Webinar: Strong Start for Mothers and Newborns - Reducing Early Elective Deliveries


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As part of the Strong Start for Mothers and Newborns effort, the CMS Innovation Center hosted a webinar to discuss why it is important to reduce early elective deliveries and share best practices on how reducing early elective deliveries improves the health of mothers and newborns across the country. Individuals representing the American College of Obstetricians and Gynecologists, the March of Dimes, providers and payers conveyed examples of successes and how reducing early elective deliveries can be accomplished. All interested parties were invited to attend this event.

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Webinar: Strong Start for Mothers and Newborns - Reducing Early Elective Deliveries

  1. 1. Strong Start for Mothers and Newborns: Reducing Early Elective Deliveries Webinar November 28, 2012
  2. 2. Housekeeping & AgendaSpeakers:Erin Smith, CMS Innovation CenterDr. Hal Lawrence, American College of Obstetricians and GynecologistsDr. Scott Berns, March of DimesDr. Kenneth Brown, Woman’s Hospital (Baton Rouge, LA)Dr. Kathleen Simpson, Mercy Hospital (St. Louis, MO)Vi Naylor and Lynne Hall, Georgia Hospital AssociationDr. Stephen Barlow, SelectHealth (Murray, UT)Questions & Answers 2
  3. 3. Erin SmithPatient Care Models Group CMS Innovation Center 3
  4. 4. Strong Start Initiative:Two Strategies to Improve Birth OutcomesThe Strong Start initiative has two different but related strategies: 1. Reducing Early Elective 2. Delivering Enhanced Prenatal Deliveries Care A test of a nationwide public- A funding opportunity for private partnership and providers, States and other awareness campaign to spread applicants to test the the adoption of best practices effectiveness of specific enhanced that can reduce the rate of early prenatal care approaches to elective deliveries before 39 reduce pre-term births in women weeks for all populations. covered by Medicaid & CHIP. 4
  5. 5. Strategy 1:Reducing Early Elective Deliveries 5
  6. 6. Strategy 1: Promote Awareness• Awareness and Visibility Events – 6 regional events• Media outreach – TV, radio, print, in store audio, search engine marketing, and waiting room TV.• WebMD consumer page 6
  7. 7. Strategy 1: Spread Best Practice• The Strong Start initiative is leveraging the existing infrastructure of the Partnership for Patients, including the participating Hospital Engagement Networks (HEN), to support hospitals across the country in their efforts to decrease the number of early elective deliveries. – HENs set individual goals related to reducing early elective deliveries.• Medscape – early elective delivery Continuing Medical Education (CME) opportunity 7
  8. 8. Strategy 1: Promote Transparency• In the FY 2013 Inpatient Prospective Payment System final rule, CMS finalized the addition of a new measure to the Inpatient Quality Reporting (IQR) Program. – Elective delivery prior to 39 completed weeks of gestation (NQF #0469) – For payment determinations in FY 2015 8
  9. 9. Hal C. Lawrence, MD, FACOG Executive Vice PresidentAmerican College of Obstetricians and Gynecologists 9
  10. 10. 39 Weeks: A Strong Start for Moms & Babies Hal C. Lawrence, MD, FACOG Executive Vice PresidentAmerican College of Obstetricians and Gynecologists Washington, DC November 28, 2012
  11. 11. ACOG• The Nation’s women’s health physicians.• Providing education and clinical guidance to 57,000 ob-gyns and partners in women’s health.• Dedicated to ensuring the safest possible pregnancies and births.• Committed to Strong Start and eliminating early elective inductions.
  12. 12. Preterm Deliveries Change ChangeGestational 1990 2004 2005 from 2010 from age 1990 2005 ↑0.1 ↓0.04<32 weeks 1.9% 2.0% 2.0% 1.96% (5%) (~2%) ↑0.2 ↓0.0732-33 weeks 1.4% 1.5% 1.6% 1.53% (~14%) (~4.4%) ↑1.8 ↓0.6134-36 weeks 7.3% 8.9% 9.1% 8.49% (~25%) (~6.7%) ↑2.1 ↓0.7TOTALS 10.6% 12.5% 12.7% 12.0% (~20%) (~5.5%)
  13. 13. Strong Start: Reducing Preterm Births• Preterm birth is the leading cause of neonatal mortality in the US.• Accounts for 35% of all US health care spending for infants and 10% for children.• Over half a million US babies were born preterm in 2008.• 12.3% of all live births occur before term in the US.• 2/3 of all infant deaths are among preterm infants.
