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SNAPSHOT OF APT QUALITY DATA 2015 - 2017
What’s happening in Arizona and in our APT facilities?
Dean V Coonrod, MD-MPH
Chair of the APRS/APT QI Committee
August 10, 2018
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ACKNOWLEDGEMENTS
APT hospitals and staff providing data
Members of the APRS/APT QI Committee Dean V Coonrod, MD, MPH (Chair)
Linda A Meiner, MSN, RNC-NIC, NE-BC (Recording Secretary)
Rhonda Anderson, RN, DNSc, FAAN, FACHE
Alan D Bedrick, MD
Martin Celaya, MPH
Mary Ellen Cunningham, MPA, RN
C Kevin Huls, MD
Shelly Lanagan, MS, WHNP, RNC-OB, C-EFM
Hugh S Miller, MD
Carol Olson, MBA, BSN, RN
Enid Quintana-Torres, MPH
Sara Salek, MD and/or Eric Tack, MD
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OBJECTIVES
Summarize available data that illuminates the health status of Arizona’s perinatal patients
Compare available annual data from APT certified facilities
Identify perinatal system opportunities for improvement
Identify outcomes of targeted perinatal certification efforts
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DATA SOURCES
Unless noted on a particular slide – data taken from APT Annual Data submitted by our APT facilities
Committee has been asked to consider avoiding duplication of data from APT from birth certificates.
Thanks to all at facilities who do the important work of data collection.
Some new information was collected in 2017. No change for 2018.
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SPEAKER DECLARATION
No conflicts of interest
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ARIZONA BIRTH TRENDS
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AZ POPULATION – FEMALES 15-44 YEARS
1,157,231
1,298,3051,312,687 1,320,640
1,050,000
1,100,000
1,150,000
1,200,000
1,250,000
1,300,000
1,350,000
2002 2014 2015 2016
Source: 2016 ADHS Population Health and Vital Statistics
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2006-2017 AZ YEARLY BIRTHS
70000
75000
80000
85000
90000
95000
100000
105000
06 07 08 09 10 11 12 13 14 15 16 17
102042102687
99215
92616
87053
8519085725
8496386648
85024 84404
81664
Source: 2017 ADHS Vital Statistics
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US BIRTH AND FERTILITY RATES
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2018-2018 AZ MONTHLY BIRTHS
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
Total Births Linear (Total Births)
Source: 2017 ADHS Vital Statistics
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TEEN BIRTHS IN ARIZONA (NOT PREGNANCIES)
188 170 161 105 67 46 40 50
4227 44504151
2910
24301770 1582
1420
7448
82967849
6401
5620 4807
4261
3916
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
2004 2006 2008 2010 2012 2014 2015 2016
Under 15 Years 15-17 Years 18-19 Years
Source: 2016 ADHS Population Health and Vital Statistics
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2012-2016 AZ MULTIPLE BIRTHS
Source: 2016 ADHS Population Health and Vital Statistics
81 102 68 84 73
2301
24452559
24342574
0
500
1000
1500
2000
2500
3000
2012 2013 2014 2015 2016
Triplets+ Twins
Note:
Past Years Peaks
Twins - 2693 in 2008
Triplets+ - 175 in 2008
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AZ PAYEE FOR DELIVERIES
2000 2010 2013 2016
AHCCCS 42.5% 53.3% 53.9% 52.3%
IHS 1.7% 2.0% 1.3% 1.3%
Private
Insurance50.5% 41.0% 41.2% 40.9%
Self 3.2% 3.0% 3.5% 5.2%
Unknown 2.2% 0.7% 0.2% 0.3%
Source: 2016 ADHS Population Health and Vital Statistics
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PRENATAL CARE IN ARIZONA – 1ST TRIMESTER
81.7% 82.6% 81.3%
66.0% 67.9%68.9%
50.0%
55.0%
60.0%
65.0%
70.0%
75.0%
80.0%
85.0%
90.0%
95.0%
100.0%
2011 2012 2013 2014 2015 2016
