OB Hospital Medicine: Improved Quality & Safety Society of - PowerPoint PPT Presentation

6/15/2019 Disclosures • No financial disclosures OB Hospital Medicine: Improved Quality & Safety • Society of OB/GYN Hospitalists (SOGH) • Board of Directors Vasiliki Tatsis, MD MS MBA • Academic Committee Chair Associate Professor Director OB/GYN Hospitalist Program University of California, San Francisco Objectives 1. Review the evolution and definition of OB hospital medicine  Increasing Patient Complexity 2. Discuss the benefits of OB hospital medicine • Patient outcomes  Competing Provider • Patient satisfaction Priorities • Quality of care & financial solvency  Diverging Skill Sets 3. Future directions 1

6/15/2019 Evolution of the OB Hospitalist Movement Today’s OB Hospitalist “The term ‘hospitalist’ refers to physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities may include patient care, teaching, research, and 2016: 2018: ACOG Committee >300 OB Hospitalist programs inpatient leadership. ACOG supports the continued development and Opinion – “The 2 new programs/month 2011: study of the OB/GYN hospitalist model as one potential approach to OB/GYN 30K hospitalists Hospitalist” improve patient safety and professional satisfaction across delivery ~165 OB 2010: settings.” Hospitalist SOGH programs ¹ founded 2003: Weinstein, AJOG – “The Laborist” 1 Olson R et al, AJOG, Aug 2012. Hospitalist Model Types: Provider Mix Hospitalist Providers: • Generalist OB/GYNs • Fellowship Trained Hybrid o MFM o Critical Care OB Hospitalist % Hospitalist o OB/GYN Hospital Medicine % Community 100% Hospitalist OB/GYNs Community × Laborist “OB Hospitalist” 100% Community OB/GYNs McCue et al. Definitions of obstetric and gynecologic hospitalists. Obstet Gynecol, 2016;0 . 2

6/15/2019 Important Quality Metrics Benefits of OB Hospitalist Programs • Cesarean rates 1994-2003: 21%  32.7% • Increased on weekdays before & clinic, at lunch ¹ • Financial costs • Commercial insurers: $9537 (34%) higher than for SVD • Clinical Outcomes • Medicaid: $4459 (33%) higher than for SVD Overall cesarean and low-risk cesarean delivery: US, 1990-2012. • 1% reduction in cesarean rates = $254M/yr!! CDC/NCHS, National Vital Statistics System. • Patient Satisfaction • Fee-for-service payment models disincentivize vaginal deliveries • Financial solvency • Privately insured births vs salaried physicians with no financial incentive ² • VBAC rates • Provider preference often drives mode of delivery ³ • Malpractice risk/litigation • Payments incentivize repeat cesarean ¹Clark SL et al. Association of obstetric intervention with temporal patterns of childbirth. Obstet Gynecol 2014;124(5):873-880. ²Kozhimannil KB et al. Trends in hospital-based childbirth care: the role of health insurance. Am J Manag Care. 19(4):e125-e132. ³Iriye et al. Implementation of a laborist program and evaluation of the effect upon cesarean delivery. Am J Obstet Gynecol. 2013;209:251.e1-e6. Two Practice Models in One Labor and Delivery Unit: Association with Cesarean Delivery Rates Nijagal M et al. Am J Obstet Gynecol , 2015. • 2005-2014 • 2006-2011, tertiary care hospital • Retrospective cohort: • Prospective: N=3560 nulliparas, N=1324 prev c/s • 9381 singleton live births • Retrospective, N=6206 nulliparas • Practice change L&D restructuring • Equal mix of publically and privately insured • Cesarean Rates Over 3 time periods: • Privately & publically insured: same care • 2 practice models in one hospital • Private MDs participate in laborist call + CNM • No laborist care, traditional model: 39.2% • Results: • Community physician laborist care: 38.7% • Primary Cesarean Rate: 31.7%  25.0% C/S Rate (%) NTSV C/S Rate (%) VBAC Rate (%) • Full-time laborists: 33.2% (p<0.001) (p=0.005) Private 31.6 29.8 28.7 • VBAC Rate: 13.3%  22.4% Laborist 17.3 15.9 58.6 NTSV c/s decreased daily by 0.45  ~$3K cost savings to the hospital p-value <000.1 <0.001 <0.001 NTSV C/S Rate VBAC Rate . Privately Insured Decreased Increased (p=0.0009) (p=0.04) Publically Insured Decreased Increased (p=0.1) (p=0.34) 3

