making sense of cesarean birth rates how should we … · making sense of cesarean birth rates how...

$: Making sense of Cesarean Birth Rates How should we … · Making sense of Cesarean Birth Rates How should we invest our QI ... (versus charting, ... Cesarean#Sec\on@@Nulliparous,#Term,#Singleton,#Vertex$
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Elliott Main, MD Medical Director, CMQCC main@ .org

Clinical Professor, OB/GYN UC San Francisco, and Stanford University

Making sense of Cesarean Birth Rates How should we invest our QI efforts?

Anne Castles, MS MPH Project Manager, CMDC acastles@ .org

California Maternal Data Center CMQCC

: Transforming Maternity Care

Today’s Discussion:

n  What are the drivers for the rise and variation in Primary CS?

n  NTSV (Nulliparous, Term Singleton, Vertex) as the focus for CS Quality Improvement

n  Importance of L&D culture, Labor practices, and use of Data and the California Maternal Data Center to drive change

n  Multi-strategy approach to address CS rates n  Public projects to support this initiative


Paradigm Shift

Most Cesarean Births are inevitable

though some are preventable

Changes in practice style can prevent

many labor Cesarean Births


Presenters’ Disclosures:

n  No financial conflicts n  We are all employees of California Maternal

Quality Care Collaborative (CMQCC) based at Stanford University, Palo Alto, CA

n  No outside business interests CMQCC is a multi-stakeholder State Quality Collaborative. The CMDC supported by the CDC and the California HealthCare Foundation


CPQCC and CMQCC Mission: Improving care for moms and newborns

California Perinatal Quality Care Collaborative (CPQCC) n  Expertise in data capture from hospitals n  Established Perinatal Data Center in 1996 n  Data use agreements in place with 130 hospitals with NICUs n  Model of working with state agencies to provide data of value California Maternal Quality Care Collaborative (CMQCC) n  Expertise in maternal data analysis n  Developer of QI toolkits n  Host of collaborative learning sessions n  Established Maternal Data Center in 2011


CMQCC Key Partner/Stakeholders State Agencies: n  MCAH, Dept Public Health n  OSHPD Healthcare Information Division n  Office of Vital Records (OVR) n  Regional Perinatal Programs of California (RPPC) n  DHCS, Medi-Cal Public Groups n  California Hospital Accountability and Reporting Taskforce (CHART) n  California HealthCare Foundation n  Kaiser Family Foundation n  March of Dimes (MOD) Professional groups n  American College of Obstetrics and Gynecology (ACOG) n  Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) n  American College of Nurse Midwives (ACNM), n  American Academy of Family Physicians (AAFP) Key Medical and Nursing Leaders n  Universities and Hospital Systems n  Kaisers, Sutter, Sharp, Dignity, Scripps, Providence, Public hospitals,


CMQCC Key Partner/Stakeholders (con’t)

Medical Associations: n  California Hospital Association n  Regional Hospital Associations n  California Medical Association Payers n  Aetna n  Anthem Blue Cross n  Blue Shield n  Cigna n  Health Net Purchasers n  CALPERS (State and local government employees and retirees) n  Medi-Cal (for managed care plans) n  Pacific Business Group on Health/ Silicon Valley Employers Forum n  Cover California (ACA entity)


CMQCC Perinatal QI Toolkits Adopted Nationally


Cesarean Births Have Risen by Over 50% in the Last 10 years


Why has Cesarean Birth Reduction been so hard?

n Direct challenge to Physician autonomy n Very complex, many factors, need to be able

to focus on areas with real preventability n Need for professional society leadership n Timing: prior attempts were often “Voices in

the wilderness”; “3rd rail of OB QI”; “Enter at your own risk…”

n Risk: “Never got sued for doing a Cesarean”


De-construction of the Cesarean Rate

n  Cesarean deliveries are done for many indications, are they all equally “worthy”? (evidence-based)

n  Is there a portion of the Cesarean rate that can be reduced without causing harm?

n  Why is there so much variation in Cesarean rates without similar variation in neonatal outcomes?

n  Is our training on labor management out-dated?


CS Indication

Proportion of Overall CS Rate

Proportion of Primary CS Rate

CS Rate for this

Indication Repeat (prior) 30-35% 90+% “Abnormal Labor” (CPD/FTP)

25-30% 35-45% variable

“Fetal Distress” 10-15% 15-20% variable Breech/Malpres. 10% 15-20% 98% Multiple Gestation 5-9% 10-15% 60-80% Other: Placenta Previa, Herpes, etc

~5% ~10-15% 90%

What are the Indications for Cesarean Section?


