ELECTIVE DELIVERY LESS ELECTIVE DELIVERY LESS THAN 39 WEEKS THAN 39 WEEKS

GESTATIONGESTATION

Steven Holt, MD, FACOGSteven Holt, MD, FACOGChair Department of OB/GYN Chair Department of OB/GYN

Rose Medical CenterRose Medical Center2/10/092/10/09

This is not new informationThis is not new information For over 2 decades, ACOG has advocated For over 2 decades, ACOG has advocated

awaiting 39 completed weeks for elective awaiting 39 completed weeks for elective deliveries with accurate dating criteria.deliveries with accurate dating criteria.

We now have good supportive data and We now have good supportive data and national quality organizations like the national quality organizations like the National Quality Forum establishing National Quality Forum establishing measurable standards that organizations measurable standards that organizations and providers will be held toand providers will be held to

Core Measures in Obstetrics and Pediatrics Core Measures in Obstetrics and Pediatrics are just around the cornerare just around the corner

Why Elective Deliveries <39 weeksWhy Elective Deliveries <39 weeks

Patient requestPatient request

1.1. Premium on having “my Doctor/Midwife” Premium on having “my Doctor/Midwife” do my deliverydo my delivery

2.2. May be for convenience. Easier to arrange May be for convenience. Easier to arrange child care, grandma’s arrival to helpchild care, grandma’s arrival to help

3.3. “ “ I DO NOT want to go into labor”I DO NOT want to go into labor”

44. “ It really isn’t dangerous for my baby, is . “ It really isn’t dangerous for my baby, is it?”it?”

Why Elective Deliveries <39 weeksWhy Elective Deliveries <39 weeks Providers schedule Providers schedule 1.1. Ob Provider’s have a special relationship with Ob Provider’s have a special relationship with

their patients and want to do their deliverytheir patients and want to do their delivery2.2. Easier to schedule with call schedule and Easier to schedule with call schedule and

availability in L&Davailability in L&D3.3. Schedule before go into labor. Lower risk of Schedule before go into labor. Lower risk of

scar rupture and would rather not do in the scar rupture and would rather not do in the middle of the night.middle of the night.

4.4. It really doesn’t have any adverse neonatal It really doesn’t have any adverse neonatal effects “in my experience”effects “in my experience”

Historical Perspective:Historical Perspective:

ACOG Technical Bulletin #10, ACOG Technical Bulletin #10, November 1999November 1999

Confirmation of Term GestationConfirmation of Term Gestation Fetal heart tones have been documented for 20 weeks Fetal heart tones have been documented for 20 weeks

by nonelectronic fetoscope or for 30 weeks by doppler.by nonelectronic fetoscope or for 30 weeks by doppler. It has been 36 weeks since a positive serum or urine It has been 36 weeks since a positive serum or urine

human chorionic gonadotropin pregnancy test was human chorionic gonadotropin pregnancy test was performed by a reliable laboratory.performed by a reliable laboratory.

An ultrasound measurement of the crown-rump length, An ultrasound measurement of the crown-rump length, obtained at 6-12 weeks, supports a gestational age of obtained at 6-12 weeks, supports a gestational age of at at least 39 weeksleast 39 weeks..

An ultrasound obtained at 13-20 weeks confirms the An ultrasound obtained at 13-20 weeks confirms the gestational age of gestational age of at least 39 weeksat least 39 weeks determined by determined by clinical history and physical examination.clinical history and physical examination.

Historical Perspective:Historical Perspective:

Focus on Late Preterm InfantsFocus on Late Preterm Infants NQF Perinatal Care Measure Meetings in NQF Perinatal Care Measure Meetings in

Washington, Spring of 2008Washington, Spring of 2008 ACOG Technical Bulletin on Fetal Lung ACOG Technical Bulletin on Fetal Lung

Maturity, Fall 2008Maturity, Fall 2008 Am J Obstet Gynecol, December, 2008 (on Am J Obstet Gynecol, December, 2008 (on

line) “Neonatal and Maternal Outcomes line) “Neonatal and Maternal Outcomes Associated with Elective Term Delivery”Associated with Elective Term Delivery”

New England Journal of Medicine, January, New England Journal of Medicine, January, 2009 “Timing of Elective Repeat Cesarean 2009 “Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes”Delivery at Term and Neonatal Outcomes”

National Quality ForumNational Quality Forum

Established in 1999Established in 1999 President’s Advisory Commission on President’s Advisory Commission on

Consumer Protection and Quality in the Consumer Protection and Quality in the Health Care IndustryHealth Care Industry

NQF recommendations “ will be the primary NQF recommendations “ will be the primary standards used to measure and report on standards used to measure and report on the quality and efficiency of healthcare in the the quality and efficiency of healthcare in the United States.”United States.”

