addressing maternal mortality and severe maternal ...thromboembolism 10-15% 5% 2% infection 10-15%...
TRANSCRIPT
Elliott K. Main, MD
Medical Director, CMQCC
Professor of Obstetrics and Gynecology,
Stanford University
Addressing Maternal
Mortality And Severe
Maternal Morbidity (SMM)
Supported by:
California Dept. of Public Health
California Health Care Foundation
Centers for Disease Control (CDC)
Merck for Mothers Project
Yellow Chair Foundation
Reduction of Maternal Mortality is One of the
Greatest Public Health Success Stories of the Last Century
CDC
17.3
In the last 15 years,
US has seen rises in:
Maternal Mortality:
Up 50-70%
Severe Maternal
Morbidity:
Up 100 %
Cesarean Births:
Up 50%
NCHS
From
cdc.gov
1.6%
2X
Search:
Severe
Maternal
Morbidity
Maternal Mortality and Severe MorbidityApproximate distributions, compiled from multiple studies
CauseMortality(1-2 per
10,000)
ICU Admit(1-2 per
1,000)
Severe Morbid
(1-2 per
100)
Thromboembolism 10-15% 5% 2%
Infection 10-15% 5% 5%
Hemorrhage 10-15% 30% 45%
Preeclampsia 10-15% 30% 30%
Cardiac Disease 25-30% 20% 10%
Main et al. Pregnancy-Related
Mortality in California.
Obstet Gynecol 2015
Pre-pregnancy BMI Among Major Causes of Death
Only two
causes had
high rates of
obesity
Cause of Death North Carolina
“Preventable”
California
“Good or strong
chance to alter
the outcome”
United Kingdom
“Substandard
care that had a
major
contribution”
Hemorrhage 93% 70% 44%
Preeclampsia 60% 60% 64%
Sepsis / Infection 43% 50% 46%
DVT / VTE 17% 50% 33%
Cardiomyopathy 22% 29% 25%
AFE 0% 0% 15%
Assessments of Preventability
• California Pregnancy Associated Mortality Reviews– Missed triggers/risk factors: abnormal vital signs, pain,
altered mental status/lack of planning for at risk patients
– Underutilization of key medications and treatments—did not have a plan!
– Difficulties getting physician to the bedside
– “Location of care” issues involving Postpartum, ED and PACU
• University of Illinois Regional Perinatal Network- Failure to identify high-risk status
- Incomplete or inappropriate management
Key Provider Quality Improvement (QI) Opportunities:
Hemorrhage and Preeclampsia
CDPH/CMQCC/PHI. The California Pregnancy-Associated Mortality Review (CA-PAMR): Report
from 2002 and 2003 Maternal Death Reviews. 2011 (available at: CMQCC.org)
Geller SE etal. The continuum of maternal morbidity and mortality: Factors associated with
severity. Am J Obstet Gynecol 2004; 191: 939-44.
Present in >95% of
cases
Present in >90% of
cases
9
◼ Most common preventable causes of
maternal mortality
◼ Far and away the most common causes of
Severe Maternal Morbidity
◼ High rates of provider
“quality improvement opportunities”
Obstetric Hemorrhage and
Preeclampsia: Summary
3 Deadly D’s:
Lost Mothers
Series
Rene Martin,
ProPublica
Renee Montagne,
NPR News
Winner of the
George Polk
Award in
Journalism
(2018)
IMPROVING POPULATION HEALTH OF WOMEN
Maternal Mortality Review Committees
conduct detailed reviews to get complete
and comprehensive data on maternal deaths to prioritize prevention
efforts.
Perinatal Quality Collaboratives
mobilize state or multi-state networks to implement quality
improvement efforts and improve care for mothers and babies.
Alliance for Innovation on Maternal Health moves established
guidelines into practice with a standard
approach to improve safety in maternity care.
MMRCs
PQCsAIM
Zaharatos, CDC, 2018
Identify Issues
CDCCreate Action Steps
HRSA/MCHB
Dissemination Implementation
MCHB / CDC
Community Maternal Health Service Providers and MCH Organizations
● Engagement of public health community programs
● Increase access to care through promotion of collaborative care.
