Transcript Slide 1

Every Week Counts
Lisa M. Hollier, MD, MPH, FACOG
Chair, District XI
American Congress of Obstetricians and Gynecologists
Objectives
• At the completion of this lecture, the
participant will be able to:
– Weigh the evidence associated with delivery < 39
weeks
– Identify barriers to implementation of new
policies to improve neonatal outcomes by
reducing NMI early deliveries
– Describe solutions for common obstacles
– Discuss potential consequences for failure of new
programs and policies
Conflicts of Interest
• According to ACCME policy, speakers must
disclose all associations with proprietary
entities that may have a direct relationship to
the subject matter of the lecture. They must
also disclose any discussion of unlabeled or
unapproved uses of products.
– I have no such financial relationships
– I will not discuss unlabeled or unapproved uses of
products
Cesarean and Labor Induction RatesSingletons, 1992 and 2002
Early Term
2002 C-S
1992 C-S
2002 Induction
1992 Induction
Source: NCHS, Final Natality Data, Prepared by March of Dimes Perinatal Data Center, April 2006.
Rates of Induction of Labor by Race
and Hispanic Origin in the U.S.
Martin JA, et al. Births: Final data for 2006. National vital statistics reports; 57(7): NCHS 2009.
Late Preterm Births in the US
1990-2006
Increase in Rates in LPTB by State
MFMU Network Study- NEJM 2009
• Observational cohort including 19 different
hospitals and 24,000 patients
• 35.8% of the elective Cesarean deliveries were
performed before 39 weeks
– infants delivered at 38 weeks had a 1.5x greater
chance of being admitted to NICU
– infants delivered at 37 had a 2x greater chance of
being admitted to NICU
– gestational age with the lowest risk for neonatal
complications was 40 weeks.
Tita ATN et al. NEJM 2009;360:111
Neonatal Outcomes by Gestational Age at
Delivery
Tita ATN et al. NEJM 2009;360:111.
Adverse Neonatal Outcomes by Gestational
Age at Delivery
37+ Weeks
16%
38+ Weeks
Percent Affected
14%
39+ Weeks
12%
10%
8%
6%
4%
2%
0%
Any adverse
outcome or death
Adverse
respiratory
outcome(overall)
RDS
TTN
Admission to
NICU
Tita ATN et al. NEJM 2009;360:111
Newborn Sepsis
(suspected or
proven)
NICU Admissions By Weeks Gestation
Deliveries Without Complications, 2000-2003
10%
8%
Percent
6.66%
NICU Admissions
6%
3.44%
3.36%
4%
2.47%
2.65%
39th Week
(33,185)
40th Week
(19,601)
4.26%
2%
0%
37th Week
(8,001)
38th Week
(18,988)
41st Week
(4,505)
42nd Week
(258)
Gestational Weeks
Oshiro et al. Obstet Gynecol 2009;113:804-811.
Infant Mortality Rate by GA among singleton live
births 1995- 2006
Reddy U et al. Obstet Gynecol 2011;117:1279-87
Timing of Fetal Brain Development
• Cortex volume increases by 50% between 34 and 40 weeks
gestation.
• Brain volume increases at rate of 15 mL/week between 29 and
41 weeks gestation.
• A 5-fold increase in myelinated white matter occurs between
35-41 wks gestation.
• Frontal lobes are the last to develop, therefore the most
vulnerable.
Huttenloher, 1984; Yakavlev, Lecours, 1967; Schade, 1961; Volpe, 2001;
Adams Chapman, 2008
Induction and Cesarean Delivery
Vrouenraets FP et al. Obstet Gynecol 2005;105(4):690-697.
Copyright © 2011 Obstetrics & Gynecology.
Published by Lippincott Williams & Wilkins.
14
Induction and Cesarean Delivery
Copyright © 2011 Obstetrics & Gynecology.
Published by Lippincott Williams & Wilkins.
Dilation and Cesarean Delivery Rate
Clark SL et al. Am J Obstet Gynecol 2009;200:156.e1-156.e4.
Implementing a Successful
Program
Decision to implement a
quality initiative
Public
Awareness
Campaign
Recruit
appropriate
leadership
Develop/revise
hospital policy for
elective delivery
Collect and
report QI
data
Active
enforcement
of policy
Rate of neonatal intensive
care unit admissions
Intermountain Health Experience
Oshiro, BT et al. Obstet Gynecol 2009;113(4):804-811.
