Why wildly vary­ing C-sec­tion rates per­sist

Modern Healthcare - - NEWS - By El­iz­a­beth Whit­man

For a baby born in the U.S., the like­li­hood of en­ter­ing the world through the birth canal or by ce­sarean sec­tion is not based strictly on clin­i­cal fac­tors. In­surance cov­er­age and the hospi­tal where that baby is de­liv­ered also play a role.

Last year, about a fifth of all ba­bies born at DMC Harper-Hutzel hos­pi­tals in Detroit were de­liv­ered by C-sec­tion. At two nearby hos­pi­tals, Henry Ford West Bloom­field Hospi­tal and McLaren Ma­comb in Mount Cle­mens, Mich., a quar­ter and well over onethird of the ba­bies were, re­spec­tively.

The rate of ba­bies born by C-sec­tion var­ied by 15.3 per­cent­age points across the three hos­pi­tals, ac­cord­ing to data they sub­mit­ted to the Leapfrog Group, an em­ployer-backed qual­ity and pa­tient-safety group in Wash­ing­ton, D.C.

But the num­bers don’t ex­plain why a higher pro­por­tion of ba­bies were born by C-sec­tion at McLaren Ma­comb than at Harper-Hutzel.

Fig­ur­ing out those driv­ers can lower the na­tion’s high C-sec­tion rate and related health­care spend­ing. But there’s a dearth of in­for­ma­tion about how de­liv­ery de­ci­sions are made at each hospi­tal.

“One of the things we don’t know a lot about in ma­ter­nity care is hospi­tal man­age­ment prac­tices,” said Katy Kozhimannil, an as­so­ciate pro­fes­sor at the Univer­sity of Min­nesota School of Pub­lic Health. “Ob­stet­rics is not the most lu­cra­tive ser­vice line for health­care de­liv­ery sys­tems, so it’s not the place where most at­ten­tion goes.”

High and wildly vary­ing rates of C-sec­tions across the U.S.—and the rea­sons for both—are well-es­tab­lished. In­sur­ers pay more for C-sec­tions than vagi­nal

“One of the things we don’t know a lot about in ma­ter­nity care is hospi­tal man­age­ment prac­tices. Ob­stet­rics is not the most lu­cra­tive ser­vice line for health­care de­liv­ery sys­tems, so it’s not the place where most at­ten­tion goes.” KATY KOZHIMANNIL As­so­ciate pro­fes­sor Univer­sity of Min­nesota School of Pub­lic Health

births, which take more time in hos­pi­tals that are of­ten pressed for space. Doc­tors also fear mal­prac­tice suits stem­ming from nat­u­ral births, even though C-sec­tions are con­sid­ered riskier than vagi­nal births un­less med­i­cally nec­es­sary.

Ac­count­ing for nearly one-third of births in 2014, C-sec­tions in the U.S. are per­formed at double the rate the World Health Or­ga­ni­za­tion con­sid­ers med­i­cally nec­es­sary.

The av­er­age rate of C-sec­tions among women con­sid­ered less likely to need the pro­ce­dure—first-time moth­ers with a sin­gle baby at term and po­si­tioned head-down—was 25.8% among hos­pi­tals that re­ported to Leapfrog in 2016. That C-sec­tion rate fell less than 1 per­cent­age point from the year be­fore, when the av­er­age rate was 26.4%. Mean­while, rates var­ied wildly by state, from 17.1% in New Mex­ico to 32.1% in Louisiana.

Kozhimannil, who re­viewed the re­port, said the vari­abil­ity was strik­ing. Her own re­search cor­rob­o­rates Leapfrog’s find­ings. C-sec­tion rates var­ied at least ten­fold across 593 U.S. hos­pi­tals, from 7.1% to 69.9%, ac­cord­ing to a Health Af­fairs study she co-au­thored in 2013.

The state of Cal­i­for­nia, which has been work­ing on low­er­ing its C-sec­tion rate, has what ex­perts call un­usu­ally good data on C-sec­tions thanks to an on­line data­base that gath­ers hospi­tal dis­charge records with birth cer­tifi­cate data. The data shed light on in­di­vid­ual doc­tors and track pro­ce­dures and flag prob­lems that lead to more C-sec­tions.

Some­times, C-sec­tions are med­i­cally nec­es­sary, de­pend­ing on the mother’s risk fac­tors—obe­sity, drug ad­dic­tion or lack of pre­na­tal care, to name a few ex­am­ples—and so the data need to go deeper, to al­low for risk ad­just­ment and to re­veal the de­cid­ing fac­tors that led to a C-sec­tion.

“The sys­tem nudges hos­pi­tals and clin­i­cians toward greater use of ce­sarean sec­tions,” Kozhimannil said. A C-sec­tion can take 30 min­utes, mak­ing them much more ap­peal­ing to doc­tors, hos­pi­tals and pa­tients. Plus, Med­i­caid and pri­vate in­sur­ers typ­i­cally pay twice as much for a C-sec­tion. The Cen­ter for Health­care Qual­ity and Pay­ment Re­form has es­ti­mated the av­er­age com­mer­cial pay­ment for vagi­nal births to be $5,809, com­pared with $11,193 for ce­sarean births.

Some ar­eas of ma­ter­nity care are straight­for­ward to im­prove. To stop early elec­tive de­liv­er­ies, for in­stance, hos­pi­tals or pay­ers can put a hard stop to them. They can refuse to sched­ule C-sec­tions or to pay for de­liv­er­ies when la­bor is in­duced with­out med­i­cal ne­ces­sity. Some states have done this with their Med­i­caid pro­grams.

With C-sec­tions, it’s more chal­leng­ing. Pay­ment re­form to re­duce fi­nan­cial in­cen­tives for C-sec­tions has been lim­ited to a hand­ful of pi­lot projects, in­clud­ing bun­dled pay­ments that pay the same amount for a de­liv­ery, be it vagi­nal or ce­sarean sec­tion.

Hos­pi­tals should rec­og­nize that pa­tients and in­sur­ers are pay­ing at­ten­tion to C-sec­tion rates and other ma­ter­nity care met­rics, Leapfrog spokes­woman Er­ica Mob­ley said. “Some hos­pi­tals are per­form­ing much bet­ter than oth­ers. There are lessons to be learned.”

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