- Email: [email protected]
636: Development of indicators to determine the quality of cesarean section care
www.AJOG.org
Epidemiology, Infectious Disease, Intrapartum Fetal Assessment, Operative Obstetrics, Obstetric Quality & Safety, Public Health-Global Health
survey of their practice, knowledge, and perception of each intervention. Team factors affecting implementation were assessed by a validated Team Climate Inventory survey (TCI). Actual practices and hospital characteristics were assessed using individual patient data collected by trained abstractors within the observational study and these were correlated to survey responses from their providers. RESULTS: Of 444 eligible, 329 (74%) providers managing 16,946 deliveries completed the survey. Provider satisfaction with knowledge about the treatment and available evidence increased with time. For all interventions, ⬎ ⫽91% incorporated them into practice (Table). However, for ACS 96%, MG 66%, and PROG 21% of eligible patients received the intervention. Treatment was higher in centers with inhouse MFMs. Hospital TCI scores were similar between patients receiving or not receiving the treatment. Barriers to treatment were greatest for progesterone (75%) (p⬍0.001). CONCLUSION: Obstetric providers report high levels of incorporation of 3 evidence-based treatments but actual implementation is inconsistent with this intent. For interventions initiated in-hospital (ACS, MG), treatment varies according to providers acceptance of the available evidence. For PROG, the discrepancy between provider intent and practice may reflect barriers to implementation or different acceptance by outpatient providers.
Poster Session IV
tions were evaluated in two rounds by an independent expert panel consisting of gynaecologists and midwives. At first, a questionnaire was sent asking the experts to rate and rank the recommendations in terms of value for measuring quality of care. Median scores were calculated, just as scores reflecting the ranking of each item. The consensus meeting resulted in a final set of recommendations which were translated into measurable quality indicators. RESULTS: A set of 24 quality indicators was developed describing both preventive measures (e.g. in case of a non-vertex position external cephalic version should be offered) as well as situations in which a planned CS should be performed (e.g. placenta previa), situations in which a CS should not be offered by the caregiver (e.g. single cephalic pregnancy) or situations in which a CS should be discussed as an option (e.g. breech presentation). CONCLUSION: The developed set of quality indicators will be used to measures CS guideline adherence in The Netherlands. This is the first step in optimizing care and possibly preventing a further rise in CSs. We offer a systematic method for the development of quality indicators aiming at reducing the CS rate without negative effect on the outcome for mother and child.
637 Residual anastomoses after fetoscopic laser coagulation in twin-to-twin transfusion syndrome: a learning curve Suzanne Peeters1, Femke Slaghekke1, Johanna Middeldorp2, Frans Klumper1, Enrico Lopriore3, Dick Oepkes1 1
Leiden University Medical Center, Obstetrics, Leiden, Netherlands, 2Leiden University Medical Center, Department of Obstetrics and Gynaecology, Leiden, Netherlands, 3Leiden University Medical Center, Department of Pediatrics, Leiden, Netherlands
636 Development of indicators to determine the quality of cesarean section care Sonja Melman1, Rosella Hermens2, Jan Nijhuis3, Liesbeth Scheepers4, SIMPLE project group5 1 Maastricht University Medical Centre, GROW- School for Oncology and Developmental Biology, Gynaecology and Obstetrics, Maastricht, Netherlands, 2Radboud University Nijmegen Medical Centre, Department of Quality of Care, IQ Healthcare, Nijmegen, Netherlands, 3Maastricht University Medical Center, Obstetrics & Gynecology, GROW School for Oncology and Developmental Biology, Maastricht, Netherlands, 4Maastricht University Medical Centre, GROW- School for Oncology and Developmental Biology,Department of Obstetrics and Gynaecology, Maastricht, Netherlands, 5 The Dutch Consortium for Studies in Women’s Health and Reproductivity, Department of Obstetrics and Gynaecology, Maastricht, Netherlands
OBJECTIVE: Worldwide there is a rising cesarean section (CS) rate, mainly in healthy women with a singleton in vertex position at term without improved perinatal outcome. Moreover, a CS is associated with higher costs, increased short term risks, and an increased risk for future pregnancies. International guidelines describe evidence based recommendations for performing a CS in specific situations. In general, large gaps exist between scientific evidence and current care. Incomplete adherence to CS recommendations may, in part, explain the rising CS rate. In order to improve care we need to measure it. Therefore, we aimed to develop a set of quality indicators on CS care. STUDY DESIGN: According to the RAND-modified Delphi method, 51 recommendations on CS performance were abstracted from guidelines of international obstetrical organizations. These recommenda-
