Assuring Safety and High-Quality, Patient Centered Services Along the Continuum of Perinatal Care

Assuring Safety and High-Quality, Patient Centered Services Along the Continuum of Perinatal Care

Secretary’s Advisory Committee on Infant Mortality

November 14, 2012

Data-Driven Perinatal Quality Improvement

Through Public-Private Partnering

Elliott K. Main, MDDirector, CMQCC

Chair, Dept. OB/GYN, California Pacific Medical Center Clinical Professor, Dept. OB/GYN, Univ. Calif. San Francisco

Visiting Professor, Dept OB/GYN, Stanford University

: Transforming Maternity Care

California…. 2011 Population: 37,691,912 1

3 large metropolitan areas, but extensive remote rural areas 2011 Births: 502,118 2

1 of 8 US births, Texas next with 377k Equal to a large European country

2010 Infant Mortality: 4.7 / 1,000 3 ~4th lowest state in US, but still ~27th in the world

2011 Preterm Birth Rate: 9.8% 4 (March of Dimes: “B”) Currently ~280 birthing facilities with >50 annual births

1 US Census Bureau (est.), June 20112 NCHS: NVSR 61:05, Oct 20123 CDPH: MCAH, May 20124 NCHS: 2011 Preliminary Natality data


Improving Maternity Outcomes

Social Determinates

Medical Determinates

4

Faster change?Easier to test?

Cheaper?


How does Data-Driven QI improve maternal and neonatal outcomes?

Multi-Stakeholder Quality Collaboratives State-wide perinatal outcomes database Significant effort for Data Quality Using transparent data to drive and

incent care

Pos: 50 states testing new ideas Neg: 50 states all “doing their own thing”


CMQCC and CPQCCMission: Data-driven QI for mothers and newbornsCalifornia Perinatal Quality Care Collaborative (CPQCC) Established 1996 >95% of all Neonatal Intensive Care Units in California Secure data center—pioneer for data driven QI Model of working with state agencies to provide data of value

California Maternal Quality Care Collaborative (CMQCC) Established 2006 California Maternal Mortality Review Committee (Title V, MCAH) QI toolkits: Elective Delivery <39wks, Hemorrhage, Preeclampsia, Large-scale QI Collaboratives: Hemorrhage, Preeclampsia Statewide Maternal Data Center (CDC and CHCF supported)


CMQCC Key Partner/StakeholdersState Agencies: MCAH, Dept Public Health OSHPD Healthcare Information Division Office of Vital Records (OVR) Regional Perinatal Programs of California (RPPC) DHCS, Medi-CalPublic Groups California Hospital Accountability and Reporting Taskforce (CHART) Kaiser Family Foundation March of Dimes (MOD) Pacific Business Group on HealthProfessional groups American College of Obstetrics and Gynecology (ACOG) Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) American College of Nurse Midwives (ACNM), American Academy of Family Physicians (AAFP)Key Medical and Nursing Leaders University and Hospital Systems Kaisers, Sutter, Sharp, CHW, Scripps, Public hospitals,


Examples of Current Maternal QI Projects

VLBW (<1500g) infants to deliver at appropriate level of care (Level III NICU)

Early (<39 weeks) Elective Delivery Reducing Low-risk First-birth Cesareans Increasing Exclusive Breast Milk Feeding Reduction of complications in pregnant

women with hypertension


Regionalization of care for VLBW has diminished in the last decade despite strong evidence of benefit

California has large variation with major quality opportunities in urban areas


VLBW infants (<1500g) Admitted Directly to NICU

MMWRNov 12, 201059:144-7


Delivery of <1500gm Infant NOT at a Level III Center

HP 2010, HP 2020,

Turn the national goal into a hospital-level quality measure CMQCC Sponsored NQF Endorsed

<1500g infant not delivered at an appropriate level of care Denominator: Livebirths >24 weeks gestation at a NON-Level III

hospital Numerator: Births <1500gm and >500gms Exclusions: none Risk Adjustment: none

Large Regional and Hospital Variation for the Delivery of VLBW not in an Appropriate Level of Care


The California Maternal Data Center(CMDC) Project Vision

Build a statewide data center to collect and report timely maternity metrics—in way that is low cost, low burden and high value for hospitals

Produce metrics that will support QI and L&D service line management

Improve quality of administrative data Facilitate reporting to national performance organizations Over time, publicly report select set of robust measures

to inform decisions of childbearing women


PDD--Discharge Diagnosis File(ICD9 codes)

Birth Certificate File(Clinical Data)

1. Links Birth Data to OSHPD file2. Runs exclusions3. Identifies CS and Inductions 4. Prints list of charts for review

CMQCC Maternal Data Center: Data Flow

CMQCC Data Center

REPORTSBenchmarks against other hospitals

Sub-measure reports

Calculates all the Measures<39wk Elective Delivery

CHART REVIEWLabor?/SROM?

(~6% of cases for brief review)

Limited manual data entry for this measure

Uploads electronic files

Mantra: “If you use it, they will improve it”

: Transforming Maternity Care 15



Built-in Quality Analysis: where do we go next?



Comprehensive Vision for Maternal Data QI in California

1) Standardize Definitions2) Education (MD’s, BC staff, Coders)3) Redesign / System Changes4) Improving Data as QI Project5) Create Value for Maternal Data QI

for hospitals

Obstetric Data Definitions Project

National MeetingAugust 2-3, 2012Arlington, Virginia

Project Objectives

To nationally standardize obstetric clinical data definitions.

