title: Potential of geographical variation analysis for realigning providers to value-based care. ECHO case study on lower-value indications of C-section in five European countries.
abstract: BACKGROUND
  Although C-section is a highly effective procedure, literature abounds with evidence of overuse and particularly misuse, in lower-value indications such as low-risk deliveries. This study aims to quantify utilization of C-section in low-risk cases, mapping out areas showing excess-usage in each country and to estimate excess-expenditure as a proxy of the opportunity cost borne by healthcare systems.
  
  
  METHODS
  Observational, ecologic study on deliveries in 913 sub-national administrative areas of five European countries (Denmark, England, Portugal, Slovenia and Spain) from 2002 to 2009. The study includes a cross-section analysis with 2009 data and a time-trend analysis for the whole period. Main endpoints: age-standardized utilization rates of C-section in low-risk pregnancies and deliveries per 100 deliveries. Secondary endpoints: Estimated excess-cases per geographical unit of analysis in two scenarios of minimized utilization.
  
  
  RESULTS
  C-section is widely used in all examined countries (ranging from 19% of Slovenian deliveries to 33% of deliveries in Portugal). With the exception of Portugal, there are no systematic variations in intensity of use across areas in the same country. Cross-country comparison of lower-value C-section leaves Denmark with 10% and Portugal with 2%, the highest and lowest. Such behaviour was stable over the period of analysis. Within each country, the scattered geographical patterns of use intensity speak for local drivers playing a major role within the national trend.
  
  
  CONCLUSIONS
  The analysis conducted suggests plenty of room for enhancing value in obstetric care and equity in women's access to such within the countries studied. The analysis of geographical variations in lower-value care can constitute a powerful screening tool.
authors.affiliation: 1 Health Services and Policy Research Unit, Health Sciences Institute in Aragon (IACS) IIS Aragon, Zaragoza, Spain 2 Agency Aragon R+D Foundation (ARAID), Zaragoza, Spain 3 Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Spain sgarciaarm.iacs@aragon.es.
authors.forename: Sandra
authors.initials: S
authors.lastname: García-Armesto
authors.affiliation: 1 Health Services and Policy Research Unit, Health Sciences Institute in Aragon (IACS) IIS Aragon, Zaragoza, Spain 3 Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Spain.
authors.forename: Ester
authors.initials: E
authors.lastname: Angulo-Pueyo
authors.affiliation: 1 Health Services and Policy Research Unit, Health Sciences Institute in Aragon (IACS) IIS Aragon, Zaragoza, Spain 3 Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Spain.
authors.forename: Natalia
authors.initials: N
authors.lastname: Martínez-Lizaga
authors.affiliation: 4 National Public Health School (ENSP), Nova Universidade de Lisboa, Portugal.
authors.forename: Céu
authors.initials: C
authors.lastname: Mateus
authors.affiliation: 4 National Public Health School (ENSP), Nova Universidade de Lisboa, Portugal.
authors.forename: Inês
authors.initials: I
authors.lastname: Joaquim
authors.affiliation: 1 Health Services and Policy Research Unit, Health Sciences Institute in Aragon (IACS) IIS Aragon, Zaragoza, Spain 3 Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Spain.
authors.forename: Enrique
authors.initials: E
authors.lastname: Bernal-Delgado
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D003695:Delivery of Health Care / Q000191:economics*; D005060:Europe; D005260:Female; D005843:Geography; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006297:Health Services Accessibility / Q000191:economics; D006300:Health Services Misuse / Q000191:economics* / Q000706:statistics & numerical data; D006801:Humans; D011247:Pregnancy; D011787:Quality of Health Care / Q000191:economics; D012111:Residence Characteristics; D012959:Socioeconomic Factors