making sense of cesarean birth rates how should we … · making sense of cesarean birth rates how...
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Elliott Main, MD Medical Director, CMQCC main@ .org
Clinical Professor, OB/GYN UC San Francisco, and Stanford University
Making sense of Cesarean Birth Rates How should we invest our QI efforts?
Anne Castles, MS MPH Project Manager, CMDC acastles@ .org
California Maternal Data Center CMQCC
: Transforming Maternity Care
Today’s Discussion:
n What are the drivers for the rise and variation in Primary CS?
n NTSV (Nulliparous, Term Singleton, Vertex) as the focus for CS Quality Improvement
n Importance of L&D culture, Labor practices, and use of Data and the California Maternal Data Center to drive change
n Multi-strategy approach to address CS rates n Public projects to support this initiative
: Transforming Maternity Care
Paradigm Shift
Most Cesarean Births are inevitable
though some are preventable
Changes in practice style can prevent
many labor Cesarean Births
: Transforming Maternity Care
Presenters’ Disclosures:
n No financial conflicts n We are all employees of California Maternal
Quality Care Collaborative (CMQCC) based at Stanford University, Palo Alto, CA
n No outside business interests CMQCC is a multi-stakeholder State Quality Collaborative. The CMDC supported by the CDC and the California HealthCare Foundation
: Transforming Maternity Care
CPQCC and CMQCC Mission: Improving care for moms and newborns
California Perinatal Quality Care Collaborative (CPQCC) n Expertise in data capture from hospitals n Established Perinatal Data Center in 1996 n Data use agreements in place with 130 hospitals with NICUs n Model of working with state agencies to provide data of value California Maternal Quality Care Collaborative (CMQCC) n Expertise in maternal data analysis n Developer of QI toolkits n Host of collaborative learning sessions n Established Maternal Data Center in 2011
: Transforming Maternity Care
CMQCC Key Partner/Stakeholders State Agencies: n MCAH, Dept Public Health n OSHPD Healthcare Information Division n Office of Vital Records (OVR) n Regional Perinatal Programs of California (RPPC) n DHCS, Medi-Cal Public Groups n California Hospital Accountability and Reporting Taskforce (CHART) n California HealthCare Foundation n Kaiser Family Foundation n March of Dimes (MOD) Professional groups n American College of Obstetrics and Gynecology (ACOG) n Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) n American College of Nurse Midwives (ACNM), n American Academy of Family Physicians (AAFP) Key Medical and Nursing Leaders n Universities and Hospital Systems n Kaisers, Sutter, Sharp, Dignity, Scripps, Providence, Public hospitals,
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CMQCC Key Partner/Stakeholders (con’t)
Medical Associations: n California Hospital Association n Regional Hospital Associations n California Medical Association Payers n Aetna n Anthem Blue Cross n Blue Shield n Cigna n Health Net Purchasers n CALPERS (State and local government employees and retirees) n Medi-Cal (for managed care plans) n Pacific Business Group on Health/ Silicon Valley Employers Forum n Cover California (ACA entity)
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CMQCC Perinatal QI Toolkits Adopted Nationally
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Cesarean Births Have Risen by Over 50% in the Last 10 years
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Why has Cesarean Birth Reduction been so hard?
n Direct challenge to Physician autonomy n Very complex, many factors, need to be able
to focus on areas with real preventability n Need for professional society leadership n Timing: prior attempts were often “Voices in
the wilderness”; “3rd rail of OB QI”; “Enter at your own risk…”
n Risk: “Never got sued for doing a Cesarean”
: Transforming Maternity Care
De-construction of the Cesarean Rate
n Cesarean deliveries are done for many indications, are they all equally “worthy”? (evidence-based)
n Is there a portion of the Cesarean rate that can be reduced without causing harm?
n Why is there so much variation in Cesarean rates without similar variation in neonatal outcomes?
n Is our training on labor management out-dated?
: Transforming Maternity Care
CS Indication
Proportion of Overall CS Rate
Proportion of Primary CS Rate
CS Rate for this
Indication Repeat (prior) 30-35% 90+% “Abnormal Labor” (CPD/FTP)
25-30% 35-45% variable
“Fetal Distress” 10-15% 15-20% variable Breech/Malpres. 10% 15-20% 98% Multiple Gestation 5-9% 10-15% 60-80% Other: Placenta Previa, Herpes, etc
~5% ~10-15% 90%
What are the Indications for Cesarean Section?
