Case study 11 Obstetric Delivery - IPART · PDF fileContents Case study 11 – Obstetric Delivery IPART iii Contents 1 Introduction and executive summary 1 1.1 Why did we select obstetric

Independent Pricing and Regulatory Tribunal

Case study 11 — Obstetric Delivery

Hospital costs and outcomes study for NSW Health

Other Industries

July 2010

Case study 11 – Obstetric Delivery Hospital costs and outcomes study for NSW Health

Other Industries July 2010

ii IPART Case study 11 – Obstetric Delivery

© Independent Pricing and Regulatory Tribunal of New South Wales 2010

This work is copyright. The Copyright Act 1968 permits fair dealing for study, research, news reporting, criticism and review. Selected passages, tables or diagrams may be reproduced for such purposes provided acknowledgement of the source is included.

ISBN 978-921628-58-0 S9-57

The Tribunal members for this review are:

Mr James Cox, Acting Chairman and Chief Executive Officer

Ms Sibylle Krieger, Part Time Member

Inquiries regarding this document should be directed to a staff member:

Alison Milne (02) 9290 8443 Bee Thompson (02) 9290 8496

Independent Pricing and Regulatory Tribunal of New South Wales PO Box Q290, QVB Post Office NSW 1230 Level 8, 1 Market Street, Sydney NSW 2000

T (02) 9290 8400 F (02) 9290 2061

www.ipart.nsw.gov.au

Contents

Case study 11 – Obstetric Delivery IPART iii

Contents

1 Introduction and executive summary 1 1.1 Why did we select obstetric delivery as one of the case studies? 4 1.2 What was the scope of the obstetric delivery case study? 4 1.3 What were the key findings of the obstetric delivery case study? 5 1.4 What are the key implications of these findings? 7 1.5 List of recommendations 8 1.6 What does the rest of this report cover? 9

2 Number and mix of patients across study hospitals 10 2.1 Number of obstetric delivery inpatient cases at each study hospital 10 2.2 Number of non-admitted occasions of service at each study hospital 11 2.3 Types of obstetric delivery cases at each study hospital 13 2.4 Comparison of casemix at the study hospitals 14

3 Length of stay across study hospitals 17 3.1 Comparing length of stay for caesarean sections and vaginal deliveries 19 3.2 Comparing length of stay by DRG 20

4 Costs of providing inpatient care 21

5 Configurations of care 22 5.1 Models of antenatal care 22 5.2 Delivery facilities 24 5.3 Early discharge programs 26

6 Outcome, safety and quality indicators 28 6.1 Adequacy of existing outcomes monitoring and reporting 28 6.2 Analysing indicators and risk-adjusting for patient characteristics 30 6.3 Clinical indicators for obstetrics delivery 31 6.4 Issues for further consideration 38

Appendices 41 A List of full recommendations from main report 43 B Risk-adjusted indicators provided by NSW Health 53

Glossary 55

1 Introduction and executive summary

Case study 11 – Obstetric Delivery IPART 1


NSW Health is currently coordinating a project that ultimately aims to improve clinical practice and efficiency consistently across the NSW hospital system. The project involves 6 components, and is designed to enable development of a methodology that makes better use of available data to compare patient mix, costs, clinical practice and outcomes and which can then be applied across other hospitals to improve performance. (See Box 1.1 for more information.)

NSW Health asked the Independent Pricing and Regulatory Tribunal of NSW (IPART) to conduct a costs and outcomes study that encompasses 3 components of this larger project. The aim of the study was to provide information and analysis that can be used by clinical experts to better understand the variation in clinical practice in NSW hospitals, and the extent to which this variation can lead to differences in hospital costs and clinical outcomes.

IPART’s study involved comparing costs, configurations of care and outcomes in 5 selected NSW hospitals:

Royal Prince Alfred Hospital (RPAH)

Royal North Shore Hospital (RNSH)

John Hunter Hospital (JHH)

Bankstown-Lidcombe Hospital (BLH), and

Gosford Hospital (GH).

To do this, we analysed management practices at the hospital-wide level and did detailed case studies of 11 specific clinical areas. As costs, configurations of care and relevant indicators of outcomes vary significantly depending on the condition of the patient and/or the procedure undertaken, these case studies allowed us to compare the hospitals on a more like-with-like basis. This document discusses our findings in one of these 11 clinical areas – obstetric delivery. (See Box 1.2 for the full list of clinical areas we examined, how they were selected, and how we conducted the case studies.)


2 IPART Case study 11 – Obstetric Delivery

Box 1.1 NSW Health Project

IPART’s hospital costs and outcomes study is part of a larger, multi-stage project NSW Health is coordinating with the assistance of other organisations. The terms of reference for this projectset out 6 components:

1. Audit the quality of current coding and costing data.

2. Analyse differences in costs between 3 principal tertiary referral hospitals and 2 otherprincipal referral hospitals.

3. Describe the different configurations of care that underpin different cost profiles.

4. Analyse available data on differences in adjusted admission rates and clinical outcomes for the 5 selected hospitals.

5. Determine whether variations in configurations of care lead to different clinical outcomes.

6. Identify the extent to which clinical variation exists, with the aim of achieving clinical bestpractice and maximum efficiency.

The first component is being completed by Health Outcomes International (audit of costing)and Pavilion Health (audit of coding). The results will assist the NSW Department of Health in further developing episode funding, in line with the national agreement by the Council of Australian Governments (COAG) to move to a more nationally consistent approach to activity-based funding. IPART has completed the second, third and fourth components through ourhospital costs and outcomes study. The results of this study will be used by clinical experts in completing the fifth and sixth components.

The NSW Health project is part of its response to the findings and recommendations made inthe Report of the Special Commission of Inquiry into Acute Care Services by Commissioner Garling.a

a Flowing from the NSW Government’s response to the Garling Inquiry (Caring Together - The Health Action Plan for NSW (2009)), ‘four pillars’ of clinical improvement have been established – Clinical Excellence Commission (CEC), Agency for Clinical Innovation (ACI), Bureau of Health Information (BHI) and Clinical Education and Training Institute (CETI). IPART’s analysis on costs, clinical practice and outcomes is to be considered by the NSW Department of Health and clinical experts in these agencies to assess whether variations in configurations of care lead to different clinicaloutcomes and to identify the extent to which clinical variation exists, with the aim of achieving clinical best practiceand maximum efficiency.



Box 1.2 IPART’s case studies

To compare costs, configurations of care and outcomes in the 5 study hospitals, we focused on11 specific conditions or procedures in detail (as well as undertaking a broad, hospital-wide analysis). These conditions/procedures are:

Hip joint replacement

Major chest procedures

Breast surgery

Cholecystectomy

Appendicectomy

Stroke

Cardiology – stents, pacemakers and defibrillators

Tracheostomy, or ventilation for greater than 95 hours

Cataract/lens procedures

Hysterectomy, and

Obstetric delivery.

In selecting these conditions/procedures, and the relevant indicators to compare for each, wewere advised by a clinical consultant (Dr Paul Tridgell) and a clinical reference group (ProfessorBruce Barraclough, Dr Anthony Burrell, Dr Patrick Cregan, Professor Phillip Harris, ProfessorClifford Hughes, Professor Brian McCaughan, Professor Peter McClusky, Dr Michael Nicholl,Professor Ron Penny, Professor Carol Pollock and Dr Hunter Watt).

The case studies were selected to provide a range of surgical procedures and a range ofmedical conditions that met one or more of the following criteria:

high volumes

high reported costs

high variability in reported costs

apparent differences in clinical practice, or

a range of models of care.

To conduct the case studies, we visited each of the hospitals and spoke with a range of staff,including clinical, nursing, management, finance, coding and administrative staff. We also collected a range of clinical and financial data from NSW Health, relevant area health servicesand hospitals. By analysing the data and speaking with clinical experts, we established themost suitable data available for comparing hospitals on a like-with-like basis.

For further information on our methodology and broad findings on costs, outcomes andconfigurations of care, see our main report, NSW Health costs and outcomes study by IPART for selected NSW hospitals. Our detailed findings on the other case study areas can be found in our reports on each area.



1.1 Why did we select obstetric delivery as one of the case studies?

Obstetric delivery was selected as one of the clinical areas for detailed study because it involves:

high volumes1

different service models (eg, birthing units, early discharge and home support)

variation in practice between hospitals (eg, different caesarean section rates).

1.2 What was the scope of the obstetric delivery case study?

The obstetric delivery case study compared the costs, configurations of care and outcomes related to caesarean section or vaginal delivery. We used diagnostic related groups (DRGs) to define the case study and identify the data included in the scope of the case study (see Table 1.1).

Table 1.1 DRGs included in the scope of the obstetric delivery case study

DRG DRG Description

O01A Caesarean delivery with catastrophic complication or comorbidity

O01B Caesarean delivery with severe complication or comorbidity

O01C Caesarean delivery without catastrophic or severe complication or comorbidity

O02A Vaginal delivery with operating room procedure with catastrophic or severe complication or comorbidity

O02B Vaginal delivery with operating room procedure without catastrophic or severe complication or comorbidity

O60A Vaginal delivery with catastrophic or severe complication or comorbidity

O60B Vaginal delivery without catastrophic or severe complication or comorbidity

O60C Vaginal delivery single uncomplicated without other condition

Unless specified otherwise in this case study, the data we analysed related to the 12-month period from 1 July 2008 to 30 June 2009.

1 In 2007/08, there were 287,451 separations in Australian hospitals for the obstetric delivery

DRGs listed in Table 1.1. See Australian Institute of Health and Welfare, AR-DRG Data Cubes, Separation, patient day and average length of stay statistics by Australian Refined Diagnosis Related Group (AR-DRG) Version 5.0/5.1, Australia, 1998-99 to 2007-08 (http://d01.aihw.gov.au/cognos/cgi-bin/ppdscgi.exe?DC=Q&E=/AHS/drgv5_9899-0708_v2).



1.3 What were the key findings of the obstetric delivery case study?

To compare the costs, configurations of care and outcomes of obstetric deliveries at the study hospitals, we collected, analysed and compared data on:

the number and mix of obstetric delivery patients at each hospital

the average length of stay for these patients at each hospital

selected costs, or major clinical resources used to provide acute inpatient care for these patients at each hospital

the configurations of care used to provide and manage obstetric delivery patients care at each hospital

indicators of outcome, safety and quality for obstetric deliveries for each hospital.

