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Campos MG, Franco-Sena AB, Rebelo F. Direct standardization method according to Robson classification for comparison of cesarean rates. BMC Pregnancy Childbirth 2023; 23:117. [PMID: 36797686 PMCID: PMC9933387 DOI: 10.1186/s12884-023-05416-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/30/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND Compare cesarean section rates between populations or within a population over time using the crude measure is biased mainly due to differences in the characteristics of the obstetric population. The Robson Ten Group Classification (RTGC) is being widely used all over the world based on a few basic obstetrics variables. OBJECTIVES Propose a method of direct standardization according to RTGC to make the overall rates of cesarean sections comparable between different populations or within the same population over time. METHODS We used data from the WHO Global Maternal and Perinatal Health Survey (WHOGS) conducted between 2004 and 2008 and data from the WHO Multinational Survey on Maternal and Neonatal Health (WHOMCS) conducted between 2010 and 2011, covering information from obstetric population of 21 countries. The standard population was based in the average size of Robson Groups in WHOMCS. The crude and standardized rates, their differences intra and inter populations, and its respective confidence intervals were calculated. RESULTS The impact and importance of the method were demonstrated. The five leading countries list on cesarean rates was completely modified and changes of cesarean rates over time in the same country varied in both directions by the standardization. CONCLUSION This method is useful to compare overall rates as an additional information when RTGC Report Table is been used or, for some type of studies as analytical ecologic studies with multiple groups, where leading with the report tables are laborious and hard to interpret. The use of Robson Ten Group Classification for direct standardization of cesarean rates is easy to apply and interpret.
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Affiliation(s)
- Marcelle Gonçalves Campos
- grid.418068.30000 0001 0723 0931Postgraduate Program in Children’s and Women’s Health, Oswaldo Cruz Foundation, National Institute of Women’s, Children’s and Adolescents’ Health Fernandes Figueira, Rio de Janeiro, RJ Brazil
| | - Ana Beatriz Franco-Sena
- grid.411173.10000 0001 2184 6919Faculty of Nutrition Emília de Jesus Ferreiro, Department of Social Nutrition, Fluminense Federal University, Niterói, RJ Brazil
| | - Fernanda Rebelo
- Clinical Research Unit, Oswaldo Cruz Foundation, National Institute of Women's, Children and Adolescents' Health Fernandes Figueira, Rio de Janeiro, RJ, Brazil.
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Colais P, Pinnarelli L, Mataloni F, Giordani B, Duranti G, D’Errigo P, Rosato S, Seccareccia F, Baglio G, Davoli M. The National Outcomes Evaluation Programme in Italy: The Impact of Publication of Health Indicators. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191811685. [PMID: 36141957 PMCID: PMC9517347 DOI: 10.3390/ijerph191811685] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/14/2022] [Accepted: 09/14/2022] [Indexed: 06/12/2023]
Abstract
In Italy the National Outcomes Evaluation Programme, (P.N.E.) is the most comprehensive comparative evaluation of healthcare outcomes at the national level. The aim of this report is to describe the P.N.E. and some of the most relevant results achieved. The P.N.E. analysed 184 indicators on quality of care in 2015-2020 period. The data sources are the Italian Health Information Systems. The indicators reported were: proportion of surgery within 2 days after hip fracture in the elderly (HF), 30-day mortality after hospital admission for acute myocardial infarction (AMI), proportion of reoperations within 90 days of breast-conserving surgery and proportion of primary caesarean deliveries. Risk adjustment methods were used to take into account patients' characteristics. From 2010 to 2020 the proportion of interventions within 2 days after HF increased from 31.3% to 64.6%, the AMI 30-day mortality decreased from 10.4% to 8.3%, the proportion of reinterventions within 90 days of breast-conserving surgery decreased from 12.0% to 5.9% and the proportion of primary caesarean deliveries decreased from 28.4% to 22.7%. Results by area of residence showed heterogeneity of healthcare quality. We observed a general improvement in different clinical areas not always associated with a reduction of heterogeneity among areas of residence.
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Affiliation(s)
- Paola Colais
- Department of Epidemiology, Lazio Regional Health Service, 00147 Rome, Italy
| | - Luigi Pinnarelli
- Department of Epidemiology, Lazio Regional Health Service, 00147 Rome, Italy
| | - Francesca Mataloni
- Department of Epidemiology, Lazio Regional Health Service, 00147 Rome, Italy
| | - Barbara Giordani
- Research and International Relations Unit, Italian National Agency for Regional Healthcare Services (AGENAS), 00187 Rome, Italy
| | - Giorgia Duranti
- Research and International Relations Unit, Italian National Agency for Regional Healthcare Services (AGENAS), 00187 Rome, Italy
| | - Paola D’Errigo
- National Centre for Global Health, Istituto Superiore di Sanità, 00161 Rome, Italy
| | - Stefano Rosato
- National Centre for Global Health, Istituto Superiore di Sanità, 00161 Rome, Italy
| | - Fulvia Seccareccia
- National Centre for Global Health, Istituto Superiore di Sanità, 00161 Rome, Italy
| | - Giovanni Baglio
- Research and International Relations Unit, Italian National Agency for Regional Healthcare Services (AGENAS), 00187 Rome, Italy
| | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, 00147 Rome, Italy
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Howbert JJ, Kauffman E, Sitcov K, Souter V. A Simple Approach to Adjust for Case-Mix When Comparing Institutional Cesarean Birth Rates. Am J Perinatol 2021; 38:370-376. [PMID: 31683324 DOI: 10.1055/s-0039-1697590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study aimed to develop a validated model to predict intrapartum cesarean in nulliparous women and to use it to adjust for case-mix when comparing institutional laboring cesarean birth (CB) rates. STUDY DESIGN This multicenter retrospective study used chart-abstracted data on nulliparous, singleton, term births over a 7-year period. Prelabor cesareans were excluded. Logistic regression was used to predict the probability of CB for individual pregnancies. Thirty-five potential predictive variables were evaluated including maternal demographics, prepregnancy health, pregnancy characteristics, and newborn weight and gender. Models were trained on 21,017 births during 2011 to 2015 (training cohort), and accuracy assessed by prediction on 15,045 births during 2016 to 2017 (test cohort). RESULTS Six variables delivered predictive success equivalent to the full set of 35 variables: maternal weight, height, and age, gestation at birth, medically-indicated induction, and birth weight. Internal validation within the training cohort gave a receiver operator curve with area under the curve (ROC-AUC) of 0.722. External validation using the test cohort gave ROC-AUC of 0.722 (0.713-0.731 confidence interval). When comparing observed and predicted CB rates at 16 institutions in the test cohort, five had significantly lower than predicted rates and three had significantly higher than predicted rates. CONCLUSION Six routine clinical variables used to adjust for case-mix can identify outliers when comparing institutional CB rates.
