quality quest for health peoria, il

transform.childbirthconnection.org www.childbirthconnection.org

Steps Toward a High-Quality, High-Value Maternity Care

System

Preventing Elective Deliveries Before 39 Weeks

Quality Quest for Health,

Peoria, Illinois

August 10, 2011

Maureen Corry, MPH, Executive DirectorChildbirth Connection

http://www.childbirthconnection.org/


• Mission is to improve the quality of maternity care through consumer engagement and health system transformation.

Childbirth Connection



Evidence-Practice Gap in Maternity Care

Much of the care women receive is not consistent with the best evidence despite unprecedented body of comparative effectiveness research to guide practice and quality improvement

www.childbirthconnection.org/ebmc


http://www.childbirthconnection.org/ebmc


Maternity Care is Procedure-Intensive and Costly

Milbank Report, Evidence-Based Maternity Care (2008) Deficiencies include:•Overuse of many practices that entail harm and waste for mothers, babies, and the system at large, (e.g. cesarean section, elective induction)•Underuse of effective, high-value practices that would improve outcomes, (smoking cessation, vaginal birth after cesarean)•Broad variations in care, outcomes, and costs across geographic regions, facilities, and providers unwarranted by health status or women’s preferences

www.childbirthconnection.org/ebmc


http://www.childbirthconnection.org/ebmc


Maternity Care Variation• In 2007, cesarean rates ranged from less than 25%

in AK, ID, NM, and UT, to over 35% in FL, LA, MI, NJ, and WV

• Recent studies affirm WHO recommendations on optimal cesarean rates: best outcomes for women and babies appears to occur with rates of 5% to 10%. Rates above 15% seem to do more harm than good (Althabe and Belizan 2006)



Practice Variation Among 10 Largest Hospitals in Greater Peoria Area

Variation:

C-section rates range from 19-34%• VBAC rates range from 0-17%

• Rates of early elective delivery range from 1-30%

– All but 3 exceed The Leapfrog Group’s threshold of 12%

Sources: Illinois Hospitals Caring for You (http://www.illinoishospitals.org/iha/home) , The Leapfrog Group Hospital Survey, 2011, (http://www.leapfroggroup.org/tooearlydeliveries)



Birth Centers: Coming Soon to Illinois

• New law authorizes 10 pilot birth centers– Hospital or FQHC owned– For low-risk women in labor at term

• Evidence for birth centers for low-risk women– Higher spontaneous vaginal birth rate– Fewer interventions– No excess in perinatal or maternal morbidity/mortality– High satisfaction– Average charges for birth center vaginal birth = $1,872

(American Association of Birth Centers, Uniform Data Set, 2007)



Healthy Childbearing Women

• Great majority of pregnant women in the U.S. are well and healthy and enter labor at “low risk” for problems

• Maternity care system often treats pregnancy and birth in healthy women as medical conditions or disease states, rather than normal life processes

• Limited attention given to ensuring that millions of healthy women receive appropriate care



Transforming Maternity Care Project

• Multi-year collaboration with more than 100 health care leaders from across health system

• Resulted in publication of two direction-setting papers in 2010:“2020 Vision for A High-Quality, High-Value Maternity Care System” and “Blueprint for Action”


http://transform.childbirthconnection.org/vision/


11 Critical Blueprint for Action

Focal AreasLiability Payment

Reform

Disparities

Performance Measurement

Development and Use of

HIT

Workforce Composition

and Distribution

Coordination of Care

Clinical Controversies

Decision Making and Consumer

Choice

Health Professions

Education

Scope of Covered Services



Blueprint for Action: Critical Focus Areas

• Performance measurement and leveraging of results• Payment reform to align incentives with quality• Improved functioning of the liability system• Disparities in access and outcomes of care• Clinical controversies (home birth, VBAC, elective

delivery, cesarean section)• Decision making and consumer choice



Changing Distribution of Singleton Live Births United States, 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, and used with permission.

Over 4 million babies born per year



Definitions

Weeks of Pregnancy

34 37 39 41

Late Preterm Early Term Full Term

22

Preterm Term

Prepared by March of Dimes and used with permission.



