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Emerging Idea

Clinical and Operational Protocols that Could Reduce OB Care Costs

15 Minute Read


The idea

Over the last decade, 120 rural obstetric (OB) units closed because of unsustainable finances, and margin erosion and declining birth volumes plague units across geographies. Births are also increasingly complex and costly: the rate of opioid use disorder at delivery increased 333% from 1999 to 2014.

The promise

For women who had a Cesarean section (C-section) delivery, early recovery after surgery (ERAS) protocols combined with a regional anesthesia (bupivacaine liposome) for pain management have been shown to reduce post-surgical opioid consumption by 47-51% and reduce hospital length of stay (LOS) by 26% (1 day) compared to traditional multimodal pain management without bupivacaine liposome. In addition to improving patients’ experience, this may lower care costs.

Why now

Covid-19 exacerbated ongoing delivery volume declines: 300,000 fewer births are expected in the U.S. in 2021 because of women’s changed pregnancy plans due to the virus. The Covid-19 pandemic also challenged OB unit finances by increasing the uninsured and Medicaid-insured populations, and subjecting units to provider rate freezes or cuts. Remaining births are increasingly complex and costly. These forces are likely to compound financial stresses on OB units, compelling them to look for savings anywhere they can to keep their doors open.

Reality check

Many OB units have already stripped extra costs from their budgets. The pandemic is thus likely to exacerbate trends in OB unit closures, particularly in rural areas, and to put additional pressure on any all opportunities to reduce costs and improve patient access and quality of care. While Advisory Board leaves clinical approvals to medical experts, we think it’s important to acknowledge any of these opportunities that have potential to advance the Triple Aim and service line strategy.

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What is it?

Enhanced Recovery after C-Section

ERAS is a set of protocols designed to help surgical patients recover more quickly. For C-section patients, the ERAS pathway includes:

  • Education and counseling before admission
  • Preoperative fasting up to six hours before surgery
  • Administration of IV antibiotics 60 minutes before skin incision
  • Delayed cord clamping for at least 30 seconds
  • Early ambulation after surgery
  • Other processes to manage maternal comorbidities, prep the patient, administer anesthesia, prevent hypothermia, and optimize operative techniques

ERAS alone can reduce length of stay by a few hours, increase breastfeeding rates, and improve patient experience, but in studies, it hasn’t been shown to reduce post-operative narcotic use.


Why is it useful?

C-sections are the most common major surgery performed in the US: nearly a third of U.S. deliveries are C-sections. Despite their prevalence, C-sections have not experienced the same attention or advancements that other surgeries, such as joint replacements and bariatrics, have received in recent years.

For low-risk C-sections, the average LOS is three days. In all labor and delivery units, and particularly those facing bed capacity constraints, reducing LOS allows for faster bed turnover and for more patients to be seen in a timely manner. This can reduce cost per patient and potentially increase revenue, if there is sufficient backlogged demand.

One way to reduce LOS in low-risk C-sections is to decrease patient time to ambulation and time to solid food. This is because patients who can move independently can be discharged sooner. The combination of ERAS protocols and liposomal bupivacaine can reduce time to ambulation by 12 hours and time to solid food by almost 10 hours. This contributes to a lower LOS for patients using this combination of treatment by a full day compared to other low-risk C-section patients, and it also improves the patient’s experience.

The combination of ERAS protocols and a TAP block with liposomal bupivacaine offer another key benefit to patients and providers: 31% of patients using this combination therapy avoided using opioids to manage pain. Seventy-eight percent of women experience pain after a C-section, and opioids are the traditional pain management option prescribed. Given the opioid crisis and many expecting mothers’ desire to avoid using opioids, this non-opioid combination therapy is appealing to many patients. Many nurses also appreciate that this reduced patient use of opioids allows them to focus on top-of-license care and help new mothers adjust to their role instead of controlling patients’ pain around the clock.


Why now?

ERAS protocols are well-established for many other types of surgery, but they are only just becoming popular for C-sections. Similarly, liposomal bupivacaine has been used as a pain management therapy in other types of surgeries with varying results for many years. The Covid-19 pandemic, however, added new urgency to reducing LOS in labor and delivery units: no longer was the challenge primarily driven by cost reduction and capacity restraints, but also patient safety and experience. This, along with newly published real-world evidence supporting the efficacy of this combination treatment, spurred more rapid adoption of the combination treatment of ERAS protocols and TAP blocks with liposomal bupivacaine in several labor and delivery units across the country.