  14. 14. Strong Start: Reducing Preterm Births• One of the most complicated and difficult issues in obstetrics.• Not much is known about the causes of preterm labor.• What we know: – A growing public health problem that cuts across social, racial, ethnic, and economic groups. – Preterm labor is the most common cause of antenatal (before birth) hospitalization. – There is a link between preterm birth and infant mortality.
  15. 15. Strong Start: Reducing Preterm Births• Growth and development in the last part of pregnancy are vital to the babys health.• The earlier a baby is born, the greater the chance he or she will have health problems.• Preterm babies tend to grow more slowly; often have problems with their eyes, ears, breathing, and nervous system; and experience learning and behavioral problems.
  16. 16. Late Preterm Infants: Outcomes• Compared to term infants, late preterm infants: – Are twice as likely to die of SIDS. – Have an 80% increased risk of ADHD. – Are 4 times more likely to have at least 1 medical condition and 3.5 times more likely to have 2 or more conditions.• The neonatal mortality rate (deaths among infants 0–27 days of age) for late–preterm infants is much higher than the rate for term infants.
  17. 17. Late Preterm Infants: Outcomes • Late preterm infants: – Are more likely to be referred for special needs in pre- school* – Are more likely to have problems with school readiness* – Are more likely to have severe hyperbilirubinemia and resultant neurological consequences* – Have a 20% increased risk of clinically significant behavior problems at 8 years of age – Are more likely to be diagnosed with developmental delay in the first 3 years*Fuchs K, Wapner R. Elective Cesarean Section and Induction and Their Impact on Late Preterm Births. Clin Perinatol 33:793-801, 2006.Adams- Chapman I. Neurodevelopmental Outcomes of the Late Preterm Infant. Clin Perinatol 33: 947-964, 2006.
  18. 18. Strong Start: Reducing Preterm Births• Labor is induced in more than 22% of all US pregnancies, a rate that more than doubled from 1990 to 2006.• The goal of induction is to achieve vaginal delivery by stimulating uterine contractions before the spontaneous onset of labor.• Induction has merit when the benefits of expeditious delivery outweigh the potential maternal and fetal risks of continuing the pregnancy.• ACOG is clear: Unless a medical indication exists, labor induction or a scheduled elective delivery should not be done before 39 weeks of pregnancy.
  19. 19. Changes in Infant & Fetal OutcomesAnanth CV, Gyamfi C, Jain L. Characterizing risk profiles of infants who are delivered at late preterm gestations: does it matter? AmJ Obstet Gynecol. 2008 Oct;199(4):329-31.
  20. 20. Strong Start: Reducing Preterm BirthsIndications for induction of labor are not absolute, but should take into accountmaternal and fetal conditions, gestational age, cervical status, and other factors.Indications may include:• Abruptio placentae;• Isoimmunization, i.e. Rh disease;• Chorioamnionitis;• Fetal demise;• Gestational hypertension;• Premature rupture of membranes;• Postterm pregnancy;• Preeclampsia, eclampsia;• HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets) syndrome• Maternal medical conditions (eg, diabetes mellitus, renal disease, chronic pulmonary disease, or chronic hypertension); and• Fetal compromise (eg, severe fetal growth restriction or a deficiency in amniotic fluid).
  21. 21. Strong Start: Reducing Preterm Births• Labor also may be induced if the patient is at risk for very rapid labor, if she lives an unsafe long distance from the hospital, or if she has serious mental health indications.• Even in these circumstances, at least one of the established gestational age criteria should be met: – Fetal heart tones have been documented as present for 30 weeks by Doppler US – US measurement at less than 20 weeks of gestation supports gestational age of 39 weeks or greater – It has been 36 weeks since a positive serum or urine human chorionic gonadotropin pregnancy test result• A mature fetal lung test result before 39 weeks of gestation, in the absence of appropriate clinical circumstances, is not an indication for delivery.• The individual patient and clinical situation must always be considered in determining when induction of labor is indicated.
  22. 22. Strong Start A Strong Partnership bringing Medicine (ACOG), the Public (MOD), and Government (CMS) together.to ensure healthy births.
  23. 23. Scott D. Berns, MD, MPH, FAAPSenior Vice President & Deputy Medical Director March of Dimes 23
  24. 24. Reducing Early Elective Deliveries November 28, 2012 Scott D. Berns, MD, MPH, FAAP Deputy Medical Director & Senior Vice President March of Dimes Foundation Clinical Professor, Pediatrics Alpert Medical School of Brown University
  25. 25. March of Dimes MissionTo improve the health of babies by preventing birth defects, premature birth and infant mortality Fund Research Help Moms Support Families to understand problems & have full-term providing comfort whendiscover answers leading to pregnancies & their baby needs help prevention & treatment. healthy babies. to survive and thrive.