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Affiliation(s)
- James Jeffry Howbert
- Obstetrical Care Outcomes Assessment Program, Foundation for Health Care Quality, Seattle, Washington
| | - Ellen Kauffman
- Obstetrical Care Outcomes Assessment Program, Foundation for Health Care Quality, Seattle, Washington
| | - Kristin Sitcov
- Obstetrical Care Outcomes Assessment Program, Foundation for Health Care Quality, Seattle, Washington
| | - Vivienne Souter
- Obstetrical Care Outcomes Assessment Program, Foundation for Health Care Quality, Seattle, Washington
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Laurita Longo V, Odjidja EN, Beia TK, Neri M, Kielmann K, Gittardi I, Di Rosa AI, Boldrini M, Melis GB, Scambia G, Lanzone A. "An unnecessary cut?" multilevel health systems analysis of drivers of caesarean sections rates in Italy: a systematic review. BMC Pregnancy Childbirth 2020; 20:770. [PMID: 33302920 PMCID: PMC7731545 DOI: 10.1186/s12884-020-03462-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 11/26/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Improvements in medical technologies have seen over-medicalization of childbirth. Caesarean section (CS) is a lifesaving procedure proven effective in reducing maternal and perinatal mortality across the globe. However, as with any medical procedure, the CS intrinsically carries some risk to its beneficiaries. In recent years, CS rates have risen alarmingly in high-income countries. Many exceeding the World Health Organisation (WHO) recommendation of a 10 to 15% annual CS rate. While this situation poses an increased risk to women and their children, it also represents an excess human and financial burden on health systems. Therefore, from a health system perspective this study systematically summarizes existing evidence relevant to the factors driving the phenomenon of increasing CS rates using Italy as a case study. METHODS Employing the WHO Health System Framework (WHOHSF), this systematic review used the PRISMA guidelines to report findings. PubMed, SCOPUS, MEDLINE, Cochrane Library and Google Scholar databases were searched up until April 1, 2020. Findings were organised through the six dimensions of the WHOHSF framework: service delivery, health workforce, health system information; medical products vaccine and technologies, financing; and leadership and governance. RESULTS CS rates in Italy are affected by complex interactions among several stakeholder groups and contextual factors such as the hyper-medicalisation of delivery, differences in policy and practice across units and the national context, issues pertaining to the legal and social environment, and women's attitudes towards pregnancy and childbirth. CONCLUSION Mitigating the high rates of CS will require a synergistic multi-stakeholder intervention. Specifically, with processes able to attract the official endorsement of policy makers, encourage concensus between regional authorities and local governments and guide the systematic compliance of delivery units with its clinical guidelines.
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Affiliation(s)
- Valentina Laurita Longo
- Department of Surgical Sciences, Department of Obstetrics and Gynaecology, University of Cagliari, SS 554 - bivio Sestu, Monserrato, 09032, Cagliari, Italy.
- Queen Margaret University, Institute for Global Health and Development, Edinburgh, EH21 6UU, Scotland, UK.
- Catholic University of Sacred Heart, 00168, Rome, Italy.
| | - Emmanuel Nene Odjidja
- Queen Margaret University, Institute for Global Health and Development, Edinburgh, EH21 6UU, Scotland, UK
| | - Thierry Kamba Beia
- Queen Margaret University, Institute for Global Health and Development, Edinburgh, EH21 6UU, Scotland, UK
- Health Services Department, Copperbelt University, Kitwe, Zambia
| | - Manuela Neri
- Department of Surgical Sciences, Department of Obstetrics and Gynaecology, University of Cagliari, SS 554 - bivio Sestu, Monserrato, 09032, Cagliari, Italy
| | - Karina Kielmann
- Queen Margaret University, Institute for Global Health and Development, Edinburgh, EH21 6UU, Scotland, UK
| | - Irene Gittardi
- Legal Department "Luca Santa Maria e associati", Via G. Serbelloni 1, 20122, Milan, Italy
| | - Amanda Isabella Di Rosa
- Queen Margaret University, Institute for Global Health and Development, Edinburgh, EH21 6UU, Scotland, UK
| | - Michela Boldrini
- Department of Economics, University of Bologna, Piazza Antonio Scaravilli 2, 40126, Bologna, Italy
| | - Gian Benedetto Melis
- Department of Surgical Sciences, Department of Obstetrics and Gynaecology, University of Cagliari, SS 554 - bivio Sestu, Monserrato, 09032, Cagliari, Italy
| | - Giovanni Scambia
- Catholic University of Sacred Heart, 00168, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Antonio Lanzone
- Catholic University of Sacred Heart, 00168, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
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Murphy NC, Burke N, Breathnach FM, Burke G, McAuliffe FM, Morrison JJ, Turner MJ, Dornan S, Higgins J, Cotter A, Geary MP, Cody F, McParland P, Mulcahy C, Daly S, Dicker P, Tully EC, Malone FD. Inter-hospital comparison of Cesarean delivery rates should not be considered to reflect quality of care without consideration of patient heterogeneity: An observational study. Eur J Obstet Gynecol Reprod Biol 2020; 250:112-116. [PMID: 32438274 DOI: 10.1016/j.ejogrb.2020.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/29/2020] [Accepted: 05/02/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Contemporary approaches to monitoring quality of care in obstetrics often focus on comparing Cesarean Delivery rates. Varied rates can complicate interpretation of quality of care. We previously developed a risk prediction tool for nulliparous women who may require intrapartum Cesarean delivery which identified five key predictors. Our objective with this study was to ascertain if patient heterogeneity can account for much of the observed variation in Cesarean delivery rates, thereby enabling Cesarean delivery rates to be a better marker of quality of care. MATERIALS AND METHODS This is a secondary analysis of the Genesis study. This was a large prospective study of 2336 nulliparous singleton pregnancies recruited at seven hospitals. A heterogeneity score was calculated for each hospital. An adjusted Cesarean delivery rate was also calculated incorporating the heterogeneous risk score. RESULTS A cut-off at the 90th percentile was determined for each predictive factor. Above the 90th percentile was considered to represent 'high risk' (with the exception of maternal height which identified those below the 10th percentile). The patient heterogeneous risk score was defined as the number of risk factors > 90th percentile (<10th percentile for height). An unequal distribution of high-risk patients between centers was observed (p < 0.001). The correlation between the Cesarean delivery rate and the patient heterogeneous risk score was high (0.76, p < 0.05). When adjusted for patient heterogeneity, Cesarean delivery rates became closer aligned. CONCLUSION Inter-institutional diversity is common. We suggest that crude comparison of Cesarean delivery rates between different hospitals as a marker of care quality is inappropriate. Allowing for marked differences in patient characteristics is essential for correct interpretation of such comparisons.
