Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity

Abstract

The objective of this study was to evaluate the impact of quality improvement (QI) and patient safety initiatives and data disaggregation on racial disparities in severe maternal morbidity from hemorrhage (SMM-H).Our hospital began monitoring and reporting on SMM-overall and SMM-H rates in 2018 using administrative data. In March 2019, we began stratifying data by race and ethnicity and noted a disparity in rates, with non-Hispanic Black women having the highest SMM rates. The data was presented as run charts at monthly department meetings. During this time, our hospital implemented several QI and patient safety initiatives around obstetric hemorrhage and used the stratified data to inform guideline development to reduce racial disparity. The initiatives included implementation of a hemorrhage patient safety bundle and in-depth case reviews of adverse patient outcomes with a health equity focus. We then retrospectively analyzed our data. Our outcome of interest was SMM-H prior to data stratification (pre-intervention: June 2018-February 2019) as compared to after data stratification (post-intervention: March 2019-June 2020).During our study time period, there were 13,659 deliveries: 37% Hispanic, 35% White, 20% Black, 7% Asian and 1% Other. Pre-intervention, there was a statistically significant difference between Black and White women for SMM-H rates (p<0.001). This disparity was no longer significant post-intervention (p=0.138). The rate of SMM-H in Black women decreased from 45.5% to 31.6% (p=0.011).Our findings suggest that QI and patient safety efforts that incorporate race and ethnicity data stratification to identify disparities and use the information to target interventions have the potential to reduce disparities in SMM.

Implementation and outcomes of a system-wide women’s health ‘team goal’ to reduce maternal morbidity for black women: a prospective quality improvement study

“… 11 Davidson et al demonstrated that implementation of a haemorrhage bundle while holding an equity lens to case reviews was associated with reduced rates of haemorrhage-related morbidity in Texas. 24 While our work focuses on one health system rather than a state, we were able to demonstrate how targeting site-specific differences in case reviews allowed for implementation of needed EBPs, which was associated with clinical improvement. Future work should evaluate if such targeted quality efforts could be made at a state collaborative level.…”

“…For example, Main et al performed a cross-sectional study of 99 hospitals participating in a haemorrhage quality improvement collaborative in California, which demonstrated significant reduction in disparities in severe maternal morbidity 11. Davidson et al demonstrated that implementation of a haemorrhage bundle while holding an equity lens to case reviews was associated with reduced rates of haemorrhage-related morbidity in Texas 24. While our work focuses on one health system rather than a state, we were able to demonstrate how targeting site-specific differences in case reviews allowed for implementation of needed EBPs, which was associated with clinical improvement.…”

Findings From Severe Maternal Morbidity Surveillance and Review in Maryland

“…Quality improvement initiatives that address racial disparities in SMM and focus on interventions that target preventable outcomes can reduce disparities and the incidence of adverse outcomes overall. 29 …”

Advancing equity, diversity and inclusion atBMJ Quality and Safety

“…7 Nevertheless, there have been some important papers published. These include studies that reduced disparities in breast cancer screening for Arab women in Israel, 8 decreased disparities in maternal morbidity between black and white women in the USA, 9 demonstrated that homeless women were less likely to be hospitalised or visit an emergency department after giving birth than low-income housed women, 10 explored the effect of income on medication non-adherence 11 and found that voluntary reporting systems underdetect safety events in vulnerable patients. 12 An important editorial, 3 commenting on this last paper, also presents a framework for advancing health equity, pitfalls to avoid and recommendations for the patient safety field to advance health equity.…”