Maternal clinical diagnoses and hospital variation in the risk of cesarean delivery: analyses of a National US Hospital Discharge Database.

Published on Oct 21, 2014in PLOS Medicine11.069
· DOI :10.1371/JOURNAL.PMED.1001745
Katy B. Kozhimannil33
Estimated H-index: 33
(UMN: University of Minnesota),
Mariana C. Arcaya19
Estimated H-index: 19
(Harvard University),
Subbaya Subramanian51
Estimated H-index: 51
(Harvard University)
Sources
Abstract
Background: Cesarean delivery is the most common inpatient surgery in the United States, where 1.3 million cesarean sections occur annually, and rates vary widely by hospital. Identifying sources of variation in cesarean use is crucial to improving the consistency and quality of obstetric care. We used hospital discharge records to examine the extent to which variability in the likelihood of cesarean section across US hospitals was attributable to individual women’s clinical diagnoses. Methods and Findings: Using data from the 2009 and 2010 Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project—a 20% sample of US hospitals—we analyzed data for 1,475,457 births in 1,373 hospitals. We fitted multilevel logistic regression models (patients nested in hospitals). The outcome was cesarean (versus vaginal) delivery. Covariates included diagnosis of diabetes in pregnancy, hypertension in pregnancy, hemorrhage during pregnancy or placental complications, fetal distress, and fetal disproportion or obstructed labor; maternal age, race/ethnicity, and insurance status; and hospital size and location/teaching status. The cesarean section prevalence was 22.0% (95% confidence interval 22.0% to 22.1%) among women with no prior cesareans. In unadjusted models, the between-hospital variation in the individual risk of primary cesarean section was 0.14 (95% credible interval 0.12 to 0.15). The difference in the probability of having a cesarean delivery between hospitals was 25 percentage points. Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics (0.16 [95% credible interval 0.14 to 0.18]). A limitation is that these data, while nationally representative, did not contain information on parity or gestational age. Conclusions: Variability across hospitals in the individual risk of cesarean section is not decreased by accounting for differences in maternal diagnoses. These findings highlight the need for more comprehensive or linked data including parity and gestational age as well as examination of other factors—such as hospital policies, practices, and culture—in determining cesarean section use. Please see later in the article for the Editors’ Summary.
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KEY FINDINGS: Data from the natality data file, national vital statistics system. After 12 years of consecutive increases, the preliminary cesarean delivery rate among singleton births was unchanged from 2009 to 2011 (31.3%). Cesarean delivery rates decreased more than 5% among births at 38 weeks of gestation, but increased 4% among births at 39 weeks. Decreases in cesarean delivery rates for births at 38 weeks occurred for non-Hispanic white, non-Hispanic black, and Hispanic women, as well as f...
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OBJECTIVE To characterize medical, obstetric, and demographic risk factors associated with nulliparous, term, singleton, vertex (NTSV) cesarean birth. STUDY DESIGN Cross sectional study. SETTING United States delivery hospitalizations. POPULATION NTSV births in 2016-2018 US natality data. METHODS This study analyzed a national sample of natality data generated by the United States National Vital Statistics System. NTSV deliveries were identified. The primary outcome was cesarean birth. Risk fact...
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