Laborist Model Research Articles

Obstetrical Outcomes After Implementation of Laborist Model During the COVID-19 Pandemic.

The COVID-19 pandemic prompted labor and delivery units to establish ways to decrease viral exposure to healthcare workers while continuing to deliver optimal patient care. A laborist model was implemented to improve safety at our tertiary care hospital in Long Island. The aim of the study is to determine whether implementation of a laborist model during the COVID-19 pandemic is associated with a change in the frequency of cesarean birth. The retrospective cohort study included patients who delivered at a single tertiary center during March 2019 to May 2019 and March 2020 to May 2020 when our laborist model was initiated. The primary outcome compared the frequency of a cesarean delivery between both models. Secondary outcomes were the frequency of adverse obstetrical complications, which included intensive care unit admission, shoulder dystocia, intra-amniotic infection, hemorrhage, and need for blood transfusion. Statistical analysis included multivariable regression to adjust for potential confounders. A total of 1506 patients were included. Baseline characteristics were similar between the 2 groups. After adjusting for potential confounders, there was no significant difference in the frequency of cesarean births between both models (37% versus 35%; adjusted odds ratio, 1.003; 95% confidence interval, 0.46-2.89). Similarly, there were no significant differences in adverse outcomes between the study populations (adjusted odds ratio, 1.064; 95% confidence interval, 0.68-1.59). A change in practice behavior during a pandemic was not associated with an increase in frequency of cesarean births or adverse obstetrical outcomes.

The Influence of an Academic Hospitalist Model on Neonatal Outcomes [36O

INTRODUCTION: Previous research has failed to demonstrate improved neonatal outcomes following implementation of a laborist model. Our goal was to examine if there was a difference in neonatal outcomes when labor and delivery was staffed with a private or academic hospitalist practice. METHODS: This retrospective cohort study was of a high volume community hospital labor and delivery unit. Institutional Review Board approval was obtained for this research. All deliveries by the laborist service over a six month period in 2018, three months by a private hospitalist group and three months by an academic hospitalist group, were examined. The primary outcome was a composite of neonatal morbidity that included: Apgar <3 at five minutes, shoulder dystocia, birth trauma, seizure, sepsis, necrotizing enterocolitis, intraventricular hemorrhage or mechanical ventilation Differences in outcomes were examined using chi-square tests. The results were presented as relative risk (RR) with 95% confidence interval (CI). RESULTS: 245 patients were delivered by private physicians and 447 by academic physicians over the study period. There was no difference in a composite neonatal morbidity (9% vs 8%: 0.85 (0.49–1.46). NICU admissions were unchanged between the groups (8% vs 11%: 1.49 [0.85–2.62]). Transient tachypnea of the newborn (5% vs 7%: 1.30 [0.67–2.55]), hyperbilirubinemia (9% vs 14%: 1.52 [0.92–2.53]) and hypoglycemia (6% vs 10%: 1.68 [0.92–3.09]) were likewise similar. CONCLUSION: There was no difference in neonatal outcomes in patients delivered by private laborists or academic hospitalists.

Midwife Laborist Model in a Collaborative Community Practice.

Since the introduction of a hospitalist physician model of care by Wachter and Goldman in 1996, important changes have occurred to address the care of hospitalized patients. This model was followed by the introduction of laborist physicians by Louis Weinstein in 2003, although large health maintenance organization practices have used this model since the 1990s. The American Congress of Obstetricians and Gynecologists supported the laborist model in a 2016 statement that was reaffirmed in 2017, recommending “the continued development and study of the obstetric and gynecologic hospitalist model as one potential approach to improve patient safety and professional satisfaction across delivery settings.” Based on a recent American College of Obstetricians and Gynecologists publication, the problem is an anticipated staffing shortage of 6000 to 8800 obstetricians and gynecologists by 2020 and nearly 22,000 by 2050. The current workforce in obstetrics is aging, retiring early, and converting to part-time employment at an increasing rate. At the same time, the number of patients seeking obstetric and gynecologic care is dramatically increasing because of health care reform and population statistics. The solution is the use of alternative labor and delivery staffing models that include all obstetric providers (health care professionals). We present an alternative to the physician laborist model—a midwife laborist model in a collaborative practice with obstetricians practicing in a high-risk community setting.

