SIVB-2 Data Overview

May 22th, 2012 Learning Session 1

James deVente MD/PhD Associate Professor, Dept. OB/Gyn Medical Director of Labor and Delivery East Carolina University Brody School of Medicine

What is PQCNC?
Perinatal Quality Collaborative of North Carolina

A community of organizations, agencies and individuals committed to making North Carolina the best place to be born.

Initiatives
1. 2. 3. 4. 5. 6. 7. How's Your Baby Immunization Registry Catheter Associated Blood Stream Infections (CABSI) Eliminating Elective Deliveries Under 39 Weeks Gestation Human Milk and Breastfeeding: Increasing exclusivity in the hospital National CABSI Initiative SIVB: Supporting Intended Vaginal Birth

Maternal Quality Initiatives

39 Week Project Supporting Intended Vaginal Birth (SIVB)

39 Weeks Project
39 Week Project
The goal of this initiative was to eliminate elective deliveries under 39 weeks gestation without documented pulmonary maturity studies in participating hospitals. Each participating hospital will set its own site-specific action plans.

39 Weeks Project
39 Weeks
Alamance Regional Medical Center Albemarle Hospital Blue Ridge Regional Hospital Carolinas Medical Center Lincoln Carolinas Medical Center University Rowan Regional Medical Center Duke University Hospital Durham Regional Hospital FirstHealth Richmond Memorial Hospital WakeMed Cary Hospital Grace Hospital, Blue Ridge Healthcare Cape Fear Valley Medical Center Carolinas Medical Center Onslow Memorial Hospital Carolinas Medical Center NorthEast Carteret General Hospital Catawba Valley Medical Center Central Carolina Hospital Columbus Regional Healthcare System FirstHealth Moore Regional Hospital Halifax Regional Medical Center Iredell Memorial Hospital Lenoir Memorial Hospital Morehead Memorial Hospital Randolph Hospital The Outer Banks Hospital The Women's Hospital of Greensboro Transylvania Regional Hospital Watauga Medical Center Wilkes Regional Medical Center Wilson Medical Center Mission Hospital Nash General Hospital New Hanover Regional Medical Center Pitt County Memorial Hospital Presbyterian Hospital Huntersville Rex Health Stanly Regional Medical Center University of North Carolina Hospitals Forsyth Medical Center

39 Weeks Project
An overall 43% decline!

Decrease of 43%

Supporting Intended Vaginal Birth (SIVB)

SIVB
Carolinas Medical CenterPineville Gaston Memorial Granville Health System Cape Fear Valley Medical Center Carolinas Medical Center Onslow Memorial Hospital Carolinas Medical Center NorthEast Carteret General Hospital Catawba Valley Medical Center Central Carolina Hospital Columbus Regional Healthcare System FirstHealth Moore Regional Hospital Transylvania Regional Hospital Johnston Health Durham Regional Hospital Presbyterian HospitalHuntersville The Womens Hospital of Greensboro Presbyterian HospitalMain Presbyterian HospitalMatthews Forsyth Medical Center Mission Hospital Nash General Hospital New Hanover Regional Medical Center Vidant Medical Center Presbyterian Hospital Huntersville Rex Health Stanly Regional Medical Center University of North Carolina Hospitals Forsyth Medical Center Halifax Regional Medical Center Duke University Hospital Gaston High Point Regional Health System McDowell Hospital

SIVB: Supporting Intended Vaginal Birth

Improve the rate of vaginal birth among first-time mothers PQCNC's goal was to increase the rate of vaginal birth in this population by 25% by January 2012. Each participating hospital set its own site-specific goal.