Complications of Non-medically Indicated Deliveries Between 37 and 39 Weeks

See CMQCC/MOD Toolkit for more data and full list of citationsClark 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



Contemporary Cesarean Delivery Practice

in the United States (2002-2008) C-Section Rates:• Overall 30.5% (variation from 20%-40%)

• First time mother: 31.2%• Prelabor repeat: 30.9%

Vaginal Birth After C-Section:• 28.8% of women with prior c-section had trial of labor– success rate

was 57.1%. Overall, 83.6% w/ prior cesarean delivered by cesarean.• 43.8% of women attempting VBAC were induced. Cesarean rate twice

as high in induced women than in spontaneous labor in all pregnancies (21.1% vs 11.8%)

• 50% for cesareans for dystocia done before 6 cm dilation

Zhang,et al. Amer J. Obstet Gynecol, Oct 2010.



Labor and Birth Charges

Source: U.S. Agency for Healthcare Research and Quality, HCUPnet, Healthcare Cost and Utilization Project. Rockville, MD: AHRQ. Available at: http://hcupnet.ahrq.gov/


http://hcupnet.ahrq.gov/


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%

11

Goldenberg RL, et al. Obstet Gynecol 2009; 114:1254-1258.



Attitudes on Medical Intervention in Birth Process

Giving birth is a process that should not be interfered with unless medically necessary:

• Agree strongly 24%• Agree somewhat 26%• Neither agree or disagree 25%• Disagree somewhat 17%• Disagree strongly 8%



Mother’s Interest in Knowing About Complications for

Decision MakingNecessary to know every or most complications

before consenting to:

• Labor induction 97%

• Cesarean 98%



Mother’s Knowledge of Impact of Interventions

• In no case did majority of mothers cite the correct response when given a series of statements on adverse effects of induction and cesarean section.

• “not sure” was most common response• When mothers did respond they were as

likely to be incorrect as correct• Having intervention did not increase

proportion of correct answers



Pressure on Mothers to Accept Interventions

Felt pressure from any health professional to have:

• Labor induction 7% all mothers, 17% with induction

• Cesarean 2% w. vaginal birth, 25% with cesarean

• Episiotomy 73% of mothers did not have choice about it



Listening to Mothers II:In Her Own Words

“My goal, this time, was to not get pressure about doing anything against my wishes because my first birth was a genuine nightmare with unnecessary induction, tons of drugs and medical students watching me push! I stayed home most of the labor to make sure I wouldn’t get any of that. And I didn’t, everything was perfect. It’s all in choosing the right doctor”.



Reasons for Rise in Elective Deliveries

• Perception that elective delivery is convenient and cost-effective among women, caregivers, and hospital administrators

• Scheduling and predictability appealing to women, providers, hospitals

• Frequent use of screening tests at the end of pregnancy, despite lack of evidence that the use of such tests improves outcomes

• The belief that the best way to manage risks in pregnancy is to deliver the baby



Elimination of Non-Medically Indicated Elective Deliveries Before 39 Weeks

Table of Contents

Making the Case

Implementation Strategy

Data Collection/QI Measurement

Clinician Education

Patient Education

Appendices

Available at: marchofdimes.com

orcmqcc.org



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.

ACOG Practice Bulletin No. 107, August, 2009



Examples of Successful Programs to Reduce Non-medically Indicated Deliveries

Before 39 week of Gestation• Magee Women’s Hospital (Pittsburgh)• Intermountain Healthcare (Utah)

– Magee Women’s and Intermountain Health found that strong leadership and strict policy enforcement were critical to success

• Ohio Perinatal Quality Collaborative (State Department of Health)– multi-stakeholder efforts resulted in decrease of scheduled births at < 39

weeks from 25% to < 5% within14 months

Source: Elimination of Non-Medically Indicated Elective Deliveries Before 39 Weeks Toolkit



QI Programs to Eliminate Elective Deliveries Before 39 Weeks Do Not Increase Perinatal

Mortality and Maternal Morbidity

QI programs do:• Improve maternal and neonatal outcomes• Reduce NICU admissions• Reduce primary cesarean rates• Reduce OB malpractice claims• Reduce costs




Hospital Corporation of America: 3 Approaches to Reducing Elective Births < 39 Weeks• “Hard stop” policy, not allowed; staff empowered to

refuse schedule or perform; • “Soft stop” policy, compliance left up to individual

doctors• Education only approach for providers re: current

evidence, ACOG guidelines, facility policies • Elective delivery may be reduced to level of <2%

using “hard stop” policy; cost savings of $1 billion annually. Correct patient misconceptions re harms to women and babies (Clark et al., AJOG, November 2010)

