Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2013 Nov;209(5):446.e1-446.e30.
doi: 10.1016/j.ajog.2013.07.019. Epub 2013 Jul 24.

Risk-adjusted models for adverse obstetric outcomes and variation in risk-adjusted outcomes across hospitals

Jennifer L Bailit  1 , William A Grobman, Madeline Murguia Rice, Catherine Y Spong, Ronald J Wapner, Michael W Varner, John M Thorp, Kenneth J Leveno, Steve N Caritis, Phillip J Shubert, Alan T Tita, George Saade, Yoram Sorokin, Dwight J Rouse, Sean C Blackwell, Jorge E Tolosa, J Peter Van Dorsten; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network
Collaborators, Affiliations

Risk-adjusted models for adverse obstetric outcomes and variation in risk-adjusted outcomes across hospitals

Jennifer L Bailit et al. Am J Obstet Gynecol. 2013 Nov.

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.

Study design: 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.

Conclusion: Evaluations based on a single risk-adjusted outcome cannot be generalized to overall hospital obstetric performance.

Keywords: obstetrics; performance improvement; quality; risk adjustment.

PubMed Disclaimer

Conflict of interest statement

The authors report no conflicts of interest

Figures

Figure 1
Figure 1
Association between hospital ranks based on observed (unadjusted) outcome frequencies and hospital ranks based on adjusted outcome frequencies. (a) Postpartum hemorrhage (b) Peripartum infection (c) Severe perineal laceration at spontaneous vaginal delivery (SVD) (d) Severe perineal laceration at forceps-assisted vaginal delivery (FVD) (e) Severe perineal laceration at vacuum-assisted vaginal delivery (VVD) (f) Composite neonatal adverse outcome
Figure 1
Figure 1
Association between hospital ranks based on observed (unadjusted) outcome frequencies and hospital ranks based on adjusted outcome frequencies. (a) Postpartum hemorrhage (b) Peripartum infection (c) Severe perineal laceration at spontaneous vaginal delivery (SVD) (d) Severe perineal laceration at forceps-assisted vaginal delivery (FVD) (e) Severe perineal laceration at vacuum-assisted vaginal delivery (VVD) (f) Composite neonatal adverse outcome
Figure 1
Figure 1
Association between hospital ranks based on observed (unadjusted) outcome frequencies and hospital ranks based on adjusted outcome frequencies. (a) Postpartum hemorrhage (b) Peripartum infection (c) Severe perineal laceration at spontaneous vaginal delivery (SVD) (d) Severe perineal laceration at forceps-assisted vaginal delivery (FVD) (e) Severe perineal laceration at vacuum-assisted vaginal delivery (VVD) (f) Composite neonatal adverse outcome
Figure 1
Figure 1
Association between hospital ranks based on observed (unadjusted) outcome frequencies and hospital ranks based on adjusted outcome frequencies. (a) Postpartum hemorrhage (b) Peripartum infection (c) Severe perineal laceration at spontaneous vaginal delivery (SVD) (d) Severe perineal laceration at forceps-assisted vaginal delivery (FVD) (e) Severe perineal laceration at vacuum-assisted vaginal delivery (VVD) (f) Composite neonatal adverse outcome
Figure 1
Figure 1
Association between hospital ranks based on observed (unadjusted) outcome frequencies and hospital ranks based on adjusted outcome frequencies. (a) Postpartum hemorrhage (b) Peripartum infection (c) Severe perineal laceration at spontaneous vaginal delivery (SVD) (d) Severe perineal laceration at forceps-assisted vaginal delivery (FVD) (e) Severe perineal laceration at vacuum-assisted vaginal delivery (VVD) (f) Composite neonatal adverse outcome
Figure 1
Figure 1
Association between hospital ranks based on observed (unadjusted) outcome frequencies and hospital ranks based on adjusted outcome frequencies. (a) Postpartum hemorrhage (b) Peripartum infection (c) Severe perineal laceration at spontaneous vaginal delivery (SVD) (d) Severe perineal laceration at forceps-assisted vaginal delivery (FVD) (e) Severe perineal laceration at vacuum-assisted vaginal delivery (VVD) (f) Composite neonatal adverse outcome
See this image and copyright information in PMC

