The California Maternal Data Center (MDC) Anne Castles, MPH, MA MDC Project Manager Kathryn Melsop, MS CMQCC Administrative Director Elliott Main, MD CMQCC Medical Director
What is the MDC? A one- stop shop to support hospitals’ obstetric quality improvement initiatives and service line management Overall hospital performance measures Drill-down to the patient level and case review worksheets to identify quality improvement opportunities — for both clinical quality and data quality Provider-level statistics — to assess variation within a hospital Benchmarking statistics--to compare your hospital to regional, state, and like-hospital peers Facilitating reporting to Leapfrog, PSF and Cal-HEN : Transforming Maternity Care
The MDC: Now Serving Hospitals in 3 States Launched August 2014 25 Hospitals Launched in April 2015 14 Hospitals Launched in 2012 148 Hospitals 72% of CA Deliveries Joined in 2015: Kaiser Permanente Dignity Health Sutter Health St. Joseph Health
Data Sources PDD — Patient Birth Certificate Discharge Data Data (ICD9 codes) Active Track: Hospital PDD to CMQCC State Vital Records Data to CMQCC Monthly/Quarterly within 45 days Monthly within 45 Days View Only Track: State PDD to CMQCC 8-14 months CMQCC Data Center Calculates all the Measures Immediately LIMITED & OPTIONAL Supplemental Data • ED<39 Weeks • Antenatal Steroids • Bilirubin Screen REPORTS • DVT Prophylaxis Benchmarks against other hospitals Sub-measure reports : Transforming Maternity Care
Two Tracks: Active and View Only MDC Features View Only Active Hospital-Level Metrics Statewide benchmarks for all of the above metrics Ability to calculate additional measures Patient-Level Drill-Down and Data Editing Provider-level metrics Timeliness of Data 8-14 months 45 days Data Source OSHPD Hospital PDD & BC PDD & BC Cost Free Free : Transforming Maternity Care
: Transforming Maternity Care 6
32 Hospital Clinical Quality Measures Today’s Highlight: NTSV C-Section
Cesarean Births Have Risen by Over 50% in the Last 15 years US 2013= 32.7% CA 2013= 33.1%
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80% Large Variation of Total Cesarean Rate Among 251 California Hospitals: 2013 70% 60% Range: 15.0 — 71.4% 50% Median: 32.5% Mean: 32.8% 40% 30% 20% “But, our patients are higher risk than other hospitals!” 10% 0% 111 206 1 6 11 16 21 26 31 36 41 46 51 56 61 66 71 76 81 86 91 96 101 106 116 121 126 131 136 141 146 151 156 161 166 171 176 181 186 191 196 201 211 216 221 226 231 236 241 246 251 Hospitals 10
Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean Section Rate Risk Stratified (“standard population”) Widely Adopted Nationally ACOG: Task Force on Cesarean Section rates (2000) DHHS: Healthy Person 2010 and 2020 NQF endorsed, Joint Commission Perinatal Core Measure (PC-02), Leapfrog Group, CMS Further risk adjustment adds little >15 years experience 11
NTSV CS Rate Among CA Hospitals: 2014 80% (Nulliparous Term Singleton Vertex) 70% (Source: Linked OSHPD-Birth Certificate Data) 60% Range: 12%—70% Median: 25.3% 50% Mean: 26.2% 40% National Target =23.9% 30% 20% 40% of CA Large Variation = 10% hospitals meet Improvement Opportunity national target 0% 1 7 13 19 25 31 37 43 49 55 61 67 73 79 85 91 97 103 109 115 121 127 133 139 145 151 157 163 169 175 181 187 193 199 205 211 217 223 229 235 241 247 12
NTSV CS Rate Among Pac/Lac Region: 2014 (Nulliparous Term Singleton Vertex) (Source: Linked OSHPD-Birth Certificate Data) 60% Range: 12%—70% Range: 17%—56% Median: 25.3% 50% Mean: 28.6% Mean: 26.2% 40% National Target =23.9% National Target =23.9% 30% 20% 10% 0% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 13
Why should we care about CS rates? Relentless Rise without Baby or Mother benefit 6% in early 70’s, 20% in mid 80’s, 33% in 2010 CP rates, neonatal seizures unchanged since 1980 Overall, no benefit for long-term urinary continence Increased maternal and neonatal morbidity Impaired neonatal respiratory function, NICU admits Affects maternal-infant interaction/Breast Feeding Increased maternal PP infections, VTE, transfusions Longer recovery, 2X PP re-admissions Prior CS can have major complications Placenta previa and accreta (invasion deep into or thru the uterine wall) hysterectomy or worse 14
