Editorials
www.AJOG .org
Reestablishing trust in the medical profession: making a significant impact on maternal mortality in the United States Michael R. Foley, MD
D
espite the most advanced technologies and facilities, outstanding and capable medical personnel, and being “under the microscope” by both professional and other national organizations, the rate of maternal death in the United States over the last 20 years has remained relatively unchanged and actually appears to be increasing.1-3 Up until now, trust in our ability to reduce maternal mortality rates has been eroding. Trust evolves from equal contributions of sincerity, competence, and reliability. It clearly seems that, although our collective “sincere care” for the well-being of our patients remains at the forefront, competence in making a significant impact on mortality rates and reliability in showing continuous improvement has been put to question. Clark et al4 in this edition of the Journal have demonstrated “landmark” steps in reestablishing trust by improving our collective competence and reliability in reducing maternal mortality rates. In a population that is representative of the US population as a whole from the ethnic, demographic, and geographic parameters, Clark et al4 showed that they were able to reduce maternal mortality rates significantly by implementing diseasespecific protocols. They performed a retrospective evaluation of maternal deaths from 2000-2006 and again from 2007-2012 after the implementation of disease-specific protocols. A policy of universal pneumatic compression devices for all cesarean deliveries resulted in a significant decrease in deaths from pulmonary embolism (7/458,097 to 1/465,880 cesarean deliveries; P ¼ .038).1-3,5 A policy of automatically implementing antihypertensive therapy for systolic blood pressure 160 mm HG or diastolic From the Department of Obstetrics and Gynecology, Banner Good Samaritan Medical Center, and the University of Arizona College of Medicine-Phoenix, Phoenix, AZ. Received March 17, 2014; accepted March 21, 2014. The author reports no conflict of interest. Reprints: Michael R. Foley, MD, Department of Obstetrics and Gynecology, University of Arizona College of MedicineePhoenix, Phoenix, AZ 85260. [email protected]. 0002-9378/free ª 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.03.053
See related article, page 32
blood pressure 110 mm HG eliminated deaths from in-hospital intracranial hemorrhage and reduced the deaths from preeclampsia from 15-3 (P ¼ .02).5,6 Unfortunately, their protocols were less effective in reducing deaths from hemorrhage,7 which suggests the need for continuous improvement in this area. The authors present a valid argument that very narrowly focused programs, as opposed to broad-based bundles or clinical tool kits, that are directed at specific clinical events are most effective in reducing morbidity and mortality rates. This philosophy is also advocated by the Institute of Medicine.8,9 Interestingly, the authors also found that most women who died during hospital care had no risk factors for the ultimate cause of death (56%). Twenty-six percent of the women had a common risk factor such as preeclampsia, which did not pose a significant risk of death on admission. In addition, a large proportion of the patients who died did so under the care of a previously established tertiary care center. The point emphasized by the authors is that our attention needs to be directed at improving the ability of smaller facilities to handle obstetric emergencies as opposed to an overly myopic focus of transporting patients to tertiary care centers only to reduce maternal mortality rates. Nevertheless, the authors point out that pneumonia (because of H1N1 pandemic) and placenta accreta (plus additional high-risk conditions) pose special circumstances of enhanced death risk and should be cared for in regional care centers. We as physicians at the bedside are sincerely trying to do what is best for our patients. In that regard, how do we successfully incorporate the “evidenced-based” message of the article by Clark et al4 with our experienced-based “art of medical practice”? In addition, how does the work of Clark et al4 assist us with enhancing our reliability with pursuing continuous improvement in reducing maternal deaths in the United States? How do we move from knowing to doing? In other words, how do we reestablish trust? Only the physicians at bedside can really answer this. Are we willing to fully implement disease-specific protocols to make a significant impact on maternal mortality rates in our country? Are we committed to incorporating the bestavailable evidence into our practice to let it serve and strengthen our clinical experience?
