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Disclosures None Laborists in Your Practice? Sarah B Wilson MD - - PowerPoint PPT Presentation

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10/25/2013 Disclosures None Laborists in Your Practice? Sarah B Wilson MD M.Ed. Assistant Professor Laborist Department of Obstetrics, Gynecology and Reproductive Sciences University of California, San Francisco Audience Poll Objectives

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SLIDE 1

10/25/2013 1

Laborists in Your Practice?

Sarah B Wilson MD M.Ed.

Assistant Professor Laborist Department of Obstetrics, Gynecology and Reproductive Sciences University of California, San Francisco

Disclosures

  • None

Objectives

  • Describe what hospitalists and laborists

are

  • Explain how laborist models work in

different practice settings

  • Describe proposed positive and negative

attributes of the laborist model

  • Summarize the evidence about how

laborists have affected practice

Audience Poll

Describe your practice:

OB only GYN only Generalist OB/... Subspecialist ... Other

0% 3% 11% 8% 78%

  • A. OB only
  • B. GYN only
  • C. Generalist OB/GYN
  • D. Subspecialist (MFM,

Gyn Onc, REI etc)

  • E. Other
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SLIDE 2

10/25/2013 2

Audience Poll

Define your practice setting:

T e a c h i n g h

  • s

p i . . . P r i v a t e P r a c t i . . . K a i s e r C

  • m

m u n i t y H

  • s

p . . . O t h e r

11% 38% 16% 16% 19%

  • A. Teaching hospital/clinics
  • B. Private Practice
  • C. Kaiser
  • D. Community Hospital: inpatient

med

  • E. Other

Internal Med Hospitalist Concept

  • Kaiser reorganized care models 1994

– “Hospital-based Specialists”

  • Wachter and Goldman 1996

– “ Emerging Role of ‘Hospitalist’ Concept in the American Health Care System” NEJM – Specialized care for inpatients

Hospitalist Concept

  • Proposed benefits

– Hospital medicine specialization, higher value care – Efficiency of care delivery – House-staff training

  • Possible disadvantages

– Decreased continuity of care – Skilled hospitalist would use specialists less

  • Questioned role of the internal med

generalist

Impact of Hospitalists on Care

  • Significant reductions in resource use

– 13.4% reduction in hospital costs – 16.6% reduction in average length of stay

  • Patient satisfaction preserved
  • Inconsistent, but some positive effects on

care

– Decreased readmission rates

Goldman JAMA 2002

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10/25/2013 3

Introduction of the “Laborist”

  • Extrapolation of the hospitalist concept to

L&D

  • Weinstein AJOG 2003

– Possible solution to problems in our field

  • Marked professional dissatisfaction/burnout
  • Stopping obstetrics at an earlier age
  • Shortage of obstetricians in some communities

What is a laborist?

  • Many different models of care
  • Strictest definition

– Physician dedicated to inpatient care, primarily on L&D – Premise of continuous coverage and

  • versight
  • Also GYN hospitalists increasing

Models of Care

  • Teaching hosp vs. community hosp
  • Full-time hospital employee vs. rotating

schedule of community physicians

  • Care of all patients in L&D vs. care for

unassigned/uninsured patients vs. only care for emergencies

Gussman et al, ACOG.org

Program Finances: Hospital Salaried Model

  • Costs

– Need 4-4.5 full time – Salaries, benefits and malpractice ≈1.5 million

  • Ways to pay for full-time laborists?

– ABOG statement: Bill separate components – Private practice bills global and pays agreed fee for using laborists – Laborist is present 24/7 so can bill more items

  • Triage, version, surgical assist

– Reduced malpractice premiums

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10/25/2013 4

UCSF Laborists

  • Dedicated to obstetrical care
  • Monthly schedule

– 1 week 5 L&D day shifts – 1 week 4 L&D night shifts – 2 weeks outpatient clinic sessions – 1 24hour weekend shift

  • Part of MFM Division
  • Cost coverage

– Global billed for faculty group, no need to divvy up – MFMs relieved for consults, outreach and PDC

What does your practice look like?

