title: Differential misclassification of confounders in comparative evaluation of hospital care quality: caesarean sections in Italy.
abstract: BACKGROUND
  Despite extensive studies on exposure and disease misclassification, few studies have investigated misclassification of confounders. This study aimed to identify differentially misclassified confounders in a comparative evaluation of hospital care quality and to quantify their impact on hospital-specific risk-adjusted estimates, focusing on the appropriateness of caesarean sections (CS).
  
  
  METHODS
  We gathered data from the Hospital Information System in Italy for women admitted in 2005-2010. We estimated adjusted proportions of CS with logistic regression models. Among several confounders, we focused on high fetal head at term (HFH), which is seldom objectively documentable in medical records.
  
  
  RESULTS
  A total of 540 maternity units were compared. The median HFH prevalence was 0.9%, ranging from 0 to 70%. In some units, HFH was coded so frequently that it was unlikely to reflect a natural heterogeneity. This "over-coding" was conditional on the outcome because it occurred more frequently for women that underwent CS. This suggested an opportunistic coding to justify the choice of a CS. HFH misclassification was not randomly distributed over Italy; it had an excess in the Campania region where, in some units, the proportion of HFHs gradually increased from 2005 to 2010 (e.g., from 0 to 26%), but the national average remained constant (2.5%). The inclusion of the misclassified diagnosis in the models favored those hospitals that codified in a less-than-fair manner.
  
  
  CONCLUSIONS
  Our findings emphasized the importance of rigorously inspecting for differential misclassification of confounders. Their validity may be subject to substantial heterogeneity over hospitals, over time and geographical areas.
authors.affiliation: Department of Epidemiology, Regional Health Service, Lazio Region, Via di Santa Costanza, 53-00198 Rome, Italy. m.dimartino@deplazio.it.
authors.forename: Mirko
authors.initials: M
authors.lastname: Di Martino
authors.forename: Danilo
authors.initials: D
authors.lastname: Fusco
authors.forename: Paola
authors.initials: P
authors.lastname: Colais
authors.forename: Luigi
authors.initials: L
authors.lastname: Pinnarelli
authors.forename: Marina
authors.initials: M
authors.lastname: Davoli
authors.forename: Carlo Alberto
authors.initials: CA
authors.lastname: Perucci
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000706:statistics & numerical data; D015986:Confounding Factors, Epidemiologic; D005260:Female; D006760:Hospitalization; D006761:Hospitals / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D007558:Italy / Q000453:epidemiology; D016015:Logistic Models; D008875:Middle Aged; D008962:Models, Theoretical; D007744:Obstetric Labor Complications / Q000601:surgery*; D011247:Pregnancy; D015995:Prevalence; D011787:Quality of Health Care / Q000706:statistics & numerical data