Risk-adjusted operative delivery rates and maternal-neonatal outcomes as measures of quality assessment in obstetric care: a multicenter prospective study

BMC Pregnancy and Childbirth

Salvatore Alberico¹  Laura Travan⁴  Caterina Businelli¹  Sara Parolin¹  Francesco De Seta²  Marcella Montico³  Luca Ronfani³  Monica Piccoli¹  Lorenzo Monasta³  Gianpaolo Maso¹ 

[1] Department of Obstetrics and Gynecology, Institute for Maternal and Child Health – IRCCS Burlo Garofolo, Via dell’Istria 65/1, Trieste 34137, Italy;Department of Obstetrics and Gynecology, Institute for Maternal and Child Health – IRCCS Burlo Garofolo and Department of Medical Sciences, University of Trieste, Trieste, Italy;Epidemiology and Biostatistics Unit, Institute for Maternal and Child Health – IRCCS Burlo Garofolo, Trieste, Italy;Department of Neonatology and Neonatal Intensive Care, Institute for Maternal and Child Health – IRCCS Burlo Garofolo, Trieste, Italy

关键词: Neonatal outcome;    Maternal outcome;    Quality of care;    Risk adjustment;    Operative delivery;   

Others  :  1125394
DOI  :  10.1186/s12884-015-0450-2

 received in 2014-01-20, accepted in 2015-01-20,  发布年份 2015

【 摘 要 】

Background

Although the evaluation of caesarean delivery rates has been suggested as one of the most important indicators of quality in obstetrics, it has been criticized because of its controversial ability to capture maternal and neonatal outcomes. In an “ideal” process of labor and delivery auditing, both caesarean (CD) and assisted vaginal delivery (AVD) rates should be considered because both of them may be associated with an increased risk of complications.

The aim of our study was to evaluate maternal and neonatal outcomes according to the outlier status for case-mix adjusted CD and AVD rates in the same obstetric population.

Methods

Standardized data on 15,189 deliveries from 11 centers were prospectively collected. Multiple logistic regression was used to estimate the risk-adjusted probability of a woman in each center having an AVD or a CD. Centers were classified as “above”, “below”, or “within” the expected rates by considering the observed-to-expected rates and the 95% confidence interval around the ratio. Adjusted maternal and neonatal outcomes were compared among the three groupings.

Results

Centers classified as “above” or “below” the expected CD rates had, in both cases, higher adjusted incidence of composite maternal (2.97%, 4.69%, 3.90% for “within”, “above” and “below”, respectively; p = 0.000) and neonatal complications (3.85%, 9.66%, 6.29% for “within”, “above” and “below”, respectively; p = 0.000) than centers “within” CD expected rates. Centers with AVD rates above and below the expected showed poorer and better composite maternal (3.96%, 4.61%, 2.97% for “within”, “above” and “below”, respectively; p = 0.000) and neonatal (6.52%, 9.77%, 3.52% for “within”, “above” and “below”, respectively; p = 0.000) outcomes respectively than centers with “within” AVD rates.

Conclusions

Both risk-adjusted CD and AVD delivery rates should be considered to assess the level of obstetric care. In this context, both higher and lower-than-expected rates of CD and “above” AVD rates are significantly associated with increased risk of complications, whereas the “below” status for AVD showed a “protective” effect on maternal and neonatal outcomes.

