Saving Money, Saving Lives
Population-Based Quality Improvement
Edward F. Donovan
Child Health Services Research Meeting
June 24, 2006
Regional Systems of Perinatal Care
The Investment Case for Quality Improvement
Economic resources spent for perinatal care
- taxes/charity (public health & gov’t sponsored insurance)
- after-tax wages (employment-sponsored insurance)
Potential savings
- avoid preterm births and consequent lifelong handicaps
Because many individuals receive a mix of tax-supported and
employment-supported services, quality improvement
should occur at the health system level
Population-based quality
improvement to save
lives and money
Regionalized Perinatal Care in Ohio
 Geographically defined
systems of perinatal care
 Individuals receive care from
different parts of the system
 Test population-based QI:
- caregiver/policy teams
- data systems operational
- QI collaborative
Investment case for population-based QI
Gestation for All Ohio Births 1995 - 2001
Singletons only, fetal deaths excluded
100%
90%
80%
Percent Still Pregnant
70%
60%
50%
40%
30%
20%
10%
0%
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
Gestation - Weeks
Region 1
Region 2
Region 3
Region 4
Region 5
Region 6
46
47
EXTREME PREMATURITY
[birth at less than 29 weeks gestational age]
• 60-70% of deaths in the first year of life are
associated with EXTREME PREMATURITY
• 50% of lifelong handicapping conditions with
onset in infancy are associated with EXTREME
PREMATURITY
• 1% of births are EXTREMELY PREMATURE, but
25% of spending for perinatal care
Gestation for All Ohio Births 1995 - 2001
Singletons only, fetal deaths excluded
white mothers
100%
90%
80%
Percent Still Pregnant
70%
60%
50%
40%
30%
20%
10%
0%
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
Gestation - Weeks
Region 1
Region 2
Region 3
Region 4
Region 5
Region 6
99.80%
99.75%
Percent Still Pregnant
99.70%
99.65%
99.60%
99.55%
99.50%
99.45%
99.40%
25
26
27
28
Gestation - Weeks
Region 1
Region 2
Region 3
Region 4
Region 5
Region 6
46
47
Gestation at Birth for All Ohio Births 1995 - 2001
Singletons only, fetal deaths excluded
African American mothers
99.5%
Percent Not Delivered
99.0%
98.5%
98.0%
97.5%
25
26
27
28
Gestation - Weeks
Region 1
Region 2
Region 3
Region 4
Region 5
Region 6
Population-based QI
to improve perinatal care in Ohio
Outcome: Extreme prematurity
QI Methods:
 Real-time, longitudinal measures of outcomes:
e-birth-certificates
 Improvement collaboratives: PDUC
 Benchmarking
 Transparent tests of change
Benchmarking
• If whites (83% of births) in less well performing regions
had the same proportions of births 25-28 weeks GA as
the best performing region, there would be roughly 135
fewer infants in this category per year in Ohio
• If African Americans (17% of births) in less well
performing regions had the same proportions of 25-28
weeks GA as African Americans in the best performing
region, there would be approximately 175 fewer infants
in this category per year
135 + 175 = 310 fewer extremely preterm infants per year
Return on Investment
Saving a few lives and a lot of money
80 fewer deaths per year
100 fewer children per year with life long disability
Total annual savings in birth spending: $ 78 million
[5% of total birth spending in Ohio]
Total savings in Medicaid birth spending: $ 24 million
Ohio Medicaid budget for families and children
= $ 2 billion (5% of Ohio’s annual spending)
Medicaid savings = 1% per year [not counting cost of
lifelong handicap]
Ohio Medicaid budget for children has been increasing
3.6% per year
Improving quality of perinatal care
for geographic regions
• Outcomes depend on multiple sources of care
• Optimal care depends on linkages among care
sources
• Processes of care are readily identifiable
• Population-based outcome measures are
available in existing administrative data sets
(birth and death certificates)
• In many areas, perinatal care is “regionalized”
• Benchmarking and learning collaboratives are
possible within jurisdictions (e.g. states)
Opportunities to Improve
• Identify best evidence
• Highly reliable use of best evidence
• Identify best practices
• Highly reliable implementation of best practices
Quality of Care Improvement
• Real-time measurement of processes and
outcomes
• Small tests of change
• Benchmarking
• Improvement collaboratives: constituency
determined from the users perspective
• Transparency
Country
Infant mortality
1998
[deaths/1000
births]
Japan
4
Germany
5
UK
6
USA
7
GDP per
capita 1992
[1985 U.S. $]
Health
expenditures
1995
[% GDP]
Public health
expenditures
1995
[% total health $]
15,105
7.2
78
10.5
78
12,724
6.9
84
17,945
14.0
47
Infant Mortality
24th
U.S. international rank in 2002
African American IM = 14.4
White IM =
5.8
U.S. international rank in 2002 for low risk infants
7th
Improving the perinatal care system:
Users’ perspectives’
What types of care do I need?
Prevention- Care in the public sector:
nutrition, housing, social
services, immunizations, primary
care
Care in the private sector:
primary care (pre-conception,
prenatal)
Improving the perinatal care system:
The users perspective
What types of care do I need?
Treatment- Care in the public sector:
Public health clinics, ‘public’
hospitals
Care in the private sector:
Offices, birthing centers,
hospitals
OHIO