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Are the agency for healthcare research and quality obstetric trauma indicators valid measures of hospital quality?
SMFM Abstracts S179 630 ARE THE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY OBSTETRIC TRAUMA INDICATORS VALID MEASURES OF HOSPITAL QUALITY? WILLIAM GROBMAN1, JOSEPH FEINGLASS2, SUMITHRA MURTHY2, 1Northwestern University, Obstetrics/Gynecology, Chicago, Illinois, 2Northwestern University, Health Services Research and Policy Studies, Chicago, Illinois OBJECTIVE: Three indicators used to assess obstetric safety within a hospital are the rates of trauma during either spontaneous vaginal delivery (SVD), assisted vaginal delivery (AVD), or cesarean (CS). The objective of this study is to assess the validity of these three Patient Safety Indicators (PSI’s). STUDY DESIGN: Patient and hospital-level administrative data for all Illinois hospitals in 2001 were used to analyze the association of a hospital’s obstetric trauma rates with 1) individual patient factors; 2) hospital CS rates; 3) hospital obstetric volume; and 4) hospital coding intensity (mean number of ICD-9 diagnosis codes per uncomplicated delivery). Multivariable random effects logistic regression analyses accounting for hospital-level clustering were used to estimate the effects of patient and hospital level factors on the incidence of the three PSI’s. RESULTS: For the 142 hospitals and 175,374 deliveries analyzed, PSI trauma rates were .154/AVD, .044/SVD and .004/CS. Multiple patient characteristics as well as hospital-level CS rates, obstetric volume, and coding intensity (CI) were significantly associated with obstetric trauma at SVD (Table). For AVD and CS, patient factors and CI also were associated with trauma rates, but CS rate and obstetric volume were no longer significant in the model. CONCLUSION: Assessment of obstetric safety by PSI’s may require risk adjustment using individual patient and hospital characteristics.
Age 10-15 Age 16-34 Age O34 Preeclampsia Prior CS Excessive fetal size Hospital CS rate Low volume Medium volume High volume Low CI Medium CI High CI
OR
95% CI
1.3 1.0 .72 1.4 1.4 1.3 1.01 .73 .89 1.0 .84 .90 1.0
1.2-1.5 d .65-.80 1.2-1.7 1.3-1.6 1.2-1.4 1.00-1.02 .64-.82 .82-.98 d .74-.94 .82-.98 d
631 ARE BRACHIAL PLEXUS INJURIES MORE COMMON ON DAYS WITH HIGH VOLUMES OF DELIVERIES? EDITH GUREWITSCH1, JOHN PEZZULLO2, ANADIR SILVA1, SHEFALI AGARWAL3, SAYEH HAMZEHZADEH1, ROBERT ALLEN4, 1Johns Hopkins University, Gynecology and Obstetrics, Baltimore, Maryland, 2Georgetown University, Biostatistics, Washington, District of Columbia, 3Johns Hopkins University, Anesthesia and Critical Care Medicine, Baltimore, Maryland, 4Johns Hopkins University, Biomedical Engineering, Baltimore, Maryland OBJECTIVE: Performance improvement initiatives aimed at increasing patient safety are often at odds with staffing limitations imposed by economic constraints of hospital administration. Shoulder dystocia (SD) is an often unpredictable emergency requiring a coordinated team approach to its management in order to minimize injury risk. We sought to determine whether risk of SD-associated brachial plexus injury (BPI) correlates with delivery caseload on Labor and Delivery (L&D). STUDY DESIGN: With IRB approval, all cephalic vaginal deliveries (VD) complicated by SD and/or BPI occuring at Johns Hopkins Hospital from Jun 1993-May 2004 were identified using ICD-9 codes and verified by review of medical records. Date and time of delivery were recorded and compared to total # of deliveries occuring in the same 24-hr period. Median number of deliveries between days with BPI and days without BPI were compared using Wilcoxon rank sum test, with P!0.05 considered significant. RESULTS: During the 12-yr study period, there were 17,059 cephalic vaginal deliveries, 337 documented SD and 118 BPI, 9 of which were permanent (residual deficit O2 yr). 74 (62%) BPI were associated with recorded SD; all but 1 permanent BPI were SD-associated. There were no differences in the median # of deliveries on days with SD compared to days without SD.
