Association between type of health insurance and elective cesarean deliveries: New Jersey, 2004-2007.
ABSTRACT I examined the relationship between insurance coverage, which may influence physician incentives and maternal choices, and cesarean delivery before labor.
I analyzed hospital discharge data for mothers without previous cesarean deliveries in New Jersey between 2004 and 2007, with adjustment for maternal age, race, marital status, and maternal, fetal, and placental conditions.
Nearly 1 in 7 women (13.9%) had a cesarean delivery without laboring. Insurance status was strongly associated with cesarean birth. Women insured by Medicaid (adjusted relative risk [ARR] = 0.88; 95% confidence interval [CI] = 0.84, 0.91) or self-paying (ARR = 0.81; 95% CI = 0.78, 0.85) had a significantly lower likelihood, and women insured by BlueCross (ARR = 1.06; 95% CI = 1.03, 1.09) or standard commercial plans (ARR = 1.06; 95% CI = 1.02, 1.10) had a significantly higher likelihood of cesarean delivery than did women insured by commercial health maintenance organizations. These associations persisted in subsets restricted to lower-risk women and in qualitative sensitivity analyses for a hypothetical single, binary, unmeasured confounder.
Insurance status has a small, independent impact on whether a woman without a previous cesarean delivery proceeds to labor or has a cesarean delivery without labor.
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ABSTRACT: When clinically indicated, common obstetric interventions can greatly improve maternal and neonatal outcomes. However, variation in intervention rates suggests that obstetric practice may not be solely driven by case criteria. Differences in obstetric intervention rates by private and public status in Ireland were examined using nationally representative hospital discharge data. A retrospective cohort study was performed on childbirth hospitalisations occurring between 2005 and 2010. Multivariate logistic regression analysis with correction for the relative risk was conducted to determine the risk of obstetric intervention (caesarean delivery, operative vaginal delivery, induction of labour or episiotomy) by private or public status while adjusting for obstetric risk factors. 403,642 childbirth hospitalisations were reviewed; approximately one-third of maternities (30.2%) were booked privately. After controlling for relevant obstetric risk factors, women with private coverage were more likely to have an elective caesarean delivery (RR: 1.48; 95% CI: 1.45-1.51), an emergency caesarean delivery (RR: 1.13; 95% CI: 1.12-1.16) and an operative vaginal delivery (RR: 1.25; 95% CI: 1.22-1.27). Compared to women with public coverage who had a vaginal delivery, women with private coverage were 40% more likely to have an episiotomy (RR: 1.40; 95% CI: 1.38-1.43). Irrespective of obstetric risk factors, women who opted for private maternity care were significantly more likely to have an obstetric intervention. To better understand both clinical and non-clinical dynamics, future studies of examining health care coverage status and obstetric intervention would ideally apply mixed-method techniques.BMC Pregnancy and Childbirth 01/2014; 14(1):13. DOI:10.1186/1471-2393-14-13 · 2.15 Impact Factor
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ABSTRACT: Objectives: Childbirth is the leading reason for hospitalization in the United States, and maternityrelated expenditures are substantial for many health insurance programs, including Medicaid. We studied the relationship between primary payer and trends in hospital-based childbirth care. Study Designs: Retrospective analysis of hospital discharge data from the Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project, a 20% stratified sample of US hospitals. Methods: Data on 6,717,486 hospital-based births for the years 2002 through 2009 came from the NIS. We used generalized estimating equations to measure associations over time between primary payer (Medicaid, private insurance, or self) and cesarean delivery, vaginal birth after cesarean (VBAC), labor induction, and episiotomy. Results: Controlling for clinical, demographic, and hospital factors, births covered by Medicaid had lower odds of cesarean delivery (adjusted odds ratio [AOR], 0.91), labor induction (AOR, 0.73), and episiotomy (AOR, 0.62) and higher odds of VBAC (AOR, 1.20; P <.001 for all AORs) compared with privately insured births. Cesarean rates increased 6% annually among births paid by private insurance (AOR, 1.06; P <.001) and less rapidly (5% annually) among those covered by Medicaid. Conclusions: US hospital-based births covered by private insurance were associated with higher rates of obstetric intervention than births paid for by Medicaid. After controlling for clinical, demographic, and hospital factors, cesarean delivery rates increased more rapidly among births covered by private insurance, compared with Medicaid. Changes in insurance coverage associated with healthcare reform may impact costs and quality of care for women giving birth in US hospitals.The American journal of managed care 01/2013; 19(4):e125-e132. · 2.17 Impact Factor
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ABSTRACT: Pre-labor cesareans in women without a prior cesarean is an important quality measure, yet one that is seldom tracked. We estimated patient-level risks and calculated how sensitive hospital rankings on this proposed quality metric were to risk-adjustment. This retrospective cohort study linked Californian patient data from the Agency for Healthcare Research and Quality with hospital-level operational and financial data. Using the outcome of primary pre-labor cesarean, we estimated patient-level logistic regressions in progressively more detailed models. We assessed incremental fit and discrimination, and aggregated the predicted patient-level event probabilities to construct hospital-level rankings. Of 408,355 deliveries by women without prior cesareans at 254 hospitals, 11.0% were pre-labor cesareans. Including age, ethnicity, race, insurance, weekend and unscheduled admission, and 12 well-known patient risk factors yielded a model c-statistic of 0.83. Further maternal comorbidities, hospital and obstetric unit characteristics only marginally improved fit. Risk-adjusting hospital rankings led to a median absolute change in rank of 44 places compared to rankings based on observed rates. Of the 48 (49) hospitals identified as in the best (worst) quintile on observed rates, only 23 (18) were so identified by the risk-adjusted model. Models predict primary pre-labor cesareans with good discrimination. Systematic hospital-level variation in patient risk-factors requires risk-adjustment to avoid considerably different classification of hospitals by outcome performance. An opportunity exists to define this metric and report such risk-adjusted outcomes to stakeholders.American journal of obstetrics and gynecology 12/2013; 210(5). DOI:10.1016/j.ajog.2013.12.007 · 3.97 Impact Factor