Our key findings are summarised below.

1.3.1 Number and mix of patients

We found differences across the study hospitals in patient numbers, caesarean section rates, obstetric delivery complexity and patient demographics.

RPAH treated the most inpatient cases, followed by JHH.

RNSH, GH and RPAH had much higher caesarean section rates than JHH and BLH.

RPAH, RNSH and JHH had a higher percentage of patients with the more complex DRGs (O01A, O01B, O02A and O06A2) than GH and BLH.

RNSH and RPAH had an older patient demographic than GH, JHH and BLH.

In addition, we found that the way the hospitals counted and reported their outpatient activity was not consistent.

1.3.2 Average length of stay

We found that the average length of stay for vaginal deliveries is lower than that for caesarean sections. Average length of stay is lowest at GH and BLH for both delivery types.

2 Respectively, caesarean delivery with catastrophic complication or comorbidity; caesarean

delivery with severe complication or comorbidity; vaginal delivery with operating room procedure with catastrophic or severe complication or comorbidity; and vaginal delivery with catastrophic or severe complication or comorbidity.



1.3.3 Costs of inpatient care

A significant proportion of obstetric delivery care involves outpatient activity. Therefore, while we were able to model the costs of inpatient care, we did not consider that this provided a reliable proxy for the total costs of obstetric delivery care. Further, as the study hospitals do not appear to count their outpatient activity consistently, we were unable to attribute a value to this activity in order to estimate the total costs.

1.3.4 Configurations of care

We analysed the way the study hospitals managed and provided care for obstetric delivery patients along a continuum, from antenatal care through obstetric delivery and then discharge from hospital. In particular, we considered the similarities and differences between the study hospitals in the following areas:

models of antenatal care

options regarding delivery facilities, and

early discharge programs.

Models of antenatal care

The study hospitals broadly use the same models of antenatal care, which are related to the complexity of the patient. The antenatal clinics staffed by obstetrician consultants and registrars are usually attended by patients with higher risk pregnancies. Midwifery care and GP shared antenatal care are available for patients with lower risk pregnancies.

Delivery facilities

All study hospitals have birthing suites and theatres for deliveries. RPAH and JHH also have birth centres for low risk pregnancies. In addition, JHH has configurations of care that support home births.

Early discharge programs

All study hospitals have some form of early discharge program. However, the study hospitals appear to have different timeframes for patients leaving hospital under these programs, with GH having the shortest timeframe.

To understand the impact of the early discharge programs, we analysed the time taken from obstetric delivery to discharge from the hospital for a patient’s acute episode. When compared to the other study hospitals, a substantially higher percentage of patients were discharged from GH within 72 hours of delivery for caesarean section and within 48 hours of delivery for vaginal delivery. These results are consistent with our findings that GH patients have shorter stays on average.



1.3.5 Outcome, safety and quality indicators

In relation to obstetric deliveries, there is already a substantial amount of monitoring and reporting on hospital performance against clinical indicators. Further, the Maternity Services Inter-Jurisdictional Committee is currently developing a core set of national maternity care performance indicators.3

As the national clinical indicators are still being finalised, we considered the performance of the study hospitals against several commonly reported clinical indicators. The study hospitals had broadly similar results for babies born with low Apgar scores. However, the indicators relating to caesarean sections highlighted significant differences between the hospitals.

GH had the highest risk-adjusted rates for caesarean sections for ‘selected primiparas’4 and caesarean sections after induction of labour. These rates were substantially lower at BLH and JHH.

1.4 What are the key implications of these findings?

Outpatient activity

In order to accurately assess a hospital’s total costs of providing obstetric delivery care, both inpatient and outpatient activity at the hospital needs to be taken into account. While costing data is available for inpatient activity, outpatient data does not appear to be reliably measured by the study hospitals.

Outcomes monitoring

There is often a considerable lag between outcome data collection and reporting, which does not allow hospitals to readily gauge the impact of their practices or compare their performance with other hospitals. As an example, the latest NSW Mothers and Babies report was released in 2009 and based on data from 2006. NSW Health should ensure that results against clinical indicators are readily disseminated to the clinical level.

3 The Maternity Services Inter-Jurisdictional Committee was established by the Australian Health

Ministers’ Advisory Council as an information sharing network of representatives from States and Territories with the principal objective of promoting primary maternity services. See Maternity Services Inter-Jurisdictional Committee (http://www.ahmac.gov.au/cms_documents/Maternity%20Services%20Interjurisdictional%20Committee(1).pdf).

4 The ‘selected primipara’ is defined as a woman who is 20-34 years of age, giving birth for the first time at between 37-41 weeks gestation and with a singleton pregnancy (pregnancy with only one baby) in cephalic presentation (head-first).



Caesarean section rates

There were significant differences between the hospitals in relation to risk-adjusted caesarean section rates, with GH having substantially higher rates than BLH and JHH. This could not be easily explained by differences in configurations of care at the study hospitals or patient complexity. Further, there was not a link between caesarean section rates and differences in other outcome indicators in our clinical indicator set, such as Apgar score and severe perineal trauma.

NSW Health is taking steps to address the issue of increasing caesarean section rates and variation in rates across hospitals. It recently released a new policy directive, Maternity – Towards Normal Birth in NSW, which outlines actions to increase the vaginal birth rate and decrease the caesarean section rate. Area Health Services will be required to report annually on their performance against key measures such as:

maternity services having a written normal birth policy

the percentage of women having vaginal births

maternity clinicians being informed of statistics relating to outcomes for vaginal birth after caesarean section.

1.5 List of recommendations

1 That NSW Health and clinical expert groups note the variation in the following clinical indicators relating to obstetric delivery: 39

– caesarean section rates for ‘selected primipara’ 39

– vaginal delivery rates following primary caesarean section 39

– caesarean section rates after induction of labour for ‘selected primipara’ 39

– repeat caesarean section rates 39

– significant tear rates 39

and monitor changes arising from the implementation of the NSW Health policy directive, Maternity – Towards Normal Birth in NSW, to determine whether this policy effectively addresses the variation. 39



1.6 What does the rest of this report cover?

The rest of this report discusses the findings of the obstetric delivery case study in more detail:

Chapter 2 compares the number and mix of obstetric delivery patients at the study hospitals.

Chapter 3 compares the length of stay for obstetric delivery patients at the study hospitals, and describes the method we used to compare length of stay on a consistent basis.

Chapter 4 describes the limitations associated with costing obstetric deliveries at the study hospitals.

Chapter 5 compares the configurations of care for obstetric delivery patients at the study hospitals.

Chapter 6 discusses the indicators of outcome, safety and quality for obstetric deliveries we identified as clinically meaningful. It then compares the available data on these indicators across the study hospitals.

The appendices contain the complete list of recommendations for our hospital costs and outcomes study and additional information for risk-adjusted indicators. A glossary is also included at the end of this report.

2 Number and mix of patients across study hospitals



We identified the total number of obstetric delivery inpatient cases at each hospital during the study period, and compared this with the outpatient activity for obstetrics reported by the study hospitals. We also examined the proportions of inpatient cases for each delivery type. We then compared the mix of cases by identifying the proportion of patients within each DRG. In addition, we considered the age of patients at the study hospitals.

We found differences across the study hospitals in patient numbers, caesarean section rates, obstetric delivery complexity and patient demographics. We also found that the study hospitals are not counting their outpatient activity using a consistent methodology.

The sections below discuss our analysis of patient numbers and mix in more detail.

2.1 Number of obstetric delivery inpatient cases at each study hospital

Our data indicates that the 5 study hospitals managed a total of 15,488 obstetric delivery cases during the study period. It also shows that there were differences between the hospitals in the number of cases and transfers (see Table 2.1).

Table 2.1 Obstetric delivery cases at study hospitals, DRGs O01A, O01B, O01C, O02A, O02B, O60A, O60B, O60C, 2008/09

RPAH GH RNSH BLH JHH

All study hospitals

Inpatient cases (no.) 5,146 2,407 1,906 2,135 3,894 15,488

Transfers in (%) 12 7 5 1 3 7

Transfers out (%) 0 9 0 2 1 2

Note: See Box 2.1 for details on how we calculated the number of cases and transfers.

Source: HIE inpatient statistics, 2008/09 and IPART analysis.

The number of cases ranged from 1,906 at RNSH to 5,146 at RPAH. GH and BLH both had a significant number of cases for hospitals of their size, with 2,407 and 2,135 cases respectively. JHH had 3,894 cases. We understand that a hospital’s volume of cases may sometimes reflect capacity issues relating to infrastructure.



RPAH had the highest percentage of patients who were transferred in (12%). The next highest rates were at GH, RNSH and JHH, with 7%, 5% and 3% respectively.

Transfers in and out at GH reflect movement to and from nearby Wyong Hospital. Similarly, the transfers in for RNSH and JHH include movement in from primary models at Ryde Hospital and Belmont Hospital respectively. For the tertiary hospitals (ie, RPAH, RNSH and JHH), some of the ‘transfers in’ may also represent higher risk pregnancies, resulting in longer stays and greater costs than lower risk pregnancies.

Box 2.1 provides more detail on how we calculated the number of cases and transfers at each hospital.

Box 2.1 How we calculated the number of obstetric delivery cases and transfers

Number of cases

To calculate the number of obstetric delivery cases in study hospitals, we:

used patient episode data for 2008/09

counted adjoining episodes as part of the same stay (ie, adjoining episodes counted as one case)

only included patient data where the whole patient stay occurred within 2008/09 (ie, allepisodes and adjoining episodes had to start on or after 1 July 2008 and end on or before30 June 2009 to be counted)

only included patient data where the first episode in the year in the study hospital wascoded as a DRG for an obstetric delivery (ie, episode sequence number had to be 1).

The approach prevented double counting. It excluded cases where the patient was admitted for a different procedure and later reclassified to an obstetric delivery DRG.

Note that our approach means that the number of cases we identified will be less than thenumber of separations in 2008/09.

