CESAREAN SECTION

Peer-Led Quality Improvement

Cesarean sections (C-sections) are among the most commonly performed surgical procedures, but there have been concerns that they are performed excessively. Healthy People 2000 contained a goal of reducing the national C-section rate to 15%. But where does a plan begin to make changes when the C-section rate is nearly 40%? The plan turned to the respected obstetricians in its community for help.

With regard to the high rate of C-sections, the plan was concerned that some members could be facing unnecessary risks considering that vaginal delivery is far safer for both mother and child.

The factors that influence the decision to perform C-sections are complex. Long-standing beliefs about appropriate obstetric procedures, concerns about legal consequences and community standards, and the personal wishes of practicing physicians and their patients all enter into the equation. To reduce the high rate of C-sections, it was necessary to change the practice patterns of some physicians. The plan needed to demonstrate that alternative procedures, appropriately used, would provide less risk to the mothers and newborns than C-section surgery.

The plan tracked data for its entire population, meaning all women who delivered during a study year. Data were obtained from medical records and claims. The plan used two measures: C-section rate and well-baby rate (the percentage of all births without a complex delivery and/or without a length of hospital stay longer than five days). The well-baby rate was measured to address concerns that efforts to reduce C-section rate could potentially be harmful to newborns.

In 1992, the plan's baseline C-section rate was 37.8%. Using a benchmark from the community (a local hospital had an 18% C-section rate), the plan's OB/GYN committee, composed entirely of practicing obstetricians, set a goal of 27.5% and planned to reevaluate this goal annually.

MEANINGFUL IMPROVEMENT Significant reduction in the C-section rate might be seen as solely a utilization management improvement. It was the inclusion of the measure of the well-baby rate that allowed the plan to demonstrate a significant improvement in outcomes. These improved outcomes demonstrated that this intervention yielded a meaningful improvement in the quality of care.

In 1993, nurses began a concurrent review analyzing C-section documentation to determine the indicators for the C-section requests. At the same time, the OB/GYN committee began conducting a clinical review of all C-sections. Each month, it reviewed hospital admission forms, operative notes, and prenatal records of more than 100 C-section cases.

When indicators for cesarean delivery were questionable, the committee members requested comments regarding the management of labor from the practitioner. Committee members and the plan medical director provided frequent feedback to those providers whose procedures appeared not to conform to current OB/GYN practice guidelines. This feedback included written comments and, on occasion, a personal visit with the provider.

It was the belief of committee members that the most important intervention was to raise provider awareness of guidelines for performing C-sections and guidelines for vaginal birth after cesarean (VBAC). The plan distributed VBAC guidelines - based on the recommendations from the American College of Obstetricians and Gynecologists (ACOG) - to its obstetricians.

The plan also increased the global reimbursement fee for deliveries requiring an additional amount of time and effort. These included vaginal delivery of unusual presentation, multiple births, and VBAC.

Comparative data from the first year of this study showed that the C-section rate dropped to 33.8% in 1993. Reviewing its progress, the plan adopted a new goal of 25%. It continued its retrospective review of prenatal and labor records of all C-sections. The OB/GYN committee requested that physicians provide a note detailing the length of labor and evidence of dystocia for those cases where such evidence was not present in the record.

That same year, a clinical OB/GYN professor from a major university convened a seminar addressing labor management and indications for VBAC to assist those physicians who had questions about the ACOG guidelines.

As a financial incentive, the plan increased the obstetric global fee for providers who had performed more than ten deliveries during the previous year if they had achieved a C-section rate of less than 25%.

Data from 1994 showed a large reduction in the C-section rate - to 24.9%. The plan set its 1995 goal at 24%.

The plan continued its retrospective review of all C-sections, It also began to give practitioners feedback on individual and group performance. The OB/GYN committee decided that further improvement would depend on increasing the VBAC rate, so it emphasized VBACs in its 1995 interventions.

The health plan sent several written communications to its obstetricians, including:

• an ACOG educational bulletin on VBAC and cesarean delivery
• a review article titled "Cesarean Birth: How to Reduce the Rate"
• a congratulatory letter to obstetricians who decreased their cesarean delivery rates

For data collected in 1995, the annual C-section rate for the plan was virtually unchanged at 25.1%. The plan set a goal of 23% for 1996.

In 1996, the plan continued its program of retrospective review and feedback. It required that its providers justify repeat C-sections without VBAC if the record review did not show a clear indication. The OB/GYN committee refined criteria used to justify C-sections without committee review.

Data from 1996 showed that the C-section rate had dropped to 21.6%. The OB/GYN committee recommended few changes in its interventions for 1997. It set a goal of a 21% C-section rate.

The retrospective reviews continued, an ACOG technical bulletin on VBACs was distributed, OB/GYN providers were invited to attend committee meetings to discuss questionable C-sections, and annual rates for individual and medical group practices were distributed.

Data from 1997 showed a performance of 21.2%. Overall, the C-section rates showed a statistically significant decrease from 1992 to 1997. Meanwhile, the efforts to reduce the plan's C-section rate did not appear to be harmful to newborns. In fact, the well-baby rate showed a significant increase from 86.2% in 1992 to 94% in 1997.

This plan continues to implement several strong actions to reduce C-sections. Particularly important is committee review of all C-sections with feedback to obstetric providers, annual distribution of C-section rates, and provider education activities, such as guidelines distribution and seminars. Outcomes, as measured by the increased rate of well newborns, continue to rise.

The success of the OB/GYN committee in this - as well as other areas - guides further efforts. As new service areas with higher C-section rates are added to the plan, the program will serve as a model for continuous improvement. The directors of the plan have decided to develop a more comprehensive program for women's health. Implemented in 1998, the program includes interventions to improve mammography and cervical cancer screening, prenatal and postnatal care, as well as continued monitoring of cesarean deliveries and other gynecologic surgeries.