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When the annual KIDS COUNT survey measuring more than 100 indicators of child wellbeing came out in July, no one in the state was particularly surprised to find Tennessee near the bottom of the list.



The state has routinely been among the nation’s worst performers, particularly in areas such as low birth weight and infant mortality. Coming in at 42nd actually represents a one-place increase from last year and a five-place increase from 2000/2001, when Tennessee made its worst showing at 47th.



“Progress is being made, but the going is painfully slow,” said Judy Aschner, MD, chief of the Division of Neonatology at Monroe Carell Jr. Children’s Hospital at Vanderbilt.



To help speed the process, Aschner has been the driving force behind the creation of the Tennessee Initiative for Perinatal Quality Care (TIPQC), a statewide effort focused on rapid cycle quality improvement, standardization of data collection, broad implementation of evidence-based best practices and educational outreach to providers and the community.



Although ambitious in scope, Aschner believes it is imperative stakeholders work together to find an effective way to improve the health of pregnant mothers and their newborns, or pay a much higher cost down the line.



After a presentation by Aschner at a meeting of the State Perinatal Advisory Committee and discussions with state health officials, the Bureau of TennCare agreed to sponsor a two-day “community forum” in Nashville last November to bring together a wide range of interested parties including neonatologists, obstetricians, insurers, hospital administrators and non-profit organizations. In addition, four national experts were invited to address the group and discuss methods to improve the state’s statistics.



Aschner said she couldn’t help but worry that after months of pushing for and planning this gathering that she’d wind up throwing a party which no one attended. That concern proved to be unfounded.



 “We ended up with more than 100 people,” she noted. “It was tremendously successful … really almost standing room only.”



The enthusiasm has continued after the meeting. “We’ve had tremendous buy in. Virtually everyone who has a NICU has expressed interest at some level in participating,” she said.



Aschner added that since the November meeting, she has been working with others to create a robust, coordinated quality improvement organization statewide. The ideal model includes not only providers but also payers and the community at large.



She noted that California is the only state with a long-established perinatal quality improvement collaborative. “North Carolina and Ohio are perhaps a year ahead of us,” she continued. “With TIPQC, Tennessee is at the vanguard of this movement.”



The state’s eagerness to improve health outcomes and neonatal statistics has not gone unnoticed. Aschner said TIPQC has already gained national recognition … even before it officially launched.



“We’ve been invited to sit at the table of every high level national planning meeting of statewide perinatal quality collaboratives that has been held this year,” she stated. “This is quickly becoming a national imperative as all neonatologists will soon have to demonstrate active participation in a sanctioned quality improvement project to maintain board certification in their subspecialty. I predict that within five years, most states will establish a similar statewide collaborative to improve the quality of perinatal care and the outcomes of pregnancy. I wanted Tennessee to be in the lead and not one of the states scrambling at the end to catch up with the rest of the country.” 



Now that the willingness to implement change is firmly established, Aschner said it is time for the fledgling organization to take its next steps. Vanderbilt neonatologist Peter Grubb, MD, has been tapped to serve in the capacity of medical director of TIPQC and will earmark a portion of his professional time toward implementing the organization’s quality programs and visiting the five regional perinatal centers, as well as other participating NICUs, according to Aschner.



Funding the initiative is another issue. Prior to the recent budget crunch, TIPQC was slated to receive $2 million over two years through the Governor’s Office of Children’s Care Coordination (GOCCC). After several heart-stopping months, when it appeared there would be no funding at all, the GOCCC was able to offer the group approximately one-quarter of the original amount.



Although Aschner would like to have more money available and will look to other grant sources, the initial outlay is enough to allow TIPQC to engage the part-time services of M.K. Key, PhD, a quality consultant who has recently worked with the nationally-acclaimed Vermont Oxford Neonatal Network, plus a full-time project manager.



Aschner said Tennessee has approximately 25 hospitals with NICU beds, but the size and types of services available vary tremendously. In addition to about 20 Level 2 and Level 3 NICUs, Tennessee has five regional perinatal centers that provide the most comprehensive medical and surgical care for neonates. These are located in Knoxville, Chattanooga, Johnson City, Memphis and in Nashville at Vanderbilt.



“Even those five perinatal centers differ in the specialized services that are available. There are some services and therapies that are only available in the state at Vanderbilt,” she said of her home base, which offers the full spectrum of pediatric specialties and surgical support.



Of the 1,200 admissions to the Vanderbilt Children’s Hospital NICU annually, almost half of the babies were born elsewhere and transported when it became apparent specialized care or surgery was required.



In addition to VCH, both Centennial Medical Center and Baptist Hospital have Level 3 NICUs onsite. Providers at all three Nashville hospitals are enthusiastic about the potential for improving outcomes through a collaborative effort. In Middle Tennessee, there are also smaller NICUs at Williamson Medical Center in Franklin, Gateway Medical Center in Clarksville, Maury Regional Hospital in Columbia and Middle Tennessee Medical Center in Murfreesboro.



“The idea is for every physician and every nursery, large or small, to apply evidence-based care for their patients … whether the patient is a pregnant mother or a tiny preterm infant in the NICU,” Aschner said of TIPQC’s goal.



Creating a statewide databank will allow TIPQC to ascertain whether changes are being implemented and if those changes have the desired effect of improving outcomes.



“We want more babies surviving with good neurological outcomes and better long term health,” she pointed out.



Aschner is quick to say that Tennessee’s low rankings in infant mortality are not a reflection of the quality of care delivered to premature babies in Tennessee but rather of the disproportionate number of preterm and low birth weight infants born in this state. Until those numbers are reduced, the state will continue to have higher rates of infant mortality.



She added that spending money on the front end is really an investment that will pay dividends for years to come as premature infants not only have expensive hospital stays at birth but are at much higher risk to develop chronic health conditions.



“Ultimately, it will save the state money and result in healthier Tennesseans. California has already shown this type of program pays off,” Aschner stated.



She added Tennessee is just a microcosm of the larger national problem.



“Among developed nations, the United States has the highest rate of preterm births … about 12 percent of all the births are less than 37 weeks,” she said. “In Tennessee that number is closer to 15 percent.”



The reasons for the high rates are multifactorial and include smoking during pregnancy, poor overall health and nutrition of the mother, poverty and education levels, prior preterm births, short intervals between pregnancies and late or no prenatal care, among other issues.



“Prematurity is a social disease,” Aschner stressed.



Despite a number of state programs such as TennCare that provide coverage once a woman becomes pregnant and for a few weeks postpartum, Aschner said there is a service gap that must be addressed by the state.



“Pre-pregnancy and inter-pregnancy care for women is crucial, and we fall down there. Women of childbearing years who are not currently pregnant do not have good access to care in this state,” she asserted. “To have a healthy baby, first you need a healthy mother.”



Knowing where gaps exist is the first step to finding effective solutions.



Aschner has been gratified to see the willingness of stakeholders to embrace change for the common goal of improving the health of mother and our tiniest newborns. Now it’s time to roll up the sleeves and get down to work.



“I hope that within five years of launching TIPQC we will see a meaningful impact on Tennessee’s rankings. This has got to be a long term, concerted effort that builds on small wins,” she concluded.







August 2008

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