National Quality ForumNational Quality Forum

Joint Commission, Medicare, Medicaid and Joint Commission, Medicare, Medicaid and Private Insurers derive their standards from Private Insurers derive their standards from the NQF endorsed listthe NQF endorsed list

Performance in these areas is being used Performance in these areas is being used and will be used in the future to impact and will be used in the future to impact reimbursement for physicians and hospitalsreimbursement for physicians and hospitals

First measures were established for public First measures were established for public reporting in Obstetrics and Newborn care in reporting in Obstetrics and Newborn care in 20032003

National Quality ForumNational Quality Forum

September 2007 at the request of HCA NQF September 2007 at the request of HCA NQF launched a new effort to establish additional launched a new effort to establish additional voluntary performance measuresvoluntary performance measures

NQF accepted recommendations from NQF accepted recommendations from multiple stakeholders to “measure what multiple stakeholders to “measure what makes a difference” with a focus on makes a difference” with a focus on outcomes, appropriateness, and outcomes, appropriateness, and cost/resource use measures, coupled with cost/resource use measures, coupled with quality measuresquality measures

National Quality ForumNational Quality Forum

33 measures were evaluated by the 33 measures were evaluated by the Perinatal Care Steering CommitteePerinatal Care Steering Committee

18 performance measures were accepted18 performance measures were accepted All NQF measures are fully disclosed All NQF measures are fully disclosed

“available for use by any interested parties”“available for use by any interested parties”

Intellectual Property OwnersIntellectual Property Owners

Agency for Healthcare and Research Quality (AHRQ)Agency for Healthcare and Research Quality (AHRQ) Asian Liver Center at StanfordAsian Liver Center at Stanford California Maternity Quality Care CollaborativeCalifornia Maternity Quality Care Collaborative CDCCDC Child Health Corporation of AmericaChild Health Corporation of America Christiana Care Health ServicesChristiana Care Health Services Council of Women and Infants Specialty Hospitals(CWISH)Council of Women and Infants Specialty Hospitals(CWISH) HCAHCA Massachusetts General HospitalMassachusetts General Hospital National Perinatal Information Center (NPIC)National Perinatal Information Center (NPIC) Providence St. Vincent Medical CenterProvidence St. Vincent Medical Center Vermont OxfordVermont Oxford

NQF National Voluntary Consensus NQF National Voluntary Consensus Standards for Perinatal CareStandards for Perinatal Care

Performance Measure SpecificationsPerformance Measure Specifications

Measure PN-007-07 submitted by HCA- St. Measure PN-007-07 submitted by HCA- St. Marks Perinatal CenterMarks Perinatal Center

Elective Delivery Prior to 39 Completed Elective Delivery Prior to 39 Completed Weeks GestationWeeks Gestation

The Steering Committee unanimously agreed The Steering Committee unanimously agreed that this measure be included as a part of that this measure be included as a part of their recommendationstheir recommendations

NQF National Voluntary Consensus NQF National Voluntary Consensus Standards for Perinatal CareStandards for Perinatal Care

Numerator = Babies from the denominator Numerator = Babies from the denominator electively delivered prior to 39 completed electively delivered prior to 39 completed weeks gestationweeks gestation

Denominator = All singletons delivered at > Denominator = All singletons delivered at > or equal to 37 completed weeks gestationor equal to 37 completed weeks gestation

Data Source - Medical Record reviewData Source - Medical Record review

NQF National Voluntary Consensus NQF National Voluntary Consensus Standards for Perinatal CareStandards for Perinatal Care Exclusions: Many of these are referenced in the Exclusions: Many of these are referenced in the

