The Application of the Ten Group Classification System (TGCS) in Caesarean Delivery Case Mix Adjustment. A Multicenter Prospective Study

Abstract

BackgroundCaesarean delivery (CD) rates are commonly used as an indicator of quality in obstetric care and risk adjustment evaluation is recommended to assess inter-institutional variations. The aim of this study was to evaluate whether the Ten Group classification system (TGCS) can be used in case-mix adjustment.MethodsStandardized data on 15,255 deliveries from 11 different regional centers were prospectively collected. Crude Risk Ratios of CDs were calculated for each center. Two multiple logistic regression models were herein considered by using: Model 1- maternal (age, Body Mass Index), obstetric variables (gestational age, fetal presentation, single or multiple, previous scar, parity, neonatal birth weight) and presence of risk factors; Model 2- TGCS either with or without maternal characteristics and presence of risk factors. Receiver Operating Characteristic (ROC) curves of the multivariate logistic regression analyses were used to assess the diagnostic accuracy of each model. The null hypothesis that Areas under ROC Curve (AUC) were not different from each other was verified with a Chi Square test and post hoc pairwise comparisons by using a Bonferroni correction.ResultsCrude evaluation of CD rates showed all centers had significantly higher Risk Ratios than the referent. Both multiple logistic regression models reduced these variations. However the two methods ranked institutions differently: model 1 and model 2 (adjusted for TGCS) identified respectively nine and eight centers with significantly higher CD rates than the referent with slightly different AUCs (0.8758 and 0.8929 respectively). In the adjusted model for TGCS and maternal characteristics/presence of risk factors, three centers had CD rates similar to the referent with the best AUC (0.9024).ConclusionsThe TGCS might be considered as a reliable variable to adjust CD rates. The addition of maternal characteristics and risk factors to TGCS substantially increase the predictive discrimination of the risk adjusted model.

Can body mass index accurately predict adiposity in newborns?

“…Moreover, mothers with a high BMI are under-represented. However, prepregnancy BMI in our sample reflects that of mothers coming from our region 7. Therefore, our results may not be generalisable to populations with a different maternal nutritional status.…”

Understanding inappropriateness in health spending: The role of regional policies and institutions in caesarean deliveries

“…First, by taking an aggregate approach, it adds to patient level studies on the determinants of caesarean deliveries (see, e.g., recent examples of different approaches in Maso et al, 2013a;Maso et al, 2013b;Bragg et al 2010;Dranove and Watanabe, 2010;Ecker and Frigoletto, 2007;Fantini et al, 2006;Baicker et al, 2006;Johanson et al, 2006). Second, proposing an analysis at the regional level, the present work is also related to papers on regional variations in health care and in medical practice (e.g., Skinner, 2012, andChandra et al, 2012 for recent surveys).…”

“…For instance, obesity, chronic hypertension, gestational diabetes are all clinical conditions used in the medical literature to adjust observed caesarean sections for risk, and to define the quality of obstetric care (see, e.g., recent works by Maso et al, 2013a;Maso et al, 2013b;Fantini et al, 2006;Bragg et al 2010 ). All these factors have deteriorated in recent decades.…”

“…The variables that have been identified as risk factors in the choice of a caesarean delivery by the medical literature based on Italian microdata (e.g., Maso et al, 2013a;Maso et al, 2013b;Fantini et al, 2006) include both foetus characteristics (like malposition/malpresentation and weight), and mother characteristics (like ante-partum haemorrhage, APH, umbilical cord prolapse, UCP, but also age, past experience of a caesarean section, and lifestyle habits). However, the literature makes clear that, even controlling for these risk factors, differences across hospitals still persist.…”

Interinstitutional Variation of Caesarean Delivery Rates According to Indications in Selected Obstetric Populations: A Prospective Multicenter Study

“…However, the objective of our study was not to evaluate the adjusted CD rates of each institution, rather to provide a simple and immediate tool to assess which groups and indications contributed to the institutional CD rates [31]. Moreover, we demonstrated that the TGCS risk adjustment either with or without the inclusion of maternal characteristics and obstetrical risk factors, as predictors, might be considered as a reliable method to properly assess inter-institutional variation of CD rates [32]. …”