Curbside Consult with Dr. Jayne 7/28/14

I had a chance to catch up with an old friend this weekend. He’s an OB/GYN, and as an employed physician, he’s had EHR in both the hospital and ambulatory settings for years.

Their efforts have resulted in massive amounts of data that can be mined to improve patient care. Surgeons can easily access their own outcomes data and compare morbidity and mortality data when incorporating new techniques (such as robotic surgery) into their practices.

There’s a dark side to that big data, however, and it’s starting to rear its head.

Although most laypeople are aware that babies are going to arrive when they’re going to arrive, administrators at his hospital may have missed that part of health class. They’re creating reports looking at delivery times and labor lengths under the guise of optimizing patient care. The seedy undercurrent of their research, however, is a desire to reduce staffing costs. Although they haven’t overtly said it, he suspects they’re on the verge of asking physicians to start acting in the hospital’s best interest rather than the patient’s.

I delivered babies at the beginning of my career. When you’re caring for a mother in labor, it can be hours of waiting punctuated by moments of terror. Although delivering a child is a natural human process, in the US, we’ve medicalized it for a variety of reasons. As a result, over the past quarter century, we’ve seen an increase in the percentage of babies delivered surgically (it sounds a little scarier when you say it that way, rather than “by C-section”) and there have been concerted efforts to try to reduce this trend.

It’s not just a problem in the United States. The World Health Organization has set a goal of 15 percent C-sections as realistic number for the procedure. In the US, it’s at about 28 percent, in Britain it’s 25 percent, and in Brazil, nearly 80 percent of women delivering in private hospitals have C-sections. Some blame cultural factors for the rise in the procedure. The ability to deliver “on schedule” is certainly a plus for some women as well as for their physicians. Others blame our medical payment system, because reimbursement is higher for a surgical delivery.

It’s not just C-sections, though. We’ve seen a rise in labor inductions, where drugs are used to start labor, often before the due date. Although there are definitely medical reasons when this might be indicated, it had become so prevalent (one in every five women) that ACOG, the OB/GYN professional organization, issued revised guidelines to try to ensure appropriate use of medical interventions.

Why would someone want to electively deliver a baby (through induction or C-section) anyway? Some blame the risk of litigation in the case of a poor outcome. Others blame physicians who want to deliver babies at their convenience. In my practice, I had a fair number of women request induction because they live far from their families and wanted to schedule the delivery to ensure relatives could travel to assist with the baby or help with young children at home.

In countries that spend a lot of money on post-partum home visits or in-home assistants, this may be less of an issue, because women may feel more supported at home after a delivery. Data is shared between community-based caregivers and coordinating physicians so that care can be delivered outside of the hospital. That kind of care has a cost, though, and isn’t an option for many US women, hence the request for inductions.

When thinking about cost controls, however, the idea of asking physicians to intervene in the labor and delivery process to try to better match facility staffing capacity is just too much to accept. Using data in this way sets us on a very slippery slope. What’s a little extra Pitocin? We can convince ourselves that it would be better for the baby to be delivered sooner than later, and if it happens so we can deliver before shift change, so much the better. Looks like the extra drugs may be creating some fetal distress, better prep the OR.

I haven’t delivered a baby in years, but I can’t imagine the stress of having my labor and delivery management decisions questioned by someone who has motives other than reducing maternal and neonatal morbidity and mortality.

Pregnant women are some of the most empowered patients I see in practice. They have more time to research various options and choose the best for themselves and their families, unlike patients facing cancer, injuries, and other unexpected issues. They share the knowledge of how to fight back against the medical establishment (as proven by anyone who has had a patient arrive with a 20-page Birth Plan) and are increasingly demanding of alternatives to the hospital birth experience. Many women in my area are using Doulas and Labor Coaches to have a dedicated patient advocate with them if they do deliver in hospitals. Some can cite the labor and delivery data and the risks of interventions better than a med student prepping for boards.

If the hospital is serious about this, I hope the physicians and nursing staff stand their ground. Better yet, I hope the patient community gets wind of it and reacts strongly.

As for my friend, he’s trying to work from the inside to convince hospital leaders that this is the wrong way to use big data. I hope he’s successful, but I also know he’s fearful for his job as an employed physician.

Have any other examples of misuse of Big Data? Email me.

Email Dr. Jayne.