PQCNC SIVB LS3 Accomplishments

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    Perinatal Quality:

    Making NC the BestPlace to be Born!

    PerinatalQuality

    Collaborative

    of NorthCarolina

    James deVente MD/PhDAssociate Professor, Dept. OB/Gyn

    Medical Director of Labor and Delivery

    East Carolina UniversityBrody School of Medicine

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    PQCNC MissionPromote high value perinatal care

    Spread best practice and reduce variation Partner with families and patients Optimize resources

    Bottom line: We are committedto making North Carolina the

    best place to be born!

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    39 Week Project Supporting Intended Vaginal Birth (SIVB)

    Maternal Quality Initiatives

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    Decrease of43%

    39 Weeks Project

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    SIVBCarolinas Medical CenterPineville Presbyterian HospitalMainGaston Memorial Presbyterian HospitalMatthewsGranville Health System Forsyth Medical Center

    Cape Fear Valley Medical Center Mission HospitalCarolinas Medical Center Nash General Hospital

    Onslow Memorial Hospital New Hanover Regional Medical CenterCarolinas Medical Center NorthEast Vidant Medical CenterCarteret General Hospital Presbyterian Hospital Huntersville

    Catawba Valley Medical Center Rex HealthCentral Carolina Hospital Stanly Regional Medical Center

    Columbus Regional Healthcare System University of North Carolina HospitalsFirstHealth Moore Regional Hospital Forsyth Medical Center

    SIVB:Suppor+ngIntendedVaginalBirth

    Improvetherateofvaginalbirthamongfirst-+memothers

    PQCNC'sgoalwastoincreasetherateofvaginalbirthinthispopula+onby25%byJanuary2012.

    Eachpar+cipa+nghospitalsetitsownsite-specificgoal.

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    SIVBinNorthCarolina

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    Dataonfortypa+entswerecollectedfromeachhospital

    InclusionCriteria:Nulliparous

    SingletonPregnancy

    Vertex

    37weeksormore

    Livefetus

    ExclusionCriteria:

    Placentaprevia

    Vasoprevia

    PreviousMyomectomy

    CordProlapse

    Ac+veHerpesInfec+on

    HIV(withviralload>1000copies)

    Diabe+cwithEFW>4500grams

    Non-Diabe+cwithEFW>5000grams

    *PhaseIinvolves23hospitalsandhascollecteddataonmorethan10,000deliveries

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    25.1%24.0% 24.1% 23.7%

    22.2% 22.0% 22.8%21.0% 20.4%

    19.1%

    21.3%

    23.5%

    0.00%

    5.00%

    10.00%

    15.00%

    20.00%

    25.00%

    30.00%

    35.00%

    40.00%

    45.00%

    50.00%

    OVERALLPRIMARYC/SRATEOVERTIME

    ALLFACILITIES

    OverallC/S

    GOAL=18.83%

    In nine months we saw a 15% increase in the likelihood of first-time

    mothers delivering vaginally in 24 participating centers

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    25.11%

    23.99% 24.12% 23.67%22.16% 21.98%

    22.80%

    21.02%20.37%

    19.11%

    21.29%

    23.95%

    20.25%

    18.23%19.32%

    18.66% 19.06% 19.19% 18.47% 18.27%16.95% 16.59%

    18.83%

    20.74%

    38.01%

    36.34%

    34.62% 34.07%

    30.20% 29.74%

    35.06%

    28.00%

    30.41%

    26.42%27.62%

    32.60%

    0.00%

    5.00%

    10.00%

    15.00%

    20.00%

    25.00%

    30.00%

    35.00%

    40.00%

    45.00%

    50.00%

    INITIATIVE-WIDECESAREANRATES

    OVERALLC/SRATE

    C/SRATE-NOC/SRISKFACTORS

    C/SRATE-1C/SRISKFACTORS

    Linear(OVERALLC/SRATE)

