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Craig SV, Ericson KM, Starc A. How important is price variation between health insurers? JOURNAL OF HEALTH ECONOMICS 2021; 77:102423. [PMID: 33838593 DOI: 10.1016/j.jhealeco.2021.102423] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/09/2020] [Accepted: 12/30/2020] [Indexed: 06/12/2023]
Abstract
Prices negotiated between payers and providers affect a health insurance contract's value via enrollees' cost-sharing and self-insured employers' costs. However, price variation across payers is difficult to observe. We measure negotiated prices for hospital-payer pairs in Massachusetts and characterize price variation. Between-payer price variation is similar in magnitude to between-hospital price variation. Administrative-services-only contracts, in which insurers do not bear risk, have higher prices. We model negotiation incentives and show that contractual form and demand responsiveness to negotiated prices are important determinants of negotiated prices.
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Affiliation(s)
- Stuart V Craig
- Wharton School, University of Pennsylvania, United States
| | | | - Amanda Starc
- Kellogg School of Management, Northwestern University and NBER, United States
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Bond AM, Schwab SD. Utilization Variation In Military Versus Civilian Care: Evidence From TRICARE. Health Aff (Millwood) 2019; 38:1327-1334. [PMID: 31381387 DOI: 10.1377/hlthaff.2019.00298] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Defense Health Agency was established five years ago to integrate and centralize the provision of health care that had been managed separately by the Army, Navy, and Air Force. One favored proposal is to increase the use of private-sector or civilian health care providers. This study compared geographic variation in health care use (a common proxy for efficiency) between patients with a military (direct care) system and those with a civilian (purchased care) system primary care provider-both of which are offered in TRICARE Prime, a health plan that resembles a health maintenance organization. We found similar levels of variation across care utilization metrics with the exception of specialty care, in which the military sample had less variation than its civilian counterpart did. In the military system, risk-adjusted utilization levels were substantially lower for primary care visits and higher for specialty care visits, compared to these visits under the civilian system. Our findings suggest that expanding the use of the civilian system might not achieve the desired efficiencies. Rather, focusing on specialty care in the military system and expanding primary care in the civilian system could help achieve operational readiness and enhanced efficiency.
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Affiliation(s)
- Amelia M Bond
- Amelia M. Bond is an assistant professor of healthcare policy and research at Weill Cornell Medical College, in New York City
| | - Stephen D Schwab
- Stephen D. Schwab ( ) is an assistant professor of health and business administration at the Army-Baylor Graduate Program, a joint program between the US Army and Baylor University, in San Antonio, Texas
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Campillo-Artero C, Serra-Burriel M, Calvo-Pérez A. Predictive modeling of emergency cesarean delivery. PLoS One 2018; 13:e0191248. [PMID: 29360875 PMCID: PMC5779661 DOI: 10.1371/journal.pone.0191248] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 01/02/2018] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To increase discriminatory accuracy (DA) for emergency cesarean sections (ECSs). STUDY DESIGN We prospectively collected data on and studied all 6,157 births occurring in 2014 at four public hospitals located in three different autonomous communities of Spain. To identify risk factors (RFs) for ECS, we used likelihood ratios and logistic regression, fitted a classification tree (CTREE), and analyzed a random forest model (RFM). We used the areas under the receiver-operating-characteristic (ROC) curves (AUCs) to assess their DA. RESULTS The magnitude of the LR+ for all putative individual RFs and ORs in the logistic regression models was low to moderate. Except for parity, all putative RFs were positively associated with ECS, including hospital fixed-effects and night-shift delivery. The DA of all logistic models ranged from 0.74 to 0.81. The most relevant RFs (pH, induction, and previous C-section) in the CTREEs showed the highest ORs in the logistic models. The DA of the RFM and its most relevant interaction terms was even higher (AUC = 0.94; 95% CI: 0.93-0.95). CONCLUSION Putative fetal, maternal, and contextual RFs alone fail to achieve reasonable DA for ECS. It is the combination of these RFs and the interactions between them at each hospital that make it possible to improve the DA for the type of delivery and tailor interventions through prediction to improve the appropriateness of ECS indications.