Early adopters


Saddleback Medical Center uses ERAS protocols with every patient post-surgery. As a result, they’ve seen reduced time to ambulation, as well as a reduction in nausea, pain, vomiting, and opioid use. However, recognizing that their market has a big opioid problem, OB anesthesiologist leaders wanted to further the impact of ERAS protocols and completely remove opioids from select patients’ treatment plans by pairing ERAS protocols with TAP blocks that include liposomal bupivacaine.

This was not an easy sell to Saddleback’s pharmacy team, who had experienced a bumpy and costly Exparel rollout several years prior. To convince pharmacy leaders, OB anesthesiologists pitched that they would start with just ten patients, and have one anesthesiologist administer the TAP blocks on all the patients to remove variation in administration. Furthermore, they included the drug on their formulary only for post-C-sections, and only for administration by OB anesthesiologists in combination with ERAS protocols and TAP blocks to eliminate the potential for abuse.

According to Dr. Stephen Garber, the results on those first ten patients were “transformational,” and he reports there’s been no looking back since their pilot. “Patients want to jump out of bed…our pharmacist is a total convert. Nurses love it too—patients are eating quicker, and they don’t need as much attention.” Additionally, patients’ babies can often stay with them all night even if their partner wants to leave, which improves patient experience.

Texas Health Resources Southwest and Fort Worth Obstetrics & Gynecology

Texas Health Resources followed a similar path to adopting ERAS and liposomal bupivacaine (Exparel) into their C-section protocols. After an initial pilot showed patients left the hospital a day earlier and had a 70% reduction in morphine equivalents compared to their non-pilot peers, the system is working to roll out the combination of ERAS with local infiltration of Exparel more widely.

Appointing nurse and physician champions was key in this process. In partnership with Pacira, the manufacturer of Exparel, Texas Health Resources hosted lunch and learns with post-partum nurses to familiarize them with Tylenol and Motrin as the new treatment plan instead of opioids. They found nurses quickly became the biggest advocates of this protocol change: they immediately saw an improvement in patient experience and noted that patients were breastfeeding and moving sooner, requiring less nursing support, and getting to bond with their babies more quickly.


Should you pursue this idea?

ERAS protocols have been widely proven to improve quality and efficiency across surgeries, but they are still being adopted in C-section care. The combined use of ERAS and TAP blocks with liposomal bupivacaine is still nascent. As such, all organizations stand to benefit from ERAS adoption in C-section recovery, but those who might consider early adoption of ERAS and liposomal bupivacaine in combination include those:

  • With bed capacity constraints for maternity care
  • In markets with a pronounced opioid crisis
  • With above average C-section rates
  • Needing to cut costs to continue providing maternity care
  • With below average patient satisfaction scores

Strategists at organizations meeting these criteria should talk with their OB and pharmacy leaders about pursuing these concepts.


What we’re keeping an eye out for

Many labor and delivery units have already been forced to cut all extraneous costs—and, at times, even some necessary ones—in order to keep their doors open. Opportunities to grow margins in OB services are thus harder to come by than in other services and service lines. We are continually looking for innovations that could either increase revenues (ex. luxury suites, fertility services) or decrease total cost of care without cutting critical clinicians or compromising on quality. ERAS protocols alone have the potential to inflect the cost equation as well as patient outcomes and experiences, and ERAS protocols coupled with liposomal bupivacaine may accomplish this to an even greater extent.

Things that change the calculus:

  • More real-world evidence on the efficacy of these treatment protocols
  • Further reimbursement cuts to labor and delivery service and/or continued declines in utilization that amplify the need to cut costs and/or grow revenues
  • Potential changes in patient behaviors demanding, or changes in policy mandating, a reduction in the use of opioids with low-risk C-sections

These outcomes could spur more rapid adoption of ERAS protocols, or of ERAS protocols coupled with TAP blocks containing a liposome bupivacaine; they could also promote more innovation around other clinical or operational changes that lead to decreased LOS for low-risk C-section patients.

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