Change in Birth Certificate 2014
Source: 2016 ADHS Population Health and Vital StatisticsHP2020-MICH-10.1 Target is 77.9%
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PRENATAL CARE IN ARIZONA – LATE OR NONE
3.1%3.2%
3.6%
5.3% 5.5% 5.6%
1.6%
1.2%1.4%
2.1% 2.2%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
9.0%
10.0%
2011 2012 2013 2014 2015 2016
3rd Trimester No PNC
Source: 2016 ADHS Population Health and Vital Statistics
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% PRETERM AND LBW BIRTHS 2006-2016 10.6 10.3 10.2
9.6 9.3 9.2 9.0 9.0 9.0 9.0
7.1 7.1 7.1 7.1 7.0 6.9 6.9 7.0 7.2 7.3
1.2 1.2 1.2 1.1 1.2 1.2 1.1 1.2 1.1 1.2
0.0
2.0
4.0
6.0
8.0
10.0
12.0
2006 2007 2008 2010 2011 2012 2013 2014 2015 2016
Preterm <37wks LBW <2500g VLBW <1500g
Source: 2016 ADHS Population Health and Vital Statistics
HP2020-MICH-9.1 PTB Target – 11.4%
HP2020-MICH-8.1 LBW Target – 7.8%
HP2020-MICH-8.2 VLBW Target – 1.4%
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2016 % AZ BIRTHS BY DAY OF THE WEEK
12%
16%
16%
16%
15%
14%
11%
0% 2% 4% 6% 8% 10% 12% 14% 16% 18%
Sat
Fri
Thur
Wed
Tues
Mon
Sun
Source: 2016 ADHS Population and Health Vital Statistics
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2016 % AZ BIRTHS BY MONTH
8.4%
8.0%8.1%
7.8%
8.0% 8.0%
8.3%
9.1% 9.1%
8.5%
8.2%
8.6%
7.0%
7.5%
8.0%
8.5%
9.0%
9.5%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Source: 2016 ADHS Population and Health Vital Statistics
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MARCH OF DIMES 2017 PREMATURE BIRTH REPORT CARD FOR ARIZONA
10.3%
9.7%
9.3%9.2% 9.1%
9.0%9.1% 9.1%
10.4%
10.0%
9.8% 9.8%9.6% 9.6% 9.6%
9.8%
8.0%
8.5%
9.0%
9.5%
10.0%
10.5%
11.0%
2007 2010 2011 2012 2013 2014 2015 2016
Arizona US
March of Dimes – PeriStats March of Dimes Goal 8.1% by 2020, 5.5% by 2030 HP 2020 Goal 11.4%
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MARCH OF DIMES 2017 PREMATURE BIRTH REPORT CARD FOR ARIZONA
March of Dimes – PeriStats
8.6%
8.5%
9.2%
9.4%
12.2%
8.5%
8.9%
9.1%
10.5%
13.3%
0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0%
Asian/Pacific Islander
White
Hispanic
American Indian/Alaskan Native
Black
2013-2015 Racial Disparity in Premature Live Births
US AZ
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MARCH OF DIMES 2017 PREMATURE BIRTH REPORT CARD FOR ARIZONA
March of Dimes – PeriStats
9.0%
9.2%
8.5%
9.1%
8.3%
8.6%
7.8% 8.0% 8.2% 8.4% 8.6% 8.8% 9.0% 9.2% 9.4%
Pinal
Maricopa
Pima
Mohave
Yavapai
Yuma
2015 Preterm Birth Rates by County of Residence
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% TOTAL CS, PRIMARY CS AND VBAC BIRTHS 2006-2016
26.0 26.6 27.5 27.7 27.6 27.9 27.6 27.8 27.6 27.627.4
17.2 17.1 17.4 17.614.9 14.7
16.9 16.7 16.4
15.8 15.6
5.4 5.5 6.7 6.4 5.9 6.7 7.68.6
15.2
16.2 17
0.0
5.0
10.0
15.0
20.0
25.0
30.0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Total CS Primary CSec VBAC
Source: 2016 ADHS Population and Health Vital Statistics
HP2020-MICH-7.1 Prim Csec Target 23.9%
In low risk (FT, singleton, vertex)
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AZ BIRTHS BY SETTING AND CHARACTERISTICS
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AZ HOSPITAL BIRTHS BY LEVEL OF CARE - 2017IHBC
0.07% Level I5.55%
Level II23.95%
Level IIE26.05%
Level III41.06%
Non APT 3.29%
ED0.04%
Source: 2017 ADHS Vital Statistics
96.7% of Arizona
Hospital Births
occur in APT
Certified Facilities
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ALTERNATIVE BIRTH LOCATIONS AND TRENDS 2014-2017
2943
53
469
713
100
2787
15
505
725
468
2376
31
619713 712
0
500
1000
1500
2000
2500
3000
3500
Non APT Facilities Ermergency Depts FS Birthing Centers Home Births "Other Births"