Copyright © 2011 Obstetrics & Gynecology.
Published by Lippincott Williams & Wilkins.
Elective deliveries < 39 wks
Oshiro, BT et al. Obstet Gynecol 2009;113(4):804-811.
Copyright © 2011 Obstetrics & Gynecology.
Published by Lippincott Williams & Wilkins.
20
Stillbirth Rates Before & After
Courtesy of March of Dimes
Magee Women’s Experience
Baseline
3 months
2004
Voluntary
3 months
2005
Enforced
14 months
2006-7
Deliveries
2,139
2,260
10,895
Elective Inductions <39 weeks (N)
Elective Inductions < 39 weeks (rate)
23
11.8%
21
10%
30
4.3%
Total Induction Rate
24.9%
20.1%
16.6%
“Voluntary”: educational program and department recommendations
“Enforced”: department standard requiring approval by the Perinatal
Committee chair before scheduling non-standard indications for inductions
Fisch et al. Obstet Gynecol 2009:113:797
HCA Experience
2007
N (%)
2009
N (%)
P value
Deliveries
17,794
17,221
NA
Deliveries ≥37 wk, n
14,995
14,863
NA
Planned + elective deliveries at 37.0-38.6
wk, n
6562
4349
<.001
Elective deliveries at 37.0-38.6 wk, n (%)
1712(9.6)
746(4.3)
<.001
Group 1: 7 hospitals, n/N (%)
320/3886(8.2)
65/3818(1.7)
.007
Group 2: 9 hospitals, n/N (%)
403/4797(8.4)
155/4646(3.3)
<.025
Group 3: 11 hospitals, n/N (%)
989/9111(10.9) 526/8757(6.0)
.135
Neonatal intensive care unit admissions at
≥37 wk, n (%)
1328(8.9)
1119(7.5)
Clark SL. et al. Am J Obstet Gynecol 2010;203:449.e1-6
<.001
HCA Experience
Hard Stop
Soft Stop/
Peer Review
Education
Only
Clark SL. et al. Am J Obstet Gynecol 2010;203:449.e1-6
Oklahoma Experience
Oklahoma Experience
Deliveries < 39 wks without Indication
Cesarean Delivery < 39 weeks
Inductions < 39 weeks
Post Intervention Deliveries by
Indication and Gestational Age
Deliveries < 39 wks without Indication
Cesarean Delivery < 39 weeks
Inductions < 39 weeks
Oklahoma Experience
• A number of hospitals already low rates of
nonmedically indicated early deliveries
• Many hospitals have implemented successful
programs
• Some hospitals still have high rates of
nonmedically indicated delivery
ACOG Practice Bulletin
Labor also may be induced for logistic reasons, for example,
risk of rapid labor, distance from hospital, or psychosocial
indications. In such circumstances, at least one of the
gestational age criteria in the box should be met, or fetal lung
maturity should be established. A mature fetal lung test result
before 39 weeks of gestation, in the absence of appropriate
clinical circumstances, is not an indication for delivery.
From the Trenches
•
•
•
•
•
That’s not how my babies do
This is an “overly restrictive policy”
It’s really a medical indication
No, really, she’s 39+ weeks
It’s not an induction, it’s an augmentation
That’s not how my babies do
•
In addition to the authors, the members of the Eunice Kennedy Shriver National Institute of
Child Health and Human Development (NICHD) Maternal–Fetal Medicine Units Network are
as follows: Ohio State University — J. Iams, F. Johnson, S. Meadows, H. Walker; University of
Alabama at Birmingham — D. Rouse, J. Hauth, A. Northen, S. Tate; University of Texas
Southwestern Medical Center — S. Bloom, J. McCampbell, D. Bradford; University of Utah —
M. Belfort, F. Porter, B. Oshiro, K. Anderson, A. Guzman; University of Chicago — J. Hibbard, P.
Jones, M. Ramos-Brinson, M. Moran, D. Scott; University of Pittsburgh — K. Lain, M.
Cotroneo, D. Fischer, M. Luce; Wake Forest University — M. Harper, M. Swain, C. Moorefield,
K. Lanier, L. Steele; Thomas Jefferson University — A. Sciscione, M. DiVito, M. Talucci, M.
Pollock; Wayne State University — M. Dombrowski, G. Norman, A. Millinder, C. Sudz, B.
