10/25/2013 Disclosures • None Laborists in Your Practice? Sarah B Wilson MD M.Ed. Assistant Professor Laborist Department of Obstetrics, Gynecology and Reproductive Sciences University of California, San Francisco Objectives Audience Poll • Describe what hospitalists and laborists Describe your practice: are A. OB only 78% • Explain how laborist models work in B. GYN only different practice settings C. Generalist OB/GYN • Describe proposed positive and negative D. Subspecialist (MFM, attributes of the laborist model Gyn Onc, REI etc) 11% 8% • Summarize the evidence about how 3% E. Other 0% laborists have affected practice .. ly /... n B t O lis Other OB o ia list c GYN only a ner ubspe e S G 1 10/25/2013 Audience Poll Internal Med Hospitalist Concept Define your practice setting: • Kaiser reorganized care models 1994 – “Hospital-based Specialists” A. Teaching hospital/clinics • Wachter and Goldman 1996 B. Private Practice 38% – “ Emerging Role of ‘Hospitalist’ Concept in C. Kaiser the American Health Care System” NEJM D. Community Hospital: inpatient 19% 16% 16% – Specialized care for inpatients med 11% E. Other r r ... ti sp... he c o a Kaise H Ot Pr te va ri munity P Teaching hospi... m Co Hospitalist Concept Impact of Hospitalists on Care • Proposed benefits • Significant reductions in resource use – Hospital medicine specialization, higher value – 13.4% reduction in hospital costs care – Efficiency of care delivery – 16.6% reduction in average length of stay – House-staff training • Patient satisfaction preserved • Possible disadvantages • Inconsistent, but some positive effects on – Decreased continuity of care care – Skilled hospitalist would use specialists less – Decreased readmission rates • Questioned role of the internal med generalist Goldman JAMA 2002 2 10/25/2013 Introduction of the “Laborist” What is a laborist? • Extrapolation of the hospitalist concept to • Many different models of care L&D • Strictest definition • Weinstein AJOG 2003 – Physician dedicated to inpatient care, primarily on L&D – Possible solution to problems in our field • Marked professional dissatisfaction/burnout – Premise of continuous coverage and oversight • Stopping obstetrics at an earlier age • Shortage of obstetricians in some communities • Also GYN hospitalists increasing Models of Care Program Finances: Hospital Salaried Model • Teaching hosp vs. community hosp • Costs – Need 4-4.5 full time • Full-time hospital employee vs. rotating – Salaries, benefits and malpractice ≈1.5 million schedule of community physicians • Ways to pay for full-time laborists? • Care of all patients in L&D vs. care for – ABOG statement: Bill separate components unassigned/uninsured patients vs. only – Private practice bills global and pays agreed fee care for emergencies for using laborists – Laborist is present 24/7 so can bill more items • Triage, version, surgical assist – Reduced malpractice premiums Gussman et al, ACOG.org 3 10/25/2013 UCSF Laborists What does your practice look like? • Dedicated to obstetrical care Do you have laborists in your hospital or • Monthly schedule practice? – 1 week 5 L&D day shifts 69% – 1 week 4 L&D night shifts – 2 weeks outpatient clinic sessions A. Yes – 1 24hour weekend shift B. No • Part of MFM Division 31% • Cost coverage – Global billed for faculty group, no need to divvy up – MFMs relieved for consults, outreach and PDC s e Y No Are you a laborist/hospitalist? Extent of Implementation of Laborists 1 A. Yes • 2010 ACOG membership survey – 15% of respondents (3.6% of the entire B. No 93% sample) identified as a laborist or OB/GYN hospitalist • National Perinatal Information Center/Quality Analytic Services 2 25/68 hospitals employ laborists 7% – s e o Y N 1: Funk et al, AJOG 2010, 2: Srinivas et al Journal of Maternal- Fetal and Neomatal Medicine 2012 4 10/25/2013 Proposed Advantages/ Disadvantages Timely Delivery of Care Positives: • Dedicated L&D coverage timely care • Dedicated 24 hour coverage • Improved quality of care • Timely response to obstetric emergencies • Increased provider satisfaction, work life balance • Improved patient safety/teamwork improves maternal and neonatal • Reduction in liability claims outcomes Negatives: • Impact of laborists on these processes • Lack of continuity of care and outcomes: no research yet • Reimbursement issues and reduced pay • Disagreement in management plans • Decreased patient satisfaction • Increased errors with more handoffs Srinivas et al AJOG 2012 Effect on Cesarean Delivery Rates Patient Safety Outcomes • Tertiary hospital: studied transition to laborists • No formal outcome studies yet • C section rates over three time periods • Full-time dedicated laborist – No laborists (first 16 months) : 39.2% c section rate – Speculated as safest option – Continuous coverage community staff (14 months) : – Attending OB knows all patients 38.7% – Primary point person for staff – Full-time laborists (24 months) : 33.2% • Significant reduction in c sections with full- time laborist vs no laborist – Adjusted OR 0.72 p<0.0001 Olsen et al AJOG 2012 Iriye et al AJOG 203 5 10/25/2013 Reduced Liability Claims Patient Satisfaction • Improved coverage decreased • Less continuity of care = less patient malpractice claims? satisfaction? • Study: Analyzed paid claims of large liability • Study: University-owned urban teaching insurance company from 2000-2005 hospital patient responses n=4166 – Compared Press-Gainey survey results – 70% of claims involved substandard care pre/post laborist implementation – Concluded that over half of hospital litigation – 90% highly satisfied costs could be avoided with 24 hr in-house – Similarly favorable results in both time coverage periods Clark et al Obstet Gynecol 2008 Srinivas et al, Patient Preference and Adherence 2013 Increased Handoffs with Shift Work Successful implementation of laborists • Lessons learned from Hospitalists • Established means of communication • Six Pillars of Handoffs between primary physician and laborist – Communicate, but do not irritate • Inpatient protocols – Consult the primary care physician – Consensus about inpatient treatment – Timeliness is next to godliness – Ex: induction or postpartum order sets – Partner with the patient – Make it clear that you are the pt’s advocate (not just part of the system) – Pass the baton as graciously as received Goldman et al Disease a Month 2002 ACOG Committee Opinion #549, 2010 6 Lessons from the IM Hospitalist movement • Focus on gathering data to demonstrate value • Intentional link between hospitalist field and patient safety and quality of care What should be OB/GYN’s next steps? Wachter J Hosp Med 2006 Thank you. • Questions? Audience Poll How do you feel about having laborist as part of your practice? A. Overall Positive B. Neutral C. Overall Negative 10/25/2013 51% 37% Overall Positi... 12% Neutral Overall Negati... 7.