The Home Team: How an Academic Practice Used Innovation Principles to Create a Novel Prenatal Model [24D

INTRODUCTION: The laborist model of obstetric care has benefits to patient safety and provider lifestyle, but requires a large group of providers to sustain. Our academic practice of 16 providers observed a disparity in patient satisfaction scores between obstetric and gynecologic patients, even for the same provider. Contextual inquiry attributed this finding to a lack of continuity for obstetric patients. Partnering with the Center for Healthcare Innovation, we designed and tested a novel team-based prenatal care model. Our hypothesis was that this would increase continuity and satisfaction for both patients and providers. METHODS: We utilized the “double diamond” methodology characterized by two rounds of divergent and convergent thinking. We first defined the problem by shadowing and interviewing stakeholders. Next, we prototyped, tested, and iterated multiple interventions, ultimately creating a team-based prenatal care model. Our pilot team consisted of two obstetricians and a nurse midwife who managed a panel of patients. We monitored the program with Press-Ganey data as well as a 5-question survey of patients and providers evaluating continuity and satisfaction. RESULTS: The “Home Team” enrolled 284 patients over 9 months. Both providers and patients in the pilot were more likely than non-participants to agree that they experienced continuity and rapport in prenatal care. Press-Ganey data (n=327) showed that pilot participants were more likely to recommend the practice (76.2% vs. 69.6%). CONCLUSION: Innovation principles provide an effective framework for problem-solving in healthcare. Using innovation techniques, our academic practice successfully piloted and implemented a team-based prenatal care model that improved patient and provider satisfaction.

575: Successful adoption and acceptance of a full-time laborist model in a community-based hospital

Our goal is to demonstrate how a full-time laborist program was fully integrated and accepted into a busy urban hospital serving voluntary medical staff from the community while improving quality metrics including the reduction in Total Cesarean Sections (CS), Primary CS, and Nulligravida Term Singleton Vertex CS rates. This was a retrospective study of CS rates from 2012-2015 at a single center following the institution of a comprehensive program to improve quality and safety. Key components of the program included: (1) Recruitment of a Medical Director and 4 full-time laborists with no private practices of their own who provided 24/7 oversight and supervision of all patients on the unit. (2) A web-based electronic scheduling program with decision support and hard stops was implemented for scheduled CS and labor inductions. (3) A collaboration was established between the laborists and the hospital's Maternal-Fetal Medicine (MFM) specialists to provide external cephalic version (ECV), second-opinion consultations for elective primary CS, and consultations for all patients admitted less than 36 weeks' EGA; and a midwifery practice to promote vaginal birth. (4) A full-time Patient Safety Nurse was recruited to assist the Medical Director to facilitate communication, team training, data collection and analysis, and best practices such as safety huddles for laborists and nurses. Data was extracted from an integrated electronic medical record for analysis. An average of 3700 of births/year took place during this time period with community practitioners attending the majority of births. The total CS rate and the primary CS rates decreased while the Vaginal Birth After CS (VBAC) rate increased (Table 1, Figure 1). The elective (non-medically indicated) induction of labor prior to 39 weeks was reduced to 0%. The decline in the CS rate from 30% to 20% led to an overall reduction of ∼400 Cesarean deliveries per year. The full-time laborist program initially alarmed the community practitioners; however, hospital champions facilitated discussions between laborists, MFMs, community physicians, midwives, nurses, and patients about timing of scheduled births, management of high risk pregnancies, VBAC, and ECV. The culture shifted on the unit to promote patient safety, quality, and best practices while supporting professional satisfaction of the community practitioners in private practice, residency training, and the faculty practices.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Academic Hospitalist Programs and the Impact on Resident Education [3C

INTRODUCTION: Hospitalist programs have increased in prevalence since their introduction in the mid-1990s, doubling over a 5-year period from 114 to 240. While the laborist model increases patient safety and decreases physician fatigue and burnout in general, its impact on resident education is unknown. The purpose of the study was to determine the number of hospitalist programs within an academic setting and to exam the perceived impact of the program on postgraduate training in obstetrics and gynecology. METHODS: A validated survey was sent to program directors at all 242 U.S. Obstetrics and Gynecology training programs using an anonymous online survey instrument. The survey included 9 questions and took approximately 3-5 minutes to complete. The email was distributed three times: initial email with follow up emails at one and six months. Groups of interest were compared by chi-square test. RESULTS: 242 OB/Gyn residency training programs were surveyed. There were 98 respondents for a response rate of 36%. Twenty-eight percent of programs had a hospitalist program. Of these programs, the majority perceived the presence of laborists to have a positive impact on resident education (n=30, 90%) and did not perceive a reduction in the number of patients or procedures available to the residents (n=26, 96.3%). In addition, resident feedback in these programs indicated a hospitalist program was beneficial to their education (n=19, 70%). CONCLUSION: The implementation of a hospitalist program in the setting of postgraduate training in Obstetrics and Gynecology does not negatively impact resident education and is perceived by program leadership and trainees as beneficial.