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    23.9%

    21.7%

    18.5%

    23.0%

    25.4%

    17.4%

    26.8%

    31.2%

    24.9%23.5%

    20.8%

    24.7%

    27.6%

    16.9%

    14.7%

    23.1%23.9%

    23.1%

    16.5%

    25.0%

    21.6%

    23.4%

    18.8%

    0.0%

    5.0%

    10.0%

    15.0%

    20.0%

    25.0%

    30.0%

    35.0%

    40.0%

    45.0%

    50.0%

    110 200 210 300 320 330 350 380 390 391 392 400 420 430 490 500 510 530 540 640 650 660 680

    AVERAGEC/SRATEBYFACILITY:

    Baseline-December

    Averagefacility

    c/srate

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    48.8% 48.6% 47.8%

    51.2%49.8%

    50.8%52.3% 51.3%

    53.4%

    50.0% 49.9%

    52.8%

    0.00%

    10.00%

    20.00%

    30.00%

    40.00%

    50.00%

    60.00%

    70.00%

    %o

    fpaBents

    inlabor

    %OFPATIENTSINLABORATADMISSION

    %ofptsin

    laborat

    CESAREANRATEFORPTS

    NOTINLABORAT

    ADMISSION:

    31.70%

    CESAREANRATEFORPTSIN

    LABORATADMISSION:

    14.61%

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    Impact of Facility Demographics

    Facilities WITH and WithOUT midwives

    Facilities WITH and withOUT Inhouse AnesthesiaEffect of Payor MixEffect of Facility size (with respect to deliveries

    per year)

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    Facilities with / without Midwives

    Facilities WITH midwives: Had a significantly lower c/s rate than facilities withOUT

    midwives

    Accomplished a statistically significant decrease in c/s rateover the year studied (p=0.001)

    Facilities withOUT midwives: Had a significantly higher c/s rate than facilities WITH

    midwives

    Did NOT accomplish a statistical decrease in c/s rate overthe year studied (p=0.365)

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    21.7%

    24.4%

    0.0%

    5.0%

    10.0%

    15.0%

    20.0%

    25.0%

    30.0%

    35.0%

    40.0%

    45.0%

    50.0%

    Midwives

    (13 hosp / 6,572 pts)

    No Midwives

    (8 hosp / 4,181 pts)

    C/S

    Rate

    Cesarean Rate by Facility Midwives / No Facility Midwives

    Midwives

    (13 hosp / 6,572 pts)

    No Midwives

    (8 hosp / 4,181 pts)

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    Facilities with / without In-HouseAnesthesia

    Facilities WITH in-house anesthesia: Accomplished a statistically significant decrease in c/s rate

    over the year studied (p=0.001)

    Facilities withOUT in-house anesthesia: Did NOT accomplish a statistical decrease in c/s rate over

    the year studied (p=0.489)

    THERE WAS NO DIFFERENCE IN TOTAL RISK OF CESAREANSECTION BETWEEN THE TWO GROUPS (see next slide)

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    23.0% 23.3%

    0.0%

    5.0%

    10.0%

    15.0%

    20.0%

    25.0%

    30.0%

    35.0%

    40.0%

    45.0%

    50.0%

    In-House Anesthesia

    (15 hosp / 8,495 pts)

    NO In-House Anesthesia

    (4 hosp / 1,577 pts)

    C/S

    Rate

    Cesarean Rate by Facility In-House Anesthesia / No FacilityIn-House Anesthesia

    In-House Anesthesia

    (15 hosp / 8,495 pts)

    NO In-House Anesthesia

    (4 hosp / 1,577 pts)

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    Cesarean Rates by Payor

    BCBS/SHP payor deliveries:

    Had a significantly higher c/s rate than Medicaid or Otherpayor deliveries

    There was no statistical difference: Between Medicaid and Other payor deliveries In c/s rate over time for any of the three groups

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    26.9%

    18.0%

    20.0%

    0.0%

    5.0%

    10.0%

    15.0%

    20.0%

    25.0%

    30.0%

    35.0%

    40.0%

    45.0%

    50.0%

    BCBS / SHP

    (475 pts)

