Unnecessary Early Deliveries June 22, 2011 Chicago, Illinois This - - PowerPoint PPT Presentation

Summit on Preventing Unnecessary Early Deliveries

June 22, 2011 Chicago, Illinois

This activity is supported through a grant from the National Business Coalition on Health and United Health Foundation

Agenda

8:30 – 8:50 I. Welcome and Introductions 8:50 – 9:30 II. What is the Status of Pre-Term Deliveries

• A. Charlene Wells, Illinois Dept of Public Health
• B. Alan Fleischman, MD, March of Dimes

9:30 – 10:50 III. What is Being Done to Reduce Unnecessary Early Deliveries?

• A. Leah Binder, Leapfrog Group
• B. Maureen Corry, Childbirth Connection
• C. Gail Amundsen, MD, Quality Quest for Health
• D. Health Plan Activities

10:50- 12:00 IV. What Gaps Exist in the Present Activities and What Can be Expanded to Chicago? 12:00- 12:30 V. Next Steps - Adjournment

Participating Organizations

Access Community Health Network Advocate Health Care Aetna American Medical Association BlueCross BlueShield of IL Chicago Dept. of Public Health Chicago Hispanic Health Coalition Chicagoland Chamber Childbirth Connection Health Alliance Healthland Healthcare Coalition Hospira, Inc. Humana

• Ill. Amer. Academy of Pediatrics
• Ill. Amer. College of OB-Gyne

Illinois Chamber

• Ill. Dept of Healthcare and Family

Services

• Ill. Dept. of Public Health
• Ill. Hospital Association
• Ill. Maternal and Child Health Coalition
• Ill. Public Health Institute

Jewish Federation of Metro. Chicago Leapfrog Group March of Dimes Midwest Business Group on Health Navistar Pactiv Corporation Quality Quest for Health Resurrection Medical Center Rush United Health Care

ELIMINATING PRETERM BIRTHS

STATISTICAL INFORMATION

DEFINITION PRETERM BIRTH

• Preterm infants (those born at <37 completed weeks of gestation)

less likely to survive to their first birthday than infants delivered at higher gestational ages, and those who do survive, especially those born at the earlier end of the preterm spectrum, more likely to suffer long-term disabilities than infants born at term (1,2).

• During 1981--2006, the U.S. preterm birth rate increased >30%, from

9.4% to 12.8% of all live births (3). Although lower during 2007 and 2008, the U.S. preterm birth rate remains higher than any year during 1981—2002 (3,4).

Live Births by Birth Weight Group and Year, Illinois Residents, 1998-2007

Birth weight Group (grams) 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Total Births 196,705 196,208 199,315 198,400 194,907 197,089 195,485 193,764 195,700 195,505 0001-0499 424 447 435 395 417 417 410 404 410 395 0500-0999 1,130 1,214 1,248 1,078 1,158 1,115 1,108 1,171 1,126 1,107 1000-1249 629 692 615 630 673 654 673 603 645 689 1250-1499 751 719 769 772 771 760 833 754 783 747 1500-1749 1,169 1,149 1,116 1,096 1,065 1,193 1,141 1,160 1,159 1,163 1750-1999 1,787 1,739 1,801 1,848 1,758 1,777 1,874 1,905 1,946 1,847 2000-2249 3,068 2,980 2,987 3,155 3,073 3,181 3,154 3,206 3,329 3,311 2250-2499 5,668 5,688 5,776 5,799 5,854 6,016 6,037 6,093 6,209 6,111 Total -<500 gms 14,202 14,181 14,312 14,378 14,352 14,696 14,820 14,892 15,197 14,975 2500-2749 9,976 9,900 9,949 10,150 9,999 10,397 10,273 10,514 10,555 10,799 2750-2999 20,285 20,256 20,523 20,659 20,247 20,982 21,080 21,257 21,809 21,908 3000-3499 66,815 66,767 68,232 68,488 67,584 68,409 68,125 68,322 69,713 69,735 3500-3999 52,502 52,226 53,138 52,198 50,998 50,898 50,153 48,646 48,300 48,511 4000-4499 15,487 15,438 15,537 14,939 14,396 14,156 13,534 12,739 12,528 12,332 4500-4999 2,503 2,475 2,526 2,491 2,279 2,132 2,058 1,882 1,750 1,681 5000-8165 277 285 300 268 239 257 188 168 176 161 Unknown 32 52 51 56 44 49 24 48 65 33

PRETERM BY MATERNAL AGE

Illinois, 2006-2008 Average

Preterm is less than 37 completed weeks gestation. Source: National Center for Health Statistics, final natality data. Retrieved June 21, 2011, from www.marchofdimes.com/peristats.

PRETERM BIRTH

Illinois, 1998-2008

Preterm is less than 37 completed weeks gestation. Source: National Center for Health Statistics, final natality data. Retrieved June 21, 2011, from www.marchofdimes.com/peristats.

PRETERM BY RACE

Illinois, 2006-2008 Average

Preterm is less than 37 completed weeks gestation. Source: National Center for Health Statistics, final natality data. Retrieved June 21, 2011, from www.marchofdimes.com/peristats.

