Assuring Safety and High-Quality, Patient Centered Services Along the Continuum of Perinatal Care Secretary’s Advisory Committee on Infant Mortality November 14, 2012

Data-Driven Perinatal Quality Improvement Through Public-Private Partnering Elliott K. Main, MD Director, CMQCC Chair, Dept. OB/GYN, California Pacific Medical Center Clinical Professor, Dept. OB/GYN, Univ. Calif. San Francisco Visiting Professor, Dept OB/GYN, Stanford University

: Transforming Maternity Care California… Population: 37,691,912 1  3 large metropolitan areas, but extensive remote rural areas 2011 Births: 502,118 2  1 of 8 US births, Texas next with 377k  Equal to a large European country 2010 Infant Mortality: 4.7 / 1,000 3  ~4 th lowest state in US, but still ~27 th in the world 2011 Preterm Birth Rate: 9.8% 4 (March of Dimes: “B”) Currently ~280 birthing facilities with >50 annual births 1 US Census Bureau (est.), June NCHS: NVSR 61:05, Oct CDPH: MCAH, May NCHS: 2011 Preliminary Natality data

: Transforming Maternity Care Improving Maternity Outcomes Social Determinates Medical Determinates 4 Faster change? Easier to test? Cheaper?

: Transforming Maternity Care How does Data-Driven QI improve maternal and neonatal outcomes? Multi-Stakeholder Quality Collaboratives State-wide perinatal outcomes database Significant effort for Data Quality Using transparent data to drive and incent care Pos: 50 states testing new ideas Neg: 50 states all “doing their own thing”

: Transforming Maternity Care CMQCC and CPQCC Mission: Data-driven QI for mothers and newborns California Perinatal Quality Care Collaborative (CPQCC) Established 1996 >95% of all Neonatal Intensive Care Units in California Secure data center—pioneer for data driven QI Model of working with state agencies to provide data of value California Maternal Quality Care Collaborative (CMQCC) Established 2006 California Maternal Mortality Review Committee (Title V, MCAH) QI toolkits: Elective Delivery <39wks, Hemorrhage, Preeclampsia, Large-scale QI Collaboratives: Hemorrhage, Preeclampsia Statewide Maternal Data Center (CDC and CHCF supported)

: Transforming Maternity Care CMQCC Key Partner/Stakeholders State Agencies: MCAH, Dept Public Health OSHPD Healthcare Information Division Office of Vital Records (OVR) Regional Perinatal Programs of California (RPPC) DHCS, Medi-Cal Public Groups California Hospital Accountability and Reporting Taskforce (CHART) Kaiser Family Foundation March of Dimes (MOD) Pacific Business Group on Health Professional groups American College of Obstetrics and Gynecology (ACOG) Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) American College of Nurse Midwives (ACNM), American Academy of Family Physicians (AAFP) Key Medical and Nursing Leaders University and Hospital Systems Kaisers, Sutter, Sharp, CHW, Scripps, Public hospitals,

: Transforming Maternity Care Examples of Current Maternal QI Projects VLBW (<1500g) infants to deliver at appropriate level of care (Level III NICU) Early (<39 weeks) Elective Delivery Reducing Low-risk First-birth Cesareans Increasing Exclusive Breast Milk Feeding Reduction of complications in pregnant women with hypertension

: Transforming Maternity Care Regionalization of care for VLBW has diminished in the last decade despite strong evidence of benefit California has large variation with major quality opportunities in urban areas

: Transforming Maternity Care VLBW infants (<1500g) Admitted Directly to NICU MMWR Nov 12, :144-7

: Transforming Maternity Care Delivery of <1500gm Infant NOT at a Level III Center HP 2010, HP 2020, Turn the national goal into a hospital-level quality measure  CMQCC Sponsored  NQF Endorsed <1500g infant not delivered at an appropriate level of care  Denominator: Livebirths >24 weeks gestation at a NON-Level III hospital  Numerator: Births 500gms  Exclusions: none  Risk Adjustment: none

Large Regional and Hospital Variation for the Delivery of VLBW not in an Appropriate Level of Care

: Transforming Maternity Care The California Maternal Data Center (CMDC) Project Vision Build a statewide data center to collect and report timely maternity metrics—in way that is low cost, low burden and high value for hospitals Produce metrics that will support QI and L&D service line management Improve quality of administrative data Facilitate reporting to national performance organizations Over time, publicly report select set of robust measures to inform decisions of childbearing women

: Transforming Maternity Care PDD--Discharge Diagnosis File (ICD9 codes) PDD--Discharge Diagnosis File (ICD9 codes) Birth Certificate File (Clinical Data) Birth Certificate File (Clinical Data) 1.Links Birth Data to OSHPD file 2.Runs exclusions 3. Identifies CS and Inductions 4. Prints list of charts for review CMQCC Maternal Data Center: Data Flow CMQCC Data Center REPORTS Benchmarks against other hospitals Sub-measure reports REPORTS Benchmarks against other hospitals Sub-measure reports Calculates all the Measures <39wk Elective Delivery CHART REVIEW Labor?/SROM? (~6% of cases for brief review) <39wk Elective Delivery CHART REVIEW Labor?/SROM? (~6% of cases for brief review) Limited manual data entry for this measure Uploads electronic files Mantra: “If you use it, they will improve it”

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: Transforming Maternity Care 17 Built-in Quality Analysis: where do we go next?

