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Rood KM, Ugwu LG, Grobman WA, Bailit JL, Wapner RJ, Varner MW, Thorp JM, Caritis SN, Tita ATN, Saade GR, Rouse DJ, Blackwell SC, Tolosa JE. Obstacles to Optimal Antenatal Corticosteroid Administration to Eligible Patients. Am J Perinatol 2024; 41:e594-e600. [PMID: 35973796 PMCID: PMC10065956 DOI: 10.1055/a-1925-1435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Administration of antenatal corticosteroids (ANCS) is recommended for individuals expected to deliver between 24 and 34 weeks of gestation. Properly timed administration of ANCS achieves maximal benefit. However, more than 50% of individuals receive ANCS outside the recommended window. This study aimed to examine maternal and hospital factors associated with suboptimal receipt of ANCS among individuals who deliver between 24 and 34 weeks of gestation. STUDY DESIGN Secondary analysis of the Assessment of Perinatal Excellence (APEX), an observational study of births to 115,502 individuals at 25 hospitals in the United States from March 2008 to February 2011, was conducted. Data from 3,123 individuals who gave birth to a nonanomalous live-born infant between 240/7 to 340/7 weeks of gestation, had prenatal records available at delivery, and data available on the timing of ANCS use were included in this analysis. Eligible individuals' ANCS status was categorized as optimal (full course completed >24 hours after ANCS but not >7 days before birth) or suboptimal (none, too late, or too early). Maternal and hospital-level variables were compared using optimal as the referent group. Hierarchical multinomial logistic regression models, with site as a random effect, were used to identify maternal and hospital-level characteristics associated with optimal ANCS use. RESULTS Overall, 83.6% (2,612/3,123) of eligible individuals received any treatment: 1,216 (38.9%) optimal and 1,907 (61.1%) suboptimal. Within suboptimal group, 495 (15.9%) received ANCS too late, 901 (28.9%) too early, and 511 (16.4%) did not receive any ANCS. Optimal ANCS varied depending on indication for hospital admission (p < 0.001). Individuals who were admitted with intent to deliver were less likely to receive optimal ANCS while individuals admitted for hypertensive diseases of pregnancy were most likely to receive optimal ANCS (10 vs. 35%). The median gestational age of individuals who received optimal ANCS was 31.0 weeks. Adjusting for hospital factors, hospitals with electronic medical records and who receive transfers have fewer eligible individuals who did not receive ANCS. ANCS administration and timing varied substantially by hospital, optimal frequencies ranged from 9.1 to 51.3%, and none frequencies from 6.1 to 61.8%. When evaluating variation by hospital site, models with maternal and hospital factors did not explain any of the variation in ANCS use. CONCLUSION Optimal ANCS use varied by maternal and hospital factors and by hospital site, indicating opportunities for improvement. KEY POINTS · Majority of individuals who deliver between 24 and 34 weeks of gestation do not receive properly timed antenatal corticosteroids.. · Optimal use of antenatal corticosteroids varies by maternal and hospital factors and hospital site.. · Significant variation in hospital sites regarding optimally timed administration of antenatal corticosteroids indicates opportunities for improvement..
