Systems Factors in Obstetric Care The Role of Daily Obstetric Volume

and the Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California.
Obstetrics and Gynecology (Impact Factor: 5.18). 10/2013; 122(4):851-857. DOI: 10.1097/AOG.0b013e3182a2dd93
Source: PubMed


To evaluate whether relatively high-volume days are associated with measures of obstetric care in California hospitals.
This is a population-based retrospective cohort study of linked data from birth certificates and antepartum and postpartum hospital discharge records for California births in 2006. Birth asphyxia and nulliparous, term, singleton, vertex cesarean delivery rates were analyzed as markers of quality of obstetric care. Rates were compared between hospital-specific relatively high-volume days (days when the number of births exceeded the 75th percentile of daily volume for that hospital) and low-volume or average-volume days. Analyses were stratified by weekend and weekday and overall hospital obstetric volume. Multivariable logistic regression was used to control for confounders.
On weekends, relatively high-volume days were significantly associated with an elevated risk of asphyxia (27 out of 10,000 compared with 17 out of 10,000; P=.013), whereas no association was present on weekdays (13 out of 10,000 on high-volume days and 15 out of 10,000 on low-volume or average-volume days; P=.182). The cesarean delivery rate among the nulliparous, term, singleton, vertex population was significantly lower on high-volume weekend days (22.0% compared with 23.6% on low-volume or average-volume weekend days; P=.009), whereas no association was present on weekdays (27.1% on high-volume days and 27.6% on low-volume or average-volume days; P=.092).
Delivery on relatively high-volume weekend days is a risk factor for birth asphyxia in California. High-volume weekend days also are associated with a lower rate of cesarean delivery in nulliparous women with singleton, vertex presentation pregnancies at term. LEVEL OF EVIDENCE:: II.

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    ABSTRACT: OBJECTIVE: To examine the relationship between an obstetrician's delivery volume and a patient's risk for cesarean delivery. METHODS: This retrospective cohort study examined patient-level and obstetrician-level data between 2000 and 2012 at a large academic hospital. All laboring patients who delivered viable, liveborn, singleton new-borns (N=58,328) were included. We measured the association of delivery volume and cesarean delivery using a multivariate logistic regression. We also assessed the association of volume by calculating adjusted cesarean delivery rates using the least squares means method. These analyses were performed on the subset of nulliparous patients with term, singleton, vertex-presenting fetuses. In addition, the association of obstetrician experience was compared against delivery volume. RESULTS: There was a twofold increase in the odds of cesarean delivery for patients whose obstetricians performed fewer than the median (60) number of deliveries per year (quartile 1: odds ratio 2.00, 95% confidence interval 1.68-2.38; quartile 2: odds ratio 2.73, 95% CI 2.40-3.11) as compared with quartile 4. The adjusted cesarean delivery rate decreased from 18.2% to 9.2% from the highest to lowest volume quartile (P<.001). Compared with the volume effects, an obstetrician's experience had a smaller effect on a patient's risk of cesarean delivery. CONCLUSION: Patients delivered by obstetricians with low delivery volume are at significantly increased risk for cesarean delivery after controlling for patient and obstetrician characteristics. In contrast, obstetrician experience had a less significant effect. These findings may prompt discussions regarding the role of volume in credentialing and practice models that direct patients to obstetricians with high delivery volume.
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