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Dr. Tessmer-Tuck is Clinical Program Director, Women and Children’s Services, and Medical Director, North Memorial Laborist Associates, North Memorial Health Care, Robbinsdale, Minnesota.
Dr. McCue is Chief, Ob/Gyn and Midwifery, Beth Israel Deaconess Hospital-Plymouth, Plymouth, Massachusetts.
A look at the evidence shows that a program using ob/gyn hospitalists makes sense for many facilities and may improve outcomes.
A 35-year-old G2P1 at 33 weeks’ gestation is serving lunch to her toddler when she experiences sudden-onset lower abdominal pain and vaginal bleeding. Her neighbor drives her to her community hospital. She arrives in obvious distress, blood saturating her clothing. The fetal heart rate is 60, rises briefly to 180, and falls again into the 80s. Her physician is notified, but she is in her office across a large parking lot. There is no obstetrician in house. A midwife covering her own patient preps the woman for an emergency cesarean delivery and calls for help. A general surgeon and emergency department physician respond, but decide to wait for the obstetrician to arrive to intervene. The baby is delivered 10 minutes after the obstetrician’s arrival and has Apgars of 0, 2, and 2. He is later diagnosed with neonatal encephalopathy.
Malpractice claims related to obstetrics are very common despite the fact that most are preventable.1,2 In 2012 more than 77% of obstetricians reported at least one liability claim, with an average of 2.6 claims during the course of a professional career.3 Clark et al demonstrated that 40% of judgments against obstetricians and their institutions could have been prevented, had an obstetrician been immediately available.2 Patient safety, medicolegal concerns, and the need for resident supervision at academic centers initially prompted the development of “in-house” obstetric programs. Such programs have a practicing ob/gyn or maternal-fetal medicine (MFM) specialist who otherwise admits his or her own patients to the hospital but also elects to cover the entire inpatient service for obstetric emergencies. The hospital generally pays that physician for his or her service and balances the cost against the costs of increased patient morbidity and potential lawsuits. The volunteer providers, however, may have different and competing priorities than those of employed, full-time ob/gyn hospitalists.
As perinatal units look to improve quality and safety of patient care, how does the hospital engage physicians in developing clinical guidelines and best practices for inpatient obstetric and gynecologic care? For example, how do we address the phenomenon demonstrated by Clark et al of the pattern of increased cesarean deliveries on weekdays just before the start of outpatient clinic, at lunch time, and immediately after clinic hours, while no such pattern is seen on weekends?4 Who takes the lead in introducing multifaceted safety initiatives on the obstetric unit that are proven to reduce adverse outcomes such as a culture of safety, team training, and simulation?5,6 Professional ob/gyn hospitalist models are evolving to help address these issues.
Also read: Debating the laborist model of care
The Society of Ob/Gyn Hospitalists (SOGH) defines an ob/gyn hospitalist as “An Obstetrician/Gynecologist who has focused their professional practice on care of the hospitalized woman” and this may include inpatient or emergency department gynecologic care. The term “laborist” is frequently used in reference to ob/gyn hospitalists and SOGH defines this practitioner as “an Obstetrician/Gynecologist who has focused their professional practice on the care of women in Labor and Delivery.” Ob/gyn hospitalists can be specialists in general obstetrics and gynecology or may be MFM subspecialists. The scope of care the ob/gyn hospitalist provides varies considerably from site to site. Coverage of Labor and Delivery is usually a priority, but responsibilities may also include coverage of the postpartum and antepartum units, the emergency department, and inpatient consultations. Labor and Delivery responsibilities vary as well and can include seeing and evaluating all triage patients in an “obstetric emergency department,” covering any unassigned obstetrical patients, backing up community ob/gyns who may be in their offices or homes, supporting non-surgical obstetric providers including family medicine physicians and certified nurse midwives (CNMs), and acting as “MFM extenders,” managing complex patients in close collaboration with an MFM who is not physically on the perinatal unit. For the purposes of this paper, we will use the more encompassing term “ob/gyn hospitalist,” recognizing that the actual scope of practice may vary considerably by site.