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Affiliation(s)
- Carlos Campillo-Artero
- Centre for Research in Health and Economics, Universitat Pompeu Fabra, Barcelona, Spain
- Balearic Health Service, Palma de Mallorca, Spain
| | - Miquel Serra-Burriel
- Centre for Research in Health and Economics, Universitat Pompeu Fabra, Barcelona, Spain
- Balearic Health Service, Palma de Mallorca, Spain
- Universitat de Barcelona, Barcelona, Spain
- Centre for Research in Health and Economics, Universitat Pompeu Fabra, Barcelona, Spain
| | - Andrés Calvo-Pérez
- Hospital de Manacor, Obstetrics and Gynecology, Carretera Manacor Alcudia, Manacor, Balearic Islands, Majorca, Spain
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Vecino-Ortiz AI, Bardey D, Castano-Yepes R. Hospital Variation in Cesarean Delivery: A Multilevel Analysis. Value Health Reg Issues 2015; 8:116-121. [PMID: 29698163 DOI: 10.1016/j.vhri.2015.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 06/13/2015] [Accepted: 07/15/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To assess the issue of hospital variations in Colombia and to contribute to the methodology on health care variations by using a model that clusters the variance between hospitals while accounting for individual-level reimbursement rates and objective health-status variables. METHODS We used data on all births (N = 11,954) taking place in a contributory-regimen insurer network in Colombia during 2007. A multilevel logistic regression model was used to account for the share of unexplained variance between hospitals. In addition, an alternative variance decomposition specification was further carried out to measure the proportion of such unexplained variance due to the region effect. RESULTS Hospitals account for 20% of the variation in performing cesarean sections, whereas region explains only one-third of such variance. Variables accounting for preferences on the demand side as well as reimbursement rates are found to predict the probability of performing cesarean sections. CONCLUSIONS Hospital variations explain large variances within a single-payer's network. Because this insurer company is highly regarded in terms of performance and finance, these results might provide a lower bound for the scale of hospital variation in the Colombian health care market. Such lower bound provides guidance on the relevance of this issue for Colombia. Some factors such as demand-side preferences and physician reimbursement rates increase variations in health care even within a single-payer network. This is a source of inefficiencies, threatening the quality of health care and financial sustainability. The proposed methodology should be considered in further research on health care variations.
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Affiliation(s)
| | - David Bardey
- University of Los Andes, Bogota, Colombia; Toulouse School of Economics, Toulouse, France
| | - Ramon Castano-Yepes
- Toulouse School of Economics, Toulouse, France; Center for excellence in health
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Chari A, Hocking KC, Broughton E, Turner C, Santarius T, Hutchinson PJ, Kolias AG. Core Outcomes and Common Data Elements in Chronic Subdural Hematoma: A Systematic Review of the Literature Focusing on Reported Outcomes. J Neurotrauma 2015; 33:1212-9. [PMID: 26295586 PMCID: PMC4931358 DOI: 10.1089/neu.2015.3983] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The plethora of studies in chronic subdural hematoma (CSDH) has not resulted in the development of an evidence-based treatment strategy, largely due to heterogeneous outcome measures that preclude cross-study comparisons and guideline development. This study aimed to identify and quantify the heterogeneity of outcome measures reported in the CSDH literature and to build a case for the development of a consensus-based core outcome set. This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and was registered with the PROSPERO international prospective register of systematic reviews (CRD42014007266). All full-text English language studies with >10 patients (prospective) or >100 patients (retrospective) published after 1990 examining clinical outcomes in CSDH were eligible for inclusion. One hundred two eligible studies were found. There were 14 (13.7%) randomized controlled trials, one single arm trial (1.0%), 25 (24.5%) cohort comparison studies, and 62 (60.8%) prospective or retrospective cohort studies. Outcome domains reported by the studies included mortality (63.8% of included studies), recurrence (94.1%), complications (48.0%), functional outcomes (40.2%), and radiological (38.2%) outcomes. There was significant heterogeneity in the definitions of the outcome measures, as evidenced by the seven different definitions of the term “recurrence,” with no definition given in 19 studies. The time-points of assessment for all the outcome domains varied greatly from inpatient/hospital discharge to 18 months. This study establishes and quantifies the heterogeneity of outcome measure reporting in CSDH and builds the case for the development of a robust consensus-based core outcome set for future studies to adhere to as part of the Core Outcomes and Common Data Elements in CSDH (CODE-CSDH) project.
