Wednesday, February 15, 2012

Mixed messages on early deliveries

The Leapfrog Group recently published its survey about the rate of early elective deliveries in US hospitals.  Here's the lede from its press release:

The employer-driven hospital quality watchdog, The Leapfrog Group, announced today that 2011 results from the annual Leapfrog Hospital Survey indicate that hospitals are making progress in eliminating early elective newborn deliveries. The Leapfrog Group announced that 39% of reporting hospitals kept their early elective delivery rate to 5% or less, compared to 30% of reporting hospitals last year.

Is this good news or bad? It seems to be good.  After all, early elective deliveries can be a cause of medical complications, interrupting the full development of babies.  As Leapfrog notes:  "There are medical reasons to schedule a delivery before the 39th completed week, such as if a woman has high blood pressure at the end of pregnancy or broken membranes before labor begins, but these are rare."

What's the bad news? 

According to Leapfrog, there is still wide variation among hospitals. 

Let's look at Central Massachusetts for examples.  St. Vincent Hospital in Worcester had a terrible rating, 39.8%.  Ditto for Heywood Hospital in Gardner, at 21%.  In comparison, the rate at Milford Regional Medical Center was 3.3%, well within the guidelines.

This is stunning.  As Leapfrog CEO Leah Binder said, "The ultimate solution is for hospitals to simply forbid early deliveries that are not medically indicated and then enforce the policy."

Some people wrongly believe that progress on this issue has to be tied to payment reform, changing the manner in which hospitals and doctors are paid for giving medical care.  For example:

Suzanne Delbanco, executive director of Catalyst for Payment Reform, noted that “We need to stop providing the perverse financial incentives to intervene in birth when it’s not medically necessary. CPR is working alongside Leapfrog to support employers and other health care purchasers, as well as health plans, to encourage adherence to clinical guidelines through payment reform.”

As demonstrated by Intermountain Health over a decade ago, you don't need payment reform to change this clinical practice.  You need to introduce and enforce a clinical protocol based on sound medical evidence: 

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.

Likewise, many other hospitals in Massachusetts and around the country meet the standard or are working towards it, even without changes in payment regimes.  WBUR's Martha Bebinger reported on this several weeks ago.  She noted:

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.

And she gave this example: 

At Massachusetts General Hospital, Dr. Jeff Ecker, a high-risk obstetrician, is the gatekeeper. Each week Ecker reviews the schedule for early inductions and C-sections to see if they are all medically necessary.

What's the other bad news?

Currently, only hospitals that participate in Leapfrog’s annual hospital survey make this information public.

How many is this?  We learn this from Medscape:

In 2011, roughly 1200 hospitals — about 1 in 4 — completed the survey.  

Again looking at Central Massachusetts, among those declining to respond were U Mass Memorial Medical Center, Marlborough Hospital, Clinton Hospital, and Health Alliance in Leominster.  Frankly, this is almost more troubling than hospitals that report bad results.  Transparency of clinical outcomes is one of the most important steps in process improvement.  After all, if you are not open and honest about how you are doing, it is very hard to improve.  Why aren't patient advocates, employers, and insurance companies demanding these recalcitrant hospitals to open up their books and show the results?  Short of that, why aren't insurance companies directing patients to those hospitals that are willing to be transparent about such matters?


Anonymous said...

A few comments. Thank you for your attention to maternity outcomes reporting! Quality measures are a relatively new phenomenon in maternity care. The elective delivery measure (ED<39 Wks) was adopted by the Joint Commission as part of its revised Perinatal Core Measure Set and available for hospital reporting only in April 2010. The issue of hospital reporting reflects a bigger problem than your blog recognizes - which is that most hospitals report on CMS Medicare measures, and many don't have resources or recognize that quality is important in maternity! As of this year, only about 5% of the nation's 3265 birthing hospitals are reporting on TJC measures.

You've posted before on some states' efforts to reduce their public reporting of quality measures. For many 'consumers' of maternity care, Leapfrog may be their only source of comparative information. Yet I've heard that hospitals are reluctant to report to Leapfrog because the data isn't validated and because they don't know how or find it difficult or costly to collect the data. Again, stemming from the fact that quality measure reporting in maternity is a new issue for hospitals.

