As part of the Strong Start for Mothers and Newborns effort, the CMS Innovation Center hosted a webinar to discuss why it is important to reduce early elective deliveries and share best practices on how reducing early elective deliveries improves the health of mothers and newborns across the country. Individuals representing the American College of Obstetricians and Gynecologists, the March of Dimes, providers and payers conveyed examples of successes and how reducing early elective deliveries can be accomplished. All interested parties were invited to attend this event. - - - CMS Innovations http://innovations.cms.gov We accept comments in the spirit of our comment policy: http://newmedia.hhs.gov/standards/comment_policy.html CMS Privacy Policy http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html

1. Strong Start for Mothers and Newborns:
Reducing Early Elective Deliveries
Webinar
November 28, 2012

2. Housekeeping & Agenda
Speakers:
Erin Smith, CMS Innovation Center
Dr. Hal Lawrence, American College of Obstetricians and
Gynecologists
Dr. Scott Berns, March of Dimes
Dr. Kenneth Brown, Woman’s Hospital (Baton Rouge, LA)
Dr. Kathleen Simpson, Mercy Hospital (St. Louis, MO)
Vi Naylor and Lynne Hall, Georgia Hospital Association
Dr. Stephen Barlow, SelectHealth (Murray, UT)
Questions & Answers
2

3. Erin Smith
Patient Care Models Group
CMS Innovation Center
3

4. Strong Start Initiative:
Two Strategies to Improve Birth Outcomes
The Strong Start initiative has two different but related strategies:
1. Reducing Early Elective 2. Delivering Enhanced Prenatal
Deliveries Care
A test of a nationwide public- A funding opportunity for
private partnership and providers, States and other
awareness campaign to spread applicants to test the
the adoption of best practices effectiveness of specific enhanced
that can reduce the rate of early prenatal care approaches to
elective deliveries before 39 reduce pre-term births in women
weeks for all populations. covered by Medicaid & CHIP.
4

5. Strategy 1:
Reducing Early Elective Deliveries
5

6. Strategy 1:
Promote Awareness
• Awareness and Visibility Events
– 6 regional events
• Media outreach
– TV, radio, print, in store audio, search engine
marketing, and waiting room TV.
• WebMD consumer page
6

7. Strategy 1:
Spread Best Practice
• The Strong Start initiative is leveraging the
existing infrastructure of the Partnership for
Patients, including the participating Hospital
Engagement Networks (HEN), to support
hospitals across the country in their efforts to
decrease the number of early elective deliveries.
– HENs set individual goals related to reducing early
elective deliveries.
• Medscape – early elective delivery Continuing
Medical Education (CME) opportunity
7

8. Strategy 1:
Promote Transparency
• In the FY 2013 Inpatient Prospective Payment
System final rule, CMS finalized the addition of
a new measure to the Inpatient Quality
Reporting (IQR) Program.
– Elective delivery prior to 39 completed weeks of
gestation (NQF #0469)
– For payment determinations in FY 2015
8

9. Hal C. Lawrence, MD, FACOG
Executive Vice President
American College of Obstetricians and
Gynecologists
9

10. 39 Weeks:
A Strong Start for Moms & Babies
Hal C. Lawrence, MD, FACOG
Executive Vice President
American College of Obstetricians and Gynecologists
Washington, DC
November 28, 2012

11. ACOG
• The Nation’s women’s health physicians.
• Providing education and clinical guidance to
57,000 ob-gyns and partners in women’s health.
• Dedicated to ensuring the safest possible
pregnancies and births.
• Committed to Strong Start and eliminating early
elective inductions.

12. Preterm Deliveries
Change Change
Gestational
1990 2004 2005 from 2010 from
age
1990 2005
↑0.1 ↓0.04
<32 weeks 1.9% 2.0% 2.0% 1.96%
(5%) (~2%)
↑0.2 ↓0.07
32-33 weeks 1.4% 1.5% 1.6% 1.53%
(~14%) (~4.4%)
↑1.8 ↓0.61
34-36 weeks 7.3% 8.9% 9.1% 8.49%
(~25%) (~6.7%)
↑2.1 ↓0.7
TOTALS 10.6% 12.5% 12.7% 12.0%
(~20%) (~5.5%)

13. Strong Start: Reducing Preterm Births
• Preterm birth is the leading cause of neonatal mortality
in the US.
• Accounts for 35% of all US health care spending for
infants and 10% for children.
• Over half a million US babies were born preterm in
2008.
• 12.3% of all live births occur before term in the US.
• 2/3 of all infant deaths are among preterm infants.