SIVB in North Carolina

Data on forty patients were collected from each hospital per month Inclusion Criteria: Nulliparous Singleton Pregnancy Vertex 37 weeks or more Live fetus Exclusion Criteria: Placenta previa Vaso previa Previous Myomectomy Cord Prolapse Active Herpes Infection HIV (with viral load >1000 copies) Diabetic with EFW > 4500 grams Non-Diabetic with EFW > 5000 grams

*Phase I involves 23 hospitals and has collected data on more than 10,000 deliveries

CESAREAN RISK FACTORS

Diabetes (any type) IUGR Maternal age greater than/equal to 35 Hypertensive disease Macrosomia (EFW greater than 4000g) Obesity

14.00%

12.00%

Risk Factor Prevalence

11.48% 11.33%

Lower 95% Upper 95%

10.00%

8.00%

6.00%

5.45% 4.02% 2.52% 0.86%

4.00%

2.00%

28.8% of all patients had at least one risk factor

0.00%

Diabetes

IUGR

AMA

HTN

Macrosomia

Obese

OVERALL PRIMARY C/S RATE OVER TIME ALL FACILITIES SIVB-1

50.00%

45.00%

In nine months we saw a 15% increase in the likelihood of first-time mothers delivering vaginally in 24 participating centers

40.00%

35.00%

Overall C/S rate

30.00%

25.11%
25.00%

23.99% 24.12% 23.67%

22.16% 21.98% 22.80%

23.54% 21.02% 20.37% 21.26% 19.05%

20.00%

15.00%

GOAL = 18.83%

10.00%

5.00%

0.00%

What is contributing to our decline in cesarean rates?

INITIATIVE-WIDE CESAREAN RATES

50.00% 45.00% 40.00% 35.00% 30.00%
25.11%

OVERALL C/S RATE C/S RATE - NO C/S RISK FACTORS C/S RATE - 1+ C/S RISK FACTORS Linear (OVERALL C/S RATE)
38.01% 36.34% 34.62% 34.07% 30.20% 29.74% 28.00% 26.42% 23.99% 24.12% 23.67% 22.16% 21.98% 22.80% 21.02% 20.37% 21.29% 19.11% 20.74% 18.23% 19.32% 18.66% 19.06% 19.19% 18.47% 18.27% 18.83% 16.95% 16.59% 35.06%

Linear (C/S RATE - NO C/S RISK FACTORS) Linear (C/S RATE - 1+ C/S RISK FACTORS)
32.60% 30.41% 27.62% 23.95%

25.00% 20.00%
20.25%

15.00% 10.00% 5.00% 0.00%

% OF PATIENTS IN LABOR AT ADMISSION

70.00%

% of pts in labor at admit

52.26% 51.30% 49.78% 50.80% 53.40% 50.00% 49.88% 52.78%

60.00%

51.23%
50.00%

48.77% 48.57% 47.77%

% of patients in labor

40.00%

30.00%

CESAREAN RATE FOR PTS NOT IN LABOR AT ADMISSION:

20.00%

31.70%
CESAREAN RATE FOR PTS IN LABOR AT ADMISSION:

10.00%

14.61%

0.00%

Impact of Facility Demographics

1. 2. 3. 4.

Facilities WITH and WithOUT midwives Facilities WITH and withOUT Inhouse Anesthesia Effect of Payor Mix Effect of Facility size (with respect to deliveries per year)

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 rate over 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 over the year studied (p=0.365)

Cesarean Rate by Facility with Midwives vs with No Facility Midwives

50.0% 45.0%

40.0%

35.0%

30.0% C/S Rate 24.4% 21.7% 20.0% Midwives (13 hosp / 6,572 pts) No Midwives (8 hosp / 4,181 pts)

25.0%

15.0%

10.0%

5.0%

0.0% Midwives (13 hosp / 6,572 pts) No Midwives (8 hosp / 4,181 pts)

Cesarean Rate by Facility with Midwives vs with No Facility Midwives

50.0% 45.0% 40.0% 35.0% 30.0% C/S Rate 25.8% 25.8% 25.6% 25.0% 24.5% 20.0% 15.0% 10.0% 5.0% 0.0% 21.7% 23.5% 22.9% 24.3% 24.6% 24.7% 22.7% 22.8% 21.7% 20.6% 19.2% 18.8% 18.2% 15.7% 21.1% 22.0% 27.7% Midwives No Midwives Linear (Midwives) Linear (No Midwives)

