Reducing Severe Maternal Morbidity for Birthing Persons with Severe Hypertension through a Statewide Quality Improvement Initiative.

BACKGROUND: Hypertensive disorders of pregnancy are a leading preventable cause of severe maternal morbidity and maternal mortality worldwide. OBJECTIVE: To assess the improvement in hospital care processes and patient outcomes associated with hypertensive disorders of pregnancy after introduction of a statewide Severe Maternal Hypertension quality improvement initiative. STUDY DESIGN: A prospective cohort design comparing outcomes before and after introduction of the Illinois Perinatal Quality Collaborative statewide hypertension quality improvement initiative among 108 hospitals across Illinois. Participating hospitals recorded data for all cases of new-onset severe hypertension (>160 systolic or >110 diastolic) during pregnancy through 6 weeks postpartum from May 2016 to December 2017. Introduction of the statewide quality improvement initiative included implementation of severe maternal hypertension protocols, standardized patient education and discharge planning, rapid access to medications and standardized treatment order sets, and provider and nurse education. The main outcome measure was the reduction of severe maternal morbidity for pregnant/postpartum patients with severe hypertension. Key process measures include time-to-treatment of severe hypertension, frequency of provider/nurse debriefs, appropriate patient education, and early postpartum follow up. RESULTS: Data were reported for 8,073 cases of severe maternal hypertension. The frequency of patients with new-onset severe hypertension treated within 60 minutes increased from 41% baseline to 87% (p<0.001) at the end of the initiative. The initiative was associated with increased proportion of patients receiving preeclampsia education at discharge (41% to 89%, p<0.001), scheduling follow-up appointments within 10 days of discharge (68% to 83%, p<0.001), and having a care team debrief after severe hypertension was diagnosed (17% to 59%, p<0.001). Conversely, severe maternal morbidity was reduced from 11.5% baseline to 8.4% (p<0.002) at the end of the study period. Illinois hospitals were able to achieve time-to-treatment goal regardless of hospital characteristics including geography, birth volume, and patient mix. CONCLUSIONS: Introduction of a statewide quality improvement effort was associated with improved time-to-treatment of severe hypertension, as well as increased frequency of provider/nurse debriefs, appropriate patient education, and early postpartum follow up scheduled at discharge, and reduced severe maternal morbidity.

Using quality improvement to address social determinants of health needs in perinatal care.

There are unacceptable racial inequities in perinatal outcomes in the United States. Social determinants of health (SDOH) are associated with health outcomes and contribute to disparities in maternal and newborn health. In this article, we (1) review the literature on SDOH improvement in the perinatal space, (2) describe the SDOH work facilitated by the Illinois Perinatal Quality Collaborative (ILPQC) in the Birth Equity quality improvement initiative, (3) detail a hospital's experience with implementing strategies to improve SDOH screening and linkage to needed resources and services and (4) outline a framework for success for addressing SDOH locally. A state-based quality improvement initiative can facilitate implementation of strategies to increase screening for SDOH. Engaging patients and communities with specific actionable strategies is key to increase linkage to needed SDOH resources and services.

Implementation of perinatal quality collaborative statewide initiative improves obstetrical opioid use disorder care and outcomes.

BACKGROUND: Maternal deaths resulting from opioid use disorder have been increasing across the United States. Opioid use disorder among pregnant persons is associated with adverse pregnancy outcomes, including preterm birth, along with racial disparities in optimal opioid use disorder care. OBJECTIVE: This study aimed to evaluate whether the Illinois Perinatal Quality Collaborative implementation of the Mothers and Newborns affected by Opioids - Obstetric quality improvement initiative was associated with improvement in opioid use disorder identification, provision of optimal opioid use disorder care for birthing patients, and reduction in racial gaps in optimal opioid use disorder care. STUDY DESIGN: Using a prospective cohort design, hospitals reported monthly key measures for all patients with opioid use disorder at delivery between July 2018 and December 2020. The Illinois Perinatal Quality Collaborative facilitates collaborative learning opportunities, rapid response data, and quality improvement support. Generalized linear mixed-effects regression models were used to evaluate improvement in optimal opioid use disorder care, including increases in linkages to medication-assisted treatment, recovery treatment services, and naloxone counseling across time, and to determine whether optimal opioid use disorder care was associated with positive outcomes, such as lower odds of preterm birth. RESULTS: A total of 91 hospitals submitted data on 2095 pregnant persons with opioid use disorder. For the primary outcomes, the rates of patients receiving medication-assisted treatment and recovery treatment services improved across the initiative from 41% to 78% and 48% to 67%, respectively. For the secondary outcomes, the receipt of recovery treatment services and both recovery treatment services and medication-assisted treatment provided prenatally before delivery admission was associated with lower odds of preterm birth (adjusted odds ratio: 0.67 [95% confidence interval, 0.50-0.91] and 0.49 [95% confidence interval, 0.31-0.75], respectively). During the first quarter of the initiative, Black patients with opioid use disorder were less likely to be linked to medication-assisted treatment than White patients (23% vs 48%, respectively); however, an increase in medication-assisted treatment rates across the initiative occurred for all patients, with the greatest improvement for Black patients with an associated reduction in this disparity gap with >70% of both Black and White patients linked to medication-assisted treatment. CONCLUSION: The Mothers and Newborns affected by Opioids - Obstetric initiative was associated with improvement in optimal opioid use disorder care for pregnant patients across Illinois hospitals, additionally racial disparities in opioid use disorder care was reduced across the initiative. Our findings implicate how optimal opioid use disorder care can improve pregnancy outcomes and close persistent racial gaps for pregnant individuals with opioid use disorder.

