1. The FMEC IMPLICIT Network: Improving the Health of Women and Their Infants through Quality Improvement Stephanie E. Rosener, MD Daniel J. Frayne, MD 3 rd National Summit on Preconception Health and Health Care Tampa, Florida June 13, 2011

2. The Problem – Preterm Birth US Preterm Birth Rate (2009) = 12.18% National Center for Heath Statistics, Dec 21, 2010

3. IMPLICIT Interventions to Minimize Preterm and Low birth weight Infants using Continuous Improvement Techniques

4. What is IMPLICIT?  Collaborative of Family Medicine Residency Programs  Continuous Quality Improvement (CQI)  Primary Prevention of Prematurity  Opportunity to influence the future practice patterns of family medicine residents

5. Our Partners: National March of Dimes Family Medicine Education Consortium

6. Participating FM Residencies Pennsylvania   WPAHS - Forbes  UPMC- McKeesport  UPMC- Shadyside  UPMC- St. Margaret  Penn State-Good Samaritan  Lancaster General Hospital  Reading Hospital Medical  University of Pennsylvania  Jefferson Medical College  Williamsport  York Hospital Massachusetts  Greater Lawrence New York  Beth Israel  Ellis Hospital  Mid-Hudson Connecticut  Middlesex Hospital North Carolina  MAHEC Asheville

7. How IMPLICIT Works  Monthly audio-conferences  Evidence leaders  Working groups  IMPLICIT website (FMEC)  Web-based data portal  Semiannual meetings

8. Continuous Quality Improvement (CQI) Proactive process to improve care Identifying and analyzing strengths and problems Testing, implementing, and revising solutions

9. Chosen Prenatal Interventions Depression Smoking cessation Inter-pregnancy interval Asymptomatic Bacteriuria Bacterial Vaginosis (dropped 2011) Progesterone (added 2006)

10. Successes/Impact

11. Bennett et al (2009) JABFM, n = 3,936, 10 sites

12. Original Depression CQI Strategy Administer both 2-Item Screen and Edinburgh Postnatal Depression Scale (EPDS) (15 & 30 weeks, postpartum) Diagnose Depression (DSMIV-TR Criteria) Treat according to usual guidelines Psychotherapy Antidepressant medication Behavioral Lifestyle interventions “During the last month have you often been bothered by: - Little interest or pleasure in doing things? - Feeling down, depressed, or hopeless?”

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15. 15 EPDS ≥13 30 Week screen Variable(s) AUC (95% CI)SensSpecPPVNPV Two item screen 0.81 (0.74-0.88) 82 80 24 91 Two item screen + Dep. Hx. 0.85 (0.76-0.94) 1 item positive 93 63 42 91 2 items positive 41 91 22 98 15 Week Screen Variable(s) AUC (95% CI)SensSpecPPVNPV Two item screen 0.80 (0.69-0.91) 9375 4498 Two item screen + Dep. Hx.0.85 (0.76-0.94) 1 item positive 97615991 2 items positive 58922199 Postpartum Variable(s) AUC (95% CI)SensSpecPPVNPV Two item screen 0.80 (0.69-0.91) 8086 3099 Two item screen + Dep. Hx. 0.85 (0.76-0.94) 1 item positive 90674496 2 items positive 60961199 Bennett et al (2008) JABFM

16. Revised 2-Stage Depression Screening Strategy Administer PHQ-2 (50-60% negative) Yes to either question = positive screen  full depression screening (PHQ-9 or EPDS) Results in only 18% of pregnant and postpartum women requiring further assessment

17. Next Steps for IMPLICIT

18. Preconception Care – The Facts By the time a woman enters prenatal care, it is often too late to significantly affect the outcome of the pregnancy Only 11% of prenatal patients have a preconception visit The extent to which women who do not become pregnant receive preconception care is unknown

19. Interconception Care “A subset of preconception care that addresses the continuity of risk from one pregnancy to the next.” (Kotelchuck, 2006) Characteristics of an Ideal Model: Brief (5 minute “capsule”) Cost effective Acceptable to patients Potential for broad implementation

20. Proposed IMPLICIT ICC Model Address maternal risk at Well Child Visits Mothers visit the office regularly even if they do not seek care for themselves Poor maternal health status adversely affects child development and well-being Achievable and acceptable to women based on pilot studies Kahn and Wise, Pediatrics, 1999. Gjerdingen et al., Ann Fam Med, 2009.

21. IMPLICIT ICC – Areas of Focus Tobacco Use* Depression Family Planning/Birth Spacing Folic Acid Supplementation* *Supported by Level A Evidence

22. IMPLICIT ICC Strategy: Utilize contact with mothers at well child visits Assess current risks Reinforce desired behaviors Connect with primary providers or community resources to address risks Collect data, analyze and develop strategies to improve care delivery Baseline data collection is under way

23. Conclusions CQI is an effective strategy for improving the delivery of maternity care processes associated with decreased preterm and LBW outcomes Collaboratives provide the opportunity for organized inquiry and larger subject numbers required for meaningful data analysis A CQI strategy for Interconception Care holds promise for improving birth outcomes and could be implemented in a wide variety of primary care settings Resident involvement provides the opportunity to influence the practice patterns of the next generation of family physicians

24. Final Questions/Comments