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DENVER – The newly published first data showing improved clinical outcomes after adoption of a full-time hospital laborist program was roundly celebrated at the annual meeting of the Society of Ob/Gyn Hospitalists.
Dr. Thomas J. Garite presented highlights of this freshly published retrospective observational study (Am. J. Obstet. Gynecol. 2013;209:251.e1-6) conducted at a large-delivery-volume tertiary hospital in Las Vegas. Dr. Garite and his coinvestigators, led by Dr. Brian K. Iriye, compared hospital-wide cesarean delivery rates for 6,206 nulliparous, term, singleton live births during 2006-2011.
This was a period of change in how labor and delivery was organized at the hospital. During the first 16 months of the study period, the traditional private-practice model of patient care was in place, with ob.gyns. on call and no laborists in the house. This was followed by a 14-month interlude in which local private-practice ob.gyns. got together and made sure that a community physician was continuously in-hospital to provide laborist coverage.
"I call that the doc-in-a-box model," said Dr. Garite, professor emeritus and former chair of obstetrics and gynecology at the University of California, Irvine.
Finally came a 24-month period with full-time laborists – that is, ob.gyns. without a private practice – providing in-hospital coverage 24/7.
In a multivariate logistic regression analysis adjusted for potential confounders, the hospital’s cesarean section rate was roughly 25% lower after implementation of the full-time laborist program than in either of the other two periods.
"I haven’t seen other studies to date that demonstrate these kinds of outcome advantages for this kind of practice. I think we’re going to see a lot more. But until we do, a lot of people who don’t like change are going to be saying, ‘Wait, where’s the proof?’ Well, this is the beginning of the proof of something I believe in strongly," declared Dr. Garite, who is also editor-in-chief of the American Journal of Obstetrics and Gynecology and chief clinical officer at PeriGen, a provider of fetal surveillance systems.
Society of Ob/Gyn Hospitalists (SOGH) board member Dr. Jennifer Tessmer-Tuck hailed the new study as "the best and almost the only" clinical outcome data to date showing the advantages of the ob.gyn. hospitalist model of care. And it was a long time coming, she noted: a full 10½ years since Dr. Louis Weinstein of the Medical College of Ohio, Toledo, heralded the birth of a radically different form of ob.gyn. practice in his seminal essay "The laborist: A new focus of practice for the obstetrician" (Am. J. Obstet. Gynecol. 2003;188:310-2).
"We have a lot to do. SOGH would really like to have more of a research platform and be able to put ourselves out there. There’s really a gap in care, and we’re hoping to jump in and fill it," said Dr. Tessmer-Tuck, director of North Memorial Medical Center Laborist Associates in Robbinsdale, Minn.
But while the SOGH leadership is eager to see the field assume a bigger research presence, it’s a challenge. Most society members, when they talk about why they became hospitalists, say they had burned out in traditional private practice, with its demanding on-call schedule. They sought well-defined hours, perhaps more family time. Given those priorities, taking on a research project can sound daunting, even though the fruits of such a project might enhance the standing of the young subspecialty.
Dr. Garite reported that the cesarean section rate at the tertiary center was 33.2% during the 24 months when full-time laborists were on hand, compared with 39.2% under the traditional private practice model with no laborists, and 38.7% with laborist coverage by community staff. In a multivariate logistic regression analysis adjusted for maternal age, physician age, race, gestational age, induction of labor, birth weight, and maternal weight, the hospital’s cesarean section rate after the introduction of full-time laborists was 27% lower than in the earlier period of no laborists and 23% less than with community laborist care.
There were no differences between the three groups in rates of low Apgar scores, metabolic acidosis, or any other parameters of adverse neonatal or maternal outcome.
During the study years of 2006-2011, cesarean section rates at the other hospitals in the city were either stable or rising.
Asked why hospital-wide cesarean section rates dropped significantly once full-time obstetric hospitalists were in place, Dr. Garite replied, "It’s not, for example, the patient with abruption who comes in the door; she’s going to get a cesarean section whether a hospitalist is there or some other doctor is covering. Instead, it’s the patient who has what I call ‘failure to wait,’ a.k.a. failure to progress, or the 4 o’clock induction that hasn’t made any progress ... There are lots of examples of why cesarean section rates change with a hospitalist in place, especially if you look at the correlation between cesarean sections and time of day."
Dr. Tessmer-Tuck said she found the Las Vegas study highly relevant because lots of hospitals throughout the country are now going through a similar transition from traditional on-call practice to around-the-clock coverage provided by rotating private practice community laborists, while pondering a possible move to full-time laborists.