Intrapartum Care Working Patterns of Midwives: The Long Road to Models of Care in Germany.

Midwifery models of care help to enhance perinatal health outcomes, women's satisfaction, and continuity of care. Despite the ubiquitous presence of certified midwives at births in Germany, no research has investigated the diversity of midwives' practice patterns. Describing the variety of working patterns through which midwives provide intrapartum care may contribute to improving the organisation of midwifery services. This cross-sectional survey took place in the region of Hannover and Hildesheim, Germany. Midwives attending births and practicing in hospitals and/or out-of-hospital were able to participate. Midwives who did not attend births were excluded. We assessed midwives' scope of services, practice locations, employment patterns, continuity of care, midwife-led births, and midwives' level of agreement with core values of midwifery care. The response rate of the survey was 32.7 % (69/211). We found that midwifery care services can be described according to midwives' employment patterns. The majority of midwives were employed in a hospital to provide intrapartum care (74.2 %, n = 49), and most also independently offered one or more antenatal and/or postpartum service/s. Only 25.8 % (n = 17) of midwives offered their services independently (laborist model of care). Independent midwives attended births in all three possible settings: hospital, free-standing birth centres and home. Significantly more independent midwives than employed midwives offered antenatal care and lactation consulting. Compared to employed midwives, significantly more independent midwives provided antenatal, intrapartum, and postpartum care to the same women, were more likely to know women before labour, and to offer one-to-one care during labour. The most common practice pattern among surveyed midwives was 'employment in a hospital' for provision of intrapartum care with additional postpartum and few antenatal services provided on an independent basis. Midwives who worked solely independently reported more continuity and one-to-one intrapartum care with women. Most midwives did not work in patterns that offered continuity of care or consistently provide one-to-one care. Future research should assess whether women in Germany desire more services similar to caseload midwifery.

The Collaborative Laborist and Midwife Model at Sanford Health: An Accepted and Sustainable Model [31Q

INTRODUCTION: To examine the effects of a Collaborative Laborist and Certified Nurse Midwife (CNM) Model on the rates of induction, primary and repeat cesarean sections, vaginal birth after cesarean (VBAC), and nursing staff satisfaction with this model of care. METHODS: This was a prospective cohort study at the largest birthing center in South Dakota between 2008-2016. Rates of induction, primary and repeat cesarean section, VBAC, and nursing staff satisfaction were compared over three 2 year time periods: before and after Laborist Model initiated and with the addition of CNM to the model. Linear regression and two-way ANOVA were used to compare trends of primary cesarean, repeat cesarean, VBAC, and induction. A two-tailed t-test compared values of nursing satisfaction. RESULTS: The primary cesarean delivery and induction rate decreased from 15.9% to 13.5% (P < .005 95% CI 0.67–0.22) and 49.38% to 30.75% (P < .006 95% CI 7.24–1.23) respectively. VBAC success rates increased from 1.55% to 2.21% (P < .017 95% CI .07-.23) of all deliveries. There was a significant increase in respect between physician and staff (P < .01 8.9% difference), NICU communication (p < .001 16.2% difference), and provider involvement in triage (P < .001 27.9%) This difference was shown following addition of CNM's. CONCLUSION: The rates of primary cesarean section and induction are significantly decreasing at the same time as the rate of VBAC is increasing. These results represent an overall positive outcome of employing the Laborist and CNM Collaboration Model.

Evaluating the impact of the laborist model of obstetric care on maternal and neonatal outcomes

