37 38 67 weeks Gestation Scott D Duncan MD MHA FAAP Associate Professor Pediatrics University of Louisville Changing Gestation of Spontaneous Birth Davidoff et al Semin Perinatol ID: 294934
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Slide1
Early Term Births37 – 38 6/7 weeks Gestation
Scott D. Duncan, MD, MHA, FAAP
Associate Professor – Pediatrics
University of LouisvilleSlide2
Changing Gestation of Spontaneous Birth
Davidoff, et al.
Semin
Perinatol, 2006Slide3
Definitions
Fleischman, et al.
Obstet
Gynecol, 2010
Preterm – Less than 37 weeks
Late Preterm – 34 – 36 6/7
Term – 37 – 41 6/7
Early Term – 37 – 38 6/7Full Term – 39 0 41 6/7Post-term – 42 weeks and beyondSlide4
Births: Final Data for 2009
Martin, et al. NSVR, 2011
Distribution of births by gestational age, all
births:
United States, 1990, 2000, 2005–2009
ModifiedSlide5
NQF #0469 PC-01 Elective Delivery
A
reduction in the number of non-medically indicated elective deliveries at >=37 to <39 weeks gestation will result in a substantial decrease in neonatal morbidity and mortality, as well as a significant savings in health care costs.
The rate of cesarean sections should decrease with fewer elective
inductions,
resulting in decreased length of stay and health care costs.
The measure will assist health care organizations (HCOs) to track non-medically indicated early term elective deliveries and reduce the occurrence. Slide6
© 2009 The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins, Inc.
Fig. 1. Rate of neonatal intensive care unit admissions for normal pregnancies by gestational age. Two standard deviations shown by vertical lines. Data from Intermountain
Healthcare.Oshiro
. Decreasing Elective Deliveries Before 39 Weeks.
Obstet
Gynecol
2009.
Decreasing Elective Deliveries Before
39 Weeks
of Gestation in an Integrated
Health Care
System
Decreasing Elective Deliveries Before 39 Weeks of Gestation in an Integrated Health Care System.
Oshiro
, Bryan; Henry, Erick; Wilson, Janie; Branch, D; Varner, Michael
Obstetrics & Gynecology. 113(4):804-811, April 2009.
DOI: 10.1097/AOG.0b013e31819b5c8cSlide7
© Mosby-Year Book Inc. 2009. All Rights Reserved.
Neonatal and maternal outcomes associated with elective term delivery.
Clark SL; Miller DD; Belfort MA;
Dildy
GA; Frye DK; Meyers JA
American Journal of Obstetrics & Gynecology. 200(2):156.e1-4, 2009 Feb.
TABLE Elective delivery and neonatal outcome
Neonatal and maternal outcomes
associated with elective term deliverySlide8
Late Preterm Infants, Early TermInfants and Timing of Elective Deliveries
Table 6
-- Respiratory distress syndrome in late preterm and term infants
Data from
Madar
J, Richmond S, Hey E. Surfactant-deficient respiratory distress after elective delivery at ‘term.’
Acta
Paediatr
1999;88:1245
Engle, et al.
Clin
Perinatol
, 2008Slide9
Copyright © 2009 Massachusetts Medical Society. All rights reserved.
Timing of elective repeat cesarean delivery at term and neonatal outcomes.
Tita
AT; Landon MB;
Spong
CY; Lai Y;
Leveno
KJ; Varner MW;
Moawad
AH;
Caritis
SN;
Meis
PJ;
Wapner
RJ; Sorokin Y;
Miodovnik
M; Carpenter M;
Peaceman
AM; OSullivan MJ; Sibai
BM; Langer O; Thorp JM;
Ramin
SM; Mercer BM; Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Network
New England Journal of Medicine. 360(2):111-20, 2009 Jan 8.
Figure 2 . Timing of Elective Repeat Cesarean Delivery and the Incidence of the Primary Outcome According to the Number of Completed Weeks of Gestation
.
Timing of Elective Repeat Cesarean Delivery at Term and Neonatal OutcomesSlide10
Copyright © 2009 Massachusetts Medical Society. All rights reserved.
Timing of elective repeat cesarean delivery at term and neonatal outcomes.
Tita
AT; Landon MB;
Spong
CY; Lai Y;
Leveno
KJ; Varner MW;
Moawad
AH;
Caritis
SN;
Meis
PJ;
Wapner
RJ; Sorokin Y;
Miodovnik
M; Carpenter M;
Peaceman
AM; OSullivan MJ; Sibai
BM; Langer O; Thorp JM;
Ramin
SM; Mercer BM; Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Network
New England Journal of Medicine. 360(2):111-20, 2009 Jan 8.