14. Strong Start: Reducing Preterm Births
• One of the most complicated and difficult issues
in obstetrics.
• Not much is known about the causes of preterm
labor.
• What we know:
– A growing public health problem that cuts across
social, racial, ethnic, and economic groups.
– Preterm labor is the most common cause of antenatal
(before birth) hospitalization.
– There is a link between preterm birth and infant
mortality.

15. Strong Start: Reducing Preterm Births
• Growth and development in the last part of
pregnancy are vital to the baby's health.
• The earlier a baby is born, the greater the chance
he or she will have health problems.
• Preterm babies tend to grow more slowly; often
have problems with their eyes, ears, breathing,
and nervous system; and experience learning and
behavioral problems.

16. Late Preterm Infants: Outcomes
• Compared to term infants, late preterm infants:
– Are twice as likely to die of SIDS.
– Have an 80% increased risk of ADHD.
– Are 4 times more likely to have at least 1 medical
condition and 3.5 times more likely to have 2 or more
conditions.
• The neonatal mortality rate (deaths among
infants 0–27 days of age) for late–preterm infants
is much higher than the rate for term infants.

17. Late Preterm Infants: Outcomes
• Late preterm infants:
– Are more likely to be referred for special needs in pre-
school*
– Are more likely to have problems with school
readiness*
– Are more likely to have severe hyperbilirubinemia and
resultant neurological consequences*
– Have a 20% increased risk of clinically significant
behavior problems at 8 years of age
– Are more likely to be diagnosed with developmental
delay in the first 3 years
*Fuchs K, Wapner R. Elective Cesarean Section and Induction and Their Impact on Late Preterm Births. Clin Perinatol 33:793-801, 2006.
Adams- Chapman I. Neurodevelopmental Outcomes of the Late Preterm Infant. Clin Perinatol 33: 947-964, 2006.

18. Strong Start: Reducing Preterm Births
• Labor is induced in more than 22% of all US pregnancies,
a rate that more than doubled from 1990 to 2006.
• The goal of induction is to achieve vaginal delivery by
stimulating uterine contractions before the spontaneous
onset of labor.
• Induction has merit when the benefits of expeditious
delivery outweigh the potential maternal and fetal risks
of continuing the pregnancy.
• ACOG is clear: Unless a medical indication exists, labor
induction or a scheduled elective delivery should not be
done before 39 weeks of pregnancy.

19. Changes in Infant & Fetal Outcomes
Ananth CV, Gyamfi C, Jain L. Characterizing risk profiles of infants who are delivered at late preterm gestations: does it matter? Am
J Obstet Gynecol. 2008 Oct;199(4):329-31.

20. Strong Start: Reducing Preterm Births
Indications for induction of labor are not absolute, but should take into account
maternal and fetal conditions, gestational age, cervical status, and other factors.
Indications may include:
• Abruptio placentae;
• Isoimmunization, i.e. Rh disease;
• Chorioamnionitis;
• Fetal demise;
• Gestational hypertension;
• Premature rupture of membranes;
• Postterm pregnancy;
• Preeclampsia, eclampsia;
• HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets) syndrome
• Maternal medical conditions (eg, diabetes mellitus, renal disease, chronic pulmonary
disease, or chronic hypertension); and
• Fetal compromise (eg, severe fetal growth restriction or a deficiency in amniotic fluid).

21. Strong Start: Reducing Preterm Births
• Labor also may be induced if the patient is at risk for very rapid labor, if
she lives an unsafe long distance from the hospital, or if she has serious
mental health indications.
• Even in these circumstances, at least one of the established gestational
age criteria should be met:
– Fetal heart tones have been documented as present for 30 weeks by Doppler
US
– US measurement at less than 20 weeks of gestation supports gestational age
of 39 weeks or greater
– It has been 36 weeks since a positive serum or urine human chorionic
gonadotropin pregnancy test result
• A mature fetal lung test result before 39 weeks of gestation, in the
absence of appropriate clinical circumstances, is not an indication for
delivery.
• The individual patient and clinical situation must always be considered in
determining when induction of labor is indicated.

22. Strong Start
A Strong Partnership
bringing
Medicine (ACOG),
the Public (MOD), and
Government (CMS)
together.
to ensure healthy births.