"This is where many of our hospitals are at: They’re in the middle phase, with private-practice docs being paid to stay in-house 24 hours in case there’s an emergency," according to Dr. Tessmer-Tuck.
She said she found particularly impressive the investigators’ calculation that a full-time laborist resulted in an average of one fewer cesarean section every 2 days in a population of primiparous, term, singleton patients, with a resultant estimated savings in patient care costs of $2,823-$3,305 per day. Because a laborist might be paid $2,500 per 24-hour shift, the reduced cesarean section rate alone covers the laborist’s salary. Those are the sort of numbers hospital administrators find persuasive.
"This is a message you guys should take home with you when you go back to your own program," she said.
While the Las Vegas study provides the first evidence to be published in a major peer-reviewed journal demonstrating superior clinical outcomes with the full-time laborist model, Dr. Tessmer-Tuck noted that in addition there are several published studies suggesting that hospitals experience fewer adverse events and markedly lower payouts for bad outcomes after they implement multipronged, comprehensive obstetric patient safety programs that include bringing a laborist on board.
"Liability has become a huge issue for us. Many hospitals implement hospitalist programs mainly in order to reduce liability," according to Dr. Tessmer-Tuck.
She cited a study by ob.gyns. at New York Presbyterian/Weill Cornell Medical Center in which they analyzed the impact of a comprehensive patient safety program initiated in stages beginning in 2003. The interventions included mandatory labor and delivery team training aimed at enhancing physician/nurse communication, development of standardized management protocols, training in fetal heart rate monitoring interpretation, creation of a patient safety nurse position, and, in 2006, introduction of a laborist.
It’s not possible to parse out just how much of the improvement in response to the multipronged safety program was the result of adopting the laborist model, Dr. Tessmer-Tuck said, but she noted the average yearly compensation payments for patient claims or lawsuits were $27.6 million during 2003-2006, plummeting to $2.5 million per year in 2007-2009, after the laborist was in place. Moreover, sentinel adverse events such as maternal death or severe neurodevelopmental impairment in a child decreased from five in the year 2000 to none in 2008 and 2009 (Am. J. Obstet. Gynecol. 2011;204:97-105).
Ob.gyns. at Yale–New Haven (Conn.) Hospital introduced a similar comprehensive patient safety program, also including implementation of a 24-hour obstetrics hospitalist, during 2004-2006. During 3 years of prospective follow-up involving nearly 14,000 deliveries, they documented a significant linear decline in obstetric adverse outcomes (Am. J. Obstet. Gynecol. 2009;200:492e1-8). They also administered a validated workplace safety attitude questionnaire four times during 2004-2009 and documented marked improvement over time in favorable scores in the domains of job satisfaction, teamwork, and safety culture (Am J. Obstet. Gynecol. 2011;204:216.e1-6).
Dr. Garite and Dr. Tessmer-Tuck reported having no germane financial relationships.
DENVER – The newly published first data showing improved clinical outcomes after adoption of a full-time hospital laborist program was roundly celebrated at the annual meeting of the Society of Ob/Gyn Hospitalists.
Dr. Thomas J. Garite presented highlights of this freshly published retrospective observational study (Am. J. Obstet. Gynecol. 2013;209:251.e1-6) conducted at a large-delivery-volume tertiary hospital in Las Vegas. Dr. Garite and his coinvestigators, led by Dr. Brian K. Iriye, compared hospital-wide cesarean delivery rates for 6,206 nulliparous, term, singleton live births during 2006-2011.
This was a period of change in how labor and delivery was organized at the hospital. During the first 16 months of the study period, the traditional private-practice model of patient care was in place, with ob.gyns. on call and no laborists in the house. This was followed by a 14-month interlude in which local private-practice ob.gyns. got together and made sure that a community physician was continuously in-hospital to provide laborist coverage.
"I call that the doc-in-a-box model," said Dr. Garite, professor emeritus and former chair of obstetrics and gynecology at the University of California, Irvine.
Finally came a 24-month period with full-time laborists – that is, ob.gyns. without a private practice – providing in-hospital coverage 24/7.
In a multivariate logistic regression analysis adjusted for potential confounders, the hospital’s cesarean section rate was roughly 25% lower after implementation of the full-time laborist program than in either of the other two periods.