Table 2 . Incidence of Adverse Neonatal Outcomes According to Completed Week of Gestation at Delivery.
Timing of Elective Repeat Cesarean Delivery at Term and Neonatal OutcomesSlide11
Adverse OutcomesSlide12
Variations in Mortality and Morbidity by Gestational Age among Infants
Born at Term
Zhang et al. J
Pediatr, 2009Slide13
© Mosby-Year Book Inc. 2010. All Rights Reserved.
Timing of elective repeat cesarean delivery at term and neonatal outcomes: a cost analysis.
Robinson CJ;
Villers
MS; Johnson DD; Simpson KN
American Journal of Obstetrics & Gynecology. 202(6):632.e1-6, 2010 Jun.
TABLE 2 Mean costs/charges by adverse outcomes
Timing of elective repeat cesarean delivery: a cost analysisSlide14
© Mosby-Year Book Inc. 2010. All Rights Reserved.
Timing of elective repeat cesarean delivery at term and neonatal outcomes: a cost analysis.
Robinson CJ;
Villers
MS; Johnson DD; Simpson KN
American Journal of Obstetrics & Gynecology. 202(6):632.e1-6, 2010 Jun.
TABLE 3 Costs/charges by adverse outcome incidence
Timing of elective repeat cesarean delivery: a cost analysisSlide15
© Mosby-Year Book Inc. 2010. All Rights Reserved.
Timing of elective repeat cesarean delivery at term and neonatal outcomes: a cost analysis.
Robinson CJ;
Villers
MS; Johnson DD; Simpson KN
American Journal of Obstetrics & Gynecology. 202(6):632.e1-6, 2010 Jun.
TABLE 4 Costs/charges by timing of cesarean
Timing of elective repeat cesarean delivery: a cost analysisSlide16
Early Term Births
KY Cabinet for Health & Family Services, 2012Slide17
Inductions
KY Cabinet for Health & Family Services, 2012Slide18
Cesarean Sections
KY Cabinet for Health & Family Services, 2012Slide19
Cost - Neonatal
Respiratory Distress Syndrome
Incidence ranges from 1.9 – 3.7%
Mean charge $147,017Costs approximates $1,363,142 to $2,654,539Total charges ~ $4,014,681
Prematurity
w/o
cc
Incidence ranges from 8 – 17.8%Mean charge $12,515Charges ranges $977,171 to $2,174,206Total charges ~ $3,151,377
KY Cabinet for Health & Family Services, 2012
Cost Data - http://hcupnet.ahrq.gov/Slide20
Advisory Committee on Infant Mortality Slide21
HRSA Infant Mortality CollaborativeSlide22
© 2009 The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins, Inc.
Decreasing Elective Deliveries Before 39 Weeks of Gestation in an Integrated Health Care System.
Oshiro
, Bryan; Henry, Erick; Wilson, Janie; Branch, D; Varner, Michael
Obstetrics & Gynecology. 113(4):804-811, April 2009.
DOI: 10.1097/AOG.0b013e31819b5c8c
Fig. 3. Percent of elective deliveries before 39 weeks of gestation. Data from Intermountain
Healthcare.Oshiro
. Decreasing Elective Deliveries Before 39 Weeks.
Obstet
Gynecol
2009.
Intermountain HealthcareSlide23
© Mosby-Year Book Inc. 2010. All Rights Reserved.
A statewide initiative to reduce inappropriate scheduled births at 36(0/7)-38(6/7) weeks' gestation.
Donovan EF;
Lannon
C;
Bailit
J; Rose B;
Iams
JD;
Byczkowski
T; Ohio Perinatal Quality Collaborative Writing Committee
American Journal of Obstetrics & Gynecology. 202(3):243.e1-8, 2010 Mar.
FIGURE 2 Percent of births at 36-38 weeks induced without medical or obstetric indication
Ohio PQCSlide24
Approach – Clinical Effectiveness
“Hard
stop”
Adoption of a policy
Policy enforcement
“Soft
stop”
Adoption of a policyPeer review committee“Education only”
Clark, et al., Am J
Obstet
Gynecol
, 2010Slide25
Approach – Clinical Effectiveness
Clark, et al., Am J
Obstet
Gynecol
, 2010
500,000 NICU Days
$1,000,000,000 per yearSlide26
Policy Development
The campaign
to reduce early term
deliveries applies only to purely elective procedures.Elective refers only
to those scheduled deliveries
that are
performed without a valid
medical indication.Clark, et al., Am J Obstet Gynecol, 2012Slide27
“The level of civilization attained by any society will be determined by the attention it has paid to the welfare of its children.”
- B.F. Andrews