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Affiliation(s)
- Aswin Chari
- 1 Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge , Cambridge, United Kingdom
| | - Katie C Hocking
- 1 Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge , Cambridge, United Kingdom
| | - Ellie Broughton
- 1 Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge , Cambridge, United Kingdom .,2 South West Neurosurgical Centre, Derriford Hospital , Plymouth, United Kingdom
| | - Carole Turner
- 1 Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge , Cambridge, United Kingdom .,3 Surgery Theme, Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust , Cambridge, United Kingdom
| | - Thomas Santarius
- 1 Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge , Cambridge, United Kingdom
| | - Peter J Hutchinson
- 1 Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge , Cambridge, United Kingdom .,3 Surgery Theme, Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust , Cambridge, United Kingdom
| | - Angelos G Kolias
- 1 Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge , Cambridge, United Kingdom .,3 Surgery Theme, Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust , Cambridge, United Kingdom
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Braun BI, Kritchevsky SB, Wong ES, Solomon SL, Steele L, Richards CL, Simmons BP. Preventing Central Venous Catheter-Associated Primary Bloodstream Infections: Characteristics of Practices Among Hospitals Participating in the Evaluation of Processes and Indicators in Infection Control (EPIC) Study. Infect Control Hosp Epidemiol 2015; 24:926-35. [PMID: 14700408 DOI: 10.1086/502161] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AbstractObjectives:To describe the conceptual framework and methodology of the Evaluation of Processes and Indicators in Infection Control (EPIC) study and present results of CVC insertion characteristics and organizational practices for preventing BSIs. The goal of the EPIC study was to evaluate relationships among processes of care, organizational characteristics, and the outcome of BSI.Design:This was a multicenter prospective observational study of variation in hospital practices related to preventing CVC-associated BSIs. Process of care information (eg, barrier use during insertions and experience of the inserting practitioner) was collected for a random sample of approximately 5 CVC insertions per month per hospital during November 1998 to December 1999. Organization demographic and practice information (eg, surveillance activities and staff and ICU nurse staffing levels) was also collected.Setting:Medical, surgical, or medical-surgical ICUs from 55 hospitals (41 U.S. and 14 international sites).Participants:Process information was obtained for 3,320 CVC insertions with an average of 58.2 (± 16.1) insertions per hospital. Fifty-four hospitals provided policy and practice information.Results:Staff spent an average of 13 hours per week in study ICU surveillance. Most patients received nontunneled, multiple lumen CVCs, of which fewer than 25% were coated with antimicrobial material. Regarding barriers, most clinicians wore masks (81.5%) and gowns (76.8%); 58.1% used large drapes. Few hospitals (18.1%) used an intravenous team to manage ICU CVCs.Conclusions:Substantial variation exists in CVC insertion practice and BSI prevention activities. Understanding which practices have the greatest impact on BSI rates can help hospitals better target improvement interventions.
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Affiliation(s)
- Barbara I Braun
- Division of Research, Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, Illinois 60181, USA
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Abstract
OBJECTIVE This review summarizes reporting of complications of esophageal cancer surgery. BACKGROUND Accurate assessment of morbidity and mortality after surgery for cancer is essential to compare centers, allow data synthesis, and inform clinical decision-making. A lack of defined standards may distort clinically relevant treatment effects. METHODS Systematic literature searches identified articles published between 2005 and 2009 reporting morbidity and mortality after esophagectomy for cancer. Data were analyzed for frequency of complication reporting and to check whether outcomes were defined and classified for severity and whether a validated system for grading complications was used. Information about reporting outcomes adjusting for baseline risk factors was collated, and a descriptive summary of the results of included outcomes was undertaken. RESULTS Of 3458 abstracts, 224 full papers were reviewed and 122 were included (17 randomized trials and 105 observational studies), reporting outcomes of 57,299 esophagectomies. No single complication was reported in all papers, and 60 (60.6%) did not define any of the measured complications. Anastomotic leak was the most commonly reported morbidity, assessed in 80 (80.1%) articles, defined in 28 (28.3%), but 22 different descriptions were used. Five papers (5.1%) categorized morbidity with a validated grading system. One hundred fifteen papers reported postoperative mortality rates, 25 defining the term using 10 different definitions. In-hospital mortality was the most commonly used term for postoperative death, with 6 different interpretations of this phrase. Eighteen papers adjusted outcomes for baseline risk factors and 60 presented baseline measures of comorbidity. CONCLUSIONS Outcome reporting after esophageal cancer surgery is heterogeneous and inconsistent, and it lacks methodological rigor. A consensus approach to reporting clinical outcomes should be considered, and at the minimum it is recommended that a "core outcome set" is defined and used in all studies reporting outcomes of esophageal cancer surgery. This will allow meaningful cross study comparisons and analyses to evaluate surgery.
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Simmons B, Braun BI, Steinberg JP, Kritchevsky SB. History of SHEA-Sponsored Research: Time to Pass the Torch. Infect Control Hosp Epidemiol 2011; 32:163-5. [DOI: 10.1086/657938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Since its inception, the Society for Healthcare Epidemiology of America (SHEA) has promoted research into prevention of adverse events in hospitals. In 1995, SHEA made this mission concrete by initiating a collaborative research project with the Joint Commission on the Accreditation of Health Care Organization (now known as the Joint Commission). In the early 1990s, the Joint Commission was implementing its “Agenda for Change” and associated Indicator Monitoring System. At the time, there were numerous competing measurement systems that used different definitions, all aimed at measuring the quality of patient care, and many had indicators measuring the incidence of hospital-acquired infections. Some of these indicators used administrative data, such as International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes, to measure adverse events.