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Affiliation(s)
| | - Naomi Burke
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Gerard Burke
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Fionnuala M McAuliffe
- UCD School of Medicine and Medical Science, National Maternity Hospital, Dublin, Ireland
| | | | - Michael J Turner
- UCD Centre for Human Reproduction Coombe Women and Infants University Hospital, Dublin, Ireland
| | | | - John Higgins
- University College Cork, Cork University Maternity Hospital, Cork, Ireland
| | - Amanda Cotter
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | | | | | - Peter McParland
- UCD School of Medicine and Medical Science, National Maternity Hospital, Dublin, Ireland
| | - Cecelia Mulcahy
- UCD School of Medicine and Medical Science, National Maternity Hospital, Dublin, Ireland
| | - Sean Daly
- Coombe Women and Infants University Hospital, Dublin, Ireland
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Di Giovanni P, Garzarella T, Di Martino G, Schioppa FS, Romano F, Staniscia T. Trend in primary caesarean delivery: a five-year experience in ABRUZZO, ITALY. BMC Health Serv Res 2018; 18:514. [PMID: 29970095 PMCID: PMC6029124 DOI: 10.1186/s12913-018-3332-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 06/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Primary caesarean section (PCS) rate is one of the main indicators of quality of care suggested by the Italian Government. Hospital rankings are usually based on it, therefore lower rates reflect more appropriate clinical practice. The aim of this study is to describe a five-year trend of PCS rate in Abruzzo region from 2009 to 2013 and to examine the medical indications for this mode of delivery. METHODS Forty-five thousand one hundred forty-nine deliveries occurring from 2009 to 2013 were collected from all hospital discharge records (HDR) and analyzed. Among them we found 12,542 PCS. Odds ratios (ORs) with 95% confidence interval (95% CI) were estimated using logistic regression methods to evaluate the relationship between maternal risk factors and PCS in hospital over 1000 delivery/yrs. RESULTS The five-year PCS rate was 28.9%, with a decreasing trend from 31.4% in 2009 to 26.1% in 2013. Vasto Civil Hospital shows the lowest PCS rate (17.9% in 2013) among hospitals with a maximum of 1000 deliveries per year, while Pescara Civil Hospital shows the lowest PCS rate (25.4% in 2013) among hospitals with over 1000 deliveries per year. Women with major risk factors for cesarean section delivered more frequently in maternity units over 1000 delivery/yrs. Logistic regression analyses showed as diabetes, hypertension, twin pregnancy, fetal distress and preterm delivery were significant risk factors to deliver in unit over 1000 delivery/yrs. The most frequent (overall 66.6%) discharge diagnosis recorded in Hospital discharge records (HDR) is "Caesarean Delivery Without Indication". 7.3% of PCS made in Abruzzo concerns women living in other Italian regions. 11.4% of PCS contains one of the indications to caesarean section (CS) that the Italian Guidelines consider appropriate. CONCLUSIONS During the analyzed period, Abruzzo showed a decreasing, but still too high, PCS rate, compared to the limits fixed by the Italian Ministry of Health. Considering the limitation of this study, based on administrative data that are poor in clinical information, it is not possible to define the appropriateness of all caesarean sections.
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Affiliation(s)
- Pamela Di Giovanni
- Department of Pharmacy, "G. d'Annunzio" University of Chieti-Pescara, via dei Vestini, 31 -, 66100, Chieti, Italy. .,Postgraduate School of Public Health and Preventive Medicine, "G. d'Annunzio" University of Chieti-Pescara, via dei Vestini, 31 -, 66100, Chieti, Italy.