A Mixed Methods Evaluation of a Quality Improvement Model to Optimize Perinatal and Primary Care in the Community Health Setting.

PURPOSE: Many maternal deaths occur beyond the acute birth encounter. There are opportunities for improving maternal health outcomes through facilitated quality improvement efforts in community settings, particularly in the postpartum period. We used a mixed methods approach to evaluate a collaborative quality improvement (QI) model in 6 Chicago Federally Qualified Health Centers (FQHCs) that implemented workflows optimizing care continuity in the extended postpartum period for high-risk prenatal patients. METHODS: The Quality Improvement Learning Collaborative focused on the implementation of a registry of high-risk prenatal patients to link them to primary care and was implemented in 2021; study data were collected in 2021-2022. We conducted a quantitative evaluation of FQHC-reported aggregate structure, process, and outcomes data at baseline (2020) and monthly (2021). Qualitative analysis of semistructured interviews of participating FQHC staff focused on the experience of participating in the collaborative. RESULTS: At baseline, none of the 6 participating FQHCs had integrated workflows connecting high-risk prenatal patients to primary care; by the end of implementation of the QI intervention, such workflows had been implemented at 19 sites across all 6 FQHCs, and 54 staff were trained in using these workflows. The share of high-risk patients transitioned to primary care within 6 months of delivery significantly increased from 25% at baseline to 72% by the end of implementation. Qualitative analysis of interviews with 11 key informants revealed buy-in, intervention flexibility, and collaboration as facilitators of successful engagement, and staffing and data infrastructure as participation barriers. CONCLUSIONS: Our findings show that a flexible and collaborative QI approach in the FQHC setting can help optimize care delivery. Future evaluations should incorporate the patient experience and patient-level data for comprehensive analysis.

Optimizing accuracy of birth certificate data through a statewide quality improvement initiative in Illinois.

OBJECTIVE: This study examines improvement in birth certificate accuracy during a statewide quality improvement initiative. STUDY DESIGN: Participating hospitals systematically sampled 10 delivery medical records per month and compared them to corresponding birth certificates for accuracy. Accuracy was computed before implementing the initiative (Aug-Oct 2014), end of phase 1 (July 2015) and end of phase 2 (Nov-Dec 2015). Accuracy data was aggregated and compared across time points using a linear mixed model and by hospital characteristics. RESULTS: 105 hospitals participated. Birth certificate accuracy increased between baseline (89.59%) and end of phase 2 (97.00%, p < 0.001). Percent accuracy at baseline was lowest in hospitals serving at-risk populations (p < 0.01). These hospitals showed relatively greater increases in overall accuracy with no difference in accuracy by the end of the initiative. CONCLUSIONS: A statewide QI effort contributed to improvements in birth certificate accuracy. Hospitals serving at-risk populations exhibited the greatest benefit and improvement.

Improving the Timely Delivery of Antihypertensive Medication for Severe Perinatal Hypertension in Pregnancy and Postpartum.

