Overview

Induction of labor has been increasing nationally for both medically indicated and non-medical reasons. Research suggests that induction of labor is a factor in escalating rates of cesarean deliveries, preterm births, and neonatal intensive care admissions. In response, an integrated health care system successfully implemented a guideline-based program to reduce inappropriate elective induction of labor.

Type of Intervention: Reducing inappropriate use of services Organization: Intermountain Health Care is an integrated health care delivery system based in Salt Lake City, Utah. IHC operates a network of open-model hospitals affiliated with physicians who practice in the community. Date of Implementation: June 2003 Target Population: The intervention targeted pregnant women and their physicians at 11 participating IHC hospitals.

Objective and Intervention: The goal was to reduce the rate of inappropriate elective labor induction through implementation of an evidence-based clinical guideline along with performance monitoring, peer review, and patient education.

Key Measures: Data were collected from an electronic medical record system on:

• Elective inductions for pregnancies of less than 39 weeks gestation;
• Elective inductions for women having their first birth with a Bishop Score (a pelvic scoring system for selecting patients suitable for elective induction, based on five components of a vaginal/cervical examination) of less than 10; and
• Maternal and neonatal combined variable costs per uncomplicated delivery resulting in a normal newborn.

Process of Change: A physician guidance council analyzed institutional data on labor induction and outcomes to determine if national research findings were relevant to the local setting. The analysis found that nearly one-third of inductions were inappropriate (baby not ready to be born according to ACOG standards). It also found an increased rate of neonatal intensive care admissions associated with induced preterm deliveries (5.3 percent for pregnancies of 37 weeks gestation versus 2.1 percent at 39 weeks). Local data also showed that the rate of cesarean deliveries among women having their first birth dropped to 5 percent among those with a Bishop Score of 10 or higher versus 15 percent for those with a Bishop Score of less than 10.

In response, the council decided to implement guidelines for labor induction across the institution's 21 labor and delivery sites.

• In the first phase of the intervention (starting July 2001), physicians were required to obtain the permission of the department head or a consultation with a perinatologist before inducing labor in women with pregnancies of less than 39 weeks gestation.
• In the second phase of the intervention (starting January 2004), physicians were required to provide a clinical reason to justify an elective labor induction for women with a Bishop Score of less than 10 (indicating that the cervix is not ready to deliver).
• Performance was monitored system wide and at individual facilities. A patient education sheet was developed to explain the institution's policy on labor induction.

Results: In the first phase of the intervention, elective inductions for pregnancies of less than 39 weeks gestation decreased from an average of 27 percent of births in the first six months of 2001 (prior to the intervention) to 6 percent of births by July 2002. This reduction was sustained during 2003 and the goal of 5 percent elective inductions in such pregnancies was reached by the first half of 2004.

In the second phase, elective inductions in women having their first birth with a Bishop Score of less than 10 decreased from 15 percent of such births in January 2003 (prior to the intervention) to 6 percent by June 2004. This intervention achieved the goal of a 50 percent reduction in the number of such induced deliveries.

As a result of these and other improvements, total maternal and neonatal variable costs decreased from $1,622 per case in January 2003 to $1,480 in the first half of 2004 (for uncomplicated deliveries resulting in normal newborns). This result was $300 better than expected based on historical trends, adjusted for producer price inflation.

Lessons Learned: Costs can be controlled by improving clinical outcomes. This is true often enough that it should be a principal part of care delivery. Physicians want to do the right thing but need data to understand where practice is falling short of achieving optimal outcomes. Local outcomes data are important to set appropriate local improvement goals and to revise goals as needed. Induction of labor deserves greater attention for quality improvement. Future studies also should assess patient perceptions of and satisfaction with care.

For Further Information: Contact Bryan Oshiro, M.D., System Medical Director, IHC Women and Newborns Clinical Integration Program (801-387-4643 or mkboshir@ihc.com) or Brent James, M.D., Executive Director, IHC Institute for Health Care Delivery Research (801-442-3592 or brent.james@ih.com). Statistical analysis for this report was prepared by Erick Henry, M.P.H., at the IHC Institute. Dr. Oshiro will present this study next month at the 2004 annual meeting of the Central Association of Obstetricians and Gynecologists in Washington, DC.

This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied organizations' experiences in ways that may aid their own efforts to become high performers. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case studies series is not an endorsement by the Fund for receipt of health care from the institution.