● Engage public voices
Hospitals, Providers, Nurses, Offices,
and Patients
● Create QI Team to implement safety bundles
● Engage wide-range of stakeholders
● Review progress through AIM Data Portal
Perinatal Collaborative: State DPH, Prof Groups Hospital Associations
● Support/coordinate/share hospital QI efforts
● Mobilize state-level resources and partners
● Use state data for outcome metrics
National Pub Health Community, and
Prof Organizations
● Engage/coordinate national partners
● Develop and share resources
● Promote Inter-state relations/sharing
● Support multi-state data platform
AIM Works at National, State, Facility and Community Levels for Implementation
11.1
7.7
10.0
14.6
11.8 11.7
14.0
7.4
7.3
10.9
9.7
11.6
9.2
6.2
16.9
8.9
15.1
13.1
12.19.9
9.9
9.8
13.3
12.7
15.516.9
16.6
19.3
19.9
22.0
0.0
3.0
6.0
9.0
12.0
15.0
18.0
21.0
24.0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Year
California Rate
United States Rate
Maternal Mortality Rate,
California and United States; 1999-2013M
ate
rnal D
eath
s p
er
100,0
00 L
ive B
irth
s
California: ~500,000 annual births, 1/8 of all US births
CA Mortality Review Committee
Key Steps for Improving Care “At Scale”
◼ Linking public health surveillance to actions
◼ Mobilizing a broad range of public and private
partners
◼ Developing a rapid-cycle Maternal Data Center
to support and sustain QI projects
◼ Implementing a series of data-driven large-
scale quality improvement projects
Main etal: Health Affairs 2018; 37:1484-93
CMQCC’s Key Stakeholders/ PartnersState Agencies
◼ CA Department of Public Health, MCAH
◼ Regional Perinatal Programs of California (RPPC)
◼ DHCS: Medi-Cal
◼ Office of Vital Records
◼ Office of Statewide Health Planning and Development (OSHPD)
◼ Covered California
Membership Associations
◼ Hospital Quality Institute (HQI)/California Hospital Association (CHA)
◼ Pacific Business Group on Health (PBGH)
◼ Integrated Healthcare Association (IHA)
Key Medical and Nursing Leaders
◼ UC, Kaiser (N&S), Sutter, Sharp, Dignity Health, Scripps, Providence, Public hospitals
16
Professional Groups (California sections of national organizations)
◼ American College of Obstetrics and Gynecology (ACOG)
◼ Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)
◼ American College of Nurse Midwives (ACNM)
◼ American Academy of Family Physicians (AAFP)
Public and Consumer Groups
◼ Consumers’ Union
◼ March of Dimes (MOD)
◼ California HealthCare Foundation (CHCF)
◼ Cal Hospital Compare
◼ Amniotic Fluid Embolism Foundation
Health Plans
◼ Commercial and Managed Medi-Cal Plans
OB Quality/Safety
Project
Performance Measures/ Public
Reporting
Collected Evidence/ QI Tool Kit
Professional Org Leadership
Data-driven QI Collaborative
Hospital Association Joint
Commission
Health Plans (Commercial
and Medicaid)
Purchaser/ Employer
Engagement
Patient + Public EngagementAddress Unit
Culture Issues
Pull As Many Levers as Possible: Collective Impact
Change at Scale Require External Pressures
18
CMQCC Maternal Data Center
Links over 1,000,000 mother/baby records each year!
Maternal Safety Bundles
◼ ReadinessEvery unit—prepare and educate
◼ Recognition & PreventionEvery patient—before event
◼ ResponseEvery Event—team approach
◼ Reporting/Systems LearningEvery unit—systems improvement
Available (with resource links) at: safehealthcareforeverywoman.org
Uniform Structure:
• “Checklist” of items and
practices for every birthing site
• Not a national protocol!!
• Facilities will modify content
based on local resources
What are they?