  26. 26. Stronger, healthier babies:75 years in the making
  27. 27. U.S. Preterm Birth Rate Declines…Data shown is % of live births*Preliminary birth dataSource: National Center for Health Statistics, final natality data, 2011 preliminary natality data.
  28. 28. Preterm Birth Rates by Gestational Age United States, 1990, 2000, 2005-2011*Source: National Center for Health Statistics, 1990-2010 final natality data and *2011 preliminarydata
  29. 29. March of Dimes Preterm Birth Goals*Preliminary dataPreterm is less than 37 completed weeks of pregnancy.Source: National Center for Health Statistics, 1990-2010 final natality data and 2011 preliminary data.Prepared by March of Dimes Perinatal Data Center
  30. 30. Strong StartThe March of Dimes is continuing its ongoingpartnership with CMS/HHS to advance the goals ofStrong Start:• March of Dimes patient education materials cobranded with HHS and ACOG being distributed• Collaborating on media coverage; CMS/HHS media buys in November 2012• Reach out to all Partnership for Patients Hospital Engagement Networks; providing menu of options
  31. 31. Partnership for PatientsMarch of Dimes is reaching out to all Hospital EngagementNetworks (HENs) to offer a menu of options forpartnering with chapter and national to reduce electivedeliveries before 39 weeks.– Use the March of Dimes 39+ Weeks Quality Improvement Service Package– Grand Rounds– Distribute 39+ weeks education materials– Co-brand 39+ weeks education materials with hospital/HEN logo– Co-brand and place March of Dimes television, radio, print, or outdoor ads
  32. 32. HBWW® Late preterm Brain Development FlyerAvailablein EnglishandSpanish
  33. 33. HBWW® Baby Poster
  34. 34. HBWW® Print PSA
  35. 35. “Babies aren’t fully developed until at least 39 weeks in the womb…… If your pregnancy ishealthy, wait for labor to begin on its own.”
  36. 36. TV PSA Time Lapse Pregnancyhttp://www.marchofdimes.com/39weeks
  37. 37. Thank you!Contact:Scott D. Berns, MD, MPH, FAAPDeputy Medical Director & Senior Vice PresidentMarch of Dimessberns@marchofdimes.com
  38. 38. Kenneth Brown, MD, MBA, FACOG Medical DirectorWoman’s Hospital (Baton Rouge, Louisiana) 41
  39. 39. 39 Weeks:A Strong Start for Moms & Babies Kenneth E. Brown, MD, MBA, FACOG Medical Director Woman’s Hospital Baton Rouge, LA
  40. 40. ACOG We don’t know very much about the causes of preterm labor. We do know that there is a link between preterm birth and infant mortality. Unless a medical indication exists, labor induction or a scheduled elective delivery should not be done before 39 weeks of pregnancy.
  41. 41. An ongoing story about Woman’s Hospitaland the State of Louisiana.
  42. 42. Statewide Leader in Obstetrics, Gynecology, Breast, and Neonatal CareAnnually 8,400 births 1,400 NICU discharges 95,000 pap smears 44,000 mammograms 7,400 surgeriesSpecialties in-house24/7/365 Anesthesia Ob/Gyn Neonatology MFM Immediately Available 45
  43. 43. Involvement of Medical Staff Education  Literature for physicians  Grand Rounds  CME( guest lectures/webinars)  IHI Perinatal Design  Literature for patients Voluntary
  44. 44. Involvement of Medical Staff Policy Development  Defining – Active labor, Augmentation, Medical indication, Multiple pregnancy, HIV  Establish Baseline  Collect Data  Oxytocin Policy
  45. 45. Multidisciplinary Involvement Hard Stop Policy  Medical Staff Leadership  Nursing Directors  Hospital Administration  Board of Directors
  46. 46. Louisiana Birth Outcomes Initiative April 2010 Louisiana ranking: 48th in infant mortality and preterm births 49th in percentage of low birth weight and very low birth weight balance 15.4% preterm birth rate November 2010 March of Dimes gives Louisiana an “F” rating on birth outcomes.
