Careful analysis needed on C-section rates
Careful analysis needed on C-section rates
One hospital lowered morbidity along with rates
Cesarean rates have become a ubiquitous measure of quality. Health plans report that data and various report cards cite the rates by hospital or medical groups.
Yet without other information, cesarean rates may tell little about the actual obstetrics practice or outcomes. In quality improvement projects, physicians generally track related items, such as indications for the primary cesarean, Apgar scores less than 7 at five minutes after delivery, uterine rupture, and infant injury or trauma.
While complications and fetal injuries or death are rare, tracking negative outcomes allows clinicians to ensure that policies to reduce cesarean rates remain safe, say leading obstetricians.
"You can’t just look at the one measure without looking at how it’s affecting [other] outcomes," says Barry Smith, MD, chairman of obstetrics and gynecology at the Dartmouth-Hitchcock Medical Center in Lebanon, NH, and director of the New Hampshire Cesarean Birth Quality Improvement Project. "If you just show that a hospital had a low cesarean section rate, you have to show they had a low cesarean section rate without complications."
Furthermore, physicians who specialize in high-risk pregnancies would be expected to have higher rates, notes Jesse Green, PhD, senior director for clinical evaluation at New York University Medical Center in New York City. However, the Health Plan Employer Data and Information Set (HEDIS) of the National Committee for Quality Assurance in Washington, DC, doesn’t risk-adjust its data.
"You can’t look at somebody’s C-section rate and say from that that they’re doing too many or too few," says Green. "It depends so much on the type of patients that they see."
The Pacific Business Group on Health in San Francisco uses 15 risk-adjustment categories to filter out appropriate and necessary cesareans, so that patient medical history and risk factors are taken into account. Those risk-adjusters include:
- breech presentation;
- previous cesarean;
- antepartum infection;
- antepartum hemorrhage for women older than 35 and for women younger than 35;
- other malpresentations;
- multiple delivery;
- fetal distress for women older than 35 and younger than 35;
- hypertension;
- postdate pregnancy;
- prolonged ruptured membranes;
- diabetes;
- dystocia.
"Even after controlling for this, we’re seeing huge variations in C-section rates at hospitals," says Anne Castles, MA, MPH, senior project manager for the Pacific Business Group on Health. "If that variation is not explained by these risk-adjusters, that’s when you start wondering."
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.