| | - Tonia Garzarella
- Postgraduate School of Public Health and Preventive Medicine, "G. d'Annunzio" University of Chieti-Pescara, via dei Vestini, 31 -, 66100, Chieti, Italy
| | - Giuseppe Di Martino
- Postgraduate School of Public Health and Preventive Medicine, "G. d'Annunzio" University of Chieti-Pescara, via dei Vestini, 31 -, 66100, Chieti, Italy
| | - Francesco Saverio Schioppa
- Postgraduate School of Public Health and Preventive Medicine, "G. d'Annunzio" University of Chieti-Pescara, via dei Vestini, 31 -, 66100, Chieti, Italy.,Department of Medicine and Aging, "G. d'Annunzio" University of Chieti-Pescara, via dei Vestini, 31 -, 66100, Chieti, Italy
| | - Ferdinando Romano
- Department of Public Health and Infectious Diseases, "La Sapienza" University of Rome, Piazzale Aldo Moro, 5 -, 00100, Rome, Italy
| | - Tommaso Staniscia
- Postgraduate School of Public Health and Preventive Medicine, "G. d'Annunzio" University of Chieti-Pescara, via dei Vestini, 31 -, 66100, Chieti, Italy.,Department of Medicine and Aging, "G. d'Annunzio" University of Chieti-Pescara, via dei Vestini, 31 -, 66100, Chieti, Italy
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Campillo-Artero C, Serra-Burriel M, Calvo-Pérez A. Predictive modeling of emergency cesarean delivery. PLoS One 2018; 13:e0191248. [PMID: 29360875 PMCID: PMC5779661 DOI: 10.1371/journal.pone.0191248] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 01/02/2018] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To increase discriminatory accuracy (DA) for emergency cesarean sections (ECSs). STUDY DESIGN We prospectively collected data on and studied all 6,157 births occurring in 2014 at four public hospitals located in three different autonomous communities of Spain. To identify risk factors (RFs) for ECS, we used likelihood ratios and logistic regression, fitted a classification tree (CTREE), and analyzed a random forest model (RFM). We used the areas under the receiver-operating-characteristic (ROC) curves (AUCs) to assess their DA. RESULTS The magnitude of the LR+ for all putative individual RFs and ORs in the logistic regression models was low to moderate. Except for parity, all putative RFs were positively associated with ECS, including hospital fixed-effects and night-shift delivery. The DA of all logistic models ranged from 0.74 to 0.81. The most relevant RFs (pH, induction, and previous C-section) in the CTREEs showed the highest ORs in the logistic models. The DA of the RFM and its most relevant interaction terms was even higher (AUC = 0.94; 95% CI: 0.93-0.95). CONCLUSION Putative fetal, maternal, and contextual RFs alone fail to achieve reasonable DA for ECS. It is the combination of these RFs and the interactions between them at each hospital that make it possible to improve the DA for the type of delivery and tailor interventions through prediction to improve the appropriateness of ECS indications.
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Affiliation(s)
- Carlos Campillo-Artero
- Centre for Research in Health and Economics, Universitat Pompeu Fabra, Barcelona, Spain
- Balearic Health Service, Palma de Mallorca, Spain
| | - Miquel Serra-Burriel
- Centre for Research in Health and Economics, Universitat Pompeu Fabra, Barcelona, Spain
- Balearic Health Service, Palma de Mallorca, Spain
- Universitat de Barcelona, Barcelona, Spain
- Centre for Research in Health and Economics, Universitat Pompeu Fabra, Barcelona, Spain
| | - Andrés Calvo-Pérez
- Hospital de Manacor, Obstetrics and Gynecology, Carretera Manacor Alcudia, Manacor, Balearic Islands, Majorca, Spain
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8
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Balinskaite V, Bottle A, Sodhi V, Rivers A, Bennett PR, Brett SJ, Aylin P. The Risk of Adverse Pregnancy Outcomes Following Nonobstetric Surgery During Pregnancy. Ann Surg 2017; 266:260-266. [DOI: 10.1097/sla.0000000000001976] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Aylin P, Bennett P, Bottle A, Brett S, Sodhi V, Rivers A, Balinskaite V. Estimating the risk of adverse birth outcomes in pregnant women undergoing non-obstetric surgery using routinely collected NHS data: an observational study. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04290] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundPrevious research suggests that non-obstetric surgery is carried out in 1–2% of all pregnancies. However, there is limited evidence quantifying the associated risks. Furthermore, of the evidence available, none relates directly to outcomes in the UK, and there are no current NHS guidelines regarding non-obstetric surgery in pregnant women.ObjectivesTo estimate the risk of adverse birth outcomes of pregnancies in which non-obstetric surgery was or was not carried out. To further analyse common procedure groups.Data SourceHospital Episode Statistics (HES) maternity data collected between 2002–3 and 2011–12.Main outcomesSpontaneous abortion, preterm delivery, maternal death, caesarean delivery, long inpatient stay, stillbirth and low birthweight.MethodsWe utilised HES, an administrative database that includes records of all patient admissions and day cases in all English NHS hospitals. We analysed HES maternity data collected between 2002–3 and 2011–12, and identified pregnancies in which non-obstetric surgery was carried out. We used logistic regression models to determine the adjusted relative risk and attributable risk of non-obstetric surgical procedures for adverse birth outcomes and the number needed to harm.ResultsWe identified 6,486,280 pregnancies, in 47,628 of which non-obstetric surgery was carried out. In comparison with pregnancies in which surgery was not carried out, we found that non-obstetric surgery was associated with a higher risk of adverse birth outcomes, although the attributable risk was generally low. We estimated that for every 287 pregnancies in which a surgical operation was carried out there was one additional stillbirth; for every 31 operations there was one additional preterm delivery; for every 25 operations there was one additional caesarean section; for every 50 operations there was one additional long inpatient stay; and for every 39 operations there was one additional low-birthweight baby.LimitationsWe have no means of disentangling the effect of the surgery from the effect of the underlying condition itself. Many spontaneous abortions will not be associated with a hospital admission and, therefore, will not be included in our analysis. A spontaneous abortion may be more likely to be reported if it occurs during the same hospital admission as the procedure, and this could account for the associated increased risk with surgery during pregnancy. There are missing values of key data items to determine parity, gestational age, birthweight and stillbirth.ConclusionsThis is the first study to report the risk of adverse birth outcomes following non-obstetric surgery during pregnancy across NHS hospitals in England. We have no means of disentangling the effect of the surgery from the effect of the underlying condition itself. Our observational study can never attribute a causal relationship between surgery and adverse birth outcomes, and we were unable to determine the risk of not undergoing surgery where surgery was clinically indicated. We have some reservations over associations of risk factors with spontaneous abortion because of potential ascertainment bias. However, we believe that our findings and, in particular, the numbers needed to harm improve on previous research, utilise a more recent and larger data set based on UK practices, and are useful reference points for any discussion of risk with prospective patients. The risk of adverse birth outcomes in pregnant women undergoing non-obstetric surgery is relatively low, confirming that surgical procedures during pregnancy are generally safe.Future workFurther evaluation of the association of non-obstetric surgery and spontaneous abortion. Evaluation of the impact of non-obstetric surgery on the newborn (e.g. neonatal intensive care unit admission, prolonged length of neonatal stay, neonatal death).FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Paul Aylin
