SCREENING IN PREGNANCY- ROLE OF THE CMQCC TOOLKIT

AFSHAN HAMEED, MD, FACOG, FACC HS Professor, Maternal Fetal Medicine & Cardiology University of California, Irvine

AWHONN California Section Conference, February 21st 2020, Long Beach CA WHY? Cardiovascular Disease Screening in Pregnancy – Role of the CMQCC Toolkit

Maternal Mortality Child Health USA 2013 Maternal Mortality Ratios in Selected Countries over the Past 30 Years

25

1980 1990 20

15 2000 2008

10 (per 100,000 births) 100,000 (per

5 Maternal Mortality Ratio Mortality Maternal

0

Hogan et al, Lancet 2010; 375: 1609–23 July 17, 2015

The US has the highest Maternal Mortality rate of any high resource country and the only country outside of Afghanistan and Sudan where the rate is rising 3-4 X

July 17, 2015 Significant reductions in maternal mortality and morbidity can not be accomplished without addressing the gaps in maternity care for black women 1.6% 2X

cdc.gov 8 Maternal Morbidity andMortality: CVD 13 Cardiovascular Related Mortalities/2007 in CA

Severe Maternal Morbidity - ICU

13

15-20x

Serious 350-400x Morbidity: (prolonged length of stay) LESSONS LEARNED FROM MATERNAL MORTALITY REVIEWS Cardiovascular Disease Screening in Pregnancy – Role of the CMQCC Toolkit Cardiovascular Disease is the leading cause of maternal mortality in CA and U.S. under-recognized in pregnant or postpartum women higher among African-American women

▪ 25% of deaths attributed to cardiovascular disease may have been prevented if the woman’s heart disease had been diagnosed earlier

▪ Pregnancy is a period of frequent interaction with health care providers and offers an opportunity to detect and treat heart disease, improve pregnancy outcomes, and affect future cardiovascular health.

Hameed A, Lawton E, McCain CL, et al. Pregnancy-Related Cardiovascular Deaths in California: Beyond Peripartum Cardiomyopathy. American Journal of Obstetrics and Gynecology 2015; DOI: 10.1016/j.ajog.2015.05.008 CA-PAMR Findings Identification and Confirmation of CVD Pregnancy-Related Deaths 2002-2006

California Birth Cohort, 2002-2006 N=2,741,220

Pregnancy-Associated Cohort N=864

Pregnancy-Related Deaths N=257

Cardiovascular Pregnancy-Related Deaths N=64

Cardiomyopathy Other Cardiovascular N=42 N=22

Hameed A, Lawton E, McCain CL, et al. Pregnancy-Related Cardiovascular Deaths in California: Beyond Peripartum Cardiomyopathy. American Journal of Obstetrics and Gynecology 2015; DOI: 10.1016/j.ajog.2015.05.008 Top 5 Causes of Death 2002-2005 Pregnancy-Related Grouped Cause of Death, Deaths per CA-PAMR Committee N (%)

Cardiovascular disease 49 (24) Cardiomyopathy 30 (15) Other cardiovascular 19 (9) Preeclampsia/eclampsia 36 (17) Obstetric hemorrhage 10 (10) DVT/ PE 20 (10) AFE 18 (9) All other causes 64 (31) TOTAL 207 CVD Pregnancy-Related Mortality Rate: 2.3 deaths /100,000 live births Proportions for Each of the Leading 5 Causes of California Pregnancy-related Mortality

25 23.7

20 17.4

15 related related Mortality - 9.7 9.7 10 8.7

5

% Pregnancy of % 0 CVD PreE/E OB Hem VTE AFE 5 Leading Causes of Pregnancy-related Deaths Note: approx 30% of pregnancy-related deaths were from a variety of “other” causes (each below 8% including sepsis, ICH, other hemorrhages) Main et al. Pregnancy-Related Mortality in California. Obstet Gynecol April 2015 CA-PAMR Findings 2002-2006 Timing of Diagnosis and Death