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Percent of the Increase in Primary Cesarean Rate Attributable to this Indication
Cesarean Indication Yale (2003 v. 2009) (Total: 26% to 36.5%)
Focus: all primary Cesareans
Kaiser So. Cal. (1991 v. 2008)
(Primary: 12.5% to 20%) Focus: all primary singleton
Cesareans
Labor complications (CPD/FTP) 28% ~38%
Fetal Intolerance of Labor 32% ~24%
Breech/Malpresentation <1% <1%
Multiple Gestation 16% Not available
Various Obstetric and Medical Conditions (Placenta Abnormalities, Hypertension, Herpes, etc.)
6% 20% (Did not separate
preeclampsia from other complications)
Preeclampsia 10%
“Elective” (defined variously) 8% (Scheduled without “medical indication”)
18% (Those “without a charted
indication”)
What Indications Have Driven the Rise in CS?
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Importance of the First Birth
n If you have a CS in the first labor, over 90% of ALL your subsequent births will be by Cesarean Section
n If you have a vaginal birth in the first labor, over 90% of ALL your subsequent births will be vaginal
A Classic Example of “Path Dependency”
How do we focus QI activity on preventing First-birth (Primary) Cesarean sections?
: Transforming Maternity Care
NTSV Cesarean Section Rate: Quality Measure
n Widely Adopted ¨ ACOG: Task Force on Cesarean Section
rates (2000) ¨ DHHS: Healthy Person 2010 and 2020 ¨ NQF, Joint Commission ¨ Similar to AHRQ Inpatient Quality Indicator
(IQI #33: Low-risk Primary Cesarean Delivery Rate) (also includes MTSV)
¨ Medicaid programs in California, Washington, others
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Total CS Rate Among 251 California Hospitals 2011-‐2012
(Source: CMQCC-‐-‐California Maternal Data Center combining primary data from OSHPD and Vital Records)
Range: 15.0—71.4% Median: 32.5% Mean: 32.8%
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Low-‐Risk First-‐Birth (Nuliparous Term Singleton Vertex) CS Rate (endorsed by NQF, TJC PC-‐02, CMS, HP2020)
Among 249 California Hospitals: 2011-‐2012 (Source: CMQCC-‐-‐California Maternal Data Center
combining primary data from OSHPD and Vital Records)
Range: 10.0—75.8% Median: 27.0% Mean: 27.7%
National Target =23.9%
36% of CA hospitals meet national target
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: Transforming Maternity Care
Variation in California CS Rates by Region (2007)
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Med
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Ces
area
n R
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(%)
NTSV CS Total CS
NTSV CS State Mean=28.1%
Total CS State Mean=31.3%
HP2020 NTSV CS Target=23.9%
: Transforming Maternity Care
What do we mean by “culture” (1)
n Nursing culture is about… ¨ Experience in managing labor (versus charting,
caring for complications and FHR interpretation) ¨ Value seen for vaginal birth ¨ Importance of labor support ¨ Flexibility and patience
n OB culture is about… ¨ All of the above, and… ¨ Outside pressure (back to the office or family) ¨ Perception of liability risk
“The way we do things around here”
: Transforming Maternity Care
So what do we mean by “culture” (2)
n Leadership (MD and Admin) culture is about… ¨ All of the above, and… ¨ Does anyone care? ¨ Do leaders feel they have leverage?
n Patient culture is about… ¨ Value of vaginal birth (friends, family, and Hollywood) ¨ Fear of pain, vaginal birth (for mother and baby), and
vaginal cosmesis ¨ Childbirth preparation
“The way we do things around here”
: Transforming Maternity Care
PDD-‐-‐Discharge Diagnosis File (ICD9 codes)
Birth Cer9ficate File (Clinical Data)
1. Links Birth Data to OSHPD file 2. Runs exclusions 3. Iden\fies CS and Induc\ons 4. Prints list of charts for review
CMQCC Maternal Data Center
CMQCC Data Center
REPORTS Benchmarks against other hospitals
Sub-‐measure reports
Calculates all the Measures <39wk Elec9ve Delivery
CHART REVIEW Labor?/SROM?
(~6% of cases for brief review)
Limited manual data entry for this measure
Uploads electronic files
Mantra: “If you use it, they will improve it”
: Transforming Maternity Care
What are some of the features of the CMDC?
