Background and Significance
The Obstetrics Clinical Outcomes Assessment Program (OB COAP) is a clinician-led data collection and analysis initiative using chart-abstracted data of the variables relating to the management of a pregnant woman who delivers in the state of Washington.
OB COAP is designed to facilitate physician leaders and hospitals working together in a voluntary and collaborative way to review clinical outcomes data and seek improvements in labor and delivery care. The goal of OB COAP is to ensure that all women in the state of Washington receive the same evidence-based obstetrical care. To achieve this goal, providers of OB care must be given complete and comprehensive information, both their own and their peers’, regarding management of the laboring/delivering woman.
Quality assurance and quality improvements are stated goals in every part of the medical community. The quality of obstetrical care in the United States, however, has not received nearly the same level of scrutiny as has the care in other specialties. In fact, there is almost no evidence to support much of what is done to and for the laboring/delivering woman¹. Tracking the process of a delivering woman from time of admission (planned or unplanned) to time of discharge is rife with many variables: gestational age, number of fetuses, specialty of clinician, existing medical condition, pregnancy complications. The possible outcome of the labor and delivery process is equally multi-faceted and includes both common complications (e.g., postpartum hemorrhage, emergent delivery, unanticipated special care nursery admission) and rare events (e.g., amniotic fluid embolus, deep venous thrombosis, death). There are insufficient data on the linkage between clinical decisions made during the process of labor and delivery and the outcome. While biology plays a role (pre-eclampsia, diabetes), the outcome for mother and newborn devolves to individual clinician decision-making influenced by a mix of personal habits of practice and knowledge-based expertise. This is particularly true in labor and delivery facilities that have a small number of clinicians, and/or an undeveloped capacity to conduct a formal review of the linkages between process and outcome.
There is some precedence for nationwide data collection in large healthcare systems, and how the use of that data has improved quality: Dr Steven Clark, Medical Director, Women and Children’s Clinical Services of Hospital Corporation of America (HCA), a hospital system comprised of 120 facilities in 21 states performing about 220,000 deliveries a year, used an internal HCA data system that “allowed the identification of several clinical situations that place patients at an increased risk for adverse outcome, and place physicians at an increased risk for litigation”. Dr. Clark reports that change has been driven by HCA’s own internal data: “We have seen improvements in patient outcomes, a dramatic decline in litigation claims, and a reduction in the primary cesarean delivery rate”².
Dr. Brent James, Chief Quality Officer at Intermountain Healthcare, a system of hospitals, surgery centers, doctors, clinics, and homecare & hospice providers serving Utah and parts of Idaho has identified 50 clinical conditions (accounting for 50% of their patients) for which “a committee made up of doctors, nurses and administrators has tried to identify variations and then figure out which treatments have not been working”³. The committees that James set up meet monthly to refine protocols, set clinical goals, and track patient outcomes. The statistics the committees examine reach down to the level of the individual doctors.
It is important to note that both Dr. Clark’s and Dr. James’ systems are under single administrative governance. As such, change can be directive. Novel challenges ensue, however, when independent and possibly competing systems are invited to coalesce for the purposes of quality review and enhancement. OB COAP will replicate Clark’s and James’ achievements on a statewide population base rather than on a governance base.
In Washington State, a 2009 report4. jointly produced by the Washington State Department of Health (DOH) and the Department of Social and Health Services (DSHS) Medical Assistance Administration that collected data tracking the labor and delivery experience of all women giving birth in the state from that year showed these key findings:
- Since 1998, vaginal births have decreased and both primary and repeat C-Sections have increased. Cesarean deliveries comprised 29% of all births in 2007.
- Infant mortality rate declined overall by almost 13% between 2002 and 2007. However, infant mortality rates in African American and Native American population groups continue to exceed infant mortality rates in Caucasian, Hispanic, and Asian population groups.
- Almost 4% of pregnant women were morbidly obese.
- The singleton low birth weight rate among African Americans alone remains twice that of the rate of Caucasians, and non-Hispanics.
- Total number of low birth weight across all population groups has increased steadily since 1990.
- Maternal morbidity as reported indicates about 6% of women had diabetes, almost 7% had hypertension, and about 1% were Group B Strep culture positive during pregnancy.