To educate and advocate for national implementation of the standardized obstetric data elements and definitions in electronic medical records, birth certificates, and data registries

To increase and improve performance measurement and implementation of the national obstetric data standards and encourage data aggregation.

Many Stakeholders… National vital records (NCHS, NAPHSIS) State vital records State departments of health (MCH) Federal agencies (CMS, CDC, NLM, AHRQ, NICHD) Quality organizations (TJC, Leapfrog, NQF) Health IT / Coding organizations EMR vendors Payers (Medicaid and commercial) Providers (obstetrics, family medicine, nursing, midwifery) Large scale QI collaboratives Advocacy groups (March of Dimes)

Data Quality Reports• Identify discrepancies or missing data in Birth Certificate

and Discharge data files• Use to target data performance/quality improvement

23Screen shot from the California Maternal Data Center

Data Quality Reports• Identify discrepancies or missing data in Birth Certificate

and Discharge data files• Use to target data quality improvement

25

A hospital with a system for transferring clinical data to the BC


Late Preterm Birth (34+0 to 36+6 wks)

Late Preterm Birth makes up >70% of all PTB Late Preterm Birth accounted for ~80% of the rise

in PTB in the prior 10 years Late Preterm Birth accounts for 75% of the decline

in PTB in the last 3 years Late Preterm Birth accounts for much of the

variation in PTB rates among states and among hospitals

Is there a QI opportunity here?

What components make up the

Preterm Birth Rate?


Health Equity <1500g Birth Not at Appropriate Location Late Preterm Birth Exclusive Breast Milk during Birth Hospitalization Low-risk First Birth Cesarean Delivery

All have significant racial/ethnic disparitiesAll could be helped by focused QI projects


Recipe for Improving Care

Quality Measures

Hospital LevelProvider Level

Define the Issues Locally

Transparency

Financial

Incent Systems Change

Public ReleaseBenchmarking

Pos/Neg IncentivesValue-Based Purchasing

Unintended Consequences? Balancing Measures!

Data quality?If you use it, they will improve it!


Role(s) for HHS

Quality Measures

Support measure developmentSupport wide-spread useSupport data collaboratives

Transparency

Financial

Support public releaseRaise awareness

Reduce perverse incentivesExplore positive incentivesValue-Based Purchasing

Support development of Balancing Measures

Support Data QI projectsUse admin data and they will improve it!


Thank You!

[email protected]


Reporting Mandates Coming ED<39 weeks measure included in Hospital IQR

Program for FY 2015 payment determination: data collection beginning with January 2013 discharges

The Joint Commission will require reporting of perinatal set for hospitals that perform deliveries

Medicaid Adult Measure Set published; Medi-Cal Quality Dashboard under development

Medi-Cal has received a federal grant to test collection and reporting of perinatal metrics. CMDC is an active participant.


CMDC’s Clinical Quality MeasuresNQF Joint

Commission Leapfrog CMS Medi-Cal

CHA HEN

Elective Deliveries 37 - 39 week rate (PC-01) C-Section rateTerm 1st Birth (NTSV) (PC-02) Infants < 1500 grams at appropriate level Episiotomy rate Healthy Term Newborn rate Antenatal Steroids (PC-03) Neonatal Blood Stream Infections (PC-04) Exclusive Breast Milk (PC-05)

Cur

rent

Soo

n

Requires some additional chart review (minimized by using the CMDC)


CMDC’s Clinical Quality MeasuresJoint

Commission Chart Review Needed with CMDC

Elective Deliveries 37 - 39 week rate (PC-01)

# of charts reduced to <6% of OB cases and then a very brief review

C-Section rateTerm 1st Birth (NTSV) (PC-02) --none--

Infants < 1500 grams at appropriate level --none--

Episiotomy rate --none--

Healthy Term Newborn rate --none--

Antenatal Steroids (PC-03) With CPQCC, >95% of cases are transferred, identifies missing cases

Neonatal Blood Stream Infections (PC-04) --none--

Exclusive Breast Milk Feeding (PC-05) Generates a “smart” randomized sample

for chart review

Cur

rent

Soo

n

Requires some additional chart review (minimized by using the CMDC)

1 (San Francisco & North)

2 (Sacramento & NE)

3 (East SF Bay)

4 (South SF Bay )

5 (Centra

l Valley)

6 (Los Angeles)

7 (Inland Empire

)

8 (Orange County)

9 (San Diego & East)

10 (Kaise

r North

)

11 (Kaiser S

outh)15

20

25

30

35

40

NTSV CS (State mean = 28.1%)Total CS (State mean = 31.3%)

HP 2020 NTSV CS Target = 23.9%

California Perinatal Region (2007 data)

Med

ian

Ces

area

n R

ate

(%)


Improving Maternity Outcomes: CMQCC Interactions with National Projects

Quality Measures

Maternal Mortality/Morbidity

Data Quality

37

JC, NQF, NPP

AMA PCPI

CDC/AMCHPACOG/CDC

MCHB

Medi-Cal AdvisCMS Expert Panel

ACOG reVITALizeNAPHSISNCHS

Documents

Assuring Safety and High-Quality, Patient Centered Services Along the Continuum of Perinatal Care