Percent of the Increase in Primary Cesarean Rate Attributable to this Indication

Cesarean Indication Yale (2003 v. 2009) (Total: 26% to 36.5%)

Focus: all primary Cesareans

Kaiser So. Cal. (1991 v. 2008)

(Primary: 12.5% to 20%) Focus: all primary singleton

Cesareans

Labor complications (CPD/FTP) 28% ~38%

Fetal Intolerance of Labor 32% ~24%

Breech/Malpresentation <1% <1%

Multiple Gestation 16% Not available

Various Obstetric and Medical Conditions (Placenta Abnormalities, Hypertension, Herpes, etc.)

6% 20% (Did not separate

preeclampsia from other complications)

Preeclampsia 10%

“Elective” (defined variously) 8% (Scheduled without “medical indication”)

18% (Those “without a charted

indication”)

What Indications Have Driven the Rise in CS?


Importance of the First Birth

n  If you have a CS in the first labor, over 90% of ALL your subsequent births will be by Cesarean Section

n  If you have a vaginal birth in the first labor, over 90% of ALL your subsequent births will be vaginal

A Classic Example of “Path Dependency”

How do we focus QI activity on preventing First-birth (Primary) Cesarean sections?


NTSV Cesarean Section Rate: Quality Measure

n Widely Adopted ¨  ACOG: Task Force on Cesarean Section

rates (2000) ¨  DHHS: Healthy Person 2010 and 2020 ¨  NQF, Joint Commission ¨  Similar to AHRQ Inpatient Quality Indicator

(IQI #33: Low-risk Primary Cesarean Delivery Rate) (also includes MTSV)

¨  Medicaid programs in California, Washington, others

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Total CS Rate Among 251 California Hospitals 2011-‐2012

(Source: CMQCC-‐-‐California Maternal Data Center combining primary data from OSHPD and Vital Records)

Range: 15.0—71.4% Median: 32.5% Mean: 32.8%

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Low-‐Risk First-‐Birth (Nuliparous Term Singleton Vertex) CS Rate (endorsed by NQF, TJC PC-‐02, CMS, HP2020)

Among 249 California Hospitals: 2011-‐2012 (Source: CMQCC-‐-‐California Maternal Data Center

combining primary data from OSHPD and Vital Records)

Range: 10.0—75.8% Median: 27.0% Mean: 27.7%

National Target =23.9%

36% of CA hospitals meet national target

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Variation in California CS Rates by Region (2007)

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NTSV CS Total CS

NTSV CS State Mean=28.1%

Total CS State Mean=31.3%

HP2020 NTSV CS Target=23.9%


What do we mean by “culture” (1)

n  Nursing culture is about… ¨ Experience in managing labor (versus charting,

caring for complications and FHR interpretation) ¨ Value seen for vaginal birth ¨  Importance of labor support ¨ Flexibility and patience

n  OB culture is about… ¨ All of the above, and… ¨ Outside pressure (back to the office or family) ¨ Perception of liability risk

“The way we do things around here”


So what do we mean by “culture” (2)

n  Leadership (MD and Admin) culture is about… ¨ All of the above, and… ¨ Does anyone care? ¨ Do leaders feel they have leverage?

n  Patient culture is about… ¨ Value of vaginal birth (friends, family, and Hollywood) ¨ Fear of pain, vaginal birth (for mother and baby), and

vaginal cosmesis ¨ Childbirth preparation

“The way we do things around here”


PDD-‐-‐Discharge Diagnosis File (ICD9 codes)

Birth Cer9ficate File (Clinical Data)

1.  Links Birth Data to OSHPD file 2.  Runs exclusions 3. Iden\fies CS and Induc\ons 4. Prints list of charts for review

CMQCC Maternal Data Center

CMQCC Data Center

REPORTS Benchmarks against other hospitals

Sub-‐measure reports

Calculates all the Measures <39wk Elec9ve Delivery

CHART REVIEW Labor?/SROM?

(~6% of cases for brief review)

Limited manual data entry for this measure

Uploads electronic files

Mantra: “If you use it, they will improve it”


What are some of the features of the CMDC?