Transfers

Due to data quality issues with the transfer in and transfer out fields in the admitted patient data, transfers in and out were calculated using a linkage key developed by the AustralianInstitute of Health and Welfare.

2.2 Number of non-admitted occasions of service at each study hospital

A significant proportion of obstetric delivery care involves outpatient activity. Table 2.2 sets out the number of non-admitted patient occasions of service (NAPOOS) reported by the study hospitals during the case study period.



Table 2.2 Non-admitted patient occasions of service by provider type


no. no. no. no. no.

Individual sessions

Provider type Setting type

Medical or surgical specialist

Hospital

4,427 542 9,406 - 7,688

Multidisciplinary team

Hospital 13,914 4,157 - - -

Hospital 17,514 14,505 13,468 22,313 54,244

Community Health Centre - 6,965 - - 5,106

Nurse or allied health professional

Home 5,502 5,457 1,941 - 14,421

Group sessions Hospital 181 118 19 - 185

Total sessions 41,538 31,744 24,834 22,313 81,644

Note: The multidisciplinary team figure for RPAH include 1,682 outpatient occasions of service for assisted reproductive technology.

Source: NSW Department of Health, 2008/09 and IPART analysis.

The outpatient activity reported by the study hospitals does not correlate with their inpatient activity, as would be expected. For example, JHH reported almost double the number of NAPOOS than RPAH, even though JHH had fewer inpatient obstetric delivery patients than RPAH (see Table 2.1). This indicates that the study hospitals are not counting their outpatient activity using a consistent methodology.

Study hospitals also seem to be classifying their NAPOOS differently. As an example, all of BLH’s NAPOOS are reported as being managed by nurses (or allied health professionals) in a hospital setting. In contrast, the other hospitals reported their NAPOOS as being managed by a number of provider types across several settings.



2.3 Types of obstetric delivery cases at each study hospital

There was substantial variation in the rates of caesarean section at the study hospitals (see Table 2.3).

Table 2.3 Obstetric delivery types

RPAH GH RNSH BLH JHH All study hospitals

% % % % % %

Caesarean section 32 34 35 20 23 29

Vaginal delivery 68 66 65 80 77 71


RNSH, GH and RPAH all had similar caesarean section rates, with 35%, 34% and 32% respectively. In comparison, JHH and BLH had much lower caesarean rates, at 23% and 20% respectively.

The caesarean section rate is higher among private patients than public patients at the study hospitals (see Table 2.4).

Table 2.4 Caesarean section rates by patient type, 2008/09


% % % % %

Patient mix Public patients 51 98 97 91 84

Private patients 49 2 3 9 16

Caesarean section rate

Public patients 29 33 35 19 22

Private patients 35 64 61 31 26


Only RPAH and JHH have significant proportions of private patients for obstetric deliveries, with 49% and 16% respectively. GH and RNSH have the lowest proportions of private patients, with 2% and 3% respectively. As such, the higher caesarean section rates at these hospitals cannot be explained by them having a higher intake of private patients.

Clinicians at most study hospitals indicated that they were trying to reduce caesarean section rates. For example, RPAH clinicians conducted an audit of their caesarean section rates to understand the factors affecting them. The audit has led to RPAH placing a greater emphasis on one-on-one midwifery care and midwives looking after women in labour. In addition, the Northern Sydney Central Coast Area Health Service (which includes RNSH and GH) is planning to implement an area wide program encouraging more women to attempt vaginal delivery for their next



birth following a caesarean section. Caesarean section rates at the study hospitals are discussed in more detail in section 6.2.

2.4 Comparison of casemix at the study hospitals

Our data indicated that there was variation in the relative proportions of cases in each DRG across study hospitals. Further, there were differences in the proportion of patients in different age groups.

2.4.1 DRG complexity

The obstetric delivery case study contains eight DRGs. Table 2.5 shows the percentage of cases ‘coded’ in each DRG, divided into the more complex and less complex categories of patient.

Table 2.5 Percentage of cases coded in each obstetric delivery DRG

DRG RPAH GH RNSH BLH JHH All study hospitals

% % % % % %

More complex DRGs

O01A – caesarean delivery with catastrophic CC 3 2 2 0 3 2

O01B – caesarean delivery with severe CC 7 5 7 3 5 6

O02A – vaginal delivery with O.R. procedure with catastrophic or severe CC

1 1 2 0 1 1

O60A – vaginal delivery with catastrophic or severe CC

9 7 8 5 10 8

Total more complex DRGs 20 14 19 9 20 17

Less complex DRGs

O01C – caesarean delivery without catastrophic or severe CC

22 27 26 16 15 21

O02B – vaginal delivery with O.R. procedure without catastrophic or severe CC

1 1 3 1 3 2

O60B – vaginal delivery without catastrophic or severe CC

49 48 46 56 51 50

O60C – vaginal delivery single uncomplicated without other condition

8 9 6 17 12 10

Total less complex DRGs 80 86 81 91 80 83

Note: “CC”= complication or comorbidity; “O.R.”=operating room.


RPAH, JHH and RNSH had the highest proportion of patients with the more complex DRGs, with 20%, 20% and 19% respectively. In contrast, GH and BLH only had 14% and 9% respectively of their patients with the more complex DRGs.



In order to help assess if the coders in each hospital are coding patients similarly, IPART compared the average number of diagnosis codes per obstetric delivery in the five hospitals5 (see Table 2.6).

Table 2.6 Average number of diagnosis codes per patient in study hospitals by DRG

DRG RPAH GH RNSH BLH JHH

no. no. no. no. no.

O01A – caesarean delivery with catastrophic CC 8.5 8.5 9.0 7.3 9.0

O01B – caesarean delivery with severe CC 6.3 6.8 6.9 5.3 6.9


4.2 4.2 4.4 3.5 4.5


6.4 6.1 7.2 5.7 7.1


4.0 4.3 4.5 4.2 4.3

O60A – vaginal delivery with catastrophic or severe CC 6.3 6.2 7.3 5.1 6.5

O60B – vaginal delivery without catastrophic or severe CC

3.8 4.1 4.1 3.4 4.0


2.5 2.7 2.4 2.6 2.6



We found that the number of diagnosis codes in the inpatient data was fairly similar across the hospitals.

5 This provides a rough guide to help assess whether there is a significant difference in coding

practice between hospitals. If one hospital is coding cases in higher complexity categories, we would expect that there were more diagnosis codes used on average. Likewise, if hospitals were paying little attention to coding complexity, we would expect few diagnosis codes to be included.



2.4.2 Age of patients

We considered the age of patients at the study hospitals (see Table 2.7).

Table 2.7 Age of patients

RPAH GH RNSH BLH JHH All study hospitals

Average age (years)

All cases 33 29 32 29 29 31

Caesarean section 34 30 33 31 30 31

Vaginal delivery 32 29 32 29 29 30

% of patients in different age groups

under 20 years 1 5 1 2 5 3

20-34 years 62 75 63 80 75 70

35 years and over 38 20 36 18 20 28

Note: Age at date of admission.


The average age of patients for caesarean section was 31 years old, ranging from an average of 30 years for GH and JHH to 34 years for RPAH. In relation to vaginal delivery, the average age of patients was 30 years old, ranging from an average of 29 years for GH, JHH and BLH to 32 years for RPAH and RNSH.

The small difference in average age for caesarean section and vaginal delivery implies that patient age is not an important factor in hospitals’ caesarean section rates. However, there appears to be some correlation between hospitals with older demographics and higher caesarean section rates.

RPAH and RNSH had the highest proportion of patients aged 35 years and over, with 38% and 36% respectively, as well as relatively high caesarean section rates. In contrast, BLH and JHH had the lowest proportion of patients aged 35 years and over, with 18% and 20% respectively, as well as relatively low caesarean section rates.

3 Length of stay across study hospitals



We examined the average length of stay of obstetric delivery inpatients because it is one of the factors that influence the cost of an individual’s hospital care. This is because a large component of this cost is nursing care (and this cost increases with the length of stay). In addition, differences in length of stay can point to differences in casemix or clinical practice between hospitals.

We calculated the average length of stay across all study hospitals for obstetric delivery cases using 3 different measures:

episode length of stay in study hospital (LOS1)

total length of stay in study hospital (LOS2)

total length of stay in study hospital and 2 other hospitals – one transfer in and one transfer out (LOS3).

Box 3.1 provides more detail on these measures. The sections below set out our analysis of length of stay for caesarean section and vaginal delivery cases, as well as for each obstetric delivery DRG, with a focus on LOS1 and LOS3.



Box 3.1 The 3 measures of length of stay we used for obstetric delivery patients

1. Episode length of stay in study hospital (LOS1)

This is the average number of days a patient stayed in the study hospital for a single acute episode. This measure is often used in DRG benchmarking analyses.

2. Total length of stay in study hospital (LOS2)

This is the total number of days a patient stayed in the study hospital from admission todischarge. It includes all consecutive episodes including acute, rehabilitation and any othertypes of care. However, for some conditions/procedures, patients can be:

transferred to the study hospital from another hospital, and/or

transferred from the study hospital to another.

LOS2 does not include the length of stay in such other hospitals, so does not provide a consistent basis for comparing average length of stay required to care for certainconditions/procedures.

3. Total length of stay in study hospital plus up to 2 other hospitals – one transfer in and one transfer out (LOS3)

The third measure is the total length of stay in the study hospital (ie, LOS2), plus the totallength of stay at 2 other hospitals – one ‘transfer in’, and one ‘transfer out’. Ideally all relatedhospital stays would be linked, but we have only added up to one additional hospital stay at either end of the stay in the study hospital. We used the linkage key developed by the Australian Institute of Health and Welfare (AIHW) for use between all public and privatehospitals. This step is not routinely done in hospital comparisons.

We consider that LOS3 is a more consistent basis for comparing average length of stay forcertain conditions/procedures because it takes account of differences in hospital:

administrative practices for reclassifying patients between their acute care and other phases of care (type changes)

access to rehabilitation facilities (transfers out)

patterns of referral from other hospitals (transfers in).



3.1 Comparing length of stay for caesarean sections and vaginal deliveries

Table 3.1 compares the average length of stay for caesarean sections and vaginal deliveries across the study hospitals, using the LOS1 and LOS3 measures.