A 2009 survey of American College of Obstetricians and Gynecologists (ACOG) fellows revealed that, on average, ob/gyn hospitalists were quite experienced, with an average age of 48.8 years and 17.0 years of work experience beyond residency training.7 Almost 32% of ob/gyn hospitalists were hospital-employed, while 26% worked for single-specialty groups and an additional 25% worked for ob/gyn hospitalist groups. Most reported working 24-hour shifts (30.8%) and generally worked 2 shifts per week (88%). Ob/gyn hospitalist programs were active across a wide spectrum of delivery volumes, with 37.3% at institutions that delivered >3000 women annually, 18.7% that delivered 2001–3000 annually, 21.9% that delivered 1000–2000 annually and 22% that delivered <1000 annually. In a 2010 survey of National Perinatal Information Center/Quality Analytic Services (NPIC/QAS) hospitals, 40% were using ob/gyn hospitalists.8 Increased hospital delivery volume was associated with an increased likelihood of having ob/gyn hospitalists, while the presence of residents/fellows and geographic location were not associated.8
Ob/gyn hospitalists work in shifts with the goal of minimizing fatigue and improving patient safety. A hospitalist may support colleagues by maintaining additional skills, such as forceps or breech delivery of a second twin. Hospitalists often maintain certifications such as neonatal resuscitation and advanced cardiac life support. Ob/gyn hospitalists are a consistent presence on perinatal units, educating and leading quality improvement efforts such as team training, use of safety checklists, adherence to practice guidelines, and management of obstetric emergencies such as shoulder dystocia and postpartum hemorrhage. In addition, hospitalists can help units prepare for emergencies by developing and leading simulation trainings, a risk reduction strategy advocated by the Joint Commission.9
Internal medicine hospitalists were the first to show the effects of inpatient physician specialists (hospitalists) on improved quality and safety of hospital care. Frigoletto and Greene first proposed ob/gyn hospitalists in 2002,10 and Weinstein coined the term “laborist” in 2003, which he defined as “an ob/gyn whose sole focus of practice is to manage the patient in labor.”11 Weinstein suggested that development of ob/gyn hospitalist models of care could “decrease stress, improve physician well-being, increase length of professional practice, and decrease burnout” in practicing ob/gyns while improving patient safety and satisfaction. These benefits of ob/gyn hospitalist programs are easily imagined and, since 2003, additional authors and articles have supported the theoretical benefits of ob/gyn hospitalist models of care.12-16 Here we examine the evidence regarding these proposed quality and safety advantages.
Full-time ob/gyn hospitalists have been shown to reduce the likelihood of cesarean deliveries. Iriye et al17 reviewed the care of more than 6,200 primiparous patients beyond 37 weeks’ gestation between 2006 and 2011. During that time, coverage on the obstetric unit changed from traditional care by a patient’s primary physician to 24/7 voluntary community “in-house” physician care, to 24/7 full-time ob/gyn hospitalist care. The cesarean delivery rate for traditional care was 39.2%, which dropped to 38.7% after implementation of community physician “in-house” care, which was not significant. Full-time ob/gyn hospitalist care, however, did significantly reduce the cesarean delivery rate to 33.2%, which represents a 27% reduction in likelihood of cesarean delivery compared to the traditional model of care (OR= 0.73, 95% CI 0.64-0.83, P < .0001) and a 23% reduction in cesarean deliveries compared to “in-house” care (OR= 0.77, 95% CI 0.67-0.87, P < .001). There were no differences between the groups for birth weight, maternal weight, diabetes, gestational age, or 5-minute Apgar score. The full-time ob/gyn hospitalist program was theorized to decrease the number of cesarean deliveries per day for a population of nulliparous, term, singleton live births by 0.41–0.48, resulting in a daily cost savings to the hospital of $2,823–$3,305 based on local reimbursement data. This savings alone could cover the costs of an ob/gyn hospitalist physician earning $118 to $138 an hour.
Nijagal et al also demonstrated a significant reduction in the likelihood of cesarean delivery when patients were managed by full-time ob/gyn hospitalists in conjunction with CNMs, as opposed to management by ob/gyns in a traditional model of care.18 More than 9,300 births were examined between 2005 and 2010. Thirty-one percent of women managed traditionally had cesarean deliveries, while only 17% of women in the CNM/hospitalist group had cesarean deliveries (P < .001).
