1 alan fleischman, m.d. senior vice president and medical director october 4, 2011 statewide...

1

Alan Fleischman,

M.D.

Senior Vice President

and Medical Director

October 4, 2011

Statewide strategies to improve birth

outcomes through timely deliveries

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March of Dimes Mission

The mission of the March of Dimes

is to improve the health of babies

by preventing birth defects,

premature birth and infant

mortality.

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March of Dimes From its beginning, the March of Dimes has carried out its mission through research, community intervention programs, education, and advocacy

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Institute of Medicine Report: Preterm Birth: Causes, Consequences, and Prevention, 2006

Preterm birth is a complex, costly and serious public health problem in the U.S.

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Consequences of Preterm Birth

Acute:– Respiratory Distress Syndrome– Cardiovascular Function– Fluid and Electrolyte Balance– Jaundice– Nutrition and Growth– Infection– Necrotizing Enterocolitis– Intraventricular Hemorrhage and

Periventricular Leukomalacia

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Consequences of Preterm Birth

• Long-term:– Chronic Respiratory Problems– Re-hospitalization– Neurodevelopmental Problems

•Cerebral Palsy•Cognitive Deficits•Hearing and Vision Impairment•Autistic Symptomatology

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Institute of Medicine Report: Preterm Birth: Causes, Consequences, and Prevention, 2006

United States cost per year:

$26.2 Billion

Total costs $26.2 Billion

8Thomson Reuters for the March of Dimes, 2009

Average Expenditure for Newborn Care(privately insured through

employer)

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Changing Distribution of Singleton Live Births

United States, 1992, 1997, 2002, 2006

0%

5%

10%

15%

20%

25%

30%

28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44

Gestational Age (weeks)

Perc

en

t

1992 1997 2002 2006

Peak Shifted: 40 to 39 weeks

Source: National Center for Health Statistics, final natality dataPrepared by March of Dimes Perinatal Data Center, 2009

Over 4 million babies born per year

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Accuracy of Gestational Dating(Guidelines for Perinatal Care 6th Edition, October,

2007)

“Management of pregnancy requires establishing an estimated date of delivery.”

An ultrasound examination is most accurate when performed before 20 weeks of gestation– 6-10 weeks +/- 3 days– 10-14 weeks +/- 5 days– 14-20 weeks +/- 7 days- >20 weeks +/- 7-14 days

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Definitions

Weeks of Pregnancy

37

41

Late Preterm

22

Preterm Term

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Definitions

Weeks of Pregnancy

34

37

41

Late Preterm

22

Preterm Term

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Definitions

Weeks of Pregnancy

34 37

39 41

Late Preterm

Early TermFull Term

22

Preterm Term

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Definitions

Weeks of Pregnancy

34 37

39 41

Late Preterm

Early TermFull Term

22

Preterm Term

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Preterm Birth Rates by Gestational Age

U. S., 1990, 2000, 2005-2009*

1.92 1.93 2.03 2.04 2.04 1.99

1.40 1.49 1.60 1.62 1.59 1.57

7.30 8.229.09 9.14 9.03 8.77

0

2

4

6

8

10

12

14

1990 2000 2005 2006 2007 2008 2009*

LPTB (34-36 wks)

32-33 wks

VLBW (<32 wks)

11.610.6

12.712.7 12.812.3 12.2

*2009, provisional -- Source: National Vital Statistics Reports

Percent

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U.S. Preterm Birth Rates

3.3 3.3 3.4 3.5

7.3 7.7 8.2 8.8

0

2

4

6

8

10

12

14

1990 1995 2000 2008

Year

less than 34 weeks Late Preterm (34-36 6/7 weeks)

71% Late

Preterm%

10.611.6

12.311.0

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Risk Factors for Preterm Labor & Delivery

• Groups at highest risk:•History of preterm labor/delivery

•Current multifetal pregnancy•African-American•Non-medically indicated Iatrogenic intervention

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Click to edit Master title style

Click to edit Master subtitle style

Why are non-medically indicated (elective

inductions and scheduled cesarean

deliveries) increasing in frequency?

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Sounds like a good idea… Advanced planning Convenience Delivered by her doctor Maternal intolerance to late

pregnancy Excess edema, backache, indigestion,

insomnia

Prior bad pregnancy And, it’s okay right?

Source: Clinical Obstetrics and Gynecology 2006;49:698-704

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Complications of Non-medically Indicated Deliveries Between 37 and

39 Weeks

*See Toolkit for more data and full list of citationsSource: Clark 2009, Madar 1999, Morrison 1995, Sutton 2001, Hook 1997

Increased NICU admissions (and separation from mother)

Increased respiratory illness--transient tachypnea of the newborn (TTN) and respiratory distress syndrome (RDS)

Increased jaundice and readmissions Increased suspected or proven sepsis Increased newborn feeding problems and

other transition issues

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What Motivates SomeObstetricians?

Physician convenience Guarantee attendance at birth Avoid potential scheduling conflicts Reduce being woken at night

… what’s the harm? Amnesia due to rare occurrence. The NICU can handle it.