- Dr Foster Unit at Imperial College London, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Phillip Bennett
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Alex Bottle
- Dr Foster Unit at Imperial College London, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Stephen Brett
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Vinnie Sodhi
- Imperial College Healthcare NHS Trust, London, UK
| | - Angus Rivers
- Imperial College Healthcare NHS Trust, London, UK
| | - Violeta Balinskaite
- Dr Foster Unit at Imperial College London, Department of Primary Care and Public Health, Imperial College London, London, UK
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Mesterton J, Lindgren P, Ekenberg Abreu A, Ladfors L, Lilja M, Saltvedt S, Amer-Wåhlin I. Case mix adjustment of health outcomes, resource use and process indicators in childbirth care: a register-based study. BMC Pregnancy Childbirth 2016; 16:125. [PMID: 27245845 PMCID: PMC4888656 DOI: 10.1186/s12884-016-0921-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 05/24/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Unwarranted variation in care practice and outcomes has gained attention and inter-hospital comparisons are increasingly being used to highlight and understand differences between hospitals. Adjustment for case mix is a prerequisite for meaningful comparisons between hospitals with different patient populations. The objective of this study was to identify and quantify maternal characteristics that impact a set of important indicators of health outcomes, resource use and care process and which could be used for case mix adjustment of comparisons between hospitals. METHODS In this register-based study, 139 756 deliveries in 2011 and 2012 were identified in regional administrative systems from seven Swedish regions, which together cover 67 % of all deliveries in Sweden. Data were linked to the Medical birth register and Statistics Sweden's population data. A number of important indicators in childbirth care were studied: Caesarean section (CS), induction of labour, length of stay, perineal tears, haemorrhage > 1000 ml and post-partum infections. Sociodemographic and clinical characteristics deemed relevant for case mix adjustment of outcomes and resource use were identified based on previous literature and based on clinical expertise. Adjustment using logistic and ordinary least squares regression analysis was performed to quantify the impact of these characteristics on the studied indicators. RESULTS Almost all case mix factors analysed had an impact on CS rate, induction rate and length of stay and the effect was highly statistically significant for most factors. Maternal age, parity, fetal presentation and multiple birth were strong predictors of all these indicators but a number of additional factors such as born outside the EU, body mass index (BMI) and several complications during pregnancy were also important risk factors. A number of maternal characteristics had a noticeable impact on risk of perineal tears, while the impact of case mix factors was less pronounced for risk of haemorrhage > 1000 ml and post-partum infections. CONCLUSIONS Maternal characteristics have a large impact on care process, resource use and outcomes in childbirth care. For meaningful comparisons between hospitals and benchmarking, a broad spectrum of sociodemographic and clinical maternal characteristics should be accounted for.
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Affiliation(s)
- Johan Mesterton
- Medical Management Centre, Karolinska Institutet, Tomtebodavägen 18 A, 171 77, Stockholm, Sweden. .,Ivbar Institute, Stockholm, Sweden.
| | - Peter Lindgren
- Medical Management Centre, Karolinska Institutet, Tomtebodavägen 18 A, 171 77, Stockholm, Sweden
| | - Anna Ekenberg Abreu
- Departement of Obstetrics and Gynecology, Akademiska Hospital, Uppsala, Sweden
| | - Lars Ladfors
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Monica Lilja
- Department of Obstetrics and Gynecology, Skane University Hospital, Lund, Sweden
| | - Sissel Saltvedt
- Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - Isis Amer-Wåhlin
- Medical Management Centre, Karolinska Institutet, Tomtebodavägen 18 A, 171 77, Stockholm, Sweden.,Department of Women and Child Health, Karolinska Institutet, Stockholm, Sweden.,Stockholm County Council, Stockholm, Sweden
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11
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Kadhel P, Delrieu D, Deloumeaux J, Ryan C, Janky E. Characterization of potentially avoidable cases in a 1-year series of consecutive cesarean sections in the tertiary maternity unit of Guadeloupe (French West Indies). J Obstet Gynaecol Res 2016; 42:944-50. [PMID: 27094021 DOI: 10.1111/jog.13007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 01/28/2016] [Accepted: 02/22/2016] [Indexed: 11/28/2022]
Abstract
AIM The global increase in the rate of cesarean sections (CS) is currently an issue. We aimed to assess the rate of CS locally and to identify cases in which this procedure may have been avoidable. METHODS In this prospective consecutive series, we analyzed the 478 CS carried out in our unit in 2009. We analyzed the characteristics of each case, and classified each as potentially avoidable or unavoidable. RESULTS The total rate of CS was 24.0%, including 1.7% that was scored as potentially avoidable. Parity, gestational age at birth, birthweight, cases requiring cervical ripening, cases of labor induction, and CS during labor were all significantly higher or more frequent among potentially avoidable CS. Multivariate analysis indicated that the risk of potentially avoidable CS was positively associated with gestational age and tended to be negatively associated with parity. The main indications for potentially avoidable CS were cervical dystocia and abnormal fetal heart rate, and for unavoidable CS they were abnormal fetal heart rate and history of previous CS. CONCLUSION Labor, especially when induced, seems to be the key period for the prevention of 'avoidable' CS. This is particularly important given that potentially avoidable CS are more frequently associated with uncomplicated pregnancies than are unavoidable CS. A woman's first CS increases the likelihood of CS for subsequent deliveries, so the prevention of the first CS is a key aim for reducing the overall rate of CS.
