Of the 757 hospitals that volunteer to report data on obstetric care quality, too many have obstetricians who still schedule dangerous elective Cesareans and inductions too early rather than encouraging spontaneous deliveries, according to the Leapfrog Group's second survey of the practice, the only one of its kind.
The rate, however, has improved a little in the last year. Of those voluntarily reporting hospitals, 39% reported a rate of 5% or fewer elective newborn deliveries, compared with 30% from the previous year, said Leapfrog CEO Leah Binder. Of all the hospitals reporting, she said, 65% improved their performance over 2010, "the first indication that hospitals are making an effort to eliminate this risky practice."
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Early elective deliveries are still unacceptably high, the report suggests, with rates widely variable throughout the country. Binder estimates that $1 billion could be saved annually in the U.S. in healthcare dollars "if the rate of early (unnecessary) elective deliveries could be reduced to 1.7%, which many of our hospitals have shown they can achieve."
About 32 hospitals are at the opposite end of the spectrum, however, with rates of early elective interventions greater than 40%, according to Leapfrog's latest survey. About 140 hospitals had rates of 20% or higher. Leapfrog's survey shows rates by state as well, with Alabama hospitals showing an average of 22.5%.
The 10-year old watchdog group, which collects hospital cost and quality data for employers, health plans, and other purchasers of healthcare services, is an advocate of transparency for hospital quality process and outcome measures.
Leapfrog embarked on the labor and delivery project because despite increasing evidence that babies need at least 39 weeks of gestation for proper development, unnecessary Cesareans were the standard of care rather than an exception at some hospitals.
Even a few weeks prematurity can result in respiratory complications requiring expensive ventilation, nitric oxide therapy, placement on a heart-lung machine and problems with brain development. Experts suggest there is a 4% increased risk of mortality in babies born between 37 and 39 weeks.
In addition to increasing the risk of fetal development problems for their newborns, women who electively give birth prematurely to babies between 37 and 39 weeks in the absence of medical necessity dramatically raise the cost of care, even if there are no complications. An uncomplicated vaginal birth was estimated to cost $9,415 in 2008, according to a Thomson Reuters analysis, while the cost of an uncomplicated Cesarean was $13,329.
If there are complications requiring an average of 11 days in a neonatal intensive care unit, that could cost an extra $33,000, said Billie Lou Short, MD, Chief, Neonatology, Children’s National Medical Center in Washington, D.C. Her hospital last year took care of about 143 newborns requiring intensive care because their mothers underwent elective early delivery, and about 20% were preventable. "It's close to $1 million (in extra costs) for these kids who are transferred here," she said.
Binder said it's been tough to get hospitals and obstetrical practices to understand the urgency and voluntarily report, although Leapfrog and collaborative organizations like Childbirth Connection and Catalyst for Payment Reform are making progress. The groups are also trying to reach pregnant women, explaining that estimates of their conception dates may be off by as much as two weeks.
The groups are also emphasizing the burden of a C-section, which includes four to six weeks of home recuperation after a two to four day stay in the hospital, and the potential for infections and bleeding.
"The unfortunate fact is that the cost savings and the financial advantage do not accrue necessarily to the hospital, quite frankly," Binder said. "The hospital could probably earn more revenue by doing more invasive procedures and having babies in NICUs, which tend to be high revenue areas.
"To the credit of the hospital community, I've never met a hospital leader who says they want to see that happen...Nonetheless, it's worth mentioning that it is a revenue loss for hospitals when they do the right thing for these babies and their mothers."
Binder was asked how hospitals and doctors justify their push to get women to undergo early elective delivery when they don't have to. She replied that in talking with hospitals and doctors, it appears "Obstetricians would like to have more control over when the deliveries are scheduled for a variety of reasons, whether it's their own scheduling issues—they're going to be in the office one week rather than the next—and by waiting after 40 weeks, there's more chance the woman will go into labor at any time.
She added that there's "a perception that's not a problem. But as we're pointing out...it is not safe and that is something they need to be much more aware of."
Additionally, pregnant women want more control over their time of delivery, and are unaware that they're putting their baby at risk.
Short added that in the last few years, "there's been an explosion of data" about early respiratory problems, neurodevelopmental outcomes, and new insights on the tremendous rate of brain growth in a fetus in weeks 37-39.
Suzanne Delbanco, Executive Director of Catalyst for Payment Reform, is pushing for health plans and other payers to change the way they reimburse for obstetric care so hospitals and doctors don't have an economic incentive to not do the right thing.
"If we were to pay hospitals a single blended rate for delivery, that resulted in added payment for vaginal births and a reduction in payment for Cesarean delivery, we would likely see the rate of elective Cesarean labor and delivery decrease," she said.
Some hospitals are enforcing programs to deter their doctors from scheduling Cesarean sections and inductions for non-medical reasons, Binder said. She indicated that Hospital Corporation of America has adopted such a policy. And from Leapfrog's data, it appears that of 27 Kaiser hospitals in California all reported data and all but three showed rates lower than 5%.
"We're not in the business of putting out fancy reports to sit on shelves and look pretty," Binder summed up. "We are in the business of making change and improving the quality, safety and efficiency of healthcare in this country. So we need this to change."