Reaching the Best for Floridas Mothers & Babies William M. - PowerPoint PPT Presentation

Reaching the Best for Florida’s Mothers & Babies William M. Sappenfield, MD, MPH, CPH Professor & Director Florida Perinatal Quality Collaborative USF College of Public Health

Conflicts of Interest No conflicts of interest to report. 2

Learning Objectives 1. Explain why quality improvement efforts in maternity care are needed in Florida. 2. Learn how quality improvement initiatives and standardization can improve clinical care. 3. Understand that active participation in multi- hospital quality initiatives can have a larger impact. 4. Discuss the potential future directions for quality improvement efforts. 3

Why is QI in maternal health care needed in Florida & the U.S.? 4

Florida Health Rankings State Leading Category Rank Florida States Health Spending 25 th $8,076 $5,982 Infant Mortality 24 th 5.8 /1,000 3.7 /1,000 Preterm Delivery 33 rd 10.2 /100 7.8 /100 Maternal Mortality 38 th 23.8 /100,000 4.5 /100,000 Cesarean 47 th 34.7 /100 22.3 /100 5

US Health Rankings Country Leading Category Rank US Peers Health Spending 36 of 36 $9,892 $4,500 Infant Mortality 30 of 39 5.8 /1,000 2.5 /1,000 Maternal Mortality 39 of 40 14 /100,000 3 /100,000 6

Mothers Assessed for Hemorrhage Risk at Admission, July-August 2013 31 FPQC OHI Hospitals 11% Mothers 18% 75%+ 1‐74% 71% None Hospitals 7

The Law of Diffusion of Innovation 0.6 Early Late Majority Majority 0.5 34% 34% Early 0.4 Adopters Laggards 13.5% 0.3 16% Innovators 0.2 2.5% 0.1 0 275 300 325 350 375 400 425 450 475 500 525 550 575 600 625 650 675 700 725 Source: E.M. Rogers, 1962 8

Percent Treated Within 1 hour with Acute Onset Maternal Hypertension, July-August, 2015 32 FPQC HIP Hospitals 7% Mothers 43% 75%+ 1‐74% 50% None Hospitals 9

Percent of All Low Risk Cesarean Deliveries Performed that Met Criteria, July-Sept, 2017 45 PROVIDE Hospitals 7% 45% Met Criteria 48% Yes No Missing & Other NTSV Cesarean Deliveries 10

Why do we need Perinatal Quality Improvement Efforts? 11

Why Not Follow Practice Guidelines? Don’t Know Know Unintentional Intentional Error Error Inadequate System Misaligned Education Complexity Incentives 12

Why Not Follow Practice Guidelines? Don’t Know Know Unintentional Intentional Error Error Inadequate System Misaligned Education Complexity Incentives Quality Align Improvement Incentives 13

Florida Pregnancy Associated Mortality Review • Florida’s process modeled after CDC’s Maternal Mortality Review & ACOG’s NFIMR Process • Consistently reviewed cases and collected data since 1999 • Funded through federal Title V Maternal and Child Health Block Grant funds • Public/Private collaborative of various organizations, institutions, providers, & specialties • Chaired by Dept. of Health and ACOG District 14

Pregnancy-Related Deaths by Cause Florida, 2006-2015 Hemorrhage 21.4% Hypertensive disorders 14.9% Infection 14.4% Other Conditions 11.8% Cardiomyopathy 9.4% Cardiovascular conditions 8.4% Thrombotic pulmonary embolism 8.2% Amniotic Fluid Embolism 4.1% Unknown 3.4% Cerebrovascular accident 2.6% 0% 5% 10% 15% 20% 25% 30% Percentage of Deaths

FL PAMR Prevention Strategies ACOG District Presentations ACOG District Newsletters Peer-Review Journal Publications Hospital Letters Urgent Maternal Mortality Messages 16

Pregnancy-Related Mortality Rate Florida 1999 to 2016 70 PRMR per 100,000 Live Births 60 50 40 30 20 10 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Total Non-Hispanic White Non-Hispanic Black Hispanic Hernandez, et. al. Florida Pregnancy Associated Mortality Review 2016 Update. 2018 Florida Department of Health

What is quality improvement and what does a Collaborative have to offer? 18

Quality Improvement is a Team Sport 19

Quality Improvement The Framework for QI What are we trying to accomplish? Do Plan How will we know that a change is an improvement? Study Act What change can we make that will result in improvement? Associates in Process Improvement: Model for Improvement 20

Quality Collaborative is like a Car… 21

Why Participate in a QI Collaborative? Education Toolkit Data Reporting Materials Technical Clinical Consult Lessons Learned Experts Assistance Guidelines Hospital Compare Peer Grand Hospitals Rounds Support Examples 22

