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The FMEC IMPLICIT Network:
Improving the Health of Women and Their Infants through Quality
Improvement
Stephanie E. Rosener, MD Daniel J. Frayne, MD
3rd National Summit on Preconception Health and Health CareTampa, FloridaJune 13, 2011
The Problem – Preterm Birth
US Preterm Birth Rate (2009) = 12.18% National Center for Heath Statistics, Dec 21, 2010
IMPLICIT
Interventions to Minimize Preterm and Low birth weight Infants using
Continuous Improvement Techniques
What is IMPLICIT?
Collaborative of Family Medicine Residency Programs
Continuous Quality Improvement (CQI)
Primary Prevention of Prematurity
Opportunity to influence the future practice patterns of family medicine residents
Our Partners:
National March of Dimes
Family Medicine Education Consortium
Participating FM Residencies
Pennsylvania WPAHS - Forbes
UPMC- McKeesport
UPMC- Shadyside
UPMC- St. Margaret
Penn State-Good Samaritan
Lancaster General Hospital
Reading Hospital Medical
University of Pennsylvania
Jefferson Medical College
Williamsport
York Hospital
Massachusetts Greater Lawrence
New York Beth Israel Ellis Hospital Mid-Hudson
Connecticut Middlesex Hospital
North Carolina MAHEC Asheville
How IMPLICIT Works
Monthly audio-conferences
Evidence leaders
Working groups
IMPLICIT website (FMEC)
Web-based data portal
Semiannual meetings
Continuous Quality Improvement (CQI)
Proactive process to improve care
Identifying and analyzing strengths and problems
Testing, implementing, and revising solutions
Chosen Prenatal Interventions
Depression
Smoking cessation
Inter-pregnancy interval
Asymptomatic Bacteriuria
Bacterial Vaginosis (dropped 2011)
Progesterone (added 2006)
Successes/Impact
Bennett et al (2009) JABFM, n = 3,936, 10 sites
Original Depression CQI Strategy
Administer both 2-Item Screen and Edinburgh Postnatal Depression Scale (EPDS) (15 & 30 weeks, postpartum)
Diagnose Depression (DSMIV-TR Criteria)
Treat according to usual guidelines PsychotherapyAntidepressant medicationBehavioral Lifestyle interventions
“During the last month have you often been bothered by: - Little interest or pleasure in doing things? - Feeling down, depressed, or hopeless?”
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_P=0.628
UCL=0.745
LCL=0.510
CQI
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Prenatal Depression Screening (15wk Visit)
Tests performed with unequal sample sizes
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P=0.545
UCL=0.695
LCL=0.395
CQI
Postpartum Depression Screen
Tests performed with unequal sample sizes
15
EPDS ≥13 EPDS ≥13
30 Week screen
Variable(s) AUC (95% CI) Sens Spec PPV NPV Two item screen 0.81 (0.74-0.88) 82 80 24 91Two item screen + Dep. Hx. 0.85 (0.76-0.94)
1 item positive 93 63 42 91 2 items positive 41 91 22 98
15 Week Screen
Variable(s) AUC (95% CI) Sens Spec PPV NPV Two item screen 0.80 (0.69-0.91) 93 75 44 98Two item screen + Dep. Hx. 0.85 (0.76-0.94)
1 item positive 97 61 59 912 items positive 58 92 21 99
Postpartum
Variable(s) AUC (95% CI) Sens Spec PPV NPV Two item screen 0.80 (0.69-0.91) 80 86 30 99Two item screen + Dep. Hx. 0.85 (0.76-0.94)
1 item positive 90 67 44 96 2 items positive 60 96 11 99
Bennett et al (2008) JABFM
Revised 2-Stage Depression Screening
Strategy
Administer PHQ-2 (50-60% negative)
Yes to either question = positive screen
full depression screening (PHQ-9 or EPDS)
Results in only 18% of pregnant and postpartum women requiring further assessment
Next Steps for IMPLICIT
Preconception Care – The Facts
By the time a woman enters prenatal care, it is often too late to significantly affect the outcome of the pregnancy
Only 11% of prenatal patients have a preconception visit
The extent to which women who do not become pregnant receive preconception care is unknown
Interconception Care “A subset of preconception care that addresses
the continuity of risk from one pregnancy to the next.” (Kotelchuck, 2006)
Characteristics of an Ideal Model:Brief (5 minute “capsule”)Cost effectiveAcceptable to patientsPotential for broad implementation
Proposed IMPLICIT ICC Model
Address maternal risk at Well Child Visits
Mothers visit the office regularly even if they do not seek care for themselves
Poor maternal health status adversely affects child development and well-being
Achievable and acceptable to women based on pilot studies
Kahn and Wise, Pediatrics, 1999.Gjerdingen et al., Ann Fam Med, 2009.
IMPLICIT ICC – Areas of Focus
Tobacco Use*
Depression
Family Planning/Birth Spacing
Folic Acid Supplementation*
*Supported by Level A Evidence
IMPLICIT ICC Strategy: Utilize contact with mothers at well child visits
Assess current risks
Reinforce desired behaviors
Connect with primary providers or community resources to address risks
Collect data, analyze and develop strategies to improve care delivery
Baseline data collection is under way
Conclusions CQI is an effective strategy for improving the delivery of
maternity care processes associated with decreased preterm and LBW outcomes
Collaboratives provide the opportunity for organized inquiry and larger subject numbers required for meaningful data analysis
A CQI strategy for Interconception Care holds promise for improving birth outcomes and could be implemented in a wide variety of primary care settings
Resident involvement provides the opportunity to influence the practice patterns of the next generation of family physicians
Final Questions/Comments