ProvenCare perinatal: a model for delivering evidence/ guideline-based care for perinatal populations

A Scoping Review of Alternative Payment Models in Maternity Care: Insights in Key Design Elements and Effects on Health and Spending

INTRODUCTION

Although effects of alternative payment models on health outcomes and health spending are unclear, they are increasingly implemented in maternity care. We aimed to provide an overview of alternative payment models implemented in maternity care, describing their key design elements among which the type of APM, the care providers that participate in the model, populations and care services that are included and the applied risk mitigation strategies. Next to that, we made an inventory of the empirical evidence on the effects of APMs on maternal and neonatal health outcomes and spending on maternity care.

METHODS

We searched PubMed, Embase and Scopus databases for articles published from January 2007 through October 2020. Search key words included 'alternative payment model', 'value based payment model', 'obstetric', 'maternity'. English or Dutch language articles were included if they described or empirically evaluated initiatives implementing alternative payment models in maternity care in high-income countries. Additional relevant documents were identified through reference tracking. We systematically analyzed the initiatives found and examined the evidence regarding health outcomes and health spending. The process was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) to ensure validity and reliability.

RESULTS

We identified 17 initiatives that implemented alternative payment models in maternity care. Thirteen in the United States, two in the United Kingdom, one in New Zealand and one in the Netherlands. Within these initiatives three types of alternative payment models were implemented; pay-for-performance (n = 2), shared savings models (n = 7) and bundled payment models (n = 8). Alternative payment models that shifted more financial accountability towards providers seemed to include more strategies that mitigated those risks. Risk mitigation strategies were applied to the included population, included services or at the level of total expenditures. Of these seventeen initiatives, we found four empirical effect studies published in peer-reviewed journals. Three of them were of moderate quality and one weak. Two studies described an association of the alternative payment model with an improvement of specific health outcomes and two studies described a reduction in medical spending.

CONCLUSIONS

This study shows that key design elements of alternative payment models including risk mitigation strategies vary highly. Risk mitigation strategies seem to be relevant tools to increase APM uptake and protect providers from (initially) bearing too much (perceived) financial risk. Empirical evidence on the effects of APMs on health outcomes and spending is still limited. A clear definition of key design elements and a further, in-depth, understanding of key design elements and how they operate into different health settings is required to shape payment reform that aligns with its goals.

Midwife-led care and obstetrician-led care for low-risk pregnancies: A cost comparison

OBJECTIVE

Low-risk pregnant women cared for by midwives have similar birth outcomes to women cared for by physicians, although experiencing fewer medical procedures. However, limited research has assessed cost implications in the United States. Using national data, we assessed costs and resource use of midwife-led care vs obstetrician-led care for low-risk pregnancies using a decision-analytic approach.

METHODS

We developed a decision-analytic model of costs (health plan payments to clinicians) and use of medical procedures during childbirth (epidural analgesia, labor induction, cesarean birth, episiotomy) and outcomes of care (birth at preterm gestation) that may differ with midwife-led vs obstetrician-led care. Model parameters for obstetric procedures were generated using Listening to Mothers III data, a national survey of women who gave birth in US hospitals in 2011-2012 and other published estimates. Cost estimates came from published or publicly available information on health insurance claims payments.

RESULTS

The costs of childbirth for low-risk women with midwife-led care were, on average, $2262 less than births to low-risk women cared for by obstetricians. These cost differences derive from lower rates of preterm birth and episiotomy among women with midwife-led care, compared with obstetrician-led care. Across the population of US women with low-risk births each year (approximately 2.6 million), the model predicted substantially fewer preterm births (167 259 vs 219 427 for midwife-led vs obstetrician-led care) and fewer episiotomies (170 504 vs 415 686, for midwife-led vs obstetrician-led care).

CONCLUSIONS

A shift from obstetrician-led care to midwife-led care for low-risk pregnancies could be cost saving.

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.

Electronic Medical Record Use and Maternal and Child Care and Health

OBJECTIVES

To evaluate effects of EHR adoption and use during pregnancy on maternal and child health care utilization and health among pregnant mothers and their infants.

METHODS

The study population was comprised of all Medicaid-insured pregnant women who delivered a singleton birth in Michigan between 1/1/2009 and 12/31/2012 and their infants (N = 226,558). Linked data included birth records, maternal and infant medical claims, and EHR adoption, implementation, upgrading and meaningful use data. Pre-post comparisons with a control group (difference-in-difference) took advantage of a natural experiment of EHR adoption and use among providers in Michigan. Women and infants who received care from providers who adopted and used EHR were compared with those who received care from other providers, in a quasi-experimental framework.

RESULTS

Over 34 % of all women in the analytic sample received perinatal care from providers who adopted and used EHR. Multivariate regressions indicate that women who received prenatal care mainly from a provider who adopted and used EHR were more likely to have any well-child visits (0.05, p = 0.04), and the appropriate number of well-child visits during the first year of life (0.03, p < 0.01).