LATE PRETERM BIRTHS BY MATERNAL AGE

Illinois, 2006-2008 Average

Late preterm is between 34 and 36 weeks gestation. Source: National Center for Health Statistics, final natality data. Retrieved June 21, 2011, from www.marchofdimes.com/peristats.

LATE PRETERM BIRTHS

Illinois, 1998-2008

Late preterm is between 34 and 36 weeks gestation. Source: National Center for Health Statistics, final natality data. Retrieved June 21, 2011, from www.marchofdimes.com/peristats.

LATE PRETERM BIRTHS BY RACE

Illinois, 2006-2008 Average

Late preterm is between 34 and 36 weeks gestation. Source: National Center for Health Statistics, final natality data. Retrieved June 21, 2011, from www.marchofdimes.com/peristats.

Completed Legislative Action

July 20 2010 - Public Act . . . . . . . . . 96-1117 Amends the Prenatal and Newborn Care Act. Provides that the Department of Public Health (IDPH) shall publish on its website information about the possible health complications associated with newborn infants who are born premature at less than 37 weeks gestational age and the proper care and support for these newborn infants. Provides that in determining what information is most beneficial to the public, the Department may consult with pediatric healthcare providers, community organizations,

• r other experts as the Department deems necessary. Requires the Illinois

Department of Healthcare and Family Services to consult with statewide organizations focused on premature infant healthcare in order to accomplish certain goals Provides that IDPH shall ensure that the information is accessible to children's health providers, maternal care providers, hospitals, public health departments, and medical

• rganizations.

Requires data regarding the incidence and cause of re-hospitalization in the first 6 months of life for infants born premature at earlier than 37 weeks gestational age to be reported to the Director of Public Health. Effective immediately.

HJR 0111

RESOLVED, BY THE HOUSE OF REPRESENTATIVES OF THE NINETY-SIXTH GENERAL ASSEMBLY OF THE STATE OF ILLINOIS, THE SENATE CONCURRING HEREIN, that we urge the Perinatal Advisory Committee within the Illinois Department of Public Health to investigate how Illinois can reduce the incidence of preterm births in Illinois; and be it further RESOLVED, That the Perinatal Advisory Committee shall consult with a representative

• f the Illinois Department of Human Services, a representative of the Illinois Department
• f Healthcare and Family Services, a representative of an organization whose main

focus is on preterm births; 2 members of the Illinois House of Representatives, one of whom shall be named by the Speaker of the House, and one of whom shall be named by the Minority Leader of the House; and 2 members of the Senate, one of whom shall be named by the President of the Senate and one of whom shall be named by the Minority Leader of the Senate; and be it further; RESOLVED, That the Perinatal Advisory Committee shall, in a written report that is to be delivered to the General Assembly on or before November 1, 2012, make findings and recommendations concerning reducing preterm births in Illinois;

Alan Fleischman, M.D.

Senior Vice President and Medical Director Midwest Business Group on Health--Summit June 22, 2011

Can we Prevent Non-Medically Indicated Early Deliveries?

President Franklin Delano Roosevelt--1938

• Bring Science into

Service for People

• Gather the Power of

Volunteers

• Earn the Public Trust

March of Dimes Mission

The mission of the March of Dimes is to improve the health of babies by preventing birth defects, premature birth and infant mortality.

March of Dimes

From its beginning, the March of Dimes has carried out its mission through research, community intervention programs, education, and advocacy

Institute of Medicine Report: Preterm Birth: Causes, Consequences, and Prevention, 2006

United States cost per year: $26.2 Billion

Total costs $26.2 Billion

Thomson Reuters for the March of Dimes, 2009

Average Expenditure for Newborn Care

(privately insured through employer)

Changing Distribution of Singleton Live Births United States, 1992, 1997, 2002, 2006

0% 5% 10% 15% 20% 25% 30% 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44

Gestational Age (weeks) Percent

1992 1997 2002 2006

Peak Shifted: 40 to 39 weeks

Source: National Center for Health Statistics, final natality data Prepared by March of Dimes Perinatal Data Center, 2009

Over 4 million babies born per year

5 10 15 20 25

28 30 32 34 36 38 40 42 44

Percent Gestation in weeks

1996 C-section 1996 Vaginal 2004 C-section 2004 Vaginal

C-section Vaginal

Singleton Births by Gestational Age and Method of Delivery, (U.S. 1996 – 2004)

Between 1996 and 2004:

• 10% increase in preterm

singleton births

• 36% increase in C-section rate

for singleton preterm births

Bettegowda VR, et al. The Relationship Between Cesarean Delivery and Gestational Age Among U.S. Singleton Births. Clinics in Perinatology, May, 2008.