ACOG Technical Bulletin #10 November, 1999ACOG Technical Bulletin #10 November, 1999 Post-dates (645)Post-dates (645) IUGR (656.5)IUGR (656.5) Oligohydramnios (658.0)Oligohydramnios (658.0) Hypertension (642)Hypertension (642) Maternal Cardiac Disease (648.8)Maternal Cardiac Disease (648.8) Diabetes (648.0)Diabetes (648.0) Previous Stillbirth (648.5)Previous Stillbirth (648.5) Placental Abruption (648.6)Placental Abruption (648.6) Maternal Renal Disease (646.7 & 646.0)Maternal Renal Disease (646.7 & 646.0) Placenta Previa (641)Placenta Previa (641) Multiple gestation (652)Multiple gestation (652) Isoimmunization (656.2)Isoimmunization (656.2) Maternal Coagulopathy (656.4)Maternal Coagulopathy (656.4) Fetal Demise (657)Fetal Demise (657) Ruptured Membranes (649.3)Ruptured Membranes (649.3) Hydramnios (658.1)Hydramnios (658.1) Acute Fatty Liver of Pregnancy (656.1) Malpresentation (656.1)Acute Fatty Liver of Pregnancy (656.1) Malpresentation (656.1) Unspecified Antenatal Hemorrhage (646.2)Unspecified Antenatal Hemorrhage (646.2)

HCA 2007 StudyHCA 2007 Study

Hospital Corporation of America – Hospital Corporation of America – 114 obstetric facilities in 21 states. 114 obstetric facilities in 21 states.

225,000 annual deliveries.225,000 annual deliveries.

HCA 2007 studyHCA 2007 study

Population sampled: All deliveries between Population sampled: All deliveries between May 1, 2007 and July 31, 2007 in 27 facilities May 1, 2007 and July 31, 2007 in 27 facilities in 14 states. (Included three Virginia in 14 states. (Included three Virginia hospitals and one Colorado hospital.)hospitals and one Colorado hospital.)

Facilities chosen to be representative of Facilities chosen to be representative of entire population – geographic and delivery entire population – geographic and delivery volume.volume.

Comprehensive data collection for all women Comprehensive data collection for all women undergoing planned delivery at 37 weeks and undergoing planned delivery at 37 weeks and 0 days or greater.0 days or greater.

MethodsMethods

Planned deliveryPlanned delivery = patient entered hospital for = patient entered hospital for delivery admission not in labor, or with ruptured delivery admission not in labor, or with ruptured membranes.membranes.

Planned deliveriesPlanned deliveries = indicated + elective. = indicated + elective.

IndicatedIndicated = any indication noted by the = any indication noted by the admitting physician or by the nurse providing OB admitting physician or by the nurse providing OB care.care.

Indications tallied, but not questionedIndications tallied, but not questioned

MethodsMethods

Probably more elective deliveries than Probably more elective deliveries than claimed because on spurious indications, claimed because on spurious indications, there was no questioning done. there was no questioning done.

For example:For example: If a patient was listed as If a patient was listed as having hypertension, but the admitting BP having hypertension, but the admitting BP was 120/60, the patient was listed as was 120/60, the patient was listed as having a medical reason for the planned having a medical reason for the planned delivery and was not listed in the delivery and was not listed in the “elective” group.“elective” group.

ResultsResults

17,794 deliveries17,794 deliveries 14,955 at 37 weeks or greater14,955 at 37 weeks or greater 6,562 were planned term deliveries 44% of term deliveries 6,562 were planned term deliveries 44% of term deliveries

37% of all deliveries37% of all deliveries 4,645 were elective planned term deliveries 71% of 4,645 were elective planned term deliveries 71% of

planned term deliveriesplanned term deliveries

31% of all term deliveries were elective31% of all term deliveries were elective 16% of all deliveries were elective inductions of labor 16% of all deliveries were elective inductions of labor 11% of all term deliveries were elective and prior to 39 11% of all term deliveries were elective and prior to 39

completed weeks gestationcompleted weeks gestation

NICU Admissions following Elective NICU Admissions following Elective DeliveryDelivery

37.0 – 37.6 weeks: 17.8% 241 deliveries 43 NICU admissions37.0 – 37.6 weeks: 17.8% 241 deliveries 43 NICU admissions 38.0 – 38.6 weeks: 8.2% 1471 patients 118 NICU admissions38.0 – 38.6 weeks: 8.2% 1471 patients 118 NICU admissions >> 39 weeks: 4.6% 2933 deliveries 135 NICU admissions 39 weeks: 4.6% 2933 deliveries 135 NICU admissions

All differences highly significant (p<0.001)All differences highly significant (p<0.001)

2/3 were direct NICU admits, 1/3 were admitted later after initial normal 2/3 were direct NICU admits, 1/3 were admitted later after initial normal newborn admission.newborn admission.– As a note, the delivery provider may not realize the baby went to the NICU As a note, the delivery provider may not realize the baby went to the NICU

after the initial admission.after the initial admission.

