Unexplained variation in hospital caesarean section rates

Abstract

Healthcare Standards (ACHS).2 The ACHS defines the 20 th centile as a "best practice rate" that is potentially achievable and uses it to identify and prioritise clinical areas in which research and quality improvement activity would have the greatest benefits. Using the 20 th centile rate for quantifying the potential impact on the overall caesarean rate of reducing practice variation is appealing, as it does not rely on an arbitrary target value but instead is data-driven, being influenced by the rates currently achieved by 20% of hospitals. Importantly, appropriately risk-adjusted caesarean rates, rather than the observed caesarean rates, should be compared with the 20 th centile.However, we urge caution in immediate use of the 20 th centile, as lower caesarean rates should not be achieved at the possible expense of increased adverse outcomes. Our initial study 1 aimed to identify clinically relevant groups with the greatest (and potentially most modifiable) variation in hospital caesarean rates, adjusted for casemix. A detailed analysis of outcomes was beyond the scope of that paper. We are currently exploring the Robson Groups with the greatest variation in hospital caesarean rates using more comprehensive data obtained through record linkage. Our aim is to identify further factors contributing to variation in each group, if any, and to examine the relationship between caesarean rates and maternal and neonatal outcomes.

Interinstitutional variations in mode of birth after a previous caesarean section: a cross-sectional study in six German hospitals

“…This is a consequence of rising rates of caesarean section during the first childbirth [8]. Not only national variations in caesarean section rates have been noted [8,34,40], regional variations within countries and interinstitutional variations have been observed as well [2,15,25,28,30,31,36]. As a consequence, when interinstitutional variations in caesarean sections rates [2,30] are analysed, variations in regional patterns [15,28,31] need to be taken into account.…”

Variation in coronary angiography rates in Australia: correlations with socio‐demographic, health service and disease burden indices

“…For example, a 2013 study of found a 4-fold variation in casemix-adjusted caesarean section rates by hospital in New South Wales. 34 Further investigation is required to determine the specific drivers of the relatively high caesarean section rates in Australia. Future work could examine variation in elective and emergency caesarean section rates, and the effect of factors such as maternal obesity and maternal requests as a drivers of variation in the rates of this procedure.…”

Variation in hospital caesarean section rates for preterm births

“…The variables and data sources in this study have been validated for use in research in several studies . We have improved on previous studies of variation in preterm caesarean section rates by including comprehensive data on maternal comorbidities and history of adverse birth outcomes and by adjusting for clustering of women with similar characteristics at different hospitals. Importantly, we have also investigated whether variation in caesarean section rates is associated with individual‐level and hospital‐level severe maternal or neonatal morbidity, which is important for determining whether observed variation is ‘unwarranted’ in terms of health outcomes .…”

“…Consistent with the lack of clear evidence about optimal mode of delivery, there is considerable variation in caesarean rates among preterm births . Variation in preterm caesarean rates may reflect differences in the demographic characteristics and health status of the source population (‘casemix’) as well as differences in clinical practice and hospital characteristics.…”

“…Variation in preterm caesarean rates may reflect differences in the demographic characteristics and health status of the source population (‘casemix’) as well as differences in clinical practice and hospital characteristics. Previous studies that have explored variation in preterm caesarean section rates have been limited by the lack of comprehensive data on maternal comorbidities, pregnancy history and hospital characteristics . There is limited evidence on the maternal and neonatal outcomes associated with variation in preterm caesarean rates …”