Similar articles

See all similar articles

Cited by

  • Variation in the Nulliparous, Term, Singleton, Vertex Cesarean Delivery Rate.
    Pasko DN, McGee P, Grobman WA, Bailit JL, Reddy UM, Wapner RJ, Varner MW, Thorp JM Jr, Leveno KJ, Caritis SN, Prasad M, Saade G, Sorokin Y, Rouse DJ, Blackwell SC, Tolosa JE; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. Pasko DN, et al. Obstet Gynecol. 2018 Jun;131(6):1039-1048. doi: 10.1097/AOG.0000000000002636. Obstet Gynecol. 2018. PMID: 29742665 Free PMC article.
  • Double Disadvantage in Delivery Hospital for Black and Hispanic Women and High-Risk Infants.
    Howell EA, Janevic T, Blum J, Zeitlin J, Egorova NN, Balbierz A, Hebert PL. Howell EA, et al. Matern Child Health J. 2020 Jun;24(6):687-693. doi: 10.1007/s10995-020-02911-9. Matern Child Health J. 2020. PMID: 32303940 Free PMC article.
  • Defining failed induction of labor.
    Grobman WA, Bailit J, Lai Y, Reddy UM, Wapner RJ, Varner MW, Thorp JM Jr, Leveno KJ, Caritis SN, Prasad M, Tita ATN, Saade G, Sorokin Y, Rouse DJ, Blackwell SC, Tolosa JE; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Grobman WA, et al. Am J Obstet Gynecol. 2018 Jan;218(1):122.e1-122.e8. doi: 10.1016/j.ajog.2017.11.556. Epub 2017 Nov 11. Am J Obstet Gynecol. 2018. PMID: 29138035 Free PMC article.
  • Busy day effect on intrapartum adverse maternal outcomes - a population-based study of 601 247 singleton deliveries.
    Vilkko R, Räisänen S, Gissler M, Stefanovic V, Heinonen S. Vilkko R, et al. BMC Pregnancy Childbirth. 2021 Jan 19;21(1):66. doi: 10.1186/s12884-021-03552-8. BMC Pregnancy Childbirth. 2021. PMID: 33468091 Free PMC article.
  • What we have learned about treating mild gestational diabetes mellitus.
    Rice MM, Landon MB; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units (MFMU) Network. Rice MM, et al. Semin Perinatol. 2016 Aug;40(5):298-302. doi: 10.1053/j.semperi.2016.03.006. Epub 2016 Apr 25. Semin Perinatol. 2016. PMID: 27126295 Free PMC article. Review.
See all "Cited by" articles

References

    1. Chassin MR, Loeb JM, Schmaltz SP, Wachter RM. Accountability measures--using measurement to promote quality improvement. N Engl J Med. 2010;363:683–8. - PubMed
    1. Burstin HR, Conn A, Setnik G, et al. Benchmarking and quality improvement: the Harvard Emergency Department Quality Study. Am J Med. 1999;107:437–49. - PubMed
    1. Draycott T, Sibanda T, Laxton C, Winter C, Mahmood T, Fox R. Quality improvement demands quality measurement. BJOG. 2010;117:1571–4. - PubMed
    1. Shroyer AL, Plomondon ME, Grover FL, Edwards FH. The 1996 coronary artery bypass risk model: the Society of Thoracic Surgeons Adult Cardiac National Database. Ann Thorac Surg. 1999;67:1205–8. - PubMed
    1. Kozower BD, Sheng S, O’Brien SM, et al. STS database risk models: predictors of mortality and major morbidity for lung cancer resection. Ann Thorac Surg. 2010;90:875–81. discussion 81–3. - PubMed

Publication types

MeSH terms

Grants and funding