Hoag Memorial Hospital Presbyterian, one of the largest and most respected
facilities in Orange County, needed to move quickly.
A big insurer had warned that its maternity costs were too high and it
might be cut from the plan's network. The reason? Too many cesarean sections.
"We were under intense scrutiny," said Dr. Allyson Brooks, executive
medical director of Hoag's women's health institute.
The C-section rate at the time, in early 2012, was about 38 percent. That
was higher than the state average of 33 percent and above most others
in the area, according to the California Maternal Quality Care Collaborative,
which seeks to use data to improve birth outcomes.
Within three years, Hoag had lowered its cesarean section rates for all
women to just over a third of all births. For low-risk births (first-time
moms with single, normal pregnancies), the rate dropped to about a quarter
of births. Hoag also increased the percentage of women who had vaginal
births after delivering previous children by C-section.
In medicine, this qualifies as a quick turnaround. And the story of how
Hoag changed sheds light on what it takes to rapidly improve a hospital's
performance of crucial services, to the benefit of patients, insurers
Decreasing C-sections results in "better health to mothers and better
health to babies and lower costs," said Stephanie Teleki, senior
program officer at the California HealthCare Foundation, which helped
fund the data collection and analysis by the California Maternal Quality
Care Collaborative. "That's like a nirvana moment in health care."
Experts have long been troubled by the wide variation of C-sections among
hospitals nationally. (In California, the rates range from 18 percent
to 56 percent.) Certainly there are instances in which C-sections are
typically recommended – such as a baby in breech position. But the
disparities suggest that decisions are being driven by factors other than
medical necessity – such as doctors' time constraints and malpractice concerns.
Over the past few years, there has been a coordinated push to cut C-section
rates in other states and in births covered by Medicaid, the health coverage
program for low-income Americans.
The Centers for Disease Control and Prevention is funding projects to reduce
scheduled births that aren't required medically. The Joint Commission,
which accredits hospitals, is requiring hospitals with more than 1,100
births annually to report on their cesarean births and elective deliveries.
The March of Dimes launched an education campaign to urge women to wait
for natural labor, and the American College of Obstetricians and Gynecologists
has publicly proposed ways to reduce the rates, such as using a doula
to support women in labor.
Still, many hospitals don't act until dollars are at stake, said Dr.
Elliott Main, medical director of the California Maternal Quality Care
Collaborative. That's what happened with Hoag, which Main said is
now becoming a model for other hospitals.
"In quality improvement, we call it 'the burning bridge,'"
he said. "You can't just stay still. You've got to move."
Focus on Physicians
At Hoag, where more than 6,000 babies are born each year, Brooks and other
administrators knew that they had to focus on changing the mindset and
behavior of physicians. "Hospitals don't do C-sections, doctors
do," she said.
So they took some aggressive steps. Among them was obtaining each doctor's
C-section rate from Dr. Main's group. First, they shared the data
with all the physicians in the department without names -- then decided
to reveal the names. Suddenly, everyone knew who had exceeded or come
in under the average.
"There was a lot of upheaval," Dr. Jeffrey Illeck, a community
OB-GYN and the hospital's obstetrics department chair. "None
of us want to look bad in front of our peers. … And some looked
Some physicians reacted with surprise and frustration. Initially, many
attributed the high rates to the patients, saying they were older, had
more complicated pregnancies or demanded scheduled C-sections. Others
questioned how the numbers were gathered.
Dr. Amy VanBlaricom, an OB-GYN who delivers about 25 to 30 babies a month,
said she wasn't opposed to sharing the data. But she said doctors
were worried that the rates would be used to penalize them rather than
to drive improvement.
"It's very heated," she said. "We should use this data
as an opportunity rather than a polarizing topic."
VanBlaricom already tracked her own rates, which she said fell in the middle
of the pack, and has only seen a small drop since. But she said being
aware that Hoag is monitoring the C-sections has changed how she thinks
about her practice and has encouraged her to let women remain in labor longer.
That's what Hoag administrators were aiming for – a realization
among doctors that C-sections should not be undertaken lightly. They carry
surgical risks, including serious infection and blood clots, and require
longer hospital stays.
"Doctors and patients look at cesareans as an easy way to time the
birth," said Dr. Marlin Mills, chief of perinatology at the hospital.
"But a C-section is not benign. It's a big surgery."
The costs are also well-documented. Surgical births cost nearly $19,000,
compared to about $11,500 for vaginal births, according to the Pacific
Business Group on Health, an organization of employers that is also working
to bring down C-section rates around the state.
The business group worked with the hospital on the financial side. It enlisted
the help of some of the biggest local employers, including Disney, and
another insurer, Blue Shield, to adjust payments so the hospital didn't
earn more from elective C-sections than vaginal births.
"The data helped people achieve the culture change," said Brynn
Rubinstein, senior manager for the business organization. "Hopefully
payment reform will help us sustain it."
In addition, the hospital set new scheduling rules. In the past, doctors
could simply call in with the woman's due date and schedule the birth.
Now, they would have to fill out a detailed form, with some requests needing
The hospital also stepped up its patient education, encouraging women
to wait for labor to come naturally. If patients did want an elective
C-section, they would have to sign an easy-to-understand consent form
in the doctor's office that detailed the risks.
Nurses were asked to help, by using techniques to avoid C-sections for
women already in labor. They got women walking around the unit to reduce
their chances of needing the surgery. The nurses received end-of-year
bonuses if they helped the hospital reach certain goals on reducing surgical births.
The hospital opened an obstetrics emergency department and gave more responsibility
to "laborists," doctors who were there around the clock to respond
to emergencies, monitor women in labor and deliver babies.
Dr. Alex Deyan, who delivered more than 500 babies at the hospital last
year, used to turn away patients who wanted vaginal births after cesarean
sections. With a busy private practice, Deyan said he couldn't always
be immediately available if labor didn't go as expected and a woman
needed a C-section. That changed with the laborist program.
"Having in-house doctors 24/7 is a huge benefit," Deyan said.
"I can be a little more patient."
Good for Patients, Too
Holly Grim appreciated Hoag's approach. She knew she didn't want
a C-section with her second baby. Her first labor at another hospital
in December 2013 was long and painful and ended with a cesarean section
that kept her in the hospital for days. Her son was healthy, but she said,
"this wasn't exactly how I had it planned – not even close."
This time, she needed to get back on her feet quickly so she could chase
after her 16-month-old. She decided to switch doctors and hospitals. And
in early April, she got her wish -- giving birth naturally to an 8-pound
girl, Agnes, at Hoag.
The day after Agnes was born, the family was packing up to go home. She
didn't have any restrictions on lifting or driving, and she wasn't
in severe pain. This, she said, is how childbirth is supposed to be.
"I'm feeling really good," she said as she nursed Agnes,
wrapped in a blanket decorated with pastel footprints. "I'm relieved
I'll be able to run around after my son."
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