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Affiliation(s)
- Philippe Kadhel
- Department of Obstetrics and Gynecology, University Hospital of Pointe-à-Pitre/Abymes, France.,French National Institute of Health and Medical Research (Inserm) U1085 - IRSET, Rennes and Pointe-à-Pitre, France
| | - Delphine Delrieu
- Department of Obstetrics and Gynecology, University Hospital of Pointe-à-Pitre/Abymes, France.,Suroit Hospital Maternity Unit,, Salaberry-de-Valleyfield, Canada
| | - Jacqueline Deloumeaux
- Clinical Epidemiology and Medicine Unit, University of French West Indies and Guiana, Pointe-à-Pitre, France
| | - Catherine Ryan
- Department of Obstetrics and Gynecology, University Hospital of Pointe-à-Pitre/Abymes, France
| | - Eustase Janky
- Department of Obstetrics and Gynecology, University Hospital of Pointe-à-Pitre/Abymes, France
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12
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Di Martino M, Fusco D, Colais P, Pinnarelli L, Davoli M, Perucci CA. Differential misclassification of confounders in comparative evaluation of hospital care quality: caesarean sections in Italy. BMC Public Health 2014; 14:1049. [PMID: 25297561 PMCID: PMC4210510 DOI: 10.1186/1471-2458-14-1049] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 09/29/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite extensive studies on exposure and disease misclassification, few studies have investigated misclassification of confounders. This study aimed to identify differentially misclassified confounders in a comparative evaluation of hospital care quality and to quantify their impact on hospital-specific risk-adjusted estimates, focusing on the appropriateness of caesarean sections (CS). METHODS We gathered data from the Hospital Information System in Italy for women admitted in 2005-2010. We estimated adjusted proportions of CS with logistic regression models. Among several confounders, we focused on high fetal head at term (HFH), which is seldom objectively documentable in medical records. RESULTS A total of 540 maternity units were compared. The median HFH prevalence was 0.9%, ranging from 0 to 70%. In some units, HFH was coded so frequently that it was unlikely to reflect a natural heterogeneity. This "over-coding" was conditional on the outcome because it occurred more frequently for women that underwent CS. This suggested an opportunistic coding to justify the choice of a CS. HFH misclassification was not randomly distributed over Italy; it had an excess in the Campania region where, in some units, the proportion of HFHs gradually increased from 2005 to 2010 (e.g., from 0 to 26%), but the national average remained constant (2.5%). The inclusion of the misclassified diagnosis in the models favored those hospitals that codified in a less-than-fair manner. CONCLUSIONS Our findings emphasized the importance of rigorously inspecting for differential misclassification of confounders. Their validity may be subject to substantial heterogeneity over hospitals, over time and geographical areas.
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Affiliation(s)
- Mirko Di Martino
- />Department of Epidemiology, Regional Health Service, Lazio Region, Via di Santa Costanza, 53-00198 Rome, Italy
| | - Danilo Fusco
- />Department of Epidemiology, Regional Health Service, Lazio Region, Via di Santa Costanza, 53-00198 Rome, Italy
| | - Paola Colais
- />Department of Epidemiology, Regional Health Service, Lazio Region, Via di Santa Costanza, 53-00198 Rome, Italy
| | - Luigi Pinnarelli
- />Department of Epidemiology, Regional Health Service, Lazio Region, Via di Santa Costanza, 53-00198 Rome, Italy
| | - Marina Davoli
- />Department of Epidemiology, Regional Health Service, Lazio Region, Via di Santa Costanza, 53-00198 Rome, Italy
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13
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Stivanello E, Rucci P, Lenzi J, Fantini MP. Determinants of cesarean delivery: a classification tree analysis. BMC Pregnancy Childbirth 2014; 14:215. [PMID: 24973937 PMCID: PMC4090181 DOI: 10.1186/1471-2393-14-215] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 06/20/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cesarean delivery (CD) rates are rising in many parts of the world. To define strategies to reduce them, it is important to identify their clinical and organizational determinants. The objective of this cross-sectional study is to identify sub-types of women at higher risk of CD using demographic, clinical and organizational variables. METHODS All hospital discharge records of women who delivered between 2005 and mid-2010 in the Emilia-Romagna Region of Italy were retrieved and linked with birth certificates. Sociodemographic and clinical information was retrieved from the two data sources. Organizational variables included activity volume (number of births per year), hospital type, and hour and day of delivery. A classification tree analysis was used to identify the variables and the combinations of variables that best discriminated cesarean from vaginal delivery. RESULTS The classification tree analysis indicated that the most important variables discriminating the sub-groups of women at different risk of cesarean section were: previous cesarean, mal-position/mal-presentation, fetal distress, and abruptio placentae or placenta previa or ante-partum hemorrhage. These variables account for more than 60% of all cesarean deliveries. A sensitivity analysis identified multiparity and fetal weight as additional discriminatory variables. CONCLUSIONS Clinical variables are important predictors of CD. To reduce the CD rate, audit activities should examine in more detail the clinical conditions for which the need of CD is questionable or inappropriate.
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Affiliation(s)
- Elisa Stivanello
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum – University of Bologna, Via San Giacomo 12, 40126 Bologna, Italy
| | - Paola Rucci
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum – University of Bologna, Via San Giacomo 12, 40126 Bologna, Italy
| | - Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum – University of Bologna, Via San Giacomo 12, 40126 Bologna, Italy
| | - Maria Pia Fantini
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum – University of Bologna, Via San Giacomo 12, 40126 Bologna, Italy
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14
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Stivanello E, Rucci P, Carretta E, Pieri G, Fantini MP. Risk adjustment for cesarean delivery rates: how many variables do we need? An observational study using administrative databases. BMC Health Serv Res 2013; 13:13. [PMID: 23305225 PMCID: PMC3554564 DOI: 10.1186/1472-6963-13-13] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2011] [Accepted: 12/26/2012] [Indexed: 11/10/2022] Open
Abstract
Background Various studies indicate that inter-hospital comparisons have to take case mix into account and that risk adjustment procedures are necessary to control for potential predictors of cesarean delivery (CD). Different data sources have been used to retrieve information on potential predictors of CD. The aim of this study was to compare the discrimination capacity and fit of predictive models of CD created using different sources and to assess whether more complex models improve inter-hospital comparisons. Methods We created 4 predictive models of CD. One model included only variables from Hospital Discharge Records of the index hospitalization, one included also information from previous hospitalizations, one also clinical variables from birth certificates (BC) and one also socio-demographic variables. We compared the four models using the Receiver Operator Curve and the Akaike and Bayesian Information Criteria. Results Information from Birth Certificates improved the discrimination and model fit. Adding socio-demographic variables or past comorbidities did not improve the discrimination capacity or the model fit. Hospital-specific CD resulting from the models were highly correlated. Conclusions Record linkage improves the performance of the models but does not affect inter-hospital comparisons.