However, the median # of deliveries on days in which BPI occurred was significantly higher than on days in which BPI did not occur [Figure; (P!0.01)] Permanent BPI were also more likely to occur on high-volume days; however, numbers were too small for meaningful statistics. CONCLUSION: Although SD is no more likely to occur on busier days on L&D, the risk of SD-associated BPI is increased when delivery volume is high, suggesting that increased patient-staff ratio can influence outcome of SD.
632 RACIAL DISPARITIES AND VBAC SUCCESS RATES CYNTHIA GYAMFI (F)1, GABOR JUHASZ2, PHYLLIS GYAMFI3, JOANNE L. STONE4, 1Columbia University, Obstetrics and Gynecology, New York, New York, 2University of Debrecen, Medical and Health Science Center, Department of Obstetrics and Gynecology, Debrecen, Hungary, 3ORC Macro, Applied Research Division, Atlanta, Georgia, 4Mount Sinai School of Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, New York, New York OBJECTIVE: To evaluate whether race has an effect vaginal birth after cesarean delivery (VBAC) success. STUDY DESIGN: Patients attempting VBAC were identified by using ICD-9 codes and by reviewing logbooks on Labor and Delivery. A chart review identified patients attempting VBAC who were eligible for inclusion. Exclusion criteria included multiple gestation, greater than one previous cesarean section, previous classical uterine scar, delivery at !36 weeks, and incomplete information. Race was defined as White, Black, Hispanic, Asian, or other, and was obtained by patient self-identification on admission. Variables of interest included previous VBAC, previous successful spontaneous vaginal delivery (SVD), number of pregnancies, history of diabetes, birthweight, time interval between deliveries, and recurrent indication for cesarean section. RESULTS: We identified 1216 patients who met inclusion criteria. There were 58.0% of patients who classified themselves as White, 14.4% Black, 22.0% Hispanic, 4.5% Asian, and 0.9% other. White patients were more likely to have VBAC success (82.7%) when compared to Black (63.4%), Hispanic (73.4%), or Asian (67.3%) patients, p!0.001. When controlling for diabetes, recurrent indication for delivery, previous SVD or VBAC, birthweight, number of pregnancies, and time interval to delivery, Black patients remained more likely to fail VBAC when compared to White patients (OR 0.31, 95% CI 0.19-0.51, pO0.001). Hispanic patients were also less likely to achieve VBAC success (OR 0.65, 95% CI 0.43-1.00, p=0.050), but this finding was not statistically significant. There were no differences between the races in uterine rupture rates. CONCLUSION: Black race may be associated with a decrease in VBAC success. Further studies to verify these findings and identify the mechanism of failure are warranted.
633 WHAT DO WOMEN KNOW ABOUT CESAREAN DELIVERY? LINDA HOPKINS (F)1, RAJITA PATIL1, AARON CAUGHEY1, 1University of California, San Francisco, Obstetrics, Gynecology and Reproductive Sciences, San Francisco, California OBJECTIVE: To assess a diverse population of pregnant women for knowledge regarding cesarean delivery and its complications. STUDY DESIGN: Cross-sectional study of women presenting for prenatal care from 7/04 to 7/05 who completed a detailed questionnaire with 18 demographic, 13 obstetrical knowledge and 4 obstetrical preferences questions. Knowledge questions analyzed by univariate and multivariate logistic regression to determine accuracy of knowledge and predictors of inaccuracy. RESULTS: 251 questionnaires received. Of all respondents, 37.2% were Caucasian, 20.0% Black, 11.6% Latina, 22.0% Asian and 9.2% Other. Regarding obstetrical risks, 8.8% of respondents answered that vaginal delivery had ‘‘more risk to baby’’. These respondents had a higher proportion of women O/=35yo (p=0.02). Regarding cesarean