The Georgia Perinatal Quality Collaborative: Applying QI Strategies to Improve Perinatal Outcomes

Georgia Hospital Association

October 22, 2014

3 BABIESWILL DIE

TODAYIN GEORGIA

Perinatal Health in GeorgiaIn 2012, Georgia ranked 49th nationally for maternal mortality – with 35.5 deaths per 100,000 births.From 1993 – 2006, Black, Hispanic and Asian women accounted for 41% of all births nationwide , and for 62% of pregnancy-related deaths.

Preconception health such as diabetes, hypertension, cardiac issues and obesity increase risk of maternal death and LBW babies.In 2010, 19.9% of women smoked within the 3 months prior to pregnancy, and 8.3% of moms smoked in the final 3 months of pregnancy in 2010.

Tobacco exposure duringpregnancy and secondhand

smoke after delivery is a risk factorfor preterm birth, sleep-related death

and poor lung development

Georgia ranked 37th nationally for infant mortality – with 6.8 deaths

per 1000 live births in 2012.

Black, non-Hispanic infants were2.5 times more likely to die

than White, non-Hispanic infants.

The rate of SIDS in Georgiaremained stagnant

between 2007-2011.

Birth defects are the2nd most common

cause of infant death in GA,

but the no. 1 most common cause in the

US.

In 2010, only 55.2% of Georgia mothers started breastfeeding after delivery.*

Maternal Health Infant Health

2006 2007 2008 2009 2010 20114

5

6

7

8

9

10

11

Infant Mortality in the Southeastern United States, 2006-2011

FloridaGeorgiaMississippiNorth CarolinaSouth CarolinaTennessee

Year

Infa

nt

Death

s p

er

1,0

00

Bir

ths

Infant Mortality Clusters within Georgia, 2002-2006

Maternal Risk Factors for Infant Mortality by Cluster

A B C D E FLess likely to have more than a high school degree

Less likely to be White non-Hispanic Less likely to have had adequate prenatal care

Less likely to be married More likely to have had a previous adverse pregnancy outcome

More likely to have had a c-section More likely to be a smoker More likely to be 19 years old or younger

More likely to have a chronic health condition

Looking at trends from across the state

Approx. 1 in 5 births

spaced < 2 years apart

in 2012

>17% of infant deaths in 2011 were

due to prematurity

or LBW

11 % of births were preterm in

2012

9.4 % of births were

LBW in 2012

Mission

VisionAll perinatal stakeholders in Georgia coming together to improve health and birth outcomes for all Georgia mothers and babies

To establish and maintain a robust statewide perinatal data and quality improvement system that engages stakeholders in evidence-based practices to improve health outcomes for mothers and babies throughout Georgia.

Georgia Perinatal Quality Collaborative

Summer 2011

The GAPQC Journey

Vision began to germinat

e for creation

of PQC

Stakeholder

engagement began, review of

other state PQCs

Formal creation

of GAPQC

2011- 2012Oct. 2012

Steering committee formed, Mission &

Vision created, projects selected

May 2013Review lessons

learned, identify

new projects,

begin recruiting

for Phase II of PQC.

Summer 2014

Pilot Launch.

July 2013

The GAPQC Steering CommitteeCo-Chairs: Catherine Bonk, MD, MPH, (OB/Gyn) and David Levine, MD, (Neo)

DPH Support: Seema Csukas, MD, PhD, MCH Director, Theresa Chapple-McGruder, PhD, Director of MCH Epidemiology, Maria Fernandez, Infant

Mortality DirectorPhysicians Community Partners and

Professional Organizations- Mike Armand, MD, Dekalb (NEO)

- David Carlton, MD, Emory & Grady (NEO)

- Armando Castillo, MD, NE GA Health System (NEO)

- Jane Ellis, MD, Grady (OB/GYN)- Jameela Harper, MD, NE GA

Health System (OB/GYN)- Demetrice Hill, MD, Columbus

Regional (OB/GYN)- Lucky Jain, MD, Emory & Grady

(NEO)- Ravi Patel, MD, Emory & Grady

(NEO)- Mitch Rodriguez, MD, Medical

Ctr of Central GA, (NEO)- Champa Woodham, MD,

Medical Ctr of Central GA, (OB/GYN)

- Pat Cota, Exec. Dir, Georgia OBGyn Society

- Fozia Eskew, Early Intervention Coordinator, GA AAP

- Lynne Hall, QI Consultant, GHA- Sarah Owens, Immediate Past

President, American College of Nurse Midwives (GA)

- Sheila Ryan, State Director, March of Dimes

- Kim Sumpter, Community Outreach, The United Way of Greater Atlanta

- Rick Ward, Exec. Dir., GA AAP- Sarah Dyer, Director, Maternal

Services, NE Georgia Health System

Maternal Health

Chronic Disease is a High Risk Factor for Maternal and Infant Outcomes

2008 2009 20100.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

0.8

0.7 0.7

1.4

1.3

1.4

Chronic conditions during pregnancy, GA birth certificate, 2008-2010

Chronic Diabetes

Chronic Hyper-tension

Perc

ent

of

live b

irth

s

Source: GA data repository, 2008-2010 final birth file

• >50% of women are overweight or obese; 1/3 are obese*

• 48% of reproductive-aged women are overweight or obese;26% are obese†

• > 40% of pregnant women are overweight or obese*

*Retrieved from BRFSS (2011) †Retrieved from PRAMS (2010)

