March of Dimes Efforts to Reduce Early

Elective Deliveries2013 NAPHSIS/NCHS

Joint MeetingPhoenix, AZ

June 6, 2013

Rebecca Russell, MSPHDirector, Perinatal Data Center

March of Dimes Foundation

The March of Dimes mission is to improve the health of

babies by preventing birth defects, premature birth and

infant mortality.

Stronger, healthier babies: 75 years in the making

Perinatal Data Center Roles & Goals

• Secure relevant and timely perinatal data.

• Develop and disseminate products and publications to support the March of Dimes mission.

• Provide technical assistance to help March of Dimes staff and volunteers effectively interpret perinatal data.

• Support mission-relevant, data-driven projects of the Foundation.

• Lead national-scope evaluation projects.

Quality Improvement

The March of Dimes is working to ensure that perinatal quality measures are developed and incorporated, as appropriate, in a consistent way into various measure sets and initiatives.• National Quality Forum Maternity Action Team• AHRQ Subcommittee on Quality Measures for Children’s Healthcare

(SNAC)• CMCS Expert Panel on Improving Maternal and Infant Health

Outcomes• ReVITALize conference (August 1-2, 2012)• MACPAC Expert Panel on Medicaid Implications of Trends in Induction

of Labor and Cesarean Deliveries

Healthy Babies Are Worth the Wait: Quality Improvement Initiative

Table of Contents:• Making the Case• Implementation

Strategy• Data Collection/QI

Measurement• Clinician Education• Patient Education• Appendices

Available at: marchofdimes.com

Toolkit ComponentsReduce Demand for Non-medically Indicated Deliveries• Provider/staff Education• Patient Education• Public Awareness

Key Change Tactics• Adoption of a policy on non-medically indicated deliveries• Implementation of a scheduling process• Increase Physician Leadership

QI Data Collection and Monitoring over time

What is the Big 5?

Big 5 States• In the U.S., the Big 5 States account for:

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• Source: National Center for Health Statistics, 2010 final natality data

Births 38.0%

Hispanic Births 63.7%

Non-Hispanic Black Births 32.5%

Preterm Births 37.1%

Late Preterm Births 37.3%

C-Sections 39.8%

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Methods

• Scheduling form implemented in all participating hospitals.• Data collected at the time of scheduling, with limited follow-up

to determine actual outcome and NICU admission• De-identified data for each singleton delivery scheduled at 34

weeks 0 days and greater were submitted monthly through a web-based data entry system.

• Gestational age at scheduled delivery date assigned by clinician based on the best clinical estimate.

• Data entry completed on a monthly basis by the 15th of the following month. Data quality checks performed for entry errors and inconsistency.

Data Collection

• Data collected:• A count of singleton live births and fetal deaths by

gestational age in weeks for each month of the project period

• Individual delivery and outcome data on scheduled deliveries ≥ 34 0/7 weeks gestation. – Scheduling data from the scheduling form – Outcome data from L&D log

Dating

Indication(s)

Cervical Exam

Scheduling InfoBEST MEDICAL CENTER

SCHEDULING FORM FOR INDUCTIONS AND CESAREAN SECTIONS Call (XXX) XXX-XXXX or Fax (XXX) XXX-XXXX

Name _____________________________________ Phone _______________________ OB Provider ________________________________________ G/P _________________ Type of Delivery Planned: Induction; C/S Desired Date/Time: _________________ DATING .................................................................................................................................. EDC: __________ Gestational Age at Date of Induction or C/S: ____________ (week+day)

EDC Based on: US <20 weeks; Doppler FHT+ for 30 weeks; +hCG for 36 weeks Other dating criteria: ______________________________________________ (details) By ACOG Guidelines, women should be 39 wks or greater before initiating an elective (no indication) delivery. ACOG also states that a mature fetal lung test in the absence of clinical indication is not considered an indication for delivery.

Fetal Lung Maturity test result: _______________ Date: ________________

INDICATION.............................................................................. .................................................. Obstetric and Medical Conditions (OK if <39 weeks) (need to deliver <39 weeks dependent on severity of condition)

Abruption Previa Preeclampsia Gestational HTN GDM with insulin PROM Fetal Demise (current) Fetal Demise (prior) Oligohydramnios Polyhydramnios IUGR Non-reassuring fetal

status Isoimmunization Fetal malformation Multiples w/ complications

Heart disease Liver disease (e.g.

cholestasis of preg.) Chronic HTN Diabetes (Type I or II) Renal disease Coag/Thrombophilia Pulmonary disease HIV infection Prior classical C/S Prior myomectomy Other: _____________

_____________________ Perinatology consult obtained and agrees with plan: ________________ (consultant name)

Scheduled 41+0 wks Scheduled C/S (39 wks) Prior C/S Breech presentation Other malpresentation Patient choice Other: _____________ Twin w/o complication

(ok 38 wks) Elective Induction (39wks) Patient choice/social Macrosomia Distance Other: _____________

Description/Details: _________________________________________________________

CERVICAL EXAM (for inductions) ............................................................................................. Date of Exam: _____________ (within 7 days of date of induction)

Bishop Score: circle each element of the exam below and add: Total Score: _________ Score_ Dilation__ Effacement__Station___Consistency __Position 0 Closed 0-30% -3 Firm Posterior 1 1-2 40-50% -2 Medium Midposition 2 3-4 60-70% -1, 0 Soft Anterior 3 5-6 80% +1, +2 ------- -----------

SCHEDULING OFFICE USE .................................................................. Procedure not scheduled: Scheduled? by Confirmed Date/TimeReferred to Dept Chair? Prenatal Record presenting LD: Yes

