Put evidence-based care in the driver’s seat
By Shelley Burns
(This is part three of a three-part blog)
I’ve previously blogged about the overutilization of C-sections and inductions and the misaligned incentives for everyone involved – physicians, parents, hospitals, businesses. Is it possible to overcome the cultural and market forces that drive overutilization in childbirth?
It’s a tall order, but not impossible. Since 1999, Intermountain Healthcare, an integrated system based in Salt Lake City – 19 birthing facilities in Utah, one in Idaho – has been changing the culture around childbirth, one step at a time. Janie Wilson of Intermountain has shared its journey with HMC partners, and at several professional society meetings over the past 10 years.
The staffers started with their mission – clinicians working together with other clinicians, health care administrators, and patients to develop high-quality, cost-efficient medical care for women and newborns, by incorporating evidence-based medicine into a program of continuing quality improvement.
They supported that mission by analyzing utilization and outcome data. They discovered that inductions at gestational ages less than 39 weeks resulted in longer labors for mothers, more C-sections, and higher costs. Now, everyone knew that the American Congress of Obstetricians and Gynecologists (ACOG), recommended against inductions at less than 39 weeks for healthy mothers and babies. But, due to convenience, the casual culture surrounding inductions, legal issues, scheduling, and other market forces, the induction rates at Intermountain had started to rise, mirroring trends in the rest of the country.
When Intermountain looked at the data and found it to be in conflict with its mission, it decided it could improve care – reduce non-necessary C-sections, reduce hours in labor – if it reduced elective inductions prior to 39 weeks. This is a key step. It decided it could do better.
The staff gathered and shared data on elective inductions and the consequences with admitting physicians and local OB/GYNs. They used the data and physician input to develop their evidence-based guidelines – among them, no elective inductions for less than 39 weeks. Several sites went a step further and agreed to no elective inductions for first time mothers. Imagine – they worked to convince all 20 sites and their concomitant clinics and physicians to agree on the guidelines and entreated all stakeholders to abide by them.
The results?
* Some sites have had very impressive successes; the most improvement in reduction of primary C-sections occurred in facilities that chose not to electively induce first-time mothers.
* After ten years, the elective inductions for less than 39 weeks gestational age has dropped from ~27 percent to under two percent.
* Utah has the lowest C-section rate in the nation, 22 percent. (Intermountain delivers 55 percent to 57 percent of the babies in Utah.)
* Costs are low. The HMC comparative databases show Intermountain facilities among the lowest-cost birthing providers.
Intermountain shared and continues to share the outcome and utilization data – to continually reinforce for the medical community and parents that having fewer elective inductions is indeed the best care they can receive.
However, the misaligned incentives in health care caused this success to come at a cost to the hospitals. The elective induction guidelines drove down revenues in labor and delivery services. Even though it drove reimbursements down, Intermountain continued to be a strong proponent of the guidelines, demonstrating commitment to its mission of evidence-based medicine and continuous improvement. This has had the unintended benefit of positioning the system well for health care reform – for best care and most appropriate utilization.
Intermountain discovered that increased interventions like inductions adversely impacted care. Instead of allowing that fact to be obscured by misaligned incentives that induce (pun intended) overutilization, Intermountain decided that evidence-based care should not take a back seat. They decided.
As a nation, we can improve healthcare and decrease the waste of overutilization by developing high-quality, cost-efficient medical care for everyone by incorporating outcome data into a program of continuing quality improvement. We just have to decide to do so.
Shelley Burns is head of knowledge management at HMC.