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: Transforming Maternity Care Comprehensive Vision for Maternal Data QI in California 1)Standardize Definitions 2)Education (MD’s, BC staff, Coders) 3)Redesign / System Changes 4)Improving Data as QI Project 5)Create Value for Maternal Data QI for hospitals

Obstetric Data Definitions Project National Meeting August 2-3, 2012 Arlington, Virginia

Project Objectives  To nationally standardize obstetric clinical data definitions.  To educate and advocate for national implementation of the standardized obstetric data elements and definitions in electronic medical records, birth certificates, and data registries  To increase and improve performance measurement and implementation of the national obstetric data standards and encourage data aggregation.

Many Stakeholders…  National vital records (NCHS, NAPHSIS)  State vital records  State departments of health (MCH)  Federal agencies (CMS, CDC, NLM, AHRQ, NICHD)  Quality organizations (TJC, Leapfrog, NQF)  Health IT / Coding organizations  EMR vendors  Payers (Medicaid and commercial)  Providers (obstetrics, family medicine, nursing, midwifery)  Large scale QI collaboratives  Advocacy groups (March of Dimes)

Data Quality Reports Identify discrepancies or missing data in Birth Certificate and Discharge data files Use to target data performance/quality improvement 23 Screen shot from the California Maternal Data Center

Data Quality Reports Identify discrepancies or missing data in Birth Certificate and Discharge data files Use to target data quality improvement

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A hospital with a system for transferring clinical data to the BC

: Transforming Maternity Care Late Preterm Birth (34+0 to 36+6 wks) Late Preterm Birth makes up >70% of all PTB Late Preterm Birth accounted for ~80% of the rise in PTB in the prior 10 years Late Preterm Birth accounts for 75% of the decline in PTB in the last 3 years Late Preterm Birth accounts for much of the variation in PTB rates among states and among hospitals Is there a QI opportunity here?

What components make up the Preterm Birth Rate?

: Transforming Maternity Care Health Equity <1500g Birth Not at Appropriate Location Late Preterm Birth Exclusive Breast Milk during Birth Hospitalization Low-risk First Birth Cesarean Delivery All have significant racial/ethnic disparities All could be helped by focused QI projects

: Transforming Maternity Care Recipe for Improving Care Quality Measures Hospital Level Provider Level Define the Issues Locally Transparency Financial Incent Systems Change Public Release Benchmarking Pos/Neg Incentives Value-Based Purchasing Unintended Consequences? Balancing Measures! Data quality? If you use it, they will improve it!

: Transforming Maternity Care Role(s) for HHS Quality Measures Support measure development Support wide-spread use Support data collaboratives Transparency Financial Support public release Raise awareness Reduce perverse incentives Explore positive incentives Value-Based Purchasing Support development of Balancing Measures Support Data QI projects Use admin data and they will improve it!

: Transforming Maternity Care Thank You!

: Transforming Maternity Care Reporting Mandates Coming ED<39 weeks measure included in Hospital IQR Program for FY 2015 payment determination: data collection beginning with January 2013 discharges The Joint Commission will require reporting of perinatal set for hospitals that perform deliveries Medicaid Adult Measure Set published; Medi-Cal Quality Dashboard under development Medi-Cal has received a federal grant to test collection and reporting of perinatal metrics. CMDC is an active participant.

: Transforming Maternity Care CMDC’s Clinical Quality Measures NQF Joint Commission LeapfrogCMS Medi- Cal CHA HEN Elective Deliveries week rate  (PC-01)  C-Section rate Term 1 st Birth (NTSV)  (PC-02)  Infants < 1500 grams at appropriate level   Episiotomy rate  Healthy Term Newborn rate  Antenatal Steroids   (PC-03)  Neonatal Blood Stream Infections  (PC-04) Exclusive Breast Milk   (PC-05) Current Soon Requires some additional chart review (minimized by using the CMDC)

: Transforming Maternity Care CMDC’s Clinical Quality Measures Joint Commission Chart Review Needed with CMDC Elective Deliveries week rate  (PC-01) # of charts reduced to <6% of OB cases and then a very brief review C-Section rate Term 1 st Birth (NTSV)  (PC-02) --none-- Infants < 1500 grams at appropriate level --none-- Episiotomy rate --none-- Healthy Term Newborn rate --none-- Antenatal Steroids  (PC-03) With CPQCC, >95% of cases are transferred, identifies missing cases Neonatal Blood Stream Infections  (PC-04) --none-- Exclusive Breast Milk Feeding  (PC-05) Generates a “smart” randomized sample for chart review Current Soon Requires some additional chart review (minimized by using the CMDC)

California Perinatal Region (2007 data) Median Cesarean Rate (%)

: Transforming Maternity Care Improving Maternity Outcomes: CMQCC Interactions with National Projects Quality Measures Maternal Mortality/ Morbidity Data Quality 37 JC, NQF, NPP AMA PCPI CDC/AMCHP ACOG/CDC MCHB Medi-Cal Advis CMS Expert Panel ACOG reVITALize NAPHSIS NCHS