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					Making Motherhood Safe in California

California Pregnancy-Related and Pregnancy-
         Associated Mortality Review
                      &
California Maternal Quality Care Collaborative

     Maternal, Child and Adolescent Health Program
                Center for Family Health
         California Department of Public Health

      California Maternal Quality Care Collaborative
                     October 16, 2007
                MCH Federal/State Partnership


                                                       1
            Presentations and Discussion
• Shabbir Ahmad, Acting Division Chief, California Department of
  Public Health, Maternal, Child and Adolescent Health Program
   – Welcome and Introductions
   – Background

• Amy L. Godecker, California Department of Public Health, Maternal,
  Child and Adolescent Health Program
   – California Pregnancy-Related and Pregnancy-Associated
     Mortality Review (CA-PAMR)

• Debra Bingham, Project Director, California Maternal Quality Care
  Collaborative
   – CA-PAMR Advisory Committee Review Process & Contributing
     Factors Analysis

• Elliott K. Main, Principal Investigator, California Maternal Quality
  Care Collaborative
   – Maternal Care Quality Improvement Programs in California
   – Discussion
  Making Motherhood Safe
       in California
     Shabbir Ahmad, D.V.M., MS, Ph.D.
    California Department of Public Health
           Center for Family Health
Maternal, Child and Adolescent Health Program

                                            3
                               California Demographic
                               Characteristics: 2006
    •     State Projected Total Population                                           37.4 million
           – Hispanic                                                                13.2 million (35%)
           – Non-Hispanic                                                            24.2 million (65%)
                • White                                                              16.4 million (44%)
                • Asian                                                              4.3 million (12%)
                • Pacific Islander                                                   0.1 million (0.4%)
                • African American                                                   2.3 million (6%)
                • American Indian                                                    0.2 million (0.6%)
                • Multi-Race                                                         0.8 million (2.1%)

    •     California Resident Women Births                                           562,157
           – 13.3% of 2005 US Births

    •     Births to Resident Hispanic Women                                          52% of total births

    •     Paid by Medi-Cal
           – Delivery                                                                47% of total births

    •     Unintended Births to California Women                                      43%
Data Sources: State of California, Department of Public Health, 2006 Birth Records; Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for 2005.
Health E-Stats. Released November 21, 2006; State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, 2000–2050.
Sacramento, CA, July 2007.; Maternal and Infant Health Assessment (MIHA) Survey, 2005.
                                              Maternal/Pregnancy-Related Mortality Rate,
                                              California Residents & United States: 1991-2004

                                 20
                                                                                             ICD-9    ICD-10
  Rate per 100,000 Live Births




                                                                                                                                  15.2
                                 15                California               United States                                                 13.6

                                      10.7                                                                   11.1          10.6
                                                                                                                    10.2                   13.1
                                                                9.7                                                                12.1
                                             9.1                                       9.1            9.9
                                 10                                   8.5
                                                      7.7
                                                                                                       8.3                  8.9
                                       7.9
                                  5                                              5.6            6.7
                                                       HP 2010 Objective – 4.3 Deaths per 100,000 Live Births


                                  0
                                      1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1991-2004. Maternal
mortality (deaths ≤ 42 days postpartum) calculated 1991-1998 using ICD-9 classification. Pregnancy-related mortality (deaths ≤ 365
days postpartum) calculated beginning 1999 using ICD-10 classification. United States data and HP2010 Objective are for maternal
mortality. Produced by California Department of Public Health, Maternal, Child and Adolescent Health Program, October 2007.
                                              Pregnancy-Related Mortality Rates by
                                              Race/Ethnicity, California Residents: 1990-2004

                               40                                                                                                                                          37.6
                                           White Non-Hispanic                                                  African American Non-Hispanic
                               35          Hispanic                                                            Asian
Rate per 100,000 Live Births




                               30                                                              ICD-9

                               25   22.1                                                                                               ICD-10

                               20

                               15                                                                                                                                          12.6
                                    10.7
                                                                                                                                                                            11.9
                               10
                                              7.3                                                                                                                          10.4
                                5
                                     6.0
                                0
                                    90-92 91-93 92-94 93-95 94-96 95-97 96-98 97-99 98-00 99-01 00-02 01-03 02-04
                                                                                     3 Year Moving Average

               SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1990-2004. Maternal mortality (deaths ≤ 42
               days postpartum) calculated 1990-1998 using ICD-9 classification. Pregnancy-related mortality (deaths ≤ 365 days postpartum) calculated beginning 1999
               using ICD-10 classification. Maternal single race code used 1990-1999; multirace code used beginning 2000. Produced by California Department of Public
               Health, Maternal, Child and Adolescent Health Program, October 2007.
        Making Motherhood Safe

   California Pregnancy-Related and
Pregnancy-Associated Mortality Review
               (CA-PAMR)

          Amy L. Godecker, MS PhD
    California Department of Public Health
Maternal, Child and Adolescent Health Program


                                            7
          Making Motherhood Safe



   California Pregnancy-Related and
Pregnancy-Associated Mortality Review
               (CA-PAMR)

   1.   California‟s outcomes
   2.   The challenge of scale
   3.   Los Angeles‟ prior mortality review
   4.   Developing CA-PAMR
   5.   CA-PAMR‟s 2002 cohort
                                              8
                                                          Maternal Mortality Rate, California,
                                                          1920-2004
  Maternal Deaths per 100,000 Live Births




                                            800

                                            700   705.4

                                            600

                                            500

                                            400

                                            300
                                                                                   HP 2010 Objective – 4.3 Deaths per 100,000 Live Births

                                            200

                                            100                                                                                                                 2004
                                                                                                                                                                13.6
                                              0
                                               1920       1930   1940   1950      1960             1970              1980             1990             2000

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1930-2004. Produced by California Department of Public
Health, Maternal, Child and Adolescent Health Program, October, 2007.
                                                                       Maternal Mortality Rate,
                                                                       California, 1970-2004
                                            25
  Maternal Deaths per 100,000 Live Births




                                            20    21
                                                             18
                                                        16        16
                                            15                         15 15                                                                                                                          15.2

                                                                               13                                                                                                                         13.6
                                                                                    11 11 11 11                                           10.7                                                11.1 10.6
                                            10                                                        10                       10                         9.7                                     10.2
                                                                                                  9                                     9     9.1                           9.1
                                                                                                           8       8                                            8.5                     8.3
                                                                                                                                                    7.7
                                                                                                                       7                                                          6.7
                                                                                                               6           6        6                                 5.6
                                             5
                                                                                                                HP 2010 Objective – 4.3 Deaths per 100,000 Live Births


                                             0
                                                 1970              1975                 1980                   1985             1990                  1995                          2000
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1970-2004.
Produced by California Department of Public Health, Maternal, Child and Adolescent Health Program, October, 2007.
                                              Maternal/Pregnancy-Related Mortality Rate,
                                              California Residents & United States: 1991-2004

                                 20
                                                                                             ICD-9    ICD-10
  Rate per 100,000 Live Births




                                                                                                                                  15.2
                                 15                California               United States                                                 13.6

                                      10.7                                                                   11.1          10.6
                                                                                                                    10.2                   13.1
                                                                9.7                                                                12.1
                                             9.1                                       9.1            9.9
                                 10                                   8.5
                                                      7.7
                                                                                                       8.3                  8.9
                                       7.9
                                  5                                              5.6            6.7
                                                       HP 2010 Objective – 4.3 Deaths per 100,000 Live Births


                                  0
                                      1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1991-2004. Maternal
mortality (deaths ≤ 42 days postpartum) calculated 1991-1998 using ICD-9 classification. Pregnancy-related mortality (deaths ≤ 365
days postpartum) calculated beginning 1999 using ICD-10 classification. United States data and HP2010 Objective are for maternal
mortality. Produced by California Department of Public Health, Maternal, Child and Adolescent Health Program, October 2007.
                                              Pregnancy-Related Mortality Rates by
                                              Race/Ethnicity, California Residents: 1990-2004

                               40                                                                                                                                            37.6
                                           White Non-Hispanic                                                  African American Non-Hispanic
                               35          Hispanic                                                            Asian
Rate per 100,000 Live Births