CONCLUSIONS

The findings of this study are consistent with EHR adoption and use supporting improved child health care utilization. The findings have the potential to provide Medicaid and other healthcare program officials with evidence of the potential gains to be derived from EHRs for vulnerable low-income women and infants.

No association of labor epidural analgesia with cerebral palsy in children

BACKGROUND

Some pregnant women avoid labor epidural analgesia because of their concerns about risk of cerebral palsy in children. Although it is believed that labor epidural does not contribute to cerebral palsy, to our knowledge no study has been published to specifically address this concern. We carried out a retrospective case-control study to investigate whether labor epidural analgesia is associated with cerebral palsy in children.

METHODS

This study used data that were collected and entered into the Geisinger electronic health records between January 2004 and January 2013. During this period, 20,929 children were born at Geisinger hospitals. Among them, 50 children were diagnosed with cerebral palsy, and 20 of those were born vaginally. Each of these 20 cerebral palsy children was matched with up to 5 non-cerebral palsy children born at the same hospitals in the same timeframe using propensity scoring methods. Analgesia was classified as epidural (including epidural or combined spinal and epidural) or non-epidural. Conditional logistic regression was used to compare the percentages of deliveries with each analgesia type between the cerebral palsy and non-cerebral palsy groups.

RESULTS

In the non-cerebral palsy group, the percentage of patients receiving labor epidural analgesia was 72 %, and in the cerebral palsy group the percentage was 45 %. There was no significant difference between non-cerebral palsy and cerebral palsy groups (odds ratio, 0.57; 95 % confidence interval, 0.14-2.24; p = 0.42).

CONCLUSION

We found no association between the use of labor epidural analgesia and the occurrence of cerebral palsy in children.

Episode-Based Approaches to Measuring Health Care Quality

Most currently available quality measures reflect point-in-time provider tasks, providing a limited and fragmented assessment of care. The concept of episodes of care could be used to develop quality measurement approaches that reflect longer periods of care. With input from clinical experts, we constructed episode-of-care frameworks for six illustrative conditions and identified potential gaps and measure development priority areas. Episode-based measures could assess changes in health outcomes ("delta measures"), the amount of time during an episode in which a patient has suboptimal health status ("integral measures"), quality contingent upon events occurring previously ("contingent measures"), and composites of measures throughout the episode. This article identifies a number of challenges that will need to be addressed to advance operationalization of episode-based quality measurement.

The gas cylinder, the motorcycle and the village health team member: a proof-of-concept study for the use of the Microsystems Quality Improvement Approach to strengthen the routine immunization system in Uganda

Background

Although global efforts to support routine immunization (RI) system strengthening have resulted in higher immunization rates, the World Health Organization (WHO) estimates that the proportion of children receiving recommended DPT3 vaccines has stagnated at 80% for the past 3 years (WHO Fact sheet—Immunization coverage 2014, WHO, 2014). Meeting the WHO goal of 90% national DPT3 coverage may require locally based strategies to support conventional approaches. The Africa Routine Immunization Systems Essentials-System Innovation (ARISE-SI) initiative is a proof-of-concept study to assess the application of the Microsystems Quality Improvement Approach for generating local solutions to strengthen RI systems and reach those unreached by current efforts in Masaka District, Uganda.

Methods

The ARISE-SI intervention had three components: health unit (HU) advance preparations, an action learning collaborative, and coaching of improvement teams. The intervention was informed and assessed using qualitative and quantitative methods. Data collection focused on changes and outcomes of improvement efforts among five HUs and one district-level team during the intervention (June 2011–February 2012) and five follow-up months.

Results

Workshops and team meetings had a 95% attendance rate. All teams gained RI system knowledge and implemented changes to address locally identified problems. Specific changes included: RI register implementation and expanded use, Child Health Card provision and monitoring, staff cross-training, staffing pattern changes, predictable outreach schedules, and health system leader—community leader meetings. Several RI system barriers prevalent across Masaka District (e.g., lack of backup HU gas cylinders, inadequate outreach transportation, and village health team underutilization) were successfully addressed. Three of five HUs significantly increased the vaccines administered. All improvements were sustained 5 months post-intervention. External evaluation validated the findings of high levels of participant engagement, empowerment to make change, and willingness to sustain improvements.

Conclusions

The Microsystems Quality Improvement Approach is a comprehensive approach, grounded in systems thinking, and coupled with intensive coaching. It provides a robust framework for engaging teams in the development of unique local solutions that strengthen RI systems in resource poor settings. The sustained improvements in local RI systems from this study provide evidence that this approach may be an effective framework for enhancing the WHO’s Reaching Every District (RED) immunization strategy.

