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

2. 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

3. 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

4. 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

5. Healthy People NTSV CD Target 23.9%

6. 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 less than cesarean births, double the risk of mortality with a c/s

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

8. Risks of Cesarean Delivery

9. 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

11. 11

12. 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

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

14. 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

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

16. 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

17. 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

18. 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

19. 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%

20. Frequency of occurrence
Cumulative Percentage

21. Drivers of Cesarean Delivery

22. 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.

23. 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

24. What is the evidence?

25. 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

26. 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

27. Suggested NICHD Consensus Algorithm
Spong et al Obstet Gynecol 2012

28. ACOG/SMFM Recommendations

29. ACOG/SMFM Recommendations

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

31. 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

33. 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

34. Results: Adherence to Guidelines

35. Abbreviated Control Chart

36. 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

37. 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

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

39. 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)

40. 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

41. 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

42. 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.

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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. Published October Accessed January 12, 2016
Data Measurement
Support
Quality Improvement
Support
Payment
Reform
Slide courtesy of California Maternal Quality Care Collaborative

50. 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

51. Readiness Assessment
Slide courtesy of California Maternal Quality Care Collaborative

52. 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

53. Next Steps Email: Pat Bohling Smith pat@cpcqc.org We look forward to
working with you!

54. 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