Do you have laborists in your hospital or practice?

Y e s N

  • 31%

69%

  • A. Yes
  • B. No

Are you a laborist/hospitalist?

Y e s N

  • 93%

7%

  • A. Yes
  • B. No

Extent of Implementation of Laborists

  • 2010 ACOG membership survey 1

– 15% of respondents (3.6% of the entire sample) identified as a laborist or OB/GYN hospitalist

  • National Perinatal Information Center/Quality

Analytic Services 2 – 25/68 hospitals employ laborists

1: Funk et al, AJOG 2010, 2: Srinivas et al Journal of Maternal- Fetal and Neomatal Medicine 2012

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10/25/2013 5

Proposed Advantages/ Disadvantages

Positives:

  • Dedicated L&D coverage timely care
  • Improved quality of care
  • Increased provider satisfaction, work life balance
  • Improved patient safety/teamwork
  • Reduction in liability claims

Negatives:

  • Lack of continuity of care
  • Reimbursement issues and reduced pay
  • Disagreement in management plans
  • Decreased patient satisfaction
  • Increased errors with more handoffs

Srinivas et al AJOG 2012

Timely Delivery of Care

  • Dedicated 24 hour coverage
  • Timely response to obstetric emergencies

improves maternal and neonatal

  • utcomes
  • Impact of laborists on these processes

and outcomes: no research yet

Effect on Cesarean Delivery Rates

  • Tertiary hospital: studied transition to laborists
  • C section rates over three time periods

– No laborists (first 16 months): 39.2% c section rate – Continuous coverage community staff (14 months): 38.7% – Full-time laborists (24 months): 33.2%

  • Significant reduction in c sections with full-

time laborist vs no laborist

– Adjusted OR 0.72 p<0.0001

Iriye et al AJOG 203

Patient Safety Outcomes

  • No formal outcome studies yet
  • Full-time dedicated laborist

– Speculated as safest option – Attending OB knows all patients – Primary point person for staff

Olsen et al AJOG 2012

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SLIDE 6

10/25/2013 6

Reduced Liability Claims

  • Improved coverage decreased

malpractice claims?

  • Study: Analyzed paid claims of large liability

insurance company from 2000-2005

– 70% of claims involved substandard care – Concluded that over half of hospital litigation costs could be avoided with 24 hr in-house coverage

Clark et al Obstet Gynecol 2008

Patient Satisfaction

  • Less continuity of care = less patient

satisfaction?

  • Study: University-owned urban teaching

hospital patient responses n=4166

– Compared Press-Gainey survey results pre/post laborist implementation – 90% highly satisfied – Similarly favorable results in both time periods

Srinivas et al, Patient Preference and Adherence 2013

Increased Handoffs with Shift Work

  • Lessons learned from Hospitalists
  • Six Pillars of Handoffs

– Communicate, but do not irritate – Consult the primary care physician – Timeliness is next to godliness – Partner with the patient – Make it clear that you are the pt’s advocate (not just part of the system) – Pass the baton as graciously as received

Goldman et al Disease a Month 2002

Successful implementation of laborists

  • Established means of communication

between primary physician and laborist

  • Inpatient protocols

– Consensus about inpatient treatment – Ex: induction or postpartum order sets

ACOG Committee Opinion #549, 2010

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10/25/2013 7

Lessons from the IM Hospitalist movement

  • Focus on gathering data to demonstrate

value

  • Intentional link between hospitalist field

and patient safety and quality of care What should be OB/GYN’s next steps?

Wachter J Hosp Med 2006

Audience Poll

How do you feel about having laborist as part of your practice?

Overall Positi... Neutral Overall Negati...

51% 12% 37%

  • A. Overall Positive
  • B. Neutral
  • C. Overall Negative

Thank you.

  • Questions?