Speedy Delivery: Not Such a Good Idea for Babies

Wednesday, February 15, 2012

Paul Levy, GoLocalWorcester MINDSETTER™

Paul Levy, GoLocal MINDSETTER™

The Leapfrog Group recently published its survey about the rate of early elective deliveries in US hospitals. Here's the lede from its press release:

The employer-driven hospital quality watchdog, The Leapfrog Group, announced today that 2011 results from the annual Leapfrog Hospital Survey indicate that hospitals are making progress in eliminating early elective newborn deliveries. The Leapfrog Group announced that 39% of reporting hospitals kept their early elective delivery rate to 5% or less, compared to 30% of reporting hospitals last year.

Is this good news or bad? It seems to be good. After all, early elective deliveries can be a cause of medical complications, interrupting the full development of babies. As Leapfrog notes: "There are medical reasons to schedule a delivery before the 39th completed week, such as if a woman has high blood pressure at the end of pregnancy or broken membranes before labor begins, but these are rare.”

What's the bad news?

According to Leapfrog, there is still wide variation among hospitals.

Let's look at Central Massachusetts for examples. St. Vincent Hospital in Worcester had a terrible rating, 39.8%. Ditto for Heywood Hospital in Gardner, at 21%. In comparison, the rate at Milford Regional Medical Center was 3.3%, well within the guidelines.

This is stunning. As Leapfrog CEO Leah Binder said, "The ultimate solution is for hospitals to simply forbid early deliveries that are not medically indicated and then enforce the policy."

Some people wrongly believe that progress on this issue has to be tied to payment reform, changing the manner in which hospitals and doctors are paid for giving medical care. For example:

Suzanne Delbanco, executive director of Catalyst for Payment Reform, noted that “We need to stop providing the perverse financial incentives to intervene in birth when it’s not medically necessary. CPR is working alongside Leapfrog to support employers and other health care purchasers, as well as health plans, to encourage adherence to clinical guidelines through payment reform.”

As demonstrated by Intermountain Health over a decade ago, you don't need payment reform to change this clinical practice. You need to introduce and enforce a clinical protocol based on sound medical evidence:

When an expectant mother arrived at the hospital for an elective induction, nurses completed an electronic check sheet that summarized appropriateness criteria. If the patient met the criteria, the induction proceeded; if not, the nurses informed the attending obstetrician that they could not proceed without approval from the chair of the obstetrics department or from a perinatalogist—a specialist in high-risk pregnancies. Elective inductions that did not meet strong indications for clinical appropriateness fell from 28 percent to less than 2 percent of all inductions.

Likewise, many other hospitals in Massachusetts and around the country meet the standard or are working towards it, even without changes in payment regimes. WBUR's Martha Bebinger reported on this several weeks ago. She noted:

There are lots of reasons why an expectant mother and her doctor might choose to deliver the baby before its due date: the health of mom or baby, the doctor's schedule, the demands of work, or even to hit or avoid a specific birthday. But if that perfect day falls before the 39th week of pregnancy, and there’s no medical reason for an early delivery, many hospitals in Massachusetts are saying no, you have to wait.

And she gave this example:

At Massachusetts General Hospital, Dr. Jeff Ecker, a high-risk obstetrician, is the gatekeeper. Each week Ecker reviews the schedule for early inductions and C-sections to see if they are all medically necessary.

What's the other bad news?

Currently, only hospitals that participate in Leapfrog’s annual hospital survey make this information public.

How many is this? We learn this from Medscape:

In 2011, roughly 1200 hospitals — about 1 in 4 — completed the survey.

Again looking at Central Massachusetts, among those declining to respond were U Mass Memorial Medical Center, Marlborough Hospital, Clinton Hospital, and Health Alliance in Leominster. Frankly, this is almost more troubling than hospitals that report bad results. Transparency of clinical outcomes is one of the most important steps in process improvement. After all, if you are not open and honest about how you are doing, it is very hard to improve. Why aren't patient advocates, employers, and insurance companies demanding these recalcitrant hospitals to open up their books and show the results? Short of that, why aren't insurance companies directing patients to those hospitals that are willing to be transparent about such matters?

Paul Levy, former CEO of Beth Israel Deaconess Medical Center, is an advocate for patient-driven care who writes a blog about health care issues entitled Not Running a Hospital.