Statewide Program Significantly Reduces Inappropriate Scheduling of Births before 39 Weeks
A statewide Ohio program significantly reduced the monthly rate of inappropriately scheduled births before 39 weeks gestation, helping to avoid expensive neonatal intensive care unit admissions and decrease the risk of infant deaths, according to two studies by the Ohio Perinatal Quality Collaborative recently published in the American Journal of Obstetrics & Gynecology.
The studies found the Ohio Perinatal Quality Collaborative (OPQC) Scheduled Birth Initiative reduced unnecessary planned late pre-term and near-term deliveries in Ohio—those occurring one to three weeks before due date—from about 15 percent to between 2 and 3 percent. Prematurity is the leading cause of death in babies before they reach one year of age. Among preterm infants, the risk of death increases the earlier they are born. A normal pregnancy is about 40 weeks.
"The decision to deliver a baby before its due date when there is no good medical reason has significant negative clinical and cost implications," said Edward F. Donovan, M.D., professor of clinical pediatrics in the Child Policy Research Center at Cincinnati Children's Hospital Medical Center and a co-founder of the collaborative. "The OPQC Scheduled Birth Initiative could well serve as a model for other states desiring to improve the health of babies and reduce health care costs."
The first OPQC study, published in the March AJOG, suggests that during the initial 12 months following the use of an OPQC intervention program, September 2008 to August 2009, more than 1,000 births were delayed, moving from 36 to 38 weeks gestation to 39 weeks or more weeks. From September 2008 through March 2010, approximately 8,256 births in Ohio that would have been delivered at 36 to 38 weeks instead delivered after 38 weeks, reflective of the results of OPQC. OPQC estimates that approximately 250 expensive neonatal intensive care unit (NICU) admissions were avoided during this time period.
In this study, the rate of births scheduled at 36, 37 and 38 weeks that lacked a medical or obstetrical reason were significantly reduced in the 20 OPQC-member hospitals which participate in the obstetrical improvement project. The monthly rate of such births significantly declined from a pre-intervention program rate of 11.6 percent in September 2008 (49 of 422 births) to 1.7 percent (six of 347 births) in August 2009, an 85 percent reduction.
"Given the potential to protect infant health and reduce health care costs, initiatives such as OPQC's Scheduled Birth Initiative offer a significant improvement in obstetrical care in Ohio that could be used nationwide," said Jay D. Iams, M.D., vice chair, department of obstetrics and gynecology, in the Division of Maternal Fetal Medicine at The Ohio State University Medical Center. "OPQC wants to share its approach, which is not complex, with all Ohio maternity hospitals, but at present we lack funding to extend the project. The infrastructure includes staff and systems to manage and analyze data, methods of improvement science to provide ongoing focus and support, and communication among teams and with state agency partners."
OPQC is a network of Ohio perinatal clinicians, hospitals, and policy makers founded in 2007 to reduce preterm births and improve outcomes for premature newborns in Ohio. OPQC comprises 24 Ohio hospitals, including all of the state's children's hospitals, which account for 47 percent of the 150,000 annual births in the state, including 96 percent of Ohio's very preterm infants. The collaborative grew from the friendship and history of professional collaborations between Dr. Donovan and Dr. Iams.
The OPQC Scheduled Birth Initiative was introduced at each participating hospital in September 2008. The initiative included recommended practices, such as the promotion of optimal determination of gestational age with ultrasound; using criteria from the American College of Obstetricians and Gynecologists (ACOG) for the indication and timing of scheduled births; increased awareness among pregnant women, nurses, and physicians of the risks of births between 36 to 38 weeks in an otherwise healthy pregnancy; improved communication between obstetricians and pediatricians; and inclusion of scheduled births as part of an overall culture of safety.
Ohio Infant Death Rates
Ohio infants born at 32 or 33 weeks gestation have a more than a six-fold increased risk of death before the first birthday compared to those born at full term, weeks 39 to 40, according to a second OPQC study published in the June AJOG. That study examined the risk of deaths in 445,593 Ohio infants born at 32 to 41 weeks of gestation from 2003 to 2005. The risk of death was increased 4.4-fold for those born at 34 weeks, three-fold for 35 weeks, about two-fold for those born at weeks 36 and 37 and 1.4-fold for those born at week 38. The Ohio infant death rate for all births regardless of gestation was 7.3 per 1000 live births.
NICU Infection Studies
In addition to the scheduled birth and infant mortality efforts, 24 NICU teams in OPQC reduced blood stream infections by 20 percent, from 18 to 14 percent, in infants at 22 to 29 weeks gestation, as measured from April 2006 to December 2009. These findings were reported at the Pediatric Academic Societies meeting in May. At this same meeting, OPQC presented a study that documented that preventing infections in a typical NICU with 200 annual, preterm admissions would result in five fewer infection-related deaths, 131 fewer bed days and $459,000 in cost savings, based on data from three large Ohio hospitals. The complete data from these infections studies will be submitted for peer-reviewed publication in a medical journal.
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