Mean NICU stay for these infants was 4.5 days.Mean NICU stay for these infants was 4.5 days.

Planned Inductions and C-Section Planned Inductions and C-Section RatesRates

0 1 2 3 4 50

10

20

30

40

50

60

Ce

sa

rea

n S

ectio

n R

ate

(%

)

Cervical Dilatation at the time of Induction (cm)

Nulliparous Multiparous

ConclusionsConclusions 11% of all term deliveries are elective and performed prior to 39 weeks 11% of all term deliveries are elective and performed prior to 39 weeks

gestation, against longstanding ACOG/AAP recommendations.gestation, against longstanding ACOG/AAP recommendations.

Given the nature of many “indications”, the actual rate is probably Given the nature of many “indications”, the actual rate is probably higher.higher.

Such infants experience significant morbidity.Such infants experience significant morbidity.

For all Planned Inductions, the cesarean delivery rate is directly related For all Planned Inductions, the cesarean delivery rate is directly related to initial cervical dilatation.to initial cervical dilatation.

Elective induction of labor with an unfavorable cervix also increases Elective induction of labor with an unfavorable cervix also increases the risk of cesarean delivery.the risk of cesarean delivery.

NEJM January 8,2009NEJM January 8,2009

Timing of Elective Repeat Timing of Elective Repeat Cesarean Delivery at Term and Cesarean Delivery at Term and

Neonatal OutcomesNeonatal Outcomes

NEJM January 8,2009NEJM January 8,2009

Consecutive patients undergoing Repeat C-Consecutive patients undergoing Repeat C-Sections at 19 Centers of the Eunice Kennedy Sections at 19 Centers of the Eunice Kennedy Shriver NICHHD MFM Units Network from 1999-Shriver NICHHD MFM Units Network from 1999-20022002

Viable singleton pregnancies without any Viable singleton pregnancies without any recognized indications for delivery before 39 recognized indications for delivery before 39 weeks gestationweeks gestation

Primary outcomes measured composite of Primary outcomes measured composite of Neonatal Death and several adverse neonatal Neonatal Death and several adverse neonatal outcomes outcomes

Primary Adverse Neonatal Primary Adverse Neonatal OutcomesOutcomes

RDS and TTNRDS and TTN HypoglycemiaHypoglycemia Newborn SepsisNewborn Sepsis NEC (0)NEC (0) Hypoxic Ischemic Encephalopathy (0)Hypoxic Ischemic Encephalopathy (0) CPR or Ventilator in first 24 hoursCPR or Ventilator in first 24 hours pH <7.0 5 min APGAR<3pH <7.0 5 min APGAR<3 NICU admissionNICU admission Prolonged Hospitalization 5 days or longerProlonged Hospitalization 5 days or longer Neonatal f/u to discharge or 120 days of lifeNeonatal f/u to discharge or 120 days of life

NEJM January 8,2009NEJM January 8,2009

24,077 Repeat C-Sections at term 13,258 were 24,077 Repeat C-Sections at term 13,258 were electiveelective

In addition to the NQF exclusions also excluded In addition to the NQF exclusions also excluded patients in labor or attempted induction, +HIV, patients in labor or attempted induction, +HIV, history of myomectomy, connective tissue history of myomectomy, connective tissue disorder, previous classical, vertical, T, J, or disorder, previous classical, vertical, T, J, or unknown uterine incision, genital herpes, unknown uterine incision, genital herpes, suspected macrosomia, major malformations, suspected macrosomia, major malformations, chorioamnionitis and 1.7% “other”chorioamnionitis and 1.7% “other”

Demographics <39 weeksDemographics <39 weeks

Patients tended to be olderPatients tended to be older Lower BMI at time of deliveryLower BMI at time of delivery Have Private InsuranceHave Private Insurance WhiteWhite MarriedMarried Early ultrasound for dating in 1Early ultrasound for dating in 1stst or 2 or 2ndnd

trimestertrimester

Weeks Gestation at Elective CSWeeks Gestation at Elective CS

6.3% at 37 completed weeks6.3% at 37 completed weeks 29.5% at 38 completed weeks29.5% at 38 completed weeks 49.1% at 39 completed weeks49.1% at 39 completed weeks 15.1% at 40 weeks15.1% at 40 weeks 35.8% OF THE ELECTIVE REPEAT C-35.8% OF THE ELECTIVE REPEAT C-

