Association Between Hospital-Level Obstetric Quality Indicators and Maternal and Neonatal Morbidity

Howell, Elizabeth A.; Zeitlin, Jennifer; Hebert, Paul L.; Balbierz, Amy; Egorova, Natalia

doi:10.1001/jama.2014.13381

Cited by 87 publications

(53 citation statements)

References 31 publications

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“…These conditions have been used to risk-adjust for severe maternal morbidity, 19 cesarean deliveries, and other maternal outcomes. 16,20,21 …”

Section: Methodsmentioning

confidence: 99%

“…The few studies that have examined this topic suggest that racial/ethnic minority women often deliver in lower quality hospitals. 14,15 In our previous work investigating quality measures and severe maternal morbidity in New York City, 16 we found wide variation in hospital performance. The objective for this study was to examine whether variation in hospital performance on severe maternal morbidity in New York City hospitals contributes to black-white disparities in this outcome.…”

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confidence: 90%

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Site of delivery contribution to black-white severe maternal morbidity disparity

Howell

Egorova

Balbierz

et al. 2016

American Journal of Obstetrics and Gynecology

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190

154

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BACKGROUND The black-white maternal mortality disparity is the largest disparity among all conventional population perinatal health measures and the mortality gap between black and white women in New York City has nearly doubled in recent years. For every maternal death, 100 women experience severe maternal morbidity, a life threatening diagnosis or undergo a lifesaving procedure during their delivery hospitalization. Like maternal mortality, severe maternal morbidity is more common among black than white women. A significant portion of maternal morbidity and mortality is preventable making quality of care in hospitals a critical lever for improving outcomes. Hospital variation in risk-adjusted severe maternal morbidity rates exists. The extent to which variation in hospital performance on severe maternal morbidity rates contributes to black-white disparities in New York City hospitals has not been studied. OBJECTIVE We examined the extent to which black-white differences in severe maternal morbidity rates in New York City hospitals can be explained by differences in the hospitals in which black and white women deliver. STUDY DESIGN We conducted a population-based study using linked 2011–2013 New York City discharge and birth certificate datasets (N= 353,773 deliveries) to examine black-white differences in severe maternal morbidity rates in New York City hospitals. Mixed-effects logistic regression with a random hospital-specific intercept was used to generate risk-standardized severe maternal morbidity rates for each hospital (N=40). We then assessed differences in the distributions of black and white deliveries among these hospitals. RESULTS Severe maternal morbidity occurred in 8,882 deliveries (2.5%) and was higher among black than white women (4.2% vs. 1.5%, p<.001). After adjustment for patient characteristics and comorbidities the risk remained elevated for black women (odds ratio=2.02; 95% CI 1.89–2.17). Risk-standardized severe maternal morbidity rates among New York City hospitals ranged from 0.8 to 5.7 per 100 deliveries. White deliveries were more likely to be delivered in low morbidity hospitals: 65% of white versus 23% of black deliveries occurred in hospitals in the lowest tertile for morbidity. We estimated that black-white differences in delivery location may contribute as much as 47.7% of the racial disparity in severe maternal morbidity rates in New York City. CONCLUSION Black mothers are more likely to deliver at higher risk-standardized severe maternal morbidity hospitals than are white mothers, contributing to black-white disparities. More research is needed to understand the attributes of high performing hospitals and to share best practices among hospitals.

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“…These conditions have been used to risk-adjust for severe maternal morbidity, 19 cesarean deliveries, and other maternal outcomes. 16,20,21 …”

Section: Methodsmentioning

confidence: 99%

mentioning

confidence: 90%

Site of delivery contribution to black-white severe maternal morbidity disparity

Howell

Egorova

Balbierz

et al. 2016

American Journal of Obstetrics and Gynecology

Self Cite

190

154

View full text Add to dashboard Cite

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“…Moreover, this study as well as a study by Howell et al demonstrated that outcomes were not clearly related to process measures that had been proposed. [29][30][31] Unauthorized reproduction of this article is prohibited.…”

Section: Measuring Quality and Safetymentioning

confidence: 99%

Obstetric Safety and Quality

Pettker

Grobman

2015

Obstetrics & Gynecology

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Obstetric safety and quality is an emerging and important topic not only as a result of the pressures of patient and regulatory expectations, but also because of the genuine interest of caregivers to reduce harm, improve outcomes, and optimize care. Although each seeks to improve care by using scientific approaches beyond human physiology and pathophysiology, patient safety methodologies seek to avoid preventable adverse events, whereas health care quality projects aim to achieve the best possible outcomes. It is well-documented that an increasingly complex medical system controlled by human workers is a circumstance subject to recurrent failure. A safety culture encourages a proactive approach to mitigate failure before, during, and after it occurs. This article highlights the key concepts in health care safety and quality and reviews the background of the quality improvement sciences with particular emphasis on obstetric outcomes and quality measures.