Table 3.1 Average length of stay by delivery type


days days days days days

Caesarean section

LOS1 5.6 3.8 5.3 4.4 6.3

LOS3 5.5 3.8 5.2 4.3 6.8

Vaginal delivery

LOS1 3.5 2.2 3.1 2.8 2.9

LOS3 3.4 2.4 3.0 2.7 3.0

Difference in LOS

LOS1 2.1 1.7 2.2 1.6 3.4

LOS3 2.1 1.4 2.2 1.6 3.8

Note: Numbers may not add due to rounding. In a few instances LOS3 will be slightly shorter than LOS1, because LOS1 is calculated using hours on the ward while LOS3 is calculated using days. For example, if a patient is admitted in the morning for surgery and discharged early afternoon of the next day, the average length of stay would be 30 hrs or 1.25 days: under LOS3 this would be 1 day and under LOS1 this would be 1.25 days.


The average total number of days in hospital for caesarean sections ranges from 3.8 days at GH to 6.8 days at JHH. For vaginal deliveries, the range was from 2.4 days at GH to 3.4 days at RPAH. The difference in length of stay between caesarean sections and vaginal deliveries ranges from 1.4 days at GH to 3.8 days at JHH using the LOS3 measure.

Patient mix may partially explain the differences in average length of stays at the study hospitals. For example, GH has a relatively young patient mix (see Table 2.7), a factor which is typically associated with shorter stays. In addition, a hospital’s average length of stay may be affected by capacity issues relating to infrastructure.

Clinicians at GH indicated that their shorter stays partly reflect the high numbers of deliveries at the hospital. Staff proactively check wards to see whether patients are ready for discharge.

The approach of study hospitals to discharging patients is discussed further in Chapter 5 on configurations of care. We note that some hospitals provide considerable support for patients at home after their discharge. As such, a shorter length of stay may be partially offset by care in the home.



3.2 Comparing length of stay by DRG

Table 3.2 compares the average length of stay for caesarean section and vaginal delivery patients by DRG across the study hospitals using the LOS3 measure.

Table 3.2 Average length of stay by DRG


days days days days days

Caesarean section

O01A – caesarean delivery with catastrophic CC 10.2 7.4 13.1 5.0 12.9

O01B – caesarean delivery with severe CC 6.5 4.7 7.0 5.3 9.6


4.6 3.5 4.0 4.1 4.7

Vaginal delivery


4.6 4.3 6.5 4.1 5.6


3.9 2.7 3.0 3.5 2.9

O60A – vaginal delivery with catastrophic or severe CC 5.3 3.6 6.4 4.5 5.7

O60B – vaginal delivery without catastrophic or severe CC 3.3 2.3 2.5 2.7 2.7


2.2 1.6 1.7 2.1 1.6



Average length of stay for the less common, more complex DRGs can be significantly influenced by a few outlier cases. As such, there is a large difference between the study hospitals for these DRGs.

In relation to the more common, less complex DRGs, GH generally had the shortest stays. For example, the average total number of days in hospital for:

DRG O01C ranges 3.5 days at GH to 4.7 days at JHH, and

DRG O60B ranges 2.3 days at GH to 3.3 days at RPAH.

These DRGs comprise over 70% of obstetric deliveries at the study hospitals (see Table 2.5).

4 Costs of providing inpatient care


4 Costs of providing inpatient care

We were unable to compare obstetric delivery costs at the study hospitals, mainly due to a lack of data on outpatient costs.

Outpatient activity represents a significant proportion of obstetric delivery care (see Table 2.2). However, as study hospitals do not count their outpatient activity using a consistent methodology, we were unable to accurately cost it.

While we did model the costs of inpatient care at the study hospitals, we did not consider that this provided a reliable proxy for the total costs of obstetric delivery care.

As an example, a hospital may provide an early discharge program to patients for the week following their deliveries. This program is an alternative to the patients remaining in hospital for that week. By only focusing on inpatient costs, the early discharge program appears to lower the hospital’s costs. However, the outpatient costs that the hospital incurs – namely, the costs of home visits by the midwives – need to be taken into account to understand the hospital’s total costs.

5 Configurations of care



The term ‘configurations of care’ refers to the way that hospitals choose to manage and provide patient care, including their clinical practices. The particular configurations of care within a hospital can be influenced by a complex array of factors, including national or state-wide guidelines or protocols, the culture, practices and controls of the individual hospital, the culture and practices of each clinical unit and its leadership and the preferences of each clinician. Differences in the way hospitals manage and provide patient care can also lead to differences in the costs and outcomes of that care.

We have considered configurations of care along a continuum, from antenatal care through obstetric delivery and then discharge from hospital. The section below describes the similarities and differences between the study hospitals in the following areas:

Models of antenatal care

Options regarding delivery facilities, and

Early discharge programs.

5.1 Models of antenatal care

The study hospitals broadly use the same models of antenatal care, which are related to the complexity of the patient. The antenatal clinics staffed by obstetrician consultants and registrars are usually attended by patients with higher risk pregnancies. Midwifery care and GP shared antenatal care are available for patients with lower risk pregnancies.

The study hospitals use a similar approach to ascertain which model of antenatal care is appropriate for each patient. Typically, patients have their first visit with an obstetrician, where they are screened for risk factors. If there are no significant risk factors regarding the pregnancy, the patient can choose to attend the midwives clinic. If there are risks, the patient attends the antenatal clinic.



5.1.1 Antenatal clinic

At RNSH, the antenatal clinic offers a ‘one-stop shop’ for high risk patients (eg, with complications like diabetes or hypertension). These patients visit the obstetric specialist at the clinic, who can then consult with the anaesthetist or haematologist as needed. Alternatively, the patients may meet directly with the appropriate clinician for their complication (eg, renal clinician).

The majority of obstetric delivery patients at RNSH attend its antenatal clinic. In contrast, only 40% of patients at GH attend the antenatal clinic.

RPAH has a high risk obstetrician consultant and registrar clinic on site. Registrar clinics are the usual points of contact where women come for set visits to review their care.

RNSH, BLH and GH have Day Assessment Units. This enables high risk pregnancies to be monitored without a hospital admission.

5.1.2 Midwifery care

RNSH and GH both have midwifery group practices providing continuity of care to patients. Under this model, each patient has a particular midwife within the midwifery group who provides the majority of care throughout the pregnancy, birth and after the birth. Each midwife looks after around 40 women.

GH also has a community midwifery practice. This is a team of midwives with no dedicated patients that assist with antenatal and post partum care as needed. Over 45% of patients choose a combination of midwifery group practice and community midwifery services.

Similar to RNSH and GH, JHH has a continuity of care model where the midwife is the primary carer throughout the patient’s antenatal and post-partum care. However, JHH is also aiming to provide more midwifery care to higher risk pregnancies. As such, there is a major initiative in place at the hospital to improve midwife skills to handle high risk cases.

RNSH, GH and JHH introduced their midwifery models of care to help meet the demands of an increasing number of patients, as well as provide greater patient choice.

At BLH, midwives handle around 50% of patients. While there is no community midwifery program at BLH, it is a model of care they are considering adopting.



5.1.3 GP shared care

Under this model, a patient’s care is shared between a GP and antenatal or midwives clinics. Typically, the GP will conduct most of the patient’s check-ups over the course of the pregnancy.

5.2 Delivery facilities

All study hospitals have birthing rooms. Several also have dedicated obstetric theatres. A birth centre is available for patients at RPAH and JHH. In addition, JHH has configurations of care that support home birth.

5.2.1 Birthing rooms

The study hospitals have similar number of birthing rooms. For example:

BLH has 7 birthing rooms.

RPAH has 9 birthing rooms.

GH has 8 birthing rooms and 1 pregnancy loss room.

As RPAH has significantly more obstetric deliveries than the other study hospitals, there have been access issues for its birthing rooms. In the last 18 months in particular, clinicians have needed to transfer early labouring women who are low risk to Canterbury Hospital.

5.2.2 Theatre

Several of the study hospitals have full-time obstetric theatres. For example, RPAH has 2 dedicated theatres. Further, RNSH has a maternity theatre in the birthing unit.

While BLH has one dedicated theatre, it is closed between 10pm and 8am. As such, clinicians cannot perform emergency caesarean sections during these times at this theatre. Instead, caesarean sections at these times are performed in the gynaecology ward for surgery.



5.2.3 Birth centre

Around 2.8% of births in NSW occur in birth centres.6 Birth centres offer both antenatal care and care during birth to women with low risk pregnancies. They are separate from the hospital and managed by midwives. Birth centres are generally characterised by a commitment to normality of pregnancy and birth, and a homelike environment.7

They have established links to a hospital referral service. As such, women intending to give birth in a birth centre may be transferred during pregnancy or labour depending on their risk factors.8

RPAH and JHH both administer birth centres:

The birth centre at RPAH has midwives, lead consultants and guidelines that are separate from the main hospital. Staff estimate that the birth centre has around 800 cases a year. This represents around 16% of obstetric delivery cases at RPAH in 2008/09.

The birth centre at JHH is located on the grounds of Belmont Hospital. Access to JHH’s birth centre is based on risk categorisation, with only low risk pregnancies able to access this service.

While RNSH does not have a physical birth centre, it provides the birth centre philosophy through its midwifery care model.

5.2.4 Home births

Planned home births represent around 0.3% of births in Australia.9 JHH offers a publicly funded home birthing service. Clinicians at JHH noted that they managed around 50 home births each year.

Clinicians indicated there was a fairly high transfer rate into hospital from home births. However, they thought this was a good outcome as it meant midwives were managing risks appropriately.

6 Australian Institute of Health and Welfare, Australia’s mothers and babies 2007, December 2009,

p 24 (http://www.aihw.gov.au/publications/per/per-48-10972/per-48-10972.pdf). 7 Australian Institute of Health and Welfare, Australia’s mothers and babies 2007, December 2009,

p 81 (http://www.aihw.gov.au/publications/per/per-48-10972/per-48-10972.pdf). 8 Ibid. 9 Australian Institute of Health and Welfare, Australia’s mothers and babies 2007, December 2009,

p 24 (http://www.aihw.gov.au/publications/per/per-48-10972/per-48-10972.pdf).



