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Childbirth Quality Data Seriously Lacking

 |  By cclark@healthleadersmedia.com  
   December 11, 2014

California is in the forefront of publicly reporting data points for childbirth, but other states lag far behind, and there is only one publicly reported national maternity measure posted on the federal Hospital Compare website.

Her obstetrician was making her nervous, seeming to pressure her into a C-section she didn't need or want, my friend suspected. She'd given birth naturally to her first child, and she'd heard absolutely no reason why she couldn't repeat that with her second.

"At my most recent appointment, he said the baby was measuring big, meaning that by 40 weeks the baby could be a whopping 7.5 pounds. And then he expressed concern about 'how that would affect me down there.' "

Her first baby, at 8 pounds, came out just fine, and she knows a normal baby might weigh up to 10 pounds. So she pushed back.

She'd asked the hospital's labor and delivery department for that doctor's C-section rate for women who'd previously delivered naturally, but was declined. She was told "don't worry. He's a good doctor," which infuriated her even more.

So, she asked me, how could she get information she needs to avoid an obstetrician who might just like to cut, as she knows some doctors do.

She can't, I explained.

Hospitals know these numbers, but keep them hidden. Arguably, attributing deliveries to specific physicians can be difficult because many doctors may be involved in decisions during a labor. Risk adjustment, too, is imperfect.

But that doesn't help healthcare consumers or payers.

Welcome to a new era of consumer demand for hospital quality data dealing with childbirth, the most common discharge diagnosis in the country.

The Next Best Thing
Luckily for my friend, she lives in California, which with 550,000 births a year, is the only state where hospital and non-profit health collaborations are offering the next best thing.

On the California HealthCare Foundation (CHCF) website, one can search rates for roughly 260 birthing hospitals to find performance on four maternity quality measures culled from federal, state, or volunteering hospitals' reports, especially the grant-supported California Maternal Quality Care Collaborative, which is leading the way in this field.

Enormous Variation
Lo and behold: The rates, show "huge, enormous variation, more so than for any other measure in healthcare, whether it's heart or lung care, or surgical safety, or process or outcome measures," says Bruce Spurlock, MD, executive director of CHART, the California Hospital Assessment and Reporting Taskforce, which collects quality data from hospitals.

"The variation with other measures is nowhere near what it is for maternity," and though there must be obvious practice reasons to explain it, there's not much research on what those are.

The site gives hospitals ratings of superior, above average, average, below average or poor and enables parents, payers and others to see rates of:

  • C-sections in first time mothers with the lowest-risk of complications giving birth to one baby in the head-down position after 37 weeks. (Lower is better.)
  • Episiotomies, a procedure carrying the potential to cause life-long problems and complications for the mother. (Lower is better.)
  • Mothers allowed to exclusively breastfeed until discharge. (Higher is better.)
  • Women who previously had a C-section who were delivered vaginally—(VBAC). (Higher is better.)

For example, one can see that among low risk women delivering at Emanuel Medical Center in Turlock, only 13% underwent a C-section (superior), but at East Los Angeles Doctor's Hospital, the rate was 59.9%, and at Hi-Desert Medical Center in Joshua Tree, the rate was 54.4%.


>>>A Tale of Two Births

The hospital where my friend was headed is just a notch above being below average for C-sections. Indeed, in the region where she lives, hospital quality for C-sections varies from "superior," at Scripps Mercy Hospital, to "below average" at Scripps Memorial.

Spurlock, who has researched this topic for years, says he doesn't know of any other state with as many publicly reported data points for childbirth. So much information makes it difficult for consumers and hospitals to evaluate themselves.

So to make it easier to distinguish practice variation, Spurlock, CHCF, and Truven Health Analytics produced a map and infographic for the foundation that shows some astonishing trends.

It shows the 33 hospitals with superior and above average rates in all four categories, and the 12 with below average and poor rates.

A few trends jump out, he says, indicating tremendous potential for hospital improvement:

  • Academic medical centers consistently have higher scores on measures dealing with C-sections and maternity care, probably because their residents have no time pressure to deliver a baby. "One of the key things you need to reduce C-sections is to take your time," he says.
  • Hospitals that scored poorly on all measures are clustered in Los Angeles.
  • Hospitals serving the poor and culturally diverse populations, such as San Francisco General, can do just as well as hospitals serving more affluent patients. Even rural hospitals were superior in all four measures.

To show in stark terms what this means for actual mothers, Spurlock's team calculated that if poor or below-average hospitals performed at the level of the superior or above-average ones, there would be 14,800 fewer C-sections, 38,900 fewer episiotomies, 119,000 more babies would be breast fed and there would be 12,300 more VBACs in California per year.

Spurlock says that other states are starting to work on similar public reports. "I was contacted recently by the folks in Massachusetts, who want to do something like this," he says.

More Maternity Measures Need Birthing
It's a most appropriate time of year to write about birth for an obvious religious reason. But it's also a good time to point out that we really need more measures to evaluate the quality of hospital care given to the four million women who will go into labor in 2015, and their newborns.

To date, there is only one publicly reported national maternity measure posted on Hospital Compare, and that one scores early elective delivery rates, or the percentage of scheduled medically unnecessary C-sections or inductions performed more than one week before due date.

The EED rate is clearly an important statistic, and was among measures targeted for reduction by the federal Partnership for Patients, but it's not nearly enough to gauge the quality of a hospital's care for mothers-to-be and their neonates.

Why So Little Maternal Reporting?
The Patient Protection and Affordable Care Act, and other incentive and penalty programs, have focused hospital efforts on reducing readmissions and hospital acquired conditions, and improving patient experience, among other measures.

They're important, but they're also where avoidable Medicare costs lie. "The quality improvement effort for obstetrics and maternity care is far behind compared to the rest of the hospital world," Spurlock says. "There's been some incredibly good work, but it's farther behind."

Spurlock says that in California, hospital rates of early elective, medically unnecessary C-sections and inductions will be added to the website's data. And it too will show variation across the state.

Hospitals are working on that in part because Hospital Compare is now reporting it, and organizations such as the Leapfrog Group are using it to score some hospitals' safety.

Another maternity measure, perhaps 12 to 18 months away, is one assessing neonatal complications. The CMQCC has other measures dealing with rates of preeclampsia, obstetrical hemorrhage, maternal mortality and other unexpected complications.

Also in the works for the foundation website is a composite childbirth score, which will assemble a lot of measures now available to individual hospitals but not to the public.

For my friend, the experience trying to get information has been "a big frustration," she says, especially after she asked a labor and delivery head nurse for information and "she blew me off.

"It's outrageous, and I deserve to know. There needs to be accountability for doctors who have high rates."

And for hospitals too. I couldn't agree more.

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