Framing the Issue
- Birth is the most common reason for hospitalization in the United States, with "live-born" accounting for more than 3.9 million, or 10 percent, of stays, in 2010.
- About one-third of U.S. births are by cesarean section. C-sections were the most commonly performed operating room procedure in U.S. hospitals in 2008.
- Evidence-based medicine is taking hold in obstetrics. For example, research showing that early elective delivery increases complications among babies and their mothers has led to a nationwide effort to stem the practice.
- The push toward value-based payment is accelerating hospitals' drive toward evidence-based medicine because it promises to improve outcomes while lowering costs.
- Preventing complications and C-sections results in systemwide savings. A maternal complication during delivery adds almost $1,000 to the cost of care, and an uncomplicated C-section adds nearly $2,000 to the bill.
Anyone who has ever known an expectant mother mostly likely has heard her grumble about how uncomfortable she is and how she wishes she could have her baby already.
Until recently, that mom's wish very well may have been granted with an induction as early as the 37th week of pregnancy, even without a medical reason for early birth. A Leapfrog Group survey of 757 hospitals found that the average rate of early elective deliveries was 17 percent in 2010. The average rate varies widely by state, from 6 to 26 percent of deliveries.
In the past few years, science has shown that early induction increases complications among babies and their mothers. At the same time, health care payment reform, sped by the Accountable Care Act, began pushing doctors and hospitals to improve care quality while reducing costs.
These two forces sparked a national campaign among quality, health care and insurance organizations to prevent early elective deliveries before 39 weeks. The results have been quick and dramatic.
Nearly two-thirds of hospitals with labor and delivery units have instituted policies to eliminate nonmedically indicated deliveries before 39 weeks of gestation, according to survey results presented in May at the American College of Obstetricians and Gynecologists' annual meeting. Of those, 69 percent have a "hard-stop" policy, under which early deliveries that don't meet medical criteria are not allowed.
The impact on the number of early elective deliveries also has been striking. About 900 hospitals with labor and delivery units are participating in the Hospital Engagement Network project run by the AHA's Health Research & Educational Trust. One of the initiative's objectives is to reduce obstetrical adverse events by promoting the prevention of elective deliveries before 39 weeks. Of the more than 400 hospitals reporting on this metric, the volume of such early deliveries dropped by 42 percent in one year. One HEN participant, Exeter Hospital in New Hampshire, dropped its rate of early elective deliveries from 35 percent to zero. Watch a video report on how that was accomplished.
The early elective delivery effort is just one of many quality initiatives in which hospitals with labor and delivery units are engaging not only to improve patient care, but also to keep pace with a payment system that is shifting from payment for volume to payment for value. "The idea that more medicine, more expensive medicine is better medicine is out the window," says Angela Silber, M.D., director of maternal-fetal medicine at Summa Akron City Hospital in Ohio. "Now, it's using whatever science you have to provide the best care."
In the case of elective deliveries before 39 weeks, the evidence is strong. Babies' brains, lungs and livers aren't fully developed until 39 weeks. Infants born earlier are more likely to require a neonatal intensive care unit stay, to have difficulty keeping warm, to have a hard time eating and to have jaundice, Silber notes.
Early induction also poses risk for mothers. Women undergoing induced labor are twice as likely to need a C-section, according to the March of Dimes.
'We're not going to do this anymore'
To succeed, hospitals had to convince physicians and patients that early elective deliveries aren't worth the risk. At Dignity Health, which includes 32 hospitals with labor and delivery units, getting physician buy-in entailed inclusion of doctors in the multidisciplinary committee that establishes OB protocols, an education campaign, meetings with senior leaders across hospitals and regular data feedback, says Barbara Pelletreau, R.N., senior vice president of patient safety.
"Working with the physicians and nurses in perinatal, we were able to start a movement that basically said, 'We're not going to do this anymore,'" she says. Less than a year after adopting the hard-stop policy, Dignity's average early elective delivery rate fell from the baseline of 7 percent to 1 percent. One member hospital reduced its rate from 27 percent to zero.
