title: The application of the Ten Group classification system (TGCS) in caesarean delivery case mix adjustment. A multicenter prospective study.
abstract: BACKGROUND
  Caesarean delivery (CD) rates are commonly used as an indicator of quality in obstetric care and risk adjustment evaluation is recommended to assess inter-institutional variations. The aim of this study was to evaluate whether the Ten Group classification system (TGCS) can be used in case-mix adjustment.
  
  
  METHODS
  Standardized data on 15,255 deliveries from 11 different regional centers were prospectively collected. Crude Risk Ratios of CDs were calculated for each center. Two multiple logistic regression models were herein considered by using: Model 1- maternal (age, Body Mass Index), obstetric variables (gestational age, fetal presentation, single or multiple, previous scar, parity, neonatal birth weight) and presence of risk factors; Model 2- TGCS either with or without maternal characteristics and presence of risk factors. Receiver Operating Characteristic (ROC) curves of the multivariate logistic regression analyses were used to assess the diagnostic accuracy of each model. The null hypothesis that Areas under ROC Curve (AUC) were not different from each other was verified with a Chi Square test and post hoc pairwise comparisons by using a Bonferroni correction.
  
  
  RESULTS
  Crude evaluation of CD rates showed all centers had significantly higher Risk Ratios than the referent. Both multiple logistic regression models reduced these variations. However the two methods ranked institutions differently: model 1 and model 2 (adjusted for TGCS) identified respectively nine and eight centers with significantly higher CD rates than the referent with slightly different AUCs (0.8758 and 0.8929 respectively). In the adjusted model for TGCS and maternal characteristics/presence of risk factors, three centers had CD rates similar to the referent with the best AUC (0.9024).
  
  
  CONCLUSIONS
  The TGCS might be considered as a reliable variable to adjust CD rates. The addition of maternal characteristics and risk factors to TGCS substantially increase the predictive discrimination of the risk adjusted model.
authors.affiliation: Department of Obstetrics and Gynaecology, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy. maso@burlo.trieste.it
authors.forename: Gianpaolo
authors.initials: G
authors.lastname: Maso
authors.forename: Salvatore
authors.initials: S
authors.lastname: Alberico
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Monasta
authors.forename: Luca
authors.initials: L
authors.lastname: Ronfani
authors.forename: Marcella
authors.initials: M
authors.lastname: Montico
authors.forename: Caterina
authors.initials: C
authors.lastname: Businelli
authors.forename: Valentina
authors.initials: V
authors.lastname: Soini
authors.forename: Monica
authors.initials: M
authors.lastname: Piccoli
authors.forename: Carmine
authors.initials: C
authors.lastname: Gigli
authors.forename: Daniele
authors.initials: D
authors.lastname: Domini
authors.forename: Claudio
authors.initials: C
authors.lastname: Fiscella
authors.forename: Sara
authors.initials: S
authors.lastname: Casarsa
authors.forename: Carlo
authors.initials: C
authors.lastname: Zompicchiatti
authors.forename: Michela
authors.initials: M
authors.lastname: De Agostinis
authors.forename: Attilio
authors.initials: A
authors.lastname: D'Atri
authors.forename: Raffaela
authors.initials: R
authors.lastname: Mugittu
authors.forename: Santo
authors.initials: S
authors.lastname: La Valle
authors.forename: Cristina
authors.initials: C
authors.lastname: Di Leonardo
authors.forename: Valter
authors.initials: V
authors.lastname: Adamo
authors.forename: Silvia
authors.initials: S
authors.lastname: Smiroldo
authors.forename: Giovanni Del
authors.initials: GD
authors.lastname: Frate
authors.forename: Monica
authors.initials: M
authors.lastname: Olivuzzi
authors.forename: Silvio
authors.initials: S
authors.lastname: Giove
authors.forename: Maria
authors.initials: M
authors.lastname: Parente
authors.forename: Daniele
authors.initials: D
authors.lastname: Bassini
authors.forename: Simona
authors.initials: S
authors.lastname: Melazzini
authors.forename: Secondo
authors.initials: S
authors.lastname: Guaschino
authors.forename: Francesco
authors.initials: F
authors.lastname: De Seta
authors.forename: Sergio
authors.initials: S
authors.lastname: Demarini
authors.forename: Laura
authors.initials: L
authors.lastname: Travan
authors.forename: Diego
authors.initials: D
authors.lastname: Marchesoni
authors.forename: Alberto
authors.initials: A
authors.lastname: Rossi
authors.forename: Giorgio
authors.initials: G
authors.lastname: Simon
authors.forename: Sandro
authors.initials: S
authors.lastname: Zicari
authors.forename: Giorgio
authors.initials: G
authors.lastname: Tamburlini
mesh_terms: D000328:Adult; D019540:Area Under Curve; D002585:Cesarean Section / Q000145:classification* / Q000592:standards / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007558:Italy; D016015:Logistic Models; D015999:Multivariate Analysis; D016017:Odds Ratio; D011247:Pregnancy; D011446:Prospective Studies; D012372:ROC Curve; D020379:Risk Adjustment