                               30                                                              ICD-9

                               25   22.1                                                                                               ICD-10

                               20

                               15                                                                                                                                            12.6
                                    10.7
                                                                                                                                                                                11.9
                               10
                                              7.3                                                                                                                            10.4
                                5
                                     6.0
                                0
                                    90-92 91-93 92-94 93-95 94-96 95-97 96-98 97-99 98-00 99-01 00-02 01-03 02-04
                                                                                     3 Year Moving Average

               SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1990-2004. Maternal mortality (deaths ≤ 42 days postpartum)
               calculated 1990-1998 using ICD-9 classification. Pregnancy-related mortality (deaths ≤ 365 days postpartum) calculated beginning 1999 using ICD-10 classification. Maternal
               single race code used 1990-1999; multirace code used beginning 2000. Asian women had too few deaths during 1996-1998 period to calculate rate. Produced by California
               Department of Public Health, Maternal, Child and Adolescent Health Program, October 2007.
                    African-American Women are
                    Over-represented in Maternal Deaths


   All Live Births = 544,685                                             All Pregnancy-Related*
                                                                                Deaths=74
                                        African-
                                        American                                                             African
                                          5%                                                                American,
                                                                                                              16%




                                                                                   All Other,
           All Other                                                                  84%
             95%



SOURCE: State of California, Department of Public Health, California Birth and Death Certificate Master Files, 2004.
Produced by California Department of Public Health, Maternal, Child and Adolescent Health Program, October 2007.
*Pregnancy-related death determined by ICD-10 coding of death certificate.
California‟s Births Are Comparable
to Many Countries

                   2005
     Countries     Births
 France            830,900
 Germany           679,981
 Great Britain     648,516
 California        550,142
 Italy             505,757
 Spain             404,120
 Texas             385,963
 Canada            354,148
                Making Motherhood Safe

            A California Region = An Average State
                                     No. of
Regional Perinatal Programs          Births                     No. of
    of California Region                          State         Births
                                     (2005)
                                                                (2005)
01 No. Coast (inc. San Francisco)     23,705
                                               Hawaii            17,925
02 NE (inc. Sacramento)               47,321
                                               Nevada            37,258
03 East Bay (inc. Oakland)            23,518
                                               Oregon            45,937
04 Mid-Coast                          40,013
                                               Washington        82,592
05 San Joaquin (Central Valley)       54,721
                                               Arizona           96,231
06 Los Angeles (regions 6.1-6.8)     158,712
                                               Connecticut       41,717
07 Inland                             48,289
                                               Mississippi       42,398
08 Orange                             44,506
                                               New Mexico        28,834
09 San Diego                          47,396
                                               Oklahoma          51,746
10 Kaiser No.                         32,004
                                               Utah              51,554
11 Kaiser So.                         29,957
                                               10 state total   496,192
                             Total   550,142
        Los Angeles County
        Maternal Mortality Review
• Review dates: 1994-1996; Report 1998
• 3 main causes: hemorrhage, embolism, and
  hypertension
  – Risk higher for women > 30 years old, African-
    Americans, inadequate prenatal care, and higher
    parity
• Judged that ¾ of deaths had some chance of
  being prevented
  – Provider factors contributed most commonly
  – Patient factors often contributed some
  – Facility and community factors contributed less
         Developing CA-PAMR

• MCAH Program concerned about trends
• Assess causes of and factors contributing to
  maternal deaths
  – Special concern about racial/ethnic disparities in
    maternal mortality
• Develop public health recommendations
• Identify clinical quality improvement
  opportunities
• Form public and private partnerships
        Developing CA-PAMR
• Collaboration between
  – CDPH MCAH Program
  – UC San Francisco
  – Public Health Institute
  – California Maternal Quality Care Collaborative
    (CMQCC)
• Pilot “year” begun 2004 for 2002 birth cohort
  – Draft report due early 2008
• Funding through November 2010
  – Use Title V Block Grant funds
        Developing CA-PAMR