Contemporary Cesarean Delivery Practice in the United States (2002-2008)

Induction Rates:

• Attempt Vaginal Delivery

43.8% (21.1% C-Section) C-Section Rates:

• Overall

30.5%

• Nulliparous:

31.2%

• Prelabor:

30.9% Vaginal Birth After C-Section:

• 28.8% of women with prior c-section had trial of labor–

57.1% of these women delivered vaginally

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

Accuracy of Gestational Dating

(Guidelines for Perinatal Care 6th Edition, October, 2007)

“Management of pregnancy requires establishing an estimated date of delivery.” An ultrasound examination is most accurate when performed before 20 weeks of gestation – 6-10 weeks +/- 3 days – 10-14 weeks +/- 5 days – 14-20 weeks +/- 7 days

• >20 weeks +/- 7-14 days

Definitions

Weeks of Pregnancy

37 41

Late Preterm

22

Preterm Term

Definitions

Weeks of Pregnancy

34 37 41

Late Preterm

22

Preterm Term

Definitions

Weeks of Pregnancy

34 37 39 41

Late Preterm Early Term Full Term

22

Preterm Term

Definitions

Weeks of Pregnancy

34 37 39 41

Late Preterm Early Term Full Term

22

Preterm Term

Preterm Birth Rates by Gestational Age

• U. S., 1990, 2000, 2005-2009*

1.92 1.93 2.03 2.04 2.04 1.99 1.40 1.49 1.60 1.62 1.59 1.57 7.30 8.22 9.09 9.14 9.03 8.77 2 4 6 8 10 12 14

1990 2000 2005 2006 2007 2008 2009*

LPTB (34-36 wks) 32-33 wks VLBW (<32 wks) 11.6 10.6 12.7 12.7 12.8 12.3 12.2 *2009, provisional -- Source: National Vital Statistics Reports Percent

U.S. Preterm Birth Rates

3.3 3.3 3.4 3.5 7.3 7.7 8.2 8.8 2 4 6 8 10 12 14 1990 1995 2000 2008 Year

less than 34 weeks Late Preterm (34-36 6/7 weeks)

71% Late Preterm

%

10.6 11.6 12.3 11.0

Change in preterm birth rates, by state: U.S., 2006 - 2008

Source: Martin JA, Osterman MJK, Sutton PD. Are preterm births on the decline in the United States? Recent data from the National Vital Statistics

• System. NCHS Data Brief, No 39. Hyattsville, MD: National Center for Health
• Statistics. 2010. Percent change prepared by the March of Dimes Perinatal

Data Center, May 2010.

• 12.8%
• 2.3%
• 1.9%
• 7.1%

+5.8%

• 2.9%
• 6.3%
• 1.9%
• 2.7%
• 3.4%
• 15.5%
• 12.5%
• 4.3%
• 6.6%
• 8.3%
• 6.3%
• 5.6%
• 5.1%
• 3.6%
• 4.8%
• 0.9%
• 2.6%
• 3.9%
• 1.5%
• 6.1%
• 4.3%
• 4.5%
• 6.1%

+1.6%

• 8.8%
• 5.3%

CT: 0% DE: -5.8%

• 3.1%

0%

• 5.0%
• 7.3%
• 7.2%

MD: -3.7% MA: -4.4% NH: -7.7%

• 1.0%

RI: -11.1% NJ: -3.1%

• 3.2%
• 5.1%
• 1.7%
• 7.1%
• 8.8%
• 2.1%

VA: -5.8%

Risk Factors for Preterm Labor & Delivery

• Behavioral
• Tobacco, AlcoholNutrition– Under-nutrition and

Obesity

• Illicit Drug Use
• Psychosocial
• Stress– Severe Acute, Chronic Unremitting
• Social Supports– Resources, Human Interactions
• Intendedness of Pregnancy and inter-pregnancy

interval

Risk Factors for Preterm Labor & Delivery

• Sociodemographic
• African-American Race
• Maternal Age-- <16 and >35
• Poverty
• Medical
• Uterine, cervical, placental abnormalities
• Prior Preterm Birth-- Genetic Predisposition
• Chronic Illness (Hypertension, diabetes, etc.)
• Assisted Reproduction– Singleton or Multiples
• Twins and Higher Order Multiples

Risk Factors for Preterm Labor & Delivery

• Groups at highest risk:
• History of preterm labor/delivery
• Current multifetal pregnancy
• African-American
• Non-medically indicated Iatrogenic

intervention

Eliminate Non-Medically Indicated Deliveries Before 39 Weeks

Available at: marchofdimes.com

• r

cmqcc.org

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Toolkit Authors:

Elliott Main, MD Bryan Oshiro, MD Brenda Chagolla, RN, MSN, CNS Debra Bingham, Dr.PH, RN Leona Dang-Kilduff, RN, MSN Leslie Kowalewski

Author Organizations:

California Maternal Quality Care Collaborative (CMQCC) California Pacific Medical Center Loma Linda University School of Medicine Catholic Healthcare West California Perinatal Quality Care Collaborative (CPQCC) March of Dimes

Funders

Federal Title V block grant--California Department of Public Health March of Dimes

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Letters of Support

• American Congress of Obstetricians and

Gynecologists District II (New York)

• American Congress of Obstetricians and

Gynecologists Illinois Section (District VI)

• American Congress of Obstetricians and

Gynecologists District IX (California)

• American Congress of Obstetricians and

Gynecologists FACOG (Florida)

• American Congress of Obstetricians and

Gynecologists District XI (Texas)

• Association of Women’s Health Obstetric and

Neonatal Nurses (National) and (California)

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Why are non-medically indicated (elective inductions and scheduled cesarean deliveries) increasing in frequency?

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Sounds like a good idea…

 Advanced planning  Convenience  Delivered by her doctor  Maternal intolerance to late pregnancy

 Excess edema, backache, indigestion,

insomnia

 Prior bad pregnancy  And, it’s okay right?

