Ocho Pasos: A Quality Improvement Pilot to Improve Outpatient Clinic Breastfeeding Support

Purpose of Study: Only a third of US mothers achieve three months of exclusive breastfeeding (BF) despite the American Academy of Pediatrics (AAP) recommendation to exclusively BF for six months. National experts have recently published evidence-based guidelines for outpatient clinics to support longer durations of BF. Our pilot study sought to evaluate the feasibility of an intervention to improve support for BF in outpatient primary care clinics. Methods Used: We compared evidence-based BF-friendly guidelines from the AAP, Academy of Breastfeeding Medicine, California’s 9 Steps, and Washington’s 10 Steps to create Ocho Pasos (Eight Steps),guidelines tailored to the New Mexico population. In 2018, we recruited an outpatient primary care clinic in rural New Mexico to participate in a 6-month pilot program using the Ocho Pasos as a framework to evaluate the clinic. After establishing a baseline for clinic practices, we focused on improving medical record documentation of BF supportive care through two Plan-Do-Study-Act (PDSA) cycles. Approximately 40 medical records were reviewed at baseline and at each subsequent medical record review (MRR). Summary of Results: Providers and staff set a goal to improve documentation of mothers’ intended BF duration. This documentation improved from 0% at baseline to 63.0% and 91.3% at the second and third MRR, respectively. A majority (16/17, 94.1%) of mothers surveyed after their infants’ well child checks reported discussing their intended duration of BF with their provider. Overall, providers and staff reported the quality improvement initiative was feasible and acceptable in terms of processes and instruments; however, staff did request that fewer medical records be reviewed to reduce the time burden. Conclusions: Our preliminary findings suggest that quality improvement initiatives aimed at implementing evidence-based practices for BF support in an outpatient setting are feasible. We plan to refine this initiative for future efforts in New Mexico

Cost-effectiveness analysis of four interventions for adolescents with a substance use disorder

Alcohol, tobacco, and illicit drug use among adolescents in the United States continues to be a serious public health challenge. A variety of outpatient treatments for adolescent substance use disorders have been developed and evaluated. Although no specific treatment modality is effective in all settings, a number of promising adolescent interventions have emerged. As policy makers try to prioritize which programs to fund with limited public resources, the need for systematic economic evaluations of these programs is critical. The present study attempted a cost-effectiveness analysis of four interventions, including family-based, individual, and group cognitive behavioral approaches, for adolescents with a substance use disorder. The results indicated that treatment costs varied substantially across the four interventions. Moreover, family therapy showed significantly better substance use outcome compared to group treatment at the 4-month assessment, but group treatment was similar to the other interventions for substance use outcome at the 7-month assessment and for delinquency outcome at both the 4- and 7-month assessments. These findings over a relatively short follow-up period suggest that the least expensive intervention (group) was the most cost-effective. However, this study encountered numerous data and methodological challenges in trying to supplement a completed clinical trial with an economic evaluation. These challenges are explained and recommendations are proposed to guide future economic evaluations in this area

Improving Support Of Breastfeeding At A Baby-Friendly™ Designated Hospital In Albuquerque, New Mexico

Purpose: Breastfeeding has conclusively proven to be the healthiest feeding option for infants. Baby-Friendly™designated hospitals and birthing centers follow the Ten Steps to Successful Breastfeeding, which are considered to be the gold standard for supporting mothers who wish to breastfeed. However, even a Baby-Friendly™designated hospital may have room for improvement. The University of New Mexico Hospital (UNMH) is an urban hospital serving a predominantly Hispanic and Native American population, and the majority of pediatric patients are covered by Medicaid. Despite its Baby-Friendly™ designation, UNMH had low rates of physician documentation of discussing the health impacts of breastfeeding in the postpartum setting and discussion of home visitation prior to discharge. We aimed to improve these measures using the Plan-Do-Study-Act (PDSA) model. Methods: We conducted this study from August 2018 to August 2019 in the UNMH Mother Baby Unit. Providers reviewed 61 to 86 charts for each of four medical record reviews (MRR). Based on the results of the first two MRRs, providers decided to focus on increasing home visitation referrals. After the third MRR, providers worked to increase discussion and documentation of the health impacts of breastfeeding. Changes made included creation of a discharge planning checklist, modifying admission and discharge templates, educating attending and resident physicians via emails, meetings, chart reviews, and bulletin boards in the team room, and adding home visitation referral forms to all patient charts. Results: Over the one year study period, rates of discussing home visitation status increased from 49.2% to 89.2%. The rates of discussing health impacts of breastfeeding increased from 31.1% to 86.5%. Conclusions: Implementation of these quality improvement measures resulted in substantial gains in several key breastfeeding metrics, despite having already earned the designation Baby-Friendly.™ All hospitals, including those that are designated Baby-Friendly™, should consider supporting breastfeeding through ongoing quality improvement initiatives