Transcript Mothers Matter Interconception Care Program

Dr. Jeanne Conry
 Jeanne Conry, MD, PhD
 Assistant Physician in Chief
 The Permanente Medical Group
 Sacramento and Roseville
Oops I did it
again…preconception health care
and interconception care
Jeanne A. Conry, MD, PhD
Chair, ACOG District IX
Well Women
• This is NOT about telling women they are only
reproductive beings
• This IS about acknowledging women’s choices over
time, and that choices change
The concept of Preconception Health Care embraces
choice: we encourage women to make healthy choices,
and if a woman elects to conceive, outcomes improve
WHY
• Healthy Women, Healthy Mothers, Healthy Infants
• Every Woman, Every Time… because 50% of
pregnancies are surprises
This is well women’s health care
Have You Met This Patient?
Obese woman in labor:
• In 2005 she had Gestational Diabetes, no follow up
• In May 2006, a miscarriage, she was seen in ED, GYN
and Med
– Starts metformin in the ED, lovastatin and lisinopril in
Medicine
– Hgba1c is 12.8
Ms Sacramento
Sept-Jan 2007: Visits Medicine Provider for 5 Months
– Hgb A1c now 9.8
– Menses now regular on Metformin
– She is still on the Lisinopril and Lovastatin
– NO ONE DISCUSSES BIRTH CONTROL,
TERATOGENS or PRECONCEPTION CARE
Ms Sacramento
February 2007
She is now pregnant and at her first OB visit she is:
• On two potential teratogens
• Hgb A1c is over 8
• Not on folic acid
Ms Sacramento
This patient had TEN VISITS to physicians before
she conceived
Have you met her at some time?
Clinical Intervention
OPTIMIZING A WOMAN’S HEALTH
• 50% of pregnancies are UNPLANNED
• 70% of women do NOT take folic acid before pregnancy
• 1 in 25 prescriptions written for women ages 18-45 is for
a potential teratogen
*2007 Ann Int Med;147(6):370-376
Individual Awareness
Systematic Approach
Lack of success in preconception health is NOT about
knowledge
• Physicians know
• Patients know
• Policy makers know
So how do we effect change?
Model a Preconception Care Program after
CCM
Chronic Conditions
Management of Medical
Disease
• Multidisciplinary approach to implement guidelines for
managing heart disease
• In less than 5 years, LDL control improved from 22 to
81%
• Blood Pressure control improved from 25% to 84%
• Heart Disease mortality is more than 30% lower in
KPNC than in the non-KP population
Hypertension Control
Obstetrician Gynecologists
Take The Lead
• Identify an at-risk population
• Partner with your counterpart
• Do you have an electronic record?
• Can you do Outreach?
• Where is the “Bang for the Buck”
What is the Ultimate Goal?
What is the Future?
• Electronic Medical Records
• The Obstetrician Gynecologist and the Medical Home
• Systematic Approach to improve care with collaborative
practices
The Patient-Centered Home
• Continuum of care
• Patient choice, affordability and access
• Team care led by a physician
• Care is evidence-based with continuous quality
improvement
• Reimbursement that reflects the added value of a
women’s medical home
Obstetrician Gynecologists
Take The Lead
• Partner and collaborate
• Pick one Project
• Be the Wellness Leader
• Make a difference: with your patients, with your practice
and with your community
ACOG District IX picked one project and we want to share
the Post Partum Re-Design project with you
INTERCONCEPTION HEALTH
CARE
What is Happening?
• Eighty percent of women in the US conceive at least one
time (another 10% are trying)
• Seventy percent of women in the US conceive a second
time
• Ninety percent of pregnancies have some complication
Statistical Brief #113: Complicating Conditions of Pregnancy and Childbirth, 2008
What is Happening?
• Forty four percent of practices have an electronic record,
but only four percent are fully functional
• Women vary by state and coverage in participating in a
post partum visit
Statistical Brief #113: Complicating Conditions of Pregnancy and Childbirth, 2008
What is Happening?