Clin Obstet Gynecol 2006;49:698-704

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

See Toolkit for more data and full list of citations Clark 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

• ther transition issues

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What Motivates Some Obstetricians?

 Physician convenience

 Guarantee attendance at birth  Avoid potential scheduling conflicts  Reduce being woken at night

 … what’s the harm?

 Amnesia due to rare occurrence.  The NICU can handle it.

 And…

Clin Obstet Gynecol 2006;49:698-704

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Women’s Perceptions Regarding the Safety

• f 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.

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

13

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Table of Contents



Making the Case



Implementation Strategy



Data Collection/QI Measurement



Clinician Education



Patient Education



Appendices

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Key Change Components



Identify Physician Champion



Create (Rewrite) Hospital Policy



Establish Professional Consensus on: “Indications for Early Delivery”

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Key Change Components



Develop Scheduling Form and Process



Establish Medical Leadership “Hard Stop” Process



Secure Buy-In



Collect Data to Drive Change



Review Progress Serially

What do we need to get started?

MAP-IT

 Mobilize  Assess  Plan  Implement  Track

Guidry, M., Vischi, T., Han, R., & Passons, O. Healthy people in healthy communities: A community planning guide using healthy people

• 2010. Washington, D.C.: U.S. Department of

Health and Human Services. The Office of Disease Prevention and Health Promotion.

Examples of Successful Programs to Reduce Non-medically Indicated Deliveries Before 39 week of Gestation

 Magee Women’s Hospital (Pittsburgh)  Intermountain Healthcare (Utah)  Ohio Perinatal Quality Collaborative

(State Department of Health)

Common Themes

 Started with professional education to

• bstetricians regarding ACOG guidelines

and best practices.

 Modest change at most, until physicians

were held accountable, nurses were empowered, and guidelines were enforced (“Hard stop”).

 Medical leadership critically important.

Magee Women’s Experience with Guidelines

Baseline 3mos 2004 Voluntary 3mos 2005 Enforced 14mos 2006-7 Deliveries 2,139 2,260 10,895 Elective Inductions <39wks (rate) 11.8% 10.0% 4.3% (p<0.001) Elective Nullip Inductions =>C/S (rate) 35.7% 15.2% 13.8% (p<0.01) Total Induction Rate 24.9% 20.1% 16.6% Fisch et al Obstet Gynecol 2009;113:797

% Non-medically Indicated Deliveries <39 Weeks January 1999 – December 2005

Oshiro, B. et al. Obstet Gynecol 2009;113:804-811.

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Results (1): Fewer Births at 360/7-386/7 Weeks Without Documented Medical or Obstetrical Indications

Am J Obstet Gynecol 2010; 202:243.e1-243.e8

OPQC Project

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Results (2): Fewer Births at 360/7-386/7 Weeks Induced Without Medical or Obstetric Indication

Am J Obstet Gynecol 2010; 202:243.e1-243.e8

(arrow indicates OPQC startup)

OPQC Project

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Results (3): Fewer Total Births at 36-38 Weeks (and More Births at 39-41 Weeks)

2% decrease in births 36-38 weeks and 2% increase in births 39-41 weeks; Approximately 1,000 births moved to >390/7

Am J Obstet Gynecol 2010; 202:243.e1-243.e8

(arrow indicates OPQC startup)

OPQC Project

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Obstetricians Voice Concerns: Do These Programs Increase Perinatal Mortality and Maternal Morbidity?

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Stillbirths Before and After Implementation of Guidelines Intermountain Healthcare

Oshiro, B. et al. Obstet Gynecol 2009;113:804-811.

1999-2000 July 2001 to June 2006

Weeks of Gestation Stillbirths Deliveri es % Stillbir ths Deliveries % Odds Ratio 95% CI 37 17 4,117 0.41 22 13,077 0.17 0.406 0.22-0.77 38 19 9,954 0.19 21 28,209 0.07 0.390 0.21-0.72 39 10 13,752 0.07 28 51,721 0.05 0.744 0.36-1.53 40 10 7,925 0.13 14 24,140 0.06 0.459 0.20-1.03 41 2 1,938 0.10 3 5,571 0.05 0.522 0.09-3.12 All 58 37,686 0.15 88 122,718 0.07 0.466 0.33-0.65

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Summary: Reasons to Eliminate Non-medically Indicated Deliveries Before 39 Weeks

• Reduction of neonatal complications
• No harm to mother if no medical or
• bstetrical indication for delivery
• Substantial cost savings
• Now a national quality measure:
• National Quality Forum (NQF)
• Leapfrog Group
• The Joint Commission (TJC)

The Big 5 States

Wh What are the uni niqu que e opportunitie rtunities for the Big g 5 St 5 States es to accomplis lish something ing signific ifican ant... t...

Big 5 States - Total

Together, the Big 5 States account for:

Source: National Center for Health Statistics

Births 1,629,521 38.2%

Hispanic Births 665,313 64.0% Non-Hispanic Black Births 202,823 32.9% Preterm Births 199,806 36.8% Late Preterm Births 142,834 36.8% C-Sections 528,018 40.0%

Current 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 5

CA, FL, IL, NY , TX

< 39 Weeks Toolkit Elimination of Elective Deliveries Implementation

• QI Hospital

Network Population- based Data Consumer Awareness

• Why the Last

Weeks of Pregnancy Count

Big 5 Hospital Network

Goal: To eliminate non-medically indicated deliveries <39 weeks in 25 network hospitals by conducting a proof of concept of the toolkit.

