Sirio CA, Jones J, Webster G, English D, Roberts MS; Academy for Health Services Research and Health Policy. Meeting.
Abstr Acad Health Serv Res Health Policy Meet. 2000; 17: UNKNOWN.
Presented by: Carl A. Sirio, M.D., University of Pittsburgh Medical Center, 612A Scaife Hall, 200 Lothrop St., Pittsburgh, PA 15213. Tel: 412-647-8403; Fax 412-647-8060; email: sirioca@anes.upmc.edu.
Research objective: The appropriate utilization of C-sections and VBAC remain controversial despite target goals enunciated by both Federal (Department of Health and Human Services - Healthy People 2000) and professional health organizations (e.g., American College of Obstetrics and Gynecology). Utilizing an existing database from the Pennsylvania Health Care Cost Containment Council (PHC4) we developed a risk stratification tool designed to distinguish between patients at high and low risk for undergoing C-section. As part of a larger ongoing evaluation of outcomes and quality of health care within the Pittsburgh region we used this tool to determine variation in utilization of C-section and VBAC by physicians and within hospitals. These data were returned to individual hospitals for improvement initiatives.Study design and population: PHC4 collects data on all admissions to acute care hospitals within Pennsylvania. Using this retrospective cohort we developed a risk stratification tool utilizing ICD.9.CM codes accounting for the likelihood of undergoing C-section and applied it to 26,358 consecutive deliveries between July 1997 and June 1998 in 22 hospitals. Previous C-section was intentionally not classified as high risk. Outcomes were analyzed including all deliveries, C-section and VBAC rates were calculated from data representing 285 physicians in all 22 Pittsburgh metropolitan statistical area hospitals.Principal findings: 5017 C-sections (19%) were performed. Ten of 24 studied conditions placed a patient at high risk for C-section: malposition (breech [87%], face/brow [84%], high head at term [88%], transverse or oblique presentation [77%], unspecified malposition [81%]), obstruction from malpositioned fetus at labor onset [95%], placenta previa [59%], severe pre-eclampsia [51%], premature separation of placenta [50%] and prolapsed cord [67%]. The overall hospital C-section and VBAC rates were 19% (range 13-25) [n=5017] and 40.5% (range 18-60) [n=1166] respectively with significant risk stratified variation by physician. Institutional low and high risk rates ranged from 8.5-19.5% and 53-92% respectively with significant variation between physicians within hospitals. 29% (1437) of all repeat C-sections were performed on patients stratified at low risk.Conclusions: Our approach differs from alternative methods of assessing maternal risk as it does not define a high-risk pregnancy, but rather identifies patients at high risk for C-section. The significant variation among physicians for C-section and VBAC rates suggests that decision making by physicians providing obstetrical care is a major contributor to overall rates. Low VBAC rates combined with high numbers of low risk repeat C-sections provide the best opportunity to modify practice patterns.Implications for Policy, Delivery of Practice: This approach has merit when attempting to determine variation in rates of utilization for C-section across patients, physicians, hospitals and regions of the country. Further study will analyze the longitudinal response of physicians and hospitals to individual reporting of this data. Linking these data to outcomes for the newborn can help refine target utilization strategies for C-section and VBAC.Primary funding source: The Jewish Healthcare Foundation, Pittsburgh, PA.
Publication Types:
Keywords:
- Cesarean Section
- Evaluation Studies
- Female
- Gynecology
- Hospitals, Urban
- Humans
- Infant, Newborn
- Obstetric Labor Complications
- Obstetrics
- Obstetrics and Gynecology Department, Hospital
- Pennsylvania
- Physicians
- Placenta Previa
- Pregnancy
- surgery
- hsrmtgs
Other ID:
UI: 102272673
From Meeting Abstracts