Past, Present and Future: Quality of Obstetric Care

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Past, Present and Future Quality of Obstetric
Care

• Jennifer L. Bailit MD, MPH
• March 31, 2004

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Overview

• Current techniques to measure OB quality
• Future techniques to measure OB quality

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Traditional methods

• Maternal mortality
• Low birth weight babies
• Neonatal mortality
• Cesarean delivery rate

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Maternal mortality

• Trauma leading cause of maternal death
• Rare
• 11.8/100,000 live births
• 470 per year in the US
• Harper M, Obstet Gynecol 1997 CDC MMWR
  2003

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Low Birth Weight

• Leading cause is prematurity
• Prematurity is not preventable
• Goldenberg R. Obstet Gynecol 2002
• ? New progesterone data

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Neonatal mortality

• 80 of neonatal mortality is related to ELBW
  infants and lethal anomalies
• Hein H Pediatrics 1999

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Cesarean rate

• What rate is right?
• Health people 2010 15
• None evidence based
• Is too low possible?

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Cesarean rate

• Primary vs repeat rate
• Measuring physician behavior vs patient behavior

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Repeat cesarean

• All patients are offered a repeat cesarean
• Risks of VBAC becoming better known
• Patient makes the mode of delivery choice
• Drs may be limited by hospital
• In-house OB and anesthesia needed

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Case-mix adjustment needed

• Enforced rules of triage between hospitals
• Level 1,2 and 3 NICUs
• Case mix very different between hospitals

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Future

• Risk-adjusted cesarean rates

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Risk-adjusted cesarean rates

• Birth certificates
• Every state currently has data available
• Overall data very accurate
• Need to know details of data set
• Avoids problem of the right rate

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Risk adjusted cesarean rate

• Measures maternal and neonatal outcomes
• Cesarean almost always worse for mother
• Infection
• Hospitalization
• Wound separation
• Recovery time
• Cost
• Blood clot risk
• Mortality risk

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Neonatal asphyxia

Bailit AJOG, 2002
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Minor trauma

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Risk-adjusted primary cesarean rates

• Meaningful maternal and neonatal outcomes
• Available from cheap plentiful data
• Right rate stays current

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Example

• Newspaper publishes risk-adjusted c-section
  rates.
• Free standing birthing center is best
• Whats wrong?
• Birthing center cant do a cesarean
• Patients requiring cesareans go to hospitals
• Hospital counts cesarean in their rate

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Example

• Dr. Y Highest hospital risk-adjusted cesarean
  rate.
• Problem
• Admitting MD for LD, Monday - Friday
• Cesareans assigned to admitting MD.

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Obstetrical error

• 1.5 adverse event rate in obstetric
  hospitalizations
• 38 due to negligence
• Brennen NEJM 1991
• 8,700 negligent adverse obstetrical events/ year

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Malpractice relation to quality

• Most claims not related to medical error
• 8/280 patient with adverse events filed suit
• Localio NEJM 1991