Eliminating Elective Early
Term Deliveries at University
Hospital
Robyn Horsager M.D.
Patricia Santiago-Munoz M.D.
There was a sharp decline in deliveries occurring after 39 weeks with a concom
se in births occurring particularly between 36-38 weeks gestation.
ng Change
in 1:Distribution
of Birth
byh Gestational Age:
Figure
Change in Dist ribut
ion of Birt
nge in Distribution of Birth by Gestational Age: United States, 1990-2006
by Gest at ional
Age: States,1990-2006
Unit ed St at es, 1990-2006
United
37 and
e in
tant
rise
abor and
50
Percent of Change
atically, from
rise has been
. 23 Data
owed that
uled
of these
weeks
eriod 1990
17.5% of
he distribuchanging
ge over a 16
veries
sharp
een 36-38
25
0
-25
-50
<34 34
35
36
37
38
39
40
41 >42
Weeks of Gest at ion
California Toolkit to Transform Maternity Care
Source: CD C/N CH S, N ational V ital Statistics System.
in deliveries between 37 and 39 weeks has been associated with an
Netherlands: Timing of Elective
Cesarean Deliveries
37 Weeks
38 Weeks
39 Weeks
40 Weeks
Wilmink et al, Am J Obstet Gynecol, 2010
Increased Adverse Neonatal Outcomes
at 370-386 Weeks of Gestation
•
•
•
•
•
•
•
Neonatal death
NICU admission
Newborn sepsis
Respiratory distress syndrome
Transient tachypnea of the newborn
Treated hypoglycemia
Hyperbilirubinemia
Wilmink et al, Am J Obstet Gynecol , 2010
Tita et al, N Eng J Med, 2009
Neonatal Death Rates
per 1000 Livebirths
0.7
0.6
0.66
0.5
0.4
0.42
0.3
0.33
0.34
0.2
0.1
0
37 Weeks
38 Weeks
39 Weeks
40 Weeks
Zhang et al, J Pediatr, 2009
Percent
Neonatal Complications: NICU
Admission Rate
10
9
8
7
6
5
4
3
2
1
0
8.85
4.51
3.34
37 Weeks
38 Weeks
39 Weeks
3.62
40 Weeks
Oshiro et al, Am J Obstet Gynecol, 2009
Neonatal Complications: Need for
Ventilator
1.6
1.4
Percent
1.2
1.39
1
0.8
0.6
0.4
0.49
0.2
0.28
0.32
0
37 Weeks
38 Weeks
39 Weeks
40 Weeks
Oshiro et al, Am J Obstet Gynecol, 2009
Netherlands: Adverse Neonatal
Outcomes After Elective Cesarean
Delivery
25
Percent
20
15
10
5
0
37 Weeks
38 Weeks
39 Weeks
Wilmink et al, Am J Obstet Gynecol , 2010
Maternal Outcomes Associated with
Labor Induction
• Increased cesarean section rate for failure
to progress in nulliparous women with
unfavorable cervix
• Increased cesarean section rate for fetal
distress
• Increased post-partum hemorrhage >500
mL
• Prolonged maternal hospital stay
Oshiro et al, Am J Obstet Gynecol, 2009
Baud et al, Am J Obstet Gynecol ,2011
Cognitive Development and Early Term
Birth: Long-term Consequences
Scotland: Increased risk for “special
education need”
Denmark: Increased reading and spelling
difficulties at age 10
Belarus: Lower IQ test scores at age 6
United States: Lower standardized math and
English/language arts scores in third grade
University Hospital Obstetrical Service
• 2010: 1440 deliveries
– 897 by community
physicians
– 543 by UT
Southwestern Medical
Center employed
physicians
12
Frequency of Births at 370- 386 Weeks
40
34.8 34.5
35
37.3
31.4
Percent of all deliveries
29.1
30
25
20
24.5
28.3
28.9 28.6 27.8
19.7
15
United States
University Hospital
10
5
0
1990 2000 2005 2006 2007 2008 2009
National Vital Statistics Report, 2010
% of Total Deliveries at 370386 weeks
University Hospital Experience:
Labor Induction Rate at 370-386 Weeks
40
35
34.6
30
25
20
25.6
27.9
28.6
29.1
21.5
15
10
5
0
2005
2006
2007
2008
2009
2010 (first
half)
Our Team
Robyn Horsager MD*
Chief OB/Gyn, University Hospital
Patricia Santiago-Munoz MD*
Maternal-Fetal Medicine
Melissa Tarango RN
Labor and Delivery
Catherine VanBeek BSN, WHCNP
Epic Analyst
John Morris
CS&E Facilitator
* CS&E Course participant
Aim Statement
The aim of this project is to eliminate
elective deliveries between 37 weeks 0 days
and 38 weeks 6 days over the next 5
months. This project is important because
delivery at this gestational age is associated
with increased neonatal morbidity and
healthcare costs and there is increasing
public reporting of this measure by
hospitals.
