Perinatal Quality: Making NC the Best Place to be Born!

Perinatal Quality Collaborative of North Carolina

James deVente MD/PhD Associate Professor, Dept. OB/Gyn Medical Director of Labor and Delivery East Carolina University Brody School of Medicine

PQCNC Mission
Promote high value perinatal care
Spread

best practice and reduce variation Partner with families and patients Optimize resources

Bottom line: We are committed to making North Carolina the best place to be born!

Maternal Quality Initiatives

39 Week Project Supporting Intended Vaginal Birth (SIVB)

39 Weeks Project

Decrease of 43%

 Improve the rate of vaginal birth among rst-+me mothers

SIVB: Suppor+ng Intended Vaginal Birth

PQCNC's goal was to increase the rate of vaginal birth in this popula+on by 25% by January 2012. Each par+cipa+ng hospital set its own site-specic goal.

Carolinas Medical CenterPineville Presbyterian HospitalMain Gaston Memorial Presbyterian HospitalMatthews Granville Health System Forsyth Medical Center Cape Fear Valley Medical Center Mission Hospital Carolinas Medical Center Nash General Hospital Onslow Memorial Hospital New Hanover Regional Medical Center Carolinas Medical Center NorthEast Vidant Medical Center Carteret General Hospital Presbyterian Hospital Huntersville Catawba Valley Medical Center Rex Health Central Carolina Hospital Stanly Regional Medical Center Columbus Regional Healthcare System University of North Carolina Hospitals FirstHealth Moore Regional Hospital Forsyth Medical Center

SIVB

SIVB in North Carolina

Data on forty pa+ents were collected from each hospital Inclusion Criteria: Nulliparous Singleton Pregnancy Vertex 37 weeks or more Live fetus Exclusion Criteria: Placenta previa Vaso previa Previous Myomectomy Cord Prolapse Ac+ve Herpes Infec+on HIV (with viral load >1000 copies) Diabe+c with EFW > 4500 grams Non-Diabe+c with EFW > 5000 grams
*Phase I involves 23 hospitals and has collected data on more than 10,000 deliveries

In nine months we saw a 15% increase in the likelihood of first-time mothers delivering vaginally in 24 participating centers
OVERALL PRIMARY C/S RATE OVER TIME ALL FACILITIES
50.00% 45.00% 40.00% 35.00% 30.00%

Overall C/S
25.1% 24.0% 24.1% 23.7% 22.2% 22.0% 22.8% 23.5% 21.0% 20.4% 19.1% 21.3%

25.00% 20.00% 15.00% 10.00% 5.00% 0.00%

GOAL = 18.83%

INITIATIVE-WIDE CESAREAN RATES

50.00% 45.00% 40.00% 35.00% 30.00%
25.11% 38.01%

OVERALL C/S RATE C/S RATE - NO C/S RISK FACTORS C/S RATE - 1+ C/S RISK FACTORS
36.34% 34.62% 34.07% 30.20% 29.74% 28.00% 23.99% 24.12% 23.67% 22.80% 21.02% 20.37% 19.11% 20.74% 18.47% 18.27% 18.83% 16.95% 16.59% 35.06%

Linear (OVERALL C/S RATE)

32.60% 30.41% 26.42% 27.62% 23.95% 21.29%

25.00% 20.00% 15.00% 10.00% 5.00% 0.00%

22.16%

21.98%

20.25% 18.23%

19.32%

18.66%

19.06%

19.19%

50.0%

AVERAGE C/S RATE BY FACILITY: Baseline - December

45.0%

40.0%

Average facility c/s rate

35.0% 31.2% 30.0% 25.0% 23.9% 21.7% 20.0% 25.4% 23.0% 26.8% 24.9% 23.5% 27.6% 24.7% 23.9% 23.1% 23.1% 25.0% 23.4% 21.6% 18.8% 16.9% 14.7% 16.5%

20.8% 17.4%

18.5%

15.0%

10.0%

5.0%

0.0% 110 200 210 300 320 330 350 380 390 391 392 400 420 430 490 500 510 530 540 640 650 660 680

% OF PATIENTS IN LABOR AT ADMISSION

70.00%

% of pts in labor at
52.3% 51.3% 53.4% 50.0% 49.9% 52.8%

60.00%

% of paBents in labor

50.00%

48.8% 48.6% 47.8%

51.2%

49.8% 50.8%

40.00%

CESAREAN RATE FOR PTS NOT IN LABOR AT ADMISSION:

30.00%

31.70%

20.00%

CESAREAN RATE FOR PTS IN LABOR AT ADMISSION:

14.61%

10.00%

0.00%

Impact of Facility Demographics

Facilities Facilities

WITH and WithOUT midwives

WITH and withOUT Inhouse Anesthesia Effect of Payor Mix Effect of Facility size (with respect to deliveries per year)

Facilities with / without Midwives

Facilities WITH midwives: Had a significantly lower c/s rate than facilities withOUT midwives Accomplished a statistically significant decrease in c/s rate over the year studied (p=0.001) Facilities withOUT midwives: Had a significantly higher c/s rate than facilities WITH midwives Did NOT accomplish a statistical decrease in c/s rate over the year studied (p=0.365)