• A minimum of 5 hospitals from each Big 5 state selected
• Hospital QI teams carrying out change components outlined in

the toolkit

• Hospital teams participate on monthly conference calls
• Baseline data and post-implementation data collected,

analyzed and given back to the hospitals

• Tools and lessons learned will support a national rollout
• Network Timeline 9/1/2010 – 12/31/2011

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

Toward Improving the Outcome of Pregnancy III:

Enhancing Perinatal Health Through Quality, Safety, and Performance Initiatives December, 15, 2010

TIOP III: Table of Contents

Chapter 1: History of the Quality Improvement Movement Chapter 2: Evolution of Quality Improvement in Perinatal Care Chapter 3: Epidemiologic Trends in Perinatal Care Chapter 4: The Role of Patients and Families in Improving Perinatal Care Chapter 5: Quality Improvement Opportunities in Preconception and Interconception Care Chapter 6: Quality Improvement Opportunities in Prenatal Care Chapter 7: Quality Improvement Opportunities in Intrapartum Care Chapter 8: Applying Quality Improvement Principles in Caring for the High Risk Infant Chapter 9: Quality Improvement Opportunities in Postpartum Care Chapter 10: Quality Improvement Opportunities to Promote Equity in Perinatal Health Outcomes Chapter 11: Systems Change Across the Continuum of Care Chapter 12: Policy Dimensions of Systems Change in Perinatal Care Chapter 13: Opportunities for Action and Summary of Recommendations

NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights

March 8–10, 2010, Bethesda, Maryland

NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights

Conclusions:

• A trial of labor after a previous c-section is “reasonable.”
• There are substantial barriers that women face in

accessing clinicians and facilities that are able and willing to offer a trial of labor.

• Medico-legal considerations add to and exacerbate these

barriers.

• Healthcare organizations and clinicians should make public

their policies about VBAC so women can make informed choices about their healthcare provider and where they wish to deliver.

Patient Brochures

Patient Brochures

Summary: Reasons to Eliminate Non-medically Indicated Deliveries before 39 Weeks

New Media Campaign

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.

New TV PSA

Television public service ad featuring Julie Bowen (30-seconds)

Can We Prevent Non-Medically Indicated Early Deliveries?

YES!!!!

Thank You!!!

Elective Deliveries Scheduled Early: Report from the Leapfrog 2010 Survey

Leah Binder June 22, 2011

2010 Leapfrog Hospital Survey (Run 3/31/11)

A Market-Driven Approach to Safety and Quality

1. Competitive Transparency 2. Apples to Apples Measurement 3. Customers Tie Payment to Value

A Regional Approach to National Participation 2000+ Purchasers

• Regions Drive

Survey Data Collection

• 43 Regional Roll

Outs invite hospitals to complete the survey

• Use various

incentives and recognition to drive further improvements

The Leapfrog Hospital Survey: The Gold Standard in Competitive Transparency

Shows contrasts Measures what matters to consumers Reported through a neutral or consumer

• riented source

Broad spectrum of competitive highs and lows

Hospital Compare

Example of State “Public Reporting”: South Carolina Reporting of Infection Rates

Leapfrog Reporting

Deliveries Scheduled Too Early

• Measure: The proportion of a hospital’s

newborns delivered with a gestational age between the 37th and 39thcompleted week, that were delivered electively

• Measure introduced to Leapfrog Hospital

Survey in 2009

• Fully aligned with Joint Commission and CDC
• 782 hospitals reported nationally

Too Early Deliveries: State Results

0% 5% 10% 15% 20% 25% 30% CO GA ME MI MA OH NV WA CA NJ WI NC TX IL TN VA FL NY MN SC IN AZ

Average Rate of Elective Deliveries State With More Than 10 Reporting Hospitals Average Rate of Elective Deliveries Between the 37th and 39th Completed Week: State Results (Leapfrog Hospital Survey Data 2/28/11)

2010 National Average: 2010 Leapfrog Target: 12%

Too Early Deliveries: Variation!

2010 Leapfrog Hospital Survey (Run 3/31/11) National Average: 17 % Illinois Average: 17.8%

Deliveries in Illinois

• 165 targeted hospitals; 87 hospitals

participate

• 66 hospitals reported an early elective

delivery rate to Leapfrog

• Best hospital reported a rate of 0
• 3 hospitals with rates over 60%

Illinois Results

Collaborating to Make Change

• March of Dimes
• Childbirth Connection
• 4 National Health Plans: Wellpoint, Cigna,

Aetna, United

• Hospitals, Physicians, Policymakers

Contact Us

Leah Binder, CEO The Leapfrog Group 1150 17th Street NW Ste. 600 Washington, DC 20036 (202)292-6713

transform.childbirthconnection.org/ www.childbirthconnection.org

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

Summit on Preventing Early Deliveries

Midwest Business Group on Health Chicago, Illinois June 22, 2011

Maureen Corry, MPH, Executive Director Childbirth Connection

transform.childbirthconnection.org/ www.childbirthconnection.org

• Mission is to improve the quality of

maternity care through research, education, advocacy, and policy.

