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
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