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Affiliation(s)
- Kara M Rood
- Department of Obstetrics and Gynecology, Ohio State University, Columbus, Ohio
| | - Lynda G Ugwu
- The George Washington University Biostatistics Center, Washington, District of Columbia
| | - William A Grobman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Jennifer L Bailit
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, MetroHealth Medical Center-Case Western Reserve University, Cleveland, Ohio
| | - Ronald J Wapner
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Michael W Varner
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - John M Thorp
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Steve N Caritis
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alan T N Tita
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - George R Saade
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
| | - Dwight J Rouse
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island
| | - Sean C Blackwell
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston, McGovern Medical School-Children's Memorial Hermann Hospital, Houston, Texas
| | - Jorge E Tolosa
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
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Kleinman LC, Howell EA. Equity and the Hazard of Veiled Injustice: A Methodological Reflection on Risk Adjustment. Pediatrics 2022; 149:184822. [PMID: 35230433 DOI: 10.1542/peds.2020-045948g] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Lawrence C Kleinman
- Division of Population Health, Quality, and Implementation Sciences, Department of Pediatrics, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey; and
| | - Elizabeth A Howell
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Gagliardi L, Amador C, Puglia M, Mecacci F, Pratesi S, Sigali E, Tomasini B, Rusconi F, Banchini R, Papi MC, Pecori D, Dani C, Ingargiola A, Moroni M, Fiorini P, Vuerich M, Santarlasci S, Boldrini A, Dilucia S, Panariello G, Vinciguerra F, Giovannoni A, Dolfi P, Moschetti R, Tognetti S, Capuzzo L, Magnanensi S, Mariotti P, Brioschi A, Martelli E, Vasarri PL, Carlotti C, Danieli R, Gragnani S, Benetti GL, Tiezzi M, Civitelli F, Magi L, Martini M, Cardinale A, Magni C, Bini R, De Filippo M, Cafaggi L, Bosi C, Gambi B, Pezzati M, Strano M, Bartoli A, Gabrielli P, Verucci E, Berni R, Corsi A, Voller F. Area-based study identifies risk factors associated with missed antenatal corticosteroid prophylaxis in women delivering preterm infants. Acta Paediatr 2017; 106:250-255. [PMID: 27577326 DOI: 10.1111/apa.13563] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 05/02/2016] [Accepted: 08/29/2016] [Indexed: 11/28/2022]
Abstract
AIM All women delivering a preterm infant should receive antenatal corticosteroid prophylaxis, but many miss this opportunity. We determined the risk factors associated with missed prophylaxis in a geographically defined area of Italy. METHODS We prospectively studied all mothers who delivered babies between 24 and 31 completed weeks of gestation, from 2009 to 2013, in all maternity units in Tuscany. RESULTS Of 1232 mothers, 186 (15.1%) did not receive prophylaxis. The risk was higher in migrant mothers, with an adjusted risk ratio (RR) of 1.28 and 95% confidence interval (95% CI) of 1.04-1.56, and in mothers hospitalised for less than 24 hours (RR 4.09, 95% CI: 2.90-5.78). Preterm prelabour rupture of membranes (RR 0.63, 95% CI: 0.41-0.96) and maternal antepartum transfer (RR 0.24, 95% CI: 0.18-0.32) were protective. Hospital level at birth and gestational age did not influence the prophylaxis rate. The population-attributable fractions were 50.4% for late hospital admissions and 10.2% for migrant status. CONCLUSION In a highly organised network of hospitals, neither level of care nor gestational age influenced prophylaxis. Timely arrival of women in hospital, better recognition of the imminence of delivery and tighter steroids administration guidelines are the most relevant targets to further increase prophylaxis.
