Caesareandeliverypractice heterogeneity ... · 01/08/2019 Perinat ARS IDF 3 • OMS statement in...

Caesarean delivery practice

heterogeneity, appropriateness and

efficiency in 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 IDF 1

Outline (work in progress)

• Background

• Objectives

• Method

• Discussion

• Future work

01/08/2019 Perinat ARS IDF 2

Background


• 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 program implementation on avoluntary 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 section

rates (C-Model) a multicountry cross-

sectional study. BJOG 2015 JP souza et al.

• Robson classification implementation

manuel: a tool to monitor and compare

caesarean section rates in a same setting

over time and between different settings.

Since 1985 caesarean sections

have become increasingly

common in both developed and

developing 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 2015

European Perinatal Health Report.

Core indicators of the health and care of

pregnant women and babies in Europe.

November 2018. www.europeristat.com


Caesarean delivery

standardized

utilization rate

/ 100 births

Caesarean rate evolution in France

Source ATIH (PMSi) https://www.scansante.fr/applications/indicateurs-de-sante-perinatale 7

0

5

10

15

20

25

30

% CS total 2013

% CS total 2017

Guidelines HAS

health quality

agency 2012

Term electivecaesarean section

• Selected indications guidelines

• Staffed decision withseveral professionnals

• Programmation at >= 39 weeks for singleton

• Informed consent / « choosing wisely » / shared decision withpatients


Objectives

• To identify outliers maternities (either with an

excess or deficiency of caesarean section rate)

• In view to reduce the gaps

• Within an active quality approach

01/08/2019 Perinat ARS -IDF 9

Me

tho

d-1

: CS

rate

va

riatio

n in

IDF

(20

17

)

•

So

urce

AT

IH P

MS

I Exp

loita

tion

Pe

rina

t-AR

S-ID

F1

0

0,0

%

5,0

%

10

,0%

15

,0%

20

,0%

25

,0%

30

,0%

35

,0%

40

,0%

45

,0%

50

,0%

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

Va

riatio

n d

u ta

ux d

e cé

sarie

nn

e p

ar é

tab

lissem

en

t (IDF

20

17

)(ve

rt : typ

es I ; ja

un

e : ty

pe

s IIA ; o

ran

ge

: typ

es IIB

; rou

ge

: type

s III)

Typ

e I

Typ

e IIA

Typ

e IIB

Typ

e III

Ex Quality criteria in Paris maternities: Term of elective CS >= 39 wk / singleton


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%

0,0%

10,0%

20,0%

30,0%

40,0%

50,0%

60,0%

70,0%

80,0%

90,0%

100,0%

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 improvmentcomittee

Source ATIH PMSI Exploitation Perinat-ARS-IDF 12

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

France

2A IDF 2A

France

2B IDF 2B

France

3 IDF 3

France

Total

IDF

Total

France

Taux de césariennes par type

(IDF 2017)

Method-3

• We focused on 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)


Method-4

• Each maternity received own CS and

obstetrical practice profiles in november 2018

• Visits on site with Obstetricians, Midwives,

Anesthesists, Direction, Quality dept during

1st trimester 2019: what do they want to

change in their practices?

• Each participant presented their maternity

action plan in a meeting in june 2019

Pzrinat-ARS-IDF 14


Ex: Maternity CS profile

Method-5

• Each maternity received own CS and

obstetrical practice profiles in november 2018

• Visits on site with Obstetricians, Midwives,

Anesthesists, Direction, Quality dept during

1st trimester 2019: « what do they want to

change in their practices ? »

• Each participant presented their maternity

action plan in a meeting in june 2019

Perinat-ARS-IDF 17

Ex: Quality Action plans

• Clinical Pathway elaboration for elective CS :

• with special mention for CS on maternal request

• Appropriate term for elective CS:

• Operating room better organisation + term control

• 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, ..)


Discussion

• How to measure heterogeneity? Which

maternities are really outliers?

• Taking case-mix into account ?

• How to ensure maternal and perinatal safety

with CS rate appropriateness approach?


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: 4,48

IDF 2017

• 39 560

• 22,5%

• 13,8%

• 46,8%

• 3,39

• 1,62

• 5,92


Discussion-2

• Taking case-mix into account ?- Impact of private health insurance on a public healthcare

system. 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?


Discussion-3

01/08/2019 22

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


[email protected]

www.perinat-ars-idf.org


CS rate variation in IDF (2018)

Source ATIH PMSI Exploitation Périnat-Ars-IDF25

Type I Type IIA Type IIB Type III

0,0%

5,0%

10,0%

15,0%

20,0%

25,0%

30,0%

35,0%

40,0%

45,0%

50,0%

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


Paris

IDF

Metropolitan France

13 Regions

67 Million inhabitants

712000 births

Paris-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

region

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