5.3 Early discharge programs

All study hospitals have some form of early discharge program. However, the study hospitals appear to have different timeframes for patients leaving hospital under these programs, with GH having the shortest timeframe.

At BLH, the midwifery support program is available for patients who want an early discharge from hospital. Midwives visit the patients in their home at regular intervals during the initial post-partum period. While the midwifery support program can cater for patients from as early as four hours after obstetric delivery, clinicians indicated that most patients under this program leave hospital on day 3.

At GH, the midwifery support program aims to return patients to their homes within 24 hours of obstetric delivery. Around 85% of patients have follow-up visits in the home, either by phone or in person within 7 days of birth.

At JHH, clinicians estimated that around 50% of patients go home under the early discharge model. Most of these patients are discharged within 24 hours of obstetric delivery, with a further one-third of these patients discharged on day 2. A home maternity service is offered for up to 5 days. Women who need an assessment for complications such as a breast abscess or newborn jaundice will be readmitted to hospital.

At RNSH, early discharge depends on the level of patient risk. If patients are low risk, clinicians indicated that they are usually discharged within 48 hours.

One program which complements RPAH’s early discharge model is the ‘bili‘ bed at home. If a newborn has mild jaundice, they can be managed at home.

To understand the impact of the early discharge programs, we analysed the time taken from obstetric delivery to discharge from the hospital for a patient’s acute episode (ie, LOS1) (see Table 5.1).



Table 5.1 Time from obstetric delivery to discharge, acute episode LOS1


% % % % %

All cases

<24 hours 3 14 4 6 17

25-48 hours 11 24 17 15 16

49-72 hours 16 25 27 37 19

>73 hours 71 36 52 42 49

Caesarean section

<24 hours 0 1 0 0 0

25-48 hours 0 5 1 1 2

49-72 hours 4 25 10 14 11

>73 hours 96 69 89 85 87

Vaginal delivery

<24 hours 5 21 6 8 21

25-48 hours 16 34 26 19 20

49-72 hours 21 25 37 42 21

>73 hours 59 20 31 31 37


When compared to the other study hospitals, a substantially higher percentage of patients were discharged from GH within 72 hours of delivery for caesarean section and within 48 hours of delivery for vaginal delivery. These results are consistent with our findings of GH having shorter average length of stays (see Table 3.1).

For caesarean section, 31% of patients at GH were discharged within 72 hours of delivery. At the other hospitals, the figure ranged from 4% at RPAH to 15% at BLH.

For vaginal delivery, 55% of patients at GH were discharged within 48 hours of delivery. At the other hospitals, the figure ranged from 21% at RPAH to 41% at JHH.

6 Outcome, safety and quality indicators



The terms of reference for this study required us to analyse available data on differences in clinical outcomes across the 5 study hospitals. In relation to obstetric deliveries, there is already a substantial amount of monitoring and reporting hospital performance against clinical indicators. Further, the Maternity Services Inter-Jurisdictional Committee is currently developing a core set of national maternity care performance indicators.10

As the national clinical indicators are still being finalised, we considered the performance of the study hospitals against several commonly reported clinical indicators. The study hospitals had broadly similar results for babies born with low Apgar scores. However, the indicators relating to caesarean sections highlighted significant differences between the hospitals.

6.1 Adequacy of existing outcomes monitoring and reporting

There is a large amount of publicly reported data on maternity outcomes:

At the state level, Australia’s mothers and babies11 includes indicators such as method of birth, birth weight and gestational age.

At the area level, Quality of Healthcare in NSW12 includes indicators such as infant well being at birth and rates of unassisted vaginal deliveries.

At the area and hospital level, NSW Mothers and Babies13 includes indicators such as induction of labour and perineal tear.

10 The Maternity Services Inter-Jurisdictional Committee was established by the Australian Health

Ministers’ Advisory Council as an information sharing network of representatives from States and Territories with the principal objective of promoting primary maternity services. See Maternity Services Inter-Jurisdictional Committee

(http://www.ahmac.gov.au/cms_documents/Maternity%20Services%20Interjurisdictional%20Committee(1).pdf).

11 Australian Institute of Health and Welfare, Australia’s mothers and babies 2007, December 2009, pp 37, 64 & 67 (http://www.aihw.gov.au/publications/per/per-48-10972/per-48-10972.pdf).

12 Clinical Excellence Commission, Quality of Healthcare in NSW, Chartbook 2007, pp 110 & 112 (http://www.cec.health.nsw.gov.au/files/chartbook/chartbook-2007_revised.pdf).

13 NSW Health, New South Wales Mothers and Babies 2006, March 2009, pp 38 & 47 (http://www.health.nsw.gov.au/pubs/2009/pdf/mothers_babies.pdf).



There are also a number of entities that have developed clinical indicators for obstetrics. For example, Women's Hospitals Australasia provides benchmarking data to its member hospitals on their performance against clinical indicators such as post partum haemorrhage rates and episiotomy rates.14 It reviews its indicator set annually, with indicators chosen on the basis that they:

are readily collectible

have a significant degree of clinical relevance

are capable of identifying a process or outcome that is capable of modification

are able to be benchmarked with comparable facilities.

In addition:

The Australian Council on Healthcare Standards, in conjunction with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, has developed a recognised set of clinical indicators for obstetric deliveries.15 These indicators are included in NSW Mothers and Babies.

The Australian Institute of Health and Welfare has proposed a number of indicators relating to obstetric deliveries to be included in a national set of clinical indicators.16

The Maternity Services Inter-Jurisdictional Committee is currently developing a core set of national maternity care performance indicators.17

Despite this, the data could be improved in the following ways:

Hospitals collecting data on a consistent basis and in a systematic way.

Hospitals receiving more timely data. There is often a considerable lag between data collection and reporting, which does not allow hospitals to readily gauge the impact of their practices or compare their performance with other hospitals. As an example, the latest NSW Mothers and Babies report was released in 2009 and based on data from 2006.

14 Women’s Hospitals Australasia, Clinical Indicators in Women’s Health, WHA's Benchmarking

Maternity Care Indicators (http://www.wcha.asn.au/index.cfm/spid/1_46.cfm). 15 Australian Council on Healthcare Standards, Obstetrics Version 6, ACHS Clinical Indicator Users’

Manual 2008. 16 Australian Institute of Health and Welfare, Towards national indicators of safety and quality in

health care, September 2009 (http://www.aihw.gov.au/publications/hse/hse-75-10792/hse-75-10792.pdf).

17 The Maternity Services Inter-Jurisdictional Committee was established by the Australian Health Ministers’ Advisory Council as an information sharing network of representatives from States and Territories with the principal objective of promoting primary maternity services. See Maternity Services Inter-Jurisdictional Committee (http://www.ahmac.gov.au/cms_documents/Maternity%20Services%20Interjurisdictional%20Committee(1).pdf).



6.2 Analysing indicators and risk-adjusting for patient characteristics

It’s important to recognise that hospitals’ performance against many outcome indicators is not simple to interpret and, when considered in isolation, can be misleading. Therefore, this performance needs to be analysed within the appropriate context.

To make meaningful and fair comparisons of the performance of the study hospitals on some outcome indicators, the analyses were risk-adjusted for factors outside the control of the hospitals. As such, the obstetric indicators were adjusted for hospital-based care group18 and socio-economic status.19 Appendix B provides further details for each risk-adjusted indicator provided by NSW Health, including the data sources used, the relevant time period for the data and the adjustment factors applied.

Most of the clinical indicators measure rates for the ‘selected primipara’ (ie, rather than for all women giving birth). The Australian Council on Healthcare Standards has noted that the selected primipara represents an uncomplicated pregnancy whereby intervention and complication rates should be low and consistent across hospitals.20 In this case study, the ‘selected primipara’ is defined as a woman who:

is 20-34 years of age at the time of giving birth

is giving birth for the first time at greater than 20 weeks gestation

has a singleton pregnancy (pregnancy with only one baby)

has cephalic presentation (head-first), and

is giving birth at term (between 37 to 41 weeks gestation).

18 That is, hospital based medical or midwife care (not transferred in or other type). 19 The ABS Index of Relative Socio-Economic Disadvantage (IRSD) was used to estimate socio-

economic status. The IRSD was assigned at Local Government Area level and grouped into quintiles from least disadvantaged to most disadvantaged for analysis.

20 Australian Council on Healthcare Standards, Obstetrics Version 6, ACHS Clinical Indicator Users’ Manual 2008.



6.3 Clinical indicators for obstetrics delivery

As the national set of clinical indicators is still being finalised, we analysed data from the study hospitals against 8 clinical indicators (see Table 6.1), with the results reported below.

Table 6.1 Clinical indicators for obstetric delivery and data availability

No. Indicator Available?

1. Caesarean section rates (risk adjusted)

Yes – data provided by NSW Health (see Appendix B)

2. Vaginal deliveries following primary caesarean section (risk adjusted)


3. Vaginal deliveries with third or fourth degree perineal tears (risk adjusted)


4. Caesarean section after induction of labour (risk adjusted)


5. Babies born with an Apgar score of 4 or below at 5 minutes (risk adjusted)


6. Repeat caesarean section rates (risk adjusted)


7. Administration of VTE prophylaxis No – data collected at hospital-wide level for VTE prophylaxis assessment

8. Administration of antibiotic prophylaxis

No – data collected at hospital-wide level for antibiotic prophylaxis assessment

6.3.1 Caesarean section rates

This indicator measures the caesarean section rate for selected primipara. While there is no agreed optimal rate for caesarean sections, there is concern that the current rates are too high for low risk pregnancies. This view has been expressed by bodies such as the Clinical Excellence Commission.21 It was also raised by clinicians at all the study hospitals. NSW Health has noted that the rate of caesarean section operations (both elective and emergency) in NSW hospitals was 28.8% in 2006, a rise of almost 10% above the rate in 1998.22

21 Clinical Excellence Commission, Quality of Healthcare in NSW, Chartbook 2007, p 102

(http://www.cec.health.nsw.gov.au/files/chartbook/chartbook-2007_revised.pdf). 22 NSW Health, Policy Directive, Maternity – Towards Normal Birth in NSW, June 2010, p 1

(http://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_045.pdf).



