Hospital variation in cost of childbirth and contributing factors: a cross-sectional study

OBJECTIVE

To examine hospital variation in cost of childbirth hospitalisations and identify factors that contribute to the variation.

DESIGN

Cross-sectional analysis of linked birth certificate and hospital discharge data.

SETTING

Two hundred and twenty hospitals in California delivering ≥ 100 births per year.

POPULATION

A total of 405 908 nulliparous term singleton vertex births during 2010-2012.

METHODS

Cost of childbirth hospitalisations was compared across hospitals after accounting for differences in patient clinical risk factors. Relative contributions of patient sociodemographic, obstetric intervention, birth attendant and institutional characteristics to variation in cost were assessed by further adjusting for these factors in hierarchical generalised linear models.

MAIN OUTCOME MEASURES

Cost of childbirth hospitalisation.

RESULTS

Median risk-standardised cost of childbirth was $7149 among the hospitals (10^th -90th percentile range: $4760-$10,644). Maternal sociodemographic characteristics and type of birth attendant did not explain hospital variation in cost. Adjustment for obstetric interventions overall reduced within-hospital variance by 15.8% (P < 0.001), while adjusting for caesarean delivery alone reduced within-hospital variance by 14.4% (P < 0.001). However, obstetric interventions did not explain between-hospital variation in cost. In contrast, adjustment for institutional characteristics reduced between-hospital variance by 30.3% (P = 0.002). Hospital type of ownership, teaching/urban-rural status, neonatal care capacity and geographic region were most impactful. Risk-standardised cost was positively correlated with risk-standardised rate of severe newborn morbidities (correlation coefficient 0.22, P = 0.001), but not associated with risk-standardised rate of severe maternal morbidities.

CONCLUSIONS

Cost of childbirth hospitalisations varied widely among hospitals in California. Institutional characteristics significantly contributed to this variation. Higher-cost hospitals did not have better outcomes, suggesting potential opportunities to enhance value in care.

TWEETABLE ABSTRACT

Hospitals vary in cost of childbirth. Institutional characteristics significantly contribute to the variation.

Low-to-moderate gestational alcohol use and intrauterine growth retardation, low birthweight, and preterm delivery

PURPOSE

Heavy drinking during pregnancy is an established risk factor for fetal alcohol syndrome and other adverse perinatal outcomes. However, there is still debate as to the effects of low-to-moderate drinking during pregnancy.

METHODS

This prospective investigation was based on 2714 singleton live births at Yale-New Haven Hospital during 1988-1992. Alcohol drinking during pregnancy was evaluated with respect to intrauterine growth retardation (IUGR), preterm delivery, and low birthweight.

RESULTS

Mild drinking, defined as > 0.10-0.25 oz of absolute alcohol per day, during the first month of pregnancy was associated with a protective effect on IUGR (OR, 0.39; 95% confidence interval (CI), 0.20-0.76). Overall, drinking during month 1 of pregnancy suggested a curvilinear effect on growth retardation, with consumption of > 1.00 oz of absolute alcohol per day showing increased risk. Drinking during month 7 was associated with a uniform increase in the odds of preterm delivery; the ORs were 2.88 (95% CI, 1.64-5.05) for light drinking and 2.96 (95% CI, 1.32-6.67) for mild-to-moderate alcohol consumption.

CONCLUSIONS

Differences in the risk estimates for IUGR and preterm delivery may indicate etiological differences that warrant further investigation of these outcomes and critical periods of exposure. Low birthweight is not a useful neonatal outcome for this exposure because it is a heterogeneous mix of preterm delivery and IUGR. Despite the observed protective effects of mild drinking on IUGR, the increased risk of preterm delivery with alcohol use supports a policy of abstinence during pregnancy.

Occupationally related magnetic field exposure and male subfertility

OBJECTIVE

To determine whether there is an association between occupationally related magnetic field exposure, as estimated in milligauss (mG), and male subfertility.

DESIGN

Nested case-control study using three defined case groups and one standard control group.

SETTING

Yale New Haven Hospital Infertility Clinic, New Haven, Connecticut. PATIENTS, INTERVENTIONS: Male partners of couples seeking diagnosis and care at the infertility clinic. Men included in the analysis had complete first semen analysis and interview information. Subjects for this investigation consisted of case groups for motility (n = 177), morphology (n = 135), and concentration (n = 172); controls included men normal on all three parameters (n = 304).

MAIN OUTCOME MEASURES

Laboratory confirmation in semen analysis of poor morphology, inadequate motility, and low concentration. Comparisons of occupational magnetic field exposure categories are made between case groups and controls.

RESULTS

The odds of high job exposure category to magnetic fields (> 3 mG [> 0.3 muT]) for morphology cases were odds ratio (OR) = 0.6, for motility cases OR = 1.1, and concentration cases OR = 1.0 as compared with controls. No significant association was demonstrated for medium exposure (> 2 to 3 mG) among all case groups. Multivariate adjustment for selected risk factors did not substantially change estimates of risk.

CONCLUSIONS

A lack of association between occupationally related categories of magnetic field exposure and male subfertility, as evaluated by morphology, motility, and concentration, has been demonstrated. These findings do not substantiate theories of deleterious effects to male reproductive health from magnetic fields.