• Foundational work by MCAH Program/UCSF
  prior to the formation of the Advisory
  Committee for case reviews
  – Protocol for IRB review
  – Public Health Institute for medical records review
  – Support from ACOG
  – Data linkage to identify cases
  – Reviewed death certificates
  – Selection of sample of cases
  – Requested coroner reports
          Authority for CA-PAMR
• General legal authority, no specific authorization
  – Health and Safety Code Section 100325-100335
     • “The department may do all of the following activities…Make any
       additional collection of data necessary to describe and analyze…
       factors related to population dynamics, public health, and the
       environment.”
     • “The furnishing of this information to the department…shall not
       subject any person, hospital…or other organization furnishing this
       information to any action for damages.”
     • http://www.leginfo.ca.gov/calaw.html
  – Similar to Fetal and Infant Mortality Review
  – Office of HIPAA Compliance review of protocol
  – HIPAA Waiver by State IRB
        CA-PAMR Confidentiality
        Protocols

• Signed confidentiality agreements
• Hospital staff trained in HIPAA-compliance
• Secure storage & handling of hard copies &
  electronic files
• Advisory Committee reviews de-identified
  materials that are destroyed after meetings
• No identifying information on final database
• Reports & publications will not identify
  any person, provider, facility, or small
  geographic area
        CA-PAMR Uses CDC and ACOG
        Mortality Definitions
• Pregnancy-related deaths under-reported
  using ICD-10 codes on death certificates

• Pregnancy-related mortality
  – Death while pregnant or within 1 year of termination
    of pregnancy from any cause related to or aggravated
    by her pregnancy or its management, but not from
    accidental or incidental causes.

• Pregnancy-associated mortality
  – The death of a woman while pregnant or within 1 year
    of termination of pregnancy, irrespective of cause.
                  CA-PAMR Case Identification

           2002                                     Pregnancy
    Birth Cohort Data                                -related
(Live birth certificates +                            deaths
fetal deaths >20 weeks)                              (ICD-10
                                                     code on
                                                       death
      2002 & 2003                                      cert.)
  Death Certificates                   Pregnancy-                 CA-
                             Linkage
(Maternal deaths within                associated                PAMR
                             process
      365 days of                        deaths                  Sample
  birth or fetal death)

                                                    Pregnancy
      2002 & 2003                                       -
Inpatient discharge data                            associated
    (Prenatal, labor &                                deaths
delivery & postpartum up
       to 365 days)
               CA-PAMR Case Identification

•   Includes women ≥ 20 weeks gestation
         •   Future years will identify women <20 weeks
             gestation by looking at diagnosis codes in
             discharge data
•   Pregnancy “check box” on death certificate
    beginning with 2003 deaths
    –   Pregnant within 1 year of death
    –   Will give additional field to select records
             CA-PAMR 2002 Cohort

                 Pregnancy
                  -related
                   deaths      60%

                 39 cases

Pregnancy-                           CA-PAMR
associated                            Sample
  deaths
194 cases                            60 cases
                  Pregnancy
                      -        25%              Sample includes:
                  associated                    24 preg.-related
                    deaths                      23 Af.-American
                  155 cases                     38 ≤ 42 days
                                                9 fetal deaths
       CA-PAMR 2002 Cohort: Selected Causes
       of Death for 194 Cases Identified

Cause of Death (ICD-10)          # Cases
Eclampsia/pre-eclampsia/stroke       8
Embolism                             7
Hemorrhage                           4
Cardiac disease                     17
Cancer                              23
Transportation accidents            29
Drug overdose                       15
Homicide                            15
Suicide                              6
                            CA-PAMR 2002 Cohort: Days from birth or
                            fetal death to pregnancy-related death
                       15
                  15
                                                         3 additional deaths at 131, 179 & 220 days
Number of women




                  10

                            5
                   5
                                           3     3
                                  2                                  2
                                      1                                     1            1            1      1     1
                   0
                       0    1     2   3    4     5      6     7      8      9    10 11 12 13 14 15 16
                                      Number of days since birth/fetal death

                                Pregnancy-related death per ICD-10 on death cert
   SOURCE: State of California, Department of Health Services, California Birth Cohort/Patient Discharge Data Linkage File,
   2002 cohort. ICD-10 used to classify whether coded pregnancy-related on death certificate.
             CA-PAMR Advisory Committee
                                                   Pregnancy-
                                                     related
                                                     deaths

