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28: Variation in primary cesarean delivery rates by individual physicians within a single hospital laborist model

      Objective

      Laborist practice models are associated with lower cesarean delivery (CD) rates than private practice models. Our objective is to evaluate the degree of variation in primary CD rates by individual laborists within a single institution employing a laborist model to better understand the observed reduction in CD.

      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 CD rates were reported as percentages with 95% CI. Deliveries managed by our midwifery service or with a contraindication to vaginal delivery were excluded. Laborists were grouped by tertile as having low, medium or high CD rates. Characteristics of the women delivered, indications for CD, and short-term neonatal outcomes were compared between these groups.

      Results

      Twenty laborists delivered 2,224 nulliparous, term women with cephalic singletons. The overall CD rate was 24.1% (95% CI 21.4-26.8). CD rates for individual providers varied from a low of 12.5% to a high of 36.0% (Figure). Between groups of providers with low, medium, and high CD rates, there were no significant differences in patient demographics or clinical characteristics of the population managed (Table). Distribution of indications for CD (fetal status, arrest disorders, elective, other) did not differ between groups. Similarly there were no differences in short-term neonatal outcomes (Table).

      Conclusion

      The nearly 3-fold variation in CD 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 physician decision-making on CD rates even within a laborist care model. Further exploration of specific physician traits that influence CD rates is warranted.
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