Using PPOR and FIMR to lead to SCIENCE-BASED ACTION In Omaha, Nebraska November 25th 2008 David Busse, Teresa Hergott, Carol Gilbert
Jan 17, 2016
Using PPOR and FIMR to lead to
SCIENCE-BASED ACTIONIn Omaha, Nebraska
November 25th 2008
David Busse, Teresa Hergott, Carol Gilbert
Objectives
• Discuss mission and purpose of local BBC Collaborative
• PPOR analysis:
– Phase 1: EXCESS MORTALITY in Douglas County
– Phase 2: Reasons and potential solutions
• Identify FIMR as an addition to local community strategy
• Demonstrate taking recommendations to action
2
Baby Blossoms CollaborativeEliminate factors that contribute to health disparities though efforts to strengthen the community capacity by:
1) identifying the contributing factors that lead to racial, geographic and economic disparities.
2) reducing overall feto-infant mortality.
3) building on the strengths of our community.
4
BBC PartnersAlegent HealthBabies R UsBig Picture ProductionsBlue Cross Blue Shield of
NebraskaCharles Drew Health Center/ Omaha Healthy StartChildren’s HospitalCityMatCHCollege of Saint Mary’sDouglas County Coroner’s OfficeEarly Childhood Consortium
of the Omaha AreaEarly Childhood Training CenterEssential Pregnancy ServiceFred Leroy Health CenterHope Medical Outreach CoalitionMarch of Dimes Nebraska Methodist Physicians ClinicMetro Omaha Medical SocietyMinisterial Alliance
NE Children and Families FoundationNE Health and Human Services System NE Medical CenterNE Methodist Health SystemNE Midwives Association NE SIDS FoundationOffice of Minority HealthOmaha District Dietetic AssociationOmaha Police DepartmentOmaha Public SchoolsOur Healthy Community PartnershipProject HarmonyRegion 6 Mental HealthSalem Baptist ChurchSalvation ArmyUnited Health CareUniversity of Creighton Medical Center University of Nebraska at OmahaUrban League of NebraskaVisiting Nurse Association
PPOR Analysis
• Phase 1: IDENTIFIES the populations and periods of risk with the most excess mortality
• Phase 2: examines REASONS for the excess deaths through further epidemiologic studies, death reviews, program and policy reviews and other community assessments.
Map of Feto-Infant Deaths
103 fetal deaths + 167 deaths of live born infants=270 Feto-infant deaths
Divided by 33,046 live births and fetal deaths
=8.2 overall feto-infant
mortality rate
Douglas County, All Races2003-2006
111/ 3.4Maternal Health/ Prematurity
(44 fetal deaths, 67 live births)
59/1.8
Maternal Care
(fetal deaths)
39/1.2
Newborn Care
(live births)
61/1.8
Infant Health
(live births)
N=21,190 live births+fetal deaths
2.6
1.7 1.0 1.3
Non-Hispanic White Feto-Infant Rate = 6.6
N=4,797 live births+fetal deaths
2.5 3.82.1
5.8
Non-Hispanic Black Feto-Infant Rate = 14.2
PPOR Map of Feto- Infant Mortality
Douglas County, By Race, 2003-2006
Map of Feto-Infant Mortality Rates 1993-2006
Douglas County, NE, All Races
4.0
2.3 1.4 2.9
Feto-Infant Rate = 10.710.7
4.1
1.8 1.9 4.0
1.4 1.8
2.5
1.9
Feto-Infant Rate = 10.3
Feto-Infant Rate = 9.19.1
1993-1996
1997-2000
2001-2004
3.4
1.2 1.81.8
Feto-Infant Rate = 8.2
2003-2006
9
Feto-Infant Mortality Ratesfor External Comparison GroupWhite non-Hispanic Mothers age 20 or older, with more
than a high school education USA 2000-2002
2.2Maternal Health/ Prematurity
(fetal deaths, live births)
1.5 Maternal
Care (fetal deaths)
1.1 Newborn
Care (live births)
0.9Infant Health
(live births)
Total 5.7 Deaths Per thousandLive Births And Fetal Deaths
10
Excess Feto-Infant Mortality Rates Using External Comparison Group
Douglas County, NE 2003-2006
3.4 – 2.2 = 1.2 excess
1.8 - 1.5
=0.3exces
s
1.2 – 1.1 = 0.1
excess
1.8-0.9 =
0.9excess
Overall8.2 – 5.7=2.5 excess
11
Excess Feto-Infant Mortality Translated into estimated numbers
of preventable deathsDouglas County, NE 2003-2006
39Maternal Health/ Prematurity
(fetal deaths, live births)
10 Maternal Care
(fetal deaths)
3 Newborn
Care (live births)
30Infant Health
(live births)
12
N=21,190 live births+fetal deaths
0.4
0.2 -.1 0.4
Non-Hispanic White Feto-Infant Rate = .9
N=4,797 live births+fetal deaths
1.4 2.90.6
3.6
Non-Hispanic Black Feto-Infant Rate = 8.5
Excess Feto- Infant Mortality
Douglas County, By Race, 2003-2006
13
Phase 1 Conclusions
• Rates have improved in all four periods of risk
• Highest excess mortality rates are in the Maternal Health/Prematurity Period and Infant Health Periods
• Black mothers continue to have higher rates than White mothers, especially in those two periods of risk
14
FIMR Process
An action-oriented community process that leads to
systems change
15
What is unique about FIMR?