【 授权许可】

   
2015 Maso et al.; licensee BioMed Central.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

【 参考文献 】

• [1]American College of Obstetricians and Gynecologists, Task Force on Cesarean Delivery Rates: Evaluation of cesarean delivery. American College of Obstetricians and Gynecologists, Washington DC; 2000.
• [2]Bailit J, Garrett J: Comparison of risk-adjustment methodologies. Obstet Gynecol 2003, 102:45-51.
• [3]Bailit JL, Joanne M, Garrett JM: Stability of risk-adjusted primary cesarean delivery rates over time. Am J Obstet Gynecol 2004, 190:395-400.
• [4]Robson M, Hartigan L, Murphy M: Methods of achieving and maintaining an appropriate caesarean section rate. Best Pract Res Clin Obstet Gynaecol 2013, 27:297-308.
• [5]Gould JB, Danielsen B, Korst LM, Phibbs R, Chance K, Main E, et al.: Cesarean delivery rates and neonatal morbidity in a low-risk population. Obstet Gynecol 2004, 104:11-9.
• [6]Bailit J, Garrett J, Miller W, McMahon M, Cefalo R: Hospital primary cesarean delivery rates and the risk of poor neonatal outcomes. Am J Obstet Gynecol 2002, 187:721-7.
• [7]Bailit JL, Love TE, Dawson NV: Quality of obstetric care and risk-adjusted primary caesarean delivery rates. Am J Obstet Gynecol 2006, 194:402-7.
• [8]Srinivas SK, Fager C, Lorch SA: Evaluating risk-adjusted caesarean delivery rate as a measure of obstetric quality. Obstet Gynecol 2010, 115:1007-13.
• [9]Janakiraman V, Ecker J: Quality in obstetric care: measuring what matters. Obstet Gynecol 2010, 116:728-32.
• [10]McMahon MJ, Luther ER, Bowes WA, Olshan AF: Comparison of a trial of labor with an elective second caesarean section. N Engl J Med 1996, 335:689-95.
• [11]Royal College of Obstetricians and Gynaecologists: Prevention and Management of Postpartum Haemorrhage In Green-top Guideline No. 52. RCOG, London; 2009.
• [12]Fong KW, Ohlsson A, Hannah ME, Grisaru S, Kingdom J, Cohen H, et al.: Prediction of perinatal outcome in fetuses suspected to have intrauterine growth restriction: Doppler US study of fetal cerebral, renal, and umbilical arteries. Radiology 1999, 213:681-9.
• [13]Sarnat HB, Sarnat MS: Neonatal encephalopathy following fetal distress: a clinical and electroencephalographic study. Arch Neurol 1976, 33:696-705.
• [14]Hjalmarsson O: Epidemiology and classification of acute, neonatal respiratory disorders: a prospective study. Acta Paediatr Scand 1981, 70:773-83.
• [15]Zhang J, Yu KF: What’s the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA 1998, 280:1690-1.
• [16]World Health Organization: Obesity: Preventing and Managing the Global Epidemic. Report of the WHO Consultation. WHO Technical Report Series. World Health Organization, Geneva; 2000.
• [17]Royal College of Obstetricians and Gynaecologists, Royal College of Anaesthetists. Classification of urgency of caesarean section - a continuum of risk. RCOG press 2010. [http://www.rcog.org.uk/classification-of-urgency-of-caesarean-section-good-practice-11]
• [18]Snowden JM, Cheng YW, Kontgis C, Caughey AB: The association between hospital obstetric volume and perinatal outcomes in California. Am J Obstet Gynecol 2012, 207:1-7. 478
• [19]Kyser KL, Lu X, Santillan DA, Santillan MK, Hunter SK, Cahill AG, et al.: The association between hospital obstetrical volume and maternal postpartum complications. Am J Obstet Gynecol 2012, 207:1-17. 42
• [20]Janakiraman V, Lazar J, Joynt KE, Jha AK: Hospital volume, provider volume, and complications after childbirth in U.S. hospitals. Obstet Gynecol 2011, 118:521-7.
• [21]Bailit JL: Measuring the quality of inpatient obstetrical care. Obstet Gynecol Surv 2007, 62:207-13.
• [22]Bailit JL, Srinivas SK: Where should I have my baby? Am J Obstet Gynecol 2012, 207:1-2.
• [23]Bailit JL: Measurement is just the beginning. Am J Obstet Gynecol 2013, 208:427-8.
• [24]Spong CY, Berghella V, Wenstrom KD, Mercer BM, Saade GR: Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver national institute of child health and human development, society for maternal-fetal medicine, and American college of obstetricians and gynecologists workshop. Obstet Gynecol 2012, 120:1181-93.
• [25]Lumbiganon P, Laopaiboon M, Gülmezoglu AM, Souza JP, Taneepanichskul S, Ruyan P, et al.: Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007–08. Lancet 2010, 375(9713):490-9.
• [26]Chescheir N, Meints L: Prospective study of coding practices for caesarean deliveries. Obstet Gynecol 2009, 114:217-23.
• [27]Goff SL, Pekow PS, Markenson G, Knee A, Chasan-Taber L, Lindenauer PK: Validity of using ICD-9-CM codes to identify selected categories of obstetric complications, procedures and co-morbidities. Paediatr Perinat Epidemiol 2012, 26:421-9.
• [28]National Collaborating Centre for Women’s and Children’s Health (UK). Caesarean section - National Institute for Health and Clinical Excellence Guidance. RCOG Press 2011. [http://www.nice.org.uk/guidance/CG132]
• [29]Walsh CA, Robson M, McAuliffe FM: Mode of delivery at term and adverse neonatal outcomes. Obstet Gynecol 2013, 121:122-8.
• [30]Grobman WA, Bailit JL, Rice MM, Wapner RJ, Varner MW, Thorp JM Jr, et al.: Can differences in obstetric outcomes be explained by differences in the care provided? Am J Obstet Gynecol 2014, 211:1-16. 147
• [31]Bailit JL, Schulkin J, Dawson NV: Risk-adjusted cesarean rates: what risk factors for cesarean delivery are important to practicing obstetricians? J Reprod Med 2007, 52:194-8.
• [32]Bailit JL, Love TE: The role of race in cesarean delivery rate case mix adjustment. Am J Obstet Gynecol 2008, 198:1-5. 69
• [33]Agency for Healthcare Research and Quality. Patient safety indicators. 2010 [http://www.qualityindicators.ahrq.gov/psi_overview.htm]
• [34]Gregory KD, Korst LM, Lu MC, Fridman M: AHRQ patient safety indicators: time to include hemorrhage and infection during childbirth. Jt Comm J Qual Patient Saf 2013, 39:114-22.
• [35]Mann S, Pratt S, Gluck P, Nielsen P, Risser D, Greenberg P, et al.: Assessing quality obstetric care: development of standardized measures. Jt Comm J Qual Patient Saf 2006, 32:497-505.
• [36]Sibanda T, Fox R, Draycott TJ, Mahmood T, Richmond D, Simms RA: Intrapartum care quality indicators: a systematic approach for achieving consensus. Eur J Obstet Gynecol Reprod Biol 2013, 166:23-9.
• [37]Gee RE, Winkler R: Quality measurement. What It means for obstetricians and gynecologists. Obstet Gynecol 2013, 121:507-10.
• [38]Main EK, Morton CH, Melsop K, Hopkins D, Giuliani G, Gould JB: Creating a public agenda for maternity safety and quality in cesarean delivery. Obstet Gynecol 2012, 120:1194-8.