Steffy; University of Cincinnati — T. Siddiqi, H. How, N. Elder; Columbia University — F.
Malone, M. D'Alton, V. Pemberton, V. Carmona, H. Husami; Brown University — H. Silver, J.
Tillinghast, D. Catlow, D. Allard; Northwestern University — M. Socol, D. Gradishar, G. Mallett;
University of Miami — G. Burkett, J. Gilles, J. Potter, F. Doyle, S. Chandler; University of
Tennessee — W. Mabie, R. Ramsey; University of Texas at San Antonio — O. Langer, S. Barker,
M. Rodriguez; University of North Carolina — K. Moise, K. Dorman, S. Brody, J. Mitchell;
University of Texas at Houston — L. Gilstrap, M. Day, M. Kerr, E. Gildersleeve; Case Western
Reserve University — P. Catalano, C. Milluzzi, B. Slivers, C. Santori; George Washington
University Biostatistics Center — E. Thom, S. Gilbert, H. Juliussen-Stevenson, M. Fischer;
Eunice Kennedy Shriver NICHD — D. McNellis, K. Howell, S. Pagliaro.
That’s not how my babies do
• First, the majority of deliveries occurring between
38 and 39 weeks of gestation do not result in
harm.
• The absolute number of newborn respiratory
complications is low.
• If an obstetrician performs 200 deliveries a year
and 10% of his or her patients are electively
delivered at 38 weeks of gestation, only one
neonate would be admitted to the NICU per year.
This is an overly restrictive policy

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Protocols and strong guidelines are used extensively
in Internal Medicine and Surgery
 Door-to-cath times, use of ASA and β-blockers
 Pre-operative antibiotics and VTE prevention
 Stroke: very strict protocols
 Publicly reported, payment-based standards
OB has been “below the radar”
Movement has now been taken up by commercial
insurers and Medicaid
It’s really a medical indication
• Edema
• Impending macrosomia
Spong, CY et al; Obstet Gynecol 2011;118:323-333.
Really, she’s 39+ weeks
• Induction not approved due to GA < 39 weeks
with no medical indication
• Pregnancy dated by LMP consistent with 10
week CRL
• 34 week ultrasound showed EFW at 75th
percentile and CGA was 2 weeks further along
– New posting sheet sent with “revised” EDD
It’s not an induction, … augmentation
Quality Marker
• The Joint Commission, CMS, Agency for
Healthcare Research and Quality, National
Quality Forum, and many insurers have listed
NMI early term deliveries as a perinatal
quality measure.
How Do You Measure
Elective Deliveries <39 weeks?
(The Joint Commission Measure Definition)
TJC (PC-01)
v2011A (latest for 2011)
Denominator
37+0 to 38+6 week births without a
STANDARD medical or OB
complication
Numerator
Inductions and CS
NOT in Active Labor or with ROM
Benchmark
?? <5-6%
https://manual.jointcommission.org/bin/view/Manual/WebHome
These are not exhaustive lists!
But close… (e.g. prior classical CS)
Caveats about the Indication List
• The Joint Commission list was developed for ease
of data collection utilizing ICD-9 codes.
• If there is not an ICD-9 code for an indication,
they did not list it (e.g. prior classical CS).
• Everyone understands that there are cases in
which earlier delivery is indicated and but the
indication is NOT on the list—but these should
be uncommon.
• No one is expecting a ZERO rate.
• Off-list indications should be prospectively
scrutinized
www.leapfroggroup.org/tooearlydeliveries
HB 1983
• Effective Oct 1, Texas Medicaid will require
providers to use CPT modifier for deliveries
less than 39 weeks
• Texas Medicaid is be able to recoup payment
from hospital and doctor for any NMI
deliveries < 39 wks
– No time limit
– Potential fraud if bill for NMI delivery
Summary
• Reduction of neonatal complications
• No harm to mother if no medical or
obstetrical indication for delivery
• Strong support from ACOG
• Now a national quality measure for hospital
performance:
– National Quality Forum (NQF)
– Leapfrog Group
– The Joint Commission (TJC)
What is the Real Importance Here?
• There will continue to be research and
technology innovations, and changes in best
practice that need to be implemented
• Physician leadership and collaboration with
nursing and hospital administration is
essential