Childbirth Connection

transform.childbirthconnection.org/ www.childbirthconnection.org

• Share selected findings from Listening to

Mothers national survey of women’s childbearing experiences and Milbank Report

• Provide overview of “2020 Vision” and “Blueprint

for Action: Steps Toward a High-Quality, High- Value Maternity Care System”

• Share selected Blueprint recommendations to

improve maternity care quality and value

Overview of Presentation

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transform.childbirthconnection.org/ www.childbirthconnection.org

Reasons for Choosing Maternity Caregiver

• Provider in my insurance plan 47%
• Past experience with provider/group 42%
• Friend or family recommendation 26%
• Office location convenient 26%
• Wanted female provider 26%
• Provider’s style/care options

fit my views 18%

• Provider attends birth at preferred

hospital 17%

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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%

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Interventions by Vaginal Birth

• Continuous EFM 90%
• Epidural or spinal analgesia 71%
• Attempted induction 49%
• Caregiver induced labor 34%
• Ruptured membranes 59%
• Pitocin to speed labor 55%
• Synthetic oxytocin to induce/speed labor 57%
• Bladder catherization 43%
• Episiotomy 25%

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Cesarean Birth and VBAC

• 32% cesarean rate: 16% primary, 16% repeat
• Among mothers with previous cesarean, 11%

had a VBAC for most recent birth

• Of women with previous cesarean, 45%

interested in option of VBAC, but 57% denied that option

• Most common reasons for denial: caregiver

unwillingness (45%) or hospital unwillingness (23%)

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Listening to Mothers II: In Her Own Words

“I feel I was railroaded into labor, pain medication and subsequently a cesarean

• section. The baby then had to be protected by

my husband from a spinal tap immediately after birth. I did not get to hold my baby for hours after birth. It was not enjoyable, only interfered with by my health care workers”.

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Mother’s Interest in Knowing About Complications for Decision Making

Necessary to know every or most complications before consenting to:

• Labor induction 97%
• Cesarean 98%

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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

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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

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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”.

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Evidence-Practice Gap in Maternity Care

Milbank Report, Evidence-Based Maternity Care (2008) found:

• Overuse of many practices that entail harm for

mothers and babies and health system waste

• Many effective, high-value practices that would

improve outcomes are underused

• 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/

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Maternity Care Procedure- Intensive and Costly

• Great majority of pregnant women in the U.S. are

well and healthy and enter labor at ―low risk‖ for problems

• Low-risk pregnant women have good reason to

expect an uncomplicated birth and a healthy newborn

• 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

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Examples of Overuse in Maternity Care

• Labor induction
• Continuous electronic fetal monitoring
• Epidural analgesia
• Rupturing membranes
• Cesarean section
• Episiotomy

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Maternity Care Variations

• 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
• ptimal 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)

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Examples of Underuse in Maternity Care

• Smoking cessation intervention
• External version (turning to avoid breech)
• Vaginal birth after cesarean
• Continuous labor support (“doula” care)
• Measures for comfort and labor progress
• Delayed and spontaneous pushing
• Non-supine positions for giving birth
• Delayed cord clamping
• Early skin-to-skin contact
• Interventions for breastfeeding initiation, duration
• Interventions for postpartum depression

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Best available evidence and high performing facilities and providers show that rapid gains in maternity care quality, value and

• utcomes are

within our reach.

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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”

transform.childbirthconnection.org/ www.childbirthconnection.org

2020 Vision’s Core Values and Principles

“2020 Vision” describes values, principles and goals for a high-performing maternity care system:

• Achieves optimal health outcomes and experiences for

mothers and babies through consistent provision of maternity care grounded in best available evidence of effectiveness with least risk of harm, and best use of resources

• Consistently provides care that supports innate,

hormonally-driven capacities of mothers and babies for labor, birth, breastfeeding, attachment

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Blueprint for Action

―Blueprint for Action‖ presents major recommendations and action steps for moving toward the 2020 Vision, and answers the question:

“Who needs to do what, to, for, and with whom to improve the quality of maternity care over the next five years?”

transform.childbirthconnection.org/ www.childbirthconnection.org

11 Critical Blueprint for Action Focal Areas

Liability Payment Reform Disparities Performance Measurement Development and Use of HIT Workforce Composition and Distribution Coordination

• f Care

Clinical Controversies Decision Making and Consumer Choice Health Professions Education Scope of Covered Services

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Selected Blueprint Recommendations

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Performance Measurement Fill Measure Gaps

Fill gaps to attain comprehensive set of high-quality national consensus measures at level of clinician, clinician group, facility, health plan, ACOs, to assess

• processes, outcomes, and value of care
• care coordination
• disparities
• experiences of women and families

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Improve Collection and Availability

Improve ease of collection and availability of standardized maternity care performance data to encourage

• high-quality clinical care
• allow performance measurement and comparison

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Establish National Reporting System

• Create, implement national reporting system for public

reporting of maternity data to all relevant stakeholders so it can be leveraged to improve maternity care

• Ensure that entities being measured have access to their

results in comparison with peers and any standards

• Ensure collection and reporting of performance data for

providers of out-of-hospital maternity care to assess quality and serve as a benchmark for physiologic care for low-risk childbearing women

