HOSPITAL QUALITY PROGRAM: CESAREAN SECTIONS AND LAPAROSCOPIC CHOLECYSTECTOMY

Improving Care for a Hospital Network

Inpatient hospital care is a major component of medical care delivery. Unnecessary procedures or poorly trained practitioners can lead to poor outcomes. This plan noted a wide variation in outcomes across its hospital network. It created a hospital quality program that not only looked at the track record of its hospitals, but also took a proactive approach to an issue that was new at the time.

This plan initiated a hospital quality program in 1992. The plan performed on-site quality assessment visits at all hospitals. The plan also began requesting quality information on a semi-annual basis.

When looking at specific measures for each hospital, the plan identified two main areas of concern: cesarean section (C-section) rates, and the granting of privileges for laparoscopic surgery. While the excessive C-section rate is a common and longstanding concern of health plans, the issue of laparoscopic surgery was new at the time this activity was initiated. This surgical technique was being rapidly adopted, and there was concern that surgeons might not be adequately trained. The literature indicated that there was a learning curve associated with the procedure, and that significant complications were more frequent when training was minimal. The plan decided to investigate the use of guidelines for granting privileges for laparoscopic surgery. Based on the literature and discussion with surgeons, it decided to use the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) guidelines for granting privileges.

This activity targeted all hospitals participating in the plan's network. Claims data were used to determine C-section rates. The plan used self-reported data from the hospitals to determine the use of SAGES guidelines.

Using 1992 data, the plan determined that its baseline performance rate of C-section was 27%; the rates at participating hospitals varied from 25% to 31%.

Based on information collected from January to June 1993, the plan also found that 10% of the hospitals followed the SAGES guidelines for credentialing.

To determine the opportunity for improvement, the plan collected industry benchmarks and consulted specialist physician consultants. The C-section benchmark of 15% was derived from the Healthy People 2000 goal. There was no benchmark established for use of the SAGES guidelines.

Initially, the plan set a performance goal to reduce the C-section rate to 20%. Based on a literature review and input from surgeons, the plan established a performance goal of 90% for SAGES guidelines utilization.

The plan performed an analysis of these baseline results. It discovered that more than 33% of C-sections were performed on patients who had a previous C-section.

The plan also determined that only 59% of the urban hospitals and 27% of the rural hospitals required demonstration of laparoscopic surgery techniques under direct clinical supervision during training. Only 66% of the urban hospitals and 45% of the rural hospitals required proctoring of this procedure prior to granting privileges.

The plan started its interventions in the last half of 1993. Staff began by establishing processes of hospital outreach, and by sharing guidelines. The plan shared the American College of Obstetricians and Gynecologists (ACOG) recommendations for C-sections with all of its hospitals. A mailing completed in the summer of 1993 furnished the SAGES guidelines to all hospitals.

Remeasurement using 1993 data showed a C-section rate of 25%, with a range of 22% to 32%. A large number of hospitals adopted the SAGES guidelines after receiving them. Data from the end of 1993 showed that 43% of hospitals were now using the SAGES guidelines.

The plan's quality improvement (QI) staff and its medical directors began conducting annual hospital quality visits to discuss the rates of C-sections, vaginal birth after C-sections (VBAC), and SAGES guidelines. These visits were intended to assist the hospitals in developing action plans for their own internal quality programs. In addition, the plan established a task force to address variations and outcomes that involved hospital QI directors.

The plan sent a package to hospitals that provided insight into hospital-specific performance. Information included feedback graphs and narrative comparisons to similarly sized hospitals in the region.

MEDICAL LEADERSHIP While it is not unusual to see health plans utilize their medical leadership in interventions, the extent to which this plan's medical leadership was involved is unusual. The medical leadership met regularly with hospital staff to share the results of their data collection and to assist the hospitals in addressing issues. The medical leadership acted as liaison to connect physicians within the network and to allow them to learn from each other. They also worked over several years with physician group practices with high C-section rates.

With hospitals that had more than 100 deliveries and a C-section rate of more than 28%, the plan's staff took a slightly more structured approach. These hospitals were required to precertify all elective C-sections using the criteria the plan had distributed.

Using 1994 data, the plan remeasured its C-section rate and found it had decreased to 24%. The use of SAGES guidelines had increased to 75%.

The plan continued its annual mailings to the hospitals. Added to the information distributed were the plan's benchmarks and expected performance goals for C-section rates.

Educational seminars, where physician speakers from ACOG gave providers insight on ways to decrease C-section rates, were sponsored by the plan to assist the providers in improving their performance. Individual physician C-section rates were trended to identify physicians who had been outliers over time.

Two hospitals had financial penalties added to their contracts if C-section rates remained above 28%. The plan also encouraged hospitals to require physicians who were performing laparoscopic surgeries to meet SAGES guidelines.

The data from 1995 showed an overall C-section rate of 21% and a SAGES guidelines usage rate of 83%, substantial improvements over baseline performance.

The plan continued its interventions in 1996. It set a new performance goal of 18% for its C-section rate. The plan's staff informed hospitals with a C-section rate of more than 24% to put immediate measures in place to evaluate inappropriate C-sections, and to identify opportunities for improvement. It consulted with an outside organization to analyze its network's C-section rates with a goal of developing a plan to achieve further decreases.

Data from 1996 showed a C-section rate of 19.7%, a significant decrease. There was no reported change in the rate of SAGES guidelines utilization.

Based on the success in these two areas, the plan is now considering expanding its hospital quality program to include benchmarks and indicators specific to children.