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Affiliation(s)
- Luigi Gagliardi
- Department of Woman and Child Health Versilia Hospital Viareggio Italy
| | - Carolina Amador
- Department of Fetal‐Neonatal Medicine Anna Meyer Children's University Hospital Florence Italy
| | | | - Federico Mecacci
- Department of Gynecology, Perinatology and Human Reproduction Careggi University Hospital Florence Italy
| | - Simone Pratesi
- Department of Neuroscience, Psychology, Drug Research and Child Health Careggi University Hospital Florence Italy
| | - Emilio Sigali
- Department of Pediatrics Division of Neonatology and Neonatal Intensive Care Unit University Hospital of Pisa Pisa Italy
| | - Barbara Tomasini
- Neonatal Intensive Care Unit University Hospital of Siena Siena Italy
| | - Franca Rusconi
- Unit of Epidemiology Anna Meyer Children's University Hospital Florence Italy
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Cuttini M. Using antenatal corticosteroids in pregnancies when there is a risk of very preterm delivery. Acta Paediatr 2017; 106:194-195. [PMID: 28071860 DOI: 10.1111/apa.13662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Marina Cuttini
- Research Unit of Perinatal Epidemiology Clinical Care and Management Innovation Research Area Pediatric Hospital Bambino Gesù IRCCS Rome Italy
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5
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Kaplan HC, Sherman SN, Cleveland C, Goldenhar LM, Lannon CM, Bailit JL. Reliable implementation of evidence: a qualitative study of antenatal corticosteroid administration in Ohio hospitals. BMJ Qual Saf 2015; 25:173-81. [DOI: 10.1136/bmjqs-2015-003984] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 05/24/2015] [Indexed: 11/04/2022]
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Evaluation of the quality of guidelines for the management of reduced fetal movements in UK maternity units. BMC Pregnancy Childbirth 2015; 15:54. [PMID: 25884544 PMCID: PMC4352260 DOI: 10.1186/s12884-015-0484-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 02/20/2015] [Indexed: 11/10/2022] Open
Abstract
Background The development of evidence-based guidelines is a key step in ensuring that maternity care is of a universally high standard. To influence patient care national and international guidelines need to be interpreted and implemented locally. In 2011, the Royal College of Obstetricians and Gynaecologists published guidelines for the management of reduced fetal movements (RFM), which can be an important symptom of fetal compromise. Following dissemination it was anticipated that this guidance would be implemented in UK maternity units. This study aimed to assess the quality of local guidelines for the management of RFM in comparison to published national standards. Methods Cross-sectional survey of maternity unit guidelines for RFM. The guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Tool and scored by two independent investigators. Two national guidelines were used as standards to evaluate unit guidelines. Results Responses were received from 98 units (42%); 12 units had no guideline. National guidelines scored highly using the AGREE II tool but there was wide variation in the quality of individual maternity unit guidelines, which were frequently of low quality. No guidelines incorporated all the recommendations from the national guideline. Maternity unit guidelines performed well for clarity and presentation but had low scores for stakeholder involvement, rigour of development and applicability. Conclusions In contrast to national evidence based guidance the quality of maternity unit guidelines for RFM is variable and frequently of low quality. To increase quality, guidelines need to include up to date evidence and audit standards which could be taken directly from national evidence-based guidance. Barriers to local implementation and resource implications need to be taken into consideration. Training may also improve the implementation of the guideline. Research is needed to inform strategies to realize the benefits of clinical guidance in practice.
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Boesveld M, Oudijk MA, Koenen SV, Brouwers HA, Van Beek E, Boon J, Drogtrop A, Euser R, Evers IM, Fiedeldeij CA, Heida KY, Huisjes AJ, Muijsers GJ, Schierbeek JM, Kwee A. Evaluation of strategies regarding management of imminent preterm delivery before 32 weeks of gestation: a regional cohort study among 1375 women in the Netherlands. Am J Obstet Gynecol 2015; 212:348.e1-7. [PMID: 25447962 DOI: 10.1016/j.ajog.2014.10.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 07/29/2014] [Accepted: 10/07/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate the management of imminent preterm delivery with respect to prescription of antenatal corticosteroids (ACS) and referral to a tertiary center. STUDY DESIGN A retrospective cohort study existing of 1 perinatal center and 9 referring hospitals. All women who received their first dose of ACS in 1 of the 10 hospitals between 24+0 and 32+0 weeks of gestation and/or delivered before 32 weeks of gestation from 2005 until 2010. Patients were identified using the electronic database of hospital pharmacies. Main outcome measures were time interval from administration to delivery for different indications and number of women who were not referred in time to a tertiary center. RESULTS In total, 1375 women received ACS. Main indications were suspected preterm labor (44.7%), preterm prelabor rupture of membranes (15.9%), maternal indication (12.8%), fetal indication (9.2%) and vaginal blood loss (8.4%). Overall, 467 (34.0%) women delivered ≤7 days after ACS administration; 8.7% of women with vaginal blood loss and 54.5% of women with maternal indication. Among the 931 women who received ACS in the secondary hospitals, 452 (48.5%) women were referred to a tertiary hospital and 89 (6.5%) women delivered in a secondary hospital with a gestational age of less than 32 weeks. CONCLUSION One-third of all women receiving ACS delivered within 7 days and half of the women who received ACS in a secondary hospital were referred to a tertiary center. There seems to be room for improvement regarding the timing of ACS administration and subsequently referral to a tertiary center.