Women who have had a poor birth outcome in a prior
pregnancy are at increased risk for having another poor
birth
outcome in a subsequent pregnancy
THE POSTPARTUM VISIT: AN OVERLOOKED OPPORTUNITY FOR PREVENTION. 2008. Sarah Beth Verbiest,
Master of Social Work and Master of Public Health, University of North Carolina
What is Happening?
The recurrence risk varies by diagnosis, but is significant
– 15 to 30 percent for preterm delivery
– 20 to 60 percent for pre-eclampsia
– 2-12 fold risk for low birth weight infants
THE POSTPARTUM VISIT: AN OVERLOOKED OPPORTUNITY FOR PREVENTION. 2008. Sarah Beth Verbiest, Master of Social Work and
Master of Public Health, University of North Carolina
Pregnancy Spacing
Closely spaced pregnancies are associated with increased
complications
– low birth weight, preterm birth, neonatal death
attributed to decreased maternal reserves and
nutritional depletion
Gregory, K., Johnson, Clark, Johnson, Timothy, Entman, Stephen.
"The Content of Prenatal Care Update 2005," Women's Health Issues (2006): 198-215.
Pregnancy Spacing
Rates of preterm delivery at spacing intervals less than 13
weeks were double those at intervals of over 2 years
Klerman, L., Cliver, SP, Goldenberg, RL. "The Impact of Short Interpregnancy Intervals on Pregnancy Outcomes in a Low-Income Population,"
American Journal of Public Health 88 (1998): 1182-1185.
Pregnancy Spacing
• Women with interpregnancy intervals of less than 18
months are 14-47 percent more likely to have premature
infants
• The most recent data suggests that approximately 14%
of women, aged 15-44, gave birth within 24 months of a
previous birth
• Rates are higher among African-American, Latina, and
poor women
Chandra A. et al. “Fertility, Family Planning and Reproductive Health of US Women: Data from the 2002 National Survey of Family Growth.
National Center for Health Statistics. Vital Health Statistics. 23(25). 2005.
Post-Partum Visits
• Social: photo op with mom, baby and provider
• Birth control
• Post delivery recovery
Reality Check
• Insurance often allows a single post partum visit
• Must integrate hospital, prenatal and post-partum
information for success
• Health care reform is unlikely to INCREASE the number
of visits, so how do we make more with less?
• Cervical cancer screening is not a given any longer
• Is there a “systems approach” to improving care?
Who Goes to the
Post-Partum Visit?
• Medicaid participation is 59.1%
• Private Insurance 79.9%
• Kaiser Permanente participation is 94%
The State of Health Care Quality 2007
Kaiser Permanente 2011
Post Partum Visit Re-Design
• Incorporate the essentials
• Integrate clinical information
• Provide information to patients and providers
But it takes more than knowledge
Interconception Care
Project
for California
Joint March of Dimes/ ACOG Project & Preconception
Health Council of California
Goal: to create guidelines for the postpartum visit that
address diagnoses that developed peri-nataly
ACOG Interconception Care
Logic Model
33
Review Committee
• Obstetrician /Gynecologists 11
• Internal Medicine 1
• Nurses 6
• MSW 5
• PhD 2
• Masters Public Health 2
• Analyst 1
28 in total
Interconception Care
Project for California Focus
Mental disorders
Intimate partner violence
Obesity/nutritional
deficiencies
Preterm delivery
Bleeding-associated
disorders
Thyroid dysfunction
Tobacco and other drug
dependence
Hypertension/cardiovascular
disorders
Neurologic disorders
 Gestational diabetes
 Infections (UTI, STIs,
Immunization)
Interconception Care
Project for
California Prevailing
Messages
• Folic acid
Breastfeeding
• Contraception
Material Review
• 200 Health Professionals in California to review
algorithms
• 100 patients to review patient brochures in Spanish
• 100 patients to review patient
brochures in English
Clinician Algorithms
Patient Brochures
Patient Brochures
Share the Project
• Bring this back to your practice
• Share it with your colleagues
• Let your section members know
• Lead your community
• Copy, reproduce and share shamelessly!!
Go to
http://www.everywomancalifornia.org/
Every Woman,
Every Time…