- The rate of singleton preterm birth increased significantly between 1993 and 2007.
- Average Medicaid expenditures per client for maternal and infant services have more than doubled since 1996.
- 47% of all deliveries were paid for by Medicaid; the infant mortality rate of these newborns exceeds the mortality of infants whose mothers did not receive Medicaid-funded maternity care.
This report reflects substantial variability. Some of these key findings reflect labor and delivery decisions affecting outcomes in the management of obstetrics care. The variability is statistically significant, and mirrors the larger national deficit of evidence-based metrics linking decisions of obstetrical management to outcomes for both planned and unplanned admissions5.
It is well known that what is measured improves, and uniformity of process improves quality. ” In most areas of human endeavor, process or procedure variation is typically associated with a poorer outcome or product, and uniformity of process is generally associated with improvement of these measures…such standardization is central to any profession or enterprise seeking consideration as a high-reliability organization…Indeed, analysis of the variation in cesarean delivery rates throughout the United States suggests that lack of such guidelines contributes to decision making regarding operative delivery that is virtually random. In terms of practice guidelines, we believe that specificity, not ambiguity, is one answer to both patient safety and litigation.”² ” Every practitioner should not only welcome but encourage the development of completely unambiguous national practice standards from our professional organizations…In the absence of such standards, many large hospitals systems and even individual states have adopted their own uniform care processes and are reaping similar benefits.”6
OB COAP is housed within the Foundation for Health Care Quality (FHCQ). FHCQ is a non-profit foundation, founded in 1988 and dedicated to providing a trusted, independent resource to all stakeholders in the health care community – patients, providers, employers, government agencies, and public health professionals. FHCQ is a statewide, inclusive organization that addresses urban as well as rural health care needs. It is neutral in its structure and support. This posture underlines FHCQ’s strength – it is not beholden to any one faction in the health care delivery system. FHCQ provides an environment in which cross-sector health care leaders can focus on innovative solutions to pressing health care issues. By providing a trusted platform, FHCQ fosters a collaborative approach to decrease variations in care, improve outcomes, reduce costs, and develop tools and procedures for use by patients and health care professionals. Its work includes all health care participants – from public and private health care professionals and providers to patients, employers, and government agencies. FHCQ hosts on-going member-based programs and undertakes both long term and short term initiatives. All programs share the common goal of sustainable health care improvement that meets or exceeds established standards and strives to reduce redundancies and administrative complexity.
Participation in OB COAP results in collection of the data needed to comply with the eight maternal performance measures and the two maternal/neonatal performance measures of the National Quality Forum (NQF) national voluntary consensus standards for perinatal care performance, October 2008:
- Elective delivery prior to 39 completed weeks gestation
- Incidence of episiotomy
- Cesarean rate for low risk first birth women
- Prophylactic antibiotics in Cesarean Section
- Appropriate DVT prophylaxis in women undergoing Cesarean delivery
- Birth trauma rate
- Appropriate use of antenatal steroids
- Infants under 1500 grams delivered at appropriate site
- Exclusive breast feeding at hospital discharge
- Hepatitis B vaccine administration to all newborns prior to discharge
- Berghella V, Baxter JK, Chauhan SP. Evidence-Based Labor and Delivery Management. American Journal of Obstetrics and Gynecology 2008;199:445-54.
- Clark SL, Belfort MA, Byrum SL, et al. Improved outcomes, fewer cesarean deliveries and reduced litigation: results of a new paradigm in patient safety. American Journal of Obstetrics and Gynecology 2008;199:105.e1-1.e7.
- Leonhardt D. If Health Care is Going to Change Dr. Brent James’s Ideas Will Change It. New York Times, Sunday Magazine November 8, 2009.
- Perinatal Indicators Report for Washington Residents
- Clark, SL, Belfort MA, Hankins GDV et al. Variation In The Rates Of Operative Delivery In The United States. American Journal of Obstetrics and Gynecology 2007;196:526.e1-526.e5.
- Clark, SL. Patient Safety and Litigation Reduction – 2 sides of the Same Coin. The Female Patient 2009;34:2024.