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Profit J, Goldstein BA, Tamaresis J, Kan P, Lee HC. Regional variation in antenatal corticosteroid use: a network-level quality improvement study. Pediatrics 2015; 135:e397-404. [PMID: 25601974 PMCID: PMC4306799 DOI: 10.1542/peds.2014-2177] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Examination of regional care patterns in antenatal corticosteroid use (ACU) rates may be salient for the development of targeted interventions. Our objective was to assess network-level variation using California perinatal care regions as a proxy. We hypothesized that (1) significant variation in ACU exists within and between California perinatal care regions, and (2) lower performing regions exhibit greater NICU-level variability in ACU than higher performing regions. METHODS We undertook cross-sectional analysis of 33,610 very low birth weight infants cared for at 120 hospitals in 11 California perinatal care regions from 2005 to 2011. We computed risk-adjusted median ACU rates and interquartile ranges (IQR) for each perinatal care region. The degree of variation was assessed using hierarchical multivariate regression analysis with NICU as a random effect and region as a fixed effect. RESULTS From 2005 to 2011, mean ACU rates across California increased from 82% to 87.9%. Regional median (IQR) ACU rates ranged from 68.4% (24.3) to 92.9% (4.8). We found significant variation in ACU rates among regions (P < .0001). Compared with Level IV NICUs, care in a lower level of care was a strongly significant predictor of lower odds of receiving antenatal corticosteroids in a multilevel model (Level III, 0.65 [0.45-0.95]; Level II, 0.39 [0.24-0.64]; P < .001). Regions with lower performance in ACU exhibited greater variability in performance. CONCLUSIONS We found significant variation in ACU rates among California perinatal regions. Regional quality improvement approaches may offer a new avenue to spread best practice.
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Affiliation(s)
- J Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, California; California Perinatal Quality Care Collaborative, Palo Alto, California;
| | - B A Goldstein
- Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina; and
| | - J Tamaresis
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - P Kan
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, California
| | - H C Lee
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, California; California Perinatal Quality Care Collaborative, Palo Alto, California
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Health services research in obstetrics and gynecology: the legacy of the Robert Wood Johnson Foundation Clinical Scholars. Curr Opin Obstet Gynecol 2014; 26:545-9. [PMID: 25310530 DOI: 10.1097/gco.0000000000000125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Howell EA, Zeitlin J, Hebert P, Balbierz A, Egorova N. Paradoxical trends and racial differences in obstetric quality and neonatal and maternal mortality. Obstet Gynecol 2013; 121:1201-1208. [PMID: 23812453 PMCID: PMC3701153 DOI: 10.1097/aog.0b013e3182932238] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate trends by race in Agency for Healthcare Research and Quality obstetric-related quality and safety indicators and their relationships to trends in inpatient maternal and neonatal mortality. METHODS We used the Nationwide Inpatient Sample from 2000 through 2009 and calculated obstetric hospital quality and patient safety indicators and inpatient maternal and neonatal mortality stratified by race. We examined differences in age and comorbidity-adjusted trends in black compared with white women over time in the United States and by geographic region. Proportions were analyzed by χ2 and trends by regression analysis. RESULTS Obstetric quality indicators varied by geographic region, but changes over time were consistent for both races. Cesarean deliveries increased similarly for black and white women, and vaginal births after cesarean delivery declined for both races but more rapidly for white women than for black women. Obstetric safety indicators improved over the study period for black and white women, with obstetric trauma decreasing significantly for both groups (28% compared with 35%, respectively) and birth trauma-injury to neonates declining for both, but changes were not significant. In striking contrast, inpatient maternal and neonatal mortality remained relatively constant during the study period, with persistently higher rates of both seen among black compared with white women (12.0 compared with 4.6 per 100,000 deliveries, P<.001 and 6.6 compared with 2.5 per 1,000 births, P<.001, respectively, in 2009). CONCLUSION Improvements in Agency for Healthcare Research and Quality quality indicators for obstetrics are not reflected in improvements in maternal and neonatal morbidity and mortality and do not explain continued racial disparities for outcomes in pregnancies in black and white women. Quality measures that are related to pregnancy outcomes are needed and these should elucidate obstetric health disparities.