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Shelbaia A, Hussein A, El Rahman SA. Lower Urinary Tract Injuries During Gynecological Operations. UROTODAY INTERNATIONAL JOURNAL 2010; 03. [DOI: 10.3834/uij.1944-5784.2010.02.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Chou YA, Chou YJ, Lee CH, Huang N. Pregnancy outcomes among native and foreign-born women in Taiwan: maternal health utilization. J Womens Health (Larchmt) 2009; 17:1505-12. [PMID: 18954239 DOI: 10.1089/jwh.2007.0714] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND As immigrant populations increase rapidly around the world and with most immigrant women being of childbearing age, their use of pregnancy-related healthcare has become an important health issue. However, there has been only limited research available on maternal health use by foreign immigrants in Asia. This study aims to compare inpatient use for pregnancy complications and type of delivery among foreign and native-born women of different socioeconomic status in Taiwan. METHODS Using the 2001 National Health Insurance (NHI) database, 232,828 deliveries were identified, of which 222,852 were to native-born mothers and 9,976 were to foreign-born mothers. Univariate and multivariate logistic regression models were used to determine the likelihood of using inpatient services for any pregnancy complication and for cesarean section. RESULTS Our results indicate that after adjusting for other factors, foreign-born women were less likely than native-born women to use inpatient services for complicated pregnancies across all socioeconomic status (SES) levels. On the other hand, a pattern emerged among the higher SES groups showing a similar likelihood of cesarean section when foreign-born and native-born mothers were compared. This was not the case for the lower SES groups, however, where native-born mothers were significantly more likely to undergo a cesarean section than foreign-born mothers. CONCLUSIONS Foreign-born mothers tended to use fewer inpatient services for complicated pregnancies than native-born mothers and were less likely to undergo cesarean section. As immigrants increase across the world as a result of globalization and with half of them being female, pregnancy-related health service use among this group needs our attention.
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Affiliation(s)
- Yun-An Chou
- Institute of Public Health, School of Medicine, School of Medicine, National Yang Ming University, Taiwan, ROC
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Berhe M, Edmond MB, Bearman G. Measurement and feedback of infection control process measures in the intensive care unit: Impact on compliance. Am J Infect Control 2006; 34:537-9. [PMID: 17015162 DOI: 10.1016/j.ajic.2005.06.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2005] [Revised: 06/06/2005] [Accepted: 06/07/2005] [Indexed: 10/24/2022]
Abstract
BACKGROUND Infection control process measures provide actionable and measurable indicators for performance improvement. OBJECTIVE To determine the relationship between the measurement and feedback of selected infection control process measures and compliance with infection control practices. METHODS We measured selected infection control process measures (hand hygiene, femoral catheter use as a proportion of all central venous catheter (CVC) days and proportion of head of bed elevations) in the medical respiratory intensive care unit (ICU) (MRICU) and the surgical trauma ICU (STICU). All data were collected by trained infection control practitioners. Baseline data were obtained April through June 2004. Baseline hand hygiene data were obtained from May to June. Follow-up observations were obtained from July 2004 through March 2005. Both baseline and follow-up observations were reported to the units' leadership. The data were reviewed for improvement in compliance with process measures. Differences in proportions were analyzed for statistical significance by the chi(2) test. RESULTS There was a statistically significant improvement in the head of bed elevation rates: 54.9% versus 98.4% (P < .001) for the MRICU and 46.5% versus 77.2% (P < .001) for the STICU, respectively. There was also a statistically significant decline in femoral catheter rates in both ICUs: 17.8% versus 10% (P = .001) in the MRICU and 8.4% versus 3% (P < .001) in the STICU, respectively. There was no significant improvement in hand hygiene rates in either ICU: 31.8% versus 39.3% (P = .1) in the MRICU and 50% versus 50.3% (P = .9) in the STICU, respectively. CONCLUSION Feedback of process measures lowered the use of femoral catheters and improved the proportion of elevated head of beds in 2 ICUs, but there was no significant improvement in hand hygiene.
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Affiliation(s)
- Mezgebe Berhe
- Division of Infectious Diseases, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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Chou YJ, Huang N, Lin IF, Deng CY, Tsai YW, Chen LS, Lee CH. Do physicians and their relatives have a decreased rate of cesarean section? A 4-year population-based study in Taiwan. Birth 2006; 33:195-202. [PMID: 16948719 DOI: 10.1111/j.1523-536x.2006.00104.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The increased rate of cesarean deliveries may be partly due to a lack of consumer knowledge. Assuming that physicians and their relatives are well informed of the risks and benefits associated with the different methods of delivery, our goal was to compare cesarean rates between female physicians, female relatives of physicians, and women with high socioeconomic status in Taiwan. METHODS Two subgroups of 588 female physicians and 5,021 relatives of physicians aged 20 to 50 years were compared with 93,737 pregnant women with a monthly wage 40,000 dollars New Taiwan (NT) dollars or more as identified in nationwide National Health Insurance databases of Taiwan from 2000 to 2003. RESULTS Female physicians (adjusted odds ratio 0.66; 95% CI 0.47, 0.93) and female relatives of physicians (adjusted odds ratio 0.84; 95% CI 0.74, 0.95) were significantly less likely to undergo a cesarean section than other high socioeconomic status women, adjusted for clinical and nonclinical factors. CONCLUSIONS In this study, the cesarean delivery rate was lower among women who may have greater access to medical knowledge. However, the lower rates observed among female physicians and physician relatives in Taiwan are still considerably higher than the national averages of many countries. This finding suggests that other than information, practice patterns, and social and cultural milieu may play a role.
