1. ELECTIVE DELIVERY LESS THAN 39 WEEKS GESTATION THE HCA EXPERIENCE Steven Holt, MD, FACOG Chair Department of OB/GYN Rose Medical Center 7/31/09

2. HCA 2007 Study  Hospital Corporation of America – 114 obstetric facilities in 21 states.  225,000 annual deliveries.

3. HCA 2007 study  Population sampled: All deliveries between May 1, 2007 and July 31, 2007 in 27 facilities in 14 states. (Included three Virginia hospitals and one Colorado hospital.)  Facilities chosen to be representative of entire population – geographic and delivery volume.  Comprehensive data collection for all women undergoing planned delivery at 37 weeks and 0 days or greater.

4. Methods  Planned delivery = patient entered hospital for delivery admission not in labor, or with ruptured membranes.  Planned deliveries = indicated + elective.  Indicated = any indication noted by the admitting physician or by the nurse providing OB care.  Indications tallied, but not questioned

5. Methods Probably more elective deliveries than claimed because on spurious indications, there was no questioning done. For example: If a patient was listed as having hypertension, but the admitting BP was 120/60, the patient was listed as having a medical reason for the planned delivery and was not listed in the “elective” group.

6. NQF National Voluntary Consensus Standards for Perinatal Care  Exclusions: Many of these are referenced in the ACOG Technical Bulletin #10 November, 1999  Post-dates (645)IUGR (656.5  Oligohydramnios (658.0)Hypertension (642)  Maternal Cardiac Disease (648.8)Diabetes (648.0)  Previous Stillbirth (648.5)Placental Abruption (648.6)  Maternal Renal Disease (646.7 & 646.0)Placenta Previa (641)  Multiple gestation (652)Isoimmunization (656.2)  Maternal Coagulopathy (656.4)Fetal Demise (657)  Ruptured Membranes ((649.3)Hydramnios (658.1)  Acute Fatty Liver of Pregnancy (656.1) Malpresentation (656.1)  Unspecified Antenatal Hemorrhage (646.2)

7. Results  17,794 deliveries  14,955 at 37 weeks of greater  6562 were planned term deliveries 44% of term deliveries  4645 were elective planned term delivery 71% of planned term deliveries  31% of all term deliveries were elective  16% of all deliveries were elective inductions of labor  11% of all term deliveries were elective and prior to 39 completed weeks gestation

8. NICU Admissions following Elective Delivery  37.0 – 37.6 weeks: 17.8%  38.0 – 38.6 weeks: 8.2%  > 39 weeks: 4.6%  All differences highly significant (p<0.001)  2/3 were direct NICU admits, 1/3 were admitted later after initial normal newborn admission. –As a note, the delivery provider may not realize the baby went to the NICU after the initial admission.  Mean NICU stay for these infants was 4.5 days.

9. Planned Inductions and C-Section Rates

10. Conclusions  11% of all term deliveries are elective and performed prior to 39 weeks gestation, in violation of longstanding ACOG/AAP recommendations.  Given the nature of many “indications”, the actual rate is probably higher.  Such infants experience significant morbidity.  For all Planned Inductions, the cesarean delivery rate is directly related to initial cervical dilatation.  Elective induction of labor with an unfavorable cervix also increases the risk of cesarean delivery.

11. 39 Week Elective Deliveries in HCA Institutions  Greater than 30 perinatal services have implemented a policy.  40 perinatal services are somewhere in the process of implementation  Other perinatal services are just beginning discussions  Do what works best for your institution, your practitioners and the safety of your patients

12. How education can change behavior  Results of 2007 non-clinically indicated IOL at less than 39 weeks.  Actions that impacted results were:  1. Following data per physician, and notifying physicians that data would be collected.  2. Provided education to physicians regarding ACOG bulletin listing appropriate clinical indicators for IOL at less than 39 weeks.  3. Provided education to physicians regarding increased morbidity, mortality and increased LOS related to the near term infant.  4. Provided feedback to department of OB/GYN and individual physicians regarding data collection results.

13. How education can change behavior  First quarter non-clinically indicated IOL < 39 weeks was 29.6% of total IOL  Second Quarter non-clinically indicated IOL < 39 weeks was 24.3% of total IOL  Third Quarter non-clinically indicated IOL < 39 weeks was 21% of total IOL  Fourth Quarter non-clinically indicated IOL < 39 weeks was 12.6% of total IOL

14. NSMC  OB Department is evaluating and considering the following  If indication for induction is not included in the ACOG Technical Bulletin # 10 and gestational age is less than 39 0/7 weeks OB Provider to discuss with L&D manager or Chairperson of OB before scheduling an elective induction  Specific consent of labor form must be completed which includes the indication-one practice is currently using this form  Any deliveries determined to be elective –prior to 39 weeks are sent to peer review  Laboring and augmented patients are excluded

15. Other HealthONE Hospitals  PSL and Aurora both have accepted this standard and are in process of tracking compliance and determining best ways to impact change in practice  Regional Perinatal Task Force meets quarterly with additional regular conference calls between HealthONE managers and HCA clinical leadership-this data is being tracked for all HealthONE and HCA Hospitals

16. PEER review-An Educational and Constructive Approach  Many centers have chosen to look at <39 week inductions on a case by case basis  Better to have a group of peers look at specific cases and make recommendations than to be “told what to do”  Is there room for “judgment” and “special cases” ?  Amniocentesis? For all or in some special cases

17. ? OTHER INDICATIONS  Advanced cervical dilation  Husband leaving for Iraq at 38 weeks and 4 days  She wants you to do her Section and you are on vacation at 39 weeks or not on call  Grandma just bought a plane ticket and has to go home at 39 completed weeks.