"I haven’t seen other studies to date that demonstrate these kinds of outcome advantages for this kind of practice. I think we’re going to see a lot more. But until we do, a lot of people who don’t like change are going to be saying, ‘Wait, where’s the proof?’ Well, this is the beginning of the proof of something I believe in strongly," declared Dr. Garite, who is also editor-in-chief of the American Journal of Obstetrics and Gynecology and chief clinical officer at PeriGen, a provider of fetal surveillance systems.
Society of Ob/Gyn Hospitalists (SOGH) board member Dr. Jennifer Tessmer-Tuck hailed the new study as "the best and almost the only" clinical outcome data to date showing the advantages of the ob.gyn. hospitalist model of care. And it was a long time coming, she noted: a full 10½ years since Dr. Louis Weinstein of the Medical College of Ohio, Toledo, heralded the birth of a radically different form of ob.gyn. practice in his seminal essay "The laborist: A new focus of practice for the obstetrician" (Am. J. Obstet. Gynecol. 2003;188:310-2).
"We have a lot to do. SOGH would really like to have more of a research platform and be able to put ourselves out there. There’s really a gap in care, and we’re hoping to jump in and fill it," said Dr. Tessmer-Tuck, director of North Memorial Medical Center Laborist Associates in Robbinsdale, Minn.
But while the SOGH leadership is eager to see the field assume a bigger research presence, it’s a challenge. Most society members, when they talk about why they became hospitalists, say they had burned out in traditional private practice, with its demanding on-call schedule. They sought well-defined hours, perhaps more family time. Given those priorities, taking on a research project can sound daunting, even though the fruits of such a project might enhance the standing of the young subspecialty.
Dr. Garite reported that the cesarean section rate at the tertiary center was 33.2% during the 24 months when full-time laborists were on hand, compared with 39.2% under the traditional private practice model with no laborists, and 38.7% with laborist coverage by community staff. In a multivariate logistic regression analysis adjusted for maternal age, physician age, race, gestational age, induction of labor, birth weight, and maternal weight, the hospital’s cesarean section rate after the introduction of full-time laborists was 27% lower than in the earlier period of no laborists and 23% less than with community laborist care.
There were no differences between the three groups in rates of low Apgar scores, metabolic acidosis, or any other parameters of adverse neonatal or maternal outcome.
During the study years of 2006-2011, cesarean section rates at the other hospitals in the city were either stable or rising.
Asked why hospital-wide cesarean section rates dropped significantly once full-time obstetric hospitalists were in place, Dr. Garite replied, "It’s not, for example, the patient with abruption who comes in the door; she’s going to get a cesarean section whether a hospitalist is there or some other doctor is covering. Instead, it’s the patient who has what I call ‘failure to wait,’ a.k.a. failure to progress, or the 4 o’clock induction that hasn’t made any progress ... There are lots of examples of why cesarean section rates change with a hospitalist in place, especially if you look at the correlation between cesarean sections and time of day."
Dr. Tessmer-Tuck said she found the Las Vegas study highly relevant because lots of hospitals throughout the country are now going through a similar transition from traditional on-call practice to around-the-clock coverage provided by rotating private practice community laborists, while pondering a possible move to full-time laborists.
"This is where many of our hospitals are at: They’re in the middle phase, with private-practice docs being paid to stay in-house 24 hours in case there’s an emergency," according to Dr. Tessmer-Tuck.
She said she found particularly impressive the investigators’ calculation that a full-time laborist resulted in an average of one fewer cesarean section every 2 days in a population of primiparous, term, singleton patients, with a resultant estimated savings in patient care costs of $2,823-$3,305 per day. Because a laborist might be paid $2,500 per 24-hour shift, the reduced cesarean section rate alone covers the laborist’s salary. Those are the sort of numbers hospital administrators find persuasive.
"This is a message you guys should take home with you when you go back to your own program," she said.
While the Las Vegas study provides the first evidence to be published in a major peer-reviewed journal demonstrating superior clinical outcomes with the full-time laborist model, Dr. Tessmer-Tuck noted that in addition there are several published studies suggesting that hospitals experience fewer adverse events and markedly lower payouts for bad outcomes after they implement multipronged, comprehensive obstetric patient safety programs that include bringing a laborist on board.
"Liability has become a huge issue for us. Many hospitals implement hospitalist programs mainly in order to reduce liability," according to Dr. Tessmer-Tuck.
She cited a study by ob.gyns. at New York Presbyterian/Weill Cornell Medical Center in which they analyzed the impact of a comprehensive patient safety program initiated in stages beginning in 2003. The interventions included mandatory labor and delivery team training aimed at enhancing physician/nurse communication, development of standardized management protocols, training in fetal heart rate monitoring interpretation, creation of a patient safety nurse position, and, in 2006, introduction of a laborist.