SECTIONS WERE PERFORMED BEFORE SECTIONS WERE PERFORMED BEFORE 39 WEEKS39 WEEKS

Primary Adverse Outcome by GAPrimary Adverse Outcome by GA

15.3% at 37 weeks15.3% at 37 weeks 11% at 38 weeks11% at 38 weeks 8.0% at 39 weeks8.0% at 39 weeks P values <.01P values <.01 Similar statistically significant trend for any Similar statistically significant trend for any

individual adverse outcomeindividual adverse outcome >40 weeks had statistically significant increased >40 weeks had statistically significant increased

adverse outcome compared to 39 weeksadverse outcome compared to 39 weeks

38 and 4 to 38 and 638 and 4 to 38 and 6

The risk of primary adverse outcome during The risk of primary adverse outcome during the last 3 days of 38 completed weeks was the last 3 days of 38 completed weeks was

significantly higher than that for deliveries at significantly higher than that for deliveries at 39 completed weeks39 completed weeks

ConfoundersConfounders

IUGR was not an exclusion-results same when IUGR was not an exclusion-results same when data rerun with <2500g neonates excludeddata rerun with <2500g neonates excluded

There is a risk of fetal death awaiting 39 There is a risk of fetal death awaiting 39 weeks-”estimated” at 1 in 1000.weeks-”estimated” at 1 in 1000.

Commentary “Deliveries that occurred before Commentary “Deliveries that occurred before 39 weeks of gestation but after positive results 39 weeks of gestation but after positive results of tests of lung maturity would not be considered of tests of lung maturity would not be considered inappropriately early” NO INFORMATION IN inappropriately early” NO INFORMATION IN STUDY REGARDING AMNIO RESULTSSTUDY REGARDING AMNIO RESULTS

Zanardo, et al. Acta Paediatr 2004Zanardo, et al. Acta Paediatr 2004

Retrospective study of 1284 elective C-Retrospective study of 1284 elective C-Sections RDS rate 25/1000 live births Sections RDS rate 25/1000 live births between 37 and 0 and 38 and 6between 37 and 0 and 38 and 6

RDS rate after 39 and 0 in this study was RDS rate after 39 and 0 in this study was 7/1000 a significantly lower incidence7/1000 a significantly lower incidence

Neonatal RDS with vaginal deliveries in this Neonatal RDS with vaginal deliveries in this study did not vary (3-4/1000) across these study did not vary (3-4/1000) across these gestational agesgestational ages

Fetal Lung Maturity TestingFetal Lung Maturity Testing

ACOG Practice Bulletin Number 97, ACOG Practice Bulletin Number 97, September 2008September 2008

““Fetal pulmonary maturity should be confirmed Fetal pulmonary maturity should be confirmed at less than 39 weeks of gestation unless fetal at less than 39 weeks of gestation unless fetal maturity can be inferred from historic criteria”maturity can be inferred from historic criteria”

Probability of RDS is dependent on both the Probability of RDS is dependent on both the fetal lung maturity test result and the fetal lung maturity test result and the gestational age at which the fetal lung maturity gestational age at which the fetal lung maturity test was performed test was performed

Fetal Lung MaturityFetal Lung Maturity

ACOG Practice Bulletin Number 97, September ACOG Practice Bulletin Number 97, September 20082008

“ “ Testing for fetal lung maturity should not be Testing for fetal lung maturity should not be performed, and is contraindicated, when delivery performed, and is contraindicated, when delivery is mandated for fetal or maternal indications. is mandated for fetal or maternal indications. Conversely, a mature fetal lung maturity test Conversely, a mature fetal lung maturity test result before 39 weeks of gestation, in the result before 39 weeks of gestation, in the absence of appropriate clinical circumstances is absence of appropriate clinical circumstances is not an indication for delivery. RDS, IVH, NEC, not an indication for delivery. RDS, IVH, NEC, and other complications have been reported in and other complications have been reported in premature newborns delivered with mature L/S premature newborns delivered with mature L/S ratios or the presence of PG”ratios or the presence of PG”

Fetal Lung MaturityFetal Lung Maturity Complications from 3Complications from 3rdrd trimester amniocentesis for trimester amniocentesis for

