- Email: [email protected]
640: The development of risk-adjusted outcomes to be used as quality indicators for obstetric care
Poster Session IV
Epidemiology, Infectious Disease, Intrapartum Fetal Assessment, Operative Obstetrics, Obstetric Quality & Safety, Public Health-Global Health
single state among serving groups of women with uniform, very low risk characteristics. STUDY DESIGN: We compared overall cesarean rates and cesarean rates among the Nulliparous Term Singleton Vertex (NTSV) population between the 49 maternity hospitals in Massachusetts using birth certificate and hospital discharge data from all 255,456 Massachusetts non anomalous livebirths births between January 1 2004 and December 31 2006. To further isolate a homogenous population, subanalyses were performed examining cesarean rates among NSTV women with infants weighing 2500-4000g and in spontaneous labor. RESULTS: There was three-fold variation in hospital-specific NTSV cesarean rates (range 14%-38%, mean 26%) which persisted after further narrowing the population to women with infants weighing 2500-4000g (15% to 39%, mean 25%) and in spontaneous labor (10% to 35%, mean 21%). Standard deviations remained similar in all subgroups indicating a persistent wide dispersion in cesarean rates. There was strong correlation between hospital overall cesarean rates and rates in the NTSV population (Pearsons correlation ⫽0.88). Adjusting for maternal and fetal characteristics including maternal age, education, race/ethnicity, infant birthweight, gestational age, and maternal conditions (hypertension, diabetes, preeclampsia or placenta previa) did not diminish the variation among hospitals cesarean rates. CONCLUSION: The observed three-fold variation in cesarean rates among a low risk population suggest that hospital practice patterns rather than maternal and fetal risk factors alone may play a role in determining delivery method among low risk women, and represents an opportunity for quality improvement.
639 Effect of education and provider transparency upon individual cesarean, episiotomy, antenatal steroid, and breastfeeding rates William Gilbert1, Mary Campbell Bliss1, Amy Johnson2, Laurie Gregg1, Christopher Swanson1 1 Sutter Medical Center Sacramento, Department of Obstetrics and Gynecology, Sacramento, CA, 2Sutter Medical Center Sacramento, Integrated Quality Services, Sacramento, CA
OBJECTIVE: To determine if a combination of quality improvement programs including making individual providers cesarean section (C/S) and episiotomy (epis) rates public, improving computer charting for antenatal steroids (AS), and education on the importance of exclusive breastfeeding (EBF) at hospital discharge, would improve these rates. STUDY DESIGN: Sutter Medical Center, Sacramento is a private practice, Level 3 community hospital with approximately 5500 deliveries per year and 35 active members of the OB/GYN Department medical staff. With concern for the increasing C/S rates nationally, and other measures of OB/GYN quality being examined by national quality groups, physician leaders within the department explored options to improve these measures. After departmental approval, individual C/S (nulliparous singleton term vertex) and epis rates (any episiotomy)
S286
www.AJOG.org
were collected for 6 months and posted blindly (codes known to each member only) within the department. For the next 6 months, data was posted and presented publically by individual provider name. Computer charting was modified to require physician input on AS for deliveries ⬍ 34 weeks of gestation. An educational pregram concerning EBF rates was performed with public listing of individual and group rates of EBF. RESULTS: Over the second 6 month open period, there were reductions in C/S rates (31 vs 27% with June 2011 being 23%) with improvements in AS (80 vs 100%) and EBF (60 vs 65%) rates while the epis rate was largely unchanged (4.3 vs 4.6%) but low to start with. CONCLUSION: A combination of physician education, change in medical record documentation, and transparency of individual provider practice data, improved almost every measure of quality and suggests several paths to positively impact quality measures within a community hospital with private practice providers.
640 The development of risk-adjusted outcomes to be used as quality indicators for obstetric care William Grobman1 1 For the Eunice Kennedy Shriver National Institute of Health and Human Development, Maternal-Fetal Units Network, Bethesda, MD
OBJECTIVE: Current quality indicators of obstetric care rely on administrative data, which, because of lack of detail, do not allow adequate risk adjustment. The objective of this study was to develop risk-adjusted obstetric outcome quality measures using detailed and reliable patient data. STUDY DESIGN: Data were obtained by trained abstractors, with ongoing data edits and audits, from maternal and neonatal charts of all deliveries on 365 randomly selected days at 25 hospitals over a 3-year period. Five outcome measures, selected a priori and rigorously defined, were chosen: venous thromboembolism (VTE), severe postpartum hemorrhage (PPH), maternal peripartum infection, perineal trauma (3rd or 4th degree laceration) at spontaneous vaginal delivery, and a composite adverse neonatal outcome. The outcomes were assessed to see whether their rates were significantly different across hospitals and whether they were related to patient-specific factors. Expected rates were determined for each hospital based on differences in patient-specific factors, and these rates were compared with the observed rates using Spearman correlation. RESULTS: Data were collected on 115,502 women. VTE occurred too infrequently (0.03%) to be used as a quality measure.The observed rates of the remaining four outcomes ranged from 0.8% to 9.5%, and varied significantly among hospitals (P ⬍.001). A core group of patient-specific factors (maternal age, BMI, GA or BW, PROM, parity, DM, and smoking) was significantly associated with the outcomes, and was used to construct an equation to estimate each hospital’s expected outcome rates. Observed and expected rates were not signficantly correlated for infection (Figure), and were correlated, albeit moderately, for the other three outcomes (Table). CONCLUSION: The frequencies of four obstetric outcome measures within a hospital are related to, but not merely a reflection of, its patient population. Patient-specific factors can be used to derive an equation that hospitals can employ to determine their own expected outcome rates, and better assess their performance regarding these outcomes.
