Reduction of Cesarean Deliveries in Women with Low-Risk Pregnancies Torri Metz, MD, MS Maternal-Fetal Medicine August 25, 2017

The problem… Cesarean delivery rate is higher than previous decades Rising cesarean delivery rates have not resulted in improved outcomes Downstream consequences of cesarean delivery can be life-threatening Tremendous variation in cesarean delivery rate by region, hospital, and provider

Today’s Agenda Review data related to cesarean delivery (CD) rates and reasons why the rate matters Describe the wide variation in cesarean rates among Colorado hospitals Discuss national efforts to reduce CD rates Share UCH experience Generate interest in participating in CD reduction project CPCQC is launching

Importance Cesarean delivery is the most common surgical procedure in the United States Over a decade CD rate increased by 50% 6% 1970s 20% mid-1980s 33% in 2010 Rates of cerebral palsy unchanged

Healthy People NTSV CD Target 23.9%

Risks of Cesarean Delivery Maternal Major abdominal surgery Surgical complications Morbidly adherent placenta (accreta spectrum) Infection Slower return to activity VTE Death Increased LOS Increased cost Vaginal births cost 5-10000 less than cesarean births, double the risk of mortality with a c/s http://contemporaryobgyn.modernmedicine.com

Risks of Cesarean Delivery Neonatal NICU admission for RDS Antibiotic exposure Interference with maternal-child bonding www.scarymommy.com

Risks of Cesarean Delivery

Why use NTSV CD rates? Quality Improvement Measure endorsed by multiple organizations Strengths Represents the nulliparous women at lowest risk for CD Risk adjusts regardless of delivery hospital Limitations Does not exclude all high risk conditions Largest contributor to recent rise, preventing the first c/s prevents subsequent c/s Declercq et al Am J Public Health 2006, Rhodes et al Pediatrics 2003, Caceres et al PlosS one 2013, Janakiraman et al Obstet Gynecol 2010

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Colorado NTSV CD Rates 19/54 birthing hospitals in Colorado exceed 23.9% Healthy People target rate! Rate varies among birthing hospitals from 10-34%, NTSV target 23.9% Healthy People goal, Data courtesy of CDPHE

How do we reduce NTSV CD rates? Financial reform Patient education Provider education Quality improvement

OB Quality Improvement and Safety Efforts Help to Decrease Liability Utilize evidence-based best practice protocols that follow national consensus (e.g. oxytocin) Utilize expert-vetted standardized approaches for labor and fetal heart rate abnormalities Communication techniques which engage the patient in “shared decision making” creates a strong deterrence to lawsuits Reducing primary cesareans, protects against post-cesarean complications and poor outcomes during future care   We have been working with the major liability carriers who stress these principles. The release of ACOG guidelines are very helpful in this matter. Slide courtesy of California Maternal Quality Care Collaborative 14

Quality Improvement Reduce “unnecessary” cesarean deliveries Appropriately timed and indicated cesarean deliveries can be life-saving Evaluate opportunities for improved adherence to national guidelines

UCH Experience “Safe Reduction of Cesarean Delivery Rate at University of Colorado Hospital” Funded by the Clinical Effectiveness and Patient Safety Small Grants for Residents and Fellows Baseline CD rate below Healthy People Goal at implementation but adherence to national guidelines poor

UCH Experience Retrospective Medical Record Review Establish baseline rates of outcome measures (NTSV CD rates) Identify drivers of CD at UCH Investigate adherence to ACOG/SMFM guidelines Delineate individual provider NTSV CD rates

UCH Experience Plan, Do, Study, Act Methodology Target drivers using California Tool Kit to Promote Vaginal Birth Implement serial PDSA cycles Assess impact of intervention Control charts Provider feedback

Pre-intervention Baseline UCH (July 2013 to September 2016) Total NTSV (JC-02) Vaginal Delivery 8,817 2.911 Cesarean Delivery 3,042 797 Missing 1,895 Outborn 25 4 Total Deliveries: 11,859* 3,708 CD Rate: 25.7% 21.5%

Frequency of occurrence Cumulative Percentage

Drivers of Cesarean Delivery

Recommendations reviewed Grade Ib Strong recommendations Obstetric Care Consensus 2014 Safe Prevention of the Primary Cesarean Delivery Recommendations reviewed Grade Ib Strong recommendations Moderate quality of evidence Benefits clearly outweigh risk and burden “Greater clinical patience” is the main focus of this document. Childbirth is unpredictable and perfect standardization of response to labor abnormalities is not realistic nor acceptable. Therefore, this document provides standardized definitions to guild care, intended to reduce variation in practice patterns.