It’s not possible to parse out just how much of the improvement in response to the multipronged safety program was the result of adopting the laborist model, Dr. Tessmer-Tuck said, but she noted the average yearly compensation payments for patient claims or lawsuits were $27.6 million during 2003-2006, plummeting to $2.5 million per year in 2007-2009, after the laborist was in place. Moreover, sentinel adverse events such as maternal death or severe neurodevelopmental impairment in a child decreased from five in the year 2000 to none in 2008 and 2009 (Am. J. Obstet. Gynecol. 2011;204:97-105).
Ob.gyns. at Yale–New Haven (Conn.) Hospital introduced a similar comprehensive patient safety program, also including implementation of a 24-hour obstetrics hospitalist, during 2004-2006. During 3 years of prospective follow-up involving nearly 14,000 deliveries, they documented a significant linear decline in obstetric adverse outcomes (Am. J. Obstet. Gynecol. 2009;200:492e1-8). They also administered a validated workplace safety attitude questionnaire four times during 2004-2009 and documented marked improvement over time in favorable scores in the domains of job satisfaction, teamwork, and safety culture (Am J. Obstet. Gynecol. 2011;204:216.e1-6).
Dr. Garite and Dr. Tessmer-Tuck reported having no germane financial relationships.
DENVER – The newly published first data showing improved clinical outcomes after adoption of a full-time hospital laborist program was roundly celebrated at the annual meeting of the Society of Ob/Gyn Hospitalists.
Dr. Thomas J. Garite presented highlights of this freshly published retrospective observational study (Am. J. Obstet. Gynecol. 2013;209:251.e1-6) conducted at a large-delivery-volume tertiary hospital in Las Vegas. Dr. Garite and his coinvestigators, led by Dr. Brian K. Iriye, compared hospital-wide cesarean delivery rates for 6,206 nulliparous, term, singleton live births during 2006-2011.
This was a period of change in how labor and delivery was organized at the hospital. During the first 16 months of the study period, the traditional private-practice model of patient care was in place, with ob.gyns. on call and no laborists in the house. This was followed by a 14-month interlude in which local private-practice ob.gyns. got together and made sure that a community physician was continuously in-hospital to provide laborist coverage.
"I call that the doc-in-a-box model," said Dr. Garite, professor emeritus and former chair of obstetrics and gynecology at the University of California, Irvine.
Finally came a 24-month period with full-time laborists – that is, ob.gyns. without a private practice – providing in-hospital coverage 24/7.
In a multivariate logistic regression analysis adjusted for potential confounders, the hospital’s cesarean section rate was roughly 25% lower after implementation of the full-time laborist program than in either of the other two periods.
"I haven’t seen other studies to date that demonstrate these kinds of outcome advantages for this kind of practice. I think we’re going to see a lot more. But until we do, a lot of people who don’t like change are going to be saying, ‘Wait, where’s the proof?’ Well, this is the beginning of the proof of something I believe in strongly," declared Dr. Garite, who is also editor-in-chief of the American Journal of Obstetrics and Gynecology and chief clinical officer at PeriGen, a provider of fetal surveillance systems.
Society of Ob/Gyn Hospitalists (SOGH) board member Dr. Jennifer Tessmer-Tuck hailed the new study as "the best and almost the only" clinical outcome data to date showing the advantages of the ob.gyn. hospitalist model of care. And it was a long time coming, she noted: a full 10½ years since Dr. Louis Weinstein of the Medical College of Ohio, Toledo, heralded the birth of a radically different form of ob.gyn. practice in his seminal essay "The laborist: A new focus of practice for the obstetrician" (Am. J. Obstet. Gynecol. 2003;188:310-2).
"We have a lot to do. SOGH would really like to have more of a research platform and be able to put ourselves out there. There’s really a gap in care, and we’re hoping to jump in and fill it," said Dr. Tessmer-Tuck, director of North Memorial Medical Center Laborist Associates in Robbinsdale, Minn.
But while the SOGH leadership is eager to see the field assume a bigger research presence, it’s a challenge. Most society members, when they talk about why they became hospitalists, say they had burned out in traditional private practice, with its demanding on-call schedule. They sought well-defined hours, perhaps more family time. Given those priorities, taking on a research project can sound daunting, even though the fruits of such a project might enhance the standing of the young subspecialty.
