GHA lowers cesareans through patient counseling
Expectant moms appreciate extra time with doctors
Patient expectations posed the biggest challenge in reducing cesarean rates at Group Health Associates (GHA) in Cincinnati. When expectant moms told obstetricians they wanted cesareans, the doctors conceded without pursuing the option of vaginal birth after cesarean (VBAC). Cesarean rates for the nine obstetricians at GHA, who attended 75 to 100 deliveries a month, averaged 20% to 21%. While this was in line with regional and national rates, there was room for improvement.
A resounding wake-up call came from the managed care companies that review cesarean rates in contract negotiations. Lisa Yang, MD, director of the department of obstetrics and gynecology, notes that, in most cases, patient outcomes following vaginal birth are superior. The length of stay is one or two days, compared to three or four days following cesareans. Recovery time from vaginal delivery is shorter, as well.
Old baggage blocked any illusions that change would come swiftly, Yang explains. "In the 1970s and 1980s, many women had unnecessary procedures for the convenience of a scheduled delivery. And the doctors didn’t have to sit through labor when a patient came in for a cesarean."
The process of reducing cesarean rates at GHA started in 1995 when a group of GHA’s doctors attended a learning session sponsored by the Boston-based Institute for Healthcare Improve ment. Since that time, they’ve pared the numbers down to 16%-17%, significantly below the regional average. Their method, as Yang tells us, was low-key and hardly noticeable to the patients. And, one reward for the obstetricians was less paperwork.
When it came to changing patient attitudes, the doctors had their work cut out for them. "There’s the old adage, once a cesarean, always a cesarean,’" Yang observes. "Women had a fear of doing it any other way. For some, it was a fear of labor."
As far as the physicians were concerned, "once they met resistance from patients, they agreed to do cesareans," Yang says. Much of GHA’s cesarean committee work involved teaching doctors how to counsel patients regarding VBAC. With stronger counseling skills, obstetricians were less likely to make automatic concessions to patient expectations. "Instead of allowing patients to control the process, the doctors were coached on how to offer a trial of labor," she explains.
Doctor-patient interaction changes
More than any tangible intervention, Yang credits success to the attitude shift among the doctors. Now, unless clear contraindications exist, they offer VBAC to each expectant mom with a cesarean history. Counseling begins at the first of the 14 standard prenatal visits.
The doctor sits down and explains the potential for successful VBAC and asks the expectant mother to consider it. He or she provides referrals to prenatal classes on labor and delivery preparation. Each counseling encounter is documented in the chart. Most women agree to a trial of labor after a few conversations with their doctors.
During the last month of pregnancy, obstetricians document the fetus’ position. If it is breech, they perform external cephalic version (ECV), turning the baby to a head-down presentation through external manipulation. Yang explains that for the 3% of fetuses who present in breach position, ECV is successful for 60% to 70%.
To schedule a cesarean, obstetricians must go through a committee for approval. If patients decline a trial of labor after counseling at several appointments, the doctor takes the case to a committee. If the committee deems the woman a candidate for successful VBAC, the doctor explains that "several physicians agreed that we should go through a trial of labor before doing a cesarean." In the rare instances where patients still insist on cesareans at this point, they are offered cesareans.
Most women report high satisfaction after a successful VBAC, Yang says. They are especially pleased with the short recovery period after vaginal birth and the extra opportunity to talk with their doctors during prenatal visits.
GHA tracks each obstetrician’s cesarean rates. But when you do that, stresses Yang, you need accurate data collection. "Doctors will question the accuracy of the system, especially if their rates happen to be high. If there is one mistake in the numbers, they’ll throw out the whole data set."
Voice mail reduces paperwork
To solve the ever-present challenges of accurate and timely data gathering, GHA turned to voice mail technology. As soon as a doctor charts a delivery, the paperwork is finished. Then, in just 30 seconds of phone time, they can complete the billing. To do it, they call a special phone number and dictate billing information including the patient identification number and baby’s birth weight, specifying whether delivery was cesarean or VBAC. Each doctor has a card, similar to a credit card, listing the data they need to report. "Everyone can get to a phone 24 hours a day," Yang notes.
The system eliminates a piece of paperwork for the physicians. She explains, "You don’t have to take a piece of paper to your office and fill it out later." Sometimes weeks or months would go by before billing slips made their way back for processing. Yang wouldn’t be surprised if some were lost forever.
For the GHA billing staff, downloading data from the voice mailbox speeds up claims processing and the turnaround of accurate labor and delivery statistics for the cesarean committee.
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