Becker's Hospital Review

67 CARE DELIVERY The Most Common Surgery in the World is Often Unnecessary — and This Physician is Out to Fix That By Emily Rappleye T he most common operation in the U.S. is the Cesearean section, and the single biggest variable that influences a woman's chance of having a C-section is the hospital she chooses to deliver her baby. is physician wants healthcare leaders to know there is something fundamentally wrong with that. Neel Shah, MD, an assistant professor of obstetrics, gynecology and reproductive biology at Boston-based Harvard Medical School and associate faculty at Ariadne Labs for Health Systems Innovation, has made it his mission to find out how hospitals can improve rates of low-intervention childbirth. As a medical student, Dr. Shah launched Costs of Care, an NGO with a global reach that helps provide insights for clinicians to provide better care at lower costs. He was previously named one of Becker's Hospital Review's "40 of the Smartest People in Healthcare." We caught up with Dr. Shah to discuss his C-section mission and his work to drive down the costs of care. Editor's note: Responses have been edited lightly for length and clarity. Question: Your research at Ariadne labs focuses on overtreatment in childbirth, and in particular C-sections. What first sparked your interest in investigating C-sections? Dr. Neel Shah: In my residency I saw C-sections had become very normalized for clinicians. When I took on a faculty position at Harvard, I looked for opportunities to improve childbirth. I zeroed in on C-sections as biggest lever I could pull. C-sections are the most common major surgery performed on human beings anywhere in the world and the most common in the U.S. ey have become 500 percent more common over the last generation of moms. We really have no idea why rates are skyrocketing. Not only are they really high, but it's hard to believe 1 in 3 humans need major surgery to be born. ere is also incredible variation in C-section rates from hospital to hospital. It ranges from 7 to 70 percent of births, which indicates the greatest risk factor for a woman to have a C-section may be the hospital she goes to — not her own risks or preference — but which door she walks through. Additionally, about half of C-sections are not necessary in retrospect. As many as 20,000 surgical complications could be avoided that cost $5 billion and a lot of unnecessary pain and suffering. Q: What are the biggest obstacles to reducing C-section rates in hospitals? NS: Both the solution and the barrier is something at the hospital level. e fact that C-section rates are so different from place to place means there is something going on at the hospital level we don't understand. A range of 7 to 70 percent of births is so spread that on one hand, that's really messed up, but on the other hand, we already know some people have figured what the solutions might be. We have to look at the people who are doing well and spread those ideas to other places. rough another lens, looking at the ways hospitals are managed, labor and delivery floors are where 99 percent of babies are born in the U.S., and they are also the hardest units to manage in the hospital. e reason is, unlike other parts of the hospital, the unit operates under incredible uncertainty all the time. ey don't know how many patients are going to show up and once the patients show up, they don't now how long it will take. Labor can be short or long and you don't know who will be healthy or suddenly need acute surgery, and the unit may need resources to operate immediately. Which patient should go to which room becomes really complicated. It's like an air traffic control problem that shis from one hour to another. Managers have to learn how to be good on the fly and learn from their predecessors, but they don't know how their peers approach these challenges. How labor and delivery units are managed is different from place to place, and we have never characterized what those meaningful differences are. at's the work that will show us what makes a high-performing versus a low-performing hospital on C-section rates. Q: You are also the founder of Costs of Care. How has the organization evolved since it first launched? NS: We started in 2009 when I was a third-year med student caring for a lot of patients who didn't have deep pockets and struggled to afford care. Everyone around me was making decisions on their behalf that impacted how they had to pay, and I realized we could make different decisions that lead to the same health outcomes but are more accountable in terms of cost. We benefitted from the timing. In 2009, healthcare reform was top- of-mind. e name 'Costs of Care' wasn't particularly creative, but people were Googling that thousands of times a day in 2009. Because of the name, we got a lot of Google hits and pretty soon we were the No. 1 hit on Google. To this day you get our website first and HHS' second. When we started, we were largely an advocacy organization focused on leadership development, building the will for change in the profession and training physicians. We wrote a whole textbook on how to think about costs while caring for patients. We created education modules to shi professional will and teach skills physicians needed to care for patients. Over the last six years, the world has been shiing with us in positive ways. We still care about learning and advocacy, but it's less of the main focus now. e policymakers have also taken this up with incentives to think about value. We are starting to shi from advocacy to an implementation organization that designs, tests and spreads solutions. Q: What have you found to be the most effective strategies in teaching physicians to consider costs? NS: You have to be really clear about the piece they own. Usually people talk about healthcare costs in abstract terms, like they account

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