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 Director Childbirth Connection
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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
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
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)
• 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)
• 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”
• 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
Source: U.S. Agency for Healthcare Research and Quality, HCUPnet, Healthcare Cost and Utilization Project. Rockville, MD: AHRQ. Available at: 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%
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Goldenberg RL, et al. Obstet Gynecol 2009; 114:1254-1258.
“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”.
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.
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
Source: Elimination of Non-Medically Indicated Elective Deliveries Before 39 Weeks Toolkit
• 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
Source: Elimination of Non-Medically Indicated Elective Deliveries Before 39 Weeks Toolkit
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
• 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.
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”
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.