Variation in the rates of operative delivery in the United States
ABSTRACT This study was undertaken to examine the national and regional rates of operative delivery among almost one quarter million births in a single year in the nation's largest healthcare delivery system, using variation as an arbiter of the quality of decision making.
We compared the variation in rates of primary cesarean and operative vaginal delivery in facilities of the Hospital Corporation of America during the year 2004.
In 124 facilities representing almost 220,000 births during a 1-year period, the primary cesarean and operative vaginal delivery rates were 19% +/- 5% (range 9-37) and 7% +/- 4% (range 1-23). Within individual geographic regions, we consistently found variations of 200-300% in rates of primary cesarean delivery and variations approximating an order of magnitude for operative vaginal delivery.
Within broad upper and lower limits, rates of operative delivery in the United States are highly variable and suggest a pattern of almost random decision making. This reflects a lack of sufficient reliable, outcomes-based data to guide clinical decision making.
SourceAvailable from: William D. Marder[Show abstract] [Hide abstract]
ABSTRACT: Background The rate of cesarean delivery in the United States is variable across geographic areas. The aims of this study are two-fold: (1) to determine whether the geographic variation in cesarean delivery rate is consistent for private insurance and Medicaid (2) to identify the patient, population, and market factors associated with cesarean rate and determine if these factors vary by payer.Methods We used the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) to measure the cesarean rate at the Core-Based Statistical Area (CBSA) level. We linked the hospitalization data to data from other national sources to measure population and market characteristics. We calculated unadjusted and risk-adjusted CBSA cesarean rates by payer. For the second aim, we estimated a hierarchical logistical model with the hospitalization as the unit of analysis to determine the factors associated with cesarean delivery.ResultsThe average CBSA cesarean rate for women with private insurance was higher (18.9 percent) than for women with Medicaid (16.4 percent). The factors predicting cesarean rate were largely consistent across payers, with the following exceptions: women under age 18 had a greater likelihood of cesarean section if they had Medicaid but had a greater likelihood of vaginal birth if they had private insurance; Asian and Native American women with private insurance had a greater likelihood of cesarean section but Asian and Native American women with Medicaid had a greater likelihood of vaginal birth. The percent African American in the population predicted increased cesarean rates for private insurance only; the number of acute care beds per capita predicted increased cesarean rate for women with Medicaid but not women with private insurance. Further we found the number of obstetricians/gynecologists per capita predicted increased cesarean rate for women with private insurance only, and the number of midwives per capita predicted increased vaginal birth rate for women with private insurance only.Conclusions Factors associated with geographic variation in cesarean delivery, a frequent and high-resource inpatient procedure, vary somewhat by payer. Using this information to identify areas for intervention is key to improving quality of care and reducing healthcare costs.BMC Pregnancy and Childbirth 11/2014; 14(1):387. DOI:10.1186/s12884-014-0387-x · 2.15 Impact Factor
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ABSTRACT: Cesarean delivery is the most common inpatient surgery in the United States, where 1.3 million cesarean sections occur annually, and rates vary widely by hospital. Identifying sources of variation in cesarean use is crucial to improving the consistency and quality of obstetric care. We used hospital discharge records to examine the extent to which variability in the likelihood of cesarean section across US hospitals was attributable to individual women's clinical diagnoses.PLoS Medicine 10/2014; 11(10):e1001745. DOI:10.1371/journal.pmed.1001745 · 15.25 Impact Factor
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ABSTRACT: BackgroundWhereas good data are available on the resuscitation of infants, little is known regarding support of postnatal transition in low-risk term infants after c-section. The present study was performed to describe current delivery room (DR) management of term infants born by c-section in our institution by analyzing videos that were recorded within a quality assurance program.MethodsDR- management is routinely recorded within a quality assurance program. Cross-sectional study of videos of term infants born by c-section. Videos were analyzed with respect to time point, duration and number of all medical interventions. Study period was between January and December 2012.Results186 videos were analyzed. The majority of infants (73%) were without support of postnatal transition. In infants with support of transition, majority of infants received respiratory support, starting in median after 3.4 minutes (range 0.4-14.2) and lasting for 8.8 (1.5-28.5) minutes. Only 33% of infants with support had to be admitted to the NICU, the remaining infants were returned to the mother after a median of 13.5 (8-42) minutes. A great inter- and intra-individual variation with respect to the sequence of interventions was found.ConclusionsThe study provides data for an internal quality improvement program and supports the benefit of using routine video recording of DR-management. Furthermore, data can be used for benchmarking with current practice in other centers.BMC Pregnancy and Childbirth 07/2014; 14(1):225. DOI:10.1186/1471-2393-14-225 · 2.15 Impact Factor