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How One Hospital Brought Its C-Sections Down in a Hurry

Many facilities don’t act until dollars are at stake, expert says

Hoag Memorial Hospital Presbyterian, one of the largest and most respected facilities in Orange County, California, needed to move quickly. A big insurer had warned that its maternity costs were too high and that it might be cut from the plan’s network. The reason? Too many Cesarean sections.

The C-section rate at the time, in early 2012, was about 38%. That was higher than the state average of 33% and above most others in the area, according to the California Maternal Quality Care Collaborative, which uses data to improve birth outcomes.

Within 3 years, Hoag had lowered its Cesarean section rates for all women to just over a third of all births. For low-risk births (first-time mothers with single, normal pregnancies), the rate dropped to about a quarter of births. Hoag also increased the percentage of women who had vaginal births after delivering previous children by C-section.

In medicine, this qualifies as a quick turnaround. The story of how Hoag changed sheds light on what it takes to rapidly improve a hospital’s performance of crucial services, to the benefit of patients, insurers, and taxpayers, according to a new report from Kaiser Health News.

Experts have long been troubled by the wide variation of C-sections among hospitals nationally. (In California, the rates range from 18% to 56%.) The disparities suggest that decisions are being driven by factors other than medical necessity, such as doctors’ time constraints and malpractice concerns.

Across California, data publicly released by the California HealthCare Foundation, the Pacific Business Group on Health, and others in the past few years have underscored the differences in how hospitals handle maternity care.

Despite the increased transparency, however, many hospitals don’t act until dollars are at stake, said Dr. Elliott Main, medical director of the California Maternal Quality Care Collaborative. That’s what happened with Hoag, which Main said is now becoming a model for others.

At Hoag, where more than 6,000 babies are born each year, administrators knew they had to focus on changing the mindset and behavior of physicians, so they took some aggressive steps. First, they shared the data with all the physicians in the department without names — and then decided to reveal the names. Suddenly, everyone knew who had exceeded or come in under the average.

Some physicians reacted with surprise and frustration. Initially, many attributed the high rates to the patients, saying they were older, had more complicated pregnancies, or demanded scheduled C-sections.

Hoag’s administrators were aiming for a realization among doctors that C-sections should not be undertaken lightly. They carry surgical risks, including serious infection and blood clots, and require longer hospital stays.

The costs are also well-documented. Surgical births cost nearly $19,000, compared with about $11,500 for vaginal births, according to the Pacific Business Group on Health, which worked with Hoag on the financial side. It enlisted the help of some of the biggest local employers, including Disney, and another insurer, Blue Shield, to adjust payments so the hospital didn’t earn more from elective C-sections than from vaginal births.

In addition, the hospital set new scheduling rules. In the past, doctors could simply call in with the woman’s due date and schedule the birth. Now, they would have to fill out a detailed form, with some requests needing special approval.

The hospital also stepped up its patient education, encouraging women to wait for labor to come naturally. If patients wanted an elective C-section, they had to sign an easy-to-understand consent form in the doctor’s office that detailed the risks. In addition, nurses received end-of-year bonuses if they helped the hospital reach certain goals on reducing surgical births.

The hospital opened an obstetrics emergency department and gave more responsibility to “laborists,” doctors who were on-site around the clock to respond to emergencies, to monitor women in labor, and to deliver babies.

Dr. Alex Deyan, who delivered more than 500 babies at the hospital last year, used to turn away patients who wanted vaginal births after cesarean sections. With a busy private practice, Deyan said he couldn’t always be immediately available if labor didn’t go as expected and a woman needed a C-section. That changed with the “laborist” program.

Source: Kaiser Health News; May 11, 2015.

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