Dr. Jeanne Conry Jeanne Conry, MD, PhD Assistant Physician in Chief The Permanente Medical Group Sacramento and Roseville

Oops I did it again…preconception health care and interconception care Jeanne A. Conry, MD, PhD Chair, ACOG District IX

Well Women This is NOT about telling women they are only reproductive beings This IS about acknowledging women’s choices over time, and that choices change The concept of Preconception Health Care embraces choice: we encourage women to make healthy choices, and if a woman elects to conceive, outcomes improve

WHY Healthy Women, Healthy Mothers, Healthy Infants Every Woman, Every Time… because 50% of pregnancies are surprises This is well women’s health care

Have You Met This Patient? Obese woman in labor: In 2005 she had Gestational Diabetes, no follow up In May 2006, a miscarriage, she was seen in ED, GYN and Med –Starts metformin in the ED, lovastatin and lisinopril in Medicine –Hgba1c is 12.8

Ms Sacramento Sept-Jan 2007: Visits Medicine Provider for 5 Months –Hgb A1c now 9.8 –Menses now regular on Metformin –She is still on the Lisinopril and Lovastatin –NO ONE DISCUSSES BIRTH CONTROL, TERATOGENS or PRECONCEPTION CARE

Ms Sacramento February 2007 She is now pregnant and at her first OB visit she is: On two potential teratogens Hgb A1c is over 8 Not on folic acid

Ms Sacramento This patient had TEN VISITS to physicians before she conceived Have you met her at some time?

Clinical Intervention OPTIMIZING A WOMAN’S HEALTH 50% of pregnancies are UNPLANNED 70% of women do NOT take folic acid before pregnancy 1 in 25 prescriptions written for women ages is for a potential teratogen *2007 Ann Int Med;147(6):

Individual Awareness

Systematic Approach Lack of success in preconception health is NOT about knowledge Physicians know Patients know Policy makers know So how do we effect change?

Model a Preconception Care Program after CCM

Chronic Conditions Management of Medical Disease Multidisciplinary approach to implement guidelines for managing heart disease In less than 5 years, LDL control improved from 22 to 81% Blood Pressure control improved from 25% to 84% Heart Disease mortality is more than 30% lower in KPNC than in the non-KP population

Measure changes to "hybrid" in 2007 Hypertension Control

Obstetrician Gynecologists Take The Lead Identify an at-risk population Partner with your counterpart Do you have an electronic record? Can you do Outreach? Where is the “Bang for the Buck”

What is the Ultimate Goal?

What is the Future? Electronic Medical Records The Obstetrician Gynecologist and the Medical Home Systematic Approach to improve care with collaborative practices

The Patient-Centered Home Continuum of care Patient choice, affordability and access Team care led by a physician Care is evidence-based with continuous quality improvement Reimbursement that reflects the added value of a women’s medical home

Obstetrician Gynecologists Take The Lead Partner and collaborate Pick one Project Be the Wellness Leader Make a difference: with your patients, with your practice and with your community

INTERCONCEPTION HEALTH CARE ACOG District IX picked one project and we want to share the Post Partum Re-Design project with you

What is Happening? Eighty percent of women in the US conceive at least one time (another 10% are trying) Seventy percent of women in the US conceive a second time Ninety percent of pregnancies have some complication Statistical Brief #113: Complicating Conditions of Pregnancy and Childbirth, 2008

What is Happening? Forty four percent of practices have an electronic record, but only four percent are fully functional Women vary by state and coverage in participating in a post partum visit Statistical Brief #113: Complicating Conditions of Pregnancy and Childbirth, 2008

What is Happening? Women who have had a poor birth outcome in a prior pregnancy are at increased risk for having another poor birth outcome in a subsequent pregnancy THE POSTPARTUM VISIT: AN OVERLOOKED OPPORTUNITY FOR PREVENTION Sarah Beth Verbiest, Master of Social Work and Master of Public Health, University of North Carolina

What is Happening? The recurrence risk varies by diagnosis, but is significant –15 to 30 percent for preterm delivery –20 to 60 percent for pre-eclampsia –2-12 fold risk for low birth weight infants THE POSTPARTUM VISIT: AN OVERLOOKED OPPORTUNITY FOR PREVENTION Sarah Beth Verbiest, Master of Social Work and Master of Public Health, University of North Carolina

Pregnancy Spacing Closely spaced pregnancies are associated with increased complications –low birth weight, preterm birth, neonatal death attributed to decreased maternal reserves and nutritional depletion Gregory, K., Johnson, Clark, Johnson, Timothy, Entman, Stephen. "The Content of Prenatal Care Update 2005," Women's Health Issues (2006):

Pregnancy Spacing Rates of preterm delivery at spacing intervals less than 13 weeks were double those at intervals of over 2 years Klerman, L., Cliver, SP, Goldenberg, RL. "The Impact of Short Interpregnancy Intervals on Pregnancy Outcomes in a Low-Income Population," American Journal of Public Health 88 (1998):

Pregnancy Spacing Women with interpregnancy intervals of less than 18 months are percent more likely to have premature infants The most recent data suggests that approximately 14% of women, aged 15-44, gave birth within 24 months of a previous birth Rates are higher among African-American, Latina, and poor women Chandra A. et al. “Fertility, Family Planning and Reproductive Health of US Women: Data from the 2002 National Survey of Family Growth. National Center for Health Statistics. Vital Health Statistics. 23(25)

Post-Partum Visits Social: photo op with mom, baby and provider Birth control Post delivery recovery

Reality Check Insurance often allows a single post partum visit Must integrate hospital, prenatal and post-partum information for success Health care reform is unlikely to INCREASE the number of visits, so how do we make more with less? Cervical cancer screening is not a given any longer Is there a “systems approach” to improving care?

Who Goes to the Post-Partum Visit? Medicaid participation is 59.1% Private Insurance 79.9% Kaiser Permanente participation is 94% The State of Health Care Quality 2007 Kaiser Permanente 2011

Post Partum Visit Re-Design Incorporate the essentials Integrate clinical information Provide information to patients and providers But it takes more than knowledge

Interconception Care Project for California Joint March of Dimes/ ACOG Project & Preconception Health Council of California Goal: to create guidelines for the postpartum visit that address diagnoses that developed peri-nataly

33 ACOG Interconception Care Logic Model

Review Committee Obstetrician /Gynecologists 11 Internal Medicine 1 Nurses 6 MSW 5 PhD 2 Masters Public Health 2 Analyst 1 28 in total

Interconception Care Project for California Focus Obesity/nutritional deficiencies Bleeding-associated disorders Hypertension/cardiovascular disorders  Gestational diabetes  Infections (UTI, STIs, Immunization) Mental disorders Intimate partner violence Preterm delivery Thyroid dysfunction Tobacco and other drug dependence Neurologic disorders

Interconception Care Project for California Prevailing Messages Folic acid Contraception Breastfeeding

Material Review 200 Health Professionals in California to review algorithms 100 patients to review patient brochures in Spanish 100 patients to review patient brochures in English

Clinician Algorithms

Patient Brochures

Share the Project Bring this back to your practice Share it with your colleagues Let your section members know Lead your community Copy, reproduce and share shamelessly!!

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Every Woman, Every Time …