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Affiliation(s)
- Yiing-Jenq Chou
- School of Medicine, National Yang Ming University, Taipei, Taiwan, ROC
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Fantini MP, Stivanello E, Frammartino B, Barone AP, Fusco D, Dallolio L, Cacciari P, Perucci CA. Risk adjustment for inter-hospital comparison of primary cesarean section rates: need, validity and parsimony. BMC Health Serv Res 2006; 6:100. [PMID: 16911770 PMCID: PMC1590020 DOI: 10.1186/1472-6963-6-100] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2006] [Accepted: 08/15/2006] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Cesarean section rates is often used as an indicator of quality of care in maternity hospitals. The assumption is that lower rates reflect in developed countries more appropriate clinical practice and general better performances. Hospitals are thus often ranked on the basis of caesarean section rates. The aim of this study is to assess whether the adjustment for clinical and sociodemographic variables of the mother and the fetus is necessary for inter-hospital comparisons of cesarean section (c-section) rates and to assess whether a risk adjustment model based on a limited number of variables could be identified and used. METHODS Discharge abstracts of labouring women without prior cesarean were linked with abstracts of newborns discharged from 29 hospitals of the Emilia-Romagna Region (Italy) from 2003 to 2004. Adjusted ORs of cesarean by hospital were estimated by using two logistic regression models: 1) a full model including the potential confounders selected by a backward procedure; 2) a parsimonious model including only actual confounders identified by the "change-in-estimate" procedure. Hospital rankings, based on ORs were examined. RESULTS 24 risk factors for c-section were included in the full model and 7 (marital status, maternal age, infant weight, fetopelvic disproportion, eclampsia or pre-eclampsia, placenta previa/abruptio placentae, malposition/malpresentation) in the parsimonious model. Hospital ranking using the adjusted ORs from both models was different from that obtained using the crude ORs. The correlation between the rankings of the two models was 0.92. The crude ORs were smaller than ORs adjusted by both models, with the parsimonious ones producing more precise estimates. CONCLUSION Risk adjustment is necessary to compare hospital c-section rates, it shows differences in rankings and highlights inappropriateness of some hospitals. By adjusting for only actual confounders valid and more precise estimates could be obtained.
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Affiliation(s)
- Maria P Fantini
- Department of Medicine and Public Health, University of Bologna, Bologna, Italy
| | - Elisa Stivanello
- Department of Medicine and Public Health, University of Bologna, Bologna, Italy
| | | | - Anna P Barone
- Department of Epidemiology, Local Health Authority RM E, Rome, Italy
| | - Danilo Fusco
- Department of Epidemiology, Local Health Authority RM E, Rome, Italy
| | - Laura Dallolio
- Department of Medicine and Public Health, University of Bologna, Bologna, Italy
| | - Paolo Cacciari
- Azienda Ospedaliera S. Orsola – Malpighi, University Hospital, Bologna, Italy
| | - Carlo A Perucci
- Department of Epidemiology, Local Health Authority RM E, Rome, Italy
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Braun BI, Kritchevsky SB, Kusek L, Wong ES, Solomon SL, Steele L, Richards CL, Gaynes RP, Simmons B. Comparing bloodstream infection rates: the effect of indicator specifications in the evaluation of processes and indicators in infection control (EPIC) study. Infect Control Hosp Epidemiol 2006; 27:14-22. [PMID: 16418981 DOI: 10.1086/498966] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2005] [Accepted: 08/19/2005] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Bloodstream infection (BSI) rates are used as comparative clinical performance indicators; however, variations in definitions and data-collection approaches make it difficult to compare and interpret rates. To determine the extent to which variation in indicator specifications affected infection rates and hospital performance rankings, we compared absolute rates and relative rankings of hospitals across 5 BSI indicators. DESIGN Multicenter observational study. BSI rate specifications varied by data source (clinical data, administrative data, or both), scope (hospital wide or intensive care unit specific), and inclusion/exclusion criteria. As appropriate, hospital-specific infection rates and rankings were calculated by processing data from each site according to 2-5 different specifications. SETTING A total of 28 hospitals participating in the EPIC study. PARTICIPANTS Hospitals submitted deidentified information about all patients with BSIs from January through September 1999. RESULTS Median BSI rates for 2 indicators based on intensive care unit surveillance data ranged from 2.23 to 2.91 BSIs per 1000 central-line days. In contrast, median rates for indicators based on administrative data varied from 0.046 to 7.03 BSIs per 100 patients. Hospital-specific rates and rankings varied substantially as different specifications were applied; the rates of 8 of 10 hospitals were both greater than and less than the mean. Correlations of hospital rankings among indicator pairs were generally low (rs=0-0.45), except when both indicators were based on intensive care unit surveillance (rs = 0.83). CONCLUSIONS Although BSI rates seem to be a logical indicator of clinical performance, the use of various indicator specifications can produce remarkably different judgments of absolute and relative performance for a given hospital. Recent national initiatives continue to mix methods for specifying BSI rates; this practice is likely to limit the usefulness of such information for comparing and improving performance.