What is the evidence? CSL data reframes anticipated labor curve Multicenter observational cohort 62, 415 women with term singleton pregnancies Active phase of labor occurs after 6cm dilation Zhang et al Obstet Gynecol 2010

What is the evidence?

What is the evidence? Prospective study 220 nullips and 99 multips in spontaneous labor Evaluated additional augmentation for 4 hours (total of 8 hrs) in labor arrest Of women who received up to 4 additional hours of augmentation 38% delivered vaginally Arulkumaran Aust NZ J Obstet Gynaecol 1987

What is the evidence? Prospective study over 500 women Extended allowable length of protracted labor from 2 hours to 4 hours 91% of multiparous women and 74% nulliparous women allowed the additional time delivered vaginally If allowed longer per practitioner preference more delivered vaginally Rouse Obstet Gynecol 1999

Suggested NICHD Consensus Algorithm Spong et al Obstet Gynecol 2012

ACOG/SMFM Recommendations

ACOG/SMFM Recommendations

ACOG/SMFM Guidelines not consistently used to define labor arrest…. Do provider practice patters vary?

Intervention Goals Increase adherence to evidence-based national guidelines Respond to feedback from providers on barriers to adherence Implement PDSA cycles in response to feedback

Implementation October November December January February MFM-- CNM-- OB Team-- Department-- OB Team-- Generalist-- OB Team-- Also: Labor arrest guidelines added to Resident L&D Orientation in January

Results: Adherence to Guidelines

Abbreviated Control Chart

Balancing Measures *pending final analysis Apgar < 5 at 5 min Umbilical cord pH < 7.0 NICU admission of a term neonate (>37 weeks) 3rd and 4th degree lacerations Chorioamnionitis* Neonatal head cooling* Maternal blood transfusion* I just want to mention that we will be tracking balancing measures. This project is not research, it is quality improvement because it focuses on evidenced-based recommendations that have already been evaluated for value, risk and benefit. *pending final analysis

Additional Interventions Responded to provider/nursing feedback Institutional oxytocin checklist too restrictive preventing meeting guidelines Checklist modified Education on titration of oxytocin with current protocol Implementation of new “high-dose” protocol for select patients Individual provider NTSV CD rates distributed Feedback to L&D team on NTSV CD rates

NTSV CD Rates by Individual Provider (1/2014-6/2016) (%)

UCH Experience Summary Implementation of labor dystocia checklist increased adherence to national guidelines Established a new mean NTSV CD rate in a hospital that was already at the Healthy People goal Significant cost savings (40-50 less CD per yr) No increase in adverse outcomes (balancing measures)

CPCQC Grant Objective By the year 2020, the rate of cesarean deliveries among the population of women with nulliparous term singleton vertex pregnancies (NTSV) will be at the Healthy People goal of 23.9% in a minimum of 4 pilot hospitals participating in the project

CPCQC Statewide Objectives Engage majority of birth hospitals in Colorado in quality improvement efforts to prevent unnecessary cesarean deliveries Track rates of NTSV CD in Colorado using vital statistics over the 5-year grant period Demonstrate a statewide reduction of NTSV CD rates over a 3-year period Monitor maternal and neonatal outcomes on a statewide level

Statewide Engagement Colorado Antibiotic Stewardship Collaborative (CASC) in yellow, hospitals participating in CASC and LOCATe in orange, hospitals participating in LOCATe and Safe Deliveries Colorado (SDC) in purple, and hospitals participating in CASC, LOCATe and SDC in green.

