1. Saving Money, Saving Lives Population-Based Quality Improvement Edward F. Donovan Child Health Services Research Meeting June 24, 2006

2. Regional Systems of Perinatal Care The Investment Case for Quality Improvement Economic resources spent for perinatal care - taxes/charity (public health & govt sponsored insurance) - after-tax wages (employment-sponsored insurance) Potential savings - avoid preterm births and consequent lifelong handicaps Because many individuals receive a mix of tax-supported and employment-supported services, quality improvement should occur at the health system level

3. Population-based quality improvement to save lives and money Geographically defined systems of perinatal care Individuals receive care from different parts of the system Test population-based QI: - caregiver/policy teams - data systems operational - QI collaborative Investment case for population-based QI Regionalized Perinatal Care in Ohio

5. EXTREME PREMATURITY [birth at less than 29 weeks gestational age] 60-70% of deaths in the first year of life are associated with EXTREME PREMATURITY 50% of lifelong handicapping conditions with onset in infancy are associated with EXTREME PREMATURITY 1% of births are EXTREMELY PREMATURE, but 25% of spending for perinatal care

8. Population-based QI to improve perinatal care in Ohio Outcome: Extreme prematurity QI Methods: Real-time, longitudinal measures of outcomes: e-birth-certificates Improvement collaboratives: PDUC Benchmarking Transparent tests of change

9. Benchmarking If whites (83% of births) in less well performing regions had the same proportions of births 25-28 weeks GA as the best performing region, there would be roughly 135 fewer infants in this category per year in Ohio If African Americans (17% of births) in less well performing regions had the same proportions of 25-28 weeks GA as African Americans in the best performing region, there would be approximately 175 fewer infants in this category per year 135 + 175 = 310 fewer extremely preterm infants per year

10. Return on Investment Saving a few lives and a lot of money 80 fewer deaths per year 100 fewer children per year with life long disability Total annual savings in birth spending: $ 78 million [5% of total birth spending in Ohio] Total savings in Medicaid birth spending: $ 24 million Ohio Medicaid budget for families and children = $ 2 billion (5% of Ohios annual spending) Medicaid savings = 1% per year [not counting cost of lifelong handicap] Ohio Medicaid budget for children has been increasing 3.6% per year

12. Improving quality of perinatal care for geographic regions Outcomes depend on multiple sources of care Optimal care depends on linkages among care sources Processes of care are readily identifiable Population-based outcome measures are available in existing administrative data sets (birth and death certificates) In many areas, perinatal care is regionalized Benchmarking and learning collaboratives are possible within jurisdictions (e.g. states)

13. Opportunities to Improve Identify best evidence Highly reliable use of best evidence Identify best practices Highly reliable implementation of best practices

14. Quality of Care Improvement Real-time measurement of processes and outcomes Small tests of change Benchmarking Improvement collaboratives: constituency determined from the users perspective Transparency

15. CountryInfant mortality 1998 [deaths/1000 births] GDP per capita 1992 [1985 U.S. $] Health expenditures 1995 [% GDP] Public health expenditures 1995 [% total health $] Japan415,1057.278 Germany510.578 UK612,7246.984 USA717,94514.047 Infant Mortality U.S. international rank in 2002 24 th African American IM = 14.4 White IM = 5.8 U.S. international rank in 2002 for low risk infants 7 th

16. Improving the perinatal care system: Users perspectives What types of care do I need? Prevention- Care in the public sector: nutrition, housing, social services, immunizations, primary care Care in the private sector: primary care (pre-conception, prenatal)

17. Improving the perinatal care system: The users perspective What types of care do I need? Treatment- Care in the public sector: Public health clinics, public hospitals Care in the private sector: Offices, birthing centers, hospitals

18. OHIO