Implementation Science is Imperative to the Optimization of Obstetric Care.

In an effort aimed at improving outcomes, obstetric teams have enacted comprehensive care bundles and other clinical tools. Yet, these practices have had limited degrees of success on a national scale. Implementation science aims to bridge the divide between the development of evidence-based interventions and their real-world utilization. This emerging field takes into account key stakeholders at the clinician, institution, and health policy levels. Implementation science evaluates how well an intervention is or can be delivered, to whom, in which context, and how it may be up-scaled and sustained. Other medical disciplines have embraced these concepts with success. The frameworks and theories of implementation science can and should be incorporated into both obstetric research and practice. By doing so, we can increase widespread and timely adoption of evidence and further our common goal of decreasing maternal morbidity and mortality. KEY POINTS: · Evidence-based practices have been implemented in obstetrics with variable success.. · Implementation science aims to bridge the divide between the development of evidence-based interventions and their real-world utilization.. · The methodologies of implementation science may be helpful to obstetric research and practice..

Prior authorization and its impact on access to obstetric ultrasound.

Prior authorization is a process requiring health care providers to obtain advance approval from a payer before a patient undergoes a procedure for the study to be covered. Prior authorization was introduced to decrease overutilization of ultrasound procedures. However, it has led to unanticipated consequences such as impeding access to obstetric imaging, increased administrative overhead without reimbursement, and contribution to physician frustration and burnout. Payers often use intermediary radiology benefit management companies without providing specialty-specific review in a timely manner as is requisite when practicing high-risk obstetrics. This article proposes a number of potential solutions to this problem: (1) consider alternative means to monitor overutilization; (2) create and evaluate data regarding providers in the highest utilization; (3) continue to support and grow the educational efforts of speciality societies to publish clinical guidelines; and (4) emphasize the importance of practicing evidence-based medicine. Understanding that not all health plans may be willing or able to collaborate with health care providers, we encourage physicians to advocate for policies and legislation to limit the implementation of prior authorization within their own states.

Quality measures in high-risk pregnancies: Executive Summary of a Cooperative Workshop of the Society for Maternal-Fetal Medicine, National Institute of Child Health and Human Development, and the American College of Obstetricians and Gynecologists.

Providers perceive current obstetric quality measures as imperfect and insufficient. Our organizations convened a "Quality Measures in High-Risk Pregnancies Workshop." The goals were to (1) review the current landscape regarding quality measures in obstetric conditions with increased risk for adverse maternal or fetal outcomes, (2) evaluate the available evidence for management of common obstetric conditions to identify those that may drive the highest impact on outcomes, quality, and value, (3) propose measures for high-risk obstetric conditions that reflect enhanced quality and efficiency, and (4) identify current research gaps, improve methods of data collection, and recommend means of change.

Web-based comparison of historical vs contemporary methods of fetal heart rate interpretation.