▪ Timing of CVD Diagnosis (n=64) 3% 8% 6% 34% 48% Preexisting (prior to pregnancy) Prenatal period At labor and delivery Postpartum period Postmortem ▪ Timing of Death ▪ 30% of all CVD deaths were >42 days from birth/fetal demise vs. 7.3% of non CVD pregnancy-related deaths ▪ Driven by Cardiomyopathy deaths, with 42.9% deaths >42 days

Hameed A, Lawton E, McCain CL, et al. Pregnancy-Related Cardiovascular Deaths in California: Beyond Peripartum Cardiomyopathy. American Journal of Obstetrics and Gynecology 2015; DOI: 10.1016/j.ajog.2015.05.008 CA-PAMR Findings 2002-2006 Presentation of Women with CVD

▪ Abnormal physical exam findings ▪ HTN >140/90 (64%) ▪ HR >120 (59%) ▪ , S3 or etc. (44%) ▪ O2 <90% (39%)

Hameed A, Lawton E, McCain CL, et al. Pregnancy-Related Cardiovascular Deaths in California: Beyond Peripartum Cardiomyopathy. American Journal of Obstetrics and Gynecology 2015; DOI: 10.1016/j.ajog.2015.05.008 CA-PAMR Findings Contributing Factors & Quality Improvement Opportunities (2002-2006) for CVD HEALTH CARE PROVIDER RELATED

• Contributing Factors: (69% of all cases) ▪ Delayed or inadequate response to clinical warning signs (61%) ▪ Ineffective or inappropriate treatment (39%) ▪ Misdiagnosis (37.5%) ▪ Failure to refer or consult (30%) ▪ Quality Improvement Opportunities ▪ Better recognition of of CVD in pregnancy ▪ , fatigue ▪ , blood pressure change, or low oxygen saturation ▪ Improved management of hypertension

Hameed A, Lawton E, McCain CL, et al. Pregnancy-Related Cardiovascular Deaths in California: Beyond Peripartum Cardiomyopathy. American Journal of Obstetrics and Gynecology 2015; DOI: 10.1016/j.ajog.2015.05.008 CA-PAMR Findings Contributing Factors & Quality Improvement Opportunities (2002-2006) for CVD PATIENT RELATED

▪ Contributing factors: (70% of all cases) ▪ Presence of underlying medical conditions (64%) ▪ Obesity (31%) ▪ Delays in seeking care (31%) ▪ Lack of recognition of CVD symptoms (22%) ▪ Quality improvement opportunities ▪ Education around when to seek care for worrisome symptoms ▪ Support for improving modifiable risk factors, such as attaining healthier weight and discontinuing drug use

Hameed A, Lawton E, McCain CL, et al. Pregnancy-Related Cardiovascular Deaths in California: Beyond Peripartum Cardiomyopathy. American Journal of Obstetrics and Gynecology 2015; DOI: 10.1016/j.ajog.2015.05.008 PREGNANCY SYMPTOMS VS. CARDIOVASCULAR Cardiovascular Disease Screening in Pregnancy – Role of the CMQCC Toolkit Pregnancy Mimics

SYMPTOMS SIGNS

• Reduction of exercise • Edema tolerance • JVD • - shortness of breath • Murmurs • • • • 96% have a “functional murmur” • Light headedness • Mid-systolic and low intensity • Dizziness/Syncope • Third heart sound is common Plasma Volume in Pregnancy

Pitkin RM Clin Obstet Gyn 1976;19:489 Physiologic changes

Signs and Symptoms of Pregnancy that mimic heart disease Affect diagnostic tests

• •Arrhythmia

DEATH History

Physical Symptoms Examination CMQCC CARDIOVASCULAR DISEASE TOOLKIT Cardiovascular Disease Screening in Pregnancy – Role of the CMQCC Toolkit California Pregnancy-Associated Mortality Review (CA-PAMR) Quality Improvement Review Cycle