23. Scott D. Berns, MD, MPH, FAAP
Senior Vice President & Deputy Medical Director
March of Dimes
23

24. Reducing Early Elective
Deliveries
November 28, 2012
Scott D. Berns, MD, MPH, FAAP
Deputy Medical Director &
Senior Vice President
March of Dimes Foundation
Clinical Professor, Pediatrics
Alpert Medical School of Brown University

25. March of Dimes Mission
To improve the health of babies by preventing birth
defects, premature birth and infant mortality
Fund Research Help Moms Support Families
to understand problems & have full-term providing comfort when
discover answers leading to pregnancies & their baby needs help
prevention & treatment. healthy babies. to survive and thrive.

26. Stronger, healthier babies:
75 years in the making

27. U.S. Preterm Birth Rate Declines…
Data shown is % of live births
*Preliminary birth data
Source: National Center for Health Statistics, final natality data, 2011 preliminary natality data.

28. Preterm Birth Rates by Gestational Age
United States, 1990, 2000, 2005-2011*
Source: National Center for Health Statistics, 1990-2010 final natality data and *2011 preliminary
data

29. March of Dimes Preterm Birth Goals
*Preliminary data
Preterm is less than 37 completed weeks of pregnancy.
Source: National Center for Health Statistics, 1990-2010 final natality data and 2011 preliminary data.
Prepared by March of Dimes Perinatal Data Center

33. Strong Start
The March of Dimes is continuing its ongoing
partnership with CMS/HHS to advance the goals of
Strong Start:
• March of Dimes patient education materials
cobranded with HHS and ACOG being distributed
• Collaborating on media coverage; CMS/HHS media
buys in November 2012
• Reach out to all Partnership for Patients Hospital
Engagement Networks; providing menu of options

34. Partnership for Patients
March of Dimes is reaching out to all Hospital Engagement
Networks (HENs) to offer a menu of options for
partnering with chapter and national to reduce elective
deliveries before 39 weeks.
– Use the March of Dimes 39+ Weeks Quality Improvement
Service Package
– Grand Rounds
– Distribute 39+ weeks education materials
– Co-brand 39+ weeks education materials with hospital/HEN
logo
– Co-brand and place March of Dimes television, radio, print,
or outdoor ads

35. HBWW® Late preterm Brain Development Flyer
Available
in English
and
Spanish

36. HBWW® Baby Poster

37. HBWW® Print PSA

38. “Babies aren’t fully
developed until at
least 39 weeks in the
womb……
If your pregnancy is
healthy, wait for labor
to begin on its own.”

39. TV PSA Time Lapse Pregnancy
http://www.marchofdimes.com/39weeks

40. Thank you!
Contact:
Scott D. Berns, MD, MPH, FAAP
Deputy Medical Director & Senior Vice President
March of Dimes
sberns@marchofdimes.com

41. Kenneth Brown, MD, MBA, FACOG
Medical Director
Woman’s Hospital (Baton Rouge, Louisiana)
41

42. 39 Weeks:
A Strong Start for Moms & Babies
Kenneth E. Brown, MD, MBA, FACOG
Medical Director
Woman’s Hospital
Baton Rouge, LA

43. ACOG
 We don’t know very much about the causes of
preterm labor.
 We do know that there is a link between preterm
birth and infant mortality.
 Unless a medical indication exists, labor induction
or a scheduled elective delivery should not be
done before 39 weeks of pregnancy.

44. An ongoing story about
Woman’s Hospital
and the State of Louisiana.

45. Statewide Leader in Obstetrics,
Gynecology, Breast, and
Neonatal Care
Annually
 8,400 births
 1,400 NICU discharges
 95,000 pap smears
 44,000 mammograms
 7,400 surgeries
Specialties in-house
24/7/365
 Anesthesia
 Ob/Gyn
 Neonatology
 MFM Immediately Available
45

46. Involvement of Medical Staff
 Education
 Literature for physicians
 Grand Rounds
 CME( guest lectures/webinars)
 IHI Perinatal Design
 Literature for patients
 Voluntary

47. Involvement of Medical Staff
 Policy Development
 Defining – Active labor, Augmentation, Medical
indication, Multiple pregnancy, HIV
 Establish Baseline
 Collect Data
 Oxytocin Policy

48. Multidisciplinary Involvement
 Hard Stop Policy
 Medical Staff Leadership
 Nursing Directors
 Hospital Administration
 Board of Directors

53. Louisiana Birth Outcomes Initiative
April 2010
Louisiana ranking:
48th in infant mortality and preterm births
49th in percentage of low birth weight and very
low birth weight balance
15.4% preterm birth rate
November 2010
March of Dimes gives Louisiana an “F”
rating on birth outcomes.