BACKGROUND: Contemporary interpretation of fetal heart rate patterns is based largely on the tenets of Drs Quilligan and Hon. This method differs from an older method that was championed by Dr Caldeyro-Barcia in recording speed and classification of decelerations. The latter uses a paper speed of 1 cm/min and classifies decelerations referent to uterine contractions as type I or II dips, compared with conventional classification as early, late, or variable with paper speed of 3 cm/min. We hypothesized that 3 cm/min speed may lead to over-analysis of fetal heart rate and that 1 cm/min may provide adequate information without compromising accuracy or efficiency. OBJECTIVE: The purpose of this study was to compare the Hon-Quilligan method of fetal heart rate interpretation with the Caldeyro-Barcia method among groups of obstetrics care providers with the use of an online interactive testing tool. STUDY DESIGN: We deidentified 40 fetal heart rate tracings from the terminal 30 minutes before delivery. A website was created to view these tracings with the use of the standard Hon-Quilligan method and adjusted the same tracings to the 1 cm/min monitoring speed for the Caldeyro-Barcia method. We invited 2-4 caregivers to participate: maternal-fetal medicine experts, practicing maternal-fetal medicine specialists, maternal-fetal medicine fellows, obstetrics nurses, and certified nurse midwives. After completing an introductory tutorial and quiz, they were asked to interpret the fetal heart rate tracings (the order was scrambled) to manage and predict maternal and neonatal outcomes using both methods. Their results were compared with those of our expert, Edward Quilligan, and were compared among groups. Analysis was performed with the use of 3 measures: percent classification, Kappa, and adjusted Gwet-Kappa (P < .05 was considered significant). RESULTS: Overall, our results show from moderate to almost perfect agreement with the expert and both between and within examiners (Gwet-Kappa 0.4-0.8). The agreement at each stratum of practitioner was generally highest for ascertainment of baseline and for management; the least agreement was for assessment of variability. CONCLUSION: We examined the agreement of fetal heart rate interpretation with a defined set of rules among a number of different obstetrics practitioners using 3 different statistical methods and found moderate-to-substantial agreement among the clinicians for matching the interpretation of the expert. This implies that the simpler Caldeyro-Barcia method may perform as well as the newer classification system.

Impact of Obstetrician/Gynecologist Hospitalists on Quality of Obstetric Care (Cesarean Delivery Rates, Trial of Labor After Cesarean/Vaginal Birth After Cesarean Rates, and Neonatal Adverse Events).

Care via obstetric hospitalists continues to expand, quickly becoming an integral part of labor and delivery management in urban and suburban areas. Overall lower cesarean delivery rates have been found with obstetric hospitalist care. Continuous 24-hour coverage of labor units has displayed lower rates of neonatal adverse events and likely reduces time in decision to delivery. Further study is needed on maternal and neonatal outcomes to corroborate earlier observations, and to closely examine the type of obstetric hospitalist model being observed to aid in planning the ideal deployment of providers in this workforce of the future.

Removal versus retention of cerclage in preterm premature rupture of membranes: a randomized controlled trial.

OBJECTIVE: The decision of whether to retain or remove a previously placed cervical cerclage in women who subsequently rupture fetal membranes in a premature gestation is controversial and all studies to date are retrospective. We performed a multicenter randomized controlled trial of removal vs retention of cerclage in these patients to determine whether leaving the cerclage in place prolonged gestation and/or increased the risk of maternal or fetal infection. STUDY DESIGN: A prospective randomized multicenter trial of 27 hospitals was performed. Patients included were those with cerclage placement at ≤23 weeks 6 days in singleton or twin pregnancies, with subsequent spontaneous rupture of membranes between 22 weeks 0 days and 32 weeks 6 days. Patients were randomized to retention or removal of cerclage. Patients were then expectantly managed and delivered only for evidence of labor, chorioamnionitis, fetal distress, or other medical or obstetrical indications. Management after 34 weeks was at the clinician's discretion. RESULTS: The initial sample size calculation determined that a total of 142 patients should be included but after a second interim analysis, futility calculations determined that the conditional power for showing statistical significance after randomizing 142 patients for the primary outcome of prolonging pregnancy was 22.8%. Thus the study was terminated after a total of 56 subjects were randomized with complete data available for analysis, 32 to removal and 24 to retention of cerclage. There was no statistical significance in primary outcome of prolonging pregnancy by 1 week comparing the 2 groups (removal 18/32, 56.3%; retention 11/24, 45.8%) P = .59; or chorioamnionitis (removal 8/32, 25.0%; retention 10/24, 41.7%) P = .25, respectively. There was no statistical difference in composite neonatal outcomes (removal 16/33, 50%; retention 17/30, 56%), fetal/neonatal death (removal 4/33, 12%; retention 5/30, 16%); or gestational age at delivery (removal mean 200 days; retention mean 198 days). CONCLUSION: Statistically significant differences were not seen in prolongation of latency, infection, or composite neonatal outcomes. However, there was a numerical trend in the direction of less infectious morbidity, with immediate removal of cerclage. These findings may not have met statistical significance if the original sample size of 142 was obtained, however they provide valuable data suggesting that there may be no advantage to retaining a cerclage after preterm premature rupture of membranes and a possibility of increased infection with cerclage retention.