• Utilize a 2-pronged approach– Case Review Team (CRT)– Community Action Team (CAT)
• Only fetal and infant death review that makes community recommendations
• Only review process that includes a home visit with Mom
16
Value of Mom’s Story
“I am the only one who can tell the story of my life. I say what it means.”
Dorothy Allison
17
Baby Blossoms CAT“Creative thinkers”
• Review initial recommendations
•Prioritize and implement recommendations
•Connect to community stakeholders
18
Prioritizing Recommendations
All CAT’s face the tough decision of identifying which of the many recommendations will have priority for implementation
19
PPOR Phase 2 Analysis What are the reasons?
How can we fix it?
20
Excess Deaths – Infant Health Period
Douglas County, NE 2003-2006 vs. National Reference Group DEATHS PER 1,000 LIVE BIRTHS – BY CAUSE
Con-genita
l Anom-alies
Ill-define
d Condi-tions
Infec-tious Diseases
Acci-dental Injury
Peri-natal Condi-tions SIDS Other Total
Douglas County 0.243 0.061 0.000 0.030 0.030 1.032 0.455 1.852
Nat'l Ref Grp 0.263 0.069 0.037 0.100 0.031 0.218 0.232 0.951
Excess Mortality Rate -.020 -.008 -.037 -.07 -.001 0.814 0.223 0.901
Estimated Excess Deaths -1 0 -1 -2 0 27 7 30
21
Excess SIDS Deaths by Race – Infant Health Period of Risk
Douglas County, NE 2003-2006 vs. National Reference Group
SIDS RateNat'l Ref
GrpExpected Deaths
Excess Deaths
Douglas County White, not Hispanic 0.710 0.218 5 10
Douglas County Black, not Hispanic 2.517 0.218 1 11
Non-Hispanic White and Non-Hispanic Black infants accounted for 77.8% of the excess SIDS deaths during this period. Non-Hispanic Black infants were 3.5 times as likely to die from SIDS as a Non-Hispanic White infant.
22
18
48
2015
2724
0
20
40
60
White
Black
Nativ
e Am
er.
Asian
/Pac
if.
Hispan
icTota
l
Safe Sleep (Percent NOT sleeping on back)Nebraska PRAMS, Douglas County 2004-2006
23
0
10
20
30
40
50
2000 2001 2002 2003 2004 2005 2006 2007
Per
cen
tBaby NOT Sleeping on Back
(and 95% confidence intervals)
Nebraska PRAMS, Douglas County 2004-2006
24
Phase 2 Green box conclusions
• Green Box– the bulk of the excess mortality is due to “SIDS” ICD-10 R95. Black/African American babies are more likely to die from SIDS than White babies. [We plan to begin to looking at accidental suffocation (W75) and Cause Unknown/Unspecified (R99) as well]
• PRAMS—Black babies are less likely to be sleeping on backs
• PRAMS—unsafe sleep position prevalence is decreasing.