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Affiliation(s)
- Elisa Stivanello
- Department of Medicine and Public Health, University of Bologna, via San Giacomo 12, Bologna, 40126, Italy.
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15
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Colais P, Fantini MP, Fusco D, Carretta E, Stivanello E, Lenzi J, Pieri G, Perucci CA. Risk adjustment models for interhospital comparison of CS rates using Robson's ten group classification system and other socio-demographic and clinical variables. BMC Pregnancy Childbirth 2012; 12:54. [PMID: 22720844 PMCID: PMC3570355 DOI: 10.1186/1471-2393-12-54] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Accepted: 05/23/2012] [Indexed: 11/17/2022] Open
Abstract
Background Caesarean section (CS) rate is a quality of health care indicator frequently used at national and international level. The aim of this study was to assess whether adjustment for Robson’s Ten Group Classification System (TGCS), and clinical and socio-demographic variables of the mother and the fetus is necessary for inter-hospital comparisons of CS rates. Methods The study population includes 64,423 deliveries in Emilia-Romagna between January 1, 2003 and December 31, 2004, classified according to theTGCS. Poisson regression was used to estimate crude and adjusted hospital relative risks of CS compared to a reference category. Analyses were carried out in the overall population and separately according to the Robson groups (groups I, II, III, IV and V–X combined). Adjusted relative risks (RR) of CS were estimated using two risk-adjustment models; the first (M1) including the TGCS group as the only adjustment factor; the second (M2) including in addition demographic and clinical confounders identified using a stepwise selection procedure. Percentage variations between crude and adjusted RRs by hospital were calculated to evaluate the confounding effect of covariates. Results The percentage variations from crude to adjusted RR proved to be similar in M1 and M2 model. However, stratified analyses by Robson’s classification groups showed that residual confounding for clinical and demographic variables was present in groups I (nulliparous, single, cephalic, ≥37 weeks, spontaneous labour) and III (multiparous, excluding previous CS, single, cephalic, ≥37 weeks, spontaneous labour) and IV (multiparous, excluding previous CS, single, cephalic, ≥37 weeks, induced or CS before labour) and to a minor extent in groups II (nulliparous, single, cephalic, ≥37 weeks, induced or CS before labour) and IV (multiparous, excluding previous CS, single, cephalic, ≥37 weeks, induced or CS before labour). Conclusions The TGCS classification is useful for inter-hospital comparison of CS section rates, but residual confounding is present in the TGCS strata.
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Affiliation(s)
- Paola Colais
- Department of Epidemiology, Regional Health Service, Lazio Region, Italy.
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16
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Fusco D, Barone AP, Sorge C, D'Ovidio M, Stafoggia M, Lallo A, Davoli M, Perucci CA. P.Re.Val.E.: outcome research program for the evaluation of health care quality in Lazio, Italy. BMC Health Serv Res 2012; 12:25. [PMID: 22283880 PMCID: PMC3276429 DOI: 10.1186/1472-6963-12-25] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Accepted: 01/27/2012] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND P.Re.Val.E. is the most comprehensive comparative evaluation program of healthcare outcomes in Lazio, an Italian region, and the first Italian study to make health provider performance data available to the public. The aim of this study is to describe the P.Re.Val.E. and the impact of releasing performance data to the public. METHODS P.Re.Val.E. included 54 outcome/process indicators encompassing many different clinical areas. Crude and adjusted rates were estimated for the 2006-2009 period. Multivariate regression models and direct standardization procedures were used to control for potential confounding due to individual characteristics. Variable life-adjusted display charts were developed, and 2008-2009 results were compared with those from 2006-2007. RESULTS Results of 54 outcome indicators were published online at http://www.epidemiologia.lazio.it/prevale10/index.php. Public disclosure of the indicators' results caused mixed reactions but finally promoted discussion and refinement of some indicators. Based on the P.Re.Val.E. experience, the Italian National Agency for Regional Health Services has launched a National Outcome Program aimed at systematically comparing outcomes in hospitals and local health units in Italy. CONCLUSIONS P.Re.Val.E. highlighted aspects of patient care that merit further investigation and monitoring to improve healthcare services and equity.
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Affiliation(s)
- Danilo Fusco
- Department of Epidemiology, Regional Health Service-Lazio Region, via Santa Costanza 53, Rome, 00198, Italy
| | - Anna P Barone
- Department of Epidemiology, Regional Health Service-Lazio Region, via Santa Costanza 53, Rome, 00198, Italy
| | - Chiara Sorge
- Department of Epidemiology, Regional Health Service-Lazio Region, via Santa Costanza 53, Rome, 00198, Italy
| | - Mariangela D'Ovidio
- Department of Epidemiology, Regional Health Service-Lazio Region, via Santa Costanza 53, Rome, 00198, Italy
| | - Massimo Stafoggia
- Department of Epidemiology, Regional Health Service-Lazio Region, via Santa Costanza 53, Rome, 00198, Italy
| | - Adele Lallo
- Department of Epidemiology, Regional Health Service-Lazio Region, via Santa Costanza 53, Rome, 00198, Italy
| | - Marina Davoli
- Department of Epidemiology, Regional Health Service-Lazio Region, via Santa Costanza 53, Rome, 00198, Italy
| | - Carlo A Perucci
- National Agency of Regional Health Services, via Puglie 23, Rome, 00187, Italy
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17
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Stivanello E, Rucci P, Carretta E, Pieri G, Seghieri C, Nuti S, Declercq E, Taglioni M, Fantini MP. Risk adjustment for inter-hospital comparison of caesarean delivery rates in low-risk deliveries. PLoS One 2011; 6:e28060. [PMID: 22132210 PMCID: PMC3223220 DOI: 10.1371/journal.pone.0028060] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Accepted: 10/31/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Caesarean delivery (CD) rates have been frequently used as quality measures for maternity service comparisons. More recently, primary CD rates (CD in women without previous CD) or CD rates within selected categories such as nulliparous, term, cephalic singleton deliveries (NTCS) have been used. The objective of this study is to determine the extent to which risk adjustment for clinical and socio-demographic variables is needed for inter-hospital comparisons of CD rates in women without previous CD and in NTCS deliveries. METHODS Hospital discharge records of women who delivered in Emilia-Romagna Region (Italy) from January, 2007 to June 2009 and in Tuscany Region for year 2009 were linked with birth certificates. Adjusted RRs of CD in women without a previous Caesarean and NTCS were estimated using Poisson regression. Percentage differences in RR before and after adjustment were calculated and hospital rankings, based on crude and adjusted RRs, were examined. RESULTS Adjusted RR differed substantially from crude RR in women without a previous Caesarean and only marginally in NTCS group. Hospital ranking was markedly affected by adjustment in women without a previous CD, but less in NTCS. CONCLUSION Risk adjustment is warranted for inter-hospital comparisons of primary CD rates but not for NTCS CD rates. Crude NTCS CD rates are a reliable estimate of adjusted NTCS CD.
