10/25/2013 Disclosures • None Laborists in Your Practice? Sarah B Wilson MD M.Ed. Assistant Professor Laborist Department of Obstetrics, Gynecology and Reproductive Sciences University of California, San Francisco Audience Poll Objectives Describe your practice: • Describe what hospitalists and laborists are A. OB only 78% • Explain how laborist models work in B. GYN only different practice settings C. Generalist OB/GYN • Describe proposed positive and negative D. Subspecialist (MFM, attributes of the laborist model Gyn Onc, REI etc) • Summarize the evidence about how 11% 8% E. Other 3% 0% laborists have affected practice OB only Generalist OB/... Other GYN only Subspecialist ... 1
10/25/2013 Audience Poll Internal Med Hospitalist Concept Define your practice setting: • Kaiser reorganized care models 1994 – “Hospital-based Specialists” A. Teaching hospital/clinics • Wachter and Goldman 1996 B. Private Practice 38% – “ Emerging Role of ‘Hospitalist’ Concept in C. Kaiser the American Health Care System” NEJM D. Community Hospital: inpatient 19% – Specialized care for inpatients 16% 16% med 11% E. Other r . r . . . e . e . . . . p i i s p h c t i s t s a o O o a K r H h P y g e t n i i t n h a u c v i m a r e P m T o C Hospitalist Concept Impact of Hospitalists on Care • Proposed benefits • Significant reductions in resource use – Hospital medicine specialization, higher value – 13.4% reduction in hospital costs care – 16.6% reduction in average length of stay – Efficiency of care delivery • Patient satisfaction preserved – House-staff training • Possible disadvantages • Inconsistent, but some positive effects on – Decreased continuity of care care – Skilled hospitalist would use specialists less – Decreased readmission rates • Questioned role of the internal med generalist Goldman JAMA 2002 2
10/25/2013 Introduction of the “Laborist” What is a laborist? • Many different models of care • Extrapolation of the hospitalist concept to • Strictest definition L&D – Physician dedicated to inpatient care, • Weinstein AJOG 2003 primarily on L&D – Possible solution to problems in our field – Premise of continuous coverage and • Marked professional dissatisfaction/burnout oversight • Stopping obstetrics at an earlier age • Also GYN hospitalists increasing • Shortage of obstetricians in some communities Models of Care Program Finances: Hospital Salaried Model • Costs • Teaching hosp vs. community hosp – Need 4-4.5 full time • Full-time hospital employee vs. rotating – Salaries, benefits and malpractice ≈1.5 million schedule of community physicians • Ways to pay for full-time laborists? • Care of all patients in L&D vs. care for – ABOG statement: Bill separate components unassigned/uninsured patients vs. only – Private practice bills global and pays agreed fee for using laborists care for emergencies – Laborist is present 24/7 so can bill more items • Triage, version, surgical assist – Reduced malpractice premiums Gussman et al, ACOG.org 3
10/25/2013 UCSF Laborists What does your practice look like? • Dedicated to obstetrical care Do you have laborists in your hospital or • Monthly schedule practice? – 1 week 5 L&D day shifts 69% – 1 week 4 L&D night shifts A. Yes – 2 weeks outpatient clinic sessions – 1 24hour weekend shift B. No • Part of MFM Division 31% • Cost coverage – Global billed for faculty group, no need to divvy up – MFMs relieved for consults, outreach and PDC s o e N Y Extent of Implementation of Laborists Are you a laborist/hospitalist? • 2010 ACOG membership survey 1 A. Yes – 15% of respondents (3.6% of the entire B. No sample) identified as a laborist or OB/GYN 93% hospitalist • National Perinatal Information Center/Quality Analytic Services 2 – 25/68 hospitals employ laborists 7% s o e N Y 1: Funk et al, AJOG 2010, 2: Srinivas et al Journal of Maternal- Fetal and Neomatal Medicine 2012 4
10/25/2013 Timely Delivery of Care Proposed Advantages/ Disadvantages Positives: • Dedicated 24 hour coverage Dedicated L&D coverage � timely care • Improved quality of care • Timely response to obstetric emergencies • Increased provider satisfaction, work life balance • improves maternal and neonatal Improved patient safety/teamwork • outcomes Reduction in liability claims • • Impact of laborists on these processes Negatives: Lack of continuity of care and outcomes: no research yet • Reimbursement issues and reduced pay • Disagreement in management plans • Decreased patient satisfaction • Increased errors with more handoffs • Srinivas et al AJOG 2012 Patient Safety Outcomes Effect on Cesarean Delivery Rates • Tertiary hospital: studied transition to laborists • No formal outcome studies yet • C section rates over three time periods • Full-time dedicated laborist – No laborists (first 16 months) : 39.2% c section rate – Speculated as safest option – Continuous coverage community staff (14 months) : – Attending OB knows all patients 38.7% – Primary point person for staff – Full-time laborists (24 months) : 33.2% • Significant reduction in c sections with full- time laborist vs no laborist – Adjusted OR 0.72 p<0.0001 Olsen et al AJOG 2012 Iriye et al AJOG 203 5
10/25/2013 Reduced Liability Claims Patient Satisfaction • Improved coverage � decreased • Less continuity of care = less patient satisfaction? malpractice claims? • Study: University-owned urban teaching • Study: Analyzed paid claims of large liability hospital patient responses n=4166 insurance company from 2000-2005 – Compared Press-Gainey survey results – 70% of claims involved substandard care pre/post laborist implementation – Concluded that over half of hospital litigation – 90% highly satisfied costs could be avoided with 24 hr in-house – Similarly favorable results in both time coverage periods Clark et al Obstet Gynecol 2008 Srinivas et al, Patient Preference and Adherence 2013 Increased Handoffs with Shift Work Successful implementation of laborists • Lessons learned from Hospitalists • Established means of communication between primary physician and laborist • Six Pillars of Handoffs – Communicate, but do not irritate • Inpatient protocols – Consult the primary care physician – Consensus about inpatient treatment – Timeliness is next to godliness – Ex: induction or postpartum order sets – Partner with the patient – Make it clear that you are the pt’s advocate (not just part of the system) – Pass the baton as graciously as received Goldman et al Disease a Month 2002 ACOG Committee Opinion #549, 2010 6
10/25/2013 Lessons from the IM Hospitalist movement Audience Poll • Focus on gathering data to demonstrate How do you feel about having laborist as value part of your practice? • Intentional link between hospitalist field A. Overall Positive and patient safety and quality of care 51% B. Neutral 37% C. Overall Negative � What should be OB/GYN’s next steps? 12% Overall Positi... Neutral Overall Negati... Wachter J Hosp Med 2006 Thank you. • Questions? 7
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