Toolkit for Reducing Cesarean Deliveries Improving Maternal & Neonatal Outcomes Fall 2013 This toolkit represents a collaborative effort among the Washington State Health Care Authority, the Optimizing Birth Outcomes Workgroup, and the Center for Evidence-based Policy at Oregon Health & Science University. The toolkit was developed and reviewed by these stakeholders and other content area experts. This document was prepared by the Center under contract No. K414 for the Washington State Health Care Authority. The document is intended as a reference and is provided with the understanding that the Center is not engaged in rendering any clinical, legal, business, or other professional advice. Suggested citation: King, V., Slaughter-Mason, S., King, A., Frew, P., Thompson, J., Evans, R. & Donsbach, L. (2013). Improving Maternal & Neonatal Outcomes: Toolkit for Reducing Cesarean Deliveries. Portland, OR: Center for Evidence-based Policy, Oregon Health & Science University. Washington State Health Care Authority Center for Evidence-based Policy 626 8th Avenue SE Oregon Health & Science University Olympia, WA 98501 3455 SW US Veterans Hospital Road Portland, OR 97239 www.hca.wa.gov www.ohsu.edu/policycenter Authors: Valerie King, MD, MPH Samantha Slaughter-Mason, MPH Anne King, MBA Patty Frew, MD Jeffery Thompson, MD, MPH Randy Evans, MA Landon Donsbach The authors are particularly grateful to the Washington State Optimizing Birth Outcomes Workgroup for their thoughtful contributions to this toolkit, and give special thanks to: Laurie Cawthon, MD Ellen Kauffman, MD Polly Taylor, CNM, MPH, ARNP Suzan Walker, RN, BSN, MPH Table of Contents Foreword Message from Dr. Daniel Lessler .............................................................................. 6 Executive Summary ..................................................................................................... 8 1. Introduction 9 Epidemiology of Cesarean Birth ............................................................................ 12 References .................................................................................................................. 17 2. Evidence-based Strategies 19 Evidence-based Medicine ......................................................................................... 20 Evidence-based Strategies to Safely Reduce Cesarean Birth Rates ............... 22 Before Labor ................................................................................................. 23 During Labor ................................................................................................ 33 Systems Level Interventions ...................................................................... 39 Evidence Summary .................................................................................................... 41 Comparing Recommendations & Guidelines to the Evidence ........................ 44 References .................................................................................................................. 47 3. Innovative Models 51 Group Health Cooperative ..................................................................................... 53 Ohio Perinatal Quality Collaborative ................................................................... 54 Seton Health ............................................................................................................... 55 Swedish Health Services .......................................................................................... 56 Yakima Valley Memorial Hospital ........................................................................... 57 4. Managing Change 58 Establishing an Environment Conducive to Change .......................................... 60 Case Study .................................................................................................... 61 Leveraging Evidence & Tools for Rapid Quality Improvement ........................ 62 Implementing the Interventions: Plan-Do-Study-Act Cycle ............................ 63 References .................................................................................................................. 66 5. Resources 67 Before Labor ............................................................................................................... 69 During Labor .............................................................................................................. 73 Systems Level ............................................................................................................. 75 Organizations & Collaborations ............................................................................ 76 Tools &Templates ...................................................................................................... 78 6. Appendices 81 A: Data & Performance Measure Definitions ...................................................... 83 B: Washington State Perinatal Quality Improvement Survey ........................... 89 Message from Dr. Daniel Lessler early one third of all NU.S. women are giving A clear, user-friendly guide to current evidence birth by Cesarean, and an of practices that can improve the quality of care ever increasing number are and outcomes is required. Evaluating data for undergoing induction of labor benchmarking outcomes and examples of best and Cesarean deliveries. practices will allow us to continuously improve. Our challenge, as health This toolkit brings together a set of resources practitioners, has been to sponsored by the Washington State Health Care understand the variations Authority and the Center for Evidence-based Policy at in clinical practices that are Oregon Health & Science University. This toolkit will affecting the decision to help to make maternal and infant care more evidence- perform a Cesarean delivery. based, transparent, consistent, and measured to reduce WeDr. Danielsimultaneously Lessler seek to improve the quality of variation in care across Washington State. Additionally, care and reduce unnecessary care, including Cesarean we hope this toolkit will help to forge stronger deliveries. According to a 2009 report on Maternal and partnerships between obstetricians, family medicine Neonatal Outcomes of Elective Induction of Labor physicians, midwives, and hospitals in order to: from the Agency for Healthcare Research and Quality Bring the best, most current evidence to (AHRQ), labor inductions increased from 9.5% in 1990 providers and care systems for the women and to 22.1% in 2004. This increase occurred without a infants of Washington State clear understanding of the medical need or rationale and without any associated improvement in outcomes. Challenge providers, hospitals, and systems to Medicaid covers over 40% of all births nationally. measure, compare, and improve to the greatest State and federal insurance programs work closely extent possible with community clinicians and facilities to provide Embrace measurement to make our healthcare maternity services. It is clear that ensuring access, system sustainable improving quality, and promoting cost efficiency are Share learning and experience with others so best achieved when we use the best available evidence we are all able to improve to guide care. Using data to highlight variations in care can help identify opportunities for improvement. We hope that this document assists you in your work There are multiple reports documenting associations to improve the health of mothers and infants in your between labor and delivery practices (i.e. elective community. delivery without a medical indication) and maternal and neonatal morbidity. We must both monitor and find “best practices,” and actively engage in discussions of why there are unnecessary variations in care. Daniel Lessler, MD, MHA Chief Medical Officer Washington State Health Care Authority 6 Figure 1.1. Washington State Timeline of Change Activities, 2008-2012 Washington Department of Health publishes 2008 Cesarean Sections in Washington State: Trends and Sep Geographic Variations Aug Washington State Perinatal Collaborative formed (initially Cesarean Section Workgroup) “Reduction of Elective Deliveries at Swedish Hospital” presented at Pacific Coast Society Oct First Washington State Perinatal Quality Improvement Survey Feb Apr 2009 Childbirth Connection sponsored national policy symposium, “Transforming Maternity Care: A High Value Proposition” in Washington, DC Safety Net Assessment (HB 2956) passed by Apr Washington Legislature 2010 Sep Early elective deliveries selected as one of five Medicaid quality measures as part of Safety Net Elimination of Non-Medically Indicated (Elective) Assessment Deliveries Before 39 Weeks Gestational Age published Oct Data Collection for 37-<39 Weeks Project for 37-<39 Weeks Data Collection Jan Laws of 2011 create Robert Bree Collaborative March of Dimes launches “Healthy Babies are Worth the Wait” awareness campaign Apr 2011 Robert Bree Collaborative convened Sep Aug Robert Bree Collaborative selects obstetric care as top priority topic Hospital-level feedback reports distributed to 2012 hospitals Jun Hospital-level feedback reports posted on Oct-Dec Washington Health Care Authority’s public website Aug Second Washington State Robert Bree Collaborative Obstetrics Report Perinatal Quality Improvement Survey published & implementation plan adopted 7 Executive Summary his toolkit contains data, evidence-based such as audit and feedback, quality improvement Tstrategies and change management techniques to methodologies,