VAGINAL BIRTH AFTER CESAREAN SECTION

A MULTIFACETED AND PERSONALIZED APPROACH

Faced with a rising volume of cesarean sections (C-sections), this health plan set out in 1994 to promote the use of vaginal birth after cesarean section (VBAC) deliveries. The American College of Obstetricians and Gynecologists (ACOG) had recently issued recommendations for VBAC when appropriate. A statewide initiative tasked with improving obstetric care was also recommending VBAC when appropriate. The health plan initiated a comprehensive approach that attacked multiple root causes for a low use of VBAC.

This plan used two measurements: the overall rate for C-section and VBAC. The baseline rate of VBAC, measured for 1993, was 19.2%.

With no data available about best practice, the plan's staff chose a national average as a benchmark, using the National Institutes of Health's 1992 figure of 25.1%.

Based on ACOG recommendations and the identified benchmark, the plan established a goal of 50%.

In 1994, the quality improvement (QI) team began its intervention by identifying concerns with the recommendations on the use of VBAC. Discussions with practitioners and members identified a number of possible barriers to the use of VBAC:

• wide variation in practice among plan obstetricians
• time restraints on physicians impeding the promotion of VBAC
• lack of physician and member education about the ACOG recommendations for VBAC
• hospital department chairs not supporting the use of VBAC
• lack of appropriate obstetric anesthesia services
• nonobstetrician medical directors discussing parameters of care with OB/GYN providers
• practitioners' fear of malpractice liability
• a solo practice medical community with limited backup support for physicians

With so many potential barriers, the plan needed to prioritize its actions. It recognized issues beyond its control and chose to focus on issues that it felt it could impact. It also prioritized its efforts with high-volume practitioners and hospitals that displayed high C-section rates.

Data for this study were accessible through claims and an existing database used to track members enrolled in a maternity management program. All precertified members scheduled for a repeat C-section or a VBAC were included. Medical record reviews were used in the intervention phase to investigate provider performance on a case-by-case basis. All pregnant members with a history of previous C-sections were also included in the study population. The annual study groups ranged in size; a rise in the absolute number of members with previous C-sections coincided with a rising overall membership during the four-year study period.

In 1994, the plan began to add VBAC components to its existing maternity management program. The revised program was to provide intensive physician and member education. It also provided incentives to providers. The new components included:

• a compensation system to reimburse providers for extra time involved in VBAC deliveries
• letters to providers detailing C-section rates and identifying opportunities for VBAC
• meetings with medical directors for providers with high C-section rates
• coordination of VBAC promotion with hospitals
• educational mailings on the benefits of VBAC to members with previous C-sections
• case management with support for members considering VBAC

The plan sent a direct mailing to providers to introduce them to these new VBAC components.

Interventions in the plan's quality initiative addressed numerous root causes for low use of VBAC which fell into 3 categories: internal, practitioner/provider, and member.

ROOT CAUSE IDENTIFICATION General categories of issues or barriers may be useful in performing a root cause analysis. A thorough analysis with representation from the practitioner community and key health plan staff helps to ensure that all possible root causes are being considered.

The initial interventions were introduced in 1994. The most successful activities were continued throughout 1995-1997, and new interventions were introduced after each evaluation. Many of these interventions were time consuming and required several years to complete.

The main internal intervention was the addition of an OB/GYN medical director. An individual trained in obstetrics had the clinical credibility needed to engage providers in discussions of obstetric care.

Focusing on practitioner-based issues, the plan revised its compensation system to acknowledge the extra time needed with VBAC. It implemented a three-tiered reimbursement scale:

• elective repeat C-section with no trial of labor
• C-section after appropriate trial of labor
• VBAC after successful trial of labor

The plan sent letters to the practitioners with high C-section rates and low VBAC rates. These letters compared their performance with that of their peers. In addition, the OB/GYN medical director reviewed samples of the practitioner's medical records for members who did not receive a VBAC but may have been likely candidates. Results of this review were sent to practitioners, along with ACOG recommendations.

The OB/GYN medical director, often with another plan medical director, visited practitioners with C-section rates >23% and a minimum of 25 deliveries per year. These visits were designed to review outcomes and physician concerns without creating ill will. The OB/GYN medical director shared data, discussed individual cases, and reviewed ACOG guidelines. Typically an hour or less, these sessions were scheduled during business hours or shortly thereafter, based on the practitioner's schedule.

The plan devised interventions aimed at members as well. Plan staff worked at identifying all pregnant members and screening them for a history of previous C-section. Educational materials were sent to all members of this targeted population. Maternity management nurses provided counseling on the benefits of VBAC during a telephone assessment performed at 20 weeks of gestation. They contacted the practitioner's office at 32 weeks of gestation to confirm the mode of delivery. When VBAC was not anticipated, case managers investigated the clinical rationale and referred any concerns to the medical director.

Missed opportunities for a comprehensive first-trimester visit caused some women to miss counseling about VBAC. The plan implemented a direct access option to promote ease access to obstetricians and encourage first-trimester visits.

PHYSICIAN-TO-PHYSICIAN INTERACTION The plan considered the one-on-one visits between a qualified OB/GYN medical director and a selected practitioner to be the most valuable intervention in reducing the rate of unnecessary C-section deliveries. An effective way to produce significant change, it also represented a significant devotion of resources by the health plan, which makes this intervention most suitable for medium-to-large sized plans.

The first evaluation revealed a VBAC rate of 26.4% for 1994 - a statistically significant improvement from 19.2%. Based on these results, the plan was encouraged to continue refining and implementing the interventions it had put into place the previous year.

For 1995, the rate of VBAC increased slightly to 29.9%. Again, the plan continued with its interventions.

The 1996 data revealed a rate of 30.3% -- not a statistically significant change from the previous evaluations. The plan decided to increase its efforts aimed at hospitals.

The plan had identified the need to communicate with hospitals about low VBAC rates at the beginning of the initiative. In the first years, the plan used letters for this communication. By 1997, it was felt that little progress had been made in managing VBAC rates together with hospitals.

In order to establish individualized action plans for each hospital, a C-section reduction hospital liaison program was developed. These programs targeted hospitals with high C-section rates and minimal use of VBAC. The plan's OB/GYN medical director met with the chief or director of OB/GYN services and/or representatives from hospital administration. The meetings included discussions of practice guidelines for maternity care and the use of VBAC, plus plans for improvement.

The plan also switched to a blended reimbursement rate for VBAC and C-sections.

In retrospect, it appears that this plan set a goal that turned out to be unrealistic. Even though it did not meet its goal, its final results demonstrated excellent improvement over baseline.

The plan is considering recent recommendations by ACOG on the use of VBAC. The emphasis is now on weighing the risks and benefits of each individual case. Since the improvement in the VBAC rate has basically leveled off over the past five years, the health plan is looking at other efforts to address the continued high C-section rate.

The plan has continued to study VBAC rates since 1997 and has maintained the improvement demonstrated in this initiative. Additional opportunities are being identified, including the need for a letter to members following all C-section births regarding a future VBAC option. The plan is also working with hospitals to develop VBAC data to be posted in places such as doctors' lounges and surgery suites.

The success of this comprehensive personalized approach will undoubtedly influence the direction of future QI initiatives.