A low-‐cost, low-‐burden, web-‐based tool providing hospitals with:

Ø Overall hospital performance measures Ø  Drill-‐down sta\s\cs and case review worksheets to iden\fy quality improvement opportuni\es—for both clinical quality and data quality

Ø  Provider-‐level sta\s\cs—to assess varia\on within a hospital

Ø  Benchmarking sta\s\cs-‐-‐to compare your hospital to regional, statewide, and like-‐hospital peers

Ø  Facilita\ng repor\ng to Leapfrog, Cal-‐HEN and PSF +


CMDC Measures Labor and Birth Measures n  Elec\ve Delivery <39 Weeks (PC-‐01)* n  Episiotomy Rate n  OB Trauma (3/4th Lacera\on)-‐Cesarean Delivery (AHRQ EXP-‐2) n  OB Trauma (3/4th Lacera\on)-‐Vaginal Delivery w/ Instrument (AHRQ PSI 18) n  OB Trauma (3/4th Lacera\on)-‐Vaginal Delivery w/o Instrument (AHRQ PSI 19) n  Cesarean Sec\on-‐-‐Nulliparous, Term, Singleton, Vertex (PC-‐02) n  Cesarean Sec\on-‐-‐Nulliparous, Term, Singleton, Vertex, Age Adjusted (PC-‐02) n  Cesarean Sec\on-‐-‐Term, Singleton, Vertex (AHRQ IQI 21) n  Cesarean Sec\on—Primary (AHRQ IQI 33) n  Total Cesarean Rate n  Induc\on Rate n  Failed Induc\on Rate n  Appropriate DVT Prophylaxis in Women Undergoing C-‐Sec\on (Leapfrog)* n  Vaginal Birth Aker Cesarean (VBAC) Rate, All (AHRQ IQI 34) n  Vaginal Birth Aker Cesarean (VBAC) Rate, Uncomplicated (AHRQ IQI 22) Newborn Measures n  Newborn Bilirubin Screening Prior to Discharge (Leapfrog)* n  5 Minute APGAR <7 Among All Deliveries >39 weeks (HEN) n  5 Minute APGAR <7 in Early Term Newborns (HEN) Birth Trauma -‐ Injury to Neonate (AHRQ PSI 17) n  Unexpected Newborn Complica\ons (NQF) Prematurity Measures n  Antenatal Steroids (PC-‐03) n  Antenatal Steroids-‐Leapfrog n  VLBW (<1500g) NOT delivered at a Level III NICU

*Requires additional limited chart review

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<<Considerations>>

n  Important to move beyond reporting metrics to addressing WHY?

n Need to have timely data (months old rather than years old)

n Need a base of the entire population and then build projects requiring special data collection on that foundation

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NTSV CS Run Charts

for 2 California Hospitals

Sample Hospital 2

Sample Hospital 1


Primary CS QI Pathways Which is the driver in my hospital??

n  Latent phase admission n  Nullip (first birth) labor induction

¨ Esp. with unfavorable cervix n  Dystocia/Failure to progress

¨ Arrest or protraction disorder n  Non-reassuring Fetal Status

n Oxytocin/misoprostol associated tachysytole n  2nd Stage (failure of descent) n  Predicted macrosomia n  Patient choice

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3 Major Drivers of the Primary CS Rate

Sample Hospital 1

Sample Hospital 2

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3 Major Drivers of the NTSV CS Rate

Sample Hospital 1

Sample Hospital 2

Comparison Rates for the 3 Major NTSV Drivers

Sample Hospital 1

Sample Hospital 1

Comparison Rates for the 3 Major NTSV Drivers Sample Hospital 1

Analysis of Numerator Cases: Macrosomia CS

Spot Light Cases Another CA hospital…


Sample Hospital


Sample Hospital 2

Provider-‐Level Cesarean Ra

tes

Sample Hospital 2

OB’S

Are there confounding factors needing risk adjustment?

