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Caesareandeliverypractice

heterogeneity, appropriateness and efficiencyin the Ile de France (IDF Paris region)

C. Crenn Hebert

a b c, C. Menguy b, M. Martinowsky c,

E. Lebreton

d, L. Anzelin d, M. Hanf d a Maternity dept, University hospital Louis Mourier, Assistance Publique

Hôpitaux de Paris,

b Perinat-ARS-IDF, Paris, France, C ARS Ile de France d SESAN, Paris, France

01/08/2019Perinat ARS IDF1

Outline(workin progress)

•Background •Objectives •Method •Discussion •Future work

01/08/2019Perinat ARS IDF2

Background

01/08/2019Perinat ARS IDF3

•OMS statement in 2014 about Caesarean section •Wide variations in european countries in CS rate •In France -french national evidence-based guidelines about termelective Caesarean section (CS) in 2012 -appropriateness programimplementation on a voluntary base •In IDF -caesarean section rate > other regions -larger variations / same level maternities CS rate -=> regional health authority ARS-IDF focus on CS rate

WHO statement

•A global reference for caesarean sectionrates (C-Model) a multicountry cross-sectional study. BJOG 2015 JP souza et al.

•Robson classification implementationmanuel: a tool to monitor and comparecaesarean section rates in a same settingover time and between different settings.Since 1985 caesarean sectionshave become increasinglycommon in both developed anddeveloping countries. ...

When medically necessary

a caesarean section can effectively prevent maternal and newborn mortality.

Other issues impact needs

further studies : mortinatality, infant and maternal morbidity, infant health, global wellbeing, ...

Contexte

5

Euro-Peristat 2015European Perinatal Health Report. Core indicators of the health and care of pregnant women and babies in Europe.November 2018. www.europeristat.com

30/08/2019Perinat ARS IDF6

Caesarean delivery

standardized utilization rate / 100 births

Caesareanrate evolutionin France

Source ATIH (PMSi) https://www.scansante.fr/applications/indicateurs-de-sante-perinatale7

051015202530

% CS total 2013% CS total 2017

Guidelines HAS healthquality

agency2012 Termelectivecaesareansection •Selected indications guidelines •Staffed decision withseveral professionnals •Programmation at >= 39 weeks for singleton •Informed consent / " choosing wisely » / shared decision withpatients

01/08/2019Perinat ARS IDF8

Objectives

•To identify outliers maternities (either withan excess or deficiency of caesareansection rate) •In viewto reduce the gaps •Withinan active quality approach

01/08/2019Perinat ARS -IDF9

Method-1: CS rate variation in IDF (2017)

Source ATIH PMSI Exploitation Perinat-ARS-IDF10

CASH DE NANTERRE

HOPITAL DES BLUETS

MATERNITE DES LILAS

CH FONTAINEBLEAU

CH EAUBONNE MONTMORENCY

GH ST-JOSEPH / ND BON SECOURS

HOPITAL PRIVE D'ANTONY

HOPITAL ROBERT DEBRE

C.H. DES PORTES DE L'OISE

CH COULOMMIERS

CH RAMBOUILLET

CH MONTREUIL

CH MELUN

CLIN GASTON METIVET

HOPITAL BEAUJON

CH VERSAILLES

GHEF MARNE LA VALLEE SITE JOSSIGNY

CH PONTOISE

CHI COURBEVOIE-NEUILLY-PUTEAUX

HOPITAL LARIBOISIERE

CLINIQUE DE L'YVETTE

CH GONESSE

HOPITAL LOUIS MOURIER

CH ARGENTEUIL

CH ORSAY

CH PROVINS

CH AULNAY

CH MEULAN

CH LE RAINCY-MONTFERMEIL

HOP. PRIVE NORD PARISIEN

CH VILLENEUVE-ST-GEORGES

GPE HOSP DIACONESSES

CLIN JEANNE D ARC

HOPITAL FRANCO-BRITANNIQUE

CMC FOCH

CLINIQUE DE TOURNAN

CH SUD SEINE ET MARNE SITE MONTEREAU

G.I.H BICHAT

HOPITAL JEAN VERDIER

CH ARPAJON

CH ST DENIS

INSTITUT MUTUALISTE MONTSOURIS

CH DES QUATRE VILLES

CLIN DES NORIETS

CH MANTES-LA-JOLIE

HOPITAL DU KREMLIN BICETRE

POLYCLINIQUE VAUBAN

HOP PRIV OUEST PARISIEN

CH SUD FRANCILIEN

HOPITAL COCHIN - SVP

CH MEAUX

HOP PRIVE SEINE ST DENIS

CLINIQUE DU VERT GALANT

CH CRETEIL

HOPITAL PITIE-SALPETRIERE

C.H.P. CLAUDE GALIEN

HOPITAL TENON

HOPITAL PRIVE DE MARNE-LA-VALLEE

CLINIQUE CARON

HOP PRIVE ARMAND BRILLARD

CH SUD ESSONNE

LES HOPITAUX DE SAINT-MAURICE

CLINIQUE SAINT LOUIS

HOPITAL TROUSSEAU

C.M.C. OBSTETRICAL D'EVRY

CLINIQUE SAINTE-THERESE

HOPITAL PRIVE PARLY 2

CLINIQUE SAINT GERMAIN

HOPITAL ANTOINE BECLERE

CLIN MATER STE FELICITE

CLINIQUE CONTI

HOPIT. EUROPEEN DE PARIS

CLINIQUE DE L'ESTREE

CH POISSY SAINT-GERMAIN

CH LONGJUMEAU

CLINIQUE DE L'ESSONNE

CLINIQUE CLAUDE BERNARD

HOPITAL NECKER

CLINIQUE LAMBERT

HOPITAL PRIVE DE VERSAILLES

CLINIQUE LES MARTINETS

CLIN DE LA MUETTE

HOPITAL AMERICAIN

Variation du taux de césarienne par établissement (IDF 2017)(vert : types I ; jaune : types IIA ; orange : types IIB ; rouge : types III)