OBJECTIVE: Most complications after laser coagulation for TTTS are related to residual anastomoses. Therefore we aimed to test the hypothesis that with increasing experience, the rate of residual anastomoses (RA) is decreasing. STUDY DESIGN: Retrospective analysis of prospectively collected data on 250 consecutive MC twins with TTTS treated with fetoscopic laser between 2002 and 2008. We excluded placentas from single or double IUFDs, and those from 2006 when we did not routinely inject the placentas. Presence of RA, determined by color-dye injection of the placenta, was evaluated over time. Associations were evaluated with placental localisation and laser technique. RESULTS: We could include 108 cases with complete data. RAs were present in 29% (31/108). We found no decrease over time of RAs, except for the last year (2008) when we started our pilot with the Solomon technique (21%). Rate of RAs in case of anterior placenta was 29% (13/45), in predominantly posterior placentas RAs were found in 29% (18/63) as well. CONCLUSION: Residual anastomoses were found in a third of placentas from double survivors of laser surgery for TTTS. Neither operator experience, nor placental localization seems to play a role. The introduction of the Solomon technique might decrease the occurrence of RAs.
638 Hospital variation in cesarean delivery rates among a very low risk population in Massachusetts: an opportunity for quality improvement? Vanitha Janakiraman Mohta1, Isabel Caceres2, Lauren Smith2, Bruce Cohen2, Gene Declercq3, SV Subramanian4, Jeffrey Ecker1 1
Massachusetts General Hospital, Obstetrics and Gynecology, Boston, MA, Massachusetts Department of Public Health, DPH, Boston, MA, 3Boston University School of Public Health, Community Health Sciences, Boston, MA, 4Harvard University, Population Health and Geography, Boston, MA 2
OBJECTIVE: To explore the effect of practice patterns on variation in cesarean rates, we compared cesarean rates between hospitals in a
Supplement to JANUARY 2012 American Journal of Obstetrics & Gynecology
S285
Epidemiology, Infectious Disease, Intrapartum Fetal Assessment, Operative Obstetrics, Obstetric Quality & Safety, Public Health-Global Health
survey of their practice, knowledge, and perception of each intervention. Team factors affecting implementation were assessed by a validated Team Climate Inventory survey (TCI). Actual practices and hospital characteristics were assessed using individual patient data collected by trained abstractors within the observational study and these were correlated to survey responses from their providers. RESULTS: Of 444 eligible, 329 (74%) providers managing 16,946 deliveries completed the survey. Provider satisfaction with knowledge about the treatment and available evidence increased with time. For all interventions, ⬎ ⫽91% incorporated them into practice (Table). However, for ACS 96%, MG 66%, and PROG 21% of eligible patients received the intervention. Treatment was higher in centers with inhouse MFMs. Hospital TCI scores were similar between patients receiving or not receiving the treatment. Barriers to treatment were greatest for progesterone (75%) (p⬍0.001). CONCLUSION: Obstetric providers report high levels of incorporation of 3 evidence-based treatments but actual implementation is inconsistent with this intent. For interventions initiated in-hospital (ACS, MG), treatment varies according to providers acceptance of the available evidence. For PROG, the discrepancy between provider intent and practice may reflect barriers to implementation or different acceptance by outpatient providers.
Poster Session IV
tions were evaluated in two rounds by an independent expert panel consisting of gynaecologists and midwives. At first, a questionnaire was sent asking the experts to rate and rank the recommendations in terms of value for measuring quality of care. Median scores were calculated, just as scores reflecting the ranking of each item. The consensus meeting resulted in a final set of recommendations which were translated into measurable quality indicators. RESULTS: A set of 24 quality indicators was developed describing both preventive measures (e.g. in case of a non-vertex position external cephalic version should be offered) as well as situations in which a planned CS should be performed (e.g. placenta previa), situations in which a CS should not be offered by the caregiver (e.g. single cephalic pregnancy) or situations in which a CS should be discussed as an option (e.g. breech presentation). CONCLUSION: The developed set of quality indicators will be used to measures CS guideline adherence in The Netherlands. This is the first step in optimizing care and possibly preventing a further rise in CSs. We offer a systematic method for the development of quality indicators aiming at reducing the CS rate without negative effect on the outcome for mother and child.