2014 2015 2017Source: 2016 ADHS Vital Statistics
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REGIONALIZATION – RIGHT LEVEL OF CAREVLBW, LBW AND HBW BIRTHS BY LEVEL - 2017
0 0 6 22 10
200
354
19 38
856
1668
38158
1308
1590
353
697
24232527
0
500
1000
1500
2000
2500
3000
ELBW <1000g VLBW <1500g LBW <2500g HBW 4000+
IHBC Level I Level II Level IIE Level III
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BIRTH LOCATION - ELBW<1000G (ABOUT <28 WEEKS)
IHBC0%
I0%
II5%
IIE9%
III86%
2017IHBC0%
I2%
II5%
IIE7%
III86%
2016
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BIRTH LOCATION - EGA<28 WEEKS
IHBC0%
I1%
II6%
IIE9%
III84%
2017IHBC0%
I3% II
4%
IIE7%
III86%
2016
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BIRTH LOCATION - VLBW<1500G (ABOUT <30 WEEKS)
IHBC0%
I1%
II4%
IIE18%
III77%
2017IHBC0%
I2%
II5%
IIE16%
III77%
2016
HP2020-MICH-33
Target 83.7%
APT 93%
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BIRTH LOCATION - LBW<2500G (ABOUT <36 WEEKS)
IHBC0%
I4%
II18%
IIE27%
III51%
2017 IHBC0%
I7%
II25%
IIE27%
III41%
2016
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BIRTH LOCATION - EGA <36 WEEKS
IHBC0%
I2%
II13%
IIE26%
III59%
2017 IHBC0%
I3%
II13%
IIE24%
III60%
2016
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Transports to and from APT Facilities 2017
IHBC I II IIE III Total
OB Sent 118 201 231 122 7 679
OB Rec’d 3 91 196 158 724 1172
Neo Sent 7 213 215 197 169 802
Neo Rec’d 0 0 1 4 61 66
Neo Back Sent0 2 18 172 324 516
Neo Back Rec’d0 0 30 25 24 79
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INDUCTIONS 2011-2016
2012 2013 2014 2015 2016 2017
Number 21,810 21,653 19,899 19,517 17,419 18,562
Rate 27.2% 27.0% 24.8% 24.3% 21.7% 24.0%
21,810 21,65319,899 19,517
17,419
18,562
27.2% 27.0%24.8%
24.3%
21.7%24.0%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
0
5,000
10,000
15,000
20,000
25,000
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INDUCTION RATES/TOTAL DELIVERIES BY LEVEL OF CARE
28.8%
23.6%
25.5%
23.2%
24.2%24.3%23.5%
25.0%
18.2%
21.7%
22.9%
26.5%
24.5%
22.6%
24.0%
15.0%
17.0%
19.0%
21.0%
23.0%
25.0%
27.0%
29.0%
31.0%
I II IIE III Total
2015 2016 2017
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C-SECTION RATES AFTER INDUCTION
20.0%
16.0%
18.2%
17.1%17.3%
15.0%
16.0%
17.0%
18.0%
19.0%
20.0%
21.0%
I II IIE III Total
2017
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PRIMARY CESAREANS 2012-2017
2012 2013 2014 2015 2016 2017
Number 12,016 12,328 11,785 11,371 11,112 10,667
Rate 15.2% 14.5% 14.2% 14.1% 13.8% 13.8%
12,016
12,328
11,785
11,371
11,112
10,667
15.2%
14.5%
14.2%
14.1%
13.8%
13.8%
13.0%
13.5%
14.0%
14.5%
15.0%
15.5%
9,500
10,000
10,500
11,000
11,500
12,000
12,500
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PRIMARY C-SECTIONS RATES/TOTAL DELIVERIES BY LEVEL OF CARE
13.6% 13.4%14.3% 14.4%
14.1%
12.3% 13.0%13.7%
14.7%13.8%
11.6%
13.4%13.1%
14.9%
13.8%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
I II IIE III Total
2015 2016 2017
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VBACS IN APT FACILITIES – 2014-2017
0 43
405342
1520
2310
0 43
446323
1130
1942
281
463
347
1041
1934
180
459 444
1083
2067
0
500
1000
1500
2000
2500
IHBC I II IIE III Total
2014 2015 2016 2017
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VBAC SUCCESS 2014-2017
82.5%
84.1%
81.2%80.7%
79.0%
80.0%
81.0%
82.0%
83.0%
84.0%
85.0%
2014 2015 2016 2017
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RATE OF VLBW AND LBW DELIVERIESBASED ON DELIVERIES IN APT FACILITIES – 2014-2016
1.40%1.06% 1.19% 1.16%
7.80%
6.98%7.25%
6.16%
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
7.00%
8.00%
9.00%
HP 2020 Target 2015 2016 2017
VLBW <1500 LBW <2500HP2020 MICH 8.1 and 8.2