While caesarean sections can be lifesaving, the Clinical Excellence Commission notes that it exposes women to anaesthesia and surgery, with their associated risks.23 Further, Chapter 3 indicates that caesarean sections generally lead to longer stays than vaginal deliveries. NSW Health has noted that there is growing evidence of increasing maternal mortality and morbidity associated with multiple caesarean operations, such as more difficult surgery, increased blood loss, abdominal organ injury and hysterectomy.24

At the 5 study hospitals, there were 2,159 caesarean sections from 9,189 births, giving an overall rate of 23.5% (see Table 6.2).

Table 6.2 Caesarean section for selected primipara, 2007 & 2008

Hospital Risk-adjusted odds ratio 95% confidence interval

RPAH 1.74 1.42-2.14

GH 3.31 2.61-4.20

RNSH 2.40 1.86-3.08

JHH 1.38 1.08-1.76

BLH 1

Note: Analysis was based on mothers (using the first birth where the mother had a multiple birth), and was adjusted for socio-economic status and type of hospital-based care group (ie, hospital based medical/midwife, not transferred in/ other). For an explanation of the odds ratio, see Box 6.1. The odds ratio used in this table only compares the odds at the 5 study hospitals. It does not provide an indication of how these study hospitals compare with other hospitals.

Source: Midwives Data Collection (HOIST), Centre for Epidemiology and Research, NSW Department of Health.

There were statistically significant differences between hospitals, with the odds of caesarean section lowest at BLH. See Box 6.1 for an explanation of the adjusted odds ratio.

23 Ibid. 24 NSW Health, Policy Directive, Maternity – Towards Normal Birth in NSW, June 2010, p 1




Box 6.1 Risk-adjusted odds ratios

Risk-adjusted odds ratios were calculated for hospitals in order to highlight differences in ratesbetween the hospitals.a The ‘odds ratio’ is the ratio of the odds of an event occurring at onehospital to the odds of it occurring at another hospital.b

If the odds ratio between two hospitals is:

1 – the event is equally likely to occur at both hospitals

>1 – the event is more likely to occur at the first hospital

<1 – the event is less likely to occur at the first hospital.

As an example, assume Hospital A has 15 infections and Hospital B has 10 infections, out of1,000 patients at each hospital. The odds of infection at Hospital A and Hospital B are 15/985 and 10/990 respectively. The odds ratio of infection between Hospital A and Hospital B is(15/985) / (10/990) or 1.51. This odds ratio indicates that the odds of infection at Hospital A arearound 50% higher than at Hospital B.

a Odds ratios are widely used in medical literature to examine the effects of other variables on the relationshipbetween two binary variables, using logistic regression (J Bland “The odds ratio”, British Medical Journal, 320, 2000, p 1468; S Simon “Understanding the Odds Ratio and the Relative Risk”, Journal of Andrology, 22, 2001, p 533). The odds ratios were risk-adjusted for patient characteristics using the approach discussed in Box 6.1. b The ‘odds of an event occurring’ is equal to the probability that the event occurs divided by the probability that it does not occur.

As the selected primipara represents the patient subgroup likely to have the least complicated pregnancies, we would expect their caesarean section rates to be substantially lower than caesarean section rates for all patients (see Table 2.3). This is the case for the study hospitals, except for GH where it was lower by only 1%.25

6.3.2 Vaginal births following primary caesarean section

This indicator measures the rate of women aged 20 to 34 years delivering vaginally following a primary caesarean section in the previous pregnancy. Due to the current high rates of caesarean sections, clinicians are exploring whether it is safe to have a vaginal birth after caesarean section (VBAC). The Australian Council on Healthcare Standards notes that repeat caesarean section can be associated with significant morbidity for women. However, it also points out that VBAC carries increased risks for the baby when compared with repeat elective caesarean section. As such, the correct rate for VBAC is unknown.26

At the 5 study hospitals, there were 489 vaginal births following 2,521 primary caesarean sections, giving an overall rate of 19.4% (see Table 6.3).

25 Note that the data in Table 6.2 is for 2007 & 2008 and the data in Table 2.2 is for 2008/09. 26 Australian Council on Healthcare Standards, Obstetrics Version 6, ACHS Clinical Indicator Users’

Manual 2008.



Table 6.3 Vaginal births following primary caesarean section among women aged 20-34 years, 2007 & 2008


BLH and RPAH 0.39 0.28-0.55

GH and RNSH 0.22 0.17-0.30

JHH 1

Note: Analysis was based on mothers (using the first birth where the mother had a multiple birth), and was adjusted for socio-economic status and hospital-based care group (ie, hospital based medical/midwife, not transferred in/ other). For an explanation of the odds ratio, see Box 6.1. The odds ratio used in this table only compares the odds at the 5 study hospitals. It does not provide an indication of how these study hospitals compare with other hospitals.


On adjustment, there was no statistically significant difference between:

BLH and RPAH

GH and RNSH,

so results for these hospitals were grouped. The odds of vaginal birth following primary caesarean section were highest at JHH. Rates were substantially lower at the remaining hospitals.

6.3.3 Vaginal deliveries with third or fourth degree perineal tears

This indicator measures the rate of vaginal deliveries with third or fourth degree perineal tears27 for selected primipara. According to the Australian Institute of Health and Welfare, in the short term, such tears can increase hospital stays and readmissions. In the long term, they can have a significant impact on a woman’s quality of life.

It also notes that there are practices clinicians can use to reduce or minimise the risk of severe perineal tears. These include antenatal determination of the baby’s weight, monitoring the position of the baby’s head throughout the labour, and maternal positioning during the second stage of labour.28

At the 5 study hospitals, there were 512 significant tears among 9,189 births, giving an overall rate of 5.6% (see Table 6.4).

27 A third degree tear is an injury to the perineum involving the anal sphincter or recto-vaginal

septum. A fourth degree tear is an injury to the perineum involving the anal sphincter complex and the anal epithelium (Australian Council on Healthcare Standards, Obstetrics Version 6, ACHS Clinical Indicator Users’ Manual 2008).

28 Australian Institute of Health and Welfare, Towards national indicators of safety and quality in health care, September 2009, p 142, (http://www.aihw.gov.au/publications/hse/hse-75-10792/hse-75-10792.pdf).



Table 6.4 Vaginal births with third or fourth degree perineal tears for selected primipara, 2007 & 2008


GH and RPAH 2.48 1.60-3.86

RNSH and JHH 3.68 2.31-5.89

BLH 1

Note: Analysis was based on mothers (using the first birth where the mother had a multiple birth), and was adjusted for socio-economic status and hospital-based care group (ie, hospital-based medical/midwife, not transferred in/other). For an explanation of the odds ratio, see Box 6.1. The odds ratio used in this table only compares the odds at the 5 study hospitals. It does not provide an indication of how these study hospitals compare with other hospitals.


On adjustment there were no statistically significant differences between RPAH and GH, and between RNSH and JHH, so results for these hospitals were grouped. BLH had the lowest odds of vaginal birth with significant tear.

6.3.4 Caesarean section after induction of labour

This indicator measures the caesarean section rate after induction of labour for selected primipara. The Australian Council on Healthcare Standards notes that interventions in obstetric deliveries frequently ‘cascade’.29 That is, having one intervention increases the risks of additional interventions. This indicator is looking at how often inducing labour then leads to a caesarean section.

At the 5 study hospitals, 931 of 2,773 mothers had a caesarean section following induction of labour, giving an overall rate of 33.6% (see Table 6.5).

Table 6.5 Caesarean section after induction of labour for selected primipara, 2007 & 2008


RPAH 1.71 1.33-2.21

GH 3.47 2.72-4.43

RNSH 2.36 1.70-3.28

BLH and JHH 1



29 Australian Council on Healthcare Standards, Obstetrics Version 6, ACHS Clinical Indicator Users’

Manual 2008).



On adjustment, no statistically significant difference was found between BLH and JHH, so results for these 2 hospitals were grouped. The odds of caesarean section after induction of labour at the remaining 3 hospitals were significantly higher than at BLH and JHH.

6.3.5 Babies born with a low Apgar score

This indicator measures the proportion of babies born with an Apgar score of 4 or below at 5 minutes after birth for selected primipara. The Apgar score gives an indication of the baby’s condition shortly after birth. It is determined by 5 characteristics of the baby (heart rate, respiratory effort, muscle tone, reflex irritability and colour). Each characteristic is rated from zero to 2. The sum of the above five characteristics is the total Apgar score of the baby (out of 10).30 A low Apgar score at 5 minutes after birth is considered to be an indicator of complications and compromise for the baby.31

At the 5 study hospitals, 61 of 9,198 babies were born with an Apgar score of less than 4 at 5 minutes, giving an overall rate of 0.7%.32 On adjustment, there were no statistically significant differences between the hospitals for this indicator.33

6.3.6 Repeat caesarean section

This indicator measures the caesarean section rate for women aged 20 to 34 years whose previous (and only) obstetric delivery was by caesarean section.

At the 5 study hospitals, there were 1,256 repeat caesarean sections among 1,563 mothers, giving an overall repeat caesarean section rate of 80.4%. (See Table 6.6.)

Table 6.6 Repeat caesarean section among women aged 20-34 years, 2007 & 2008


RPAH, GH, RNSH and BLH 2.75 2.01-3.75

JHH 1



30 Ibid. 31 Australian Institute of Health and Welfare, Australia’s mothers and babies 2007, December 2009, p

75 (http://www.aihw.gov.au/publications/per/per-48-10972/per-48-10972.pdf). 32 The analysis based on babies, and included both stillborn and live born babies. It was carried

out using the NSW Midwives Data Collection for the 2007 and 2008 calendar years. 33 The analysis was adjusted for socio-economic status and hospital-based care group (ie, hospital

based medical/midwife, not transferred in/other).



On adjustment, there were no statistically significant differences between RPAH, GH, RNSH and BLH, so results for these hospitals were grouped.