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Affiliation(s)
- Elizabeth A Howell
- Departments of Health Evidence & Policy, Obstetrics, Gynecology, and Reproductive Science, and Psychiatry, Mount Sinai School of Medicine, New York, New York; the Epidemiological Research Unit on Perinatal Health and Women's and Children's Health, UMRS 953, INSERM Paris, France; and the Department of Health Services, University of Washington School of Public Health, Seattle, Washington
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Rowley DL, Hogan V. Disparities in infant mortality and effective, equitable care: are infants suffering from benign neglect? Annu Rev Public Health 2012; 33:75-87. [PMID: 22224890 DOI: 10.1146/annurev-publhealth-031811-124542] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Quality care for infant mortality disparity elimination requires services that improve health status at both the individual and the population level. We examine disparity reduction due to effective care and ask the following question: Has clinical care ameliorated factors that make some populations more likely to have higher rates of infant mortality compared with other populations? Disparities in postneonatal mortality due to birth defects have emerged for non-Hispanic black and Hispanic infants. Surfactant and antenatal steroid therapy have been accompanied by growing disparities in respiratory distress syndrome mortality for black infants. Progesterone therapy has not reduced early preterm birth, the major contributor to mortality disparities among non-Hispanic black and Puerto Rican infants. The Back to Sleep campaign has minimally reduced SIDS disparities among American Indian/Alaska Native infants, but it has not reduced disparities among non-Hispanic black infants. In general, clinical care is not equitable and contributes to increasing disparities.
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Affiliation(s)
- Diane L Rowley
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina 27599-7445, USA.
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Abstract
Quality improvement initiatives have been successfully employed in many areas of medicine, but few have been implemented in preventing prematurity (or preterm birth), which continues to be one of the most common complications in obstetrics, and the leading cause of perinatal morbidity and mortality in the United States. Due to the complex nature of the causes of prematurity, developing and instituting a quality improvement program to prevent prematurity can be challenging. However, using proven quality improvement principles and techniques, along with institutional will and commitment, are invaluable in rapidly implementing evidence-based initiatives for the prevention of preterm births.
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Pronovost PJ, Holzmueller CG, Ennen CS, Fox HE. Overview of progress in patient safety. Am J Obstet Gynecol 2011; 204:5-10. [PMID: 21187195 DOI: 10.1016/j.ajog.2010.11.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 10/19/2010] [Accepted: 11/01/2010] [Indexed: 11/19/2022]
Abstract
In the 11 years since the Institute of Medicine reported ubiquitous problems with the quality and safety of patient care in the United States, efforts been made to improve health care. Obstetrics and gynecology has made some improvements; however, similar to other areas of health care, progress has been slow. The major deterrents are complexities in our health care system and culture and an immature science of safety and quality that makes measurement and evaluation of progress difficult. This article describes the efforts that have been made in obstetrics and gynecology to identify causes or factors that contribute to adverse outcomes, to develop measures of quality and safety, and to make improvements. It also offers a framework to help organize patient safety research and improvement. Finally, this article offers ways the American Congress of Obstetricians and Gynecologists can organize and support future work.
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Affiliation(s)
- Peter J Pronovost
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD 21231, USA.
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