NTSV CS=28.5%

Sample Hospital 2

Sample Hospital 2

Are there confounding factors needing risk adjustment? A Bay Area Story

NTSV CS=24.0%

Sample Hospital

Sample Hospital

Are there confounding factors needing risk adjustment? A Central Valley Story

NTSV CS=25.9%

Sample Hospital

Sample Hospital

Risk Adjustment: Summary •  Hospitals with high rates of advancing maternal age ALSO have high rates of low BMIs (and vice-‐versa)

•  On analysis, they balance each other out •  “Fully loaded” Risk Adjustment does not change hospital rankings by more than a few spots and no hospital changed quin\les in California and Massachuseps

Main EK et al. Manuscript in preparation, CMQCC Ecker J et al. Mass General Hospital

Preliminary “Diagnoses”: Summary

•  Sample Hospital 1 – Nullip Spontaneous Labor: FTP/CPD – Nullip Induc\on: Fetal Distress – Nullip Medical Indica\ons

•  Sample Hospital 2 – Nullip Spontaneous Labor: FTP/CPD – Nullip Induc9on: FTP/CPD

New Tools in Our Toolkit!

•  New research on normal labor •  New recommenda\ons from NICHD Consensus Commipee

•  New ACOG/SMFM guidelines on labor management

Consor9um on Safe Labor Defining An Alterna9ve to Friedman’s Labor Curve

•  19 hospitals across the US with EHRs that contained detailed labor & delivery data and neonatal outcomes

•  228,668 deliveries (87% in 2005-‐7) •  62,415 spontaneous labor NTSV births with normal outcomes

•  Focus on redefining normal labor

Zhang J et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol 2010;116:1281–7.

Finding: Multips had a clear inflexion point at 6cm, nullips less clear

Finding: More than 50% of induced nullips are <6cm at CS

Spong CY et al. Obstet Gynecol Nov 2012;120(5):1181–1193.

Safe Preven\on of the First Cesarean

•  Defining abnormal first-‐stage labor •  Management of abnormal first stage labor •  Defining abnormal second-‐stage labor •  Management of abnormal second stage labor •  Interven\ons for abnormal fetal heart rate tracings •  Effect of induc\on of labor on cesarean birth •  Special cases: breech, twins, suspected macrosomia

Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:693–711.

Case Review For Cesarean during First Stage Labor (for Dystocia/Arrest Disorders)

q  Cervix 6 cm or greater q  Membranes ruptured, then q  No change X 4 hours with Adequate Uterine ac\vity

Case Review Checklist: Spontaneous Labor (All 3 should be present)

Take the “Test” in Your Hospital…

•  Iden\fy 20 cases of CS in the first sage of labor performed for Labor Dystocia/Failure To Progress/Arrest of Dila\on

•  Review using the Check List

How many will fail to meet the 3 criteria?


Recommenda9ons for Labor Induc9on

Common sense approach to Category II fetal monitor strips!

Clark SL et al. Am J Obstet Gynecol Aug 2013;209(2):89-97

A Good Base for Provider Education and QI for

Fetal Monitoring

The image cannot be displayed. Your computer may not have enough memory to open the : Transforming Maternity Care

Public Engagement in Primary Cesarean Prevention: 2014

•  NQF, Joint Commission, LeapFrog, CHCF, and CMS all

reporting NTSV CS •  Patient Safety First: CA Hospital Collaborative for

NTSV CS •  National Partnership for Patient Safety:—

NTSV CS Focus for 2015-2016 •  CalSIM (payer and purchaser coalition)—Maternity and

NTSV Cesarean focus for payment reform in CA: 2015--

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Primary Cesarean QI Steps

n  Identify the local leaders ¨ MD, RN and Admin

n  Identify your hospital's issue (Focus!) ¨ CMDC is available in your hospital ¨ Use the Checklists ¨ Identify best practices

n CMQCC Toolkit and Change packages n Ready in 2014

n QI Mentoring ¨ Sharing of experiences

Main EK et al. Obstet Gynecol Nov 2012;120(5):1194–1198.

5 Key Complimentary Strategies: 1) QI projects for labor management practices 2) Payment reform to eliminate negative or

perverse incentives 3) Education for the value of normal birth (culture) 4) Transparency with Public Reporting 5) Continued public engagement


Today’s Discussion:

n  What are the drivers for the rise and variation in Primary CS?

n  NTSV (Nulliparous, Term Singleton, Vertex) as the focus for CS Quality Improvement

n  Importance of L&D culture, Labor practices, and use of Data and the California Maternal Data Center to drive change

n  Multi-strategy approach to address CS rates n  Public projects to support this initiative


Thank You!

To enroll in the California Maternal Data Center Contact: [email protected]

making sense of cesarean birth rates how should we … · making sense of cesarean birth rates how...

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