Hemorrhage Toolkit
>14,000 Downloads to date
CMQCC.org
11.1
7.7
10.0
14.6
11.8 11.7
14.0
7.4
7.3
10.9
9.7
11.6
9.2
6.2
16.9
8.9
15.1
13.1
12.19.9
9.9
9.8
13.3
12.7
15.516.9
16.6
19.3
19.9
22.0
0.0
3.0
6.0
9.0
12.0
15.0
18.0
21.0
24.0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Year
California Rate
United States Rate
Maternal Mortality Rate,
California and United States; 1999-2013M
ate
rnal D
eath
s p
er
100,0
00 L
ive B
irth
s
California: ~500,000 annual births, 1/8 of all US births
CMQCC
CA Mortality Review Committee
Toolkits and Collaboratives
California Quality Improvement Projects
Years Projects
2006 California Pregnancy-Associated Mortality Review established
2008 CMQCC/CDPH OB Hemorrhage Task Force
2009-10 CMQCC Hemorrhage QI collaboratives I and II
2010-11 CMQCC/CDPH Preeclampsia Task Force and QI collaborative
2011 Release of CDPH Maternal Mortality report and education campaign
2011-14HEN/CMQCC/CHA-HQI QI collaborative focused on Hemorrhage and
Preeclampsia
2015-16CMQCC/Merck for Mothers QI collaborative for Reduction of Hemorrhage
and Hypertension (HTN) severe morbidity
2016-19CMQCC QI collaboratives (3 cohorts) for Supporting Vaginal Birth and
Reducing Primary Cesarean Delivery
Preeclampsia
◼ Toolkits and Safety Bundles
CMQCC Preeclampsia Toolkit: 2014
Council on Patient Safety in Women’s Health Safety Bundle: 2017
◼ Early treatment of severe HTN decreases SMM and eclampsia
(Shields, AJOG 2017)
Adoption of CMQCC toolkit at 23 hospitals
◼ Focused on early recognition and treatment, MgS04, PP follow up
Eclampsia decreased by 43%, SMM decreased by 29%
Intensive monitoring of HTN treatment metrics necessary to cause change
(in practice and outcome)
◼ Successful QI requires monitoring, clear metrics
Controlling blood pressure
is the key intervention
to prevent deaths due to stroke
in women with preeclampsia.
“Treat the Damn Blood Pressure!”
Over the last decade, the UK has focused
QI efforts on aggressive treatment of both
systolic and diastolic blood pressure and
has demonstrated a reduction in deaths.
Severe Maternal Hypertension Treated Within 60 Minutes
27
41%
48%51% 53% 55%
60%65% 66%
73%70% 72%
77% 77%73% 72%
76%
82%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Baseline(Oct -
Dec 15)
July-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 June-17 July-17 Aug-17 Sep-17 Oct-17
Proportion of Hospitals with 80% of women treated within 60 min
Percent overall women in collaborative treated within 60 min
13%
Increased 41% to 82%Change per Month, aOR = 1.11, 95% CI 1.10-1.12 P < 0.001
71%
Severe Maternal Hypertension with Severe Maternal Morbidity Reported
28
15%15%
16%
14%
12%
18%
9%
16%
10%
11%
17%
11%
13%
8%
12%
10%
9%
9%
9%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
Baseline(Oct -Dec
2015)
May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
Pe
rce
nt
of
Wo
me
n w
ith
SM
M
Monthly change, aOR=0.98, 95% CI 0.96-0.99P < 0.004
15% baseline to 9% last quarter41% reduction
*When adjusted for hospital characteristics results were unchanged
Serena Williams’ Story
of Not Being Listened To
Despite history of multiple PE, her doctors and
nurses minimized her PP complaints and refused
a CT scan (later positive for multiple small PE)
Lt. Comdr. Shalon Irving PhD
U.S. Maternal Mortality by Race/Ethnicity
Moaddab A et al. Obstet Gynecol
2018;131:707-12.