Changes are on the way with Medicaid taking an interest in this and with the publicity around the CMQCC/March of Dimes toolkit. However, what is needed is cultural change at hospitals, as you rightly point out, by those willing to adopt a 'hard stop' policy and enforce it! Hospitals which have some control over physician practices are able to adopt and enforce this policy more easily than others, which have community physicians, who threaten to go to other hospitals where they can do as they like. If payment reform is a way to encourage this, in the absence of valid transparent reporting mechanisms, than what is wrong with that?

The news article you cited is fairly balanced in its description of this practice being driven by both physicians and women. But a lot of the press presents a one sided view that suggests hospitals are suddenly putting the brakes on this phenomenon of women scheduling elective deliveries as easily as they schedule a haircut!

In any event, elective deliveries at this gestational age represent about 8-15% of all births. Future efforts to reduce the first cesarean in low risk women will be interesting to watch. Getting hospitals to report on that cesarean rate is also an important goal for advocates of maternal quality measures.

Anonymous said...

Is this what you mean by 'transparent' reporting? Not sure this type of interface is all that helpful but would love your comments about this new feature at Intermountain HealthCare.
Utah OB/GYN ratings available to the public

My initial review: Rather challenging and user-unfriendly interface. Can't seem to compare providers. Have to select OB/GYN separately from Midwives. Not intuitive but once you click on a provider, and if they have this link on their info page: Satisfaction and Performance Ratings, you click on that, opens a new tab. You see customer satisfaction ratings first. If you click on tab: "Clinic Performance Ratings", and you click on WOMEN AND NEWBORNS line, you get a pop up window showing rates on three measures: primary cesarean, chlamydia and breast cancer screening. Seems like a lot of steps to try to find and evaluate a provider. Not to mention a zillion tabs on your web browser.

Anonymous said...

What is the cost to hospitals of reporting to Leapfrog? Do they have to pay to participate in addition to the costs of completing the survey?

Leah Binder, CEO, Leapfrog said...

Thank you for your support for hospital transparency and for urging hospital leadership to put a stop to the harmful practice of early elective deliveries.For the record on the comments you recieved anonymously above, Leapfrog data is indeed closely reviewed for accuracy and a large percentage of reporting hospitals are required to submit additional documentation and answer more questions. (In other words, Leapfrog doesn't just print what the hospitals tell us). Leapfrog is also harmonized with Joint Commission, CMS, and/or NQF-endorsed measures so its measures are no more difficult than anything else for hospitals to collect.

I would challenge you to rethink your position on payment reform, however. In our current health care "system", most hospitals have significant payment incentives to continue the practice of early deliveries. For one thing, NICUs produce significant revenue to hospitals and ending the practice of early elective deliveries can reduce NICU admissions by as much as half, according to our anecdotal observations. To the credit of hospital executives and clinicians I've met, I know they all stopped the practice instantly without regard to the financial consequences as soon as they found out about the problem. But it seems fair that our payment system would acknowledge and reward that responsibility and not punish it. It also seems fair that employer purchasers would balk at paying for this harmful and unnecessary procedure.Catalyst for Payment Reform has been a leader in helping purchasers define and act on these common sense principles, which is why we support their work.

Thanks again for your call to action on hospital leadership and transparency.

Former quality analyst in a MA community hospital said...

Thank you Paul for reporting on the important issue of non-medically-indicated early elective deliveries trends.

My comment is directed to Ms. Binder: In June 2010, the most recent due date for which I was part of a hospital's effort to complete the Leapfrog survey, my understanding is that the only item that was validated for all hospitals was the presence of a Computerized Physician Order Entry system. So unless this has changed since then, or my hospital happened to be off the radar for everything else, or I am somehow mistaken, none of the items in which we submitted a numerator and denominator were validated. Also, you did not answer Anonymous's concern regarding the cost to hospitals to do the Leapfrog reporting. I will say firsthand that the number of results we could copy-and-paste from our TJC/CMS reports were less than half of the items requested. Some of the NQF measures requested were reported to Leapfrog and no one else, and so a deep dig of the medical records had to be done to do the calculations. Not to mention the cost of preparing for validation that never happened.