Cesarean section rates vary widely among hospitals, changes are suggested

The rate of cesarean (c-section) deliveries varies significantly among hospitals across the country, according to a recent study, ranging from 7% of all births at the hospital with the lowest share of cesarean deliveries to 70% at the hospital with the highest rate.

C-section delivery is the most common surgery in the United States, performed on 1.67 million American women annually. The research from the University of Minnesota’s School of Public Health in Minneapolis was published recently in the journal Health Affairs. To arrive at their results, School of Public Health researchers examined hospital discharge data from a representative sample of 593 hospitals with at least 100 births in 2009.

Cesarean delivery is an important, potentially lifesaving, medical procedure, and some variance in hospital rates would be expected based on differences in patient characteristics, explains lead author Katy B. Kozhimannil, PhD, assistant professor in the School of Public Health. To address this issue, researchers also examined cesarean rates among a subgroup of lower-risk patients: mothers whose pregnancies were not preterm, breech, or multiple gestation, and who had no history of cesarean delivery.

Among this group of women with lower-risk pregnancies, in which more limited variation might be expected, hospital cesarean rates varied fifteen-fold, from 2.4% to 36.5%. “We were surprised to find greater variation in hospital cesarean rates among lower-risk women. The variations we uncovered were striking in their magnitude and were not explained by hospital size, geographic location, or teaching status,” Kozhimannil says. “The scale of this variation signals potential quality issues that should be quite alarming to women, clinicians, hospitals, and policymakers.”

Childbirth is the most common and most costly reason for hospitalization in the United States. Cesarean births are more expensive than vaginal deliveries, and cesarean rates have increased from 20.7% in 1996 to 32.8% in 2011. Nearly half of all U.S. births are financed by state Medicaid programs. In 2009 alone, public insurance programs paid out more than $3 billion for cesarean deliveries.

“Cesarean deliveries save lives, and every woman who needs one should have one,” Kozhimannil says. “The scope of variation in the use of this procedure, especially among low-risk women, is concerning, as its use also carries known risks compared to vaginal delivery such as higher rates of infection and re-hospitalization, more painful recovery, breastfeeding challenges, and complications in future pregnancies.”

The authors offer four major policy recommendations to reduce these variations:

• First, women need to be offered the right care for their own pregnancies. Evidence from earlier studies shows women with healthy pregnancies benefit from care provided by midwives, support from trained doulas, and access to care in licensed birth centers. Women with low-risk pregnancies should have access to care options that might benefit them, with strong referral systems and specialized care for complications that might arise.

• More and better data on the quality of maternity care are needed to support the rapidly advancing clinical evidence base in obstetrics. Clinicians and hospitals cannot improve maternity care, and insurers cannot pay for such improvements, without clear and consistent measures of quality.

• Tying Medicaid payment policies to quality improvement programs may influence hospital policies and practices and provide incentives and reward hospitals and clinicians for providing consistent, evidence-based care.

• Finally, information about cesarean rates and maternity care should be more readily available to pregnant women, who have time, motivation, and interest to research their options. However, they lack access to unbiased, publicly reported information about cesarean delivery rates and other aspects of maternity care.

An abstract of the journal article is available at http://tinyurl.com/rates-vary. The full text requires a membership or one-time purchase of $12.95. (For more on unnecessary c-sections, see “Healthcare Risk Management,” April 2013, pp. 37-41.)

Minnesota adverse events hold steady despite safety efforts

Minnesota hospitals and ambulatory surgery centers reported the same number of adverse events last year as in the previous one, despite intense efforts to improve patient safety. And even more worrying, a recent report from the state says more patients were injured or dead as a result of those adverse incidents.

The Minnesota Department of Health’s ninth annual public accounting of adverse health events shows that the state’s surgical facilities reported 314 adverse events between October 2011 and October 2012, a figure unchanged from the previous 12 months. That included 14 patient deaths (up from five) and 89 serious injuries (up from 83).

Falls accounted for almost 90% of the patient injuries or deaths. The 79 reported falls, which resulted in six deaths, were not as high as the 95 falls in 2008 with 10 deaths. However, the 79 reported falls were an increase over 71 falls with three deaths in 2011.

The report notes that in 2003, Minnesota became the first state in the nation to pass a law requiring all hospitals, and later ambulatory surgical centers, to report whenever a serious adverse health event occurs and to conduct a thorough analysis of the reasons for the event. In 2012, the ninth year of reporting, the total number of events reported under the law was 314, essentially unchanged from the previous year.

“A closer look at the overall profile of reported events shows an increase in falls, wrong body part surgical/procedural events, and patient protection events (suicides/elopements), while showing a decrease in medication errors, retained foreign objects, and pressure ulcers,” the report says. “While the number of total reported events is similar to last year, and the number of cases of harm increased, this masks improvement in several key areas.”

The report cites these examples of improvement in 2012:

• The number of pressure ulcers declined by 8%. This is the first decline of this magnitude in the nine years of reporting. This year’s total of 130 is down from an all-time high of 141 last year.

• Retained foreign objects declined by 16%. This is the first decline in this category in five years.

• Medication errors dropped by 75% from the previous year and were at the lowest level in all nine years of reporting.

The full report is available to readers online at http://tinyurl.com/minnesotareport.