Pregnancy-related
Mortality Rates By Race:
New York City
12X
7.0
7.1
26.4
37.2
33.8
41.1
46.1
51.0
41.5
45.7
35.3
32.2
29.0
29.5
27.7
4.9
9.1 7.8
7.6
3.83.2
3.83.74.3
3.9
3.93.1 3.0 3.0
3.8 3.8
4.4
0
10
20
30
40
50
60
1999-
2001
2000-
2002
2001-
2003
2002-
2004
2003-
2005
2004-
2006
2005-
2007
2006-
2008
2007-
2009
2008-
2010
2009-
2011
2010-
2012
2011-
2013
Three-Year Moving Average
0
1
2
3
4
5
6
7
8
9
10White, Non-Hispanic African-American, Non-Hispanic
Hispanic Asian, Non-Hispanic
AA-W Mortality Disparity Ratio
Mate
rnal M
ort
alit
y R
atio
(pe
r 1
00
,000
liv
e b
irth
s)
Morta
lity D
isparity
Ratio
Maternal Mortality Rate, By Race/Ethnicity
Three–Year Moving Averages; 1999-2013California Only Data
California Racial / Ethnic Disparities
Total sample
~3.1million (8 years)
Hispanic/
Latina
Non-
Hispanic
White
Asian/
Pacific
Islander
Non-
Hispanic
Black
American
Indian
Proportion of Births 52% 29% 13% 5.5% 0.3%
Maternal Mortality (per 100,000, 2011-2013)
4.9 7.0 7.8 26.4 n.a.
Severe Maternal
Morbidity (SMM)1.5% 1.2% 1.4% 2.2% 1.9%
Pre-preg. Obesity 27% 17% 8% 30% 35%
Pre-preg. Comorbidity 6% 8% 6% 14% 11%
Maternal Age ≥35 14% 23% 30% 14% 12%
Total Cesarean 33% 33% 33% 38% 34%
Why do black women do
so much worse?
Usual explanation by doctors and nurses
is that black women have more obesity,
more hypertension, more diabetes,
and more social disadvantages…
What If We Looked At B:W Disparity In SMM
Only Among College Graduates?
California linked data: 2010-2015 Q3
Black-White disparity in SMM is
highest among college graduates
(2.2x higher than whites)
Looking At Absolute Rates:
•SMM rate in Black women with
college degrees: 2.4%
•SMM rate in White women without
high school diplomas: 1.6%
And adjusted for age, BMI and other clinical and demographic risk factors…
Educational Attainment
• Rank NYC hospitals by SMM & compare distributions of births
• 65% of whites, 23% of blacks deliver at lowest-SMM tertile hospitals
• If blacks delivered at same hospitals as white… explained 47% of black-white disparity
3 States on the ‘Runway’
How does a state Perinatal Quality Collaborative (PQC) Improve Care and Outcomes?
• Not just a convening of interested stakeholders
• Not just a system of outreach education
Courtesy: Dr. Ann Borders, Medical Director, Illinois Perinatal Quality Collaborative
Successful PQC’s:• Focus on Building Hospital
Capacity to Drive Systems & Culture Change
• Focus on building bridges with Public Health and Communities
AIM Successful AIM:• Focus on Building State
Capacity to Drive Systems & Culture Change
• Focus on building bridges with Public Health and Communities
Successful EXTERNAL Strategies for PQCs to Achieve High Rates (>90%) of Hospital Engagement
Strategy TX CA IL
Legislation encouraging participation
Promotion by DPH /Linkage to Regionalization
Linkage to LOMC program (Levels of Maternal Care)
DSRIP incentives (CMS updated disproportionate care)
News Saturation / Attention
Promotion by State Hospital Association
Health Plan incentives
Cumulative Successes (momentum)
Importance of Timely data
• Data drives hospital (and PQC) QI efforts
• No data: No direction—Are we better ? Are we worse?
• No data: Less effort—easy to put off in face of competing demands
• Benchmarking against like hospitals is powerful
• Current data cuts thru denial: “Our care is great!”
• QI Data is only good if timely: “We are much better than that currently”
• AIM data set tries to give balance to frequency vs burden (cost)
National Safety Bundle Commentary
August 2019
All these Materials Introduce a New Narrative
Key State PQC Opioid Toolkits
MNO-OB Toolkit. *Updated January 2019*
http://www.nnepqin.org/wp-content/uploads/2019/03/Toolkit-for-
Perinatal-Care-of-Women-with-Substance-Use-Disorders_Final-2019.pdf
https://www.acog.org/About-ACOG/ACOG-
Districts/District-II/Opioid-Use-Disorder-in-
Pregnancy?IsMobileSet=false
http://ilpqc.org/?q=MNO-OB
Conclusions
• We know what to do to reduce maternal mortality and morbidity
• It takes collective action of all key stakeholders
• State Perinatal Quality Collaboratives are central but need support
• There are Federal agencies involved but state organizations are critical