The FMEC IMPLICIT Network:

Improving the Health of Women and Their Infants through Quality

Improvement

Stephanie E. Rosener, MD Daniel J. Frayne, MD

3rd National Summit on Preconception Health and Health CareTampa, FloridaJune 13, 2011

The Problem – Preterm Birth

US Preterm Birth Rate (2009) = 12.18% National Center for Heath Statistics, Dec 21, 2010

IMPLICIT

Interventions to Minimize Preterm and Low birth weight Infants using

Continuous Improvement Techniques

What is IMPLICIT?

Collaborative of Family Medicine Residency Programs

Continuous Quality Improvement (CQI)

Primary Prevention of Prematurity

Opportunity to influence the future practice patterns of family medicine residents

Our Partners:

National March of Dimes

Family Medicine Education Consortium

Participating FM Residencies

Pennsylvania WPAHS - Forbes

    UPMC- McKeesport

    UPMC- Shadyside

    UPMC- St. Margaret

Penn State-Good Samaritan

    Lancaster General Hospital

    Reading Hospital Medical

    University of Pennsylvania

Jefferson Medical College

Williamsport

York Hospital

Massachusetts Greater Lawrence

New York Beth Israel Ellis Hospital Mid-Hudson

Connecticut     Middlesex Hospital

North Carolina MAHEC Asheville

How IMPLICIT Works

Monthly audio-conferences

Evidence leaders

Working groups

IMPLICIT website (FMEC)

Web-based data portal

Semiannual meetings

Continuous Quality Improvement (CQI)

Proactive process to improve care

Identifying and analyzing strengths and problems

Testing, implementing, and revising solutions

Chosen Prenatal Interventions

Depression

Smoking cessation

Inter-pregnancy interval

Asymptomatic Bacteriuria

Bacterial Vaginosis (dropped 2011)

Progesterone (added 2006)

Successes/Impact

Bennett et al (2009) JABFM, n = 3,936, 10 sites

Original Depression CQI Strategy

Administer both 2-Item Screen and Edinburgh Postnatal Depression Scale (EPDS) (15 & 30 weeks, postpartum)

Diagnose Depression (DSMIV-TR Criteria)

Treat according to usual guidelines PsychotherapyAntidepressant medicationBehavioral Lifestyle interventions

“During the last month have you often been bothered by: - Little interest or pleasure in doing things? - Feeling down, depressed, or hopeless?”

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CQI

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Prenatal Depression Screening (15wk Visit)

Tests performed with unequal sample sizes

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CQI

Postpartum Depression Screen

Tests performed with unequal sample sizes

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EPDS ≥13 EPDS ≥13

30 Week screen

Variable(s) AUC (95% CI) Sens Spec PPV NPV Two item screen 0.81 (0.74-0.88) 82 80 24 91Two item screen + Dep. Hx. 0.85 (0.76-0.94)

1 item positive 93 63 42 91 2 items positive 41 91 22 98

15 Week Screen

Variable(s) AUC (95% CI) Sens Spec PPV NPV Two item screen 0.80 (0.69-0.91) 93 75 44 98Two item screen + Dep. Hx. 0.85 (0.76-0.94)

1 item positive 97 61 59 912 items positive 58 92 21 99

Postpartum

Variable(s) AUC (95% CI) Sens Spec PPV NPV Two item screen 0.80 (0.69-0.91) 80 86 30 99Two item screen + Dep. Hx. 0.85 (0.76-0.94)

1 item positive 90 67 44 96 2 items positive 60 96 11 99

Bennett et al (2008) JABFM

Revised 2-Stage Depression Screening

Strategy

Administer PHQ-2 (50-60% negative)

Yes to either question = positive screen

full depression screening (PHQ-9 or EPDS)

Results in only 18% of pregnant and postpartum women requiring further assessment

Next Steps for IMPLICIT

Preconception Care – The Facts

By the time a woman enters prenatal care, it is often too late to significantly affect the outcome of the pregnancy

Only 11% of prenatal patients have a preconception visit

The extent to which women who do not become pregnant receive preconception care is unknown

Interconception Care “A subset of preconception care that addresses

the continuity of risk from one pregnancy to the next.” (Kotelchuck, 2006)

Characteristics of an Ideal Model:Brief (5 minute “capsule”)Cost effectiveAcceptable to patientsPotential for broad implementation

Proposed IMPLICIT ICC Model

Address maternal risk at Well Child Visits

Mothers visit the office regularly even if they do not seek care for themselves

Poor maternal health status adversely affects child development and well-being

Achievable and acceptable to women based on pilot studies

Kahn and Wise, Pediatrics, 1999.Gjerdingen et al., Ann Fam Med, 2009.

IMPLICIT ICC – Areas of Focus

Tobacco Use*

Depression

Family Planning/Birth Spacing

Folic Acid Supplementation*

*Supported by Level A Evidence

IMPLICIT ICC Strategy: Utilize contact with mothers at well child visits

Assess current risks

Reinforce desired behaviors

Connect with primary providers or community resources to address risks

Collect data, analyze and develop strategies to improve care delivery

Baseline data collection is under way

Conclusions CQI is an effective strategy for improving the delivery of

maternity care processes associated with decreased preterm and LBW outcomes

Collaboratives provide the opportunity for organized inquiry and larger subject numbers required for meaningful data analysis

A CQI strategy for Interconception Care holds promise for improving birth outcomes and could be implemented in a wide variety of primary care settings

Resident involvement provides the opportunity to influence the practice patterns of the next generation of family physicians

Final Questions/Comments