Outcome Measures Cesarean delivery rates at hospital and provider level CD rate for labor arrest among NTSV spontaneous labors CD rate for labor arrest among NTSV induced labors Overall NTSV CD rate

Balancing Measures Neonatal Maternal Unexpected newborn complications 5-minute Apgar scores ≤ 5 among NTSV births Hypoxic ischemic encephalopathy Perinatal death Maternal Maternal ICU admission Transfusion of 4 or more units blood products Hospitals can set other priority outcomes

Process for Participating Hospitals Establish baseline facility NTSV CD rates Internally and in collaboration with CDPHE Initiate PDSA cycles with labor arrest checklist Tailor PDSA cycles to institutional needs based on provider feedback Monitor outcomes

CPCQC CD Project Team CPCQC Executive Director CPCQC Co-Medical Directors Obstetrics and Neonatology QI Project Specialist Hospital level data analyst State epidemiology data analyst at CDPHE NTSV CD reduction program assistant

CPCQC CD Project Team Goals Assist with extraction of historical data for baseline NTSV CD rates Provide templates for CD rate distribution to providers and labor dystocia checklists Provide in-person support for project implementation including introductory training for facility champions Provide access to QI specialists for PDSA cycle implementation and CDPHE analysts

Will this work? California Maternal Quality Care Collaborative has piloted NTSV CD reduction projects in 3 hospitals Hoag Hospital, Newport Beach, CA Miller Children’s and Women’s Hospital, Long Beach, CA Saddleback Memorial Medical Center, Laguna Hills, CA

Pilot QI Project Components: 2014-15 Data measurement support: Use of CMQCC Maternal Data Center (MDC), Physician-level data was analyzed to identify drivers of cesarean. allowed the hospital to tailor their individual programs to the needs of that facility. The data also allowed for physician-level comparisons and an understanding of variation between providers. With this data, balancing measures were also monitored e.g. Term Unexpected Newborn Complications (NQF metric), to monitor for any unintended consequences of cesarean reduction QI improvement support: After identification of cesarean “drivers” at each facility, CMQCC and hospital, administrative, physician, and nursing leaders spearheaded efforts to identify strategies to reduce or eliminate the drivers, such as implementing: Simple algorithms, Easy checklists, Induction of labor scheduling policies. They also focused on the nursing component of labor support, and frequently reporteof unblinded physician-level cesarean rates in order to address variation between physicians and to give specific support to outlier physician s. Many of these pilot tools were adapted and are included in the toolkit Payment Reform: Health plan partners were identified that agreed to pay a “blended rate” for births. The resulting reimbursement rate was above the typical reimbursement rate for vaginal birth, but below typical reimbursement for cesarean. The change signaled to hospital systems that major payers were actively reducing any financial incentives for cesarean. Change in payment also prompted senior administrative support at each facility . The actual payment change did not occur until 9 months into the project. Nonetheless, the proposed payment changes, and employer concerns, motivated Refs: Pacific Business Group on Health. Case study: maternity payment and care redesign pilot. http://pbgh.org/storage/documents/TMC_Case_Study_Oct_2015.pdf. Published October 2015. Accessed January 12, 2016 Data Measurement Support Quality Improvement Support Payment Reform Slide courtesy of California Maternal Quality Care Collaborative

Impressive Results: within 6 months Hoag Miller Saddleback 24.2 % Reduction 22.1% Reduction 19.5% Reduction Baseline – 32.6% After QI – 24.7% Baseline – 31.2 After QI – 24.3% Baseline – 27.2% After QI – 21.9% Slide courtesy of California Maternal Quality Care Collaborative

Readiness Assessment Slide courtesy of California Maternal Quality Care Collaborative

Next Steps Volunteer to participate in the CPCQC cesarean reduction project 4 hospitals in the first year Grant funding provides access to our team Support with implementation of labor dystocia checklist Ongoing evaluation of NTSV cesarean delivery rates at your hospital Opportunity to set an example for other hospitals and be involved with the CPCQC

Next Steps Email: Pat Bohling Smith pat@cpcqc.org We look forward to working with you! https://autodo.info/pages/p/pick-me-pick-me/

Acknowledgments Centers for Disease Control and Prevention (CDC) for funding perinatal quality care collaboratives Executive Committee of the CPCQC Colorado Department of Public Health and Environment Amy Hermesch, MD, PhD