6.3.7 Administration of VTE prophylaxis

This indicator measures the proportion of patients who are administered venous thrombo-embolism (VTE) prophylaxis. The Australian Institute of Health and Welfare notes that VTE can cause pain, loss of function and sometimes death. Further, the incidence of VTE is an indicator of the quality of postoperative care, and can reflect inappropriate or inadequate medical and nursing care. VTE invariably prolongs the duration of hospitalisation and requires additional medical intervention.34

The study hospitals do not systematically collect this data at the clinical level. Instead, they conduct hospital-wide audits to see whether VTE prophylaxis assessments are being conducted. Refer to Chapter 16 of our main report for further information.35

6.3.8 Administration of prophylaxis

This indicator measures the proportion of patients who are administered antibiotic prophylaxis. The Australian Council of Healthcare Standards has noted that an appropriate prophylactic antibiotic at the time of caesarean section significantly reduces maternal post operative infectious morbidity.36

The study hospitals do not systematically collect this data at the clinical level. Instead, they conduct hospital-wide audits to see whether antibiotic prophylaxis assessments are being conducted. Refer to Chapter 16 of our main report for further information.37

34 Australian Institute of Health and Welfare, Towards national indicators of safety and quality in

health care, September 2009, p 155, (http://www.aihw.gov.au/publications/hse/hse-75-10792/hse-75-10792.pdf).

35 IPART, NSW Health costs and outcomes study by IPART for selected NSW hospitals, July 2010. 36 Australian Council on Healthcare Standards, Obstetrics Version 6, ACHS Clinical Indicator Users’

Manual 2008). 37 IPART, NSW Health costs and outcomes study by IPART for selected NSW hospitals, July 2010.



6.4 Issues for further consideration

There are significant differences between the hospitals in relation to caesarean section rates, with GH having substantially higher rates than BLH and JHH. This cannot be easily explained by differences in configurations of care at the study hospitals or patient complexity. Further, there is not a link between caesarean section rates and differences in other outcome indicators in our clinical indicator set, such as Apgar score and significant perineal trauma.38

NSW Health is taking steps to address the issue of increasing caesarean section rates and variation in rates across hospitals. It recently released a new policy directive, Maternity – Towards Normal Birth in NSW. The document aims to provide direction to NSW maternity services regarding actions to increase the vaginal birth rate and decrease the caesarean section rate. It outlines 10 principles of providing woman centred labour and birth care (see Box 6.2).

Box 6.2 NSW Health policy directive, Maternity – Towards Normal Birth in NSW

The 10 principles of providing woman centred labour and birth care are:

1. Have a written normal birth policy that is routinely communicated to all health care staff.

2. Train all health care staff in skills necessary to implement this policy.

3. Facilitate access to midwifery continuity of carer programs in collaboration with GPs and obstetricians for all women with appropriate consultation, referral and transfer guidelines inplace.

4. Inform all pregnant women about the benefits of normal birth and factors that promotenormal birth.

5. Have a written policy on pain relief in labour that includes the use of water immersion inlabour and birth.

6. Have a written postdates policy that is routinely communicated to all health care staff.

7. Facilitate access to vaginal birth after caesarean section operation that is supported by a written vaginal birth after caesarean section operation policy and health care staff with theskills necessary to implement this policy.

8. Facilitate access to external cephalic version (where a clinician turns the baby from breech to head-first presentation in late pregnancy).

9. Provide one to one care to all women experiencing their first labour or undertaking avaginal birth after caesarean section operation, vaginal breech or vaginal twin birth.

10. Provide formal debriefing in the immediate postpartum period for all women requiring primary caesarean section operation or instrumental birth with the opportunity for furtherdiscussion and information transfer.

Source: NSW Health, Policy Directive, Maternity – Towards Normal Birth in NSW, June 2010, p 8, (http://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_045.pdf).

38 For example, RNSH and JHH both had similar significant tear rates, but RNSH had a

substantially higher caesarean section rate than JHH.



The policy directive outlines key measures to facilitate Area Health Services in adopting these 10 principles. The key measures include:

maternity services having a written normal birth policy (target 100% by 2015)

the percentage of women having vaginal births (target >80% by 2015)

maternity clinicians being informed of statistics relating to outcomes for vaginal birth after caesarean section (target 100% by 2015).

From June 2011, Area Health Services will be required to report annually on their performance against these key measures.39

We consider that NSW Health and clinical expert groups should note the variation in caesarean section rates and monitor changes arising from the implementation of NSW Health’s new policy directive, Maternity – Towards Normal Birth in NSW, to determine whether the policy effectively addresses the variation.

Recommendation

1 That NSW Health and clinical expert groups note the variation in the following clinical indicators relating to obstetric delivery:

– caesarean section rates for ‘selected primipara’

– vaginal delivery rates following primary caesarean section

– caesarean section rates after induction of labour for ‘selected primipara’

– repeat caesarean section rates

– significant tear rates

and monitor changes arising from the implementation of the NSW Health policy directive, Maternity – Towards Normal Birth in NSW, to determine whether this policy effectively addresses the variation.

39 NSW Health, Policy Directive, Maternity – Towards Normal Birth in NSW, June 2010, pp 7-14,




Appendices



A List of full recommendations from main report



Consistency of DRG groupings

Our recommendations in this area are mainly aimed at making users of hospital data aware of some of the limitations of using DRG groupings for hospital comparisons in certain clinical areas.

1 That users of hospital cost and outcome data note that DRGs may contain a range of patient types with varying clinical resource requirements, costs of care and expected clinical outcomes. Therefore DRGs may not always provide the optimal basis for comparing costs and outcomes among hospitals.

2 In light of Recommendation 1, that the NSW Department of Health, and other health research bodies at both the state and national level, consider whether DRGs are a suitable basis for determining funding and comparing performance among hospitals (for various different types of hospital activity). Where they are not suitable, continue research to develop better approaches for these areas.

Consistency of patient numbers

Our recommendations on patient numbers are aimed at making users of hospital data aware of differences in patient counting practices and patient datasets between hospitals that can affect hospital comparisons, to improve consistency of patient counting practices between hospitals and lead to better integration of patient datasets.

3 That users of hospital data note that there are differences in practices relating to counting of patients that can affect hospital patient numbers and average cost comparisons eg, counting differences relating to admission status, billing status, location of care and collaborative care arrangements.

4 In light of Recommendation 3, that NSW Health clarifies and standardises administrative procedures including guidelines for recording of non-inpatients of various types, as well as ‘collaborative care’ patients.

5 That NSW Health considers ways of better integrating patient information held locally by hospital clinical units (such as eye clinics and cardiac catheter labs) with the HIE data set.



Consistency of lengths of stay

Our recommendations aim to improve consistency between hospitals on length of stay measures, and to make users of hospital data aware of the limitations of measures based on ‘acute episodes’.

6 That NSW Health monitors hospital practices relating to the classification of episodes into care types and type-changing practices (eg, timing of type changes from acute to rehabilitation care) and provide clear and consistent guidelines to hospitals, so episode measures are more consistent among hospitals.

7 That users of hospital data note that 'acute episodes' often only represent a part of a patient's hospital stay. Therefore, comparisons among hospitals using acute length of stay measures or acute costs may produce misleading results. This is particularly important for conditions that involve both acute and sub-acute care and/or transfers between facilities.

Coding

We have made recommendations aimed at improving the quality of medical records documentation and clinical coding in hospitals to both improve the quality of data for clinical research as well as to more accurately reflect casemix complexity.

8 That NSW Health should continue to improve the quality of medical record documentation and the accuracy and consistency of coding.

9 That hospitals should encourage consistent education on coding and facilitate communication between clinical staff and coders regarding both the coding process and the documentation required to code common clinical conditions, diagnoses or complications, such as AMI, angina and chest pain.

10 Where pathology test information can be readily extracted (eg, Cerner sites), that systems be developed so this information can be used to validate coding and support work on variation in clinical practice and measuring clinical quality.

11 That NSW Health considers undertaking further analysis to identify pathology or imaging tests that can be used to help target audits of coding and support work on variation in clinical practice and measuring clinical quality – such as identifying types of pathology tests that correspond closely with diagnosis coding.



Clinical costing

Our recommendations are aimed at improving the quality and consistency of clinical costing data, and helping to ensure that quality costing data and clinical inputs to the costing process (such as data from prosthesis, pathology and imaging systems) can be used to inform hospital management about resource use, and clinicians about clinical practice.

12 That the NSW Department of Health works with the area health services and hospitals to apply a consistent set of rules for clinical costing covering cost centres and IFRACs so that data are consistent and comparable between the hospitals.

13 That NSW Health regularly audits the accuracy of cost centres and IFRACs used for clinical costing.

14 That NSW Health uses standard clinical data feeds (actual patient data) for clinical costing where this is feasible and useful.

15 That the data used for clinical costing purposes be available to hospitals and clinicians so they can undertake comparative analysis on clinical practices and performance.

Medical staff costs

Given our finding that there was a lack of consistency in the treatment of medical staff costs and the difficulty this created in estimating medical staff costs for our case study areas, we recommend:

16 That further work be undertaken to strengthen the quality and consistency of available information on medical staff costs.

Prosthesis costs

Our recommendations on prosthesis costs are aimed at improving prosthesis purchasing and making cost savings in this area. These should be considered in conjunction with our recommendation that clinical experts should review the appropriateness of clinical variation in prosthesis use and address this variation (see Recommendation 31).

17 That NSW Health notes the variation in prostheses use among the study hospitals including:

– drug-eluting stents versus bare metal stents

– single chamber pacemakers versus dual chamber pacemakers

– different types of components for hip replacement procedures.

18 That NSW Health notes the range of approaches to prosthesis controls and the variation in prices currently paid for prostheses, including for exactly the same models.



19 That NSW Health facilitates sharing of information on purchase prices for prostheses to assist price negotiations with suppliers.

20 That NSW Health optimises prosthesis cost savings through tenders, supplier price agreements and controlled approaches to prosthesis purchasing, noting that clinical consultation and cooperation is essential as is retaining some flexibility to allow for special orders when clinically indicated.

Imaging and pathology costs

Our recommendations are aimed at encouraging better use of imaging and pathology data, and consideration of whether there should be standard treatment of imaging and pathology within clinical costing and whether internal charges should reflect actual costs. These recommendations should be considered in conjunction with our clinical case studies, which include comparisons of imaging use, and Recommendation 31, relating to clinical variation in imaging use for diagnosing appendicitis.

