The encouraging results of a 14-hospital childbirth safety initiative are a reminder of the nation's notoriously high infant mortality rate and high rate of adverse events in the delivery room. They also shed light on how some simple interventions can be highly effective, but that institutions can also be penalized—in the form of generating lower revenues—when they do the right things.
With an infant mortality rate of six deaths per 1,000 live births, the U.S. ranked 11th out of 11 wealthy countries, according to the Commonwealth Fund. Federal estimates cited by the Premier healthcare alliance, which led the initiative, put the adverse event rate for deliveries at 9% and that 30% of these are considered preventable, with miscommunication cited as the most common reason for their occurrence. Premier estimated that the interventions used in the initiative prevented harm to 110 mothers and newborns and reduced injuries that can cause infant brain damage by 25%.
The interventions tested included enhanced communication techniques, emergency training using simulated “worst-case scenarios,” and the use of evidence-based bundles of care for situations such as elective induced labor and augmented or “sped-up” labor.
The first item in the elective induced-labor bundle was limiting deliveries to pregnancies that were at 39 weeks or longer. Prohibiting elective births before the 39-week mark has been promoted by the March of Dimes and others as an obvious step toward improving newborn health.
Tiffany Kenny, a nurse and women's health services informatics administrator at one of the participating hospitals, Summa Health System's Akron (Ohio) City Hospital, said the policy has been in effect for almost three years at Akron. She said, in the past, patients were choosing elective deliveries for reasons such as “discomfort or the doctor you like happens to be on call that day.”
Helen Haskell, president of Mothers Against Medical Error, said “there's no question” that early elective induced labor was leading to a high number of adverse events and neonatal intensive-care-unit admissions. “It would take almost willful blindness to what they were doing to not recognize that,” said Haskell, who was not involved with the initiative. She attributed the problem to a fragmented healthcare system. “They don't see the whole picture—only patients see the whole picture.”
But some patients at North Oaks Medical Center, Hammond, La., had been resistant to a policy in effect since last December against such deliveries, said Kirsten Constantino, a nurse and assistant vice president of patient services. North Oaks was not involved in the Premier initiative. “Initially, there was a lot of pushback because, historically, they've been able to dictate how the end of their pregnancy is going to go,” she said. Implementing the 39-week mandate required a patient education effort, which included the slogan “39 weeks means chubby cheeks,” said Jan Takewell, the hospital's performance management director.
Childbirth Connection, a New York group that promotes evidence-based maternity care, also promotes limiting elective labor inducement and cesarean sections to 39 weeks or later, but the organization's associate director of programs, Amy Romano, said it's difficult to point to one intervention among many as the reason for lowering adverse events.
“These things can be hard to study because you have to comprehensively do all these things at once,” Romano said. “So, you can't tease out if it's the hard stop at 39 weeks, simulation training or developing a culture of safety.”
Romano, however, didn't hesitate to say the solution to medical malpractice troubles lies not with legislatures, but with clinical efforts such as Premier's. “These kind of patient-safety initiatives are really the most promising intervention for tort reform—instead of capping damages,” she said.
While acknowledging that claims are typically filed two years after an injury, Premier noted that liability claims fell by 39% among the initiative's participants. They had totaled 10 obstetric liability claims in 2009 and were “trending” toward eight for 2010, compared with 18 in the baseline years of 2006 and 2007.
Nobody delivers more babies than HCA, the largest hospital system in the U.S. About 220,000 babies are born each year at HCA's facilities, and—since the Nashville-based healthcare giant instituted standardized, evidence-based protocols aimed at improving obstetric safety—it has seen its number of liability claims per 10,000 births drop to four in 2009 from 13 per 10,000 births in 2000.
Similar numbers have been reported by New York-Presbyterian Hospital/Weill Cornell Medical Center, where a comprehensive obstetric safety program went into effect in 2003. Between 2007 and 2009, average annual compensation payments were down to less than $2.6 million from almost $27.6 million between 2003 and 2006, as serious obstetric adverse events fell to zero from five in 2000.
But these savings can come with a cost.
The Seton Healthcare Family, a division of Ascension Health with eight hospitals in Texas, said it has had a major decrease in Medicaid reimbursement as a result of lowering its trauma rate to 0.2 per 1,000 live births for the past five years from three traumas per 1,000 live births for fiscal years 2001 through 2003.
For fiscal 2008 and 2009, Medicaid reimbursement for diagnoses related to birth trauma fell below $26,000 compared with around $1.3 million for fiscal 2001 through 2003. Seton, which did not participate in the Premier initiative, concluded in a white paper that the state should adopt pay-for-performance principles in its Medicaid program.
North Oaks' Constantino also noted that there is a payoff when word gets around about an institution's higher-quality care. “If you do what's best for your patients, in the long run, it's going to pay off.”