Driven by safety evidence and new reporting requirements, obstetric units are curbing elective early deliveries. But some patients are insistent.
This article appears in the September issue of HealthLeaders magazine.
The well-heeled women planning to give birth at 451-bed Valley Hospital in Ridgewood, N.J., have been a tough crowd to please.
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Most are affluent, with 95% covered by private insurance, and many work in high-pressure jobs 25 miles away in Manhattan. "They have things they do in their lives every day, and they schedule everything, including how and when they have their babies," says Claire Grande, RN, Valley's assistant vice president of women's and children's services.
"They'd say they need to schedule their deliveries early because on their regular due date they need to attend a conference. Or their mom is coming from Texas but can only stay a week. Or she needs to schedule now because she's too uncomfortable; her back is killing her." And with this demographic, they're used to getting what they want, Grande says.
So a few years ago, when key studies began to amass evidence of the significantly greater chances that babies born before 39 weeks would develop cognitive disabilities or pulmonary function problems, or would require time in an expensive neonatal intensive care unit, Valley officials knew they had to make some changes.
They'd need to stop medically unnecessary early deliveries that their patients were insisting on, and that their obstetricians were willingly performing, either for the patient's or the physician's convenience. Valley's rate in 2009 was an unacceptable 31.2%, far higher than recommendations from professional groups.
"We knew we had a lot of work to do," Grande says.
With guidance from the American Congress of Obstetricians and Gynecologists and the New Jersey Hospital Association, as of 2013, Valley's rate of early avoidable elective deliveries has dropped to 3.1%.
Mitchell Rubinstein, MD, Valley's chief medical officer and vice president of medical affairs and education, notes that some people may question how much impact "an additional one or two or three days' gestation can have on a baby."
But he says buy-in from the C-suite was robust. "We could not ignore the strong recommendations from organizations such as the March of Dimes and the ACOG. This was clearly an issue of safety versus convenience, and it would be inexcusable for safety not to win."
Now, hospitals across the country are ramping up efforts to monitor and reduce their elective early deliveries, or they should be, because money and reputations are at stake. Starting Jan. 1, The Joint Commission mandates that as a condition of accreditation, any hospital with at least 1,100 births a year will have to report five new obstetric measures, including preterm elective deliveries and C-sections.
Starting Oct. 1, 2014, the Centers for Medicare & Medicaid Services wants hospitals to start reporting these measures and other maternal care processes as part of the Hospital Inpatient Quality Reporting Program—or suffer financial penalties.
For some hospitals, failure to change could be an embarrassing mark of poor quality for the nation's most common hospital discharge. And that could result in employers and insurance companies dropping contracts or negotiating lower rates.
Last year, three federal agencies, including CMS, together launched the Strong Start for Mothers and Newborns Initiative to raise hospital and patient awareness and allocate funding to reduce elective premature births.
The Leapfrog Group, a Washington, D.C.–based organization that focuses on healthcare safety and quality, now publishes online rates of early elective inductions and C-sections at each of 773 hospitals that report to the organization, with press conferences each year to announce results of which hospitals provide the best motherhood services.
Melissa Danforth, senior director for hospital ratings for The Leapfrog Group, says that while more hospitals are reaching a target rate of 5%, "still more than half of the hospitals reporting to Leapfrog do not meet our target of 5%," and 138 had rates of at least 20% in 2012. "As more and more people look at these rates, question their doctor, and put pressure on hospitals to improve, we are confident that deliveries will be safer and fewer newborns will be harmed," Danforth says.
At Valley Hospital, executives first had to lay down the law with their physicians, many of whom were not aware of the latest evidence that allowing these early deliveries was potentially harming newborns, Grande says.
"A lot of the problem was the fear among our physicians that if they didn't do what the patient asked, they'd go find another doctor," Grande says. "It was a financial issue." Valley's 52 obstetrician-gynecologists of course wanted to provide safe care, she says, but they "didn't have up-to-date evidence that shows 39 weeks really does make a difference" in the well-being of the newborn.
"We used the March of Dimes toolkit, which has tremendous graphics, and a picture of the size of a baby's brain at 35 weeks versus the size of the brain at full term. That definitely got their attention."
At Valley Hospital, Grande says, the campaign first targeted just hospital policies and physician practices, which led to physician leadership agreeing to a strict "hard stop," a refusal to schedule any woman's delivery prior to 39 weeks without documented medical necessity. That meant everyone had to agree "that 38 weeks and six days did not equal 39 weeks."
The policy had an impact. Valley had to staff up to perform inductions and C-sections spontaneously—now on weekends, too—which Grande says increased hospital costs. And Valley saw a decrease in revenue from what she called the hospital's "cash cow," the 15-bed NICU, because premature baby NICU admissions dropped from 15.2% of births in 2009 to 12.9% in 2012, with shorter lengths of stay and lower payments to the hospital amounting to $10,000 per day per child not admitted.
Asked if that makes the hospital's chief financial officer nervous, Grande responds, "It does. But we really live by our patient safety culture. And when we can explain that it's safety and quality we're after, it's okay."
There were a few missteps along the path to Valley's success, she acknowledges.