Dr. Garite reported that the cesarean section rate at the tertiary center was 33.2% during the 24 months when full-time laborists were on hand, compared with 39.2% under the traditional private practice model with no laborists, and 38.7% with laborist coverage by community staff. In a multivariate logistic regression analysis adjusted for maternal age, physician age, race, gestational age, induction of labor, birth weight, and maternal weight, the hospital’s cesarean section rate after the introduction of full-time laborists was 27% lower than in the earlier period of no laborists and 23% less than with community laborist care.
There were no differences between the three groups in rates of low Apgar scores, metabolic acidosis, or any other parameters of adverse neonatal or maternal outcome.
During the study years of 2006-2011, cesarean section rates at the other hospitals in the city were either stable or rising.
Asked why hospital-wide cesarean section rates dropped significantly once full-time obstetric hospitalists were in place, Dr. Garite replied, "It’s not, for example, the patient with abruption who comes in the door; she’s going to get a cesarean section whether a hospitalist is there or some other doctor is covering. Instead, it’s the patient who has what I call ‘failure to wait,’ a.k.a. failure to progress, or the 4 o’clock induction that hasn’t made any progress ... There are lots of examples of why cesarean section rates change with a hospitalist in place, especially if you look at the correlation between cesarean sections and time of day."
Dr. Tessmer-Tuck said she found the Las Vegas study highly relevant because lots of hospitals throughout the country are now going through a similar transition from traditional on-call practice to around-the-clock coverage provided by rotating private practice community laborists, while pondering a possible move to full-time laborists.
"This is where many of our hospitals are at: They’re in the middle phase, with private-practice docs being paid to stay in-house 24 hours in case there’s an emergency," according to Dr. Tessmer-Tuck.
She said she found particularly impressive the investigators’ calculation that a full-time laborist resulted in an average of one fewer cesarean section every 2 days in a population of primiparous, term, singleton patients, with a resultant estimated savings in patient care costs of $2,823-$3,305 per day. Because a laborist might be paid $2,500 per 24-hour shift, the reduced cesarean section rate alone covers the laborist’s salary. Those are the sort of numbers hospital administrators find persuasive.
"This is a message you guys should take home with you when you go back to your own program," she said.
While the Las Vegas study provides the first evidence to be published in a major peer-reviewed journal demonstrating superior clinical outcomes with the full-time laborist model, Dr. Tessmer-Tuck noted that in addition there are several published studies suggesting that hospitals experience fewer adverse events and markedly lower payouts for bad outcomes after they implement multipronged, comprehensive obstetric patient safety programs that include bringing a laborist on board.
"Liability has become a huge issue for us. Many hospitals implement hospitalist programs mainly in order to reduce liability," according to Dr. Tessmer-Tuck.
She cited a study by ob.gyns. at New York Presbyterian/Weill Cornell Medical Center in which they analyzed the impact of a comprehensive patient safety program initiated in stages beginning in 2003. The interventions included mandatory labor and delivery team training aimed at enhancing physician/nurse communication, development of standardized management protocols, training in fetal heart rate monitoring interpretation, creation of a patient safety nurse position, and, in 2006, introduction of a laborist.
It’s not possible to parse out just how much of the improvement in response to the multipronged safety program was the result of adopting the laborist model, Dr. Tessmer-Tuck said, but she noted the average yearly compensation payments for patient claims or lawsuits were $27.6 million during 2003-2006, plummeting to $2.5 million per year in 2007-2009, after the laborist was in place. Moreover, sentinel adverse events such as maternal death or severe neurodevelopmental impairment in a child decreased from five in the year 2000 to none in 2008 and 2009 (Am. J. Obstet. Gynecol. 2011;204:97-105).
Ob.gyns. at Yale–New Haven (Conn.) Hospital introduced a similar comprehensive patient safety program, also including implementation of a 24-hour obstetrics hospitalist, during 2004-2006. During 3 years of prospective follow-up involving nearly 14,000 deliveries, they documented a significant linear decline in obstetric adverse outcomes (Am. J. Obstet. Gynecol. 2009;200:492e1-8). They also administered a validated workplace safety attitude questionnaire four times during 2004-2009 and documented marked improvement over time in favorable scores in the domains of job satisfaction, teamwork, and safety culture (Am J. Obstet. Gynecol. 2011;204:216.e1-6).
Dr. Garite and Dr. Tessmer-Tuck reported having no germane financial relationships.
AT THE SOGH ANNUAL CLINICAL MEETING