JULY 2014 American Journal of Obstetrics & Gynecology
1
Editorials Clark et al4 have demonstrated that, in populations just like yours and mine, it can be done successfully. It’s time to reestablish that trust! REFERENCES 1. Clark SL, Belfort MA, Dildy GA, et al. Maternal death in the 21st century: prevention and relationship to cesarean delivery. Am J Obstet Gynecol 2008;199:36.e1-5. 2. Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancyrelated mortality in the United States, 1998 to 2005. Obstet Gynecol 2010;116:1302-9. 3. Main EK, Menard MK. Maternal mortality: time for national action. Obstet Gynecol 2013;122:735-6. 4. Clark SL, Christmas JT, Frye DR, et al. Maternal mortality in the United States: predictability and the impact of protocols on fatal postcesarean
2 American Journal of Obstetrics & Gynecology JULY 2014
www.AJOG.org pulmonary embolism and hypertension-related intracranial hemorrhage. Am J Obstet Gynecol 2014;211:32.e1-9. 5. Clark SL, Meyers JA, Frye DK, Perlin JB. Patient safety in obstetrics: the Hospital Corporation of America experience. Am J Obstet Gynecol 2011;204:283-7. 6. Clark SL, Hankins GDV. Preventing maternal death: 10 clinical diamonds. Obstet Gynecol 2012;119:360-4. 7. Clark SL. Strategies for reducing maternal mortality. Semin Perinatol 2012;36:42-7. 8. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000. 9. Committee on Quality Health Care in America and Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
www.AJOG .org
Reestablishing trust in the medical profession: making a significant impact on maternal mortality in the United States Michael R. Foley, MD
D
espite the most advanced technologies and facilities, outstanding and capable medical personnel, and being “under the microscope” by both professional and other national organizations, the rate of maternal death in the United States over the last 20 years has remained relatively unchanged and actually appears to be increasing.1-3 Up until now, trust in our ability to reduce maternal mortality rates has been eroding. Trust evolves from equal contributions of sincerity, competence, and reliability. It clearly seems that, although our collective “sincere care” for the well-being of our patients remains at the forefront, competence in making a significant impact on mortality rates and reliability in showing continuous improvement has been put to question. Clark et al4 in this edition of the Journal have demonstrated “landmark” steps in reestablishing trust by improving our collective competence and reliability in reducing maternal mortality rates. In a population that is representative of the US population as a whole from the ethnic, demographic, and geographic parameters, Clark et al4 showed that they were able to reduce maternal mortality rates significantly by implementing diseasespecific protocols. They performed a retrospective evaluation of maternal deaths from 2000-2006 and again from 2007-2012 after the implementation of disease-specific protocols. A policy of universal pneumatic compression devices for all cesarean deliveries resulted in a significant decrease in deaths from pulmonary embolism (7/458,097 to 1/465,880 cesarean deliveries; P ¼ .038).1-3,5 A policy of automatically implementing antihypertensive therapy for systolic blood pressure 160 mm HG or diastolic From the Department of Obstetrics and Gynecology, Banner Good Samaritan Medical Center, and the University of Arizona College of Medicine-Phoenix, Phoenix, AZ. Received March 17, 2014; accepted March 21, 2014. The author reports no conflict of interest. Reprints: Michael R. Foley, MD, Department of Obstetrics and Gynecology, University of Arizona College of MedicineePhoenix, Phoenix, AZ 85260. [email protected]. 0002-9378/free ª 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.03.053
See related article, page 32
blood pressure 110 mm HG eliminated deaths from in-hospital intracranial hemorrhage and reduced the deaths from preeclampsia from 15-3 (P ¼ .02).5,6 Unfortunately, their protocols were less effective in reducing deaths from hemorrhage,7 which suggests the need for continuous improvement in this area. The authors present a valid argument that very narrowly focused programs, as opposed to broad-based bundles or clinical tool kits, that are directed at specific clinical events are most effective in reducing morbidity and mortality rates. This philosophy is also advocated by the Institute of Medicine.8,9 Interestingly, the authors also found that most women who died during hospital care had no risk factors for the ultimate cause of death (56%). Twenty-six percent of the women had a common risk factor such as preeclampsia, which did not pose a significant risk of death on admission. In addition, a large proportion of the patients who died did so under the care of a previously established tertiary care center. The point emphasized by the authors is that our attention needs to be directed at improving the ability of smaller facilities to handle obstetric emergencies as opposed to an overly myopic focus of transporting patients to tertiary care centers only to reduce maternal mortality rates. Nevertheless, the authors point out that pneumonia (because of H1N1 pandemic) and placenta accreta (plus additional high-risk conditions) pose special circumstances of enhanced death risk and should be cared for in regional care centers. We as physicians at the bedside are sincerely trying to do what is best for our patients. In that regard, how do we successfully incorporate the “evidenced-based” message of the article by Clark et al4 with our experienced-based “art of medical practice”? In addition, how does the work of Clark et al4 assist us with enhancing our reliability with pursuing continuous improvement in reducing maternal deaths in the United States? How do we move from knowing to doing? In other words, how do we reestablish trust? Only the physicians at bedside can really answer this. Are we willing to fully implement disease-specific protocols to make a significant impact on maternal mortality rates in our country? Are we committed to incorporating the bestavailable evidence into our practice to let it serve and strengthen our clinical experience?
JULY 2014 American Journal of Obstetrics & Gynecology
1
Editorials Clark et al4 have demonstrated that, in populations just like yours and mine, it can be done successfully. It’s time to reestablish that trust! REFERENCES 1. Clark SL, Belfort MA, Dildy GA, et al. Maternal death in the 21st century: prevention and relationship to cesarean delivery. Am J Obstet Gynecol 2008;199:36.e1-5. 2. Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancyrelated mortality in the United States, 1998 to 2005. Obstet Gynecol 2010;116:1302-9. 3. Main EK, Menard MK. Maternal mortality: time for national action. Obstet Gynecol 2013;122:735-6. 4. Clark SL, Christmas JT, Frye DR, et al. Maternal mortality in the United States: predictability and the impact of protocols on fatal postcesarean
2 American Journal of Obstetrics & Gynecology JULY 2014
www.AJOG.org pulmonary embolism and hypertension-related intracranial hemorrhage. Am J Obstet Gynecol 2014;211:32.e1-9. 5. Clark SL, Meyers JA, Frye DK, Perlin JB. Patient safety in obstetrics: the Hospital Corporation of America experience. Am J Obstet Gynecol 2011;204:283-7. 6. Clark SL, Hankins GDV. Preventing maternal death: 10 clinical diamonds. Obstet Gynecol 2012;119:360-4. 7. Clark SL. Strategies for reducing maternal mortality. Semin Perinatol 2012;36:42-7. 8. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000. 9. Committee on Quality Health Care in America and Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