26.9%

23.1% 23.2%

Facilities with / without In-House Anesthesia

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 CESAREAN SECTION BETWEEN THE TWO GROUPS (see next slide)

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

50.0% 45.0%

40.0%

35.0%

30.0% C/S Rate In-House Anesthesia (15 hosp / 8,495 pts) NO In-House Anesthesia (4 hosp / 1,577 pts)

25.0%

23.0%

23.3%

20.0%

15.0%

10.0%

5.0%

0.0% In-House Anesthesia (15 hosp / 8,495 pts) NO In-House Anesthesia (4 hosp / 1,577 pts)

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

35.0%

30.0% 25.3% 24.6% 24.9% 25.0%

28.3% 28.6% 27.3% 25.5% 22.7% 22.5% 23.4% 22.9% 21.8% 20.8% 19.7% 18.1% 17.9% 19.6% 18.8% 19.6% In-House Anesthesia NO In-House Anesthesia Linear (In-House Anesthesia) Linear (NO In-House Anesthesia) 23.1% 24.1% 23.1% 24.4% 25.5%

C/S Rate

20.0%

15.0%

10.0%

5.0%

0.0%

Cesarean Rates by Payor

BCBS/SHP payor deliveries: Had a significantly higher c/s rate than Medicaid or Other payor deliveries There was no statistical difference: Between Medicaid and Other payor deliveries In c/s rate over time for any of the three groups

Cesarean Rate by Payor

50.0% 45.0%

40.0%

35.0%

30.0% C/S Rate 26.9% 25.0% 20.0% 20.0% 18.0% BCBS / SHP (475 pts) Medicaid (595 pts) Other (390 pts)

15.0%

10.0%

5.0%

0.0% BCBS / SHP (475 pts) Medicaid (595 pts) Other (390 pts)

Cesarean Rate by Payor

50.0% 45.0%

40.0%

35.0% 29.3% 30.0% C/S Rate 26.2% 28.3% 25.0% 18.7% 20.2% 15.0% 14.3% 10.0% 13.0% 11.8% 15.0% 19.8% 16.3% 18.2% 22.4% 25.0% 20.0% 25.0% 27.8% 24.2% BCBS / SHP Medicaid Other 29.6%

5.0%

0.0% July August September October November December

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 in c/s rate over the year studied (p<0.0001) These numbers are likely the product of centereffect and should be taken with a grain of salt

No other differences were noted between facility size groups

Cesarean Rate by Deliveries per Year

50.0% 45.0%

40.0%

35.0%

30.0% C/S Rate 24.6% C/S Rate 19.4%

25.0%

23.4%

22.7%

23.5%

20.0%

15.0%

10.0%

5.0%

0.0% 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)

What have we learned?

Cesarean rate for patients in labor at admission 0-3 cm 4+ cm 18.38% 10.86%

Cesarean rate for induction patients 0-3 cm 4+ cm 31.34% 28.42%

Where are we starting Phase 2 of SIVB!

OVERALL PRIMARY C/S RATE OVER TIME ALL FACILITIES SIVB-2 50% 40% 30% 20% 10% 0% Mar-12 Apr-12 May-12 36% 30% 27% 23% 18% 17% 16% GOAL = 18.83% 27% 37%

Total N=2063 deliveries

What are we going to focus on in Phase 2 of SIVB?

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 your patients educated with respect to the importance of labor? 4. Do you have multiple mechanisms to support a patients labor? 5. Does your institution track vaginal delivery rate and report it back to the providers specifically in nulliparous patients

Where do we go from here? What is our next maternal initiative ?

Faces of PQCNC

Thank you!

Questions?