6/15/2019 CNMs & Obstetricians: Embracing Collaboration • Midwife-laborist practice models show decreased cesarean¹ and increased VBAC rates² • 1998-2011, cohort study • Interprofessional collaboration – best way to • >500,000 patients save lives (Lancet Midwifery Series) • Scaled global perspective  institution level • 24 hospitals (8 laborist, 16 non- • Have mechanisms/processes laborist) • System strengthening & institutional preparedness • Laborist program implementation: • Fewer inductions • Increasing complexity and diverse care needs • Decreased preterm birth • Humanistic supportive care reflected in CNM core competencies • No adverse effects on other • Call to re-examine traditional roles: integrate outcomes care for patient-centered focus ¹Nijagal et al. Two practice models in one labor and delivery unit: association with cesarean delivery rates. Am J Obstet Gynecol. 2014;212:1.e1-e8. ²Rosenstein et al. The association of expanded access to a collaborative midwifery and laborist model with cesarean delivery rates. Obstet Gynecol. 2015;126(4):716-723. OB Hospitalists & Patient Satisfaction Comprehensive Safety Strategies & Adverse Patients are willing to trade familiarity for availability/competence ¹ Outcomes • Satisfaction surveys after implementation of full-time laborist program ² • Pre and post laborist program Press-Ganey scores compared • No change  pts NOT less satisfied • 93% rated childbirth experience as “excellent” or “very good” • 49% delivered by their own provider • 85% were made aware their provider might not deliver baby 24/7 Hospitalists • Key: Setting expectations of hospital birth experience Pettker CM et al. Impact of a comprehensive patient safety strategy on obstetric adverse events. Am J Obstet Gynecol. 2009 May;200(5):492.e1-8 ¹Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA 2002;287:487-94 ² Srinivas SK, et al. Patient satisfaction with the laborist model of care in a large urban hospital. Patient Preference and Adherence 2013;7:217-222. 4

6/15/2019 Malpractice: OB Triage  OB Emergency Department Fewer Claims & Compensation Payments CRITICAL ELEMENTS: 24/7 Hospitalists • Dept of Public Health Licensing • 2 dedicated RNs • Medical Screening Exam by MD - <30 minutes • Goal: determine if an emergency condition exists • Fewer disparities & care delays • Poor outcomes mitigated • Increased nursing satisfaction/retention ¹ • Processes to bill as an ED • Modest increase in prof fees, substantial increase in facility fee Gruenbaum et al. Effect of a comprehensive obstetric patient safety program on compensation payments and • Increased reimbursement at ED rates outside of global sentinel events. Am J Obstet Gynecol. 2011 Feb;204(2):97-105. • FINANCIAL SOLVENCY Pettker CM et al, A comprehensive obstetric patient safety program reduces liability claims and payments. ¹Wolfe S. Hospitalists: good or bad for nurses? RN 2000;63(3):31-3. Am J Obstet Gynecol. 2014 Oct;211(4):319-25. “Focused Practice” Designation? “OB/GYN Hospitalists in this country are the “Recognizes areas of practice that either evolve as physicians and wave of the future. There’s no question about it.” specialists progress throughout their professional careers or emerge as medicine changes due to advances in medical knowledge.” J. Joshua Kopelman MD, Chair ACOG District VIII 5

6/15/2019 Leadership on L&D Rapidly growing •Patient safety •Outcomes Thank You! practice •Quality metrics Vasiliki.Tatsis@ucsf.edu Take Home Points Questions? Future directions: Sustainable & Focused practice? solvent model Role in maternal mortality? 6