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Affiliation(s)
- Barbara I Braun
- Division of Research, Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL 60181, USA.
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Korst LM, Gregory KD, Lu MC, Reyes C, Hobel CJ, Chavez GF. A Framework for the Development of MaternalQuality of Care Indicators. Matern Child Health J 2005; 9:317-41. [PMID: 16160758 DOI: 10.1007/s10995-005-0001-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND In collaboration with the California Department of Health Maternal and Child Health Branch, the authors formed a Working Group to identify potential clinical indicators that could be used to inform decision making regarding maternal health care quality. OBJECTIVE To develop potential indicators for the assessment of maternal health care quality. MATERIALS AND METHODS A Working Group was convened to review information from the published literature and expert opinion. Selection of potential indicators was guided by the following goals: 1) To identify key areas for routine aggregate monitoring; 2) To include perspectives of relevant stakeholders in maternal health care services; 3) To include measures that are comprehensive and reflect a balance between maternal and fetal interests; and 4) To develop measures that would be valid, generalizable, mutable, and feasible. RESULTS Ninety potential indicators were identified. Each underwent a thorough review based on: its definition, objective, and validity; its contribution to innovation; the cost and timeliness of implementation; its feasibility, acceptability, and potential effectiveness; and its compatibility with ethics, values, and social policy. This process yielded 24 final indicators from the following categories: Health Status and Access (e.g., availability of 24 h inpatient anesthesia); Preconception and Interconception Care (e.g., Pap smear use); Antenatal Care (e.g., hospitalization for uncontrolled diabetes or pyelonephritis); Labor and Delivery Care (e.g., chorioamnionitis or obstetrical hemorrhage), and Postpartum Care (e.g., rate of postpartum visits). CONCLUSIONS These potential indicators, representative of the women's health continuum, can serve as a foundation to structure the development of consensus and methods for maternal health care quality assessment.
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Affiliation(s)
- Lisa M Korst
- Saban Research Institute of Childrens Hospital Los Angeles, Los Angeles, 90033, USA.
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Wu N, Miller SC, Lapane K, Roy J, Mor V. The quality of the quality indicator of pain derived from the minimum data set. Health Serv Res 2005; 40:1197-216. [PMID: 16033500 PMCID: PMC1361186 DOI: 10.1111/j.1475-6773.2005.00400.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To examine facility variation in data quality of the level of pain documented in the minimum data set (MDS) as a function of level of hospice enrollment in nursing homes (NHs). DATA SOURCE Clinical assessments on 3,469 nonhospice residents from 178 NHs were merged with On-line Survey Certification and Reporting data of 2000, Medicare Claims data of 2000 and the MDS of 2000-2002. STUDY DESIGN Using the same assessment protocol, NH staff and study nurses independently assessed 3,469 nonhospice residents. Study nurses' assessments being gold standard, we quantified and compared quality of NH staff's pain rating across NHs with high, medium, or low hospice use. Multilevel models were built to assess the effect of NH hospice use levels on the occurrence of false positive (FP) and false negative (FN) errors in NH-rated "severe pain." PRINCIPAL FINDINGS Of 178 NHs, 25 had medium and 41 high hospice use. NHs with higher hospice use had lower sensitivities. In multilevel analysis, we found a significant facility-level variation in the probability of FP and FN errors in facility-rated "severe pain." Resident characteristics only explained 4 and 0 percent of the facility variation in FP and FN, respectively; characteristics and locations (state) of NHs further explained 53 and 52 percent of the variance. After controlling for resident and NH characteristics, staff in NHs with medium or high hospice use were less likely to have FP or FN errors in their MDS documentation of pain than were staff in NHs with low or no hospice use. CONCLUSIONS The examination of data quality of pooled MDS data from multiple NHs is insufficient. Multilevel analysis is needed to elucidate sources of heterogeneity in the quality of MDS data across NHs. Facility characteristics, e.g., hospice use or NH location, are systematically associated with overrated/underrated pain and may bias pain quality indicator (QI) comparisons. To ensure the integrity of QI comparison in the NH setting, the government may need to institute regular audits of MDS data quality.