A low-‐cost, low-‐burden, web-‐based tool providing hospitals with:
Ø Overall hospital performance measures Ø Drill-‐down sta\s\cs and case review worksheets to iden\fy quality improvement opportuni\es—for both clinical quality and data quality
Ø Provider-‐level sta\s\cs—to assess varia\on within a hospital
Ø Benchmarking sta\s\cs-‐-‐to compare your hospital to regional, statewide, and like-‐hospital peers
Ø Facilita\ng repor\ng to Leapfrog, Cal-‐HEN and PSF +
: Transforming Maternity Care
CMDC Measures Labor and Birth Measures n Elec\ve Delivery <39 Weeks (PC-‐01)* n Episiotomy Rate n OB Trauma (3/4th Lacera\on)-‐Cesarean Delivery (AHRQ EXP-‐2) n OB Trauma (3/4th Lacera\on)-‐Vaginal Delivery w/ Instrument (AHRQ PSI 18) n OB Trauma (3/4th Lacera\on)-‐Vaginal Delivery w/o Instrument (AHRQ PSI 19) n Cesarean Sec\on-‐-‐Nulliparous, Term, Singleton, Vertex (PC-‐02) n Cesarean Sec\on-‐-‐Nulliparous, Term, Singleton, Vertex, Age Adjusted (PC-‐02) n Cesarean Sec\on-‐-‐Term, Singleton, Vertex (AHRQ IQI 21) n Cesarean Sec\on—Primary (AHRQ IQI 33) n Total Cesarean Rate n Induc\on Rate n Failed Induc\on Rate n Appropriate DVT Prophylaxis in Women Undergoing C-‐Sec\on (Leapfrog)* n Vaginal Birth Aker Cesarean (VBAC) Rate, All (AHRQ IQI 34) n Vaginal Birth Aker Cesarean (VBAC) Rate, Uncomplicated (AHRQ IQI 22) Newborn Measures n Newborn Bilirubin Screening Prior to Discharge (Leapfrog)* n 5 Minute APGAR <7 Among All Deliveries >39 weeks (HEN) n 5 Minute APGAR <7 in Early Term Newborns (HEN) Birth Trauma -‐ Injury to Neonate (AHRQ PSI 17) n Unexpected Newborn Complica\ons (NQF) Prematurity Measures n Antenatal Steroids (PC-‐03) n Antenatal Steroids-‐Leapfrog n VLBW (<1500g) NOT delivered at a Level III NICU
*Requires additional limited chart review
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<<Considerations>>
n Important to move beyond reporting metrics to addressing WHY?
n Need to have timely data (months old rather than years old)
n Need a base of the entire population and then build projects requiring special data collection on that foundation
: Transforming Maternity Care
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NTSV CS Run Charts
for 2 California Hospitals
Sample Hospital 2
Sample Hospital 1
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Primary CS QI Pathways Which is the driver in my hospital??
n Latent phase admission n Nullip (first birth) labor induction
¨ Esp. with unfavorable cervix n Dystocia/Failure to progress
¨ Arrest or protraction disorder n Non-reassuring Fetal Status
n Oxytocin/misoprostol associated tachysytole n 2nd Stage (failure of descent) n Predicted macrosomia n Patient choice
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3 Major Drivers of the Primary CS Rate
Sample Hospital 1
Sample Hospital 2
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3 Major Drivers of the NTSV CS Rate
Sample Hospital 1
Sample Hospital 2
Comparison Rates for the 3 Major NTSV Drivers
Sample Hospital 1
Sample Hospital 1
Comparison Rates for the 3 Major NTSV Drivers Sample Hospital 1
Analysis of Numerator Cases: Macrosomia CS
Spot Light Cases Another CA hospital…
Comparison Rates for the 3 Major NTSV Drivers Sample Hospital 2
Sample Hospital
Comparison Rates for the 3 Major NTSV Drivers Sample Hospital 2
Sample Hospital 2
Provider-‐Level Cesarean Ra
tes
Sample Hospital 2
OB’S
Are there confounding factors needing risk adjustment?