1. Identification of cases

5. Evaluation and Toolkits 2. Information collection, Implementation of QI CVD review by multidisciplinary strategies and tools Venous committee Thromboembolism Hemorrhage Preeclampsia

4. Strategies to 3. Cause of Death, improve care and Contributing Factors and reduce morbidity and Quality Improvement (QI) mortality Opportunities identified IMPROVING HEALTH CARE RESPONSE TO CARDIOVASCULAR DISEASE IN PREGNANCY AND POSTPARTUM: A CALIFORNIA QUALITY IMPROVEMENT TOOLKIT

The CVD Toolkit was developed by CMQCC at Stanford University under contract with CDPH with funding from federal Title V MCH Block grant

© California Department of Public Health, 2017 Cardiovascular Disease in Pregnancy and Postpartum Task Force

Chair: Afshan Hameed MD—UC Irvine Co-Chair: Christine H. Morton PhD—CMQCC

WRITING GROUP REVIEWER GROUP ◼ Deirdre Anglin MD, MPH—USC ◼ Kathleen Belzer, CNM, NP—East Bay Perinatal ◼ Julie Arafeh MSN, RN—Stanford ◼ Chloe Bird, PhD—RAND ◼ Alisa Becket—WomenHeart ◼ Susan Bogar, MSN, CNM—UCLA ◼ Leona Dang-Kilduff, RN, MS, CDE—RPPC ◼ Elisabeth Chicoine, MS, RN, PNP—Sonoma County Department of ◼ Elyse Foster, MD—UC San Francisco Health Services ◼ Abha Khandelwal, MD—Stanford ◼ Karen Clemmer, MN, PHN—Sonoma County Department of Health Services ◼ Elizabeth Lawton, MHS—CDPH/MCAH ◼ Uri Elkayam, MD—USC ◼ Elliott Main, MD—CMQCC ◼ William (Bill) Gilbert, MD—Sutter Health System Sacramento ◼ Barbara Murphy, MSN, RN—CMQCC ◼ Tipu Khan, MD—California Academy of Family Physicians ◼ Monica Sood, MD—Kaiser Walnut Creek ◼ Nathana Lurvey, MD—ACOG IX ◼ Maryam Tarsa MD, MAS—UC San Diego ◼ Karen Ramstrom, DO, MSPH—CDPH/ Center for Family Health ◼ Lisa Townsend—Sister to Sister ◼ Mari-Paule Thiet, MD—UCSF ◼ Jan Trial, EdD, RN, CNM—Memorial Care ◼ Julie Vasher, DNP, MSN, RNC-OB, CNS-BC—CMQCC CVD Case Presentation

▪ 25 year old obese (BMI 38) African-American G2P2 presents 10 days after an uncomplicated vaginal delivery with fatigue and persistent since delivery.

▪ BP 110/80, HR 110, RR 28, afebrile, with O2 sat 94% on room air.

▪ She gets diagnosed with respiratory infection and is prescribed an antibiotic. Fatigue is attributed to lack of sleep. CVD Case Presentation (CONTINUED)

▪ One week later, she presents again with continued symptoms. Antibiotics are switched and beta-agonists are added for presumptive “new-onset .”

▪ Two days later, the patient experiences cardiac arrest at home and resuscitation attempts are unsuccessful.