              Pregnancy                             Possibly
               -related                            pregnancy-
                deaths                               related
                                                     deaths

Pregnancy-                  CA-      Advisory      Pregnancy-
associated                 PAMR      Committe      associated
  deaths                   Sample    e Review        deaths

              Pregnancy                               Quality
                  -                               improvement &
              associated              CMQCC        public health
                deaths                             opportunities
                                    Translating
                                       Data
                                    Into Action
         Making Motherhood Safe



CA-PAMR Advisory Committee
     Review Process
     California Maternal Quality
          Care Collaborative
 Elliott Main, MD, Principle Investigator
Debra Bingham, RN MS DrPH student,
            Program Director
                                            29
                CA-PAMR
                Advisory Committee

• Honoring Women’s Lives
• Honoring the Teams

• Each Death Has an Important Story to Tell
• Each Death is a Tragedy

CMQCC Role:
Extract the Lessons
Translate the Lessons Learned into Actions

CMQCC: A Collaborative to advance maternity through data-driven quality improvement.
             CA-PAMR Advisory Committee
• Advisory Committee reviews (de-identified)
   –   Abstracted medical records
   –   Autopsy
   –   Coroner reports
   –   Selected hospital-level data
• Advisory Committee reviews to determine
   –   Pregnancy-related
   –   Cause
   –   Contributing factors
   –   QI opportunities

CMQCC: A Collaborative to advance maternity through data-driven quality improvement.
             CA-PAMR Advisory Committee
             Members (Clinicians)
• Physician and nursing leaders statewide
  – Elliott Main, MD, Chair, CMQCC
  – Debra Bingham, MS, RN, CMQCC

  –   Lisa Bollman, MS, RN, Regional Perinatal Programs of California, Perinatal Profiles
  –   Conrad Chao, MD, UC Fresno
  –   Sheila Cohen, MD, OB Anesthesia, Stanford
  –   Patsy Dailey, MD, OB Anesthesia, Mills-Peninsula Hosp / CSA
  –   Maurice Druzin, MD, Stanford
  –   Michael Fassett, MD, Kaiser So California
  –   Dodi Gauthier, MEd, RN, Assn. of Women’s Health, Obstetrics & Neonatal Nurses
  –   Katherine Gregory, MD, MPH, American College of Obstetricians and Gynecologists
  –   Kim Gregory, MD, MPH, UCLA/Cedars Sinai
  –   Thomas Kelly, MD, UC San Diego
  –   Barbara Murphy, MS, RN, California Perinatal Quality Care Collaborative
  –   Larry Newman, MD, Kaiser No California
  –   Carolina Reyes, MD, LA Best Babies
  –   Linda V. Walsh, CNM, PhD, American College of Nurse Midwives
  –   Lynn Yonekura, MD, USC
         CA-PAMR Will Report Quantitative
         and Qualitative Findings
• Quantitative
  – Database of key elements
     • Data from medical record, vital record, or discharge
       data
        – Best source, sometimes multiple sources
     • Contributing factors & judgments from Advisory
       Committee review
     • Add each successive cohort as it is completed
• Qualitative
  – Vignettes for case summaries
  – Summary of QI and teaching opportunities
            CA-PAMR Advisory Committee
            Contributing Factors Analysis
Data Elements and          Example:
 Judgments:                Obesity - Did the fact
  – Community Factors
                             that the patient is
  – Patient Factors
                             obese contribute to
  – Health Care Facility
    Factors                  the death?
  – Provider Factors       Lack of Tubing – Did
                             the lack of tubing in
Categorized As:              the L&D area
  No                         contribute to the
  Probably
  Definitely
                             death?
  Insufficient
      CA-PAMR Advisory Committee
      Contributing Factors Analysis

• Pregnancy Related: Yes/No/Possibly
• Chance to Alter Outcome:
  None/Some/Good/Strong
• Pre-conception Care Chance to Alter
  Outcome: None/Some/Good/Strong
• Cause of Death: Based on expert review
  opinion, not death certificate
• QI Opportunities:
  • Free text
  • Will be coded for themes
           CA-PAMR Quality Improvement
           Opportunities and Action Items

