ELECTIVE DELIVERY LESS THAN 39 ELECTIVE DELIVERY LESS THAN 39 WEEKS GESTATIONWEEKS GESTATION

THE HCA EXPERIENCETHE HCA EXPERIENCE

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

Rose Medical CenterRose Medical Center7/31/097/31/09

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 Comprehensive data collection for all women undergoing planned delivery at 37 women undergoing planned delivery at 37 weeks and 0 days or greater.weeks and 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 = = anyany indication noted by the 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.

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 (656.5IUGR (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)

ResultsResults

17,794 deliveries17,794 deliveries 14,955 at 37 weeks of greater14,955 at 37 weeks of greater 6562 were planned term deliveries 44% of term deliveries6562 were planned term deliveries 44% of term deliveries 4645 were elective planned term delivery 71% of planned 4645 were elective planned term delivery 71% of planned

term deliveriesterm 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%37.0 – 37.6 weeks: 17.8% 38.0 – 38.6 weeks: 8.2%38.0 – 38.6 weeks: 8.2% >> 39 weeks: 4.6% 39 weeks: 4.6%

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

the NICU after the initial admission.the NICU 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, in violation of longstanding ACOG/AAP recommendations.gestation, in violation of 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.

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

NSMC NSMC

OB Department is evaluating and considering the followingOB Department is evaluating and considering the following If indication for induction is not included in the ACOG If indication for induction is not included in the ACOG

Technical Bulletin # 10 and gestational age is less than 39 Technical Bulletin # 10 and gestational age is less than 39 0/7 weeks OB Provider to discuss with L&D manager or 0/7 weeks OB Provider to discuss with L&D manager or Chairperson of OB before scheduling an elective inductionChairperson of OB before scheduling an elective induction

Specific consent of labor form must be completed which Specific consent of labor form must be completed which includes the indication-one practice is currently using this includes the indication-one practice is currently using this formform

Any deliveries determined to be elective –prior to 39 weeks Any deliveries determined to be elective –prior to 39 weeks are sent to peer revieware sent to peer review

Laboring and augmented patients are excludedLaboring and augmented patients are excluded

Other HealthONE HospitalsOther HealthONE Hospitals

PSL and Aurora both have accepted this PSL and Aurora both have accepted this standard and are in process of tracking standard and are in process of tracking compliance and determining best ways to compliance and determining best ways to impact change in practiceimpact change in practice

Regional Perinatal Task Force meets Regional Perinatal Task Force meets quarterly with additional regular conference quarterly with additional regular conference calls between HealthONE managers and calls between HealthONE managers and HCA clinical leadership-this data is being HCA clinical leadership-this data is being tracked for all HealthONE and HCA Hospitalstracked for all HealthONE and HCA Hospitals

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 look at Better to have a group of peers look at specific cases and make recommendations specific cases and make recommendations than to be “told what to do”than to be “told what to do”

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

Amniocentesis? For all or in some special Amniocentesis? For all or in some special casescases

? OTHER INDICATIONS? OTHER INDICATIONS

Advanced cervical dilation Advanced cervical dilation 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.

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

Started Auditing Charts Feb. 2008 with Started Auditing Charts Feb. 2008 with discussions at department meetings and peer discussions at department meetings and peer reviewreview

Memos and department Newsletters highlighting Memos and department Newsletters highlighting NQF and ACOG recommendationsNQF and ACOG recommendations

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

True “fall outs” reviewed in PEER review and True “fall outs” reviewed in PEER review and “educational letters” sent to those providers along “educational letters” sent to those providers along with a copy of recent ACOG technical Bulletinwith a copy of recent ACOG technical 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. educational tool for the next 3 months. After this time frame we will begin After this time frame we will begin assigning Peer Review Levels to all Providers who electively deliver assigning Peer Review Levels to all Providers who electively deliver patients at less then 39 completed weeks gestation. The specific Level patients at less then 39 completed weeks gestation. The specific Level assigned will be determined on a case by case basis. This information assigned will be determined on a case by case basis. This information will become a part of your Credentialing File in the Medical Staff Officewill become a part of your Credentialing File in the Medical Staff Office