The system publishes the rates by hospital, and every hospital gets individual results by physician. "When you get down to it and you start being very transparent in results by physician, people get on board fairly quickly," Pelletreau says. Now the system is tracking cases that didn't follow the protocol to see if they're specific to a particular physician or if a valid reason underpinned the decision to induce early.
Once physicians were on board, it wasn't difficult to bring around expecting mothers. "The physicians will say, and truthfully so, 'This is really in the best interest of you and your baby, and this is what studies support,'" Pelletreau says. "Once we put that out there, most moms are going to want to do what's right for their newborns."
At Woman's Hospital in Baton Rouge, La., one practice has taken its efforts to prevent early elective inductions further than the 39-week mark. Physicians in the group won't perform nonmedically indicated inductions before 41 weeks, says Terrie Thomas, M.D. After 41 weeks, induction is considered medically indicated.
"There is a reason why labor ensues," Thomas says. "We just felt that to preserve the integrity of that and to have the best clinical outcomes for our patients and their newborn infants, this was the right thing to do."
The ACOG recommends against elective inductions and C-sections before 39 weeks and against them between 39 and 41 weeks unless the woman's cervix is deemed favorable. Summa Health System has adopted such a policy, with an ultimate goal of eliminating nonmedically indicated inductions, says Vivian von Gruenigen, M.D., chair of obstetrics and gynecology and system director for women's health services. Making sure a woman's cervix is ready for labor is important because the better the score, the less chance that induction will result in a C-section, she explains.
Patients before 'financial ramifications'
Some insurers are adopting policies to discourage elective inductions before 39 weeks. These steps include adding the measure to performance-based contracts or requiring providers to use claims modifiers to justify early induction.
Under the still dominant fee-for-service payment system, preventing early elective deliveries creates a conundrum for providers because it negatively impacts revenue even as it boosts quality of care. For example, the 42 percent reduction in early elective deliveries among the hospitals participating in the HRET Hospital Engagement Network translates into $10 million in cost savings from avoided complications and NICU stays.
But patient care trumps revenues, hospital leaders say. "As health care providers, we go into the field — not the business, but the field — to take care of patients," von Gruenigen says. "We are here to do the right thing, and we will adapt to any potential financial ramifications."
The hope is that new payment models, such as bundled payment or accountable care, that try to align financial risk with the right care delivery will catch on, says Maulik Joshi, president of HRET and AHA senior vice president. "But it doesn't happen overnight. So we are in a transition where hospitals are continuously balancing the 'I'm doing the right thing for our communities, and it's hurting me financially.'"
At Dignity Health, the reduction in NICU stays that resulted from its hard-stop policy might be having an unexpected upside by opening up NICU space for infants from outside the hospital system, Pelletreau says. "NICUs are precious. They're highly specialized areas. So if they're full and you can't accept a baby that needs a NICU, that's a problem."
Standardization to simulation
Hospitals' quality improvement efforts have reached beyond early elective deliveries and are focused on complications that pose the highest risk to maternal and fetal health, including post-partum hemorrhage, infection and premature birth.
Over the past two years, Dignity Health has rolled out a bundle of treatment protocols. Major components include assessing patients before use of the delivery-speeding drug Pitocin and monitoring the fetus during its use; handling shoulder dystocia to avoid injury to the child; preventing and managing obstetrical hemorrhage; and following up on discharged babies to identify and treat severe jaundice, Pelletreau says. Each protocol includes documentation.
Dignity's quality improvement effort also features competency training for doctors and nurses. The online education through Advanced Practice Strategies puts every physician and nurse on the same page. "We're all reading electronic fetal strip monitors the same way. We all have the same understanding of shoulder dystocia, and we all have the same understanding of operative vaginal delivery," Pelletreau says.