• Education
• Collaborative Quality Improvement Projects
    – County Public Health Department Projects
    – Hospital/Provider Projects
•   Regulation, e.g., State, Joint Commission
•   Payer Pressure
•   Year One of Five Year Process
•   CMQCC: Develop and Implement Changes
         CA-PAMR Preliminary
         Quality Improvement Themes

• Health care professional and facility factors
  – Response to obstetric hemorrhage and acute emergencies
  – Prophylaxis for pulmonary embolism and deep vein
    thrombosis
  – Management of heart disease
  – Emergency Department teams’ recognition & treatment of
    pregnancy-related conditions
     • Examples: pre-eclampsia, heart disease
• Under-appreciation of high-risk conditions
  – Appropriate level of care facility
  – Early recognition of maternal distress, use of “triggers”
  – Missing Post-partum Depression
           CA-PAMR Preliminary Quality
           Improvement Themes


• Fragmentation of care
  – Chronic care management (pre-conception and post
    delivery)
  – Access to high-risk specialists, i.e., payment, availability
  – Prenatal record availability at delivery hospital
• Lack of Public Awareness
  –   Harmful effects of Inductions
  –   Importance of pre-conception care
  –   Post-Partum Depression – recognition & treatment
  –   Connection of mortality and morbidity associated with cesarean
      sections
                CA-PAMR
                Advisory Committee
• Honoring Women’s Lives
• Honoring the Teams

• Each Death Has an Important Story to Tell
• Each Death is a Tragedy

CMQCC Role:
Extract the Lessons
Translate the Lessons Learned into Actions

CMQCC: A Collaborative to advance maternity through data-driven quality improvement.
         Making Motherhood Safe



    Improving Quality of
 Maternity Care in California

     California Maternal Quality
          Care Collaborative
 Elliott Main, MD, Principle Investigator
Debra Bingham, RN MS DrPH student,
            Program Director
                                            40
            Making Motherhood Safe

           Current MCAH Programs, CDPH

             Improving Maternal
                 Outcomes:
           Turning data into action
(1) California Maternal Quality Care Collaborative
    (CMQCC)
(2) California Pregnancy-Related and Pregnancy-
    Associated Mortality Review (CA-PAMR)
(3) Local Maternal Care Quality Improvement Project
    (Local Dept. of Health)
(4) Under Development: Regional Maternal Programs
    of California (Hospital QI)
                                                      41
             Making Motherhood Safe

            Quality Improvement Challenges

• Scale:
    – 350 Maternity hospitals with 560,000
      annual births
    – Distances, diversity, medical cultures
• Organization and Scope
    – “Lot of cats to herd”
    – Not much precedent (Great Britain)
• Budget:
    – We don’t have the budget of 10 states…
CMQCC: A Collaborative to advance maternity through data-driven quality improvement.
             Making Motherhood Safe
             California Maternal Quality Care
             Collaborative (CMQCC)

 • Data-driven Quality Improvement
 • Develop and Refine Quality Measures
 • Develop a State-wide Effort for
   Collaborative Quality Improvement
      – Leverage every existing professional group
        and hospital system
 • Examine Approaches to Reduce
   Disparities in Outcomes
CMQCC: A Collaborative to advance maternity through data-driven quality improvement.
                                                                       Call to Action!
  Maternal Deaths per 100,000 Live Births




                                            25
                                                                  Maternal Mortality Rate, California, 1970-2004
                                            20    21
                                                             18
                                                        16        16
                                            15                         15 15                                                                                                                         15.2

                                                                               13                                                                                                                        13.6
                                                                                    11 11 11 11                                           10.7                                               11.1 10.6
                                            10                                                        10                       10                        9.7                                    10.2
                                                                                                  9                                     9    9.1                           9.1
                                                                                                           8       8                                           8.5                     8.3
                                                                                                                                                   7.7
                                                                                                                       7                                                         6.7
                                                                                                               6           6        6                                5.6
                                             5
                                                                                                                HP 2010 Objective – 4.3 Deaths per 100,000 Live Births