FLM are uncommon with ultrasound guidanceFLM are uncommon with ultrasound guidance 562 amnios for FLM resulted in a 0.7% 562 amnios for FLM resulted in a 0.7%

complication rate PROM, PTL, Abruption and fetal-complication rate PROM, PTL, Abruption and fetal-maternal hemorrhage-one of each. None required maternal hemorrhage-one of each. None required urgent deliveryurgent delivery

913 amnios for FLM urgent delivery in 6 patients 913 amnios for FLM urgent delivery in 6 patients 0.7% 3 FHT problems, one each of placental 0.7% 3 FHT problems, one each of placental bleeding, abruption and uterine rupturebleeding, abruption and uterine rupture

Indications for AmniocentesisIndications for AmniocentesisTechnical Bulletin #97, Sept 2008Technical Bulletin #97, Sept 2008

Twins at 37 and 0 to 37 and 6 without other Twins at 37 and 0 to 37 and 6 without other indications for deliveryindications for delivery

Diabetics with poor glycemic control if Diabetics with poor glycemic control if delivery is contemplated at <39 completed delivery is contemplated at <39 completed weeksweeks

““It has been suggested” in well controlled It has been suggested” in well controlled diabetics “rare risk” of RDS at 38 weeks and diabetics “rare risk” of RDS at 38 weeks and amniocentesis not needed- Level III amniocentesis not needed- Level III evidence “expert opinion” evidence “expert opinion”

Other Indications for Amniocentesis Other Indications for Amniocentesis or <39 week delivery exclusionsor <39 week delivery exclusions

Expanded list from the NEJM study including Expanded list from the NEJM study including full thickness surgery in the upper uterine full thickness surgery in the upper uterine segment, T,J or unknown uterine incisionssegment, T,J or unknown uterine incisions

Other Medical and Surgical conditions Other Medical and Surgical conditions LGMD, HIV, Major Congenital Malformations, LGMD, HIV, Major Congenital Malformations, genital herpesgenital herpes

Logistical reasons-risk of rapid labor, distance Logistical reasons-risk of rapid labor, distance from the hospital or “psychosocial” indicationsfrom the hospital or “psychosocial” indications

? OTHER INDICATIONS? OTHER INDICATIONS

Advanced cervical dilation Advanced cervical dilation Footling breech presentationFootling breech presentation Husband leaving for Iraq at 38 weeks and 4 Husband leaving for Iraq at 38 weeks and 4

daysdays She wants you to do her Section and you She wants you to do her Section and you

are on vacation at 39 weeks or not on callare on vacation at 39 weeks or not on call Grandma just bought a plane ticket and has Grandma just bought a plane ticket and has

to go home at 39 completed weeks. to go home at 39 completed weeks.

So what do we doSo what do we do

Ignore national data driven guidelinesIgnore national data driven guidelines Prohibit the behavior-some institutions are Prohibit the behavior-some institutions are

taking this approach with implementation of taking this approach with implementation of strict Policiesstrict Policies

Don’t forget- Anthem BC/BS and United Don’t forget- Anthem BC/BS and United Health Care sees the same NICU data we Health Care sees the same NICU data we do and it costs them lots of money. do and it costs them lots of money.

What is happening in other HCA Hospitals?What is happening in other HCA Hospitals?

39 Week Elective Deliveries in HCA 39 Week Elective Deliveries in HCA InstitutionsInstitutions

Greater than 30 perinatal services have Greater than 30 perinatal services have implemented a policy.implemented a policy.

40 perinatal services are somewhere in the 40 perinatal services are somewhere in the process of implementationprocess of implementation

Other perinatal services are just beginning Other perinatal services are just beginning discussionsdiscussions

Do what works best for your institution, your Do what works best for your institution, your practitioners and the safety of your patientspractitioners and the safety of your patients

How education can change How education can change behaviorbehavior

Results of 2007 non-clinically indicated IOL at less than 39 Results of 2007 non-clinically indicated IOL at less than 39 weeks.weeks.

Actions that impacted results were:Actions that impacted results were: 1. Following data per physician, and notifying physicians 1. Following data per physician, and notifying physicians

that data would be collected.that data would be collected. 2. Provided education to physicians regarding ACOG 2. Provided education to physicians regarding ACOG

bulletin listing appropriate clinical indicators for IOL at less bulletin listing appropriate clinical indicators for IOL at less than 39 weeks. than 39 weeks.