A study of New York City obstetrics units demonstrates the potential for reducing hospital inpatient capacity

Hospitals are under significant pressure from payers to reduce costs. The single largest fixed cost for a hospital is inpatient beds, yet there is significant variation in hospital capacity utilization. We study bed capacity in New York City hospital obstetrics units and find that while many hospitals have an insufficient number of beds to provide timely access to care, overall there is significant excess capacity. Our findings, coupled with current demographic and clinical practice trends, indicate that a large fraction of obstetrics units nationwide could likely reduce their bed capacity while assuring timely access to care, resulting in large savings in capital and staffing costs. Given emerging health care delivery and payment models that will likely decrease demand for other types of hospital beds, our study suggests that data-based methodologies should be used by hospitals and policy makers to identify opportunities for reducing excess bed capacity in other inpatient units as well.

Implementing family communication pathway in neurosurgical patients in an intensive care unit

OBJECTIVE

Family-centered care provides family members with basic needs, which includes information, reassurance, and support. Though national guidelines exist, clinical adoption often lags behind in this area. The Geisinger Health System developed and implemented a program for reliable delivery of best practices related to family communication to patients and families admitted to the intensive care unit (ICU).

METHOD

Using a quasiexperimental study design and the 24-item Family Satisfaction in the Intensive Care Unit questionnaire (FSICU-24©) to determine family satisfaction, we measured the impact of a "family communication pathway" facilitated by tools built into the electronic health record on the family satisfaction of neurosurgical patients admitted to the ICU.

RESULTS

There was no statistically significant difference noted in family satisfaction as determined by FSICU-24 scores, including the Care and Decision Making constructs between the pre- and post-intervention pilot population. The percentage of families reporting the occurrence of a family conference showed only minimal improvement, from 46.5% before to 52.5% following the intervention (p = 0.565). This was mirrored by low numbers of documented family conferences by providers, suggesting poor uptake despite buy-in, use of electronic checklists, and repeated attempts at education.

SIGNIFICANCE OF RESULTS

This paper reviews the challenges to and implications for implementing national guidelines in the area of family communication in an ICU coupled with the principles of clinical reengineering.

Reengineering acute episodic and chronic care delivery: the Geisinger Health System experience

Comparative effectiveness research (CER) represents an evolution in clinical decision-making research that allows for the study of heterogeneous groups of patients with complex diseases processes. It has foundations in decision science, reliability science, and health care policy research. Health care finance will increasingly rely on CER for guidance in the coming years. There is increasing awareness of the importance of decreasing unwarranted variation in health care delivery. In the past 7 years, Geisinger Health System has performed broad reengineering of its acute episodic and chronic care delivery models utilizing macrosystem-level application of CER principles. These provider-driven process initiatives have resulted in significant improvement across all segments of care delivery, improved patient outcomes, and notable cost containment. These programs have led to the creation of novel pricing models, and when "hardwired" throughout a care delivery system, they can lead to correct medical decision making by 100% of providers in all patient encounters. Neurosurgery as a specialty faces unique challenges and opportunities with respect to broad adoption and application of CER techniques.

Improving venous thromboembolism prevention processes and outcomes at a community hospital

BACKGROUND

Venous thromboembolism (VTE) is a cause of significant morbidity and mortality in hospitalized patients in the United States. Quality improvement (QI) strategies to increase the rates of prophylaxis in patients at-risk for VTE have been shown to be successful. The development of a formal, active strategy addressing the prevention of VTE, as a written, institutionwide VTE prophylaxis policy, presents a challenge for hospitals

METHODS

In 2007 a multidisciplinary VTE committee was initiated to develop and implement a hospitalwide QI program to standardize VTE risk assessment and prophylaxis prescribing practices at Saint Francis Hospital (Tulsa, Oklahoma). The QI program included clinician education, VTE order set and electronic trigger implementation, and changes in mechanical prophylaxis usage.

RESULTS

The VTE prophylaxis order set was successfully piloted and implemented hospitalwide within three months of the project's initiation. Standardization of VTE prophylaxis practices across surgical and medical specialties was the key aim of this QI program. As a result, patient-related outcomes were also improved. The number of hospital-acquired VTE events decreased from 123 (0.39%) in 2008 to 99 (0.32%) in 2009 and 87 (0.27%) in 2010, and a reduction in the VTE rate between 2008 and 2010 of 31.6%. There was a significant decrease between 2008 and 2010 in the number of hospital-acquired VTE events (p = .035).

CONCLUSIONS

Keys to the success of this QI program included leveraging multidisciplinary VTE committee members, physician champions, multiple approaches to communication and education, and providing evidence to support the changes. Sharing the hospital's QI process may provide a model for other hospitals challenged with developing and sustaining positive outcomes in patients at risk for VTE.