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6/15/2019 Disclosures No financial disclosures OB Hospital Medicine: Improved Quality & Safety Society of OB/GYN Hospitalists (SOGH) Board of Directors Vasiliki Tatsis, MD MS MBA Academic Committee Chair Associate Professor

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6/15/2019 1

OB Hospital Medicine: Improved Quality & Safety

Vasiliki Tatsis, MD MS MBA Associate Professor Director OB/GYN Hospitalist Program University of California, San Francisco

Disclosures

No financial disclosures
Society of OB/GYN Hospitalists (SOGH)
Board of Directors
Academic Committee Chair

Objectives

1. Review the evolution and definition of OB hospital medicine
2. Discuss the benefits of OB hospital medicine
Patient outcomes
Patient satisfaction
Quality of care & financial solvency
3. Future directions

 Increasing Patient Complexity  Competing Provider Priorities  Diverging Skill Sets

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2003: Weinstein, AJOG – “The Laborist” 2011: 30K hospitalists ~165 OB Hospitalist programs¹

1Olson R et al, AJOG, Aug 2012.

2018: >300 OB Hospitalist programs 2 new programs/month

Evolution of the OB Hospitalist Movement

Today’s OB Hospitalist

2016: ACOG Committee Opinion – “The OB/GYN Hospitalist”

2010: SOGH founded

“The term ‘hospitalist’ refers to physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities may include patient care, teaching, research, and inpatient leadership. ACOG supports the continued development and study of the OB/GYN hospitalist model as one potential approach to improve patient safety and professional satisfaction across delivery settings.”

Hospitalist Model Types: Provider Mix

Hybrid

% Hospitalist % Community OB/GYNs

Community Laborist

100% Community OB/GYNs

Hospitalist

100% Hospitalist

Hospitalist Providers:

Generalist OB/GYNs
Fellowship Trained
MFM
Critical Care OB
OB/GYN Hospital Medicine

McCue et al. Definitions of obstetric and gynecologic hospitalists. Obstet Gynecol, 2016;0.

×

“OB Hospitalist”

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Benefits of OB Hospitalist Programs

Clinical Outcomes
Patient Satisfaction
Financial solvency

Important Quality Metrics

Cesarean rates 1994-2003: 21%  32.7%
Increased on weekdays before & clinic, at lunch¹
Financial costs
Commercial insurers: $9537 (34%) higher than for SVD
Medicaid: $4459 (33%) higher than for SVD
1% reduction in cesarean rates = $254M/yr!!
Fee-for-service payment models disincentivize vaginal deliveries
Privately insured births vs salaried physicians with no financial incentive²
VBAC rates
Provider preference often drives mode of delivery³
Malpractice risk/litigation
Payments incentivize repeat cesarean

¹Clark SL et al. Association of obstetric intervention with temporal patterns of childbirth. Obstet Gynecol 2014;124(5):873-880. ²Kozhimannil KB et al. Trends in hospital-based childbirth care: the role of health insurance. Am J Manag Care. 19(4):e125-e132. ³Iriye et al. Implementation of a laborist program and evaluation of the effect upon cesarean delivery. Am J Obstet Gynecol. 2013;209:251.e1-e6. Overall cesarean and low-risk cesarean delivery: US, 1990-2012. CDC/NCHS, National Vital Statistics System.

2006-2011, tertiary care hospital
Retrospective, N=6206 nulliparas
Cesarean Rates Over 3 time periods:
No laborist care, traditional model: 39.2%
Community physician laborist care: 38.7%
Full-time laborists: 33.2% (p<0.001)

NTSV c/s decreased daily by 0.45  ~$3K cost savings to the hospital .

Retrospective cohort:
9381 singleton live births
Equal mix of publically and privately insured
2 practice models in one hospital
2005-2014
Prospective: N=3560 nulliparas, N=1324 prev c/s
Practice change L&D restructuring
Privately & publically insured: same care
Private MDs participate in laborist call + CNM
Results:
Primary Cesarean Rate: 31.7%  25.0%

(p=0.005)

VBAC Rate: 13.3%  22.4%

NTSV C/S Rate VBAC Rate

Privately Insured Decreased (p=0.0009) Increased (p=0.04) Publically Insured Decreased (p=0.1) Increased (p=0.34)

C/S Rate (%) NTSV C/S Rate (%) VBAC Rate (%) Private 31.6 29.8 28.7 Laborist 17.3 15.9 58.6 p-value <000.1 <0.001 <0.001 Two Practice Models in One Labor and Delivery Unit: Association with Cesarean Delivery Rates

Nijagal M et al. Am J Obstet Gynecol , 2015.

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CNMs & Obstetricians: Embracing Collaboration

Midwife-laborist practice models show

decreased cesarean¹ and increased VBAC rates²

Interprofessional collaboration – best way to

save lives (Lancet Midwifery Series)

Scaled global perspective  institution level
Have mechanisms/processes
System strengthening & institutional preparedness
Increasing complexity and diverse care needs
Humanistic supportive care reflected in CNM

core competencies

Call to re-examine traditional roles: integrate

care for patient-centered focus

¹Nijagal et al. Two practice models in one labor and delivery unit: association with cesarean delivery rates. Am J Obstet Gynecol. 2014;212:1.e1-e8. ²Rosenstein et al. The association of expanded access to a collaborative midwifery and laborist model with cesarean delivery rates. Obstet Gynecol. 2015;126(4):716-723.

1998-2011, cohort study
>500,000 patients
24 hospitals (8 laborist, 16 non-

laborist)

Laborist program implementation:
Fewer inductions
Decreased preterm birth
No adverse effects on other
utcomes

Comprehensive Safety Strategies & Adverse Outcomes

Pettker CM et al. Impact of a comprehensive patient safety strategy on obstetric adverse events. Am J Obstet

Gynecol. 2009 May;200(5):492.e1-8

24/7 Hospitalists

OB Hospitalists & Patient Satisfaction

Patients are willing to trade familiarity for availability/competence¹

Satisfaction surveys after implementation of full-time laborist program²
Pre and post laborist program Press-Ganey scores compared
No change  pts NOT less satisfied
93% rated childbirth experience as “excellent” or “very good”
49% delivered by their own provider
85% were made aware their provider might not deliver baby
Key: Setting expectations of hospital birth experience

¹Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA 2002;287:487-94 ²Srinivas SK, et al. Patient satisfaction with the laborist model of care in a large urban hospital. Patient Preference and Adherence 2013;7:217-222.

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OB Triage  OB Emergency Department

CRITICAL ELEMENTS:

Dept of Public Health Licensing
2 dedicated RNs
Medical Screening Exam by MD - <30 minutes
Goal: determine if an emergency condition exists
Fewer disparities & care delays
Poor outcomes mitigated
Increased nursing satisfaction/retention¹
Processes to bill as an ED
Modest increase in prof fees, substantial increase in facility fee
Increased reimbursement at ED rates outside of global
FINANCIAL SOLVENCY

¹Wolfe S. Hospitalists: good or bad for nurses? RN 2000;63(3):31-3.

Malpractice: Fewer Claims & Compensation Payments

Gruenbaum et al. Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events. Am J Obstet Gynecol. 2011 Feb;204(2):97-105.

Pettker CM et al, A comprehensive obstetric patient safety program reduces liability claims and payments. Am J Obstet Gynecol. 2014 Oct;211(4):319-25.