The laborist model of obstetric care represents a change in care delivery with the potential of improving maternal and neonatal outcomes. We evaluated the effectiveness of the laborist model of care compared to the traditional model of obstetric care using specific maternal and neonatal outcome measures. This is a population cohort study with laborist and nonlaborist hospitals matched 1:2 on delivery volume, geography, teaching status, and neonatal intensive care unit level using data from the National Perinatal Information Center/Quality Analytic Services database. A before-and-after study design with an untreated comparison group analyzed with the method of difference-in-differences was used to examine the impact of laborists on maternal and neonatal outcome measures within the 3 years after implementing the laborist system, after adjusting for secular trends, sociodemographic factors, and maternal medical conditions. The final outcome measures evaluated included cesarean delivery, chorioamnionitis, induction oflabor, preterm birth, prolonged length of stay, Apgar at 5minutesof<7, birth asphyxia, birth injury, birth trauma, and neonataldeath. We studied nearly 550,000 women from 24 hospitals (8 laborist and 16 nonlaborist hospitals) from 1998 through 2011. Implementation of laborists was associated with fewer labor inductions (adjusted odds ratio, 0.85; 95% confidence interval, 0.71-0.99) and decreased rate of preterm birth (adjusted odds ratio, 0.83; 95% confidence interval, 0.72-0.96) after controlling for confounders. Laborists did not impact the cesarean delivery rate, chorioamnionitis, or prolonged length of stay. Implementation of the laborist model was associated with a significant reduction in labor induction rate and preterm birth without adversely affecting other outcomes.

Variation in primary cesarean delivery rates by individual physician within a single-hospital laborist model

Laborist practice models are associated with lower rates of cesarean delivery than individual private practice models in several studies; however, this effect is not uniform. Further exploration of laborist models may help us better understand the observed decrease in rates of cesarean delivery in some hospitals that implement a laborist model. Our objective was to evaluate the degree of variation in rates of primary cesarean delivery by individual laborists within a single institution that uses a laborist model. In addition, we sought to evaluate whether differences in rates of cesarean delivery resulted in different maternal or short-term neonatal outcomes. At this teaching institution, one laborist (either a generalist or maternal-fetal medicine attending physician) is directly responsible for labor and delivery management during each shift. No patients are followed in a private practice model nor are physicians incentivized to perform deliveries. We retrospectively identified all laborists who delivered nulliparous, term women with cephalic singletons at this institution from 2007 to 2014. Overall and individual primary cesarean delivery rates were reported as percentages with exact Pearson 95% confidence intervals. Laborists were grouped by tertile as having low, medium, or high rates of cesarean delivery. Characteristics of the women delivered, indications for cesarean delivery, and short-term neonatal outcomes were compared between these groups. A binomial regression model of cesarean delivery was estimated, where the relative rates of each laborist compared with the lowest-unadjusted laborist rate were calculated; a second model was estimated to adjust for patient-level maternal characteristics. Twenty laborists delivered 2224 nulliparous, term women with cephalic singletons. The overall cesarean delivery rate was 24.1% (95% confidence interval 21.4-26.8). In an unadjusted binomial model, the overall effect of individual laborist was significant (P < .001), and a 2.9-fold (1.5-5.4, P = .001) variation between the cesarean delivery rates of the greatest (35.9%) and lowest (12.5%) physicians was observed. When adjusted for hypertensive disease, gestational age at delivery, race, and maternal age, the physician effect remained overall significant (P = .0265) with the difference between physicians expanding to 3.58 (1.72-7.47, P <. 001). Between groups of laborists with low, medium, and high rates of cesarean delivery, patient demographics and clinical characteristics of the population managed were clinically similar and not different statistically. The primary indication for cesarean delivery did not differ between groups. Similarly there were no differences in short-term neonatal outcomes, including Apgar scores, arterial cord blood pH, or the incidence of neonatal encephalopathy. The 3-fold variation in cesarean delivery rates between laborists at the same institution without observed differences in patient characteristics or short-term neonatal outcomes draws attention to the impact of individual physician decision-making on cesarean delivery rates even within a laborist care model. Further exploration of the role of individual physician decision-making on cesarean rates may help to better elucidate the effect of the laborist model.

28: Variation in primary cesarean delivery rates by individual physicians within a single hospital laborist model

28: Variation in primary cesarean delivery rates by individual physicians within a single hospital laborist model

Implementation of a laborist program and evaluation of the effect upon cesarean delivery

Laborist programs have expanded throughout the United States in the last decade. Meanwhile, there has been no published research examining their effect on patient outcomes. Cesarean delivery is a key performance metric with maternal health implications and significant financial impact. Our hypothesis is that the initiation of a full-time dedicated laborist staff decreases cesarean delivery. In a tertiary hospital staffed with private practice physicians, data were retrospectively reviewed for 3 time periods from 2006 through 2011. The first period (16 months) there were no laborists (traditional model), followed by 14 months of continuous in-hospital laborist coverage provided by community staff (community laborist), and finally a 24-month period with full-time laborists providing continuous in-hospital coverage. The primary hypothesis was that full-time laborists would decrease cesarean delivery rates. Data from 6206 term nulliparous patients were retrospectively reviewed. The cesarean delivery rate for no laborist care was 39.2%, for community physician laborist care was 38.7%, and for full-time laborists was 33.2%. With adjustment via logistic regression, full-time laborist presence was associated with a significant reduction in cesarean delivery when contrasted with no laborist (odds ratio, 0.73; 95% confidence interval, 0.64-0.83; P < .0001) or community laborist care (odds ratio, 0.77; 95% confidence interval, 0.67-0.87; P < .001). The community laborist model was not associated with an effect upon cesarean delivery. A dedicated full-time laborist staff model is associated with lower rates of cesarean delivery. These findings may be used as part of a strategy to reduce cesarean delivery, lower maternal morbidity and mortality, and decrease health care costs.