Some hospitals are using simulations to reinforce protocols and improve care quality. Summa Health developed a "Code C" for emergency C-sections that mobilizes the team to take care of the patient as quickly as possible. Because time is of the essence, the staff practice Code C drills to improve performance on the quality indicator of time between the decision to perform an emergency C-section and incision, Silber says.
The team — nurses, anesthetists, medical residents, attending physicians — also participates in simulations on maternal hemorrhage. Exercises include evaluating the amount of blood loss and managing treatment. The idea is to "hardwire into your brain" the appropriate response, Silber says.
Other hospital efforts involve identifying the risk of complications and preventing them before they start or minimizing their impact. As part of Summa Health's project focused on maternal hemorrhage, staff assess patients' risk and flag those at high risk. Women are at high risk if they're carrying multiples, have a history of postpartum hemorrhage, have had several deliveries, have prolonged labor or have an infection. "If you identify those patients as they come in, you can have things available and you're ready to manage as soon as it starts to become a problem," Silber says.
Summa Health participates in the Ohio Perinatal Quality Collaborative, which aims to reduce the number of preterm births and improve care quality for premature newborns. Nationwide, nearly 500,000 babies are born before 37 weeks' gestation each year. The Ohio collaborative has conducted projects to reduce elective delivery before 39 weeks; increase the use of antenatal corticosteroids, an evidence-based therapy to reduce mortality and morbidity among preterm infants; decrease blood stream infections in preterm babies; and improve birth certificate accuracy.
As part of Summa Health's efforts to prevent preterm birth, women with certain risk profiles are screened using cervical length ultrasound at 20 weeks, Silber says. Smoking increases the risk of preterm labor, so pregnant mothers who smoke are offered smoking cessation services.
In Baton Rouge, Woman's Hospital has changed catheter use for maternity patients to prevent urinary tract infections. Previously, every patient with an epidural got an in-dwelling Foley catheter, Thomas says. Recognition that these catheters boost the risk of UTIs led insurance companies to declare that they'd stop paying hospitals for infections associated with Foley catheters. Now, physicians have switched to using an in-and-out catheter for patients getting an epidural.
The facility also is expanding its blood clot risk assessment and prevention protocol to OB surgical patients, Thomas says. Woman's Hospital has antibiotic prophylaxis protocols to screen and treat pregnant women for Group B strep so they don't spread the infection to their infants and to prevent surgical infections. "We're trying to improve our efficiency and decrease our complications," Thomas says.
Wanting a C-section not enough
Hospitals' quality improvement projects, including those discouraging early elective deliveries, could lead to a decline in the troubling rate of C-sections. Nationwide, the C-section rate rose from less than 21 percent of all deliveries in 1996 to nearly 33 percent in 2010, according to the Centers for Disease Control and Prevention.
Although C-sections often are lifesavers, they come with increased risk of infection, maternal blood loss, injury to other organs, blood clots and adverse reactions to anesthesia. "C-sections cause morbidity," von Gruenigen says. "You're making a surgical incision on a woman and her uterus."
Between 2003 and 2009, half of the increase in the C-section rate was attributed to a rise in first-time C-sections, according to a July 2011 Obstetrics and Gynecology article. Women who have C-sections are more likely to deliver subsequent children via C-section. Among the documented reasons for C-sections that contributed to the increased rate, nearly all were medical in nature. These indications included nonreassuring fetal status, arrest of dilation, multiple gestation, preeclampsia and suspected overly large fetus. However, 8 percent of the increase was because of maternal requests for a C-section, the article reported.
In April 2013, the American College of Obstetricians and Gynecologists issued a recommendation against C-sections based on maternal request without a medical indication. It is particularly not recommended for women who want to have more children because C-section increases the risk of serious complications in future pregnancies.
Because of the years-long lag in federal statistics, it will take time to determine if current quality improvement efforts impact the cesarean delivery rate. "We haven't seen the C-section rate go down yet in the nation, but I anticipate it's coming," von Gruenigen says.
