Tuesday, December 27, 2011

Early terms news arrives late in MA

(Yes, I know I was going to take a holiday break, but is it my fault if an engaging radio story caused me to backslide?)

WBUR, NPR, and Kaiser Health News have teamed up to produce radio and "print" health care related stories, and the reporting partnership brings together some excellent capabilities.  I especially like the open source aspect of the stories.  They even include this note: "All original KHN material – articles, graphics and videos – can be used for free, if you credit us and link to us."  (Er, note to The Joint Commission!)

Here's the story by Martha Bebinger about recent efforts by Massachusetts hospitals to avoid early term Caeserian section births.  (If you prefer, you can listen to the radio version.) Here's the lede:

There are lots of reasons why an expectant mother and her doctor might choose to deliver the baby before its due date: the health of mom or baby, the doctor's schedule, the demands of work, or even to hit or avoid a specific birthday. But if that perfect day falls before the 39th week of pregnancy, and there’s no medical reason for an early delivery, many hospitals in Massachusetts are saying no, you have to wait.

She goes on to explain that pre-39-week deliveries result in more complications for the babies:

"Early-term infants have higher rates of respiratory distress. There are also issues with feeding," says Dr. Lauren Smith, medical director at the state Department of Public Health. "The most recent evidence shows that babies born before 39 weeks may also have developmental issues, so when you add up the increased risks and you weigh that against a situation when it’s purely elective, then you really can’t justify it."

What is sad about this story is that while it is considered news among the medical community here in Massachusetts, it is "olds" elsewhere in the country.

A decade ago, the folks at Utah's Intermountain Health instituted a protocol to reduce the number of early term C-sections.  Within just a few months, they were seeing major results.  Brent James and Lucy Savitz provided a description in Health Affairs:

[I]n 2001 the Intermountain pregnancy, labor, and delivery leadership dyad focused on the induction of early labor as a target for improvement. They created a shared baseline that identified when elective induction is medically appropriate and deployed it across the entire Intermountain system, which performs more than 32,000 deliveries each year. When an expectant mother arrived at the hospital for an elective induction, nurses completed an electronic check sheet that summarized appropriateness criteria. If the patient met the criteria, the induction proceeded; if not, the nurses informed the attending obstetrician that they could not proceed without approval from the chair of the obstetrics department or from a perinatalogist—a specialist in high-risk pregnancies.
Elective inductions that did not meet strong indications for clinical appropriateness fell from 28 percent to less than 2 percent of all inductions. The length of time women collectively spent in labor fell by roughly thirty-one days per year. As a result, Intermountain is now able to deliver about 1,500 additional newborns each year without any additional beds or nurses. The new protocol reduced the rates of unplanned surgical delivery (cesarean section) and the attendant higher costs. Intermountain’s overall rate of deliveries by cesarean section is now 21 percent, while the national rate is approaching 34 percent. The protocol also reduced admission rates to our newborn intensive care units, reducing their costs as well.

We estimate that the Intermountain elective induction protocol reduces health care costs in Utah by about $50 million per year. If applied nationally, it would lower health care delivery costs by about $3.5 billion annually.

(A more technical description is offered in this article in Obstetrics and Gynecology by Oshiro, et al.)

What other innovations in the delivery of health care have yet to arrive in Massachusetts?  The state's academic medical centers are tops at scientific research but often lag with regard to adopting process improvement and applying the scientific method in care delivery.  In so doing, they cause harm to patients and permit waste and extra cost to persist in the state.  I hope Martha and her team have a chance to focus on that question.


Keith said...

My guess is process improvement research does not generate the revenue or prestige. It also often leads to a more efficient and less costly health care system. How many health care executives are driven by the desire to have their institution generate less revenue?

Anonymous said...

The other group that has done well with this issue is Ascension Health – 62 far-flung Catholic hospitals.

Martha Bebinger said...

Thanks Keith for weighing in on why, as Paul suggests, MA teaching hospitals are more interested in research than in efficient and effective care.

Will the move to global payments, with some different financial incentives, shift the priorities at hospitals?

Are there cultural factors that shape the focus within MA hospitals?

Paul Levy said...


Doesn't MA have a law allowing mothers to go to the hospital of their choice, regardless of their insurance plan? If so, the bundled payment regime would have to exclude childbirth.

@midwifeamy said...

From Twitter:

Amy Romana: MA is not the only state late to the party. Multiple forces aligned to make this the QI project of the year in OB.

My recent blog post on 39wks and other improvement trends in 2011:

Martha Bebinger said...

Paul - interesting - do you know if this is a major concern for hospitals or physician groups with GP or bundled payment contracts?

Anonymous said...

The Seton Hospitals in Austin, TX., will not allow alective inductions of labor prior to 39 weeks and took their birth trauma rate to the lwoest in the nation. Texas Medicaid has since eliminated early induction of labor as a Medicaid benefit.

Paul Levy said...

Well, I hope they didn't go too far and eliminate the ones that are clinically necessary.