  47. 47. Louisiana Birth Outcomes Initiative A Statewide Effort  State Department of Health & Hospitals  Louisiana March of Dimes  Louisiana Hospital Association  Louisiana Medical Mutual Insurance Co.  Woman’s Hospital
  48. 48. Louisiana Birth Outcomes Initiative July 18, 2012 Louisiana Receives the March of Dimes President’s Prematurity Leadership award. August 2012 Preterm Birth Rate - 12.4%(preliminary 2011) Goal for 2014 – 8%
  49. 49. Kathleen Simpson, PhD, RN, FAAN Perinatal Clinical Nurse SpecialistMercy Hospital (St. Louis, Missouri) 57
  50. 50. Early Term Elective Birth Prevention Kathleen R. Simpson, PhD, RN
  51. 51. Mercy Hospital - St. Louis• Community teaching hospital• 8,000 births• 100 + attending physicians in private practice responsible for 96% of births• Elective births < 39 weeks ~ 3%
  52. 52. Hospital Based Strategies• Interdisciplinary OB Practice Committee• Review of standards and guidelines related to timing of elective births and evidence of morbidity with early term elective births• Policy development / practice adoption• Leadership support• Team building / consensus
  53. 53. Hospital Based Strategies• Reevaluation of scheduling processes for elective births / flexibility / evening and weekend options• Empowerment / support for elective birth policy• OB hospitalist program• Patient education• Ongoing quality monitoring / process measures / follow-up with selected individuals as needed• Join or organize an OB quality collaborative (area, state, healthcare system, March of Dimes)
  54. 54. Mercy Hospital – St. Louis• Patient education re: risks of elective induction and early term birth• Prepared childbirth classes• Cue cards for discussion with providers• N = 3,337 nulliparous women• Elective inductions ↓ 20% over 7 months• Elective inductions <39 weeks ↓ 40% (Simpson, Newman & Chirino, 2010)
  55. 55. Health System Success• 26 hospitals with OB services in 9 states• Began process to eliminate early term births in 2009• Implemented system-wide policy / ongoing monitoring• Current rate of elective inductions < 39 wks = 0.4%; decreased from 15% in 2009 (O’Rourke et al., 2011)
  56. 56. Hospitals in State-Wide (Michigan)Perinatal Patient Safety ProjectN = 68 Michigan Hospitals with an OB UnitEducation, collaboration, protocols, teambuilding, measurement, webinars,conferences, coaching, leadership support5 process and 8 outcome measures of OBquality including elimination of earlyelective births (Simpson et al., 2011)
  57. 57. Elective Induction of Labor <39 Weeks
  58. 58. Go the Full 40: A Consumer Campaign• Partnership between AWHONN and its Healthy Mom&Baby media• Healthy Mom&Baby: magazine, iPad app, http://www.health4mom.org/ HMB social media• Nurse distribution 66 ©2012 AWHONN
  59. 59. Campaign goals#1. Increase the # 3. Increase nurses’percentage of women effectiveness towho complete at least reduce the number40 weeks of #2. Decrease the percentage of elective inductionspregnancy of women who choose and cesarean births. elective induction or elective cesarean birth. 67 ©2012 AWHONN
  60. 60. Themes of Go the Full 40• Full-term babies• Spontaneous labor• Breastfeeding promotion• Reduction of elective inductions, elective cesareans 68 ©2012 AWHONN
  61. 61. Campaign materials 69 ©2012 AWHONN
  62. 62. Pledge: “Wait for Labor to Start on its Own”http://www.awhonn.org/full40pledge 70 ©2012 AWHONN
  63. 63. Go the Full 40 71 ©2012 AWHONN
  64. 64. Vi Naylor, Executive Vice PresidentLynne Hall, Quality Improvement Specialist Georgia Hospital Association 72
  65. 65. Data Results:Early Elective Deliveries September 17, 2012
  66. 66. Where did we start? • CMS and the National Content Developer charged all HENs to reduce HAC’s by 40% • Adding reducing readmissions by 20% • Adding reducing EEDs by 40%Learn. Act. Improve. Spread. 74 Keep the Drum Beat Going.
  67. 67. Who helped us start? • Buy-in from hospitals • March of Dimes • Department of Public Health • Georgia Chapter of OBGYN Society • Georgia Chapter of the Society for CNM • Georgia Nurses Association • AmeriGroup • And othersLearn. Act. Improve. Spread. 75 Keep the Drum Beat Going.
  68. 68. How did we start? • EED Action Group met in April 2012 to review 2009 data regarding EED – Key stakeholders: March of Dimes, Department of Public Health, OB/GYN Society of Georgia Atlanta Chapter, Georgia Nurses Association, and other were in attendance • Developed and agreed upon plan to reduce EED’s by 40% – Ultimate overall goal for Georgia: 0% – Timely goal for August 2012: 5% or less • Plan: Encourage use of “hard stops”, March of Dimes Toolkit or IHI bundles to empower nurses and schedulersLearn. Act. Improve. Spread. 76 Keep the Drum Beat Going.