                                             0
                                                 1970              1975                 1980                   1985             1990                 1995                          2000
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1970-2004.
Produced by California Department of Public Health, Maternal, Child and Adolescent Health Program, October, 2007.
Call to Action (2)!!
Iceberg View of OB Quality
                       Mortality: 1/10,000
                          Near Misses: 1/1,000
                              Serious
                              Morbidity: 1/100
          Call to Action (3)!!
      Maternal Quality Indicator Project (MQI)
•   Based at UCLA/Cedars Sinai (M. Lu, Lead)
•   Reviewed California Discharge Diagnosis Data
    (hospital specific) over 3 years
•   Two key maternal outcomes that exhibit great
    variability among hospitals:
     – OB Hemorrhage (range: 0.43% to 14.2%)
     – Maternal Infection (range: 0.05% to 1.67%)
       (both in adjusted, low-risk populations)
•   Large Variation (20x), well beyond what can be
    explained by coding differences
                      47
N Engl J Med 2003;349:868-74.
        “Lost in Translation”


• Biggest issue in Medicine today is not the
  lack of new cures but turning what we already
  know into action
• There is very poor compliance with specialty
  vetted recommendations and guidelines
• Hospitals/ Clinics/ Labs are very complicated
  organizations
• Complex systems are strongly homeostatic
  – Resistant to change
  – Rewards for preservation of status quo
             Making Motherhood Safe

            CMQCC: Key Founding Organizations

• State of California: Maternal, Child and Adolescent Health
  Program, Department of Public Health:
  Susann Steinberg, MD, Division Chief
  Shabbir Ahmad, DVM, MS, PhD, Acting Division Chief

• California Perinatal Quality Care Collaborative (CPQCC)
  (est. 1996):
  Jeffrey Gould, MD, MPH,
  Elliott Main, MD,
  Barbara Murphy, MS, RN,
  Debra Bingham, MS, RN, DrPH Student

CMQCC: A Collaborative to advance maternity through data-driven quality improvement.
           Making Motherhood Safe

           CMQCC Partner Organizations:

State Agencies:
• DPH: Maternal-Child and Adolescent Health
• OSHPD Healthcare Information Division
• Office of Vital Records (OVR)
• Regional Perinatal Programs of California (RPPC)
Public Groups
• California Hospital Accountability and Reporting Taskforce (CHART)
• March of Dimes (MOD)
Professional groups
• American College of Obstetrics and Gynecology (ACOG)
• Association of Women’s Health, Obstetric and Neonatal Nurses
   (AWHONN)
• American College of Nurse Midwives (ACNM)
Key Medical and Nursing Leaders
• University and Hospital Systems
• Kaisers, Sutter, Sharp, CHW, Scripps, Public hospitals
               CMQCC “Spheres of Activity”



Executive
Committee               Analysis                Data



                                                    Qual
                 Partners                          Improv

                                Commun-
                                 ications

CMQCC: A Collaborative to advance maternity through data-driven quality improvement.
             Analysis Sphere

Maternal                                    Pregnancy
Quality                                     Associated
                                            Mortality
Indicators     MQI          PAMR            Review
             -ID/Valid of   -Review of
             measures       Mat Mort
             -Analysis of   -ID of improv
             large admin    opportunities
             data sets      -Pub Health

                      Other
                      -Systems
                Data Sphere

California                                      California
Maternal                                        Perinatal
Quality Care      CMQCC         CPQCC           Quality Care
Collaborative                                   Collaborative
                 -All births:   -<1500gm
                 -Vital Rec‟s   -“Big babies”
                 -M+C Dx
                 Diagnoses           MIT         Maternal
                                                 Information
                      Other       -Systems       Technology
                                                 Workgroup
                    -Other State
                      data sources
              Quality Improvement Sphere


                                              California
Maternal         MQIP        CHART            Hospital
Quality
                                              Accountability
Improvement    -Tool kits   -Public release   Reporting
Project
               -Regional      measures        Taskforce
               -Capacity
               -Diffusion
                             Other
               -Sustain-    -Conferences
                ability     -Collaboration
                            -Web
Public Release Measures
        Confidential Release Measures