The prevention of maternal complications and C-sections stands to save significant costs. The mean cost per stay for a vaginal delivery without complications was $2,900 in 2008, compared with $3,800 for vaginal delivery with complications, $4,700 for a C-section without complications, and $6,500 for a cesarean with complications, according to a 2011 Agency for Healthcare Research and Quality brief.
Hospitals and obstetricians hope the embrace of evidence-based medicine and documentation of its use will help when it comes to lawsuits. Dignity Health tracks how its quality initiative will impact the number of lawsuits and its ability to defend them, but it's too early to show results, Pelletreau says.
"Not all children are going to be born perfectly, but that doesn't always mean we did something wrong," she says. "So making sure we follow evidence-based practices helps us in the defense."
Geri Aston is a contributing writer to H&HN.
Keeping moms-to-be and new moms alive
The risk of dying from a pregnancy-related condition is relatively low for U.S. women. However, the mortality rate rose steadily from 7.2 maternal deaths per 100,000 live births in 1987, when the federal Pregnancy Mortality Surveillance System launched, to a peak of 16.8 in 2003. Since then, the rate has declined slightly to 15.5 deaths per 100,000 live births in 2008, the latest figures available.
The federal government defines pregnancy-related death as death of a woman while pregnant or within one year of pregnancy termination from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.
The reasons for the upward trend are unclear, but likely include better maternal mortality data collection by the states, growth in the number of women who are having children later in life and increased incidence of obesity.
Both increased maternal age and obesity result in higher rates of such chronic diseases as high blood pressure and diabetes among pregnant women. Poorly controlled diabetes during pregnancy can cause birth defects, larger-than-usual fetuses that require C-section delivery, preterm birth, stillbirth or miscarriage, and dangerously low blood sugar in the mother. High blood pressure increases the risk of problems with the placenta and with fetal growth, and can cause a potentially fatal hypertensive condition called preeclampsia.
Obesity on its own increases the risk of blood clots, C-sections and C-section complications, and postpartum infection. Older maternal age increases the chance of carrying twins or other multiples, which raises the risk of C-section and such complications as preeclampsia and gestational diabetes.
At Summa Akron City Hospital, pregnant patients with obesity receive diet counseling, get clear instructions on the expectations for weight gain during pregnancy, and are screened for diabetes and hypertension, says Angela Silber, M.D., director of maternal-fetal medicine.
Summa Health also has a high-risk pregnancy clinic for women with diabetes, hypertension, cardiac disease, a history of blood clots, severe asthma, addiction or a multiple pregnancy. "We see the patients once a week, and we have a tailored plan of care for each patient that we follow closely," Silber says. — Geri Aston
- A growing national movement to eliminate early elective deliveries is demonstrating the benefits of evidence-based medicine in the obstetrics service line. The projects are helping to prepare hospitals for value-based payment by improving patient outcomes and reducing costs.
- Efforts to improve OB outcomes have expanded beyond early elective delivery initiatives. Other projects target the most severe health risks to mothers and their newborns — from preterm birth to post-partum hemorrhage.
- Hospitals' efforts to improve OB quality come at a challenging time. Growth in the number of women having children later in life and the increased incidence of obesity mean more pregnant women than ever before have chronic illnesses that pose increased risk to themselves and their babies.
- Competency training and simulations for nurses and physicians are useful tools to support evidence-based OB protocols. Online competency training fosters uniformity of understanding among team members so that, for example, everyone reads fetal strip monitors the same way. Simulations prepare the team for real medical crises, such as postpartum hemorrhage or emergency C-sections.
- Regular feedback on adherence to the protocol and on resulting improvement in patient outcomes helps to strengthen physician buy-in. As time goes by, identify physicians who remain noncompliant so they can get one-on-one contact and clarification.
- Use of evidence-based protocols in OB and documentation of them holds the hope of fewer medical malpractice lawsuits and helps providers in their defense. A bundle of perinatal safety protocols at the Hospital Corporation of America resulted in fewer maternal and fetal injuries and half the number of malpractice claims.