3. Provided education to physicians regarding increased 3. Provided education to physicians regarding increased morbidity, mortality and increased LOS related to the near morbidity, mortality and increased LOS related to the near term infant.term infant.

4. Provided feedback to department of OB/GYN and 4. Provided feedback to department of OB/GYN and individual physicians regarding data collection results.individual physicians regarding data collection results.

How education can change behaviorHow education can change behavior

First quarter non-clinically indicated IOL < First quarter non-clinically indicated IOL < 39 weeks was 29.6% of total IOL39 weeks was 29.6% of total IOL

Second Quarter non-clinically indicated IOL Second Quarter non-clinically indicated IOL < 39 weeks was 24.3% of total IOL< 39 weeks was 24.3% of total IOL

Third Quarter non-clinically indicated IOL < Third Quarter non-clinically indicated IOL < 39 weeks was 21% of total IOL39 weeks was 21% of total IOL

Fourth Quarter non-clinically indicated IOL < Fourth Quarter non-clinically indicated IOL < 39 weeks was 12.6% of total IOL39 weeks was 12.6% of total IOL

PEER Review-An Educational PEER Review-An Educational Process at RoseProcess at Rose

Oct, Nov, Dec audit of all “Elective Oct, Nov, Dec audit of all “Elective Deliveries” both inductions and C-Sections Deliveries” both inductions and C-Sections

True “fall outs” reviewed in PEER review True “fall outs” reviewed in PEER review and “educational letters” sent to those and “educational letters” sent to those providers along with a copy of recent ACOG providers along with a copy of recent ACOG technical Bulletintechnical Bulletin

Educational LetterEducational Letter Dear Dr. Holt,Dear Dr. Holt,

Your patient, ____, was electively delivered at between 38 and 39 completed Your patient, ____, was electively delivered at between 38 and 39 completed weeks gestation. This letter is from the OBQI committee and serves as a weeks gestation. This letter is from the OBQI committee and serves as a reminder that all elective deliveries at this gestational age both Cesarean reminder that all elective deliveries at this gestational age both Cesarean Sections and Inductions of labor are being audited by the Committee, This is Sections and Inductions of labor are being audited by the Committee, This is based on the recommendations of ACOG, the American Academy of Pediatrics based on the recommendations of ACOG, the American Academy of Pediatrics and the National Quality Forum advising against elective deliveries less then 39 and the National Quality Forum advising against elective deliveries less then 39 completed weeks gestation due to adverse neonatal outcomes associated with completed weeks gestation due to adverse neonatal outcomes associated with this practicethis practice

We have decided to provide this information to our OB Providers as an We have decided to provide this information to our OB Providers as an educational tool for the next 3 months. After this time frame we will begin educational tool for the next 3 months. After this time frame we will begin assigning Peer Review Levels to all Providers who electively deliver patients at assigning Peer Review Levels to all Providers who electively deliver patients at less then 39 completed weeks gestation. The specific Level assigned will be less then 39 completed weeks gestation. The specific Level assigned will be determined on a case by case basis. This information will become a part of determined on a case by case basis. This information will become a part of your Credentialing File in the Medical Staff Officeyour Credentialing File in the Medical Staff Office

Educational Letter Educational Educational Letter Educational

We would be glad to provide you with data in We would be glad to provide you with data in support of this practice for you to share with your support of this practice for you to share with your patients as you decide timing for elective patients as you decide timing for elective deliveries. The Green Journal has had ACOG deliveries. The Green Journal has had ACOG Practice Bulletins and articles of support of this Practice Bulletins and articles of support of this practice this year.practice this year.

We appreciate your continued efforts to provide We appreciate your continued efforts to provide the best possible quality of care for your OB the best possible quality of care for your OB patients at Rose Medical Centerpatients at Rose Medical Center

Your OBQI committeeYour OBQI committee

PEER Review-An Educational PEER Review-An Educational ProcessProcess

Oct.-1 letter was sent 3 charts reviewed- NQF Oct.-1 letter was sent 3 charts reviewed- NQF reporting 1/283 term singleton deliveries= .35%reporting 1/283 term singleton deliveries= .35%

Nov.- 3 letters were sent 20 charts reviewed- NQF Nov.- 3 letters were sent 20 charts reviewed- NQF reporting 3/272= 1.1%reporting 3/272= 1.1%