Obesity in Georgia

2008 2009 2010 2011 201220

21

22

23

24

25

26

All of GeorgiaRural Non-Rural

% o

f t

ota

l liv

e b

irth

s

Only 12% of women indicated a desire to have a child in the next year,* but more than 20% are having a baby in <2 years

* Based on recent Medicaid/CHIP Health Care Quality survey

States with highest rate of repeat teen pregnancy

*

* Based on recent Medicaid/CHIP Health Care Quality survey

While 6:10 women want to space their pregnancies, 6:10 women also are not using the most effective birth control to achieve their goals

AL FL MA NC NY TNEarly Elective Deliveries

Post-partum Hemorrhage (AWHONN)

ANCS Hypertension/Preeclampsia

Breastfeeding

Maternal Health: Opportunities

What about supporting high risk women (teens, preexisting chronic conditions) to better plan and space their pregnancies?

Maternal Health: QI Strategy

AimImprove maternal and infant health outcomes by increasing rate of immediate post-partum LARC insertion to help high risk women better control chronic conditions and achieve birth planning goals

Key Drivers

- Address policies and processes that impact women receiving preferred birth control option at discharge

- Increase training and awareness in the inpatient and outpatient setting for providers, clinicians and others

- Provide patient-focused and sensitive education and counseling

- Leverage changes in Medicaid reimbursement to expand LARC access to women who may not have received LARCS previously

Collaborative Opportunity

DCH and DPH Collaboration on QI project sponsored by CMS. Kick off begins in November for nine-month cycle.

Infant Health

10 Leading Causes of Infant DeathGeorgia, 2002-2006

Cause of Death #

% of total Rate

Rank

All Causes 5743

100 8.24 --

Disorders related to short gestation and low birth weight, not elsewhere classified

1117

19.5 1.62 1

Congenital malformations, deformations and chromosomal abnormalities

964 16.8 1.39 2

Sudden infant death syndrome & sleep-related deaths

621 10.8 0.90 3

Newborn affected by complications of pregnancy

321 5.6 0.46 4

Respiratory distress of newborn 245 4.3 0.35 5

Accidental/unintentional injuries 181 3.2 0.26 6

Bacterial sepsis of newborn 169 2.9 0.24 7

Newborn affected by complications of placenta, cord and membranes

164 2.9 0.24 7

Necrotizing enterocolitis of newborn 134 2.3 0.19 9

Disease of circulatory system 131 2.3 0.19 9

Georgia’s NBS program panel expansion

Congenital heart defects are the most common birth defect. By expanding the panel to include screening, we can have an impact on:• Infant, child and adolescent mortality rates• Healthcare utilization and costs for children with special healthcare needs

Three new screens added to the panel

1CCHD screen detects 12 conditions

3Hemoglobinopathi

es

20Inborn Metabolic

errors

4Other Metabolic errors (includes

SCID)

2Endocrine disorders

1Audiology screen

for hearing impairment

Infant Health: QI Strategy

AimImprove support hospitals in the implementation of CCHD as part of newborn screening to increase awareness, identification and treatment of children born with congenital heart defects.

Key Drivers

- Address policies, staffing models, supply chain considerations and procedures to support efficient implementation and reduce rejections of NBS cards.

- Identify and implement best practices for short-term and long-term training of physicians, clinicians and other staff

- Provide patient-focused and sensitive education and counseling to families

Collaborative Opportunity

Both Children’s National Medical Center and the University of Minnesota have issued toolkits to support CCHD screening implementation. Georgia is developing a toolkit that integrates best practices from both to support the implementation in Georgia, across a variety of hospital settings.

AL FL MA NC NY TNNeonatal Abstinence Syndrome

CLABSIs and other HAIs

NICU Human Milk The “Golden Hour”* Newborn Screening/CCHD

Neonatal High Risk Follow-Up Clinic*

Infant Health: Opportunities

* Based on toolkit from California toolkit

Why Join GAPQC?

Working together we accomplish more:

- Bringing together neonatologists and ob/gyns, we can address the spectrum of factors that impact perinatal outcomes.

- Larger numbers let us pool resources, see more changes and outcomes more quickly.

- We can attract other stakeholders and partners – combining the clinical interventions with patient/family education we can address the variety of issues that impact outcomes.

- The better our outcomes and the larger our reach, the more we are able to demonstrate our value to payors, funding sources and communities

GaPQC Timeline July 1, 2014 - June 30, 2015

Sept

July15

Oct. Nov. Jan.

Launch recruitment effort and Phase II QI Project planning begins Finalize

project planning

GA AAP Meeting

Full day Kickoff Session

Design PlanningImplementation &

Reporting

2 Education sessions

Education Session

Next Wave Recruited and Project Planning Launched

Ongoing Monthly Conference Calls to Review Data and Plan PDSA Cycles

Recruitment Goal: Statewide Collaborative with All Perinatal Stakeholders

Pilot 2015 2016 2017

No. of Hospitals:

5 12-18 25-40 41+

Kick-Off Educational Session: January 2015

Atlanta, GA

Application Deadline: November 25

For more information, contact Maria.Fernandez@dph.ga.gov or call 404-657-2852