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BIRTHS BY GESTATIONAL AGE
EGA Number Percent
<24 161 0.2%
24-27 299 0.4%
28-31 598 0.8%
32-35 3,247 4.2%
36-38 24,031 31.0%
39+ 49,101 63.4%
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INSTRUMENT DELIVERIES – LEVEL OF CARE
0.0%
6.0%
3.9%3.6%
3.2%
3.6%
0.0%
5.1%
4.0%
3.5%
3.1%
3.6%
0.0%
6.0%
3.7% 3.7%
3.0%
3.5%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
IHBC Level I Level II Level IIE Level III All Levels
2015 2016 2017
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GENERAL ANESTHESIA FOR C-SECTIONS– LEVEL OF CARE 2016 & 2017
5.4%
3.3% 3.3%3.5% 3.5%
5.4%
3.0%
3.6%3.3% 3.4%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
Level I Level II Level IIE Level III All Levels
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5 MIN APGARS 6 OR LESS – RATE BY LOC – 2016 & 2017
1.13%
0.9… 0.91%
1.57%
1.21%1.10%
1.25%
1.05%
1.45%
1.27%
0.00%
0.20%
0.40%
0.60%
0.80%
1.00%
1.20%
1.40%
1.60%
1.80%
Level I Level II Level IIE Level III All Levels
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ADMISSION TO CCN OR NICU – TOTALS BY LOC - 2017
2103
2882
4294
9279
36 220
443 669
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
Level II Level IIE Level III All Levels
Inborn Transports
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INBORN ADMISSION TO CCN OR NICU– RATE BY LOC 2017
11.5%
13.8%
13.1%
12.0%
10.0%
10.5%
11.0%
11.5%
12.0%
12.5%
13.0%
13.5%
14.0%
Level II Level IIE Level III All Levels
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SCHEDULED DELIVERIES AT 36, 37 OR 38 WEEKS – NOT MED NECESSARY
2013
United States Average – 6% not medically necessary
Arizona Average – 7% not medically necessary
Involving at least 6061 newborns
APT Hospitals average 6.2% (Range 0 – 26%) – 38 hospitals reporting
Non APT Hospitals average 12.6% (Range 0 – 33%) – 5 hospitals reporting
2013 CMS Data – Analysis by Nathan Lepp, MD
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SCHEDULED DELIVERIES AT 36, 37 OR 38 WEEKS – NOT MED NECESSARY
2015-16
APT Hospitals range from 0 – 25% - 37 hospitals reporting
2016-2017
APT Hospitals range from 0 – 9% - 39 hospitals reporting
2016-17 CMS Data – Based on a sample of cases
% 0 1 2 3 4 5 6 7 8 9 -- 25
2015-16 12 8 6 4 2 0 2 0 0 2 1
2016-17 18 2 3 2 5 0 1 2 2 2 0
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EARLY ELECTIVE DELIVERIES APT DATA:APT 62 VS ABOUT 90 PER CMS
5
32
4
21
62
0.15
10.15
20.15
30.15
40.15
50.15
60.15
70.15
I II IIE III Total
2017
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MATERNAL AND INFANT MORBIDITY AND MORTALITY
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MAT DEATHS IN APT FACILITIES –DELIVERY ADMISSION 2015-2017
0 0
1
0
2
3
0 0 0 0
5 5
0 0 0 0
7 7
0
1
2
3
4
5
6
7
8
IHBC I II IIE III Total
2015 2016 2017
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PREGNANCY RELATED DEATHS: AZ VS 4 STATE REPORT
Hemorrhage24%
CV / HTN27%
Other49%
AZ N=37 Hemorrhage13%
CV / HTN32%
Other55%
4 State N=175
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SEVERE MATERNAL MORBIDITY APT
012
47 49
99
207
0 9
49 43
98
196
021
96 92
197
403
0
50
100
150
200
250
300
350
400
450
IHBC I II IIE III Total
Blood ICU Either
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SEVERE MATERNAL MORBIDITY APTRATES PER 1000
2.352.57
2.34
3.01
2.68
2.001.76
2.68
2.05
2.98
2.54
3.50
4.00
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
4.50
I II IIE III Total Study 1 Study 2
Blood ICU
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CDC ICD BASED SMM RATES
Source:https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html
Accessed 7/27/18
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“CDC” SMM ARIZONA 2016RATES PER 10,000 BY LEVEL