Education is Not Sufficient Reduction in Elective Delivery by Group, 2007-2009 Education Baseline Afterwards Soft Stop * Hard Stop * 0 5 10 15 20 Percent of Elective Deliveries Clark, et. al. Reduction in elective delivery at <39 weeks of gestation: comparative effectiveness of 3 approaches to change and the impact on neonatal intensive care admission and stillbirth. 2010 American Journal of Obstetrics Gynecology 23

Participating in a Perinatal QI Collaborative Makes a Difference Adjusted Odds Ratios for Post-Intervention & Baseline Neonatal Resuscitation Initiatives, CPQCC Hypothermia Intubation at Delivery Surfactant at Delivery 0.1 0.8 1 0.2 0.4 0.6 Series 3 Series 2 Series 1 Collaborative QI NICU QI Non‐Participants Lee, et al. Implementation Methods for Delivery Room Management. Pediatrics 2014

Participating in a Collaborative More than Once Makes a Difference Severe Maternal Morbidity Rates among Hemorrhage Patients by Hospital Category, CMQCC Hospitals Baseline Post Percent Rate Rate Reduction Not participating 48 28.6 28.2 1.2% No prior 74 22.7 19.2 15.4% experience Prior experience 25 22.7 16.2 28.6% Main et al. Reduction of severe maternal morbidity from hemorrhage. Am J Obstet Gynecol 2017.

Standardizing Clinical Practice Alone Can Improve Quality “In the absence of evidence-based medicine for a given clinical decision, development of these protocols sometimes may be challenging. However, the use of checklists and protocols has been clearly demonstrated to improve outcomes and their use is strongly encourage.” Clinical Guidelines & Standardization of Practice to Improve Outcomes—ACOG Committee Opinion 629 26

CMQCC. CA‐PAMR (Maternal Mortality Review). Retrieved July 2, 2018. https://www.cmqcc.org/research/ca‐pamr‐maternal‐mortality‐review 27

What is the Florida Perinatal Quality Collaborative? 28

Vision “All of Florida’s mothers and infants will have the best health outcomes possible through receiving high quality evidence-based perinatal care.” Values • Voluntary • Population-Based • Data-Driven • Evidence-Based • Value Added 29

FPQC Partners & Funders 30

AIM States Serious Intent Interested Added OUD State Undecided 31

National Network of Perinatal Quality Collaboratives State PQC Status PQC Available PQC & CDC Funding Unknown PQC Status 32

Past FPQC Initiatives Hypertension in Pregnancy Maternal Early Elective Deliveries OB Hemorrhage Health Antenatal Steroids Neonatal Infant Mother’s Golden Hour Catheter Own Milk Health Infections Data Perinatal QI Indicators 2010 2011 2012 2013 2014 2015 2016 2017 33

Ongoing & New FPQC Initiatives Maternal Primary Vaginal Deliveries Health Long‐Acting Reversible Contraception Infant Mother’s Own Milk Neonatal Abstinence Health Perinatal QI Indicators Data Birth Certificate Initiative Pilot Birth Certificate Initiative 2017 2018 2019 34

FPQC Hospital Participation—2018 Infant Health Initiatives: 25 Maternal Health Initiatives: 47 QI Indicators: 39 FPQC Annual Meeting: 35 68 Florida 115 Florida Licensed Delivery NICUs Hospitals 35

What have we been able to accomplish together as a Collaborative so far? 36

Hypertension in Pregnancy Initiative—HIP 37

Percent of All Reporting HIP Hospitals that treated women with persistent new-onset severe HTN in 1 hour 100% 7% 15% 75 to 100% of 90% 28% 31% women 38% Perecentage of Hospitals 80% treated within 50% 1 hour 70% 63% 50% 1 to 74% of 60% women 50% treated within 76% 1 hour 63% 40% 69% 62% No women 30% 50% treated within 43% 20% 38% 1 hour 10% 9% 9% 0% Baseline Q1-16 Q2-16 Q3-16 Q4-16 Q1-17 Apr-17 38

Percent of All Reporting HIP Hospitals where women received discharge education material 100% 90% 26% 28% 75 to 100% of 80% women received discharge Percentage of Hospitals 58% 70% education material 69% 72% 75% 60% 27% 1 to 74% of 92% women received 50% discharge 53% education material 40% 30% No women received discharge 46% 39% 20% education material 28% 28% 22% 10% 19% 8% 3% 3% 3% 0% Baseline Q1-16 Q2-16 Q3-16 Q4-16 Q1-2017 Apr-17 39

Usefulness of FPQC HIP Resources and Tool 27 of 32 Participating HIP Hospitals HIP Online Tool Box Monthly hospital QI data reports Project Kick Off event In-person Mid-Project Meeting Email/Phone Technical… Collaborative Webinars 0% 20% 40% 60% 80% 100% Not Aware Very Useful Somewhat Useful Not at all Useful 40