominator (number of first blood spot samples received by the laboratory in the reporting period), and therefore the percentage should be low not high.