C-sections give way to VBACs and better quality
QI project spurs 'cutting-edge quality'
A recent quality improvement project in Arkansas not only effected cost reductions but also provided Medicaid recipients and their physicians safer childbirth options. By encouraging hospitals and physicians to perform fewer repeat cesarean deliveries, the Arkansas Foundation for Medical Care (AFMC) in Fort Smith saved its state's Medicaid program nearly a quarter of a million dollars last year.
Participating hospitals throughout Arkansas successfully reduced their Medicaid cesarean rates by 11%. At the core was a 51% increase in vaginal births after cesareans (VBACs). The total number of institutions with cesarean rates greater than 30% fell from 15 to 10. Those 15 hospitals performed more than 1,000 cesarean deliveries in 1994; in the 1996-1997 data, 10 hospitals performed 394 sections. Efforts to increase VBAC rates were successful as well.
In a statement about the project, Roy Jeffus, assistant director for the Arkansas Division of Medical Services, said, "Hospitals that participated in AFMC's study are on the cutting edge of quality consciousness." When a medical procedure can reduce risk to mother and child while leading to fewer complications and shorter hospital stays, he said, it not only cuts costs but improves the overall quality of the care received.
Successful vaginal delivery reduces the risk of maternal mortality and morbidity and reduces length of stay. Cesareans typically cost about $2,000 more than vaginal deliveries.
At the start of AFMC's project in 1995, cesarean rates in Arkansas were higher than national figures - about 27% vs. just under 23%. The VBAC rate for that year was just under 25% in the United States, while it was about 16% in Arkansas. The project demonstrated that some Arkansas hospitals - particularly smaller ones - had cesarean rates higher than 35%. It also demonstrated that there is little difference in cesarean rates between Arkansas institutions with low delivery volumes and those with high volumes. A trend was seen, however, toward more cesareans in older women.
AFMC is a nonprofit peer review and quality improvement organization for both Medicare and Medicaid in the state. Arkansas Medicaid covers approximately 14,000 deliveries each year - 40% of the state's total - so AFMC's project made a sizable impact. But results impact more than just Medicaid's bottom line," says William E. Golden, MD, principal clinical coordinator of the foundation. "Positive results like these encourage hospitals and health care providers to monitor their own performance improvement opportunities."
Sixty-two percent of Arkansas hospitals providing obstetrical services embarked on studying or implementing a project. Once the project team gathered data from participating hospital administrators related to Medicaid cesarean rates, they shared the information with hospitals statewide, says Sandy Grinder, RN, BSN, CPHQ, Health Care Quality Improvement Program Director at AFMC. "We let them know what the rates were and encouraged them to review their facilities' relative use of C-sections compared to state norms. Then we offered suggestions and recommendations for looking at their VBAC programs and how they might improve their own rates." AFMC followed up a year or two later to see if interventions at the hospitals had affected the cesarean rates. "We found that the hospitals that participated in the project decreased their C-section rates significantly," says Grinder.
AFMC is an ORYX vendor. The foundation collects measures from 10 to 15 hospitals statewide and sends them on to the Joint Commission for analysis. "The hospitals have signed on with us to be their intermediary with the Joint Commission," says Golden. "Many have used QI projects that we've suggested, and they've gone ahead and offered the implementation of those projects to the Joint Commission as evidence of CQI in their hospitals." The ORYX system requires ongoing performance measurement, and obstetrics is a major category of discharge.
"We plan to take the project C-section data and risk-adjust it," continues Golden. The project team has identified high-risk patients, and is using administrative data to eliminate them from the data. Once that's done, the team will reconfigure the statistics and feed the data back to the hospitals so they can have more uniform information regarding performance on low-risk cases.
"It's a win for everybody," says Golden. "This is one in a series of projects we've done with providers throughout the state that has proven to be an effective mechanism to change clinical practice. Through this study, we have been able to bring about more ideal care while at the same time reducing health system costs. We are moving the standard of care closer to what is described by experts in guidelines while reducing cost."
According to the U.S. Department of Health and Human Services, the mortality rate for mothers giving cesarean births is two to 26 times higher than for mothers having vaginal deliveries, yet cutting-procedure rates have increased dramatically since 1965. In 1993, the rate of cesareans in the United States was 22.8 per 100 deliveries, the lowest since 1985, but approximately four times that of 1970. The Public Health Service has recommended that, by the year 2000, the cesarean rate be reduced to 15%. Repeat cesareans constituted 8.3% of all deliveries and 34% of all cesareans.
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