• Build out from existing public reporting, e.g., Hospital

Compare, Joint Commission, state and regional websites

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Leverage for Improvement

Develop initiatives that use performance measurement to improve maternity care quality and value throughout the system, including

• Encourage development of state and regional quality

collaboratives that bring together health systems, health plans, Medicaid programs, employers, clinicians and consumers

• Create demo projects to test impact of performance

measures on P4P, audit and feedback, public reporting, and other QI strategies

transform.childbirthconnection.org/ www.childbirthconnection.org

Progress in Filling Measure Gaps

National Quality Forum Consensus Standards for Perinatal Care: endorsed 17 measures -9 OB

• Episiotomy rate
• Elective delivery before 39 completed weeks
• Cesarean rate for low-risk first births
• Prophylactic antibiotics for cesarean birth
• DVT prophylaxis for women having cesarean birth
• Exclusive breastfeeding at hospital discharge
• Birth trauma rate

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Progress in Filling Measure Gaps

• Joint Commission Perinatal Core Measure Set: elective

delivery prior to 39 weeks, Cesarean rate for low-risk first birth mothers, exclusive breastfeeding

• AMA Physician Consortium for Performance Improvement
• Health IT Meaningful Use Performance Measures
• Foster measure development, testing, and refinement of

priority measures through regional and state quality collaboratives, health plans, NCQA, AHRQ CVEs, others

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Progress in Filling Measure Gaps

Recommended to Secretary of HHS:

• CHIPRA Child Health Measures: Cesarean rate for low-risk

women

• Medicaid Adult Quality Measures: Elective delivery before

39 completed weeks gestation

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Shared Decision Making and Consumer Choice

• Expand opportunities/capacity for SDM processes, tools and

resources to facilitate informed choices in maternity care

• Design system incentives that reward provider and

consumer behaviors that lead to healthy pregnancies and high quality outcomes

• Revive and broaden reach of CBE through expanded

models and innovative teaching modalities

• Promote a cultural shift in attitudes toward childbirth

transform.childbirthconnection.org/ www.childbirthconnection.org

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 & concerns

honored

transform.childbirthconnection.org/ www.childbirthconnection.org

Patient Decision Aids Work

• In 55 trials addressing 23 different screening
• r treatment decisions, use has led to:
• Greater knowledge
• More accurate risk perceptions
• Greater comfort with decisions
• Greater participation in decision-making
• Fewer people remaining undecided
• Fewer patients choosing major surgery

O’Connor et al. Cochrane Database of Systematic Reviews, 2009

transform.childbirthconnection.org/ www.childbirthconnection.org

FIMDM and Childbirth Connection: Shared Decision Making Maternity Initiative

• Initiative aims to expand opportunities for SDM in

maternity care and develop electronic tools and resources to facilitate women’s informed choice

• Publish and make relevant tools available to the

public via all stakeholder channels (health plans, employers, providers, government agencies, etc.)

transform.childbirthconnection.org/ www.childbirthconnection.org

FIMDM and Childbirth Connection: Shared Decision Making Maternity Initiative

Goals include:

• improved knowledge of care options, benefits, harms
• greater consumer participation and satisfaction in

decision making

• improved provider participation and satisfaction
• reduced use of overused interventions, increased use
• f underused interventions that improve outcomes
• improved maternity care quality and value

transform.childbirthconnection.org/ www.childbirthconnection.org

Consumer Education Resources

• Women need access to full, accurate and complete

evidence-based information on harms and benefits

• f elective induction and cesarean section before 39

weeks, and at 40 or 41 weeks without a clear medical reason. childbirthconnection.org/induction. Other topics include:

• Choosing a caregiver and place of birth
• Labor pain
• Labor support
• Cesarean section
• VBAC or repeat cesarean section

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transform.childbirthconnection.org/ www.childbirthconnection.org

transform.childbirthconnection.org/ www.childbirthconnection.org

2000 4000 6000 8000 10000 12000 14000 16000 18000 20000 22000 birth center vaginal (2007) hospital vaginal no complications hospital vaginal complications hospital cesarean no complications hospital cesarean complications $12,779 $16,104 $21,775 $21,779 $1,872 $12,534 $15,779 $21,519 $21,495

National Average Charge Site and Method of Birth

Il and U.S. Average Facility Labor and Birth Charge By Method

• f Birth, 2009

Illinois US Notes: Figures do not include the following: • additional anesthesia services charge for all cesarean and most vaginal births in hospitals • additional maternity provider and newborn care charges for all hospital births. Birth center figure is average charge reported by 75 out-of-hospital birth centers in 2007. Sources: U.S. Agency for Healthcare Research and Quality, HCUPnet, Healthcare Cost and Utilization Project. Rockville, MD:

• AHRQ. Available at: http://hcupnet.ahrq.gov/

American Association of Birth Centers. Uniform Data Set. Perkiomenville, PA: AABC, 2007.

Opportunities to Improve Quality and Value in Illinois

transform.childbirthconnection.org/ www.childbirthconnection.org

Use Best Evidence About Effective Change Strategies to Guide All Initiatives

Key maternity care sources include:

• Chaillet et al. Evidence-based strategies for implementing guidelines in
• bstetrics: a systematic review. Obstet Gynecol 2006;108(5):1234-45.
• Chaillet and Dumont. Evidence-based strategies for reducing cesarean

section rates: a meta-analysis. Birth 2007;34(1):53-64.