Patient satisfaction with the laborist model of care in a large urban hospital

BackgroundThe obstetric practice environment is evolving to include more laborists staffing obstetric units, with the hope of improving quality of care and provider satisfaction, yet there are scant data on the impact of a laborist care model on patient satisfaction or delivery outcomes. We sought to assess patient satisfaction after implementation of the laborist model of obstetric care in a large urban teaching hospital.MethodsPostpartum patients were asked to complete an anonymous survey assessing their satisfaction with care, particularly with regard to the laborist model. Survey questions included rating the overall experience of labor and delivery. All responses were based on a five-point Likert scale. Press-Ganey results were compared from before and after initiation of the model. Descriptive statistics were used to analyze the results.ResultsPost-laborist implementation obstetric and delivery experience surveys were collected from 4166 patients, representing a 54% response rate. Ninety percent of patients reported that they were highly satisfied with the overall experience in the labor and delivery unit. A subgroup was asked to rate their experience with the practitioner for their current delivery. Of the 687 respondents, 75% answered excellent, 18% answered good/very good, and 3.4% answered neutral. Eighty-five percent of this subgroup stated that they were informed during prenatal care that they may be delivered by someone other than the practitioner or group that they saw during the pregnancy. Thirty-seven percent (n = 1553) of the total respondents reported that they had had a previous delivery at this institution, 97% (n = 1506) of whom stated “yes” to having their next delivery at this institution. Press-Ganey results were similarly favorable in both time periods (91.3 [n = 811] versus 93.4 [n = 747], P = 0.08).ConclusionPatient satisfaction does not appear to be adversely affected by initiation of the laborist model. Additional research is needed to understand further the implications of this model for provider satisfaction, and maternal and neonatal outcomes.

79: Does the laborist model improve obstetric outcomes?

79: Does the laborist model improve obstetric outcomes?

The laborist model of obstetric care: we need more evidence

Literature suggesting improved patient outcomes and patient satisfaction with the hospitalist model of inpatient medical care coupled with the desire to improve provider satisfaction led to the introduction of the laborist in obstetrics. This represents a significant change in the way obstetrics has been experienced and practiced from both a patient and provider perspective. The laborist was designed as a plausible model of obstetric care delivery where hospitals employ physicians to provide continuous coverage of labor and delivery units without other competing clinical duties. Anecdotal use of the laborist model in the provision of obstetric care is growing rapidly, despite the lack of research regarding its impact on maternal outcomes, neonatal outcomes, patient and provider satisfaction, and graduate medical education. We provide an overview of both the positive and negative attributes of this model of obstetric care delivery, discuss the current state of research addressing these attributes, and propose a research strategy to improve understanding of the impact of this model of care delivery.

Laborist model of care: who is using it?

Objective. Utilization of the laborist model in the provision of obstetric (OB) care appears to be growing. In collaboration with the National Perinatal Information Center/Quality Analytic Services (NPIC/QAS), we assessed the utilization of this model of care delivery and hospital-level characteristics associated with its use. Methods. A cross-sectional electronic survey of all NPIC/QAS member hospitals (26 states) was performed in February 2010. Questions assessed staffing and clinical capabilities and utilization of laborists. The association between laborists and hospital-level characteristics were calculated using chi-square analyses or Fisher’s exact tests for categorical variables and t tests for continuous variables. Results. Ninety-three percent of hospitals (69/74) responded and only those that provide OB services were analyzed (N = 68). Nearly 40% (25/68) of hospitals responded that they are utilizing laborists. Delivery volume is significantly associated with implementation of laborists whereas OB level, presence of residents and fellows, and geography were not. Conclusion. Laborists are being introduced into the OB care delivery model rapidly. This is the first assessment of their use in a large sample of US hospitals. Given the millions of women who deliver each year, it is imperative to evaluate the impact of this model on patient safety and outcomes.