title: Risk-adjusted models for adverse obstetric outcomes and variation in risk-adjusted outcomes across hospitals.
abstract: OBJECTIVE
  Regulatory bodies and insurers evaluate hospital quality using obstetrical outcomes, however meaningful comparisons should take preexisting patient characteristics into account. Furthermore, if risk-adjusted outcomes are consistent within a hospital, fewer measures and resources would be needed to assess obstetrical quality. Our objective was to establish risk-adjusted models for 5 obstetric outcomes and assess hospital performance across these outcomes.
  
  
  METHODS
  We studied a cohort of 115,502 women and their neonates born in 25 hospitals in the United States from March 2008 through February 2011. Hospitals were ranked according to their unadjusted and risk-adjusted frequency of venous thromboembolism, postpartum hemorrhage, peripartum infection, severe perineal laceration, and a composite neonatal adverse outcome. Correlations between hospital risk-adjusted outcome frequencies were assessed.
  
  
  RESULTS
  Venous thromboembolism occurred too infrequently (0.03%; 95% confidence interval [CI], 0.02-0.04%) for meaningful assessment. Other outcomes occurred frequently enough for assessment (postpartum hemorrhage, 2.29%; 95% CI, 2.20-2.38, peripartum infection, 5.06%; 95% CI, 4.93-5.19, severe perineal laceration at spontaneous vaginal delivery, 2.16%; 95% CI, 2.06-2.27, neonatal composite, 2.73%; 95% CI, 2.63-2.84). Although there was high concordance between unadjusted and adjusted hospital rankings, several individual hospitals had an adjusted rank that was substantially different (as much as 12 rank tiers) than their unadjusted rank. None of the correlations between hospital-adjusted outcome frequencies was significant. For example, the hospital with the lowest adjusted frequency of peripartum infection had the highest adjusted frequency of severe perineal laceration.
  
  
  CONCLUSIONS
  Evaluations based on a single risk-adjusted outcome cannot be generalized to overall hospital obstetric performance.
authors.affiliation: Department of Obstetrics and Gynecology, Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH.
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Bailit
authors.forename: William A
authors.initials: WA
authors.lastname: Grobman
authors.forename: Madeline Murguia
authors.initials: MM
authors.lastname: Rice
authors.forename: Catherine Y
authors.initials: CY
authors.lastname: Spong
authors.forename: Ronald J
authors.initials: RJ
authors.lastname: Wapner
authors.forename: Michael W
authors.initials: MW
authors.lastname: Varner
authors.forename: John M
authors.initials: JM
authors.lastname: Thorp
authors.forename: Kenneth J
authors.initials: KJ
authors.lastname: Leveno
authors.forename: Steve N
authors.initials: SN
authors.lastname: Caritis
authors.forename: Phillip J
authors.initials: PJ
authors.lastname: Shubert
authors.forename: Alan T
authors.initials: AT
authors.lastname: Tita
authors.forename: George
authors.initials: G
authors.lastname: Saade
authors.forename: Yoram
authors.initials: Y
authors.lastname: Sorokin
authors.forename: Dwight J
authors.initials: DJ
authors.lastname: Rouse
authors.forename: Sean C
authors.initials: SC
authors.lastname: Blackwell
authors.forename: Jorge E
authors.initials: JE
authors.lastname: Tolosa
authors.forename: J Peter
authors.initials: JP
authors.lastname: Van Dorsten
mesh_terms: D000328:Adult; D015331:Cohort Studies; D036861:Delivery, Obstetric / Q000706:statistics & numerical data*; D005260:Female; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D007231:Infant, Newborn; D022125:Lacerations / Q000453:epidemiology; D015233:Models, Statistical; D015999:Multivariate Analysis; D007744:Obstetric Labor Complications / Q000453:epidemiology*; D017063:Outcome Assessment, Health Care / Q000379:methods*; D010502:Perineum / Q000293:injuries; D058725:Peripartum Period; D006473:Postpartum Hemorrhage / Q000453:epidemiology; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular / Q000453:epidemiology; D011251:Pregnancy Complications, Infectious / Q000453:epidemiology; D011645:Puerperal Infection / Q000453:epidemiology; D058996:Quality Improvement; D020379:Risk Adjustment / Q000379:methods*; D014481:United States / Q000453:epidemiology; D054556:Venous Thromboembolism / Q000453:epidemiology; D055815:Young Adult
keywords: obstetrics; performance improvement; quality; risk adjustment
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