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The Identification and Validation of Neural Tube Defects in the General Practice Research Database

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The Identification and Validation of Neural Tube Defects in the General Practice Research Database THE IDENTIFICATION AND VALIDATION OF NEURAL TUBE DEFECTS IN THE GENERAL PRACTICE RESEARCH DATABASE Scott T. Devine A dissertation submitted to the faculty of the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the School of Public Health (Epidemiology). Chapel Hill 2007 Approved by Advisor: Suzanne West Reader: Elizabeth Andrews Reader: Patricia Tennis Reader: John Thorp Reader: Andrew Olshan © 2007 Scott T Devine ALL RIGHTS RESERVED - ii- ABSTRACT Scott T. Devine The Identification And Validation Of Neural Tube Defects In The General Practice Research Database (Under the direction of Dr. Suzanne West) Background: Our objectives were to develop an algorithm for the identification of pregnancies in the General Practice Research Database (GPRD) that could be used to study birth outcomes and pregnancy and to determine if the GPRD could be used to identify cases of neural tube defects (NTDs). Methods: We constructed a pregnancy identification algorithm to identify pregnancies in 15 to 45 year old women between January 1, 1987 and September 14, 2004. The algorithm was evaluated for accuracy through a series of alternate analyses and reviews of electronic records. We then created electronic case definitions of anencephaly, encephalocele, meningocele and spina bifida and used them to identify potential NTD cases. We validated cases by querying general practitioners (GPs) via questionnaire. Results: We analyzed 98,922,326 records from 980,474 individuals and identified 255,400 women who had a total of 374,878 pregnancies. There were 271,613 full-term live births, 2,106 pre- or post-term births, 1,191 multi-fetus deliveries, 55,614 spontaneous abortions or miscarriages, 43,264 elective terminations, 7 stillbirths in combination with a live birth, and 1,083 stillbirths or fetal deaths. A marker of pregnancy care was identifiable for 330,153 pregnancies, eighty-four percent of which had data available at least 180 days prior to the first marker of pregnancy care. From the same population of 980,474 individuals, 217 NTD cases were identified. We attempted to validate all 217 NTD cases and 165 GP - iii- questionnaires were returned. We validated a NTD diagnosis for 117 cases, giving our electronic case definitions a positive predictive value of 0.71. The positive predictive value varied by NTD type: 0.81 for anencephaly, 0.83 for cephalocele, 0.64 for meningocele, and 0.47 for spina bifida. Conclusions: We were successful in identifying a large number of pregnancies in the GPRD. Our use of a hierarchical approach to identify pregnancy outcomes builds upon the methods suggested in previous work, while implementing additional steps to minimize potential misclassification of pregnancy outcomes. Our NTD identification algorithm was useful in identifying three of the four types of NTDs studied. Additional information is necessary to accurately identify cases of spina bifida. - iv- DEDICATION To my wife Julie and my son Adam. I could not have done this without their love and support. - v- ACKNOWLEDGEMENTS Thank you to Dr. Suzanne West for her leadership throughout this process. I would like to thank the Center for Education and Research of Therapeutics for their financial support of this project. Thank you to all the members of my dissertation committee for their time and effort for the past four years. Thank you to Susan Eaton from the General Practice Research Database for her guidance through the learning of the nuances of the database. I would also like to thank Dr. Newell McElwee for his support and mentorship throughout my dissertation journey. Finally, I would like to thank Dr. Harry Guess who supported this project from the beginning. - vi- TABLE OF CONTENTS ABSTRACT.................................................................................................................................................iii DEDICATION..............................................................................................................................................v ACKNOWLEDGEMENTS........................................................................................................................vi TABLE OF CONTENTS...........................................................................................................................vii LIST OF TABLES......................................................................................................................................xii LIST OF FIGURES...................................................................................................................................xiv LIST OF ABBREVIATIONS..................................................................................................................xvii Chapter Page I. INTRODUCTION.................................................................................................................................1 II. REVIEW OF THE LITERATURE.....................................................................................................2 A. Neural Tube Defects........................................................................................................................2 1. Biology............................................................................................................................................2 2. The Role Of Folic Acid .................................................................................................................3 3. Genetic Risk Factors ......................................................................................................................7 4. Maternal Factors.............................................................................................................................9 5. Medications ..................................................................................................................................11 6. Other Risk Factors........................................................................................................................13 B. Clinical Definitions........................................................................................................................13 1. Anencephaly .................................................................................................................................14 2. Encephalocele...............................................................................................................................15 3. Spina Bifida And Meningocele ...................................................................................................16 - vii- C. Prenatal Diagnostic And/Or Screening Tests: .............................................................................18 1. Alpha-fetoprotein .........................................................................................................................18 2. Amniocentesis ..............................................................................................................................19 3. Ultrasonography ...........................................................................................................................21 4. Current UK Guidelines For NTD Screening..............................................................................22 D. NTD Monitoring In The UK.........................................................................................................23 1. The National Congenital Anomaly System................................................................................24 2. The European Concerted Action On Congenital Anomalies And Twins.................................25 3. Differences Between NCAS And EUROCAT Systems............................................................26 E. The GPRD ......................................................................................................................................28 1. Introduction ..................................................................................................................................28 2. The Mother-Baby Linkage ..........................................................................................................30 3. Previous Birth Defect Research In The GPRD ..........................................................................32 4. Previous Pregnancy Research Using The GPRD.......................................................................35 III. STATEMENT OF SPECIFIC AIMS ..............................................................................................37 A. Hypotheses .....................................................................................................................................37 B. Rationale.........................................................................................................................................37 C. Research Questions And Specific Aims.......................................................................................41 IV. METHODS .......................................................................................................................................43 A. Overview Of Methods Used..........................................................................................................43 B. Data Used .......................................................................................................................................44 C. Procedure For Pregnancy Identification.......................................................................................47
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