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7/28/2019 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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