Risk-adjusted models for adverse obstetric outcomes and variation in risk-adjusted outcomes across hospitals

Bailit, Jennifer L.; Grobman, William A.; Rice, Madeline Murguia; Spong, Catherine Y.; Wapner, Ronald J.; Varner, Michael W.; Thorp, John M.; Leveno, Kenneth J.; Caritis, Steve N.; Shubert, Phillip J.; Tita, Alan T.N.; Saade, George R.; Sorokin, Yoram; Rouse, Dwight J.; Blackwell, Sean C.; Tolosa, Jorge E.; Dorsten, J. Peter Van

doi:10.1016/j.ajog.2013.07.019

Cited by 88 publications

(101 citation statements)

References 21 publications

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“…20,30 Numerous other studies have found a lack of correlation between quality indicators and the clinical outcomes they are supposed to reflect. Hospital Compare measures only predict small differences in hospital-risk adjusted mortality rates for heart failure, pneumonia and acute MI.…”

Section: Discussionmentioning

confidence: 99%

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

Howell

Zeitlin

Hebert

et al. 2014

JAMA

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Importance In an effort to improve the quality of care, several obstetric-specific quality measures are now monitored and publically reported. The extent to which these measures are associated with maternal and neonatal morbidity is not known. Objective To examine whether 2 Joint Commission obstetric quality indicators are associated with maternal and neonatal morbidity. Design, Setting, and Participants Population-based observational study using linked 2010 New York City discharge and birth certificate datasets. All delivery hospitalizations were identified and two perinatal quality measures were calculated. Published algorithms were used to identify severe maternal morbidity (delivery associated with a life threatening complication or performance of a life-saving procedure) and morbidity in non-anomalous term newborns (births associated with complications such as birth trauma, hypoxia, and prolonged length of stay). Mixed-effects logistic regression models were used to examine the association between maternal morbidity, neonatal morbidity, and hospital-level quality measures while risk-adjusting for patient sociodemographic and clinical characteristics. Exposure Two Joint Commission perinatal quality measures: 1) elective (non-medically indicated) deliveries at >= 37 and < 39 weeks of gestation and 2) cesarean delivery performed in low-risk mothers. Main Outcomes and Measures Individual and hospital level maternal and neonatal morbidity. Results Severe maternal morbidity occurred among 2.4% of 115,742 deliveries and neonatal morbidity occurred among 7.8% of 103,416 non-anomalous term newborns. Rates for elective deliveries performed before 39 weeks of gestation ranged from: 15.5 to 41.9 per 100 deliveries among 41 hospitals. There were 11.7 to 39.3 cesareans per 100 deliveries performed in low-risk mothers. Overall maternal morbidity ranged from 0.9 to 5.7 mothers with complications per 100 deliveries and 3.1 to 21.3 neonates with complications per 100 deliveries. The maternal quality indicators elective delivery before 39 weeks of gestation and cesarean delivery performed in low-risk mothers were not associated with severe maternal complications (RR, 1.00; 95% CI: 0.98–1.02 and RR, 0.99, 95% CI: 0.96–1.01, respectively) or neonatal morbidity (RR, 0.99; 95% CI: 0.97–1.01 and RR, 1.01, 95% CI: 0.99–1.03, respectively). Conclusions and Relevance Rates for the quality indicators elective delivery before 39 weeks of gestation and cesarean delivery performed in low risk mothers varied widely in New York City hospitals as did maternal and neonatal complications rates. However, there were no correlations between the quality indicator rates and maternal and neonatal morbidity. Current quality indicators may not be sufficiently comprehensive for guiding quality improvement in obstetric care.

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Section: Discussionmentioning

confidence: 99%

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

Howell

Zeitlin

Hebert

et al. 2014

JAMA

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“…11 The same methodologies were used to determine the patient characteristics that should be used for risk adjustment for preeclampsia and shoulder dystocia. Only women eligible for a given outcome were included (e.g., women who did not deliver vaginally were not assessed with regard to shoulder dystocia).…”

Section: Methodsmentioning

confidence: 99%

Does the presence of a condition-specific obstetric protocol lead to detectable improvements in pregnancy outcomes?

Bailit

Grobman²,

McGee

et al. 2015

American Journal of Obstetrics and Gynecology

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Objective To evaluate whether the presence of condition-specific obstetric protocols within a hospital was associated with better maternal and neonatal outcomes. Study Design Cohort study of a random sample of deliveries performed at 25 hospitals over three years. Condition-specific protocols were collected from all hospitals and categorized independently by two authors. Data on maternal and neonatal outcomes, as well as data necessary for risk adjustment were collected. Risk-adjusted outcomes were compared according to whether the patient delivered in a hospital with condition-specific obstetric protocols at the time of delivery. Results Hemorrhage-specific protocols were not associated with a lower rate of postpartum hemorrhage or with fewer cases of EBL >1000cc. Similarly, in the presence of a shoulder dystocia protocol, there were no differences in the frequency of shoulder dystocia or number of shoulder dystocia maneuvers used. Conversely, preeclampsia-specific protocols were associated with fewer ICU admissions (OR 0.28, 95% CI 0.18–0.44) and fewer cases of severe maternal hypertension (OR 0.86, 95% CI 0.77–0.96). Conclusion The presence of condition-specific obstetric protocols was not consistently shown to be associated with improved risk-adjusted outcomes. Our study would suggest that the presence or absence of a protocol does not matter and regulations to require protocols are not fruitful.

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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: 98%

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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Risk-adjusted models for adverse obstetric outcomes and variation in risk-adjusted outcomes across hospitals

Cited by 88 publications

References 21 publications

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

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

Does the presence of a condition-specific obstetric protocol lead to detectable improvements in pregnancy outcomes?

Obstetric Safety and Quality

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