18. PEER Review-An Educational Process at Rose  Started Auditing Charts Feb. 2008 with discussions at department meetings and peer review  Memos and department Newsletters highlighting NQF and ACOG recommendations  Oct, Nov, Dec, Jan audit of all “Elective Deliveries” both inductions and C-Sections  True “fall outs” reviewed in PEER review and “educational letters” sent to those providers along with a copy of recent ACOG technical Bulletin

19. Educational Letter Dear Dr. Holt, Dear Dr. Holt, Your patient, ____, was electively delivered at between 38 and 39 completed weeks gestation. This letter is from the OBQI committee and serves as a reminder that all elective deliveries at this gestational age both Cesarean Sections and Inductions of labor are being audited by the Committee, This is based on the recommendations of ACOG, the American Academy of Pediatrics and the National Quality Forum advising against elective deliveries less then 39 completed weeks gestation due to adverse neonatal outcomes associated with this practice Your patient, ____, was electively delivered at between 38 and 39 completed weeks gestation. This letter is from the OBQI committee and serves as a reminder that all elective deliveries at this gestational age both Cesarean Sections and Inductions of labor are being audited by the Committee, This is based on the recommendations of ACOG, the American Academy of Pediatrics and the National Quality Forum advising against elective deliveries less then 39 completed weeks gestation due to adverse neonatal outcomes associated with this practice We have decided to provide this information to our OB Providers as an educational tool for the next 3 months. After this time frame we will begin assigning Peer Review Levels to all Providers who electively deliver patients at less then 39 completed weeks gestation. The specific Level assigned will be determined on a case by case basis. This information will become a part of your Credentialing File in the Medical Staff Office We have decided to provide this information to our OB Providers as an educational tool for the next 3 months. After this time frame we will begin assigning Peer Review Levels to all Providers who electively deliver patients at less then 39 completed weeks gestation. The specific Level assigned will be determined on a case by case basis. This information will become a part of your Credentialing File in the Medical Staff Office

20. EDUCATIONAL LETTER We would be glad to provide you with data in support of this practice for you to share with your patients as you decide timing for elective deliveries. The Green Journal has had ACOG Practice Bulletins and articles of support of this practice this year. We would be glad to provide you with data in support of this practice for you to share with your patients as you decide timing for elective deliveries. The Green Journal has had ACOG Practice Bulletins and articles of support of this practice this year. We appreciate your continued efforts to provide the best possible quality of care for your OB patients at Rose Medical center. We appreciate your continued efforts to provide the best possible quality of care for your OB patients at Rose Medical center. Your OBQI committee Your OBQI committee

21. PEER Review-An Educational Process  Oct.-1 letter was sent 3 charts reviewed  Nov.- 3 letters were sent 20 charts reviewed  December 1 letter was sent 18 charts reviewed  Jan. 4 letters sent and 14 charts reviewed  During this “educational period” we experienced < 2% elective delivery rate at <39 weeks.

22. Rose Experience  We continue to review all charts without medical indications for delivery at less than 39 weeks in Peer Review  2 nd Q data 4/372=1.08% <39 week elective delivery rate  We have decided to trend these cases and not assign a peer review level at this time  New educational letter in preparation for public reporting as a Perinatal Core Measure starting April 2010  Work group is designing a patient education piece

23. Current Peer Review letter Dear __________ Dear __________ Re: Medical Record Number _______ Re: Medical Record Number _______ In our routine chart audits for quality improvement, this case “fell-out” for elective delivery at less than 39 weeks gestation. This letter is from the OBQI Committee and serves as a reminder that all elective deliveries less than 39 weeks, both Cesarean Sections and Inductions of labor are being reviewed, The Joint Commission plans to include public reporting of elective deliveries < 39 weeks as a part of the Perinatal Core Measures which will be introduced in April of 2010 In our routine chart audits for quality improvement, this case “fell-out” for elective delivery at less than 39 weeks gestation. This letter is from the OBQI Committee and serves as a reminder that all elective deliveries less than 39 weeks, both Cesarean Sections and Inductions of labor are being reviewed, The Joint Commission plans to include public reporting of elective deliveries < 39 weeks as a part of the Perinatal Core Measures which will be introduced in April of 2010

24. Current Peer Review letter This letter is intended to assist you in tracking and trending your practice against this indicator and to provide education regarding the latest research on this issue. Enclosed are two recent articles, one from AJOG and one from the New England Journal of Medicine documenting the significant differences in outcomes in neonates delivered 39 weeks. This includes outcome differences in those delivered at 38 weeks and 4 days to 38 weeks and 6 days in the NEJM study This letter is intended to assist you in tracking and trending your practice against this indicator and to provide education regarding the latest research on this issue. Enclosed are two recent articles, one from AJOG and one from the New England Journal of Medicine documenting the significant differences in outcomes in neonates delivered 39 weeks. This includes outcome differences in those delivered at 38 weeks and 4 days to 38 weeks and 6 days in the NEJM study

25. Current Peer Review letter There are no plans to restrict this practice at Rose. We understand every patient situations is unique. We plan to trend <39 week elective (not medical) deliveries by provider in preparation for public reporting There are no plans to restrict this practice at Rose. We understand every patient situations is unique. We plan to trend <39 week elective (not medical) deliveries by provider in preparation for public reporting Your OBQI Committee Your OBQI Committee

26. Thank you Steven Holt, MD, FACOG Chair Department of OB/GYN Rose Medical Center