Disclosures

Dr. Iams has contracts via Ohio State University with:•NICHD for clinical research projects•OPQC for quality improvement projects•Elsevier for editorial & authorship roles in AJOG and Creasy & Resnik’s MFM textbook

Objectives

2013-20152013-2015

Prematurity is the Most Common Cause of Infant Mortality

34.3%34.3% of Infant Deaths Are Caused by Preterm Birth

2010 2010 Infant Mortality Infant Mortality RatesRates

March of Dimes 2013 Report CardPremature Birth Rate

Rates of Contributing Factors 2012 2013 Grade Uninsured WomenUninsured Women 17.8% 17.0% Late Preterm BirthLate Preterm Birth 8.2% 8.1% Women Who SmokeWomen Who Smoke 30.6% 27.3%

The Medical Model of Care for Preterm Birth

BandAid

BandAid

Care for Preterm Birth During Pregnancy 1985 - 2006

Detection & Suppression of Contractions Detection & Suppression of Infections Detection & Replacement of Nutrients

CalciumCalcium, Omega-3, Protein, Vitamins C + E Detection & Surgical Rx of Short Cervix Detection & Attention to Social Support ProgesteroneProgesterone ???

2010 2011

11.9%

11.7%

2012

11.5%

Who Decreased the Preterm Birth Rate?

Report issued Nov 2011 by CDC – NCHS *

ASRM Statements On Fertility Care And Twins, Triplets, & Higher Order Multiples

*

OPQC 39 Weeks Project in Sustain Phase Decreasing Non-Medically Indicated Decreasing Non-Medically Indicated

Scheduled Deliveries Between 37 and 39 Weeks GestationScheduled Deliveries Between 37 and 39 Weeks Gestation

14

5% Goal5% Goal

Data Is From All Ohio Maternity Hospitals105 of 107 Hospitals Participated in the OPQC 39 Week Project

2010 2011

11.9%

11.7%

2012

11.5%

Obstetricians Obstetricians Have The Band AidsHave The Band Aids

• Antenatal SteroidsAntenatal SteroidsoReview Documentation of ANCS UseoSystems Improvements in Birth RegistryoPublish Rates of Documented Use Publish Rates of Documented Use

• Progesterone SupplementationProgesterone SupplementationoWomen with a prior preterm birthoWomen with short cervix in

this pregnancy

BandAid

BandAid

Birth Registry Documentation of ANCS Use Birth Registry Documentation of ANCS Use Aggregate Rate in 19 OPQC Sites 2006 - 2014Aggregate Rate in 19 OPQC Sites 2006 - 2014

The Ohio OPQC Progesterone Project• Goal: Reduce Ohio PTB & Related Infant Mortality

o Reduce Preterm Birth < 37 & 32 Weeks by 10% by 7-1-15Reduce Preterm Birth < 37 & 32 Weeks by 10% by 7-1-15• Find Women with Prior Preterm Birth• Find Women with Short Cervix• Make it Easy to Prescribe and Rx Progesterone

o Protocols, Medicaid & Insurance Support, Navigators• Outcome Measures

o Preterm Birth Rate• Medicaid Data • Birth Registry Data – Births < 32 & 37 Weeks

o Process Measures

o The Infant Mortality RateThe Infant Mortality Rate

Why? Preterm Birth Largest Contributor to Infant

Mortality Preterm Birth Largest Driver of Disparity in PTB

Who? Women with a Prior Preterm Birth Women with Very Short Cervical Length

How? Find & Rx Candidates for Progestogens When? ASAP – in Ohio & in Each Pregnancy

Find a ProgesteroneFind a ProgesteroneProtocol You LikeProtocol You LikeAnd Use It.And Use It.

HereHere’’s One.s One.

Find OneFind OneThat FitsThat FitsYourYourPractice.Practice.

What Formulations of Progestogens Should Be Used? What Formulations of Progestogens Should Be Used? Standard Answers:

Hx SPTB: 17-OHPC 250 mg IM Q 7d 16 36 wks Short Cx ≤ 20 mm: Vag P, 200 mg QHS, Dx 36 wks

But Life is Not That Simple 17-OHPC – Manufactured vs. Compounded

Cost vs. Hassle Vaginal P – multiple formulations - which to Rx? Who pays for what, when, & after how much hassle?Who pays for what, when, & after how much hassle?

