Monday, September 30, 2013

MPH Project - Part 2a

Find context and Part I here.

The next section of my culminating project included two parts:
  • first, information about the major existing quality initiatives and measurements in US maternity care, and
  • second, a literature review intended to answer the question: What do people in the US want from their maternity care?
The first part was an exercise in achieving brevity even within the fairly generous confines of the assignment; here it is going to be barely more than a list.

Major public initiatives
  • Healthy People 2020 - a once-a-decade project that measures a pretty incredible number of health indicators and sets goals for improvement. In the area of maternity care, it currently includes objectives and national-level data for various fetal and infant death measurements, a maternal morbidity indicator, cesarean births, low birth weight and preterm birth (including births at appropriately-equipped hospitals), prenatal care and several prenatal health behavioral indicators, postpartum home visits, several breastfeeding and breastfeeding support measures, percent of pregnant women receiving flu shots and HIV testing, and iron deficiency in pregnant women. (If you've never been to before, go check it out; it's nicely put together and will give you warm fuzzies about the government, something we can all use a touch of now and again.)
  • AHRQ measures - The Agency for Healthcare Research and Quality has established standardized measures in several categories; 11 measures relate to maternity care, including low birth weight rate, four measures having to do with method of delivery, three having to do with (physical) obstetric trauma, and three measures of neonatal care quality. Note: AHRQ doesn't collect data itself using these measures; it provides them to other organizations as standardized ways of looking at their own data. For example, a state might report on its hospitals' achievements on one or more of the AHRQ measures.
Major private initiatives
  • The National Quality Forum, similar to AHRQ, has a set of 14 perinatal care measures that have undergone stringent consensus processes. They include elective early delivery, cesarean rates, breastfeeding, and several infection-prevention and prematurity-related process measures. Also like AHRQ, NQF does not collect data using these measures.
  • The Joint Commission (JCAHO), which is the largest hospital accrediting organization in the US, recently created a set of five perinatal care measures: elective delivery, cesarean section, antenatal steroids, bloodstream infections in newborns, and exclusive breast milk feeding. Beginning in 2014, hospitals with more than 1,100 births annually that are accredited by JCAHO will be required to report their quality data using these measures. Furthermore, JCAHO reports the data they collect to the public! Woohoo!
  • Leapfrog and Healthgrades are two of the best consumer-oriented hospital quality resources currently available, although neither has complete data: Leapfrog data is reported by hospitals that choose to participate; Healthgrades purchases all-payer data for some of the states. In the area of maternity care, Leapfrog currently provides measures for experience with very low birth-weight babies, elective early delivery, episiotomy, jaundice screening, and blood clot prevention for cesarean deliveries. HealthGrades reports complication rates following vaginal and cesarean delivery, newborn survival, volume, and cesarean rate.
Unreported Measures

Here are two major ideas from the scholarly literature about measuring maternity care quality. As far as I know (haven't looked extensively or recently, though), no large jurisdictions are regularly collecting and reporting using these measures.
  • The Optimality Index is designed to measure maternity care quality with the presupposition that "non-intervention in the absence of complications" is the goal. It awards points on 41 items from prenatal care through newborn outcomes and yields a single percentage score for a group of births, allowing (in theory) comparisons between facilities, states, etc.
  • The Adverse Outcomes Index is designed to measure major bad outcomes in maternity care without the small numbers problems that come from looking at e.g. just maternal mortality. It measures ten adverse events and yields a single summary score.
  • (There has also been tons of work trying to figure out what the best way is to look at quality in the area of delivery method (cesarean or vaginal). Recently, there has been momentum toward using the "NTSV" (nulliparous, term, singleton, vertex) cesarean rate. This serves as a sort of crude risk-adjustment since it eliminates e.g. twin births, breech births, VBAC candidates, preemies, etc.)
A few takeaways and summary points:
  • Where data is reported, it's often not useful for a consumer trying to pick a facility. Either the data is not offered at the facility level (e.g. Healthy People), or not reported uniformly (AHRQ measures), or not available for all the facilities one might want to compare (e.g. Leapfrog). The new JCAHO requirement is really exciting because it avoids most of these problems (it won't have all hospitals, but it will have a lot).
  • There are plenty of good measures available, but not enough coordinated action to use the measures to gather and publicize comparative data. Hint: this might go better if we had something resembling a national healthcare system.
  • Even the best consumer-oriented resources often need caveats. For example, although this has been corrected, HealthGrades used to give a higher score to hospitals with a higher volume of cesareans on the assumption that more experience is better. (This might work for e.g. heart surgery!) This is an extreme example, but similar interpretation problems are very common.

This post is already too long, so I'm going to break it into two posts (ugh). Part B will cover my literature review.

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