10/27/2016 Disclosures & Funding • No conflict of interest The Laborist Revolution- What is the evidence? • Women’s Reproductive Health Research, NIH Melissa G. Rosenstein, MD, MAS – 5K12HD001262-15 Assistant Professor Division of Maternal-Fetal Medicine Department of OB/GYN & RS University of California, San Francisco Objectives Do you have laborists at your hospital? 1) Who is a laborist and how many of them are out there? A. Yes B. No 2) What are the outcomes associated with laborists? 51% 49% 3) What are the difficulties in studying outcomes of laborists? 1
10/27/2016 Are YOU a laborist? Workforce Concerns • 35% of obstetrician-gynecologists in practice are A. Yes 69% over the age of 50 years. B. No • Fewer US medical students entering OB/GYN 31% • Dissatisfaction leads to early retirement (Physicians Only) • 41% of full time OB/GYNs would be interested in part-time work – Most don’t have that option Anderson 2008 Workforce Concerns The best of times, the worst of times • Most satisfying activities: – vaginal deliveries, planned cesarean deliveries, • Conflict between L&D responsibilities and and surgery office practice – “fulfillment, competence, friendliness, and energy” – Ob/Gyns who do not perform deliveries have • Least satisfying activities higher career satisfaction – on-call/in-hospital time – Have more personal control, manageable – “ frustration, anxiety, fatigue, and impatience for workload it to end, depression, pressure, hostility, and criticism” Bettes 2004 Bettes 2004 2
10/27/2016 Laborist Types of Laborists • Who are they? • “a physician whose sole focus of practice is – Full-time laborist managing the patient in labor” • No office responsibilities – Weinstein, AJOG, 2003 – “Community” Laborist • may be able to: • Physicians who do have office responsibilities but spend – improve patient care and satisfaction dedicated shifts on Labor and Delivery – – remove from the obstetrician the need to be always OB/GYN Hospitalist • minimal outpatient and elective surgical responsibilities available to the laboring patient • primary role is to care for hospitalized obstetric patients – decrease stress, improve physician well-being, and to help manage obstetric emergencies that occur in the hospital increase length of professional practice, and decrease • may provide urgent gynecologic care and consultation to burnout. the emergency department or hospital inpatient services. Laborists Laborists: Prevalence • ACOG survey 2010: • Whom do they serve? – 25% response rate – All patients on L&D? – 15% responders described themselves as laborists – Only those without assigned physician and • SOGH 2014: emergencies? – >1,700 ob-gyn hospitalists – >243 hospitals in the United States, • (~10% of obstetric hospitals) • National Perinatal Information Center survey 2010 – 74 hospitals in 26 states • Most are regional perinatal center, have residents – 40% using laborists Funk, AJOG, 2010; Srinivas, JMFNM, 2012, http://www. societyofobgynhospitalists.org 3
10/27/2016 Laborists in California California maternity hospital survey Korst , AJOG 2015 http://www.hospitalmedicine.org T he A m e rica n C olleg e of O bs tetricia ns a nd G yne colog is ts Hospitalists Across Specialties W O M E N’S H E AL T H C A R E P H Y S IC IA NS C O M M IT T EE O PIN IO N (R eplaces C om m ittee O pinion Num ber 459, July 2010) Num ber 657 • F ebruary 2016 C om m ittee on Patient Safety and Q uality Im provem ent The Obstetric and Gynecologic Hospitalist • ACOG supports the continued development and study of the ob-gyn hospitalist model as one potential approach to improve patient safety and professional satisfaction across delivery settings. • Additional outcomes research is needed to determine the effect of the ob-gyn hospitalist model on the safety and quality of care and to determine the economic feasibility of various models 4