EDUCATIONAL LETTEREDUCATIONAL LETTER

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

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

Your OBQI committeeYour OBQI committee

PEER Review-An Educational PEER Review-An Educational ProcessProcess

Oct.-1 letter was sent 3 charts reviewedOct.-1 letter was sent 3 charts reviewed Nov.- 3 letters were sent 20 charts reviewedNov.- 3 letters were sent 20 charts reviewed December 1 letter was sent 18 charts December 1 letter was sent 18 charts

reviewedreviewed Jan. 4 letters sent and 14 charts reviewedJan. 4 letters sent and 14 charts reviewed During this “educational period” we During this “educational period” we

experienced < 2% elective delivery rate at experienced < 2% elective delivery rate at <39 weeks.<39 weeks.

Rose Experience Rose Experience

We continue to review all charts without medical We continue to review all charts without medical indications for delivery at less than 39 weeks in indications for delivery at less than 39 weeks in Peer ReviewPeer Review

22ndnd Q data 4/372=1.08% <39 week elective delivery Q data 4/372=1.08% <39 week elective delivery raterate

We have decided to trend these cases and not We have decided to trend these cases and not assign a peer review level at this timeassign a peer review level at this time

New educational letter in preparation for public New educational letter in preparation for public reporting as a Perinatal Core Measure starting April reporting as a Perinatal Core Measure starting April 20102010

Work group is designing a patient education pieceWork group is designing a patient education piece

Current Peer Review letterCurrent Peer Review letter Dear __________Dear __________

Re: Medical Record Number _______Re: Medical Record Number _______

In our routine chart audits for quality improvement, this In our routine chart audits for quality improvement, this case “fell-out” for elective delivery at less than 39 weeks case “fell-out” for elective delivery at less than 39 weeks gestation. This letter is from the OBQI Committee and gestation. This letter is from the OBQI Committee and serves as a reminder that all elective deliveries less than serves as a reminder that all elective deliveries less than 39 weeks, both Cesarean Sections and Inductions of 39 weeks, both Cesarean Sections and Inductions of labor are being reviewed, The Joint Commission plans to labor are being reviewed, The Joint Commission plans to include public reporting of elective deliveries < 39 weeks include public reporting of elective deliveries < 39 weeks as a part of the Perinatal Core Measures which will be as a part of the Perinatal Core Measures which will be introduced in April of 2010introduced in April of 2010

Current Peer Review letterCurrent Peer Review letter This letter is intended to assist you in tracking This letter is intended to assist you in tracking

and trending your practice against this indicator and trending your practice against this indicator and to provide education regarding the latest and to provide education regarding the latest research on this issue. Enclosed are two recent research on this issue. Enclosed are two recent articles, one from AJOG and one from the New articles, one from AJOG and one from the New England Journal of Medicine documenting the England Journal of Medicine documenting the significant differences in outcomes in neonates significant differences in outcomes in neonates delivered <39 weeks compared to >39 weeks. delivered <39 weeks compared to >39 weeks. This includes outcome differences in those This includes outcome differences in those delivered at 38 weeks and 4 days to 38 weeks delivered at 38 weeks and 4 days to 38 weeks and 6 days in the NEJM studyand 6 days in the NEJM study

Current Peer Review letterCurrent Peer Review letter

There are no plans to restrict this practice at There are no plans to restrict this practice at Rose. We understand every patient Rose. We understand every patient situations is unique. We plan to trend <39 situations is unique. We plan to trend <39 week elective (week elective (not medicalnot medical) deliveries by ) deliveries by provider in preparation for public reportingprovider in preparation for public reporting

Your OBQI CommitteeYour OBQI Committee

Thank youThank you

Steven Holt, MD, FACOGSteven Holt, MD, FACOG

Chair Department of OB/GYNChair Department of OB/GYN

Rose Medical CenterRose Medical Center