American Journal of Obstetrics & Gynecology Supplement to JANUARY 2012
www.AJOG.org
Epidemiology, Infectious Disease, Intrapartum Fetal Assessment, Operative Obstetrics, Obstetric Quality & Safety, Public Health-Global Health
Poster Session IV
similar, although there was change in rank of individual hospitals, as illustrated by the Figure for perineal trauma. The range of the difference in ranks as well as the median difference in ranks are presented in the Table. CONCLUSION: Among 25 participating hospitals, risk-adjustment using detailed patient data resulted in a similar overall ranking of hospitals for the chosen outcome measures. However, individual hospitals did change rank after risk adjustment. This movement may have relevance in the assessment of an individual hospital’s performance regarding specific quality measures.
641 Does risk adjustment for patient characteristics affect assessment of hospital quality performance?
642 The contribution of patient age to the Robson cesarean section classification
William Grobman1 1
For the Eunice Kennedy Shriver National Institute of Health and Human Development, Maternal-Fetal Units Network, Bethesda, MD
OBJECTIVE: The objective of this analysis was to determine whether
risk adjustment, using detailed patient data, affects assessment of hospital performance regarding quality measures. STUDY DESIGN: Data were obtained by trained abstractors, with ongoing data edits and audits, from maternal and neonatal charts of all deliveries on 365 randomly selected days at 25 hospitals over a threeyear period. A priori outcome measures, rigorously predefined, were severe postpartum hemorrhage (PPH), maternal peripartum infection, perineal trauma (3rd or 4th degree laceration) at spontaneous vaginal delivery (SVD), and a composite adverse neonatal outcome. Observed rates of each outcome were calculated for each hospital, and hospitals were ranked from 1 (lowest frequency) to 25 (highest frequency). Patient-specific factors associated with each outcome were determined, and used to estimate each hospitals expected outcome rate. The observed/expected ratio (O/E) was calculated for each outcome (e.g. a ratio ⬍ 1 indicates that the observed outcome rate was less frequent than expected on the basis of the hospitals patient characteristics), and each hospital was re-ranked according to this ratio. Descriptive statistics were performed, and Kendall’s test used to assess the concordance between the ranks based on the observed rate and O/E ratio for each outcome measure. RESULTS: Data were collected on 115,502 women. For all outcomes, the observed rank and O/E ratio (risk adjusted) rank were statistically
Amos Grunebaum1, Stephanie Lin2, Eleni Greenwood1, Arielle Lehman1 1 Weill Cornell Medical College, Department of Obstetrics and Gynecology, New York, NY, 2New York Presbyterian Hospital, Weill Cornell Medical Center, Department of Obstetrics and Gynecology, New York, NY
OBJECTIVE: To examine the contribution of patient age to the Robson Ten Group Classification System (RTGCS). STUDY DESIGN: Each cesarean section between 2009-10 was classified according to the Robson TGCS. Patients age groups were added to the classification. The distribution of TGCS within each age group was calculated and compared. RESULTS: The overall CD rate was 36.1% (3,260/9,021), and it increased continuously from 20.0% below age 25 to 75% at age 45 years and above. Overall, most CD were done in group 5 (prior CD) followed by group 2 (Nullip induced labor), then group 1 (Nullip spontaneous labor). The highest contributor to the CD rate in women age 30 and under was group 2 (Nullip induced labor) followed by groups 1 (Nullip spontaneous labor) and groups 5 (prior CD), while in women age 40 and over the highest rate of CD was in group 5 (prior CD), followed by group 2 (Nullip induced labor) and group 8 (Multiple Pregnancies). CONCLUSION: Using the Robson Ten Group Classification System (TGCS) facilitates the assessment of CD data in a standardized fashion. Adding patient age groups assists in further focusing on assessing
Supplement to JANUARY 2012 American Journal of Obstetrics & Gynecology
S287
Epidemiology, Infectious Disease, Intrapartum Fetal Assessment, Operative Obstetrics, Obstetric Quality & Safety, Public Health-Global Health
single state among serving groups of women with uniform, very low risk characteristics. STUDY DESIGN: We compared overall cesarean rates and cesarean rates among the Nulliparous Term Singleton Vertex (NTSV) population between the 49 maternity hospitals in Massachusetts using birth certificate and hospital discharge data from all 255,456 Massachusetts non anomalous livebirths births between January 1 2004 and December 31 2006. To further isolate a homogenous population, subanalyses were performed examining cesarean rates among NSTV women with infants weighing 2500-4000g and in spontaneous labor. RESULTS: There was three-fold variation in hospital-specific NTSV cesarean rates (range 14%-38%, mean 26%) which persisted after further narrowing the population to women with infants weighing 2500-4000g (15% to 39%, mean 25%) and in spontaneous labor (10% to 35%, mean 21%). Standard deviations remained similar in all subgroups indicating a persistent wide dispersion in cesarean rates. There was strong correlation between hospital overall cesarean rates and rates in the NTSV population (Pearsons correlation ⫽0.88). Adjusting for maternal and fetal characteristics including maternal age, education, race/ethnicity, infant birthweight, gestational age, and maternal conditions (hypertension, diabetes, preeclampsia or placenta previa) did not diminish the variation among hospitals cesarean rates. CONCLUSION: The observed three-fold variation in cesarean rates among a low risk population suggest that hospital practice patterns rather than maternal and fetal risk factors alone may play a role in determining delivery method among low risk women, and represents an opportunity for quality improvement.