NTSV CS=28.5%
Sample Hospital 2
Sample Hospital 2
Are there confounding factors needing risk adjustment? A Bay Area Story
NTSV CS=24.0%
Sample Hospital
Sample Hospital
Are there confounding factors needing risk adjustment? A Central Valley Story
NTSV CS=25.9%
Sample Hospital
Sample Hospital
Risk Adjustment: Summary • Hospitals with high rates of advancing maternal age ALSO have high rates of low BMIs (and vice-‐versa)
• On analysis, they balance each other out • “Fully loaded” Risk Adjustment does not change hospital rankings by more than a few spots and no hospital changed quin\les in California and Massachuseps
Main EK et al. Manuscript in preparation, CMQCC Ecker J et al. Mass General Hospital
Preliminary “Diagnoses”: Summary
• Sample Hospital 1 – Nullip Spontaneous Labor: FTP/CPD – Nullip Induc\on: Fetal Distress – Nullip Medical Indica\ons
• Sample Hospital 2 – Nullip Spontaneous Labor: FTP/CPD – Nullip Induc9on: FTP/CPD
New Tools in Our Toolkit!
• New research on normal labor • New recommenda\ons from NICHD Consensus Commipee
• New ACOG/SMFM guidelines on labor management
Consor9um on Safe Labor Defining An Alterna9ve to Friedman’s Labor Curve
• 19 hospitals across the US with EHRs that contained detailed labor & delivery data and neonatal outcomes
• 228,668 deliveries (87% in 2005-‐7) • 62,415 spontaneous labor NTSV births with normal outcomes
• Focus on redefining normal labor
Zhang J et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol 2010;116:1281–7.
Finding: Multips had a clear inflexion point at 6cm, nullips less clear
Finding: More than 50% of induced nullips are <6cm at CS
Spong CY et al. Obstet Gynecol Nov 2012;120(5):1181–1193.
Spong CY et al. Obstet Gynecol Nov 2012;120(5):1181–1193.
Safe Preven\on of the First Cesarean
• Defining abnormal first-‐stage labor • Management of abnormal first stage labor • Defining abnormal second-‐stage labor • Management of abnormal second stage labor • Interven\ons for abnormal fetal heart rate tracings • Effect of induc\on of labor on cesarean birth • Special cases: breech, twins, suspected macrosomia
Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:693–711.
Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:693–711.
Case Review For Cesarean during First Stage Labor (for Dystocia/Arrest Disorders)
q Cervix 6 cm or greater q Membranes ruptured, then q No change X 4 hours with Adequate Uterine ac\vity
Case Review Checklist: Spontaneous Labor (All 3 should be present)
Take the “Test” in Your Hospital…
• Iden\fy 20 cases of CS in the first sage of labor performed for Labor Dystocia/Failure To Progress/Arrest of Dila\on
• Review using the Check List
How many will fail to meet the 3 criteria?
Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:693–711.
Recommenda9ons for Labor Induc9on
Common sense approach to Category II fetal monitor strips!
Clark SL et al. Am J Obstet Gynecol Aug 2013;209(2):89-97
A Good Base for Provider Education and QI for
Fetal Monitoring
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Public Engagement in Primary Cesarean Prevention: 2014
• NQF, Joint Commission, LeapFrog, CHCF, and CMS all
reporting NTSV CS • Patient Safety First: CA Hospital Collaborative for
NTSV CS • National Partnership for Patient Safety:—
NTSV CS Focus for 2015-2016 • CalSIM (payer and purchaser coalition)—Maternity and
NTSV Cesarean focus for payment reform in CA: 2015--
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Primary Cesarean QI Steps
n Identify the local leaders ¨ MD, RN and Admin
n Identify your hospital's issue (Focus!) ¨ CMDC is available in your hospital ¨ Use the Checklists ¨ Identify best practices
n CMQCC Toolkit and Change packages n Ready in 2014
n QI Mentoring ¨ Sharing of experiences
Main EK et al. Obstet Gynecol Nov 2012;120(5):1194–1198.
5 Key Complimentary Strategies: 1) QI projects for labor management practices 2) Payment reform to eliminate negative or
perverse incentives 3) Education for the value of normal birth (culture) 4) Transparency with Public Reporting 5) Continued public engagement
: Transforming Maternity Care
Today’s Discussion:
n What are the drivers for the rise and variation in Primary CS?
n NTSV (Nulliparous, Term Singleton, Vertex) as the focus for CS Quality Improvement
n Importance of L&D culture, Labor practices, and use of Data and the California Maternal Data Center to drive change
n Multi-strategy approach to address CS rates n Public projects to support this initiative
: Transforming Maternity Care
Thank You!
To enroll in the California Maternal Data Center Contact: [email protected]