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“…11 However, despite substantial face validity, there is growing evidence that guideline compliance alone is an inaccurate and inadequate measure of hospital quality. 12,13 Multiple studies have demonstrated a loose association between compliance with Medicare's Hospital Compare measures (eg, giving aspirin within 24 hours of an acute myocardial infarction) and inpatient mortality rates. 14,15 More specific to surgery, hospitals that score well on perioperative safety measures do not appear to have lower rates of surgical site infection, 16 venous thromboembolism, 17 or mortality.…”

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confidence: 99%

Compliance With Evidence-Based Guidelines and Interhospital Variation in Mortality for Patients With Severe Traumatic Brain Injury

et al. 2015

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IMPORTANCECompliance with evidence-based guidelines in traumatic brain injury (TBI) has been proposed as a marker of hospital quality. However, the association between hospital-level compliance rates and risk-adjusted clinical outcomes for patients with TBI remains poorly understood.OBJECTIVE To examine whether hospital-level compliance with the Brain Trauma Foundation guidelines for intracranial pressure monitoring and craniotomy is associated with risk-adjusted mortality rates for patients with severe TBI. DESIGN, SETTING, AND PARTICIPANTS All adult patients (N = 734) who presented to a regional consortium of 14 hospitals from January 1, 2009, through December 31, 2010, with severe TBI (ie, blunt head trauma, Glasgow Coma Scale score of <9, and abnormal intracranial findings from computed tomography of the head). Data analysis took place from December 2013 through January 2015. We used hierarchical mixed-effects models to assess the association between hospital-level compliance with Brain Trauma Foundation guidelines and mortality rates after adjusting for patient-level demographics, severity of trauma (eg, mechanism of injury and Injury Severity Score), and TBI-specific variables (eg, cranial nerve reflexes and findings from computed tomography of the head). MAIN OUTCOMES AND MEASURESHospital-level risk-adjusted inpatient mortality rate and hospital-level compliance with Brain Trauma Foundation guidelines for intracranial pressure monitoring and craniotomy.RESULTS Unadjusted mortality rates varied by site from 20.0% to 50.0% (median, 42.6; interquartile range, 35.5-46.2); risk-adjusted rates varied from 24.3% to 56.7% (median, 41.1; interquartile range, 36.4-47.8). Overall, only 338 of 734 patients (46.1%) with an appropriate indication underwent placement of an intracranial pressure monitor and only 134 of 335 (45.6%) underwent craniotomy. Hospital-level compliance ranged from 9.6% to 65.2% for intracranial pressure monitoring and 6.7% to 76.2% for craniotomy. Despite widespread variation in compliance across hospitals, we found no association between hospital-level compliance rates and risk-adjusted patient outcomes (Spearman ρ = 0.030 [P = .92] for ICP monitoring and Spearman ρ = −0.066 [P = .83] for craniotomy). CONCLUSIONS AND RELEVANCEHospital-level compliance with evidence-based guidelines has minimal association with risk-adjusted outcomes in patients with severe TBI. Our results suggest that caution should be taken before using compliance with these measures as independent quality metrics. Given the complexity of TBI care, outcomes-based metrics, including functional recovery, may be more accurate than current process measures at determining hospital quality.

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Association Between Hospital-Level Obstetric Quality Indicators and Maternal and Neonatal Morbidity

Cited by 87 publications

References 31 publications

Site of delivery contribution to black-white severe maternal morbidity disparity

Site of delivery contribution to black-white severe maternal morbidity disparity

Obstetric Safety and Quality

Compliance With Evidence-Based Guidelines and Interhospital Variation in Mortality for Patients With Severe Traumatic Brain Injury

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