single state among serving groups of women with uniform, very lowrisk characteristics.STUDY DESIGN: We compared overall cesarean rates and cesareanrates among the Nulliparous Term Singleton Vertex (NTSV) pop-ulation between the 49 maternity hospitals in Massachusetts usingbirth certificate and hospital discharge data from all 255,456 Mas-sachusetts non anomalous livebirths births between January 1 2004and December 31 2006. To further isolate a homogenous popula-tion, subanalyses were performed examining cesarean rates amongNSTV women with infants weighing 2500-4000g and in spontane-ous labor.RESULTS: There was three-fold variation in hospital-specific NTSVcesarean rates (range 14%-38%, mean 26%) which persisted afterfurther narrowing the population to women with infants weighing2500-4000g (15% to 39%, mean 25%) and in spontaneous labor(10% to 35%, mean 21%). Standard deviations remained similar inall subgroups indicating a persistent wide dispersion in cesareanrates. There was strong correlation between hospital overall cesar-ean rates and rates in the NTSV population (Pearsons correlation�0.88). Adjusting for maternal and fetal characteristics includingmaternal age, education, race/ethnicity, infant birthweight, gesta-tional age, and maternal conditions (hypertension, diabetes, pre-eclampsia or placenta previa) did not diminish the variationamong hospitals cesarean rates.CONCLUSION: The observed three-fold variation in cesarean ratesamong a low risk population suggest that hospital practice patternsrather than maternal and fetal risk factors alone may play a role indetermining delivery method among low risk women, and representsan opportunity for quality improvement.

639 Effect of education and provider transparencyupon individual cesarean, episiotomy, antenatalsteroid, and breastfeeding ratesWilliam Gilbert1, Mary Campbell Bliss1, AmyJohnson2, Laurie Gregg1, Christopher Swanson1

1Sutter Medical Center Sacramento, Department of Obstetricsand Gynecology, Sacramento, CA, 2Sutter Medical CenterSacramento, Integrated Quality Services, Sacramento, CAOBJECTIVE: To determine if a combination of quality improvementprograms including making individual providers cesarean section(C/S) and episiotomy (epis) rates public, improving computer chart-ing for antenatal steroids (AS), and education on the importance ofexclusive breastfeeding (EBF) at hospital discharge, would improvethese rates.STUDY DESIGN: Sutter Medical Center, Sacramento is a private prac-tice, Level 3 community hospital with approximately 5500 deliveriesper year and 35 active members of the OB/GYN Department medicalstaff. With concern for the increasing C/S rates nationally, and othermeasures of OB/GYN quality being examined by national qualitygroups, physician leaders within the department explored options toimprove these measures. After departmental approval, individual C/S(nulliparous singleton term vertex) and epis rates (any episiotomy)

were collected for 6 months and posted blindly (codes known to eachmember only) within the department. For the next 6 months, data wasposted and presented publically by individual provider name. Com-puter charting was modified to require physician input on AS fordeliveries � 34 weeks of gestation. An educational pregram concern-ing EBF rates was performed with public listing of individual andgroup rates of EBF.RESULTS: Over the second 6 month open period, there were reduc-tions in C/S rates (31 vs 27% with June 2011 being 23%) with im-provements in AS (80 vs 100%) and EBF (60 vs 65%) rates while theepis rate was largely unchanged (4.3 vs 4.6%) but low to start with.CONCLUSION: A combination of physician education, change in med-ical record documentation, and transparency of individual providerpractice data, improved almost every measure of quality and suggestsseveral paths to positively impact quality measures within a commu-nity hospital with private practice providers.

640 The development of risk-adjusted outcomes tobe used as quality indicators for obstetric careWilliam Grobman1

1For the Eunice Kennedy Shriver National Institute of Health and HumanDevelopment, Maternal-Fetal Units Network, Bethesda, MDOBJECTIVE: Current quality indicators of obstetric care rely on admin-istrative data, which, because of lack of detail, do not allow adequaterisk adjustment. The objective of this study was to develop risk-ad-justed obstetric outcome quality measures using detailed and reliablepatient data.STUDY DESIGN: Data were obtained by trained abstractors, with ongo-ing data edits and audits, from maternal and neonatal charts of alldeliveries on 365 randomly selected days at 25 hospitals over a 3-yearperiod. Five outcome measures, selected a priori and rigorously de-fined, were chosen: venous thromboembolism (VTE), severe postpar-tum hemorrhage (PPH), maternal peripartum infection, perinealtrauma (3rd or 4th degree laceration) at spontaneous vaginal delivery,and a composite adverse neonatal outcome. The outcomes were as-sessed to see whether their rates were significantly different acrosshospitals and whether they were related to patient-specific factors.Expected rates were determined for each hospital based on differencesin patient-specific factors, and these rates were compared with theobserved rates using Spearman correlation.RESULTS: Data were collected on 115,502 women. VTE occurred tooinfrequently (0.03%) to be used as a quality measure.The observedrates of the remaining four outcomes ranged from 0.8% to 9.5%, andvaried significantly among hospitals (P �.001). A core group of pa-tient-specific factors (maternal age, BMI, GA or BW, PROM, parity,DM, and smoking) was significantly associated with the outcomes,and was used to construct an equation to estimate each hospital’sexpected outcome rates. Observed and expected rates were not sign-ficantly correlated for infection (Figure), and were correlated, albeitmoderately, for the other three outcomes (Table).CONCLUSION: The frequencies of four obstetric outcome measureswithin a hospital are related to, but not merely a reflection of, itspatient population. Patient-specific factors can be used to derive anequation that hospitals can employ to determine their own expectedoutcome rates, and better assess their performance regarding theseoutcomes.

PosterSessionIV Epidemiology, Infectious Disease, Intrapartum Fetal Assessment, Operative Obstetrics, Obstetric Quality & Safety, Public Health-Global Health www.AJOG.org

S286 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2012