delivery, 47.6% of respondents felt that cesarean delivery had ‘‘more risk to mom’’. In multivariate analysis women with a postgraduate education identified mom at greater risk after undergoing cesarean delivery (OR=0.097, p=0.041), while Black women were more likely to not identify that cesarean delivery carries higher maternal risk (OR=4.89 p=0.043). Regarding knowledge of rate of cesarean delivery, 28.4% answered 20-29%, 9.3% answered !20%, 62.3% answered O29%. See Table for ethnic breakdown. Those who overestimated tended to be younger (p=0.002), Black (p=0.046), Asian (p=0.052), less educated (p=0.014) and multiparous (p=0.01). CONCLUSION: The majority of women in a diverse population overestimate the rate of cesarean delivery, underestimate the risk to the baby with a vaginal delivery and underestimate the risk to mom with a cesarean birth. Patient education regarding the actual risks of mode of delivery is important for them to make decisions that appropriately reflect true risk. Cesarean rate: Responses by ethnicity Response
Rate !20%
Rate 20-29%
Rate O29%
Caucasian Black Latina Asian Other
8.9% 4.9% 0.0% 15.2% 17.6%
37.1% 14.6% 19.1% 34.8% 11.8%
54.0% 80.5% 80.9% 50.0% 70.6%
Age 10-15 Age 16-34 Age O34 Preeclampsia Prior CS Excessive fetal size Hospital CS rate Low volume Medium volume High volume Low CI Medium CI High CI
OR
95% CI
1.3 1.0 .72 1.4 1.4 1.3 1.01 .73 .89 1.0 .84 .90 1.0
1.2-1.5 d .65-.80 1.2-1.7 1.3-1.6 1.2-1.4 1.00-1.02 .64-.82 .82-.98 d .74-.94 .82-.98 d
631 ARE BRACHIAL PLEXUS INJURIES MORE COMMON ON DAYS WITH HIGH VOLUMES OF DELIVERIES? EDITH GUREWITSCH1, JOHN PEZZULLO2, ANADIR SILVA1, SHEFALI AGARWAL3, SAYEH HAMZEHZADEH1, ROBERT ALLEN4, 1Johns Hopkins University, Gynecology and Obstetrics, Baltimore, Maryland, 2Georgetown University, Biostatistics, Washington, District of Columbia, 3Johns Hopkins University, Anesthesia and Critical Care Medicine, Baltimore, Maryland, 4Johns Hopkins University, Biomedical Engineering, Baltimore, Maryland OBJECTIVE: Performance improvement initiatives aimed at increasing patient safety are often at odds with staffing limitations imposed by economic constraints of hospital administration. Shoulder dystocia (SD) is an often unpredictable emergency requiring a coordinated team approach to its management in order to minimize injury risk. We sought to determine whether risk of SD-associated brachial plexus injury (BPI) correlates with delivery caseload on Labor and Delivery (L&D). STUDY DESIGN: With IRB approval, all cephalic vaginal deliveries (VD) complicated by SD and/or BPI occuring at Johns Hopkins Hospital from Jun 1993-May 2004 were identified using ICD-9 codes and verified by review of medical records. Date and time of delivery were recorded and compared to total # of deliveries occuring in the same 24-hr period. Median number of deliveries between days with BPI and days without BPI were compared using Wilcoxon rank sum test, with P!0.05 considered significant. RESULTS: During the 12-yr study period, there were 17,059 cephalic vaginal deliveries, 337 documented SD and 118 BPI, 9 of which were permanent (residual deficit O2 yr). 74 (62%) BPI were associated with recorded SD; all but 1 permanent BPI were SD-associated. There were no differences in the median # of deliveries on days with SD compared to days without SD.
However, the median # of deliveries on days in which BPI occurred was significantly higher than on days in which BPI did not occur [Figure; (P!0.01)] Permanent BPI were also more likely to occur on high-volume days; however, numbers were too small for meaningful statistics. CONCLUSION: Although SD is no more likely to occur on busier days on L&D, the risk of SD-associated BPI is increased when delivery volume is high, suggesting that increased patient-staff ratio can influence outcome of SD.