Initiate Progesterone ASAP for Hx SPTBInitiate Progesterone ASAP for Hx SPTB Accelerated 1st Prenatal Visit Presumptive Eligibility for Antenatal Care

Adopt a Local Management Protocol Adopt a Local Management Protocol For Hx SPTB For Short Cervix Test them via OPQC !Test them via OPQC !

Make Make ““Screen for PTB RiskScreen for PTB Risk”” ≈ GBS, Rh, GDM ≈ GBS, Rh, GDM

https://www.perinatalquality.org/CLEAR/

http://www.fetalmedicine.com/fmf/online-education/05-cervical-assessment/

The Importance of Credentialing for Cervical SonographyIams JD et al. Am J Obstet Gynecol 2013

OPQC’s Tasks:Remove Administrative Barriers to Receiving Progesterone Supplementation

Pharmacy Coordination Insurance / Medicaid Coverage & Protocols Delivery and Administration of 17 α- OHPC Use of Vaginal Formulations

Generic 200 mg capsules = cheapest & fastest Rx Designate a Progesterone Coordinator Convene Participants to Assure Rx Received

Why Are We Missing P-Eligible Women?What Have You Told OPQC About That?What Have You Told OPQC About That?

• Do Providers Know About Progesterone? YesYes.• Do Providers Know What to Rx? Yes, mostlyYes, mostly.• Do Providers Know The Rx Gets to Patient?

Not So MuchNot So Much.• Do Providers Know Why Women Don’t Seek

Care ‘til It’s Too Late? Yes, mostlyYes, mostly.•Do Providers Know What They Can Do To Overcome That? Not So MuchNot So Much.

What Have Providers Done About What Have Providers Done About Late for CareLate for Care??• No Appointment Needed!No Appointment Needed!

– 11stst Visits Welcomed Anytime in Cincinnati Visits Welcomed Anytime in Cincinnati• Community Open Houses with Food PrepCommunity Open Houses with Food Prep

– ““Moms2BMoms2B”” in Columbus Builds Social Networks in Columbus Builds Social Networks• Business Community InvolvementBusiness Community Involvement

– Ohio Metro Counties Have High Infant MortalityOhio Metro Counties Have High Infant Mortality• High Infant Mortality = A Measure of Community HealthHigh Infant Mortality = A Measure of Community Health

– Bring Your Business Here? Bring Your Business Here? No Way! No Way! Goin’ to Georgia!Goin’ to Georgia!

• Hospital Geographic Responsibility for HealthHospital Geographic Responsibility for Health

Improving Access to Progesterone in Ohio

• Drive Community Changes to Increase Drive Community Changes to Increase Awareness of PTB as Cause of Infant Mortality Awareness of PTB as Cause of Infant Mortality

• Increase Avenues to Enter Prenatal CareIncrease Avenues to Enter Prenatal Care• Recognize Candidates at First ContactRecognize Candidates at First Contact• Accelerate Appts & THEN get detailed OB HxAccelerate Appts & THEN get detailed OB Hx• Track Receipt of Progesterone After RxTrack Receipt of Progesterone After Rx• Think Outside the Medical Paradigm to Find Think Outside the Medical Paradigm to Find

Eligible Women Late To Prenatal CareEligible Women Late To Prenatal Care

• Publish The Data for Your County & Your State:Publish The Data for Your County & Your State:o Infant Mortality, Preterm Birth, & Smoking.o Scheduled Births < 39 Weeks – 1% goal.oMulti-fetal Pregnancy Rates. o Antenatal Corticosteroids.o Include Racial Disparity Rates for All the Above.Include Racial Disparity Rates for All the Above.

• Track All Over Time Track All Over Time – Use Graphs, Not Tables.• Promote Public AwarenessPromote Public Awareness

o Risks of Preterm Birtho Prevention with Progesteroneo Availability of Cervical Ultrasound