25
Priority FIMR Recommendation
There will be an increase in community awareness regarding risks associated with bed sharing
– Adult co-sleeping with infant
– Infant sleeping non back position on soft surface
– Autopsy unable to rule out suffocation as cause of death
– Poor provider communication regarding suffocation vs. SIDS
26
Taking Recommendations to Action
Safe Sleep Initiative
Maternal Health/ Maternal Health/ PrematurityPrematurity
Birthweight Distribution
Birthweight- Specific Mortality
Phase 2 Analysis: Maternal Health/Prematurity Period
28
Excess Deaths – Maternal Health/Prematurity
Douglas County, NE 2003-2006 vs. National Reference Group
• due primarily (67%) to a higher than normal proportion of very small babies• due partly (33%) to lower than normal survival rates of very small babies
Specific Mortality
33%
Birthweight Distribution
67%
29
Local, population-based data on risk factors for Prematurity
(need for pre-conception care)
% Among
White
% Among
Black
% Among
All
Unintended Pregnancy 38 67 44
Late or no Prenatal Care 11 31 18
No insurance prior to preg. 14 30 25
Overweight/Obese prior (PRAMS 2004-2006)
33 44 35
Mother < 19 years old 2 14 5
Nebraska PRAMS, Douglas County 2004-2006(all but smoking are statistically significant by race/ethnicity)
30
Local, population-based data on risk factors for Prematurity
(need for prenatal care, screening)
Nebraska PRAMS, Douglas County 2004-2006(all but smoking are statistically significant by race/ethnicity)
% Among
White
% Among
Black
% Among
All
Previous Preterm 4 11 6
Below 200% Poverty Level 27 84 43
Smoking prior to pregnancy 26 27 22
Stress (4 or more events PRAMS 2004-2006)
16 35 19
Physical Abuse 7 13 9
31
Mental Health and Depression,Prenatal and Post-partum
Nebraska PRAMS, Douglas County 2004-2006
0
5
10
15
20
25
Whit
eBlac
k
Native
Am
er.
Asian/
Pac
Hispan
ic All
Pe
rce
nt
Sought help for depression during pregnancyFelt depressed post-partum--always or oftenFelt no interest post-partum--always or often
32
Taking Recommendations to Action
BBC members were informed and educated on ACOG standards for prenatal risk assessment
Tobacco prevention education incorporated into Now and Beyond preconception health education program
33
Smoking and Prematurity(attributable risk example)
• The odds of having a preterm birth if a woman smokes is 1.5 times the odds of having a preterm birth if she doesn’t (Creasy et al., 2004)
• The prevalence of smoking during the last three months of pregnancy in Douglas County 2000-2003 was 14% (PRAMS Nebraska 2004-2006).
Population Attributable Risk= PARP = PREV*(OR-1)/[PREV*(OR-1) + 1] =6.5% (we could eliminate 6.5% of prematurity by not smoking)
34
Priority FIMR Recommendation
Tobacco cessation services and resources will be covered and available for women of child bearing age, their families and involved significant others. – Maternal tobacco use before, during and after
pregnancy– Tobacco use of involved significant others in
home– Lack of resources/ services for tobacco
cessation with pregnant Moms
35
Priority FIMR Recommendation
Every pregnant woman should receive early prenatal risk assessment that identifies physical, psychosocial, economic and cultural/ linguistic issues– Previous preterm birth– Pre-existing maternal health conditions– Late entry to prenatal care
36
Priority FIMR Recommendation
Mental health services/ resources will be available to women of child bearing age, involved significant other and their families– Multiple life stressors/ social chaos for Mom and
family prior to pregnancy– Maternal history of mental illness before pregnancy– Lack of mental health services prior to and after
pregnancy
37
Priority FIMR Recommendation
Every woman should receive preconception education including birth spacing– Short pregnancy spacing– Previous poor pregnancy outcome with preterm
delivery– Unintended pregnancy
38
Supported by theDouglas County
Health Department
Taking Recommendations to Action
39
What FIMR and PPOR can Accomplish
• Vital records narrow the focus to problem areas, and justify starting FIMR.
• Population-based data help find likely causes.
• FIMR promotes better understand of contributing factors, and discovers information not previously measured.
• Population-based data support and prioritize FIMR recommendations.
40
FIMR and PPOR both rely on community / stakeholder engagement to . . .
• Ensure priority recommendations are translated into science-based action
• Build on existing resources and strengths in community
41
Thank you.