And…

Source: Clinical Obstetrics and Gynecology 2006;49:698-704Alan Fleishman21



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Women’s Perceptions Regarding the Safety of Birth at Various

Gestational Ages• When is a baby full term?

• 34-36 weeks is full term 24.0%• 37-38 weeks is full term 50.8%

• What is the earliest point in pregnancy that it is safe to deliver the baby, should there be no other medical complications requiring early delivery? 34-36 weeks 51.7% 37-38 weeks 40.7% 39-40 weeks 7.6%Source: Goldenberg RL, et al. Obstet Gynecol 2009;

114:1254-1258.Alan Fleishman23

American College of Obstetricians and Gynecologists – Practice Bulletin, August, 2009

• No elective induction or elective cesarean delivery before 39 weeks without clinical indication.

• Even a mature fetal lung test result before 39 weeks of gestation, in the absence of appropriate clinical circumstances, is not an indication for delivery.

Source: ACOG Practice Bulletin No. 107, August, 2009

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Eliminate Non-Medically Indicated Deliveries Before 39 Weeks

Available at: marchofdimes.c

omor

cmqcc.org

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Table of Contents

Making the Case Implementation

Strategy Data Collection/QI

Measurement Clinician Education Patient Education Appendices

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Key Change Components Identify Physician

Champion Create (Rewrite)

Hospital Policy Establish

Professional Consensus on: “Indications for Early Delivery”

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Examples of Successful Programs to Reduce Non-medically Indicated

Deliveries Before 39 week of Gestation

Magee Women’s Hospital (Pittsburgh)

Intermountain Healthcare (Utah)Ohio Perinatal Quality

Collaborative (State Department of Health)

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Common Themes

Started with professional education to obstetricians regarding ACOG guidelines and best practices.

Modest change at most, until physicians were held accountable, nurses were empowered, and guidelines were enforced (“Hard stop”).

Medical leadership critically important.

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% Non-medically Indicated Deliveries

<39 Weeks January 1999 – December 2005

Source: Oshiro, B. et al. Obstet Gynecol 2009;113:804-811.Alan Fleishman 31

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Summary: Reasons to Eliminate Non-

medically Indicated Deliveries Before 39 Weeks

• Reduction of neonatal complications• No harm to mother if no medical or

obstetrical indication for delivery• Substantial cost savings• Now a national quality measure:

• National Quality Forum (NQF)• Leapfrog Group• The Joint Commission (TJC)

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The Big 5 States

What are the unique opportunities for the Big 5 States to accomplish something significant...

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Big 5 States - Total

Together, the Big 5 States account for:

Source: National Center for Health Statistics

Births 1,629,521

38.2%

Hispanic Births 665,313 64.0%

Non-Hispanic Black Births 202,823 32.9%

Preterm Births 199,806 36.8%

Late Preterm Births 142,834 36.8%

C-Sections 528,018 40.0%

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Big 5 Hospital NetworkGoal: To eliminate non-medically indicated deliveries <39

weeks in 25 network hospitals by conducting a study of the proof of concept that the toolkit can result in positive change.

A minimum of 5 hospitals from each Big 5 state selected Hospital QI teams carrying out change components

outlined in the toolkit Hospital teams participate on monthly conference calls Baseline data and post-implementation data collected,

analyzed and given back to the hospitals Tools and lessons learned will support a national rollout Network Timeline 9/1/2010 – 12/31/2011

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Toward Improving the Outcome of Pregnancy III:

Enhancing Perinatal Health

Through Quality, Safety,

and Performance

Initiatives

December, 15, 2010

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TIOP III: Table of Contents

Chapter 1: History of the Quality Improvement MovementChapter 2: Evolution of Quality Improvement in Perinatal CareChapter 3: Epidemiologic Trends in Perinatal CareChapter 4: The Role of Patients and Families in Improving Perinatal CareChapter 5: Quality Improvement Opportunities in Preconception and

Interconception CareChapter 6: Quality Improvement Opportunities in Prenatal CareChapter 7: Quality Improvement Opportunities in Intrapartum CareChapter 8: Applying Quality Improvement Principles in Caring for the High Risk InfantChapter 9: Quality Improvement Opportunities in Postpartum CareChapter 10: Quality Improvement Opportunities to Promote Equity in Perinatal Health

OutcomesChapter 11: Systems Change Across the Continuum of CareChapter 12: Policy Dimensions of Systems Change in Perinatal CareChapter 13: Opportunities for Action and Summary of Recommendations

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Patient

Brochures

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Patient

Brochures

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New Media Campaign

Babies aren’t fully developed until at least 39 weeks in the womb…… If your pregnancy is healthy, wait for labor to begin on it’s own.

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New TV PSATelevision public service ad featuring Julie Bowen

(30-seconds)

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Can We Improve Birth Outcomes Through Timely Deliveries?

YES!!!!Alan Fleishman 43

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Thank You!!!

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1 alan fleischman, m.d. senior vice president and medical director october 4, 2011 statewide...

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