INTEGRIS Canadian Valley Hospital Every Week Counts Collaborative

Terminology First day of LMP 0 Week # 37 0/7 41 6/7 PretermPost term 34 0/7 Term Modified from Drawing courtesy of William Engle, MD, Indiana University 20 0/7 Raju TNK. Pediatrics, 2006; Oshiro BT Obstet Gynecol 2009;113: /7 Late PretermEarly Term The “New” Term

Change in Distribution of Births by Gestational Age: United States, Martin JA, Hamilton BE, Sutton PD, Ventura SJ, et al. Births: Final data for National vital statistics reports; vol 57 no 7. Hyattsville, MD: National Center for Health Statistics

U.S. Cesarean Section and Labor Induction Rates Singleton Live Births by Week of Gestation,1992 and Source: NCHS, Final Natality Data, Prepared by March of Dimes Perinatal Data Center, April Induction 2002 C-S C-S 1992 Induction Early Term

Percent of singleton births by gestational age at delivery: Oklahoma, Source: Oklahoma Vital Statistics

Impact of Cost Average length of stay in L&D for nulliparous women in large, urban hospital of 8,000 birth/year – Induction of labor = 18.7 hours (intensive nursing care and increased amount of resources) – Spontaneous labor = 11.2 hours Average postpartum LOS – C/S after failed induction = 4.2 days – Repeat C/S = 3.8 days – Vaginal birth = 2.0 days Simpson, 2010, J Perinat Neonat Nurs 8

Timing of Fetal Brain Development Cortex volume increases by 50% between 34 and 40 weeks gestation. (Adams Chapman, 2008) Brain volume increases at rate of 15 mL/week between 29 and 41 weeks gestation. A 5-fold increase in myelinated white matter occurs between wks gestation. Frontal lobes are the last to develop, therefore the most vulnerable. (Huttenloher, 1984; Yakavlev, Lecours, 1967; Schade, 1961; Volpe, 2001).

A tool to educate patients marchofdimes.com © 2007 Bonnie Hofkin

Examples of Successful Programs to Reduce Non-medically Indicated (Elective) Deliveries Before 39 weeks of Gestation Magee Women’s Hospital (Pittsburg) Intermountain Healthcare (Utah) Hospital Corporation of America (HCA) Ohio State Department of Health

Mean IQ Scores in 6 yo Children from Healthy Term Pregnancies 13,824 healthy term infants followed for an average of 6.5 years. IQ scores adjusted for multiple factors including: sex, birthweight for gestational age, maternal height and age at birth, smoking and drinking during pregnancy, parental marital status, number of children in the household, parental education and occupation. Yang et al. Am J Epidemiol 2010;171:

Cerebral Palsy among Term and Postterm Births Norwegian birth cohort of 1,682,441 singleton term births without congenital anomalies followed for a minimum of 4 years (maximum of 20 years) with identified CP in the National Health Insurance Registry. Moster et al. JAMA 2010;304: CP is 2.3x higher at 37wks and 1.5x higher at 38 wks than at wks

Caveats on CNS Outcomes… Best outcomes are at 40 weeks. Note that these studies are associations and can not show NOT causation. Nonetheless, the onus is on us to show that earlier birth is better…

Support for this Initiative comes from across the board ACOG strong support National Quality Organizations – Joint Commission, Leapfrog, NQF measures March of Dimes Many state collaboratives State Medicaid programs are exploring options – “Do not pay”, withholds, incentives, pre-auths – Commercial Insurance has acted in other states

JC Core Measure Set NQF National Consensus Standards for Perinatal Care 2008 (17 measures—9 OB) Episiotomy rate Elective delivery prior to 39 weeks Cesarean rate for low-risk first births Prophylactic antibiotics for Cesarean birth DVT prophylaxis for women having a Cesarean birth Exclusive breastfeeding at hospital discharge Birth trauma rate (limited ICD9 codes) Rate of antenatal steroids for under 34 week births Infants under 1500g (VLBW) not delivered at Level III center OB/ Mom OB/B aby Leapfrog Group Measures =Measures that are highest value (Quality + Savings)

Examples of Successful Programs to Reduce Non-medically Indicated (Elective) Deliveries Before 39 weeks of Gestation Magee Women’s Hospital (Pittsburg) Intermountain Healthcare (Utah) Hospital Corporation of America (HCA) Ohio State Department of Health