• Khunpradit S, Tavender E, et al. Non-clinical interventions for reducing

unnecessary cesarean section. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD005528. DOI: 10.1002/14651858. CD005528.pub2.

transform.childbirthconnection.org/ www.childbirthconnection.org

transform.childbirthconnection.org/ www.childbirthconnection.org

transform.childbirthconnection.org/ www.childbirthconnection.org

Thank You!

Maureen Corry, Executive Director Childbirth Connection corry@childbirthconnection.org

―2020 Vision‖: transform.childbirthconnection.org/vision/ ―Blueprint for Action‖: transform.childbirthconnection.org/blueprint/

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Healthy Babies, Healthy Moms

June 22, 2011 Gail M. Amundson, MD, FACP President and CEO

www.qualityquest.org

Our vision is to become the region with the healthiest people and the highest value healthcare. Our mission is to achieve exceptional patient service and healthier communities by serving as a catalyst for healthcare transformation. We provide a neutral forum, combine performance data and increase our impact by aligning our action.

www.qualityquest.org

m delete

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Opportunity Statement Safe and healthy births are a primary goal for expectant mothers and their families. While many births are positive experiences, childbirth also bring substantial risks for both the mother and infant. The

• pportunity to eliminate elective deliveries before 39 weeks is
• considerable. Illinois lacks sufficient publicly reported maternity

measures to aid in decision making. Evidence-based clinical guidelines, offering direction regarding the perinatal care and management of childbirth, can be used to decrease variation and improve the quality of perinatal care.

www.qualityquest.org

139

www.qualityquest.org

According to a 2009 article published in PEDIATRICS, the average 2004 hospital cost at birth for a term infant was $2,061. Infants born late preterm had a substantially longer average stay

• f 8.8 days and a significantly higher average cost of $26,054.

Total first-year costs after birth discharge were, on average, 3 times as high among late-preterm infants ($12,247) compared with term infants ($4,069). The opportunity cost, in 2004 dollars, is $32,000 per late preterm infant.

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www.qualityquest.org

Illinois has just over 171,000 births annually. Our late preterm percentage is 12.7 percent. The March of Dimes best practice goal is 7.6 percent. A 5.1% reduction in Illinois would mean 13,000 fewer late preterm births per year and an estimated $416 Million in potential savings per year.

Reports REC 2011 Reports March of Dimes - Washington D.C. LaMaze International - New York OptumHealth - Minneapolis Healthy Babies, Health Moms HIE

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Healthy Babies, Healthy Moms Team

BroMenn/Advocate LeeAnn Wallace Carle Foundation Hospital Nancy Arnold, Julie Lauritson, Robin Grubbs , Adanna Amanze MD Caterpillar Rick Horndasch MD Decatur Memorial Hospital Jenny Brandenburg, Martin Okpalike MD Illinois Chapter March of Dimes Susan Knight, Derin Rominger MD Lamaze International Frieda Norris, Linda Harmon Illinois Department of HFS Deb Saunders, Gwen Smith, Linda Wheal, Julie Doetsch Illinois Hospital Association Pat Merryweather , Tiana Kieso MD Lamaze International Frieda Norris, Linda Harmon Memorial Hospital Ada Bair, Lila Brooks-Fritz Methodist Medical Center Craig Griebel MD, Rahmat Na'Allah MD Midwest Business Group on Health Larry Boress OB/GYN, Peoria private practice Lindsey Ma MD Optum Health/United Health Group Karen Babos MD OSF St. Francis Hospital Michael Leonardi MD, James Hocker MD, Yolanda Renfroe MD, Bill Scharf MD, Elaine Shaffer Pekin Hospital Darlene Hammond Peoria County Health Department Curt Fenton Quality Quest for Health of Illinois Alan Cooper, Tracey Arahood, Gail Amundson MD Rockford Memorial, President ACOG Illinois Chapter Phil Higgins MD United Health Care of Iowa and Illinois Reina Davis

Agree on Best Care Measure What Matters Create Positive Incentives Report Results Publicly - Together

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Common Priorities

www.qualityquest.org

Redesign for Results

Changing Maternity Outcomes in Illinois

• Statewide collaboration – Become a champion
• Standardized policies/practices in all hospitals
• Statewide consumer engagement initiative
• Payment alignment – HFS, health plans
• Public reporting by practitioner and hospital
• Malpractice reform

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www.qualityquest.org

Agenda

8:30 – 8:50 I. Welcome and Introductions 8:50 – 9:30 II. What is the Status of Pre-Term Deliveries

• A. Charlene Wells, Illinois Dept of Public Health
• B. Alan Fleischman, MD, March of Dimes

9:30 – 10:50 III. What is Being Done to Reduce Unnecessary Early Deliveries?

• A. Leah Binder, Leapfrog Group
• B. Maureen Corry, Childbirth Connection
• C. Gail Amundsen, MD, Quality Quest for Health
• D. Health Plan Activities

10:50- 12:00 IV. What Gaps Exist in the Present Activities and What Can be Expanded to Chicago? 12:00- 12:30 V. Next Steps - Adjournment