639 Effect of education and provider transparency upon individual cesarean, episiotomy, antenatal steroid, and breastfeeding rates William Gilbert1, Mary Campbell Bliss1, Amy Johnson2, Laurie Gregg1, Christopher Swanson1 1 Sutter Medical Center Sacramento, Department of Obstetrics and Gynecology, Sacramento, CA, 2Sutter Medical Center Sacramento, Integrated Quality Services, Sacramento, CA
OBJECTIVE: To determine if a combination of quality improvement programs including making individual providers cesarean section (C/S) and episiotomy (epis) rates public, improving computer charting for antenatal steroids (AS), and education on the importance of exclusive breastfeeding (EBF) at hospital discharge, would improve these rates. STUDY DESIGN: Sutter Medical Center, Sacramento is a private practice, Level 3 community hospital with approximately 5500 deliveries per year and 35 active members of the OB/GYN Department medical staff. With concern for the increasing C/S rates nationally, and other measures of OB/GYN quality being examined by national quality groups, physician leaders within the department explored options to improve these measures. After departmental approval, individual C/S (nulliparous singleton term vertex) and epis rates (any episiotomy)
S286
www.AJOG.org
were collected for 6 months and posted blindly (codes known to each member only) within the department. For the next 6 months, data was posted and presented publically by individual provider name. Computer charting was modified to require physician input on AS for deliveries ⬍ 34 weeks of gestation. An educational pregram concerning EBF rates was performed with public listing of individual and group rates of EBF. RESULTS: Over the second 6 month open period, there were reductions in C/S rates (31 vs 27% with June 2011 being 23%) with improvements in AS (80 vs 100%) and EBF (60 vs 65%) rates while the epis rate was largely unchanged (4.3 vs 4.6%) but low to start with. CONCLUSION: A combination of physician education, change in medical record documentation, and transparency of individual provider practice data, improved almost every measure of quality and suggests several paths to positively impact quality measures within a community hospital with private practice providers.
640 The development of risk-adjusted outcomes to be used as quality indicators for obstetric care William Grobman1 1 For the Eunice Kennedy Shriver National Institute of Health and Human Development, Maternal-Fetal Units Network, Bethesda, MD
OBJECTIVE: Current quality indicators of obstetric care rely on administrative data, which, because of lack of detail, do not allow adequate risk adjustment. The objective of this study was to develop risk-adjusted obstetric outcome quality measures using detailed and reliable patient data. STUDY DESIGN: Data were obtained by trained abstractors, with ongoing data edits and audits, from maternal and neonatal charts of all deliveries on 365 randomly selected days at 25 hospitals over a 3-year period. Five outcome measures, selected a priori and rigorously defined, were chosen: venous thromboembolism (VTE), severe postpartum hemorrhage (PPH), maternal peripartum infection, perineal trauma (3rd or 4th degree laceration) at spontaneous vaginal delivery, and a composite adverse neonatal outcome. The outcomes were assessed to see whether their rates were significantly different across hospitals and whether they were related to patient-specific factors. Expected rates were determined for each hospital based on differences in patient-specific factors, and these rates were compared with the observed rates using Spearman correlation. RESULTS: Data were collected on 115,502 women. VTE occurred too infrequently (0.03%) to be used as a quality measure.The observed rates of the remaining four outcomes ranged from 0.8% to 9.5%, and varied significantly among hospitals (P ⬍.001). A core group of patient-specific factors (maternal age, BMI, GA or BW, PROM, parity, DM, and smoking) was significantly associated with the outcomes, and was used to construct an equation to estimate each hospital’s expected outcome rates. Observed and expected rates were not signficantly correlated for infection (Figure), and were correlated, albeit moderately, for the other three outcomes (Table). CONCLUSION: The frequencies of four obstetric outcome measures within a hospital are related to, but not merely a reflection of, its patient population. Patient-specific factors can be used to derive an equation that hospitals can employ to determine their own expected outcome rates, and better assess their performance regarding these outcomes.