2009 Leapfrog Data: Dallas Area
HOSPITAL
ELECTIVE DELIVERIES AT 37-39
WEEKS
Baylor
4.8%
Medical City Dallas
29.8%
Methodist Charlton
11.2%
Methodist
5.3%
Presbyterian Dallas
25%
Doctors Hospital
13.5%
Presbyterian Plano
4.7%
Medical Center Plano
11.4%
17
CS&E Project Checklist
 Revise AIM statement (all)
 Write policy (RH &MT)
 Outside speaker with similar experience
Speaker (RH)
Room/breakfast (RH &PSM)
CME (RH)
CEU (MT)
 Create Clarity report (CV)
 Change scheduling log in L&D (MT)
 Mailing to physicians (RH&PSM)
 Find a “face” to the story (PSM)
Obtain patient list
Review charts
 Patient and nursing materials (all)
Obtain
Distribute
 Gather previous data (RH)
2005-2008
2009-2010
Create run chart (RH & PSM)
 Update OB/Gyn Best Practices Committee
Policy Revision
Scheduled induction of labor or
cesarean delivery is not permitted
before 39 weeks of gestation…
Data Collection
Communication
Education
Eliminating Elective
Delivery < 39 Weeks
Seton’s Experience
Michael Nix , MD
November 2, 2010
Our Results
November 1, 2010- September
30, 2011
Elective Deliveries Between 37 and 39 Weeks of Gestation
Elective Deliveries*
Median
UCL
LCL
8
CS&E Project - Start
Number of Deliveries
10
OB/Gyn Section Meeting
12
ACOG Practice Bulletin
#107 Induction of Labor
14
6
4
2
0
* Jan 09 - Aug 09 data includes elective inductions only
% total deliveries at 370-386 weeks
University Hospital Experience:
Elective Inductions* at 370-386 Weeks
35
30
25
20
15
10
5
0
30
13.5
7.4
2008
2009
2010 (first half)
2.4
11/2010-9/2011
* Project time period includes elective inductions and scheduled cesarean deliveries
Decreased NICU Admissions with
Intervention
• Based on 2008 rate of elective delivery 4
fewer infants admitted to NICU
• Based on 2009 rate of elective delivery 2-3
fewer infants admitted to NICU
Dollars
Cost per 100 Neonates for Treatment
of Adverse Outcome
500,000
450,000
400,000
350,000
300,000
250,000
200,000
150,000
100,000
50,000
0
37 Weeks
38 Weeks
39 Weeks
Robinson et al, Am J Obstet Gynecol, 2010
Potential Revenue Loss without
Intervention
• In 2009 there were 61 vaginal deliveries
without medical necessity between 37-39
weeks
• Would estimate approximately 30
scheduled repeat cesarean deliveries
without medical necessity at same
gestational age
Professional Fees
Hospital Stay
• 61 vaginal deliveries @
$663 per patient=
$40,443
• 30 cesarean sections @
$802 per patient=
$24,060
• 61 vaginal deliveries @
$1742 per patient=
$106,262
• 30 cesarean sections @
$2762 per patient=
$82,860
Grand Total $253,625
Additional Savings
• Reduced costs for other neonatal
morbidities like treatment and readmission for hyperbilirubinemia
• Reduced costs for maternal complications
• What are costs for educational system
long-term?
What’s Next?
• October 1, 2011 “hard stop” for scheduling
cases with review by physicians
• Determination of “medical necessity” for
delivery before 39 weeks of gestation
Thank you!
References
Baud D, Rouiller S, Hohlfeld P, Tolsa J et al. Am J Obstet Gynecol 2011;204:S328.
Herson V, Feldman D, Borgida A, Fang YM et al. Full term NICU admission for respiratory
morbidity: the role of gestational age. Am J Obstet Gynecol 2011;204:S85.
Elimination of non-medically indicated (elective) deliveries before 39 weeks gestational age.
A California Toolkit toTransform Maternity Care.
Induction of labor. ACOG Practice Bulletin No. 107. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2009;114:386-97.
Kirkegaard MD, Obel C, Hedegaard M, et al. Gestational age and birth weight in relation to
school performance of 10 year old children: a follow-up study of children born after 32
completed weeks. Pediatrics 2006; 118:1600-1606.
Lipkind HS, Slopen ME, Pfeiffer MR, McVeigh KH. School-age outcomes of late preterm
infants. Am J Obstet Gynecol 2011;204:S37.
MacKay DF, Smith GCS, Dobbie R, et al. Gestational age at delivery and special
educational need: retrospective cohort study of 407,503 schoolchildren. Plos Med 7
(6):e1000289.
Martin JA, Hamilton BE, Sutton PD, Ventura SJ et al. Births: final data for 2008. National
Vital Statistics Report 2010;59.
References
Oshiro BT, Henry E, Wilson J, Branch DW et al. Decreasing elective deliveries before 39
weeks of gestation in an integrated health care system. Obstet Gynecol
2009;113:804-811.
Robinson CJ, Villers MS, Johnson DD, Sampson KN. Timing of elective repeat cesarean
delivery at term and neonatal outcomes: a cost analysis. Am J Obstet Gynecol
2010;202:632.e1-6.
Tita A, Landon MB, Spong CY, Lai Y et al. Timing of Elective Repeat Cesarean Delivery
at Term and Neonatal Outcomes. N Engl J Med 2009; 360:111-120.
Wilmink FA, Chantal WP, Lunshof S, Mol BW et al. Neonatal outcome following elective
cesarean section beyond 37 weeks of gestation: a 7-year retrospective analysis of a
national registry. Am J Obstet Gynecol 2010;202:250.e1-8.
Yang S, Platt RW, Kramer MS. Variation in Child Cognitive Ability by Week of Gestation
Among Healthy Term Births. Am J Epidemiol 2010; 171:399-406.
Zhang X, Kramer MS. Variation in mortality and morbidity by gestational age among
infants born at term. J Pediatr 2009;154:358-362.