637 Residual anastomoses after fetoscopic laser coagulation in twin-to-twin transfusion syndrome: a learning curve Suzanne Peeters1, Femke Slaghekke1, Johanna Middeldorp2, Frans Klumper1, Enrico Lopriore3, Dick Oepkes1 1
Leiden University Medical Center, Obstetrics, Leiden, Netherlands, 2Leiden University Medical Center, Department of Obstetrics and Gynaecology, Leiden, Netherlands, 3Leiden University Medical Center, Department of Pediatrics, Leiden, Netherlands
636 Development of indicators to determine the quality of cesarean section care Sonja Melman1, Rosella Hermens2, Jan Nijhuis3, Liesbeth Scheepers4, SIMPLE project group5 1 Maastricht University Medical Centre, GROW- School for Oncology and Developmental Biology, Gynaecology and Obstetrics, Maastricht, Netherlands, 2Radboud University Nijmegen Medical Centre, Department of Quality of Care, IQ Healthcare, Nijmegen, Netherlands, 3Maastricht University Medical Center, Obstetrics & Gynecology, GROW School for Oncology and Developmental Biology, Maastricht, Netherlands, 4Maastricht University Medical Centre, GROW- School for Oncology and Developmental Biology,Department of Obstetrics and Gynaecology, Maastricht, Netherlands, 5 The Dutch Consortium for Studies in Women’s Health and Reproductivity, Department of Obstetrics and Gynaecology, Maastricht, Netherlands
OBJECTIVE: Worldwide there is a rising cesarean section (CS) rate, mainly in healthy women with a singleton in vertex position at term without improved perinatal outcome. Moreover, a CS is associated with higher costs, increased short term risks, and an increased risk for future pregnancies. International guidelines describe evidence based recommendations for performing a CS in specific situations. In general, large gaps exist between scientific evidence and current care. Incomplete adherence to CS recommendations may, in part, explain the rising CS rate. In order to improve care we need to measure it. Therefore, we aimed to develop a set of quality indicators on CS care. STUDY DESIGN: According to the RAND-modified Delphi method, 51 recommendations on CS performance were abstracted from guidelines of international obstetrical organizations. These recommenda-
OBJECTIVE: Most complications after laser coagulation for TTTS are related to residual anastomoses. Therefore we aimed to test the hypothesis that with increasing experience, the rate of residual anastomoses (RA) is decreasing. STUDY DESIGN: Retrospective analysis of prospectively collected data on 250 consecutive MC twins with TTTS treated with fetoscopic laser between 2002 and 2008. We excluded placentas from single or double IUFDs, and those from 2006 when we did not routinely inject the placentas. Presence of RA, determined by color-dye injection of the placenta, was evaluated over time. Associations were evaluated with placental localisation and laser technique. RESULTS: We could include 108 cases with complete data. RAs were present in 29% (31/108). We found no decrease over time of RAs, except for the last year (2008) when we started our pilot with the Solomon technique (21%). Rate of RAs in case of anterior placenta was 29% (13/45), in predominantly posterior placentas RAs were found in 29% (18/63) as well. CONCLUSION: Residual anastomoses were found in a third of placentas from double survivors of laser surgery for TTTS. Neither operator experience, nor placental localization seems to play a role. The introduction of the Solomon technique might decrease the occurrence of RAs.
638 Hospital variation in cesarean delivery rates among a very low risk population in Massachusetts: an opportunity for quality improvement? Vanitha Janakiraman Mohta1, Isabel Caceres2, Lauren Smith2, Bruce Cohen2, Gene Declercq3, SV Subramanian4, Jeffrey Ecker1 1
Massachusetts General Hospital, Obstetrics and Gynecology, Boston, MA, Massachusetts Department of Public Health, DPH, Boston, MA, 3Boston University School of Public Health, Community Health Sciences, Boston, MA, 4Harvard University, Population Health and Geography, Boston, MA 2
OBJECTIVE: To explore the effect of practice patterns on variation in cesarean rates, we compared cesarean rates between hospitals in a
Supplement to JANUARY 2012 American Journal of Obstetrics & Gynecology
S285