Elective Induction Bundling Criteria Should Include Favorable Cervix

WASHINGTON – Bundling criteria for elective induction would result in better outcomes and reduced costs if favorable cervix were added as a criterion, according to the results of a prospective trial.

"Among women achieving elective induction bundle criteria, favorable cervix is associated with significantly better outcomes and costs," said Tiffany Kenny, R.N., of Summa Health System in Akron, Ohio. "It’s not a novel finding that outcomes are better when the cervix is favorable. However, this study indicates that the current bundle is missing this key component and does not adequately guarantee cost or quality."

The elective induction bundle includes four criteria: a gestational age of at least 39 weeks, a normal fetal status at the start, pelvic exam documented prior to the start, and recognition and management of uterine tachysystole.

The investigators included all women at one institution who had delivered from October 2009 to October 2010 and had an elective induction. Data were collected prospectively for all 180 women, and all underwent quality bundling, which included a bundle audit, related education, and peer review, Ms. Kenny said at the annual meeting of the American College of Obstetricians and Gynecologists.

The study patients were divided into two groups – those achieving bundle criteria and those who did not. Those who achieved bundling criteria were then grouped by favorable cervix on admission. A favorable cervix was defined as a Bishop score greater than 6, determined by hospital admission exam by a physician or certified nurse midwife before the start of the induction.

At the end of the study period, a control group (prebundling) was retrospectively abstracted using the same methods, and included all women who had delivered from January 2005 to December 2007 and met the inclusion criteria.

Among the prebundling control group of 473 women, none achieved bundling. Of the 180 women included in the study group, 96% achieved bundling.

The two primary end points were cesarean delivery rate and rates of special or intensive care required. The cesarean delivery rate was 21% for women in the prebundling group and 12% with bundling, a significant difference. Women in the study group also had significantly less maternal blood loss and shorter lengths of stay. However, there were no differences in the rates of special or intensive care required – around 5.5%.

"Those who achieved bundle criteria did not always have favorable outcomes," Ms. Kenny said. "When bundle achievers were grouped by Bishop score, those with a poor Bishop score had higher rates of cesarean, more neonates to special care, longer lengths of labor, and higher rates of cesarean for dystocia and poor fetal heart rate pattern."

Among women in the study group, those with a Bishop score greater than 6 – considered a favorable cervix – had a 4% cesarean rate, compared with 19% for women who had a Bishop score of 6 or less, which was a significant difference. In addition, women with a Bishop score greater than 6 were significantly less likely to have a neonate requiring special or intensive care – 1% vs. 10% for women with a Bishop score of 6 or less.

In addition, "bundle achiever dyads with a poor Bishop score were significantly more costly than those with a Bishop score greater than 6, particularly if delivered vaginally."

Among vaginal delivery dyads, the net loss was $341 for those with a Bishop score greater than 6 vs. a net loss of $1,706 for those with a Bishop score of 6 or less. Likewise, among cesarean delivery dyads, the net loss was $2,166 for those with a Bishop score greater than 6 vs. a net loss of $6,342 for those with a Bishop score of 6 or less.

"Overall, the study cohort totaled a net income loss of over $270,000 for the hospital," said Ms. Kenny. "Elective induction was identified as the top drain to our department. The financial concerns of elective inductions will further intensify with health care reform, as reimbursement will soon be based on quality and cost – transitioning from fee-for-service to value-based care."

"Our findings also suggest that education and peer review interventions are not sufficient. Hard stops at the point of scheduling may be required," she said.

The investigators reported that they had no relevant financial disclosures.

WASHINGTON – Bundling criteria for elective induction would result in better outcomes and reduced costs if favorable cervix were added as a criterion, according to the results of a prospective trial.

"Among women achieving elective induction bundle criteria, favorable cervix is associated with significantly better outcomes and costs," said Tiffany Kenny, R.N., of Summa Health System in Akron, Ohio. "It’s not a novel finding that outcomes are better when the cervix is favorable. However, this study indicates that the current bundle is missing this key component and does not adequately guarantee cost or quality."

The elective induction bundle includes four criteria: a gestational age of at least 39 weeks, a normal fetal status at the start, pelvic exam documented prior to the start, and recognition and management of uterine tachysystole.

The investigators included all women at one institution who had delivered from October 2009 to October 2010 and had an elective induction. Data were collected prospectively for all 180 women, and all underwent quality bundling, which included a bundle audit, related education, and peer review, Ms. Kenny said at the annual meeting of the American College of Obstetricians and Gynecologists.

The study patients were divided into two groups – those achieving bundle criteria and those who did not. Those who achieved bundling criteria were then grouped by favorable cervix on admission. A favorable cervix was defined as a Bishop score greater than 6, determined by hospital admission exam by a physician or certified nurse midwife before the start of the induction.

At the end of the study period, a control group (prebundling) was retrospectively abstracted using the same methods, and included all women who had delivered from January 2005 to December 2007 and met the inclusion criteria.

Among the prebundling control group of 473 women, none achieved bundling. Of the 180 women included in the study group, 96% achieved bundling.

The two primary end points were cesarean delivery rate and rates of special or intensive care required. The cesarean delivery rate was 21% for women in the prebundling group and 12% with bundling, a significant difference. Women in the study group also had significantly less maternal blood loss and shorter lengths of stay. However, there were no differences in the rates of special or intensive care required – around 5.5%.

