PHC4 FYI - Purchaser's Role in Quality Maternity Care

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Hospitalizations related to childbirth and maternity care are the most frequent reasons for hospital admissions in the United States and in Pennsylvania. In 2002, for people under the age of 65, almost 28 percent of all hospital discharges in Pennsylvania were related to maternity care. They accounted for approximately 13 percent of dollars spent in hospitals and almost 21 percent of all hospital days in this age group. However, expectant mothers are not considered to be "sick" and traditional outcome measures such as mortality rates are not particularly useful because mortality is rare when it comes to maternity care. As a result, this area of health care delivery has not received much attention in regard to quality outcomes studies.

Maternity care and delivery outcomes can have significant implications in terms of quality of life for mothers and babies, some of which may be life-long. There are also cost implications. Thus, it is important for purchasers and the public to understand the factors that influence decisions regarding childbirth and maternity care outcomes, and to examine the quality of the maternity care and childbirth services provided by hospitals, physicians and health plans.

A Lack of Consensus

Delivery of appropriate maternity care is a very complex issue. Women who receive care, professionals who provide care and those who pay for care all want that care to be safe, effective and cost efficient. But, there is much less agreement about how best to deliver appropriate care. While some stakeholders give priority to each woman's personal childbirth experience, others aim to minimize the occurrence of negative health consequences in the baby despite a potential increase in the mother's risk or discomfort. Still others, concerned with rising costs of care and the limited resources available, consider efficiency to be the most important objective. The diversity of goals and priorities results in widely differing practices for care during childbirth.

The appropriate use of the cesarean section procedure has emerged as the most prominent quality issue within maternity care. According to the Centers for Disease Control and Prevention (CDC), 26.1 percent of all births in the United States were cesarean deliveries in 2002 - the highest rate ever reported in the United States. In 2002, the cesarean delivery rate in Pennsylvania was 25.3 percent, according to PHC4 data.

The issue of whether this cesarean delivery rate is good or bad for women and their babies is the subject of intense debate. Some researchers advocate the advantages of a vaginal delivery over a cesarean delivery. They argue that cesarean sections are more expensive, potentially more dangerous, and lead to a far more difficult recovery. Other researchers propose that women who deliver vaginally are more likely to have potential long-term health problems including pelvic support problems and incontinence. Much less controversial, though, is the importance of avoiding failed attempts of vaginal delivery. When a woman attempts to go through labor and fails, thereby necessitating a cesarean delivery, the consequences can be severe. The rate of morbidity, infection and operative injuries increase substantially, as does cost.

The Need for Unified, Risk-Adjusted Outcomes Data

There is currently no consensus regarding the best mode of delivery for some types of high-risk pregnancies. Further complicating the debate is the absence of complete and accurate data in a single database that focuses on both the mother and the baby. By having combined data on both mothers and babies, it would be possible to identify health factors that may lead to unsuccessful labor attempts and to develop alternative care practices.

Cesarean section rates that take a patient's health status or "risk" into account (i.e., "risk-adjusted rates") represent a step forward in recognizing that important health differences exist among expectant mothers and that these differences may influence childbirth outcomes. Nevertheless, cesarean section rates are a measure of the "process of care" and are not an "outcome measure." Cesarean delivery rates do provide information about the mode of delivery, but do not indicate whether that mode of delivery resulted in the best possible outcome for the mother and the baby.

Progress has been made through national and statewide initiatives to develop standards, many of which account for different risk groups. But more research based on unified data is needed to develop methodologically sound measures that accurately reflect the quality of obstetric care. Access to comprehensive data, based on sound risk-adjustment methodology, would allow for the evaluation of specific pregnancy management initiatives and for comparisons on many levels.

Through a collaborative effort with the Pittsburgh Regional Healthcare Initiative (PRHI), a coalition dedicated to improving health care and patient safety for the people of Southwest Pennsylvania, PHC4 has developed a breakthrough methodology that provides for a risk-adjusted approach to studying maternity care outcomes for mothers. This methodology identifies women who are more likely to develop major and/or minor complications based on their pre-labor risk, and gives "credit" to hospitals for treating higher proportions of these women. The approach offers the promise of enhancing the quality of care, by accounting for pre-labor risk, and then identifying areas for improvement.

This innovative project has been possible because of cooperation and teamwork of many different constituencies, including health care providers, insurers, government agencies, and the purchaser community. Working together, they have begun to address maternity care issues and to support the best possible outcomes. Unfortunately, because of data limitations, this project has only been able to focus on maternal outcomes. Although PHC4 and the PRHI Obstetrical Subcommittee have advanced the science of measuring quality outcomes through this project, more complete, accurate and unified data is needed to enable even further research on both mothers and babies.

A Purchaser's Role

For many purchasers, pregnancy-related care is the largest single component of health care costs, both in terms of actual medical expenses and indirect costs (absenteeism and diminished productivity while on the job). In particular, poor birth outcomes, including complications in labor and delivery for the mother and/or baby, can result in even higher costs and more missed days. This is especially important to purchasers since 57 percent of the workforce in the United States is female and 38 million working women are of childbearing age, as reported by Insights and

In Pennsylvania, PHC4's data reveals that over 30 percent of all newborns were born either prematurely or with health problems in 2002. These babies average 7.0 days in the hospital and an average charge of $25,371. Babies born without significant health problems in 2002 averaged 2.2 days in the hospital and an average charge of only $2,091. This is an enormous difference and affects purchasers' direct and indirect costs.

Purchasers could begin to improve maternal outcomes through worksite prenatal health education programs. Women who receive regular prenatal education and care significantly decrease their risk of adverse pregnancy outcomes, and workplace programs can lead to significant savings in health and disability costs. These programs also can enable earlier return to work after delivery, increased productivity, decreased absenteeism and a healthier future workforce. Purchasers also can begin to ask insightful questions about the quality of maternal care when negotiating with health insurers and providers. By holding both insurers and providers accountable for the maternity care provided, purchasers will be better positioned to realign care and reimbursement practices to best practices.

Most importantly, purchasers can request that the entire health care community, including health plans, begin to focus on identifying the risk factors and problems that impact modes of delivery. Moreover, purchasers can begin to ask questions about the use of risk-adjusted, comparative data to evaluate health outcomes of both mothers and babies. When there is comprehensive, unified data and public outcomes information about the health of both mothers and babies, purchasers as well as their employees or members will be able to make truly informed decisions about maternity care. This will ultimately lead to improved quality and lower overall costs.

FOR MORE INFORMATION ON THIS TOPIC - See: The American College of Obstetricians and Gynecologists. The resources below also offer further information.


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