OBJECTIVE: Sustained blood pressures ≥160/110 during pregnancy and the postpartum period require timely antihypertensive therapy. Hospital-level experiences outlining the efforts to improve timely delivery of care within 60 minutes have not been described. The objective of this analysis was to assess changes in care practices of an inpatient obstetrical health care team following the implementation of a quality improvement initiative for severe perinatal hypertension during pregnancy and the postpartum period. STUDY DESIGN: In January 2016, NorthShore University HealthSystem Evanston Hospital launched a quality improvement initiative focusing on perinatal hypertension, as part of a larger, statewide quality initiative via the Illinois Perinatal Quality Collaborative. We performed a retrospective cohort study of all pregnant and postpartum patients with sustained severely elevated blood pressure (two severely elevated blood pressures ≤15 minutes apart) with baseline data from 2015 and data collected during the project from 2016 through 2017. Changes in clinical practice and outcomes were compared before and after the start of the project. Statistical process control charts were used to demonstrate process-behavior changes over time. RESULTS: Comparing the baseline to the last quarter of 2017, there was a significant increase in the administration of medication within 60 minutes for severe perinatal hypertension (p <0.001). Implementation of a protocol for event-specific debriefing for each severe perinatal hypertension episode was associated with increased odds of the care team administering medication within 60 minutes of the diagnosis of severe perinatal hypertension (adjusted odds ratio 3.20, 95% confidence interval 1.73-5.91, p < 0.01). CONCLUSION: Implementation of a quality improvement initiative for perinatal hypertension associated with pregnancy and postpartum improved the delivery of appropriate and timely therapy for severely elevated blood pressures and demonstrated the impact of interdisciplinary communication in the process. KEY POINTS: · Process of hospital-level implementation of a state quality improvement initiative.. · Evidence of improvement in care delivery for severe perinatal hypertension (HTN).. · Episode related debriefing by the clinical team improved perinatal HTN care..

Advances in Maternal Fetal Medicine: Perinatal Quality Collaboratives Working Together to Improve Maternal Outcomes.

State-based perinatal quality collaboratives (PQCs) address preventable causes of maternal and infant morbidity and mortality by implementing statewide quality improvement (QI) initiatives. They work with hospital clinical teams, obstetric provider and nursing leaders, patients and families, public health officials, and other stakeholders to provide opportunities for collaborative learning, rapid-response data, and QI science support to achieve clinical culture change. PQCs show that the application of collaborative improvement science methods to advance evidence-informed clinical practices using QI strategies contributes to improved perinatal outcomes. With appropriate staffing, infrastructure, and partnerships, PQCs can achieve sustainable improvements in perinatal care.

A Framework to Harness the Power of Quality Collaboratives to Improve Perinatal Outcomes.

The Illinois Perinatal Quality Collaborative developed a framework for successfully engaging teams and implementing statewide obstetric and neonatal quality improvement (QI) initiatives. This framework includes: (1) engaging hospitals to create an environment of improvement; (2) motivating hospital teams to facilitate change at their hospital; and (3) supporting hospital teams through the 3 pillars of QI-collaborative learning opportunities, rapid-response data, and QI support-to achieve initiative goals and improve outcomes for mothers and newborns. Utilizing this framework, the Illinois Perinatal Quality Collaborative Severe Maternal Hypertension Initiative engaged teams and achieved initiative goals.

The Hard Work of Improving Outcomes for Mothers and Babies: Obstetric and Perinatal Quality Improvement Initiatives Make a Difference at the Hospital, State, and National Levels.

Quality improvement efforts are an increasingly expanding focus for perinatal care providers across the United States. From successful hospital-level initiatives, there has been a growing effort to use and implement quality improvement work in substantive and meaningful ways. This article summarizes the foundations of maternal-focused, birth-focused, and neonatal-focused quality improvement initiatives to highlight the underpinnings and potential future directions of current state-level perinatal quality care collaboratives.

Role of patient treatment beliefs and provider characteristics in establishing patient-provider relationships.

BACKGROUND: Positive patient-provider relationships have been associated with improved depression treatment outcomes. Little is known about how patient treatment beliefs influence patient-provider relationships, specifically treatment alliance and shared decision making in primary care (PC). OBJECTIVE: We evaluated the relationship between patient treatment beliefs and patient-provider relationships by gender, race and current depression. METHODS: We used a deductive parallel convergent mixed method design with cross-sectional data. Participants were 227 Black and White patients presenting with depression symptoms in PC settings. Individuals were randomized into either a quantitative survey (n = 198) or qualitative interview (n = 29) group. We used multiple ordinary least squares regression to evaluate the association between patient beliefs, as measured by the Treatment Beliefs Scale and the Medication Beliefs Scale, and treatment alliance or shared decision making. We concurrently conducted thematic analyses of qualitative semistructured interview data to explicate the nature of patient-provider relationships. RESULTS: We found that patients who believed their provider would respectfully facilitate depression treatment reported greater bond, openness and shared decision making with their provider. We also identified qualitative themes of physicians listening to, caring about and respecting patients. Empathy and emotive expression increased patient trust in PC providers as facilitators of depression treatment. CONCLUSIONS: This work systematically demonstrated what many providers anecdotally believe: PC environments in which individuals feel safe sharing psychological distress are essential to early identification and treatment of depression. Interprofessional skills-based training in attentiveness and active listening may influence the effectiveness of depression intervention.