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Affiliation(s)
- Elisa Stivanello
- Department of Medicine and Public Health-Alma Mater Studiorum University of Bologna, Bologna, Italy.
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18
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Bragg F, Cromwell DA, Edozien LC, Gurol-Urganci I, Mahmood TA, Templeton A, van der Meulen JH. Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross sectional study. BMJ 2010; 341:c5065. [PMID: 20926490 PMCID: PMC2950923 DOI: 10.1136/bmj.c5065] [Citation(s) in RCA: 179] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2010] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine whether the variation in unadjusted rates of caesarean section derived from routine data in NHS trusts in England can be explained by maternal characteristics and clinical risk factors. DESIGN A cross sectional analysis using routinely collected hospital episode statistics was performed. A multiple logistic regression model was used to estimate the likelihood of women having a caesarean section given their maternal characteristics (age, ethnicity, parity, and socioeconomic deprivation) and clinical risk factors (previous caesarean section, breech presentation, and fetal distress). Adjusted rates of caesarean section for each NHS trust were produced from this model. SETTING 146 English NHS trusts. Population Women aged between 15 and 44 years with a singleton birth between 1 January and 31 December 2008. MAIN OUTCOME MEASURE Rate of caesarean sections per 100 births (live or stillborn). RESULTS Among 620 604 singleton births, 147 726 (23.8%) were delivered by caesarean section. Women were more likely to have a caesarean section if they had had one previously (70.8%) or had a baby with breech presentation (89.8%). Unadjusted rates of caesarean section among the NHS trusts ranged from 13.6% to 31.9%. Trusts differed in their patient populations, but adjusted rates still ranged from 14.9% to 32.1%. Rates of emergency caesarean section varied between trusts more than rates of elective caesarean section. CONCLUSION Characteristics of women delivering at NHS trusts differ, and comparing unadjusted rates of caesarean section should be avoided. Adjusted rates of caesarean section still vary considerably and attempts to reduce this variation should examine issues linked to emergency caesarean section.
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Affiliation(s)
- Fiona Bragg
- London School of Hygiene and Tropical Medicine, London, UK
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19
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Habib MR, Solomon MJ, Young JM, Armstrong BK, O'Connell D, Armstrong K. Evidence-based and clinical outcome scores to facilitate audit and feedback for colorectal cancer care. Dis Colon Rectum 2009; 52:616-22; discussion 622-3. [PMID: 19404063 DOI: 10.1007/dcr.0b013e31819edb7d] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE To describe a methodology for surgical audit and feedback based on hospital-level indicators of the quality of colorectal cancer care. METHODS Process and outcome indicators were identified from a population-based database (N = 3095 patients treated by 258 surgeons at 130 hospitals across New South Wales between February 1, 2000 and January 31, 2001). Hospitals were ranked on each indicator, with those in the lowest 20th percentile receiving a score of 0 and the remainder receiving a score of 1. Scores for individual indicators were then summed for each hospital and divided by the number of relevant indicators to provide an evidence-based score (EBS) and a clinical outcome score. RESULTS Ten process and six clinical outcome indicators were identified. Hospital-level summary scores ranged from 0.14 to 1.0 for evidence-based processes and from 0.17 to 1.0 for clinical outcomes. Evidence-based score and clinical outcome score were independent (r = 0.12, P = 0.32). There was a small positive association between evidence-based score and caseload (r = 0.33, P = 0.005) but clinical outcome score and caseload were unrelated (r = 0.11, P = 0.36). CONCLUSIONS Evidence-based score and clinical outcome score address different aspects of quality of care. The wide variability of hospitals' outcome scores and an association of evidence-based score and caseload indicate that simple scores may be useful in audit and feedback.
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Affiliation(s)
- Miriam R Habib
- Surgical Outcomes Research Centre, University of Sydney, Royal Prince Alfred Hospital, Sydney, Australia
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20
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Abstract
BACKGROUND The cesarean section rate has increased worldwide over the past 20 years; in Italy, it is now more than 35 percent. Although clinical factors are important, the attitudes of health practitioners toward cesarean section need further investigation to correctly identify facilitators and barriers to changes. The objective of this study was to explore the attitudes toward cesarean section of midwives and obstetricians who worked in the same geographical area. METHODS Face-to-face structured interviews using an adaptation of the Survey of Clinicians' Views on Caesarean Section, an anonymous questionnaire with 35 open and closed answers on practitioners' views on cesarean section, were conducted. The questionnaire was given to the entire group of midwives and obstetricians working in Modena, a northern Italian district. RESULTS Of 262 eligible practitioners, 248 were interviewed (response rate 94.6%). The midwives' attitudes toward cesarean section differed from those of the obstetricians. Sixty-five percent of midwives considered the rates of cesarean section in their hospitals to be too high compared with 34 percent of obstetricians (p < 0.001). Midwives were also less inclined to believe that cesarean section provides benefits to the mother (p = 0.02) or that it is indicated by previous cesarean delivery (p < 0.001). No differences were observed between male and female obstetricians. CONCLUSIONS In this survey, the attitudes toward cesarean section were correlated more with professional role than with gender. This information can help policy makers to shape interventions aimed at providing better care for pregnant and childbearing women.
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Affiliation(s)
- Francesca Monari
- Department of Obstetrics and Gynecology, University Hospital, Modena, Italy
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