Implementation of a laborist program and evaluation of the effect upon cesarean delivery.

OBJECTIVE: Laborist programs have expanded throughout the United States in the last decade. Meanwhile, there has been no published research examining their effect on patient outcomes. Cesarean delivery is a key performance metric with maternal health implications and significant financial impact. Our hypothesis is that the initiation of a full-time dedicated laborist staff decreases cesarean delivery. STUDY DESIGN: In a tertiary hospital staffed with private practice physicians, data were retrospectively reviewed for 3 time periods from 2006 through 2011. The first period (16 months) there were no laborists (traditional model), followed by 14 months of continuous in-hospital laborist coverage provided by community staff (community laborist), and finally a 24-month period with full-time laborists providing continuous in-hospital coverage. The primary hypothesis was that full-time laborists would decrease cesarean delivery rates. RESULTS: Data from 6206 term nulliparous patients were retrospectively reviewed. The cesarean delivery rate for no laborist care was 39.2%, for community physician laborist care was 38.7%, and for full-time laborists was 33.2%. With adjustment via logistic regression, full-time laborist presence was associated with a significant reduction in cesarean delivery when contrasted with no laborist (odds ratio, 0.73; 95% confidence interval, 0.64-0.83; P < .0001) or community laborist care (odds ratio, 0.77; 95% confidence interval, 0.67-0.87; P < .001). The community laborist model was not associated with an effect upon cesarean delivery. CONCLUSION: A dedicated full-time laborist staff model is associated with lower rates of cesarean delivery. These findings may be used as part of a strategy to reduce cesarean delivery, lower maternal morbidity and mortality, and decrease health care costs.

Putting the "M" back in maternal-fetal medicine.

Although maternal death remains rare in the United States, the rate has not decreased for 3 decades. The rate of severe maternal morbidity, a more prevalent problem, is also rising. Rise in maternal age, in rates of obesity, and in cesarean deliveries as well as more pregnant women with chronic medical conditions all contribute to maternal mortality and morbidity in the United States. We believe it is the responsibility of maternal-fetal medicine (MFM) subspecialists to lead a national effort to decrease maternal mortality and morbidity. In doing so, we hope to reestablish the vital role of MFM subspecialists to take the lead in the performance and coordination of care in complicated obstetrical cases. This article will summarize our initial recommendations to enhance MFM education and training, to establish national standards to improve maternal care and management, and to address critical research gaps in maternal medicine.

Prenatal detection of congenital heart disease in southern Nevada: the need for universal fetal cardiac evaluation.

OBJECTIVE: Congenital cardiac malformations are common developmental anomalies. In the United States, congenital heart disease is the number one cause of infant mortality from congenital malformations. Prenatal diagnosis of congenital heart defects aids treatment coordination. Our aim was to evaluate prenatal detection of serious congenital heart malformations in Clark County, Nevada. METHODS: We electronically searched our research department-maintained computer database for patients with serious congenital heart disease born in Clark County between May 2003 and April 2006. We excluded patients that did not have at least 1 local prenatal ultrasound examination. All pre-natal ultrasound studies were performed in obstetric offices, radiology imaging centers, or maternal-fetal medicine specialty practices. Fetal echocardiography was performed in maternal-fetal medicine specialists' offices under the supervision of a fetal cardiologist. Pediatric cardiologists performed all postnatal echocardiographic examinations. RESULTS: During the study period, we diagnosed serious congenital heart malformations in 161 patients among a total estimated 77,000 births (2/1000). Of the 161 patients, 58 (36%) had a prenatal diagnosis, and 103 (64%) had an exclusively postnatal diagnosis. CONCLUSIONS: Standard prenatal ultrasound fails to show congenital heart disease in most fetuses.