Variation in primary cesarean delivery rates by individual physician within a single-hospital laborist model

Abstract

Background Laborist practice models are associated with lower cesarean delivery rates than individual private practice models in several studies; however, this effect is not uniform. Further exploration of laborist models may help us better understand the observed reduction in cesarean delivery rates in some hospitals with implementation of a laborist model. Objective Our objective was to evaluate the degree of variation in primary cesarean delivery rates by individual laborists within a single institution employing a laborist model. In addition, we sought to evaluate whether differences in cesarean delivery rates resulted in different maternal or short-term neonatal outcomes. Study Design At this teaching institution, one laborist (either a generalist or maternal-fetal medicine attending physician) is directly responsible for labor and delivery management during each shift. No patients are followed in a private practice model nor are physicians incentivized to perform deliveries. We retrospectively identified all laborists who delivered nulliparous, term women with cephalic singletons at this institution from 2007-14. Overall and individual primary cesarean delivery rates were reported as percentages with exact Pearson 95% CI. Laborists were grouped by tertile as having low, medium or high cesarean delivery rates. Characteristics of the women delivered, indications for cesarean delivery, and short-term neonatal outcomes were compared between these groups. A binomial regression model of cesarean delivery was estimated, where the relative rates of each laborist compared to the lowest-unadjusted laborist rate were calculated; a second model was estimated to adjust for patient-level maternal characteristics. Results Twenty laborists delivered 2,224 nulliparous, term women with cephalic singletons. The overall cesarean delivery rate was 24.1% (95% CI 21.4-26.8). In an unadjusted binomial model, the overall effect of individual laborist was significant (p<0.001), and a 2.9 fold (1.5, 5.4, p=0.001) variation between the cesarean delivery rates of the highest (35.9%) and lowest (12.5%) physicians was observed. When adjusted for hypertensive disease, gestational age at delivery, race, and maternal age, the physician effect remained overall significant (p=0.0265) with the difference between physicians expanding to 3.58 (1.72-7.47, p<0.001). Between groups of laborists with low, medium, and high cesarean delivery rates, patient demographics and clinical characteristics of the population managed were clinically similar and not different statistically. The primary indication for cesarean delivery did not differ between groups. Similarly there were no differences in short-term neonatal outcomes including Apgar scores, arterial cord blood pH or incidence of neonatal encephalopathy. Conclusion The 3-fold variation in cesarean delivery rates between laborists at the same institution without observed differences in patient characteristics or short-term neonatal outcomes draws attention to the impact of individual physic...

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