December to be reviewed by QI end of the Month December to be reviewed by QI end of the Month with letters to be sent. I-3 cases to be reviewed with letters to be sent. I-3 cases to be reviewed and 18 charts reviewed 253 qualifying deliveriesand 18 charts reviewed 253 qualifying deliveries

WE ARE DOING VERY WELL AT ROSEWE ARE DOING VERY WELL AT ROSE

PEER Review-An Educational and PEER Review-An Educational and Constructive ApproachConstructive Approach

Many centers have chosen to look at <39 Many centers have chosen to look at <39 week inductions on a case by case basisweek inductions on a case by case basis

Better to have a group of peers make Better to have a group of peers make determinations than to be “told what to do”determinations than to be “told what to do”

Is there room for “judgment” and “special Is there room for “judgment” and “special cases” ?cases” ?

Amniocentesis appropriate in some cases?Amniocentesis appropriate in some cases?

Patient Education is KeyPatient Education is Key““Why The Last Weeks of Pregnancy CountWhy The Last Weeks of Pregnancy Count

The Colorado March of Dimes has an excellent The Colorado March of Dimes has an excellent patient educational pamphlet that could be patient educational pamphlet that could be incorporated into patient information packets in incorporated into patient information packets in OB practitioners offices and in prenatal classesOB practitioners offices and in prenatal classes

Laminated Baby Brain pamphlet $1 Laminated Baby Brain pamphlet $1 6 page color pamphlet $15.50/506 page color pamphlet $15.50/50 For ordering 1-800-367-6630 #37-2209-07 Why For ordering 1-800-367-6630 #37-2209-07 Why

the Last Weeks of Pregnancy Count 10/08 the Last Weeks of Pregnancy Count 10/08

Patient Education is the KeyPatient Education is the Key The Colorado Perinatal Care Council is very The Colorado Perinatal Care Council is very

interested in having this pamphlet available to interested in having this pamphlet available to every pregnant patient in our State. Looking every pregnant patient in our State. Looking into possible grant fundinginto possible grant funding

March 25March 25thth Round Table Discussion-How to Round Table Discussion-How to best Implement this throughout the State of best Implement this throughout the State of ColoradoColorado

Do we make our own pamphlet-suggestion last Do we make our own pamphlet-suggestion last week from the Rose Perinatal Development week from the Rose Perinatal Development TeamTeam

Take Home MessageTake Home Message Babies electively delivered before 39 completed Babies electively delivered before 39 completed

weeks have statistically significant greater weeks have statistically significant greater morbidity particularly if elective C-Section without morbidity particularly if elective C-Section without labor. Look at larger numbers to see the labor. Look at larger numbers to see the difference.difference.

Amnios are not for everybody. In selective non-Amnios are not for everybody. In selective non-elective cases may help make decisions about elective cases may help make decisions about timing of deliverytiming of delivery

Provider and patient behavior does change with Provider and patient behavior does change with educationeducation

Quality and patient safety is the reason to waitQuality and patient safety is the reason to wait

Thank youThank you

Steven Holt, MD, FACOGSteven Holt, MD, FACOG

Chair Department of OB/GYNChair Department of OB/GYN

Rose Medical CenterRose Medical Center

References:References: American College of Obstetricians and Gynecologist Technical Bulletin #10. American College of Obstetricians and Gynecologist Technical Bulletin #10.

Induction of Labor. November 1999 Induction of Labor. November 1999 American College of Obstetricians and Gynecologist Technical Bulleting #97. Fetal American College of Obstetricians and Gynecologist Technical Bulleting #97. Fetal

Lung Maturity. September 2008 Lung Maturity. September 2008 Clark SL, Belfort MA, Miller DK et al: Neonatal and Maternal Outcomes associated Clark SL, Belfort MA, Miller DK et al: Neonatal and Maternal Outcomes associated

with elective term delivery. Am J Obstet Gynecol , January 2009 with elective term delivery. Am J Obstet Gynecol , January 2009 Alan TN, Landon Mark, Spong CY et al: NEJM, January 2009 “Timing of Elective Alan TN, Landon Mark, Spong CY et al: NEJM, January 2009 “Timing of Elective

Repeat Cesarean Delivery at Term and Neonatal Outcomes” Repeat Cesarean Delivery at Term and Neonatal Outcomes” National Quality Forum National Voluntary Consensus Standards for Perinatal Care National Quality Forum National Voluntary Consensus Standards for Perinatal Care

20082008