Intermountain Healthcare’s Experience Intermountain Healthcare is a vertically integrated healthcare system that operates 21 hospitals in Utah and Southeast Idaho and delivers approximately 30,000 babies annually. Computerized L&D system. MFMs hired by system, but OBs are independent. January 2001: 9 urban facilities participated in a process improvement program for elective deliveries. 28% of elective deliveries were occurring before 39 completed weeks of gestation. Oshiro, B. et al. Obstet Gynecol 2009;113:

% Non-medically Indicated Deliveries <39 Weeks, January 1999 – December 2005 Oshiro, B. et al. Obstet Gynecol 2009;113:

% Non-medically Indicated Deliveries <39 Weeks, January 1999 – December 2005 Oshiro, B. et al. Obstet Gynecol 2009;113: Superior Outcomes and $1 Million Dollars saved in 2009

Common Themes Noted in Intermountain Healthcare’s Experience Education provided to obstetricians regarding ACOG guidelines, best practice. Little change until physicians were held accountable, nurses were empowered, and guidelines were enforced. Medical leadership important.

Intermountain Healthcare System Initiative Elective inductions: 28% to >2% Length of time in labor: decreased by roughly 31 days/year (*this allowed for an additional 1500 births per year without any additional beds or nurses) Unplanned cesarean sections(with associated costs): reduced to 21% (national average 34%) Reduction in admissions to Neonatal Intensive Care Unit (and associated costs) ESTIMATED REDUCTION IN HEALTHCARE COSTS IN UTAH FROM THIS INITIATIVE: $50 MILLION/YR If applied nationally, would lower healthcare delivery costs by approximately $3.5 billion annually

Magee-Women’s Hospital’s Experience Magee-Womens Hospital is the largest maternity hospital in Western Pennsylvania, performing more than 9,300 deliveries in A rise in the use of induction, reaching a high of 28% in 2003, L&D too busy! In 2006, a process improvement initiative changed the induction scheduling process and strictly enforced the guidelines. “Elective”: not before 39weeks and without cervical ripening agents if 39+0 to 40+6). Fisch et al Obstet Gynecol 2009;113:797

Magee Women’s Experience with Guidelines Baseline 3mos 2004 Voluntary 3mos 2005 Enforced 14mos Deliveries2,1392,26010,895 Elective Inductions <39wks (N) Elective Inductions <39wks (rate) (elective inductions <39 / total elective inductions) % % % (p<0.001) Total Induction Rate24.9%20.1%16.6% Fisch et al Obstet Gynecol 2009;113:797 “Voluntary”: educational program and dept. recommendations “Enforced”: Department standard requiring approval by the Perinatal Committee Chair before scheduling non-standard indications for inductions

These are not exhaustive lists! But close… (e.g. prior classical CS)

Adverse Neonatal Outcomes According to Completed Week of Gestation at Delivery: Absolute Risk Tita AT, et al, NEJM 2009;360:111

Adverse Neonatal Outcomes According to Completed Week of Gestation at Delivery: Odds Ratios Tita AT, et al, NEJM 2009;360:111

Lots of Pressures on Obstetricians Clin Obstet Gynecol 2006;49: Physician Convenience Guarantee attendance at birth (“co-dependency”) Avoid scheduling conflicts Reduce being woken at night …what’s the harm? Bad outcomes are unrecognized and rare The NICU handles these issues just fine Limit my risk of a bad pregnancy outcome And…payment pressures to deliver own pts

Suspected Fetal Macrosomia (Non-Diabetic Population) Does not reduce risk of shoulder dystocia Doubles risk of cesarean section 262 pregnancies EFW>90% Elective group: 57% cesarean section rate 5.3% shoulder dystocia Spontaneous labor group: 31% cesarean delivery rate 2.5% shoulder dystocia

Physicians Convenience Economics Pt. Satisfaction Patients Convenience Comfort Scheduling Babies ? Hospitals Cost Liability Risk Safety

Board Issues 1.“Of course, why not? Make it policy immediately” 2. What precedent are we setting by elevating this quality assessment item above all the other things we routinely evaluate? 3. For the Board of Governors (mostly non- physicians) to make a policy that limits physicians’ autonomy regarding clinical decision making requires a very high standard. Does this issue pass the test for scientific and clinical need?

Team Members Physician Champion Executive Leader Day to Day Leader Technical Expert Pediatrician Champion Risk Management Quality - CNS Childbirth Educator Unit Nursing Leadership

Scheduled initial committee meeting Established agenda: Overview Data Implementation Strategies Hard stop/Soft stop Policy Time Frame Team Discussion

Unresolved Challenges 1. Appeal Process: not local doctor to doctor or nurse to doctor. Who exactly and how do they get paid? 2. Exact wording of the policy.