Clinical needs of in-treatment pregnant women with co-occurring disorders: implications for primary care.

We investigated social vulnerability and behavioral health clinical profiles (symptom severity) of pregnant women with co-occurring disorders, defined as substance abuse, mental illness, and trauma at treatment entry compared to their nonpregnant counterparts and the role of interpersonal abuse in clinical presentation among pregnant women. Our objective was to provide primary health care providers with insight into the needs of pregnant patients with high behavioral health risks to serve them better during the critical window of opportunity for long-term impact. We conducted cross-sectional secondary analysis of baseline data from women enrolled in treatment programs in the Women, Co-occurring Disorders and Violence Study from nine sites across the United States. We used analysis of variance and Cochran-Mantel-Haenszel statistical analyses to compare means and frequencies of social vulnerability indicators and baseline Addiction Severity Index, Brief Symptom Inventory of mental health, and Posttraumatic Stress Diagnostic Scale scores between 152 pregnant and 2,577 nonpregnant women, and between pregnant women with and without current interpersonal abuse. Compared to nonpregnant women, pregnant women evidenced more social vulnerability but better behavioral health clinical profiles at treatment entry. Current interpersonal abuse was associated with increased mental health and trauma symptomatology but not with alcohol or drug abuse severity among pregnant women. The prenatal period is an important time for screening and intervention for factors such as social vulnerability and co-occurring disorders, known to affect pregnancy and infant outcomes; social and behavioral health services are particularly essential among pregnant women with co-occurring disorders.

Perinatal HIV testing among African American, Caucasian, Hmong and Latina women: exploring the role of health-care services, information sources and perceptions of HIV/AIDS.

Perinatal HIV transmission disproportionately affects African American, Latina and potentially Hmong women in the United States. Understanding racially and ethnically diverse women's perceptions of and experiences with perinatal health care, HIV testing and HIV/AIDS may inform effective health communications to reduce the risk of perinatal HIV transmission among disproportionate risk groups. We used a qualitative descriptive research design with content analysis of five focus groups of African American, Caucasian, Hmong and Latina women of reproductive age with low socioeconomic status distinguished by their race/ethnicity or HIV status. A purposive stratified sample of 37 women shared their health-care experiences, health information sources and perceptions of HIV testing and HIV/AIDS. Women's responses highlighted the importance of developing and leveraging trusted provider and community-based relationships and assessing a woman's beliefs and values in her sociocultural context, to ensure clear, consistent and relevant communications. Perinatal health communications that are culturally sensitive and based on an assessment of women's knowledge and understanding of perinatal health and HIV/AIDS may be an effective tool for health educators addressing racial and ethnic disparities in perinatal HIV transmission.

The relationship between trajectories of family/cultural stressors and depression and suicidal ideation among substance using Mexican-American adults.

We used an intersectional minority stress perspective to examine the association between family/cultural stress and mental health among substance-using Mexican-Americans. Employing a unique longitudinal sample of 239 socioeconomically disadvantaged, non-injecting heroin-using Mexican-Americans from San Antonio, Texas, we examined how culturally relevant stressors are related to depression and suicidal ideation. First, we identified depression and suicidal ideation prevalence rates for this disadvantaged sample. Second, we determined how cultural stress is experienced over time using stress trajectories. Third, we evaluated how family/cultural stressors and stress trajectories are related to depression and suicidal ideation outcomes. Results showed high rates of baseline depression (24 %) and suicidal ideation (30 %). We used latent class growth analysis to identify three primary stress trajectories (stable, high but decreasing, and increasing) over three time points during 1 year. We found that the increasing stressors trajectory was associated with higher rates of depression and suicidal ideation, and that stress trajectories had unique relationships with mental illness. We also showed that baseline stressors, sum stressors, and high but decreasing stressors maintained positive associations with mental illness after controlling for baseline depression. Our results highlight the importance of focusing on within-group, culturally specific stressors and addressing both operant and cumulative stressors in the study of mental health for marginalized populations and suggest the importance of early intervention in minimizing stressors.