▪ Autopsy findings were indicative of cardiomyopathy. CVD Assessment Algorithm for Pregnant and Postpartum Women SYMPTOMS VITAL SIGNS RISK FACTORS ABNORMAL PHYSICAL *NYHA class > II EXAMINATION • Resting HR ≥110 bpm • Age ≥40 years Suggestive of Heart Failure: • Systolic BP ≥140 mm Hg • African American Heart: Loud murmur or • Dyspnea • RR ≥24 • Pre-pregnancy obesity • Mild orthopnea Lung: Basilar crackles • • Oxygen sat ≤96% (BMI ≥35) • Asthma unresponsive • Pre-existing diabetes to therapy • Hypertension Suggestive of Arrhythmia: • (cocaine, • Palpitations Substance use alcohol, methamphetamines) • Dizziness/syncope Suggestive of Coronary Artery • History of cardiotoxic NO Disease: chemotherapy YES • • Dyspnea

Consultation with ≥ 1 Symptom + ≥ 1 Vital Signs Abnormal + ≥ 1 Risk Factor or Pregnancy Heart Team ANY COMBINATION ADDING TO ≥ 4

Obtain: EKG, Echocardiogram, BNP +/- CXR; arrhythmia monitor Consider: CBC, Comprehensive metabolic profile, Arterial blood gas, Drug screen, TSH, etc. Follow-up within one week

Results abnormal Results negative

Signs and symptoms resolved Modified from: ©California Department of Public Health, 2017; supported by Title V funds. Developed in Reassurance and routine follow-up partnership with California Maternal Quality Care Collaborative Cardiovascular Disease in Pregnancy and Postpartum Taskforce. CVD Algorithm Validation

▪ We applied the algorithm to 64 CVD deaths from 2002-2006 CA- PAMR.

▪ 56 out of 64 (88%) cases of maternal mortality would have been identified.

▪ Detection increased to 93% when comparison was restricted to 60 cases that were symptomatic.

Hameed, AB, Morton, CH and A Moore. Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum Developed under contract #11-10006 with the California Department of Public Health, Maternal, Child and Adolescent Health Division. Published by the California Department of Public Health, 2017. Maternal Mortality Rate, California and United States; 1999-2013

24.0 California Rate 22.0 21.0 19.3 United States Rate 16.9 18.0 19.9 15.5 16.6 15.1 16.9 14.6 15.0 14.0 13.1 12.7 10.9 11.6 13.3 12.0 9.9 10.0 9.9 12.1 11.8 11.7 9.2 11.1 9.0 9.8 9.7 7.4 8.9 7.3 6.0 7.7 OB 6.2 Hemorrhage Preeclampsia 3.0 HP 2020 Objective – 11.4 Deaths per 100,000 Live BirthsQI Toolkit, QI Toolkit, Collaboratives Collaboratives

Maternal Deaths per 100,000 Live Births Live 100,000per DeathsMaternal 0.0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for California (deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). United States data and HP2020 Objective use the same codes. U.S. maternal mortality data is published by the National Center for Health Statistics (NCHS) through 2007 only. U.S. maternal mortality rates from 2008 through-2013 were calculated using CDC Wonder Online Database, accessed at http://wonder.cdc.govon March 11, 2015. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, March, 2015. Maternal Mortality Rate (early and late deaths), California Residents; 1999-2013

25.0 (standard MMR calculation)Early Maternal Deaths <=42 days postpartum Early and Late Maternal Deaths up to one year postpartum

19.1 19.0 20.0 18.0 16.3 17.1 15.2 15.7 15.5 13.8 13.4 15.0 15.2 16.9 10.9 14.6 9.9 10.0 14.0 10.0 7.7 10.9 11.8 11.7 11.1 11.6 9.7 10.2 9.2 7.3 7.7 7.4 5.0 6.2 HP 2020 Objective – 11.4 Deaths per 100,000 Live Births

Maternal Deaths per 100,000 Live Births Live 100,000per DeathsMaternal 0.0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for California (Early maternal deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99) and code O96 is also included when calculating Early and Late Maternal Deaths up to one year postpartum. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, March, 2015. CA-PAMR Findings 2002-2006 Timing of Diagnosis and Death

▪ Timing of CVD Diagnosis (n=64)