After controlling for covariates, the adjusted odds of cesarean delivery among women in the traditional group was twice that of women in the CNM/hospitalist group (aOR=2.11; 95% CI = 1.73–2.58). These results held true for the population of nulliparous, term, singleton, vertex patients who were also almost twice as likely to have cesarean deliveries with the traditional model of care compared to the CNM/hospitalist model (29.8% vs. 15.9%; P < .001; aOR=1.86; 95% CI, 1.33–2.58). In the subset of women who were candidates for trial of labor after cesarean (TOLAC), women in the traditional model were 3 times as likely to have a scheduled elective repeat cesarean delivery than the CNM/hospitalist model (71.3% v. 41.4%; P < .001; aOR, 3.19; 95% CI, 1.74–5.88). CNM/hospitalist patients were also more likely to have a successful vaginal birth after cesarean (VBAC) than those under the traditional model of care (38.5% vs 18%; P=0.008, aOR=0.42, 95% CI 0.22-0.80).
Limited additional published evidence exists regarding ob/gyn hospitalists and quality of care. Abstracts presented at the Society of Maternal Fetal Medicine annual meeting and the ACOG Annual Clinical and Scientific Meeting have demonstrated a positive effect of ob/gyn hospitalist programs on rates of labor induction, maternal length of stay, term neonatal intensive care admissions, and incidence of preterm birth. We look forward to seeing these preliminary studies published for general dissemination and review.
The ultimate value of an ob/gyn hospitalist program results from improved quality and safety of care. Consider the effects of comprehensive obstetric safety initiatives, such as those at Yale University and New York Presbyterian–Weill Cornell Medical Center. Although many factors are involved, including the use of standardized protocols, obstetric safety nurses, anonymous event reporting, team training, and electronic fetal heart rate monitoring certification, both programs also implemented ob/gyn hospitalist programs. Both have achieved substantial reductions in adverse outcomes, malpractice claims, and payouts on malpractice cases.19,20
The ob/gyn hospitalist in the Yale program has critical leadership responsibility. The Yale On-Call Attending (YOCA) “ … has responsibility for the quality of care of the entire obstetric service by providing services to patients within the university practices and emergency backup and consultation for all community physicians.” Yale has demonstrated improvements in obstetric adverse outcomes and culture of safety, and reduced median annual malpractice claims (1.31 to 0.64, P=.02) and median annual payments per 1000 deliveries ($1.1 million to $63,470, P<.01).20 New York Presbyterian–Weill Cornell reduced sentinel events per 1,000 deliveries from 1.04 in 2000 to 0 in 2008 and 2009 and reduced compensation payments from $50,940,309 in 2003 to $250,000 in 2009.19
Yale author Christian Pettker, MD, wrote, “This positive impact on liability exposure is particularly important as it impacts the point of care, rather than the political or statutory structures of the medical liability machine.”20
How does a clear reduction in liability translate into an economic advantage for an ob/gyn hospitalist program? Full-time ob/gyn hospitalists can pay for themselves while funding the other elements of a comprehensive safety program. Yale estimated a 95% reduction in direct liability payments and a savings of $48.5 million over 5 years20 while New York-Presbyterian-Weill Cornell saw yearly savings of approximately $25 million in compensation payments, which “dwarf the incremental costs of the safety program.”19
Ongoing research exploring the role of ob/gyn hospitalists in increasing perinatal quality and safety is needed. As we strive to meet the Institute for Healthcare Improvement’s triple aim of improving patient experience (including quality and satisfaction), improving the health of populations, and reducing healthcare costs, evidence is mounting that the ob/gyn hospitalist model may help us meet those lofty goals.
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13. Committee opinion no. 459: The obstetric-gynecologic hospitalist. Obstet Gynecol. 2010;116(1):237–239.
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17. Iriye BK, Huang WH, Condon J, et al. Implementation of a laborist program and evaluation of the effect upon cesarean delivery. Am J Obstet Gynecol. 2013;209(3):251.e1–6.
18. Nijagal MA, Kuppermann M, Nakagawa S, Cheng Y. Two practice models in one labor and delivery unit: association with cesarean delivery rates. Am J Obstet Gynecol. 2015;212(4):491.e1-8.
19. Grunebaum A, Chervenak F, Skupski D. Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events. Am J Obstet Gynecol. 2011;204(2):97–105.
20. Pettker CM, Thung SF, Lipkind HS, et al. A comprehensive obstetric patient safety program reduces liability claims and payments. Am J Obstet Gynecol. 2014;211(4):319–325.