54. Louisiana Birth Outcomes Initiative
 A Statewide Effort
 State Department of Health & Hospitals
 Louisiana March of Dimes
 Louisiana Hospital Association
 Louisiana Medical Mutual Insurance Co.
 Woman’s Hospital

56. Louisiana Birth Outcomes Initiative
July 18, 2012
Louisiana Receives the
March of Dimes President’s
Prematurity Leadership award.
August 2012
Preterm Birth Rate - 12.4%(preliminary 2011)
Goal for 2014 – 8%

57. Kathleen Simpson, PhD, RN, FAAN
Perinatal Clinical Nurse Specialist
Mercy Hospital (St. Louis, Missouri)
57

58. Early Term Elective Birth Prevention
Kathleen R. Simpson, PhD, RN

59. Mercy Hospital - St. Louis
• Community teaching hospital
• 8,000 births
• 100 + attending physicians in private
practice responsible for 96% of births
• Elective births < 39 weeks ~ 3%

60. Hospital Based Strategies
• Interdisciplinary OB Practice Committee
• Review of standards and guidelines related to
timing of elective births and evidence of
morbidity with early term elective births
• Policy development / practice adoption
• Leadership support
• Team building / consensus

61. Hospital Based Strategies
• Reevaluation of scheduling processes for elective
births / flexibility / evening and weekend options
• Empowerment / support for elective birth policy
• OB hospitalist program
• Patient education
• Ongoing quality monitoring / process measures /
follow-up with selected individuals as needed
• Join or organize an OB quality collaborative (area,
state, healthcare system, March of Dimes)

62. Mercy Hospital – St. Louis
• Patient education re: risks of
elective induction and early term
birth
• Prepared childbirth classes
• Cue cards for discussion with providers
• N = 3,337 nulliparous women
• Elective inductions ↓ 20% over 7 months
• Elective inductions <39 weeks ↓ 40%
(Simpson, Newman & Chirino, 2010)

63. Health System Success
• 26 hospitals with OB
services in 9 states
• Began process to eliminate
early term births in 2009
• Implemented system-wide
policy / ongoing monitoring
• Current rate of elective
inductions < 39 wks = 0.4%;
decreased from 15% in
2009
(O’Rourke et al., 2011)

64. Hospitals in State-Wide (Michigan)
Perinatal Patient Safety Project
N = 68 Michigan Hospitals with an OB Unit
Education, collaboration, protocols, team
building, measurement, webinars,
conferences, coaching, leadership support
5 process and 8 outcome measures of OB
quality including elimination of early
elective births
(Simpson et al., 2011)

65. Elective Induction of Labor <39 Weeks

66. Go the Full 40: A Consumer Campaign
• Partnership between AWHONN
and its Healthy Mom&Baby
media
• Healthy Mom&Baby: magazine,
iPad app,
http://www.health4mom.org/
HMB social media
• Nurse distribution
66 ©2012 AWHONN

67. Campaign goals
#1. Increase the # 3. Increase nurses’
percentage of women effectiveness to
who complete at least reduce the number
40 weeks of #2. Decrease the percentage of elective inductions
pregnancy of women who choose and cesarean births.
elective induction or elective
cesarean birth.
67 ©2012 AWHONN

68. Themes of Go the Full 40
• Full-term babies
• Spontaneous labor
• Breastfeeding
promotion
• Reduction of elective inductions, elective
cesareans
68 ©2012 AWHONN

69. Campaign materials
69 ©2012 AWHONN

70. Pledge: “Wait for Labor to Start on its Own”
http://www.awhonn.org/full40pledge
70 ©2012 AWHONN

71. Go the Full 40
71 ©2012 AWHONN

72. Vi Naylor, Executive Vice President
Lynne Hall, Quality Improvement Specialist
Georgia Hospital Association
72

73. Data Results:
Early Elective Deliveries
September 17, 2012

74. Where did we start?
• CMS and the National Content Developer charged all HENs to
reduce HAC’s by 40%
• Adding reducing readmissions by 20%
• Adding reducing EEDs by 40%
Learn. Act. Improve. Spread. 74 Keep the Drum Beat Going.