Strategies to Reduce Elective Deliveries




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

• Effective particularly when interventions are data-driven, involve multidisciplinary teams, and reference to specific guidelines that can be enforced

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

• Medical leadership critically important

Successful QI Programs




More Strategies to Minimize Elective Labor Inductions

• No elective births unless 41 weeks or cervical readiness without pharmacologic agents

• Elimination of the time factor as a driving force

• Performance measurement and public reporting

Source: Reconsideration of the Cost of Convenience, Quality, Operational, and Fiscal Strategies to Minimize Elective Labor Induction, Kathleen Rice Simpson, PhD, RNC, FAAN, J Perinat Neonat Nurs, Vol. 24, No. 1, pp. 43-52



More Strategies to Minimize Elective Labor Inductions

• Re-evaluation of costs of care: cost of cesarean birth after failed labor induction are nearly double that of spontaneous vaginal birth due to longer intrapartum and postpartum length of stay

• Reconsideration of provider reimbursement/patient payment: financial disincentives could be coming and should be strongly considered: increase co-pay, decreased reimbursement to provider

Source: Kathleen Rice Simpson, PhD, RNC, FAAN



Current March of Dimes Big 5 Collaboration

<39 Weeks Toolkit – input, review and local endorsements

Implementation – 5x5 QI Hospital Network

Data – outlining the population-based data to support the initiative

Consumer Awareness– Why the Last Weeks of Pregnancy Count, Prematurity Awareness Day

March of Dimes

Big 5CA, FL, IL,

NY, TX

Source: March of Dimes with permission



Hospitals Participating in Illinois Big 5 QI Initiative

University of Illinois Medical Center -Chicago

St. Elizabeth Hospital – Belleville

Decatur Memorial Hospital - Decatur

Edward Hospital - Naperville

Katherine Shaw Bethea Hospital, Dixon

St. Joseph Hospital - Breese




March of Dimes Patient

Brochures




March of Dimes New Media Campaign:

Healthy Babies are Worth the Wait

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.




Childbirth Connection Consumer Education Resources

• Women need access to full, accurate and complete evidence-based information on harms and benefits of elective induction and cesarean section before 39 weeks, and at 40 or 41 weeks without a clear medical reason. childbirthconnection.org/induction.



Promising Consumer Engagement Strategy: Shared Decision Making

Collaboration between women and caregivers to come to an agreement about a health care decision:

• Supports & encourages women to participate in their maternity care decisions

• Fully informs them with accurate, unbiased & understandable information

• Respects them by having their goals & preferences honored



FIMDM and Childbirth Connection: Shared Decision Making Maternity Initiative

Initiative aims to expand opportunities for SDM in maternity care and develop tools and resources to facilitate women’s informed choice.

Goals: • improved knowledge of care options, benefits, harms• improved provider participation and satisfaction with SDM process• reduced use of overused harmful interventions • increased use of underused interventions that improve outcomes• improved maternity care quality and value



“How to Stop the Relentless Rise in Cesarean Deliveries”

“The rising cesarean rate is a threat to the profession and there’s no time for complacency.” John Queenan, MD

He calls for concerted action by his profession to confront the problem and commit to action to “curtail the runaway increase in cesarean deliveries.”

He offers two “complex” solutions:

“make VBAC more accessible and more desirable” and “prevent primary deliveries in the first place.”



“How to Stop the Relentless Rise in Cesarean Deliveries”

He offers many specific strategies, among them:

• Implementing hospital quality improvement programs• Increasing utilization of midwives• Addressing problems in the liability system• Improving shared decision making



All of the great leaders have had one characteristic in common: it was the willingness to confront unequivocally the major anxiety of their people in their time. This, and not much else, is the essence of leadership.

- John Kenneth Galbraith



Rapid gains in maternity care

quality, value and outcomes are

within our reach, through multi-stakeholder, collaborative

efforts.



Thank You!

Maureen Corry, Executive DirectorChildbirth Connection

[email protected]

“2020 Vision”: transform.childbirthconnection.org/vision/ “Blueprint for Action”: transform.childbirthconnection.org/blueprint/


mailto:[email protected]




http://transform.childbirthconnection.org/blueprint/

http://transform.childbirthconnection.org/blueprint/


quality quest for health peoria, il

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