Cesarean Rate by Facility Midwives / No Facility Midwives

50.0%

45.0%

40.0%

35.0%

30.0% C/S Rate 24.4% 21.7% 20.0% Midwives (13 hosp / 6,572 pts) No Midwives (8 hosp / 4,181 pts)

25.0%

15.0%

10.0%

5.0%

0.0% Midwives (13 hosp / 6,572 pts) No Midwives (8 hosp / 4,181 pts)

Facilities with / without In-House Anesthesia

Facilities WITH in-house anesthesia: Accomplished a statistically significant decrease in c/s rate over the year studied (p=0.001) Facilities withOUT in-house anesthesia: Did NOT accomplish a statistical decrease in c/s rate over the year studied (p=0.489) THERE WAS NO DIFFERENCE IN TOTAL RISK OF CESAREAN SECTION BETWEEN THE TWO GROUPS (see next slide)

Cesarean Rate by Facility In-House Anesthesia / No Facility In-House Anesthesia

50.0% 45.0% 40.0% 35.0% 30.0% C/S Rate 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% In-House Anesthesia (15 hosp / 8,495 pts) NO In-House Anesthesia (4 hosp / 1,577 pts) 23.3% In-House Anesthesia (15 hosp / 8,495 pts) NO In-House Anesthesia (4 hosp / 1,577 pts)

23.0%

Cesarean Rates by Payor

BCBS/SHP payor deliveries: Had a significantly higher c/s rate than Medicaid or Other payor deliveries There was no statistical difference: Between Medicaid and Other payor deliveries In c/s rate over time for any of the three groups

Cesarean Rate by Payor

50.0%

45.0%

40.0%

35.0%

30.0% C/S Rate 26.9% 25.0% 20.0% 20.0% 18.0% BCBS / SHP (475 pts) Medicaid (595 pts) Other (390 pts)

15.0%

10.0%

5.0%

0.0% BCBS / SHP (475 pts) Medicaid (595 pts) Other (390 pts)

Cesarean Rate by Payor

50.0%

45.0%

40.0%

35.0% 29.3% 27.8% 26.2% 25.0% 28.3% 22.4% 25.0% 20.0% 20.2% 15.0% 14.3% 10.0% 11.8% 15.0% 13.0% 18.7% 19.8% 16.3% 18.2% 25.0% 24.2% BCBS / SHP Medicaid Other 29.6%

30.0% C/S Rate

5.0%

0.0% July August September October November December

NC vital Statistical Brief: Trends in Cesarean Delivery Rates for NC Live Births (July 2012)

Both medicaid and non-medicaid payers increased

Cesarean Rates by Facility Deliveries per Year

Facilities delivering 3000-3999 infants per year: Had a significantly lower c/s rate than any other size facility Accomplished a statistically significant decrease in c/s rate over the year studied (p<0.0001) These numbers are likely the product of center-effect and should be taken with a grain of salt

No other differences were noted between facility size groups

Cesarean Rate by Deliveries per Year

50.0%

45.0%

40.0%

35.0%

30.0% C/S Rate 24.6% C/S Rate 19.4%

25.0%

23.4%

22.7%

23.5%

20.0%

15.0%

10.0%

5.0%

0.0% 250-999 (4 hosp / 882 pts) 1000-1999 (4 hosp / 1,738 pts) 2000-2999 (4 hosp / 2,795 pts) 3000-3999 (4 hosp / 2,468 pts) 4000+ (5 hosp / 2,870 pts)

BOTTOM LINE!

Labor is Important

*Phase I involves 23 hospitals and has collected data on more than 10,000 deliveries

SIVB-2/3 Data
A focus on Labor!

*Phase 2/3 involves 31 hospitals and has collected data on more than 10,000 deliveries

GOAL = 18.83%

Labor is Important !!!

nulips patients are being induced!

50% of our term

Drilling down on the data!

Where are these Inductions coming from?

Mothers may have more than one risk factor

BMI 30 OR last maternal weight 200 lbs

BMI 30 OR last maternal weight 200 lbs

Includes gestational diabetes) well or poorlycontrolled; preexisting Type II or Type 1 diabetes

Includes chronic hypertension, gestational hypertension, preeclampsia, eclampsia, HELLP syndrome

C-section Rate for the No Risk factor inductions was 29.7%!

762 c-sections

Use of self-prepared Birth plan decreased C-section rate, increased use of epidural, decrased lacerations J. Of MatFetal&Neonatal Medicine, 25 (10): 2055-2057, 2012

Questions to ask your unit?

1. 2. 3. 4. 5.

Do you have a physician or team of physician champions? Do you have adequate time, space, and/or expertise to diagnosis labor? Are your patients educated with respect to the importance of labor? Do you have multiple mechanisms to support a patients labor? Does your institution track vaginal delivery rate and report it back to the providers specifically in nulliparous patients? Do you have an induction protocol for Nulliparous patients? Do you Track and review nulliparous C-sections and elective inductions less than 41 wk?

6. 7.

Constructively Review Your C-sections!

Faces of PQCNC

Thank you! Questions?

James deVente MD/PhD Associate Professor, Dept. OB/Gyn Medical Director of Labor and Delivery East Carolina University Brody School of Medicine Pager: 252-413-4153 (please page me)