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A new index for obstetrics safety and quality of care: integrating cesarean delivery rates with maternal and neonatal outcomes

  • Sangeeta Ramani
    Correspondence
    Corresponding author: Sangeeta Ramani, MD.
    Affiliations
    Department of Obstetrics and Gynecology, NYU Langone Hospital—Long Island, NYU Long Island School of Medicine, Mineola, NY
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  • Tara A. Halpern
    Affiliations
    Department of Obstetrics and Gynecology, NYU Langone Hospital—Long Island, NYU Long Island School of Medicine, Mineola, NY
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  • Meredith Akerman
    Affiliations
    Biostatistics Core, NYU Langone Hospital—Long Island, NYU Long Island School of Medicine, Mineola, NY

    Division of Health Services Research, Department of Foundations of Medicine, NYU Long Island School of Medicine, Mineola, NY
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  • Cande V. Ananth
    Affiliations
    Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ

    Cardiovascular Institute of New Jersey and Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ

    Environmental and Occupational Health Sciences Institute, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ

    Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ
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  • Anthony M. Vintzileos
    Affiliations
    Department of Obstetrics and Gynecology, NYU Langone Hospital—Long Island, NYU Long Island School of Medicine, Mineola, NY
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Published:October 08, 2021DOI:https://doi.org/10.1016/j.ajog.2021.10.005

      Background

      Cesarean delivery rates have been used as obstetrical quality indicators. However, these approaches do not consider the accompanying maternal and neonatal morbidities. A challenge in the field of obstetrics has been to establish a valid outcomes quality measure that encompasses preexisting high-risk maternal factors and associated maternal and neonatal morbidities and is universally acceptable to all stakeholders, including patients, healthcare providers, payers, and governmental agencies.

      Objective

      This study aimed to (1) establish a new single metric for obstetrical quality improvement among nulliparous patients with term singleton vertex-presenting fetus, integrating cesarean delivery rates adjusted for preexisting high-risk maternal factors with associated maternal and neonatal morbidities, and (2) determine whether obstetrician quality ranking by this new metric is different compared with the rating based on individual crude and/or risk-adjusted cesarean delivery rates. The single metric has been termed obstetrical safety and quality index.

      Study Design

      This was a cross-sectional study of all nulliparous patients with term singleton vertex-presenting fetuses delivered by 12 randomly chosen obstetricians in a single institution. A review of all records was performed, including a review of maternal high-risk factors and maternal and neonatal outcomes. Maternal and neonatal medical records were reviewed to determine crude and adjusted cesarean delivery rates by obstetricians and quantify maternal and neonatal complications. We estimated the obstetrician-specific crude cesarean delivery rates and rates adjusted for obstetrician-specific maternal and neonatal complications from logistic regression models. From this model, we derived the obstetrical safety and quality index for each obstetrician. The final ranking based on the obstetrical safety and quality index was compared with the initial ranking by crude cesarean delivery rates. Maternal and neonatal morbidities were analyzed as ≥1 and ≥2 maternal and/or neonatal complications.

      Results

      These 12 obstetricians delivered a total of 535 women; thus, 1070 (535 maternal and 535 neonatal) medical records were reviewed to determine crude and adjusted cesarean delivery rates by obstetricians and quantify maternal and neonatal complications. The ranking of crude cesarean delivery rates was not correlated (rho=0.05; 95% confidence interval, −0.54 to 0.60) to the final ranking based on the obstetrical safety and quality index. Of note, 8 of 12 obstetricians shifted their rank quartiles after adjustments for high-risk maternal conditions and maternal and neonatal outcomes. There was a strong correlation between the ranking based on ≥1 maternal and/or neonatal complication and ranking based on ≥2 maternal and/or neonatal complications (rho=0.63; 95% confidence interval, 0.08–0.88).

      Conclusion

      Ranking based on crude cesarean delivery rates varied significantly after considering high-risk maternal conditions and associated maternal and neonatal outcomes. Therefore, the obstetrical safety and quality index, a single metric, was developed to identify ways to improve clinician practice standards within an institution. Use of this novel quality measure may help to change initiatives geared toward patient safety, balancing cesarean delivery rates with optimal maternal and neonatal outcomes. This metric could be used to compare obstetrical quality not only among individual obstetricians but also among hospitals that practice obstetrics.

      Key words

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