• Perinatal Profiles
  – Hospital level FMR, NMR, PMR
  – Delivery of VLBW infants at hospitals without
    appropriate level of care
• Neonatal outcomes
  – CPQCC (VONN)
• Maternal outcomes
  – Based on yearly combined BC/DxDx data set
    (both mother and infants)
        Maternal Quality Improvement
        Panel (MQIP)—Direct to Hospitals

• State-wide Collaborative (provider-driven)
  – Identify key quality topics
  – Develop Tool-Kits and intervention strategies
  – Increase Quality Improvement Capacity
  – Expand and regionalize QI efforts (diffusion)
  – Maintain gains (sustainability)
  – Coordinate with measures
  – Develop Partnerships!
              What are Quality Priorities?
              Variation of Opinion…
• Maternal Mortality Reviews:       • Provider Interviews:
   – OB hemorrhage                      – Labor inductions
   – Critical care support              – OB hemorrhage
   – Venous Thrombosis                  – Early labor admissions
      prevention                        – Lack of access to
   – Lack of recognition of               specialists
      severe maternal illness           – Lack of standardization for
   – Prior Cesarean birth                 oxytocin use
   – Maternal obesity               • Payers/Public Interviews:
   – Lack of access to                  – Labor Cesarean births rate
      specialists
                                        – Poor term baby outcomes
   – Lack of recognition/care for
                                        – 3rd and 4th degree lac’s
      Postpartum depression
                                        – VBAC accessibility
                                        – Preterm birth, particularly
                                          34-37 weeks
               (3) Engaging Local Public Health
                  Departments in Maternal QI
 • Maternal Care Quality Improvement Project
      – Three-year quality improvement project with
        2-5 Local Health Jurisdictions (LHJ)
      – Focus on the role of LHJs’ to reduce
        maternal mortality and morbidity thereby
        improving pregnancy and birth outcomes
      – Provide technical assistance to LHJs’ for
        quality improvement interventions.
      – Build Partnerships
 • Implementation Phase – State FY 2008/2009

CMQCC: A Collaborative to advance maternity through data-driven quality improvement.
                (4) Regional Maternal Programs of
                   California (In Development Phase)
                               Teach and Implement Rapid-Cycle Change
                               Approach to Quality Improvement
       (5) Track         (1) Mobilize               MAP-IT:
          Making Motherhood Safe                    •Mobilize Groups
                                                    •Assess data
                                                    •Plan Standards &
                                                    Changes
                                                    •Implement
                                                    Changes
(4) Implement                  (2)Assess            •Track Progress

                                                    Sustain and
                                                    continue to improve
                                                    (upward spiral)
                   (3) Plan

  Regional Hospital-Based QI: Six-year projects for 4 of the 11
  existing regional perinatal programs
Communications Sphere



    Web        Partners
  -Information -Newsletters
  -Push News -Agendas
  -Meetings    -Links
  -Community

           Other
        -Conferences
        -Speakers
Partners Sphere




  „Strategic‟     Other
    -Govt       -Qual Org
    -Prof Org   -Other States
    -Systems    -National
    -Payers       Prof Org
                -CDC
             CMQCC Spheres



                       Analysis                 Data
                     MQI PAMR              CM- CP-
                                             MIT

                                                    Qual
                 Partners
                              Web                  Improv
                „Strategic‟
                                                     MQIP
                   Other    Partners
                                                    CHART
                                Commun-
                                 ications
CMQCC: A Collaborative to advance maternity through data-driven quality improvement.
                Interactions



                        Analysis                Data



                                                    Qual
                 Partners                          Improv

                                Commun-
                                 ications

CMQCC: A Collaborative to advance maternity through data-driven quality improvement.
8 Cell Embryo…




        …give us another 9 months!
               CMQCC---Summary

• Analysis of maternal death cases and
  administrative data sets have identified
  significant improvement opportunities
• We have developed a large-scale
  evidence-based data-driven quality
  improvement collaborative and are “off
  and running”
• The scale of California remains a
  daunting challenge…
CMQCC: A Collaborative to advance maternity through data-driven quality improvement.

				
DOCUMENT INFO
Description: California Birth Certificate document sample