188.4
97.5
172.7
116.8 117.6
49.341.4
62.3
100.2
39.9
0.0
20.0
40.0
60.0
80.0
100.0
120.0
140.0
160.0
180.0
200.0
I II IIE III Non APT
SMM overall SMM no transfusion
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“CDC” SMM ARIZONA 2016RATES PER 10,000
150.2
112.8
174.4 171.9
327.9
162.0
71.560.3
77.3 76.1
136.4
84.3
0.0
50.0
100.0
150.0
200.0
250.0
300.0
350.0
Overall NH White NH Black Hispanic NH Nat Am Asian/Pac Is
SMM overall SMM no transfusion
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AIM STATE OVERALL SMM 4 COHORT RESULTSRATES PER 10,000
209.2 208.6
189.8 185.0
166.2
190.3
147.9
169.6
0.0
50.0
100.0
150.0
200.0
250.0
1 2 3 4
Pre Post
Decreases of:
20.5%
8.8%
22.1%
8.3%
Respectively
All statistically
significant
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NEONATAL DEATHS IN APT FACILITIES– 2015-2017
0 417
25
155
201
1 312
19
162
197
0 621 15
148
189
0
50
100
150
200
250
IHBC I II IIE III Total
2015 2016 2017
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RATE OF CHILD DEATHS DUE TO PREMATURITYBORN BEFORE 37 WEEKS WITH NO UNDERLYING CAUSE OF DEATH OTHER TH AN PREMATURITY
3.0
2.7 2.6
2.3 2.3 2.2 2.42.6
2.1
1.9
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Rate per 1000 live births
2017 AZ Child Fatality Review Program
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CHILD DEATHS DUE TO PREMATURITY - DISPARITYBORN BEFORE 37 WEEKS WITH NO UNDERLYING CAUSE OF DEATH OTHER TH AN PREMATURITY
52%
25%
17%
8%5%
40%45%
5% 6% 4%
0%
10%
20%
30%
40%
50%
60%
Hispanic White, non-Hispanic African American American Indian Asian
% Prematurity deaths % of Births
2017 AZ Child Fatality Review Program
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NEONATAL MORTALITY BY BIRTHWEIGHTALL LEVELS COMBINED PER 1,000
Birthweight Number NMR
<500 100 610.00
500-999 312 179.49
1000-1499 491 32.59
VLBW 903 147.29
LBW 4,793 3.34
2500+ 71,997 0.26
4000+ 6,141 0.16
Neonatal deaths of
those < 500 gm
weeks made up
36% of the deaths
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NEONATAL MORTALITY BY GESTATIONAL AGEALL LEVELS COMBINED PER 1,000
EGA Number NMR
<24 73 453.42
24-27 43 143.81
28-31 16 26.76
32-35 17 5.24
36-38 11 0.46
39+ 6 0.12
Neonatal deaths
of those < 24
weeks made up
44% of the
deaths
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SUID, BY CAUSE (INFANTS <1YR)CHILD FATALITY REPORTS – 2011 - 2016
2011 2013 2015 2016
Sudden unexplained infant death 114 74 78 80
Death from unsafe sleeping
environment
64 65 74 79
Sleeping on side or stomach 36 28 25 24
Bed sharing with adult and/or
other children
36 34 36 41
2017 AZ Child Fatality Review Program - 24th Annual Report
• 93% determined to be preventable.
• African American and American Indian infant deaths disproportionately higher than population they
compose.
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NAS IN APT FACILITIES
136
116152
533
838
0
100
200
300
400
500
600
700
800
900
IHBC I II IIE III Total
2017
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TRENDS IN NEWBORN HOSPITALIZATION DUE TO MATERNAL DRUG USE
Source: 2016 ADHS Population Health
and Vital Statistics
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DISCUSSION – APRS/APT QI COMMITTEE GOALS
Follow IOM’s recommendation of “Measure, Report, Improve”
Investigate methods to leverage routinely collected data for tracking perinatal outcomes
Facilitate identification of improvement opportunities
Consider collaborative approaches to perinatal outcome improvementJoin AIM?
Work on NAS?
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AND LET ME SAY……….
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ARIZONA BIRTH DEMOGRAPHICS