10/27/2016 Laborists Laborists: Cesarean Delivery • Potential decrease in CD rate Possible Positives Possible Negatives • 24hr coverage • – More comfortable monitoring equivocal FHR Discontinuity of care • • Lack of distraction Disagreement between tracing inpatient and outpatient • Improved team work – More comfortable being patient with labor • Decreased patient satisfaction • Improved ability to respond • Decreased pay dystocia to emergencies • Worse outcomes due to • Reduced liability claims increased handoffs • Improved work hours • Overmedicalization due to • Improved work/life balance overvigilance • • Increased oversight Decreased autonomy senior residents residents Srinivas, AJOG, 2012 Night float Laborists: Cesarean Delivery Rates • Sunrise Hospital and Medical Center, NV • Change to night float system associated with – Tertiary care hospital without residents or CNMs – Fewer induction of labor – ~4500 deliveries/year – Less oxytocin – Analysis of 3 time periods: – Fewer perineal lacerations • Oct 2006 – Jan 2008: traditional private practice – No change in CD rates (14.5% v 13.2%) • Feb 2008 – April 2009: community laborist • Nov 2009 – October 2011: full-time laborist – Laborist cared for emergencies, unsassigned patients, and for private patients on request • 10% of all deliveries with “full-time” program Iriye, AJOG, 2013 Barber, Obstet Gynecol, 2011 5
10/27/2016 Laborists: Cesarean Delivery Laborists: Community vs. Full-time • Why CD reduction seen only with full-time? – Community laborist still has competing duties – Competitive market discourages relinquishing care to community laborist – Infrequent in-house call (>1 shift/month) • Other possibilities – Laborists only cared for 10% of patients – Time periods too short – No indication of secular trends Iriye, AJOG, 2013 Laborists + Midwives The New Model • Marin General Hospital • Privately insured and publicly insured – Equal mix of publicly and privately insured managed within same system – Publicly insured cared for by CNM and laborist – Privately insured delivered under “private practice • Midwifery care offered to privately insured model” patients – Higher CD among privately insured • Private practice OBs participate in laborist call pool caring for all patients Nijagal, AJOG, 2014 Rosenstein, Obstet Gyencol, 2014 6
10/27/2016 NTSV CD Rate Among Privately Insured NTSV CD Rate Among Privately Insured Women Before and After Expansion Women Before and After Expansion 60% 60% Before Expansion (Observed Quarterly Rate) After Expansion (Observed Quarterly Rate) Before Expansion (Observed Quarterly Rate) After Expansion (Observed Quarterly Rate) Before Expansion (Regression Line) After Expansion (Regression Line) Before Expansion (Regression Line) After Expansion (Regression Line) 50% 50% 40% 40% 30% 30% 20% 20% p=0.01 10% 10% Before Expansion: After Expansion: Before Expansion: After Expansion: Annual change in rate: 0.6% Annual change in rate: 0.6% Annual change in rate: -1.7% Annual change in rate: -1.7% 0% 0% 2005 2006 2007 2008 2009 2010 2011 2012 2013 2005 2006 2007 2008 2009 2010 2011 2012 2013 NTSV CD Rate Among NTSV CD Rate Among Privately Insured Women Before and After Expansion Publicly Insured Women 60% 60% Before Expansion (Observed Quarterly Rate) After Expansion (Observed Quarterly Rate) Public - Before Expansion (Observed Quarterly Rate) Public - After Expansion (Observed Quarterly Rate) Before Expansion (Regression Line) After Expansion (Regression Line) Public - Before Expansion (Regression Line) Public - After Expansion (Regression Line) 50% 50% 40% 40% p=0.1 30% 30% 20% Change due to expansion: 20% 7% decrease (p=0.0009) 10% 10% Before Expansion: After Expansion: After Expansion: Before Expansion: Annual change in rate: 0.6% Annual change in rate: -1.7% Annual change in rate: -1.4% Annual change in rate: 1.1% 0% 0% 2005 2006 2007 2008 2009 2010 2011 2012 2013 2005 2006 2007 2008 2009 2010 2011 2012 2013 7
Recommend
More recommend
