DENVER – The newly published first data showing improved clinical outcomes after adoption of a full-time hospital laborist program was roundly celebrated at the annual meeting of the Society of Ob/Gyn Hospitalists.
Dr. Thomas J. Garite presented highlights of this freshly published retrospective observational study (Am. J. Obstet. Gynecol. 2013;209:251.e1-6) conducted at a large-delivery-volume tertiary hospital in Las Vegas. Dr. Garite and his coinvestigators, led by Dr. Brian K. Iriye, compared hospital-wide cesarean delivery rates for 6,206 nulliparous, term, singleton live births during 2006-2011.
Bruce Jancin/IMNG Medical Media
Dr. Thomas Garite
This was a period of change in how labor and delivery was organized at the hospital. During the first 16 months of the study period, the traditional private-practice model of patient care was in place, with ob.gyns. on call and no laborists in the house. This was followed by a 14-month interlude in which local private-practice ob.gyns. got together and made sure that a community physician was continuously in-hospital to provide laborist coverage.
"I call that the doc-in-a-box model," said Dr. Garite, professor emeritus and former chair of obstetrics and gynecology at the University of California, Irvine.
Finally came a 24-month period with full-time laborists – that is, ob.gyns. without a private practice – providing in-hospital coverage 24/7.
In a multivariate logistic regression analysis adjusted for potential confounders, the hospital’s cesarean section rate was roughly 25% lower after implementation of the full-time laborist program than in either of the other two periods.
"I haven’t seen other studies to date that demonstrate these kinds of outcome advantages for this kind of practice. I think we’re going to see a lot more. But until we do, a lot of people who don’t like change are going to be saying, ‘Wait, where’s the proof?’ Well, this is the beginning of the proof of something I believe in strongly," declared Dr. Garite, who is also editor-in-chief of the American Journal of Obstetrics and Gynecology and chief clinical officer at PeriGen, a provider of fetal surveillance systems.
Society of Ob/Gyn Hospitalists (SOGH) board member Dr. Jennifer Tessmer-Tuck hailed the new study as "the best and almost the only" clinical outcome data to date showing the advantages of the ob.gyn. hospitalist model of care. And it was a long time coming, she noted: a full 10½ years since Dr. Louis Weinstein of the Medical College of Ohio, Toledo, heralded the birth of a radically different form of ob.gyn. practice in his seminal essay "The laborist: A new focus of practice for the obstetrician" (Am. J. Obstet. Gynecol. 2003;188:310-2).
"We have a lot to do. SOGH would really like to have more of a research platform and be able to put ourselves out there. There’s really a gap in care, and we’re hoping to jump in and fill it," said Dr. Tessmer-Tuck, director of North Memorial Medical Center Laborist Associates in Robbinsdale, Minn.
But while the SOGH leadership is eager to see the field assume a bigger research presence, it’s a challenge. Most society members, when they talk about why they became hospitalists, say they had burned out in traditional private practice, with its demanding on-call schedule. They sought well-defined hours, perhaps more family time. Given those priorities, taking on a research project can sound daunting, even though the fruits of such a project might enhance the standing of the young subspecialty.
Dr. Garite reported that the cesarean section rate at the tertiary center was 33.2% during the 24 months when full-time laborists were on hand, compared with 39.2% under the traditional private practice model with no laborists, and 38.7% with laborist coverage by community staff. In a multivariate logistic regression analysis adjusted for maternal age, physician age, race, gestational age, induction of labor, birth weight, and maternal weight, the hospital’s cesarean section rate after the introduction of full-time laborists was 27% lower than in the earlier period of no laborists and 23% less than with community laborist care.
There were no differences between the three groups in rates of low Apgar scores, metabolic acidosis, or any other parameters of adverse neonatal or maternal outcome.
During the study years of 2006-2011, cesarean section rates at the other hospitals in the city were either stable or rising.
Asked why hospital-wide cesarean section rates dropped significantly once full-time obstetric hospitalists were in place, Dr. Garite replied, "It’s not, for example, the patient with abruption who comes in the door; she’s going to get a cesarean section whether a hospitalist is there or some other doctor is covering. Instead, it’s the patient who has what I call ‘failure to wait,’ a.k.a. failure to progress, or the 4 o’clock induction that hasn’t made any progress ... There are lots of examples of why cesarean section rates change with a hospitalist in place, especially if you look at the correlation between cesarean sections and time of day."