"Those who achieved bundle criteria did not always have favorable outcomes," Ms. Kenny said. "When bundle achievers were grouped by Bishop score, those with a poor Bishop score had higher rates of cesarean, more neonates to special care, longer lengths of labor, and higher rates of cesarean for dystocia and poor fetal heart rate pattern."

Among women in the study group, those with a Bishop score greater than 6 – considered a favorable cervix – had a 4% cesarean rate, compared with 19% for women who had a Bishop score of 6 or less, which was a significant difference. In addition, women with a Bishop score greater than 6 were significantly less likely to have a neonate requiring special or intensive care – 1% vs. 10% for women with a Bishop score of 6 or less.

In addition, "bundle achiever dyads with a poor Bishop score were significantly more costly than those with a Bishop score greater than 6, particularly if delivered vaginally."

Among vaginal delivery dyads, the net loss was $341 for those with a Bishop score greater than 6 vs. a net loss of $1,706 for those with a Bishop score of 6 or less. Likewise, among cesarean delivery dyads, the net loss was $2,166 for those with a Bishop score greater than 6 vs. a net loss of $6,342 for those with a Bishop score of 6 or less.

"Overall, the study cohort totaled a net income loss of over $270,000 for the hospital," said Ms. Kenny. "Elective induction was identified as the top drain to our department. The financial concerns of elective inductions will further intensify with health care reform, as reimbursement will soon be based on quality and cost – transitioning from fee-for-service to value-based care."

"Our findings also suggest that education and peer review interventions are not sufficient. Hard stops at the point of scheduling may be required," she said.

The investigators reported that they had no relevant financial disclosures.

WASHINGTON – Bundling criteria for elective induction would result in better outcomes and reduced costs if favorable cervix were added as a criterion, according to the results of a prospective trial.

"Among women achieving elective induction bundle criteria, favorable cervix is associated with significantly better outcomes and costs," said Tiffany Kenny, R.N., of Summa Health System in Akron, Ohio. "It’s not a novel finding that outcomes are better when the cervix is favorable. However, this study indicates that the current bundle is missing this key component and does not adequately guarantee cost or quality."

The elective induction bundle includes four criteria: a gestational age of at least 39 weeks, a normal fetal status at the start, pelvic exam documented prior to the start, and recognition and management of uterine tachysystole.

The investigators included all women at one institution who had delivered from October 2009 to October 2010 and had an elective induction. Data were collected prospectively for all 180 women, and all underwent quality bundling, which included a bundle audit, related education, and peer review, Ms. Kenny said at the annual meeting of the American College of Obstetricians and Gynecologists.

The study patients were divided into two groups – those achieving bundle criteria and those who did not. Those who achieved bundling criteria were then grouped by favorable cervix on admission. A favorable cervix was defined as a Bishop score greater than 6, determined by hospital admission exam by a physician or certified nurse midwife before the start of the induction.

At the end of the study period, a control group (prebundling) was retrospectively abstracted using the same methods, and included all women who had delivered from January 2005 to December 2007 and met the inclusion criteria.

Among the prebundling control group of 473 women, none achieved bundling. Of the 180 women included in the study group, 96% achieved bundling.

The two primary end points were cesarean delivery rate and rates of special or intensive care required. The cesarean delivery rate was 21% for women in the prebundling group and 12% with bundling, a significant difference. Women in the study group also had significantly less maternal blood loss and shorter lengths of stay. However, there were no differences in the rates of special or intensive care required – around 5.5%.

"Those who achieved bundle criteria did not always have favorable outcomes," Ms. Kenny said. "When bundle achievers were grouped by Bishop score, those with a poor Bishop score had higher rates of cesarean, more neonates to special care, longer lengths of labor, and higher rates of cesarean for dystocia and poor fetal heart rate pattern."

Among women in the study group, those with a Bishop score greater than 6 – considered a favorable cervix – had a 4% cesarean rate, compared with 19% for women who had a Bishop score of 6 or less, which was a significant difference. In addition, women with a Bishop score greater than 6 were significantly less likely to have a neonate requiring special or intensive care – 1% vs. 10% for women with a Bishop score of 6 or less.

In addition, "bundle achiever dyads with a poor Bishop score were significantly more costly than those with a Bishop score greater than 6, particularly if delivered vaginally."

Among vaginal delivery dyads, the net loss was $341 for those with a Bishop score greater than 6 vs. a net loss of $1,706 for those with a Bishop score of 6 or less. Likewise, among cesarean delivery dyads, the net loss was $2,166 for those with a Bishop score greater than 6 vs. a net loss of $6,342 for those with a Bishop score of 6 or less.

"Overall, the study cohort totaled a net income loss of over $270,000 for the hospital," said Ms. Kenny. "Elective induction was identified as the top drain to our department. The financial concerns of elective inductions will further intensify with health care reform, as reimbursement will soon be based on quality and cost – transitioning from fee-for-service to value-based care."

"Our findings also suggest that education and peer review interventions are not sufficient. Hard stops at the point of scheduling may be required," she said.

The investigators reported that they had no relevant financial disclosures.