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Affiliation(s)
- Ning Wu
- Health Research and Evaluation, Abt Associates Inc., Cambridge, MA 02138, USA
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Abstract
OBJECTIVE To quantify the amount of variation in caesarean section (CS) rates between maternity units explained by case mix differences. DESIGN Cross-sectional study. SETTING All 216 maternity units in England and Wales. POPULATION Women giving birth at these maternity units between May and July 2000. METHODS Logistic regression models were developed to investigate the relationship between case mix characteristics, and odds of (i) CS before labour, (ii) CS in labour. Using these results, overall CS rates standardised for case mix were calculated for each maternity unit. Random-effects meta-analysis was used to examine heterogeneity between maternity units. MAIN OUTCOME MEASURES CS before labour and CS during labour. RESULTS Adjustment for case mix differences between maternity units explained 34% of the variance in CS rates. Odds of CS (before and in labour) increased with maternal age. Women from ethnic minority groups had lower odds of CS before labour, and increased odds of CS in labour. Women with a previous vaginal delivery had lower odds of CS, although the magnitude of this for CS before and in labour is markedly different. CONCLUSIONS Case mix adjustment is important to enable understanding of the factors that influence the CS rate. These include organisational and staffing levels as well as women's preferences for childbirth and clinician's attitudes. An understanding of how these factors influence the CS rate is essential for evaluation of quality and appropriateness of obstetric care provided to women.
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Affiliation(s)
- S Paranjothy
- National Collaborating Centre for Women's and Children's Health, 27 Sussex Place, London NW1 4RG, UK
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18
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Yossepowitch O, Baniel J, Livne PM. Urological injuries during cesarean section: intraoperative diagnosis and management. J Urol 2004; 172:196-9. [PMID: 15201771 DOI: 10.1097/01.ju.0000128632.29421.87] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE We report a single center experience with emergency urological consultations and interventions during cesarean sections, and provide several guidelines for the intraoperative diagnosis and management of urological trauma in this specific clinical setting. MATERIALS AND METHODS From 1996 to 2003 urological consultations were required in 29 of 10,439 abdominal deliveries (0.3%). Patient files were reviewed for obstetric, surgical and followup data. RESULTS In 20 patients (69%) cesarean section was done on an emergency basis for fetal distress or placental abruption. Of the 29 urological consults 12 (42%) were for inadvertent cystotomy and 17 (58%) were for suspected injuries to the ureter. Patients with inadvertent cystotomy underwent concomitant assessment of ureteral patency by direct insertion of ureteral catheters through the ureteral orifice. Ureteral obstruction was identified in 1 case and promptly repaired by dissecting the ureter and releasing offending sutures that were angulating the ureter and occluding the lumen. Patients with suspected ureteral damage and an intact bladder were studied by endoscopic means (14) or direct surgical dissection and exposure of the ureter (3). Endoscopic assessment was performed by cystoscopic inspection of stained urine flow from the orifices following the administration of intravenous dye (indigo carmine) or by retrograde ureteral catheterization. One patient was found to have incomplete ureteral transection, which was repaired primarily over a self-retaining ureteral stent. CONCLUSIONS Key factors to obtain optimal results in the management of urological injuries during cesarean sections are the early recognition and immediate repair of damage. Ureteral catheterization via a cystoscope or directly through the orifices should be considered the modality of choice to assess ureteral intactness. Algorithms for urological assessment in this clinical setting are provided.
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Affiliation(s)
- Ofer Yossepowitch
- Institute of Urology, Rabin Medical Center, Beilinson Campus, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Peaceman AM, Feinglass J, Manheim LM. Risk-adjustment of cesarean delivery rates: a practical method for use in quality improvement. Am J Med Qual 2002; 17:113-7. [PMID: 12073867 DOI: 10.1177/106286060201700306] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Risk-adjustment of cesarean birthrates has been hampered by inadequacies in the existing secondary data sources or by the need for extensive chart review. This study presents an efficient risk-adjustment model for cesarean birth, based on easily retrievable ICD-9 codes and clinical risk factors least influenced by physician practice style. Data are presented for mothers undergoing 7322 deliveries from 1997-1998 at a large academic medical center with a cesarean birth rate of 15.9%. Multiple logistic regression was used to predict the likelihood of cesarean delivery controlled for maternal age, 10 risk factors identified through ICD-9 coding, and 3 additional clinical variables (nulliparity, birth weight, and gestational age) derived from a perinatal (birth certificate) database. All risk factors were significant predictors of cesarean birth, producing an area under the receiver-operating characteristic curve of 0.86 and a 60-fold increase in cesarean delivery from highest to lowest deciles of predicted risk. This methodology can be used widely for quality improvement without the need for extensive chart review.