75. Who helped us start?
• Buy-in from hospitals
• March of Dimes
• Department of Public Health
• Georgia Chapter of OBGYN Society
• Georgia Chapter of the Society for CNM
• Georgia Nurses Association
• AmeriGroup
• And others
Learn. Act. Improve. Spread. 75 Keep the Drum Beat Going.

76. How did we start?
• EED Action Group met in April 2012 to review 2009 data
regarding EED
– Key stakeholders: March of Dimes, Department of Public Health,
OB/GYN Society of Georgia Atlanta Chapter, Georgia Nurses
Association, and other were in attendance
• Developed and agreed upon plan to reduce EED’s by 40%
– Ultimate overall goal for Georgia: 0%
– Timely goal for August 2012: 5% or less
• Plan: Encourage use of “hard stops”, March of Dimes Toolkit
or IHI bundles to empower nurses and schedulers
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77. EED Action Group
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78. The Journey
• In-person meeting inviting all birthing hospitals in Georgia
– March of Dimes
– Department of Public Health
– Best Practice Hospitals Presented:
• WellStar Health System
• Athens Regional Health System
• Liberty Medical Center
• Pledge was signed to reduce EEDs across Georgia
• Telnets/Webinars and one-on-one calls with hospitals were held
including subjects on physician engagement, hard stops, risks
to moms and babies and more!
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79. Commitment Poster signing
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80. The Journey
• WSB Channel 2 News covered the event:
– WSB did a video Labor of Love.
– http://www.wsbtv.com/news/news/labor-of-love-examining-elective-
deliveries/nDk4G/
• Covered the in-person meeting
– Did a follow-up in September with our results
• Dr. Fitzgerald was interviewed
• Atlanta Medical Center was featured
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81. Learn. Act. Improve. Spread. 81 Keep the Drum Beat Going.

82. The Journey
• Several hospitals shared their Best Practices in reducing EED’s
– Atlanta Medical Center
– Emory University Midtown
– Piedmont Henry
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83. The Results
• There are 83 birthing hospitals in Georgia
• 58 (70%) of those hospitals turned in data
• 19 (31%) of the 58 hospitals were already at a 0% EED rate
• Of the 39 hospitals needing improvement about ½ showed
significant gains!!
• 3 of those hospitals went from a 14% or higher EED rate to a
0% rate sustained for at least 3 months!!
– Habersham Medical Center went from a 30% EED rate down to 0% and
has sustained the rate for 4 months
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84. The Results 1
• 2009 – 65%
• 2010 – 35.3%
• August 2012 – 3.67%
• YTD 2012 – 5.90%
• That’s a 58% decrease in Early Elective Deliveries!!!
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85. The Results 2
• From March 2012 baseline data to August 2012 data:
– We can celebrate a 58% decrease in EEDs
Learn. Act. Improve. Spread. 85 Keep the Drum Beat Going.

86. The Results 3
• According to Managed Care Magazine it costs around $41,000
for a late preterm NICU visit
• The incidents went from 147 incidents in March 2012 to just
32 in August 2012
• That’s a decrease of 117 incidents
• If even a ¼ of the babies went to NICU, we saved Georgia
Healthcare $1,178,750.00
OVER 1 MILLION Dollars!!
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87. The Results 4
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88. The Results 5
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89. The Results 6
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90. Lessons Learned
• Important to work as a team
• Get physician buy-in and have a physician champion
• Empower your schedulers and nurses
• Have a peer review for non-medically necessary EED
• Educate patients early starting at first visit
• Collaborate with others even outside your hospital:
– Share best practices
– Share forms
– IHI
– March of Dimes
Learn. Act. Improve. Spread. 90 Keep the Drum Beat Going.

91. Lessons Learned 2
• Use data to sustain the gain
• Present data to administration and physicians
• Build on existing relationships
• Celebrate your success!!!
Learn. Act. Improve. Spread. 91 Keep the Drum Beat Going.

92. Questions??

93. Stephen L. Barlow, MD
Vice President & Chief Medical Officer
SelectHealth (Murray, Utah)
93

96. Questions
Additional information available on CMMI
website: http://innovation.cms.gov/
Program email: StrongStart@cms.hhs.gov
96

97. Thank you
http://innovation.cms.gov/
97