Effectiveness and Outcomes in Health Care Proceedings of an Invitational Conference (1990) / Chapter Skim
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22 An Attempt to Manage Variation in Obstetrical Practice
22 An Attempt to Manage Variation in Obstetrical Practice
Pages 190-200
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From page 190... ...
, decided that as part of his quality measurement activities it would be important to develop data bases on common clinical activities. The data bases would contain information on outcomes of interest.
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From page 191... ...
VARIATIONS IN PRACTICE BETWEEN TWO HOSPITALS Hospitals A and B have fully developed academic departments of obstetrics and gynecology headed by full professors at Harvard Medical School. They are believed to have comparable outcomes in terms of neonatal mortality for comparable populations, although hospital A serves as a regional perinatal center, takes care of more referred high-risk obstetrical patients, and has a much larger and more sophisticated neonatal intensive-care unit (ICU)
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From page 192... ...
The lowest rates of operative deliveries are for health centers using hospital B (see Table 3~. The occurrence of forceps deliveries is much lower in the hospital with the lower cesarean section rate; this is an unexpected finding, since one might predict that in order to avoid a cesarean section for problems such as cephalopelvic disproportion, the physician would have to extract the baby with forceps.
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From page 193... ...
Although substantial center-to-center differences exist, no single characteristic correlates with a high cesarean section or forceps delivery rate. A multivariate analysis with a large number of potential confounding variables was unable to demonstrate any important contributor to the observed variation in type of delivery by health center other than the hospital at which the delivery occurred.
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From page 194... ...
Cesarean section is associated with significant maternal morbidity, including infections, increased length of stay, and higher hospitalization costs. In recent years, despite continued increases in cesarean section rates nationwide, it has not been possible to show a continued concomitant improvement in neonatal outcomes.
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From page 195... ...
but he had also practiced in hospital A a decade earlier and was respected by the chairman in hospital A He had moved back to hospital B and had developed the departments of obstetrics in the two health centers using hospital B
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From page 196... ...
The burdens of obtaining data for the obstetrical data base were sufficiently great that no additional data were collected for deliveries between July 1987 and September 1988. Data collection resumed in the fall of 1988, but only for a 50 percent sample of deliveries; the data shown in Table 5, therefore, are for only a small number of patients.
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From page 197... ...
Even though HCHP has automated medical records for all but two centers, and thus easy access to prenatal records, the information presented here does not come from routinely collected data. It is hard to collect and analyze the data for enough potential confounders
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From page 198... ...
I believe that there is enough softness in the definitions of cephalopelvic disproportion, failure to progress, and fetal distress that an independent group of experts assessing only the records of patients having a cesarean section in the two hospitals would have concluded that a similar percentage of the cesarean sections in the hospitals was "appropriate." The departments of obstetrics in these hospitals have regular reviews of their own cesarean sections and rarely conclude that one is inappropriate. Accordingly, had we followed the appropriateness approach to assessing variation in surgical practices, we might have concluded that the overall difference in cesarean rates between these two hospitals was most likely due to some occult underlying difference in the populations rather than to a difference in the process of care.
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From page 199... ...
Most important, health care experts and providers will have to learn how information, once obtained, can be used to generate process improvements. The trick is in getting from Health Care Financing Administration mortality data or HCHP cesarean rates to some intervention.
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From page 200... ...
That would be very unfortunate, for we will have lost a major opportunity to examine, evaluate, and improve the way we give medical care. ACKNOWLEDGMENTS I wish to thank the following persons on the HCHP obstetrical data base staff who developed and maintained this data base and who kindly made available the data in this chapter: Kay Larholtz, statistical specialist; Debra Cookson, project coordinator; Diana Parks Forbes, obstetrical database consultant; and Donald M
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