  69. 69. EED Action GroupLearn. Act. Improve. Spread. 77 Keep the Drum Beat Going.
  70. 70. The Journey • In-person meeting inviting all birthing hospitals in Georgia – March of Dimes – Department of Public Health – Best Practice Hospitals Presented: • WellStar Health System • Athens Regional Health System • Liberty Medical Center • Pledge was signed to reduce EEDs across Georgia • Telnets/Webinars and one-on-one calls with hospitals were held including subjects on physician engagement, hard stops, risks to moms and babies and more!Learn. Act. Improve. Spread. 78 Keep the Drum Beat Going.
  71. 71. Commitment Poster signingLearn. Act. Improve. Spread. 79 Keep the Drum Beat Going.
  72. 72. The Journey • WSB Channel 2 News covered the event: – WSB did a video Labor of Love. – http://www.wsbtv.com/news/news/labor-of-love-examining-elective- deliveries/nDk4G/ • Covered the in-person meeting – Did a follow-up in September with our results • Dr. Fitzgerald was interviewed • Atlanta Medical Center was featuredLearn. Act. Improve. Spread. 80 Keep the Drum Beat Going.
  73. 73. Learn. Act. Improve. Spread. 81 Keep the Drum Beat Going.
  74. 74. The Journey • Several hospitals shared their Best Practices in reducing EED’s – Atlanta Medical Center – Emory University Midtown – Piedmont HenryLearn. Act. Improve. Spread. 82 Keep the Drum Beat Going.
  75. 75. The Results • There are 83 birthing hospitals in Georgia • 58 (70%) of those hospitals turned in data • 19 (31%) of the 58 hospitals were already at a 0% EED rate • Of the 39 hospitals needing improvement about ½ showed significant gains!! • 3 of those hospitals went from a 14% or higher EED rate to a 0% rate sustained for at least 3 months!! – Habersham Medical Center went from a 30% EED rate down to 0% and has sustained the rate for 4 monthsLearn. Act. Improve. Spread. 83 Keep the Drum Beat Going.
  76. 76. The Results 1 • 2009 – 65% • 2010 – 35.3% • August 2012 – 3.67% • YTD 2012 – 5.90% • That’s a 58% decrease in Early Elective Deliveries!!!Learn. Act. Improve. Spread. 84 Keep the Drum Beat Going.
  77. 77. The Results 2 • From March 2012 baseline data to August 2012 data: – We can celebrate a 58% decrease in EEDsLearn. Act. Improve. Spread. 85 Keep the Drum Beat Going.
  78. 78. The Results 3 • According to Managed Care Magazine it costs around $41,000 for a late preterm NICU visit • The incidents went from 147 incidents in March 2012 to just 32 in August 2012 • That’s a decrease of 117 incidents • If even a ¼ of the babies went to NICU, we saved Georgia Healthcare $1,178,750.00 OVER 1 MILLION Dollars!!Learn. Act. Improve. Spread. 86 Keep the Drum Beat Going.
  79. 79. The Results 4Learn. Act. Improve. Spread. 87 Keep the Drum Beat Going.
  80. 80. The Results 5Learn. Act. Improve. Spread. 88 Keep the Drum Beat Going.
  81. 81. The Results 6Learn. Act. Improve. Spread. 89 Keep the Drum Beat Going.
  82. 82. Lessons Learned • Important to work as a team • Get physician buy-in and have a physician champion • Empower your schedulers and nurses • Have a peer review for non-medically necessary EED • Educate patients early starting at first visit • Collaborate with others even outside your hospital: – Share best practices – Share forms – IHI – March of DimesLearn. Act. Improve. Spread. 90 Keep the Drum Beat Going.
  83. 83. Lessons Learned 2 • Use data to sustain the gain • Present data to administration and physicians • Build on existing relationships • Celebrate your success!!!Learn. Act. Improve. Spread. 91 Keep the Drum Beat Going.
  84. 84. Questions??
  85. 85. Stephen L. Barlow, MDVice President & Chief Medical Officer SelectHealth (Murray, Utah) 93
  86. 86. QuestionsAdditional information available on CMMI website: http://innovation.cms.gov/Program email: StrongStart@cms.hhs.gov 96
  87. 87. Thank youhttp://innovation.cms.gov/ 97