HIGH-RISK PREGNANCY MANAGEMENT

Preventing Prematurity With a Comprehensive Approach

Although measurement is a key component of quality improvement, managed care organizations are often frustrated with inadequate data systems. Sometimes, problems faced by their membership are too important to wait for the development of tracking systems, performance measures, and baseline results. Faced with this situation, this health plan simultaneously developed both a high-risk pregnancy management program and the measures used to track its success.

An analysis of the 1993 data showed that extended hospital stays were more likely related to prematurity than any other diagnosis.

A task force, convened with participating obstetricians, identified three major concerns:

• Wide variation in obstetric practice
• No systematic case finding of high-risk mothers
• Failure of patients to adhere to treatment plans

In response, in 1994 the plan created a premature delivery prevention program (PDPP).

The program was designed to focus on early identification of high-risk pregnancies and to provide careful monitoring of the progress of those pregnancies and to provide careful monitoring of the progress of those pregnancies to ensure full-term deliveries. The program included the following services:

• Risk assessment
• Physician incentive
• Case management
• Member education
• Physician practice guideline

The plan collaborated with three other plans in the service area to develop a risk-assessment form. The purpose of the form was twofold: to capture the physician's assessment and to enroll members in the program when necessary. The physician forwarded the completed risk-assessment form to the health plan.

COLLABORATIVE EFFORTS Collaborating with other plans that address high-risk pregnancies was ingenious. Standardizing the risk-assessment process made it more credible and easier to use for participating physicians.

The plan also reimbursed physicians for time spent in completing the assessment forms. The amount of reimbursement for managing high-risk pregnancies was increased to reflect the greater time commitment required in these pregnancies.

Members identified as high risk by the physicians' risk assessments were invited to participate in a case management program. Case managers provided education, ensured continuity of services, reminded/encouraged members to participate in the program, managed covered issues, and advocated for benefit coverage for services that could potentially help prevent a preterm delivery. The frequency and length of contact with members varied from once per trimester to daily contact.

The case management process had three purposes:

• Allow the plan to individualize interventions such as home care, education, and specialty referrals
• Keep the physician informed
• Ensure that patients adhered to treatment plans

Educational materials on the signs and symptoms of preterm labor and actions that encouraged a healthy pregnancy were provided to all high-risk members to reinforce the case manager's messages.

A physician's prenatal practice guideline was developed for use with all pregnant members, including members at high risk for preterm delivery.

The initiative targeted all pregnant members served by the plan. Since no baseline measures were taken before the program was initiated, the plan measured outcomes in two populations throughout the activity:

• All plan deliveries
• All deliveries managed by the PDPP

The measurements for the PDPP were:

• Preterm delivery rate (<37 weeks)
• Percentage of deliveries at least 33 weeks
• Average gestational age

The plan used the following measures plan-wide:

• Preterm delivery rate
• Rate of ICD-9-CM disorders associated with low gestational age (babies with disorders/total live births)
• Average length of stay (ALOS) for complex newborns (HEDIS 2.0 and 2.5 methodology)

Data were collected through review of hospital records, administrative data sets, and telephone interviews with physicians and members.

The baseline measurement occurred in 1994. See Table 1 for the results.

DATA SOURCES Measuring the rate of preterm deliveries was fundamental to the assessment of the impact of the PDPP. Because no baseline plan-wide rates were available prior to establishing the PDPP, it's difficult to know what the effects of the first year of the program might be. Any replication of this study therefore requires careful attention to data sources. Unless a full tracking system is in place, this type of initiative requires labor-intensive data collection such as medical record review.

As a benchmark, the plan chose the United States national preterm delivery rate of 10.8%, as published in a 1991 Monthly Vital Statistics Report.

The plan set two goals for the PDPP:

• Preterm delivery rate <37 weeks for program participants of 28.7%
• 98% rate for deliveries at least 33 weeks

Since the program had already been implement, further interventions were designed to improve the effectiveness of the case finding and intervention efforts. In the summer of 1995, the plan used a telephone survey to evaluate the program from the point of view of all 140 of the program's participants, with a response rate of more than 40%. The survey contained 33 questions covering topics such as referral method, pregnancy restrictions, case management services, and global satisfaction. The plan also used a telephone survey to evaluate the PDPP from the point of view of newer member participants.

The results from these two surveys had similar findings. Overall, 94% of the women found the program a positive experience, while three main barriers to care and service were identified:

• Physicians did not consistently complete the risk-assessment form
• High-risk members refused to participate because of time constraints
• Members lacked education about healthy lifestyle behaviors

In response to the surveys, the plan implemented new interventions in the PDPP.

Office visits to key obstetricians were used to reinforce the program and the process for complementing risk-assessment forms.

For member convenience the plan added two additional case managers to extend the service hours. Also, the plan included an information sheet about smoking and its impact on pregnancy in the mailing to pregnant members.

In the second year of the PDPP, the number of participants more than doubled, although the plan's overall number of pregnant members increased by only 4%. The 1995 data produced the results shown in the charts below and on the next page.

Based on the results of the surveys and the program's performance in its second year, the plan continued its support of the PDPP.

Data from 1669 showed a statistically significant reduction in both the plan-wide rate of preterm delivery and ICD-9-CM disorders relating to prematurity.

By 1997, improvements in data collection techniques and enhanced member enrollment in the maternity management program led the plan to drop the measurements related to all pregnancies. Measurements have since focused exclusively on outcomes for the PDPP.

Opportunities to make the PDPP more effective by increasing its enrollment have been explored. Expanding the program hours for telephone contact is an intervention under considerations.

Involving physicians in both the design and implementation of the program was the secret to active participation and program enhancement. The plan has discussed providing physicians with statistically significant outcome measures that show the value of the program.