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Cleveland Clinic looks at complication rate for maternity cases


Weeks before Cleveland Clinic Florida stepped into the birthing business by acquiring Indian River Medical Center and two other Treasure Coast hospitals doing labor and delivery, officials at the hospitals were under siege.

While in the throes of preparing for the Jan. 1 Cleveland takeover, the hospital officials were being peppered with “10 million questions,” as one insider put it, about their maternity complication rates.

The scrutiny came not from ratings organizations, accreditation commissions or even the state or federal government. Instead, the questions came from USA Today and its affiliate Gannett papers, who assigned reporters to grill hospital officials over their reportedly high rates of serious maternal complications – problems before, during and after delivery.

This month, multiple articles emerged filled with disturbingly graphic accounts of hemorrhage, horrible pain and even death in hospitals nationwide. In the local Treasure Coast Gannett papers, Martin Health System’s hospitals in Stuart and Tradition were singled out as having maternal complication rates close to twice the state and national medians, according to the “secret” data Gannet says it found.

Martin Medical Center in Stuart saw serious complications in 2.9 percent of births, while the rate at Tradition Medical Center in Port St. Lucie was 2.4 percent, the papers claimed.

Indian River Medical Center also came under fire, with a reported rate of 2 percent, a third higher than the state median of 1.5 – even though it has been working since 2015 with a statewide healthcare collaborative to reduce maternal complication rates.

According to the Gannett stories, all three hospitals had significantly worse rates of complications than Lawnwood Regional Medical Center, owned by HCA, whose rate equaled the state’s median.

Now the newly expanded Cleveland Clinic Florida is pushing back with its own data analysis after USA Today would not release its methodology for assigning complication rates to the hospitals, even to its own reporters.

While awaiting the outcome of its study, Cleveland Clinic Indian River said state data tracked by the Florida Perinatal Quality Collaborative showed the hospital was “at or better than state averages on the majority of [maternity complication] indicators.”

For years, what is now Cleveland Clinic Indian River has been the only hospital in the Indian River County delivering babies. For that reason, labor and delivery was named a “required service” for the next 10 years in the takeover agreement between Cleveland Clinic and Indian River Medical Center, meaning Cleveland would continue the service.

But there is an out for Cleveland that no one wants to think about: If, within 25 miles of the hospital, there is another hospital that can provide the same service “at a comparable level,” Cleveland Clinic can discontinue that required service.

Fort Pierce’s Lawnwood Regional Medical Center, which is 18 miles south of 37th Street in Vero, appears potentially within that defining range.

The possibility that Indian River Cleveland Clinic Hospital might stop delivering babies – remote though Cleveland officials claimed it to be in the partnering process – struck fear in Andrea Berry, CEO of Indian River Healthy Start Coalition. “I would lay on the tracks before anything happened to labor and delivery at Indian River,” Berry said. “How would a woman with a problem pregnancy in Fellsmere even get to Lawnwood? I can’t imagine. That would be crazy high risk. It takes two hours and four bus changes just to get to Indian River [from Fellsmere].”

Until now, the issue getting the most attention in Indian River County has been infant mortality. It is one of four top priorities named in the 2016 to 2019 Community Health Improvement Plan.

That focus has led to improved maternal care as well, in the form of greatly increased prenatal and postpartum care provided by the Partners in Women’s Health Collaborative. That clinic, across the street from the hospital, is a joint effort of the county’s taxpayer-funded Hospital District and Cleveland Clinic Indian River hospital.

In another effort to improve care, Indian River Medical Center, beginning in 2012, became part of the Obstetric Hemorrhage Initiative, a program intended to reduce excessive bleeding when women give birth developed by the University of South Florida College of Public Health’s Florida Perinatal Quality Collaborative.

The 18-month-long initiative offered hospitals ways to prepare for or prevent maternal complications, and improve response and reporting by tracking blood loss, transfusions and unplanned hysterectomies, among other data. It also required an annual drill by doctors and nurses.

Indian River upped those drills to quarterly, with the entire 50-member staff on the maternity floor participating along with six Partners in Women’s Health doctors – OB-GYNs now employed by Cleveland Clinic. Two other obstetricians deliver babies at Indian River but are in independent practice.

That high ratio of employed physicians at the Indian River hospital could give leadership here an advantage in initiating change in labor and delivery practices as compared to Martin and Tradition, which use independent obstetricians.

Employer oversight may have helped reduce rates of C-sections, according to a spokesman for USF’s Florida Perinatal Quality Collaborative.

C-sections are known to increase a woman’s risk for blood clots and infection. High rates have been hard to rein in nationally. Statewide, they range from 17 percent to 61 percent, the spokesman said. But they have come down at Indian River to 25.5 percent, according to the national safety ratings organization, the Leapfrog Group.

Only a fifth of Florida’s hospitals have hit the national goal of 23.9 percent. Lawnwood’s rate is also improving, at 25.2. But Martin Medical Center’s rate is still very high at 34.9 percent. Tradition is slightly better at 31.3.

There has been greater success here and nationally in another key focus for improvement in maternal health: elective deliveries before 39 weeks of gestation. The formerly common practice of delivering babies early by induction or C-section has far more frequent complications for mother and infant. Indian River’s percentage of early elective deliveries was zero last year, as it was at Martin Medical Center and Tradition. That is well below a target of 5 percent set by Leapfrog.

In a statement, Cleveland Clinic Indian River said the state data tracked by the Florida Perinatal Quality Collaborative did show room for improvement on the number of blood transfusions after delivery.

Indian River began an effort to reduce transfusions hospital-wide in 2016 and has seen a reduction in transfusions of 5.6 percent, the statement said.       

At the same time, Indian River’s rate for another frowned-on procedure, the once routine episiotomy, is far higher than surrounding hospitals: 18.1 percent as measured by Leapfrog.

Lawnwood’s rate again was the best in the area, with episiotomies in just 5.4 percent of births, close to the Leapfrog goal of 5 percent. Episiotomy is an incision in the perineum, the area at the outside of the birth canal, made during a vaginal delivery. It must be sutured once the baby is delivered and can cause significant pain and dangerous complications.

The procedure once was thought to prevent tears in the perineum but has been found to make tears worse and can result in loss of bladder or bowel control and damage to the pelvic floor. Episiotomies can also cause vaginal hematomas that can lead to hemorrhage.  And like all unnecessary procedures, they add to the cost of the birth.

Another positive step at Indian River is its involvement in an initiative to increase access to long-acting reversible contraception in the hopes of lengthening the time between women’s pregnancies. Adequate spacing can reduce the risk of low-birthweight and premature babies, studies show.

“I see Cleveland Clinic as an agent for change,” said Healthy Start’s Berry, as she dug into her own research on maternal complications following the recent USA Today articles.

In January, Berry spoke with Cleveland Clinic Indian River’s new CEO, Dr. Greg Rosencrance, and came away encouraged. “When they say they care about population health, I believe them. There’s a lot of innovation going on.”