    Medicaid

    (595 pts)

    Other

    (390 pts)

    C/S

    Rate

    Cesarean Rate by Payor

    BCBS / SHP

    (475 pts)

    Medicaid

    (595 pts)

    Other

    (390 pts)

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    29.3%

    26.2%

    19.8%

    25.0%

    27.8%

    29.6%

    20.2%

    18.7%

    11.8%

    16.3%

    15.0%

    24.2%28.3%

    14.3%

    22.4%

    13.0%

    25.0%

    18.2%

    0.0%

    5.0%

    10.0%

    15.0%

    20.0%

    25.0%

    30.0%

    35.0%

    40.0%

    45.0%

    50.0%

    July August September October November December

    C/S

    Rate

    Cesarean Rate by Payor

    BCBS / SHP

    Medicaid

    Other

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    NC vital Statistical Brief:Trends in Cesarean Delivery Rates for NC Live Births

    (July 2012)

    Both medicaid and non-medicaid payers increased

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    Cesarean Rates by Facility Deliveries per Year

    Facilities delivering 3000-3999 infants per year: Had a significantly lower c/s rate than any other size

    facility

    Accomplished a statistically significant decrease inc/s rate over the year studied (p

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    23.4%22.7%

    23.5%

    19.4%

    24.6%

    0.0%

    5.0%

    10.0%

    15.0%

    20.0%

    25.0%

    30.0%

    35.0%

    40.0%

    45.0%

    50.0%

    250-999

    (4 hosp / 882 pts)

    1000-1999

    (4 hosp / 1,738 pts)

    2000-2999

    (4 hosp / 2,795 pts)

    3000-3999

    (4 hosp / 2,468 pts)

    4000+

    (5 hosp / 2,870 pts)

    C/S

    Rate

    Cesarean Rate by Deliveries per Year

    C/S Rate

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    BOTTOM LINE!

    Labor is Important

    *PhaseIinvolves23hospitalsandhascollecteddataonmorethan10,000deliveries

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    SIVB-2/3 Data

    A focus on Labor!

    *Phase2/3involves31hospitalsandhascollecteddataonmorethan10,000deliveries

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    GOAL=18.83%

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    Labor isImportant !!!

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    50% of our termnulips patients are

    being induced!

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    Drilling down on the data!

    Where are theseInductions

    coming from?

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    Mothers mayhave more thanone risk factor

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    BMI 30 OR lastmaternal weight

    200 lbs

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    BMI 30 OR lastmaternal weight

    200 lbs

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    Includes gestationaldiabetes) well orpoorlycontrolled;

    preexisting Type II orType 1 diabetes

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    Includes chronichypertension, gestational

    hypertension,

    preeclampsia, eclampsia,HELLP syndrome

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    C-section Rate forthe No Risk factor

    inductions was

    29.7%!

    762 c-sections

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    1. Do you have a physician or team of physician champions?2. Do you have adequate time, space, and/or expertise to

    diagnosis labor?

    3. Are yourpatients educated with respect to the importanceof labor?

    4. Do you have multiple mechanisms to support a patientslabor?

    5. Does your institution track vaginal delivery rate and report itback to the providers specifically in nulliparous patients?

    6. Do you have an induction protocol for Nulliparous patients?7. Do you Track and review nulliparous C-sections and

    elective inductions less than 41 wk?

    Questions to ask your unit?

    Use of self-prepared Birth plan decreasedC-section rate, increased use of epidural,

    decrased lacerations J. Of Mat-

    Fetal&Neonatal Medicine, 25 (10):2055-2057, 2012

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    Constructively Review Your C-sections!

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    Faces of PQCNC

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    Thank you!

    Questions?

    James deVente MD/PhDAssociate Professor, Dept. OB/Gyn

    Medical Director of Labor and DeliveryEast Carolina University

    Brody School of MedicinePager: 252-413-4153 (please page me)

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