New Statewide Initiative in 2016! Supporting Vaginal Birth and Reducing Primary Cesarean Section ■ NEW TOOLKIT! To be distributed in February 2016 ■ QI Implementation Project: Seeking engaged hospital participants for 2016 project □ Develop a maternity culture that values, promotes, and supports intended vaginal birth □ General labor support □ Response to labor challenges □ Lessons from Hospitals that have successfully reduced their NTSV CS Rate □ Data to drive improvement
Hospital Performance Over Time For each hospital quality measure: View reports on monthly/quarterly/annual basis Easy downloads of the graphics or numerical data
Drill Down Information • Drill down to case-level information within own hospital account • Hover boxes show definitions for ICD-9 codes : Transforming Maternity Care
State, Regional, Nursery-Level Comparisons Benchmark your hospital against other peer comparison groups : Transforming Maternity Care 18
System Comparisons If part of a multi-hospital system, can view all hospital rates within the system : Transforming Maternity Care 19
Provider-Level Cesarean Rates Screen Shot from the CMQCC Sample Medical Center Maternal Data Center G5xxxx G6xxxx G7xxxx G8xxxx Note the A8xxxx two busiest providers A6xxxx had widely different A5xxxx rates A4xxxx A8xxxx A9xxxx
Measure Analysis: Identify Drivers of the CS Rate (Step 1) NTSV: Nulliparous (first-birth), Term, Singleton, Vertex presentation MTSV: Multiparous (second or more-birth), Term, Singleton, Vertex presentation Screen Shot from the CMQCC Maternal Data Center
Measure Analysis: Identify Drivers of the CS Rate (Step 2) What Drives Our Nulliparous Term Singleton Vertex (NTSV) CS Rate? Screen Shot from the CMQCC Maternal Data Center
New National Guidelines for Defining Labor Abnormalities and Management Options
ACOG/SMFM Criteria for Dystocia: CMQCC Checklist 1. Diagnosis of Dystocia/Arrest Disorder (All 3 should be present) Cervix 6 cm or greater Membranes ruptured, then No change X 4 hours with Adequate Uterine activity (or 6hrs with oxytocin) 2. Diagnosis of Failed Induction before 6 cm dilation (both should be present) Bishop Score ≥ 6 cm before elective induction Oxytocin used for a minimum of 12 hrs after membrane rupture 3. Diagnosis of Failed Induction after 6 cm dilation (see criteria 1) 24
Measuring Adherence to Labor Management Guidelines Case Reviews of NTSV CS—Do we follow the Labor Guidelines? Other Labor Management Bundles Discouraging Early Labor Admissions Labor Inductions Screen Shot from the CMQCC Maternal Data Center
Balancing Measure: Unexpected Newborn Complications Term infants without “pre -existing conditions ” that experienced unexpected complication
Balancing Measure: Unexpected Newborn Complications
Measure Analysis Unexpected Newborn Complications
Impact of MDC’s Data -Driven QI: NTSV C-Section Pilot Hospital: PBGH / RWJ C-Section Pilot 33.6% 35% 32.9% 31.8% 31.2% NTSV CS Rate 33% 30% 28.3% QI Project 28% 25.0% Started: 24.3% 25% 23.4% Jan 16 23% 20% National Target for NTSV CS = 23.9% 18% 15% 2011 2012 2013 Jan-14 Feb-14 Mar-14 Apr-14 May-14 29
How to Access the MDC Hospital is Not Active Track Contact CMQCC to request access with your name, role, e- mail, and hospital name CMQCC will invite you to access the system Registration takes less than 1 minute--NO PAPERWORK Hospital is already Active Track Contact personnel at your hospital with MDC Administrator status (usually Director of MCH) Contact CMQCC to get the list CMQCC Contact Datacenter@cmqcc.org 30
Becoming an Active Track Participant Coordination Complete a Participation Agreement with CMQCC Appoint Project Coordinator for the hospital. Data Submissions Identify IT staff to upload patient discharge data to the CMDC on a monthly or quarterly basis: Best to delegate to department responsible for OSHPD PDD submission Use Results for Clinical and Data QI Participate in training and quality review session with CMQCC staff. : Transforming Maternity Care
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