Saving Money, Saving LivesPopulation-Based Quality

Improvement

Edward F. DonovanChild Health Services Research Meeting

June 24, 2006

Regional Systems of Perinatal CareThe Investment Case for Quality

Improvement

Economic resources spent for perinatal care - taxes/charity (public health & gov’t sponsored

insurance) - after-tax wages (employment-sponsored insurance)

Potential savings - avoid preterm births and consequent lifelong

handicaps

Because many individuals receive a mix of tax-supported and employment-supported services, quality improvement should occur at the health system level

Population-based quality improvement to save lives and money

Geographically defined systems of perinatal care

Individuals receive care from different parts of the system

Test population-based QI: - caregiver/policy teams - data systems operational - QI collaborative

Investment case for population-based QI

Regionalized Perinatal Care in Ohio

Gestation for All Ohio Births 1995 - 2001Singletons only, fetal deaths excluded

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47

Gestation - Weeks

Per

cen

t S

till

Pre

gn

ant

Region 1 Region 2 Region 3 Region 4 Region 5 Region 6

EXTREME PREMATURITY[birth at less than 29 weeks gestational age]

• 60-70% of deaths in the first year of life are associated with EXTREME PREMATURITY

• 50% of lifelong handicapping conditions with onset in infancy are associated with EXTREME PREMATURITY

• 1% of births are EXTREMELY PREMATURE, but 25% of spending for perinatal care

Gestation for All Ohio Births 1995 - 2001Singletons only, fetal deaths excluded

white mothers

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47

Gestation - Weeks

Per

cen

t S

till

Pre

gn

ant

Region 1 Region 2 Region 3 Region 4 Region 5 Region 6

99.40%

99.45%

99.50%

99.55%

99.60%

99.65%

99.70%

99.75%

99.80%

25 26 27 28

Gestation - Weeks

Pe

rce

nt

Sti

ll P

reg

nan

t

Region 1 Region 2 Region 3 Region 4 Region 5 Region 6

Gestation at Birth for All Ohio Births 1995 - 2001Singletons only, fetal deaths excluded

African American mothers

97.5%

98.0%

98.5%

99.0%

99.5%

25 26 27 28

Gestation - Weeks

Per

cen

t N

ot

Del

iver

ed

Region 1 Region 2 Region 3 Region 4 Region 5 Region 6

Population-based QI to improve perinatal care in Ohio

Outcome: Extreme prematurity

QI Methods:

Real-time, longitudinal measures of outcomes: e-birth-certificates

Improvement collaboratives: PDUC

Benchmarking

Transparent tests of change

Benchmarking• If whites (83% of births) in less well performing

regions had the same proportions of births 25-28 weeks GA as the best performing region, there would be roughly 135 fewer infants in this category per year in Ohio

• If African Americans (17% of births) in less well performing regions had the same proportions of 25-28 weeks GA as African Americans in the best performing region, there would be approximately 175 fewer infants in this category per year

135 + 175 = 310 fewer extremely preterm infants per year

Return on Investment Saving a few lives and a lot of money

80 fewer deaths per year100 fewer children per year with life long disability

Total annual savings in birth spending: $ 78 million[5% of total birth spending in Ohio]

Total savings in Medicaid birth spending: $ 24 million

Ohio Medicaid budget for families and children= $ 2 billion (5% of Ohio’s annual spending)

Medicaid savings = 1% per year [not counting cost of lifelong handicap]

Ohio Medicaid budget for children has been increasing 3.6% per year

Improving quality of perinatal care for geographic regions

• Outcomes depend on multiple sources of care• Optimal care depends on linkages among care

sources• Processes of care are readily identifiable• Population-based outcome measures are

available in existing administrative data sets (birth and death certificates)

• In many areas, perinatal care is “regionalized”• Benchmarking and learning collaboratives are

possible within jurisdictions (e.g. states)

Opportunities to Improve

• Identify best evidence

• Highly reliable use of best evidence

• Identify best practices

• Highly reliable implementation of best practices

Quality of Care Improvement

• Real-time measurement of processes and outcomes

• Small tests of change• Benchmarking• Improvement collaboratives: constituency

determined from the users perspective• Transparency

Country Infant mortality 1998

[deaths/1000 births]

GDP per capita 1992

[1985 U.S. $]

Health expenditures

1995[% GDP]

Public health expenditures

1995[% total health $]

Japan 4 15,105 7.2 78

Germany 5 10.5 78

UK 6 12,724 6.9 84

USA 7 17,945 14.0 47

Infant Mortality

U.S. international rank in 2002 24th

African American IM = 14.4

White IM = 5.8

U.S. international rank in 2002 for low risk infants 7th

Improving the perinatal care system: Users’ perspectives’

What types of care do I need?

Prevention- Care in the public sector: nutrition, housing, social services, immunizations,

primary care Care in the private sector:

primary care (pre-conception, prenatal)

Improving the perinatal care system: The users perspectiveWhat types of care do I need?

Treatment- Care in the public sector: Public health clinics,

‘public’ hospitals Care in the private sector:

Offices, birthing centers, hospitals

OHIO