This section is used only by those hospitals using cervical exam criteria for scheduling inductions. T

Data Portal to Monitor Scheduled Deliveries

• Secure, web-based system

• Data entry across multiple hospitals

• User friendly, intuitive

• Report monthly and quarterly progress to eliminate elective deliveries < 39 weeks

• Comparison data for state and Big 5

Reporting

• Purpose: to inform hospitals about their progress towards eliminating NMI deliveries <39 weeks

• Frequency:

– Monthly and Quarterly with benchmarking

– Optional Provider report quarterly

– Ad hoc reporting done by request

• Diverse group of hospitals, with a majority:• Located in large Metropolitan Counties (66.7%)• 2,000-4,999 annual deliveries (62.5%)• Designated Level III NICU/Regional Perinatal Center (70.8%)• Nonprofit (75%)

In 2011:• 65,123 singleton deliveries• 29,030 scheduled singleton deliveries ≥34 weeks 0 days

Characteristics of HospitalsBig 5 Hospital Network, 2011

Early term is 37 0/7 to 38 6/7 weeks gestation.For each delivery type, the numerator is the number of scheduled singleton early term non-medically indicated inductions and cesarean deliveries and the denominator is the number of scheduled singleton early term deliveries.Source: Oshiro BT et al. A Multistate Quality Improvement Program to Decrease Elective Deliveries Before 39 Weeks of Gestation. Obstet Gynecol. May, 2013.

Source: Big 5 Hospital Network, <39 Weeks Elective Delivery pilot project. Prepared by March of Dimes Perinatal Data Center.

Singleton deliveries, by gestational ageBig 5 Hospital Network, 2011

Gestational age group Q1 Q2 Q3 Q4 p-value

37-38 completed weeks 27.3% 26.7% 25.4% 25.9% <0.01

39-41 completed weeks 61.7% 61.4% 63.3% 63.3% <0.01

Other Clinical Outcomes

• NICU Admissions• Among scheduled singleton early term deliveries, NICU

admissions declined from 1.5 per 100 singleton term deliveries to 1.2 (p=0.024).

• Fetal Mortality• The fetal morality rate among deliveries at 37-41

weeks fluctuated over the four quarters of 2011 with no discernible trend.

• Similar fluctuations when stratified into 37-38 weeks and 39-41 weeks.

Conclusions

• Rate of non-medically indicated scheduled early term deliveries decreased 83% over the 12 month pilot period.• Significant declines observed for both inductions (72%,

p=0.002) and cesarean deliveries (84%, p<0.001).• No change in medically indicated or unscheduled early

term deliveries.• Project demonstrated a successful model for

implementation of a multi-hospital, multi-state quality improvement initiative.

Additional Outcomes Increased consistency among practitioners in defining what is

medically and non-medically necessary Nurses empowered to call into question deliveries that were not

medically necessary Hospitals reported shift in staffing needs and an increase in babies

being born at night and on the weekends

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Limitations

• Lack of comparable baseline data or outcomes among comparable hospitals not participating in initiative.

• Long term sustainability yet to be determined.

March of Dimes 39+ Weeks Quality Improvement Service Package• Professional Education: Grand Rounds• Online Services

• Webinars• Access to Experts in the Field

• Public Education: March of Dimes Materials• Web Based Data Portal

 

39+ Weeks Quality Improvement Service Package

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OR

CA

NV

ID

MT

WY

COUT

NMAZ

TX

OK

KS

NE

SD

ND MN

WI

IL

IA

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AR

LA

AL

TN

MI

PA

NY

VT

GA

FL

MS

KY

SC

NC

MDOH DE

IN WV

NJCT

MA

ME

VA

Michigan(upper peninsula)

Alaska

Hawaii

NH

RI

DC

PR

Strong Start Components

1. An initiative to reduce the rate of preterm births for women who are at-risk for preterm birth and covered by Medicaid by testing enhanced prenatal care models

2. A test of a nationwide public-private partnership and awareness campaign (Healthy Babies Are Worth the Wait™) to spread the adoption of best practices that can reduce the rate of early elective deliveries prior to 39 weeks for all populations

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Strong Start Initiative• U.S. HHS is working in partnership with other organizations

nationwide, including:—March of Dimes—American Congress of Obstetricians and Gynecologists —National Partnership for Women and Families—Society for Maternal and Fetal Medicine—American College of Nurse Midwives—Childbirth Connections—Leapfrog Group—National Priorities Partners—National Quality Forum

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Healthy Babies Are Worth the Wait™• HHS has become a national partner in the March of

Dimes Healthy Babies are Worth the Wait™ education and awareness campaign

• This campaign aims to reduce elective induction and cesarean section prior to 39 completed weeks of pregnancy

• The March of Dimes campaign, which was launched in June 2011, was expanded

• Expansion included advertising placement and co-branding of March of Dimes advertising and educational materials by HHS and ACOG

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“Babies aren’t fully developed until at least 39 weeks in

the womb…… If your pregnancy is healthy, wait for

labor to begin on its own.”

ASTHO Challenge

In 2011, ASTHO President David Lakey challenged all state health officials to reduce their state’s preterm birth rate by 8% by 2014

• MOD joined ASTHO in issuing the challenge• MOD chapters are working with state health officials to

offer assistance and resources• 50 states (DC & Puerto Rico) have joined• MOD has created a new award for states who meet the

challenge

Contact:Becky Russellrrussell@marchofdimes.com914.997.4207

Thank you!