Type I

Type IIA

Type IIB

Type III

Ex Qualitycriteriain Paris maternities: Termof electiveCS >= 39 wk/ singleton

01/08/2019Perinat ARS IDF11

77,9%74,9%

54,5%

40,3%76,2%

75,3%

38,1%86,0%

44,3%
54,4%
52,6%

39,3%61,0%

59,7%

44,3%57,5%

Ranking // increasing CS rate:

High rate of CS -> low rate of elective CS >=39 Wk

Method-2

•Maternities with CS rate: < - 1,5 DS: none > + 1,5 DS / 2017

Metropolitan France

->Type I : 28,55% ->Type IIA: 26,45% ->Type IIB: 24,39% ->Type III: 25,69%

Validated by Regional care

appropriateness improvment comittee

Source ATIH PMSI Exploitation Perinat-ARS-IDF12

23,2%

20,4%23,8%

20,2% 20,4%

19,1%23,1%

21,0%22,5%

20,2%

0,0%5,0%10,0%15,0%20,0%25,0%

1 IDF 1

France2A IDF 2A

France2B IDF 2B

France3 IDF 3

FranceTotal

IDFTotal

FranceTaux de césariennes par type

(IDF 2017)

Method-3

•We focusedon 11 maternities/ 83 in IDF

7 Private 4 Public above treshold for Type

-2/25 Types I -5 /25 Types IIA -1/18 Types IIB -3/15 Types III (3 universitary)

01/08/2019Perinat ARS IDF13

Method-4

•Eachmaternity receivedownCS and obstetrical practice profiles innovember 2018 •Visits onsite withObstetricians, Midwives,

Anesthesists, Direction, Quality dept during

1st trimester 2019: what dothey want to

change intheir practices? •Eachparticipant presentedtheir maternity actionplanina meeting injune 2019

Pzrinat-ARS-IDF14

30/08/2019Perinat ARS IDF15

Ex: Maternity CS profile

30/08/2019Perinat ARS IDF16

Method-5

•Eachmaternity receivedownCS and obstetrical practice profiles in november 2018•Visits on site withObstetricians, Midwives,

Anesthesists, Direction, Quality dept during

1st trimester 2019:

" what do they want to change in their practices ? •Eachparticipant presentedtheir maternity action plan in a meeting in june 2019

Perinat-ARS-IDF17

Ex: QualityAction plans

•Clinical Pathway elaboration for elective CS : •with special mention for CS on maternal request •Appropriate termfor elective CS: •Operating room better organisation + termcontrol •Shared decision with patient: •information improvement (documents, enquiry, ..) •Multidisciplinary Staffed decision •Safety improvement in labour ward: obstetrician H24

•Professional audit (internal benchmark, peer reviewof appropriateness, ..)01/08/2019Perinat ARS IDF18

Discussion

•How to measure heterogeneity? Whichmaternities are really outliers? •Taking case-mix intoaccount? •How to ensure maternal and perinatal safetywithCS rate appropriateness approach?

01/08/2019Perinat ARS IDF19

Discussion-1

Heterogeneity:

France 2017

Nb of stays with CS:

144 947

Mean CS rate:

20,2%

Minimum:

7,6%

Maximum:

46,8%

Ratio (max/min):

6,16

Ratio (P90-P10):

1,66

Global StDev:

4,48IDF 2017

•39 560 •22,5% •13,8% •46,8% •3,39 •1,62 •5,92

01/08/2019Perinat ARS IDF20

Discussion-2

•Taking case-mix into account ? - Impact of private health insurance on a public healthcaresystem. Milcent C , Zbiri s. Heath economics 2019 (submitted) - Cesarean delivery rate and staffing levels of the maternityunit. Zbiri S, et al. PloS One 2018. - Prenatal care and socioeconomics status : effect on cesarean delivery. Health Economics Review. 2018

•How to ensure maternal and perinatal safety with CS rate appropriateness approach?01/08/2019Perinat ARS IDF21

Discussion-3

01/08/201922

Scandinavian countries: low CS rate and low neonatal mortality rate

Data from EUROPERISTAT 2015

Future works

- Quality Process with IDF maternities - Action plans reports: next step in january 2010 - Involve maternities with lowest CS rate in a regional working group - Experience sharing final meeting september 2020 - Multilevel analysis CS rate? - Regional epidemiological data on morbi- mortality (perinatal and maternal) development

01/08/2019Perinat ARS IDF23

01/08/2019Perinat ARS IDF24

CS rate variation in IDF (2018)

Source ATIH PMSI Exploitation Périnat-Ars-IDF25

Type I

Type IIA

Type IIB

Type III

Variation du taux de césariennes par établissement (IDF 2018) (vert : types I ; jaune : types IIA ; orange : types IIB ; rouge : types III)

01/08/2019Perinat ARS IDF26

Paris IDF

Metropolitan France

13 Regions

67 Million inhabitants

712000 birthsParis-Ile de France Region

8 districts, 1276 municipalities

12 Million inhabitants (18%)

3 Million women 15-49 y old

175,000 births (25%)

Paris Paris IDF

European Union

IDF regionquotesdbs_dbs26.pdfusesText_32

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