"What we forgot to do at the beginning was really educate the patients," she says. There was pushback, for example, from women who had delivered with a scheduled labor at 36 weeks and recalled that everything went fine. So the hospital took pamphlets to physician offices, offered prenatal classes, established a hotline, and set up booths at area health fairs. "We talked about the importance of letting nature take its course," she says.
Across the country, several other hospitals have noted stellar improvement.
An hour outside of Chicago, for example, with a much less affluent population, 210-bed Rush-Copley Medical Center in Aurora has seen its early elective delivery rate drop from 33.5% to zero, says Diane Homan, MD, Rush-Copley's patient safety officer and vice president of quality. With more than 4,000 births a year at the hospital, Homan acknowledges that getting those numbers down was a challenge.
"We've been interested in making sure we're providing culturally sensitive care for a long time, so when it became apparent to us in 2010 that many organizations, especially ACOG and the American Academy of Pediatrics, were endorsing not intervening electively until the completion of 39 weeks of gestation, we found we weren't following those recommendations, including those scheduling a repeat cesarean.
"And when we talked with our medical staff, we learned that women were, more and more, pushing for early deliveries and our medical staff was complying; they weren't really going by evidence-based guidelines."
Initially, it was tough to convince their 35 obstetricians that they might be part of the problem. "Everyone said they were doing it right; it was the other doctors who were doing it wrong," she says.
So twice a year, the hospital provided each physician with his or her own data. "How many women they were delivering prior to 39 completed weeks without medical justification. It was eye-opening for them."
"We had a significant number [of doctors] who complied only when we supplied their personal data. They could see what everyone else was doing, and that others were doing it better. They fixed it on their own," Homan says.
Rush-Copley "changed its entire system" to include a hard-stop policy requiring any physician scheduling a C-section or an induction of labor to complete a form listing any medical justification, and required that the maternal fetal medicine specialist sign off on it. That allayed a concern among nursing staff, who didn't want to be put in the position of being a gatekeeper telling doctors they couldn't do what they wanted.
Sometimes there can be questions about the gestational age of the fetus, and in those cases the specialist or department chair may look at the woman's ultrasound, which is considered extremely accurate if it's done in the first trimester, Homan explains.
It's been a "changing culture," Homan acknowledges. "Women had kept pushing their deliveries sooner and sooner, because they're uncomfortable or because their husband was going back to Iraq; they had all kinds of excuses. But these are not medical justifications."
Rush-Copley steers away from fear tactics about early delivery complications that other hospitals may be using. "You can't scare women too much," Homan says, "because what about the poor woman who goes into spontaneous labor at 37 weeks. If we make a big deal about brain development, they'll flip out."
Instead, Homan says, education for the patient should begin even before the woman conceives, teaching "that a normal pregnancy takes 40 weeks. And if you're not willing to allow that normal process, you should think whether you want to conceive."
One poster child for zero unnecessary elective births before 39 weeks is Geisinger Health System, which serves a 31-county region in northeastern Pennsylvania.
John Bulger, DO, MBA, Geisinger's chief quality officer, says the quality gains from having fewer complications and fewer patients in the NICU "far outweigh any of the costs we put into the program." He adds that because Geisinger is a physician-led system, it's the physicians who have made the cultural change, not top down, "but bottom up."
William M. Gilbert, MD, medical director for women's services for Sutter Health's Sacramento Sierra Region's five-hospital 846-bed system in California, said that back in 2010, with the move to measure healthcare quality in many specialties, his system began examining obstetrics.
"We found we had a 15.3% elective delivery rate and a 31.3% C-section rate," he says. "That was way too high. So we put up barriers for doctors to schedule these, and if there was no clinical indication, we said, 'We're sorry. You'll have to wait.' "
There, too, Sutter got pushback. "Patients had come to their doctors saying, 'Oh, why can't you deliver me early? I'm tired. My feet are swollen. Can't we get this over?' "
It was, he says, "like drawing a line in the sand."
But last year, the numbers dropped. Early elective deliveries without medical indication are down to 2.3% at Sutter Medical Center in Sacramento, which performs 5,500 deliveries a year, and C-sections are down to 24.7%. Similar policies have been or are being pushed out to the other four hospitals.
And like at Rush-Copley, doctors get to see all obstetrical rates by practitioner. Sutter has moved on, improving physician rates for other measures soon to be reported to The Joint Commission, such as increasing use of antenatal steroids prior to a preterm delivery and enabling the mother to exclusively breast feed during the newborn's entire hospitalization.
"We post in the doctor's lounge everybody's elective delivery rate, which is now zero," Gilbert says. "We also post everybody's C-section and episiotomy rates and I email them to the entire department."
There are exceptions, he says. Sometimes the patients live far away, they tend to have fast labors, and they're three or four centimeters dilated.
But Sutter is in an especially competitive market. "If the patient doesn't like what the doctor tells them, they may leave and go to somebody else," Gilbert says. "So physicians have to really work with their patients."
Gilbert says Sutter is poised to improve other measures of prenatal care quality as well. "We need to make sure our data is accurate and clean. We want to look good so insurers will say, 'Wow. Your C-section rate is lower than your competition's. That means my bill is going to be lower. And your outcomes are better. I am going to maybe pay you more.'
"My focus was, improve the quality and the business will follow."
Reprint HLR0913-10
This article appears in the September issue of HealthLeaders magazine.