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Affiliation(s)
- Alan M Peaceman
- Division of Maternal and Fetal Medicine, Northwestern University Medical School, Chicago, Ill., USA.
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20
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Gregory KD, Korst LM, Platt LD. Variation in elective primary cesarean delivery by patient and hospital factors. Am J Obstet Gynecol 2001; 184:1521-32; discussion 1532-4. [PMID: 11408876 DOI: 10.1067/mob.2001.115496] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Our purpose was to describe variation in elective primary cesarean rates by nonclinical factors. STUDY DESIGN With use of California discharge data and American Hospital Association data for 1995, patients were classified into 13 mutually exclusive categories for elective primary cesarean delivery. With use of recursive partitioning algorithms, women in each category were then studied to determine whether nonclinical factors were associated with elective primary cesarean delivery. RESULTS A total of 463,196 women were delivered at 288 hospitals, and the elective primary cesarean delivery rate was 4.25% (19,664/463,196). Risk for elective primary cesarean delivery varied by clinical condition. The most discriminant risk factors were hospital type (malpresentation, multiple gestation, macrosomia, other hypertension), maternal age (antepartum bleeding, uterine scar, soft tissue disorder, preterm, unspecified), and teaching status (herpes, severe hypertension, unengaged head). CONCLUSION This article presents methods that use administrative data to isolate and monitor the impact of nonclinical factors on the use of elective primary cesarean.
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Affiliation(s)
- K D Gregory
- Cedars-Sinai Medical Center Burns and Allen Research Institute, the Department of Obstetrics and Gynecology, and Women's Health Services Research, University of California, Los Angeles School of Medicine, 90048, USA
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21
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Gross PA, Braun BI, Kritchevsky SB, Simmons BP. Comparison of clinical indicators for performance measurement of health care quality: a cautionary note. CLINICAL PERFORMANCE AND QUALITY HEALTH CARE 2001; 8:202-11. [PMID: 11189082 DOI: 10.1108/14664100010361755] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The use of clinical performance data is increasing rapidly. Yet, substantial variation exists across indicators designed to measure the same clinical event. We compared indicators from several indicator measurement systems to determine the consistency of results. Five measurement systems with well-defined indicators were selected. They were applied to 24 hospitals. Indicators for mortality from coronary artery bypass graft surgery and mortality in the perioperative period were chosen from these measurement systems. Analyses results and concludes that it is faulty to assume that clinical indicators derived from different measurement systems will give the same rank order. Widespread demand for external release of outcome data from hospitals must be balanced by an educational effort about the factors that influence and potentially confound reported rates.
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Affiliation(s)
- P A Gross
- Society of Healthcare Epidemiologists of America, Mt Royal, New Jersey, USA
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Kritchevsky SB, Braun BI, Wong ES, Solomon SL, Steele L, Richards C, Simmons BP. Impact of hospital care on incidence of bloodstream infection: the evaluation of processes and indicators in infection control study. Emerg Infect Dis 2001; 7:193-6. [PMID: 11294704 PMCID: PMC2631716 DOI: 10.3201/eid0702.010207] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The Evaluation of Processes and Indicators in Infection Control (EPIC) study assesses the relationship between hospital care and rates of central venous catheter-associated primary bacteremia in 54 intensive-care units (ICUs) in the United States and 14 other countries. Using ICU rather than the patient as the primary unit of statistical analysis permits evaluation of factors that vary at the ICU level. The design of EPIC can serve as a template for studies investigating the relationship between process and event rates across health-care institutions.
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Affiliation(s)
- S B Kritchevsky
- University of Tennessee Health Sciences Center, Memphis, Tennessee, USA.
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23
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Abstract
Cesarean rate as a clinical indicator for health care quality continues to be a focus of discussion and research among clinicians and health policy advocates. Over the review period, there were several studies regarding statistical strategies for monitoring and reporting cesarean rates, clinical and nonclinical risk factors for cesarean, and clinical interventions related to the management of labor that may help to decrease the likelihood of cesarean delivery. Future research should focus on developing and refining the statistical strategies for monitoring and adjusting cesarean rates to allow for meaningful comparisons.
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Affiliation(s)
- K D Gregory
- Department of Obstetrics & Gynecology, Cedars Sinai Medical Center, Burns Allen Research Institute and University of California, Los Angeles School of Medicine, 90048, USA.
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