3% 8% 6% 34% 48%

Preexisting (prior to pregnancy) Prenatal period At labor and delivery Postpartum period Postmortem ▪ Timing of Death ▪ 30% of all CVD deaths were >42 days from birth/fetal demise vs. 7.3% of non CVD pregnancy-related deaths ▪ Driven by Cardiomyopathy deaths, with 42.9% deaths >42 days

Hameed A, Lawton E, McCain CL, et al. Pregnancy-Related Cardiovascular Deaths in California: Beyond Peripartum Cardiomyopathy. American Journal of Obstetrics and Gynecology 2015; DOI: 10.1016/j.ajog.2015.05.008 Timing of Diagnosis of Peripartum Cardiomyopathy Elkayam et al. Circulation 2005;111:2050

75 Early Traditional

50 N=123

25 Number of patients Number

0 <27 28-32 33-36 37-40 1 2 3 4 5

Months PP Weeks DELIVERY BNP levels in Normal Pregnancy B-Type Natriuretic Peptide

Inhibits renin-angiotensin Relaxes vascular aldosterone system smooth muscle

Increases natriuresis and diuresis IMPLEMENTATION AT THE HOSPITAL LEVEL Cardiovascular Disease Screening in Pregnancy – Role of the CMQCC Toolkit UCI – QI Study Protocol

• Descriptive study of algorithm implementation • Goals: • Clinical burden of CVD screening • Outcomes for women designated “at risk” based on the algorithm • Numbers • Percentage of women with CVD UCI – QI Study Protocol

• Applying algorithm to all patients: • First prenatal visit • Postpartum visit • Anytime with symptoms and/or vital sign abnormalities with no known cardiovascular disease

SMFM 2019 SMFM 2020

846 women screened 8% screen + True + 1.5% CVD confirmed in 30% of screen +

SMFM 2020

THE FUTURE: BROADER DISSEMINATION OF CVD SCREENING Cardiovascular Disease Screening in Pregnancy – Role of the CMQCC Toolkit DEVELOPING CARDIOVASULAR SCREENING MEASURES FOR PREGNANT & POSTPARTUM WOMEN

KICK-OFF MEETING, SEATTLE, JAN. 10, 2020

Improving Diagnostic Excellence: Gordon and Betty Moore Foundation

University of California, Irvine, Medical Center Health Systems UCI Health 1,500 births a year, 3% black Hameed/Thiel de Bocanegra/Crosland University of California, San Diego, Medical Center Health Systems UCSD Jacobs & Hillcrest 3,000 births a year, 5-6% black Tarsa University of Tennessee, St Thomas Health Systems St Thomas Health Systems 12,000 deliveries in 2018, 25% black Graves APPROACH

Integrate CVD algorithm into Clinicians receive immediate Follow up monitored the EMR by placing and dot score SCREEN POSITIVE phrase with drop down menu through EMR Upload data to UCI • Fill in the blanks in the dot phrase • Follow up imaging RedCap • CVD screening added to problem list • Follow up laboratory test • Elicit feedback • Follow up consultations • Review measures with the work group Measures

Pregnant + postpartum women screened for CVD using algorithm ______1. CVD Risk Assessment = All pregnant + postpartum women seen at facility

Women who received follow up for CVD risk 2. CVD Risk Follow-up = ______Women who screened positive for CVD risk Feasibility Evaluation Aim of current study:

1. Demonstrate the feasibility to calculate meaningful and actionable measures using data from the hospital wide network - Potential to scale from pilot to system wide implementation

2. Explore whether the system wide administration of the measure will produce a similar yield to that of the pilot studies - Clinical and epidemiological value; important for business case Summary

• Cardiovascular deaths are preventable • 25% to 68% • A large proportion of CVD deaths are beyond the 42 day postpartum • Most of the women who died of CVD have underlying risk factors • There is a need for universal screening for CVD to improve maternal outcomes [email protected] For More Information and to Download the Toolkit

• Visit • www.cmqcc.org • https://www.cdph.ca.gov • Contact: [email protected]