632 RACIAL DISPARITIES AND VBAC SUCCESS RATES CYNTHIA GYAMFI (F)1, GABOR JUHASZ2, PHYLLIS GYAMFI3, JOANNE L. STONE4, 1Columbia University, Obstetrics and Gynecology, New York, New York, 2University of Debrecen, Medical and Health Science Center, Department of Obstetrics and Gynecology, Debrecen, Hungary, 3ORC Macro, Applied Research Division, Atlanta, Georgia, 4Mount Sinai School of Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, New York, New York OBJECTIVE: To evaluate whether race has an effect vaginal birth after cesarean delivery (VBAC) success. STUDY DESIGN: Patients attempting VBAC were identified by using ICD-9 codes and by reviewing logbooks on Labor and Delivery. A chart review identified patients attempting VBAC who were eligible for inclusion. Exclusion criteria included multiple gestation, greater than one previous cesarean section, previous classical uterine scar, delivery at !36 weeks, and incomplete information. Race was defined as White, Black, Hispanic, Asian, or other, and was obtained by patient self-identification on admission. Variables of interest included previous VBAC, previous successful spontaneous vaginal delivery (SVD), number of pregnancies, history of diabetes, birthweight, time interval between deliveries, and recurrent indication for cesarean section. RESULTS: We identified 1216 patients who met inclusion criteria. There were 58.0% of patients who classified themselves as White, 14.4% Black, 22.0% Hispanic, 4.5% Asian, and 0.9% other. White patients were more likely to have VBAC success (82.7%) when compared to Black (63.4%), Hispanic (73.4%), or Asian (67.3%) patients, p!0.001. When controlling for diabetes, recurrent indication for delivery, previous SVD or VBAC, birthweight, number of pregnancies, and time interval to delivery, Black patients remained more likely to fail VBAC when compared to White patients (OR 0.31, 95% CI 0.19-0.51, pO0.001). Hispanic patients were also less likely to achieve VBAC success (OR 0.65, 95% CI 0.43-1.00, p=0.050), but this finding was not statistically significant. There were no differences between the races in uterine rupture rates. CONCLUSION: Black race may be associated with a decrease in VBAC success. Further studies to verify these findings and identify the mechanism of failure are warranted.
633 WHAT DO WOMEN KNOW ABOUT CESAREAN DELIVERY? LINDA HOPKINS (F)1, RAJITA PATIL1, AARON CAUGHEY1, 1University of California, San Francisco, Obstetrics, Gynecology and Reproductive Sciences, San Francisco, California OBJECTIVE: To assess a diverse population of pregnant women for knowledge regarding cesarean delivery and its complications. STUDY DESIGN: Cross-sectional study of women presenting for prenatal care from 7/04 to 7/05 who completed a detailed questionnaire with 18 demographic, 13 obstetrical knowledge and 4 obstetrical preferences questions. Knowledge questions analyzed by univariate and multivariate logistic regression to determine accuracy of knowledge and predictors of inaccuracy. RESULTS: 251 questionnaires received. Of all respondents, 37.2% were Caucasian, 20.0% Black, 11.6% Latina, 22.0% Asian and 9.2% Other. Regarding obstetrical risks, 8.8% of respondents answered that vaginal delivery had ‘‘more risk to baby’’. These respondents had a higher proportion of women O/=35yo (p=0.02). Regarding cesarean delivery, 47.6% of respondents felt that cesarean delivery had ‘‘more risk to mom’’. In multivariate analysis women with a postgraduate education identified mom at greater risk after undergoing cesarean delivery (OR=0.097, p=0.041), while Black women were more likely to not identify that cesarean delivery carries higher maternal risk (OR=4.89 p=0.043). Regarding knowledge of rate of cesarean delivery, 28.4% answered 20-29%, 9.3% answered !20%, 62.3% answered O29%. See Table for ethnic breakdown. Those who overestimated tended to be younger (p=0.002), Black (p=0.046), Asian (p=0.052), less educated (p=0.014) and multiparous (p=0.01). CONCLUSION: The majority of women in a diverse population overestimate the rate of cesarean delivery, underestimate the risk to the baby with a vaginal delivery and underestimate the risk to mom with a cesarean birth. Patient education regarding the actual risks of mode of delivery is important for them to make decisions that appropriately reflect true risk. Cesarean rate: Responses by ethnicity Response
Rate !20%
Rate 20-29%
Rate O29%
Caucasian Black Latina Asian Other
8.9% 4.9% 0.0% 15.2% 17.6%
37.1% 14.6% 19.1% 34.8% 11.8%
54.0% 80.5% 80.9% 50.0% 70.6%