A statewide progestogen promotion program that aimed to reduce early premature births in Ohio by 10% is exceeding its goals, thanks to a joint effort of maternity hospitals and clinics, Ohio’s Medicaid program, Medicaid insurers, and service agencies.
The organizations joined forces via the Ohio Perinatal Quality Collaborative (PQC) beginning in 2014, and by February 2016 a sustained reduction in singleton births before 32 weeks of gestation was evident. The reduction was particularly pronounced among women with a prior preterm birth, African American women, and women on Medicaid, with reductions of 20.5%, 20.3%, and 17.1%, respectively, according to Jay D. Iams, MD, the obstetrics lead for the collaborative and emeritus professor at Ohio State University; Mary S. Applegate, MD, medical director for the Ohio Department of Medicaid; and their colleagues.
Dr. Jay D. Iams
What was the key driver of their success? A collaborative effort among local- and system-level organizations and individuals to overcome the numerous barriers to providing the preventive, highly effective progestogen treatments to at-risk women, according to Dr. Iams and Dr. Applegate.
“Ohio has one of the worst rates of infant mortality and a high rate of premature birth – especially very early premature birth [before 32 weeks],” Dr. Iams said in an interview.
Those very early births account for more than half of infants who die before their first birthday, so while 13% may seem like a small number, it has the potential to have a very large effect on long-term health and infant mortality, he said.
The Ohio program was developed in the wake of practice guidelines from the Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists, both issued in 2012, on the use of progestogens to reduce the incidence of preterm birth (Am J Obstet Gynecol 2012;206:376-86 and Obstet Gynecol 2012;120:964-73).
Large, high-quality, randomized placebo-controlled trials supported the use of 17-alpha hydroxyprogesterone caproate (17-p) injections or progesterone administered vaginally, and the Ohio Department of Medicaid and Ohio Department of Health asked the Ohio PQC – a volunteer network of stakeholders dedicated to improving perinatal health outcomes – to design a statewide quality improvement project to promote progestogen prescribing for eligible women.
Dr. Mary S. Applegate
To facilitate identification and management of women at risk for preterm birth, clinicians were asked to notify the Ohio Medicaid agency when a patient became pregnant so that a care manager could be assigned to help remove barriers to care.
“It turned out that piece of it was key,” she said. “It was the communication between these two, and then just dealing with whatever the issues were that actually made the difference.”
Care managers helped the patients navigate the system by notifying the county to make sure they didn’t “fall off Medicaid,” by addressing transportation issues to ensure patients could get to their weekly treatment visits, and by addressing cultural issues, for instance.
“It never really occurred to clinicians that Medicaid could actually be helpful in finding women and actually doing the right thing for them,” Dr. Applegate said, explaining that most only thought of Medicaid as “after the fact ... the doctors do what they need to and afterward we pay claims.”
“So this was kind of a new concept to them,” she added.
In fact, a quality improvement plan was structured on the managed care plan side, just like one was structured on the clinical side, she said. “In essence we have these parallel systems that were actually connecting, identifying barriers as we went,” Dr. Applegate said.
In the article in Obstetrics & Gynecology, the investigators describe the quality improvement processes, including training, evidence reviews, and strategy sharing. Steps toward efficient identification of eligible patients and prescription of progestogens were developed, and participating sites were encouraged to follow them.
At the system level, efforts focused on maintaining the patient’s Medicaid coverage, expanding eligibility for Medicaid, and streamlining forms and processes to improve efficiency and improve data collection.
The effects of these cumulative efforts emerged over time, with the drop in early premature births becoming apparent about 16-18 months after the project started. The investigators reviewed other possible causes for the decrease, such as an increase in the rate of cervical cerclage, but confirmed that the change was likely the result of the progestogen promotion program, Dr. Iams said.
In all, 2,562 women were eligible for progestogen at participating clinics between Jan. 1, 2014, and Nov. 30, 2015. Most (93%) were eligible because of a prior preterm birth, and the remainder had a short cervix on ultrasound. A progestogen was prescribed at or before 20 6/7 weeks of gestation in 64%, and at or before 24 6/7 weeks gestation in 72%. Injections were prescribed in 65%, and vaginal preparations in 30%; 5% were prescribed both or had no documentation of the formulation.
The progestogen program had no effect on the overall rate of births before 37 weeks. “So we can’t say that we changed the prematurity rate, but we changed the rate of births that are most likely to result in infant death and we were pretty excited about that,” Dr. Iams said.
Next steps for the program include expansion to rural areas and development of an electronic notification system to further streamline communication between the various players (pharmacies, insurance companies, Medicaid, etc.). Dr. Applegate said she also hopes to harness the lessons of this program for use in other high-risk scenarios, such as pregnancies complicated by substance abuse.
As for whether other states will follow Ohio’s lead, Dr. Iams said almost all the states are involved in quality improvement efforts, including several with programs similar to Ohio’s.
In fact, the Centers for Disease Control and Prevention is currently providing support to PQCs in California, Illinois, Massachusetts, North Carolina, and New York, in addition to the Ohio PQC, according to Zsakeba Henderson, MD, a medical officer on the CDC division of reproductive health in Atlanta.
“CDC has developed a resource guide to help develop and advance the work of state PQCs, and in collaboration with March of Dimes has spearheaded the development and launch of the National Network of Perinatal Quality Collaboratives,” she said. “This network is a consultative resource for state PQCs, with a mission is to support the development and enhance the ability of state perinatal quality collaboratives to make measurable improvements in statewide maternal and infant health care and health outcomes.”
Dr. Applegate stressed the importance of collaboration in achieving results.
“I think the message is you can’t do it in a silo. It really has taken this collaborative and fairly comprehensive approach to understand not only how complex the system is, but how complicated people’s lives are. You just have to hang in there over lots and lots of weeks to get the outcome you want,” she said, adding that the effort is well worth it.
“These are babies that are born weighing less than a pound and a half. When we’re helping them be born closer to term that changes the next 60 years of their life,” she said. “It totally changes not just that baby’s life, but the hardship that comes to that family as well, so the impact is actually huge.”