American Journal of Obstetrics & Gynecology Supplement to JANUARY 2012
www.AJOG.org
Epidemiology, Infectious Disease, Intrapartum Fetal Assessment, Operative Obstetrics, Obstetric Quality & Safety, Public Health-Global Health
Poster Session IV
similar, although there was change in rank of individual hospitals, as illustrated by the Figure for perineal trauma. The range of the difference in ranks as well as the median difference in ranks are presented in the Table. CONCLUSION: Among 25 participating hospitals, risk-adjustment using detailed patient data resulted in a similar overall ranking of hospitals for the chosen outcome measures. However, individual hospitals did change rank after risk adjustment. This movement may have relevance in the assessment of an individual hospital’s performance regarding specific quality measures.
641 Does risk adjustment for patient characteristics affect assessment of hospital quality performance?
642 The contribution of patient age to the Robson cesarean section classification
William Grobman1 1
For the Eunice Kennedy Shriver National Institute of Health and Human Development, Maternal-Fetal Units Network, Bethesda, MD
OBJECTIVE: The objective of this analysis was to determine whether
risk adjustment, using detailed patient data, affects assessment of hospital performance regarding quality measures. STUDY DESIGN: Data were obtained by trained abstractors, with ongoing data edits and audits, from maternal and neonatal charts of all deliveries on 365 randomly selected days at 25 hospitals over a threeyear period. A priori outcome measures, rigorously predefined, were severe postpartum hemorrhage (PPH), maternal peripartum infection, perineal trauma (3rd or 4th degree laceration) at spontaneous vaginal delivery (SVD), and a composite adverse neonatal outcome. Observed rates of each outcome were calculated for each hospital, and hospitals were ranked from 1 (lowest frequency) to 25 (highest frequency). Patient-specific factors associated with each outcome were determined, and used to estimate each hospitals expected outcome rate. The observed/expected ratio (O/E) was calculated for each outcome (e.g. a ratio ⬍ 1 indicates that the observed outcome rate was less frequent than expected on the basis of the hospitals patient characteristics), and each hospital was re-ranked according to this ratio. Descriptive statistics were performed, and Kendall’s test used to assess the concordance between the ranks based on the observed rate and O/E ratio for each outcome measure. RESULTS: Data were collected on 115,502 women. For all outcomes, the observed rank and O/E ratio (risk adjusted) rank were statistically
Amos Grunebaum1, Stephanie Lin2, Eleni Greenwood1, Arielle Lehman1 1 Weill Cornell Medical College, Department of Obstetrics and Gynecology, New York, NY, 2New York Presbyterian Hospital, Weill Cornell Medical Center, Department of Obstetrics and Gynecology, New York, NY
OBJECTIVE: To examine the contribution of patient age to the Robson Ten Group Classification System (RTGCS). STUDY DESIGN: Each cesarean section between 2009-10 was classified according to the Robson TGCS. Patients age groups were added to the classification. The distribution of TGCS within each age group was calculated and compared. RESULTS: The overall CD rate was 36.1% (3,260/9,021), and it increased continuously from 20.0% below age 25 to 75% at age 45 years and above. Overall, most CD were done in group 5 (prior CD) followed by group 2 (Nullip induced labor), then group 1 (Nullip spontaneous labor). The highest contributor to the CD rate in women age 30 and under was group 2 (Nullip induced labor) followed by groups 1 (Nullip spontaneous labor) and groups 5 (prior CD), while in women age 40 and over the highest rate of CD was in group 5 (prior CD), followed by group 2 (Nullip induced labor) and group 8 (Multiple Pregnancies). CONCLUSION: Using the Robson Ten Group Classification System (TGCS) facilitates the assessment of CD data in a standardized fashion. Adding patient age groups assists in further focusing on assessing
Supplement to JANUARY 2012 American Journal of Obstetrics & Gynecology
S287