21/25 That NSW Health notes that imaging and pathology data can be used to monitor changes in imaging use and inform clinical practice, and that:

– All hospitals obtain detailed reports from pathology and imaging services on their test ordering patterns, including the number of tests by major test type and the cost of these tests.

– Hospitals routinely provide data to heads of clinical units to help inform them on resource use and provision of care to improve patient outcomes and discuss trends at management meetings – for example, summary reports that include both the number of tests by test type, and the value (or preferably cost) of these tests.

– NSW Health develops reports comparing the use of imaging and pathology tests for clinical groupings and circulates these to area health services and hospitals.

22. That NSW Health considers whether, for clinical costing purposes, it is appropriate for hospitals and area health services to base the value of imaging tests on the MBS rate for these tests and, if so, what standard percentage of this rate is appropriate for use by all hospitals given the actual costs of providing the test.

23 That NSW Health seeks to obtain detailed information from the pathology services on the number and type of tests and the actual cost of undertaking a range of typical tests for future comparisons of pathology costs.

24 That NSW Health addresses issues that prevent the actual costs associated with specific pathology tests and ordering patterns being disclosed by pathology services.

26. That NSW Health considers whether the detailed cost estimates that pathology services prepare as part of the benchmarking pathology project could be used for more accurate pricing between pathology services and hospitals, to enable clinicians to consider the actual cost of their clinical decisions.



Operating theatre costs

Our recommendations in relation to operating theatres aim to facilitate improvements in theatre management arrangements, and the quality and consistency of theatre data.

27 That NSW Health notes the differences in approaches to theatre management among hospitals and consider if there is scope to share information about how the better theatre arrangements are organised.

28 That NSW Health notes the issues regarding theatre data and work with the hospitals to improve the completeness of datasheets and apply a consistent set of rules for recording operating theatre times.

29 That NSW Health considers routine auditing of the quality of data on returns to theatre and considers the best way for achieving accuracy and consistency in this indicator.

Pharmacy costs

As we were not able to undertake a detailed comparison of pharmacy services and costs, our recommendations focus on encouraging further analysis in this area.

30 That NSW Health:

– Notes the wide variation in the proportion of drugs dispensed versus held on imprest across the study hospitals.

– Monitors the value of expired pharmacy stock and compares this among hospitals.

– Considers standardised guidelines for the return of unused medication, principally to ensure patient safety but also to minimise wastage and reduce costs.

– Considers whether antimicrobial stewardship programs should be implemented at the major hospitals where such programs are not currently in place. The purpose of these programs would be to help prevent antimicrobial resistance and reduce costs by preventing inappropriate use of antimicrobials.



Configurations of care – Review of clinical variations during Stages 5 and 6 of the wider NSW Department of Health study

Our case studies identified a number of differences in the way care is provided among study hospitals in specific clinical areas. We recommend that clinical experts consider these clinical differences or clinical issues as part of Stages 5 and 6 of the wider health study. This recommendation should be dealt with in conjunction with Recommendation 36, relating to variation in indicators of safety, quality and outcomes.

31 That NSW Health arranges for appropriate clinical expert groups to consider the following clinical issues identified in our case studies; and that where appropriate, NSW Health and the expert groups take steps to address clinical differences.

– Hip joint replacement:

o Note that separation of planned and emergency cases may reduce lengths of stay for planned (arthritis) cases.

o Address the variation in the selection of hip prosthesis components (including press fit, cementless hip stems versus cemented hip stems and ceramic femoral heads versus metal femoral heads) among study hospitals.

– Major chest procedure:

o Note the different clinical pathways and high day of surgery admission rates for thoracic surgery patients at RPAH compared with other study hospitals.

o Consider whether aspects of the model of care at RPAH are suitable to be used in other hospitals.

– Breast surgery:

o Note the early discharge models at RNSH for breast surgery patients having mastectomies and

o Consider whether such models should be followed more widely in NSW hospitals and the types of patient cases they should be used for (eg, simpler, unilateral cases or younger patients).

– Cholecystectomy:

o Note the variation in the proportion of patients with cholelithiasis or cholecystitis who are operated on acutely as emergency admissions.

o Consider whether this variation has significant quality of care implications.

o Consider the relative costs and benefits of an emergency surgical services team model for ensuring early diagnosis and treatment of conditions like cholecystectomy and whether it should be more widely applied.

o Note that costing of cholecystectomy should take into account the costs of prior related emergency department attendances. A similar approach should be adopted for other clinical conditions that are likely to involve multiple prior emergency department attendances.



o Consider the relative costs and benefits of cholecystectomies with and without the use of fluoroscopy.

– Appendicectomy

o Note the variation in the use of imaging tests for diagnosing appendicitis.

o Consider establishing standard protocols for diagnosing appendicitis, indicating when it is appropriate to use CT scans, MRIs and ultrasounds.

o As part of establishing standard protocols for diagnosing appendicitis, consider whether CT scans, MRIs and ultrasounds should only be used for certain patient groups (eg, older patients who are more likely to be suffering from other conditions with symptoms similar to appendicitis).

o Consider the relative costs and benefits of laparoscopic versus open surgery for appendicitis.

– Stroke

o Consider ways to reduce the proportion of stroke patients coded with a principal diagnosis of 'stroke, not specified as haemorrhage or infarction' (ICD10 code I64).

o Consider developing consistent guidelines for the administration of tPA.

o Consider including tPA administration as a procedure in coding standards.

o Consider ways to improve transfers of suspected stroke patients to stroke units with minimum delay, including consultation with the Ambulance Service and Emergency Departments.

o Investigate whether it is useful and possible to combine Ambulance Service data on response time with hospital patient data to monitor time from call to ambulance to arrival at an appropriate hospital.

o Consider the costs and benefits of providing more rehabilitation care in the home.

o Pursue the collection of the data on outcome indicators from the National Stroke Research Institute.

– Cardiology – Stents, Pacemakers and Defibrillators:

o Address the variation in the use of drug-eluting stents versus bare metal stents among study hospitals.

o Address the variation in the types of pacemakers used among study hospitals.

o Investigate whether there are differences in treatment procedures, or waiting times between presentation and procedure, for patients who present to hospitals without a 24 hour cardiac catheter laboratory, compared to patients who present to hospitals with a 24 hour cardiac catheter laboratory, and whether any differences in procedure or waiting times have implications for clinical outcomes.



o Consider ways of better integrating information held in cardiac catheter laboratories with the HIE data set.

– Tracheostomy or ventilation greater than 95 hours:

o Note that at BLH, clinicians tend to perform surgical tracheostomies, whereas at the other hospitals, these are usually performed percutaneously.

– Cataract/lens procedure:

o Assess the costs and benefits of toric lenses and develop guidelines for their use in public hospitals.

– Hysterectomy:

o That any future studies of hysterectomy compare the costs and outcomes for hysterectomies with the costs and outcomes of other procedures such as endometrial ablation and uterine artery embolisation.

Improving outcome, safety and quality indicators

While current Commonwealth and State initiatives will improve outcomes data, we have made recommendations that will assist this process.

32 That NSW Health enhances understanding and use of mortality, survival, unplanned readmission and wound infection indicators and their risk adjustment by:

– continuing to contribute to the development of ACSQHC’s safety and quality standards for these indicators

– refining the methodology used for standardising or risk-adjusting these indicators

– continuing to consult with clinicians regarding the agreed presentation of mortality, survival unplanned readmission and wound infection information

– reporting this information on a more routine and regular basis consistent with ACSQHC data sets.

33 That NSW Health encourages hospitals to put in place systems to facilitate accurate coding of comorbidities and ensures that coding practices are consistent across hospitals.

34 That NSW Health works with ACSQHC to negotiate more streamlined arrangements for access to data held by third parties (such as clinical registries) for clinical analysis, and makes these data available to hospitals and clinicians.

35 That NSW Health explores the possibility of providing outcomes information to clinicians in a more systematic way as an aid to clinical improvement and a key indicator of performance.



Indicators of safety, quality or outcomes, - review of clinical variations during stages 5 and 6 of the wider NSW Department of Health project

We have also made a number of findings relating to variations in indicators of safety, quality or outcomes. Where we have observed apparent differences among hospitals, these should be considered by clinical expert groups in completing stages 5 and 6 of the Department of Health’s wider project. These differences should be considered in conjunction with differences in clinical practice (Recommendation 31).

36 That clinical expert groups consider the following clinical issues; and where appropriate, NSW Health and clinical expert groups take steps to address clinical variations as part of Stages 5 and 6 of the broader NSW Health review:

– Review the variations in outcome, safety and quality indicators among study hospitals, including their:

o unplanned readmission rates

o wound infection rates for selected surgical procedures.

– Review the variation in mortality and survival rates for all major chest surgery patients and consider whether to recommend changes to clinical practice or conduct further investigation involving:

o a larger sample of hospitals, and

o more detailed analyses for ‘like patients’ (ie, lung cancer, infection-related abscess/pyothorax and collapsed/punctured lung patients).

– Review the variation in the following clinical indicators for hip joint replacement surgery at the study hospitals:

o wound infection rates

o unplanned readmission rates.

– Review the variation in wound infection rates for appendicectomy and cholecystectomy surgery at the study hospitals.

– Note the variation in the following clinical indicators relating to obstetric delivery:

o caesarean section rates for ‘selected primipara’

o vaginal delivery rates following primary caesarean section

o caesarean section rates after induction of labour for ‘selected primipara’

o repeat caesarean section rates

o significant tear rates

and monitor changes arising from the implementation of the NSW Health policy directive, Maternity – Towards Normal Birth in NSW, to determine whether this policy effectively addresses the variation.



Additional outcome indicators

We made recommendations to consider the costs and benefits of collecting data for the following areas where indicators are not commonly used.

37 That NSW Health considers the costs and bene�ts of collecting data and monitoring performance against the following indicators:

– warfarin management

– visual outcomes for patients undergoing lens procedures.

We also made a recommendation to develop a set of standard indicators for measuring care and/or outcomes in ICUs.

38 That NSW Health undertakes further work to develop a set of standard indicators for measuring care and/or outcomes in ICUs.

Time Out audits

Finally, we made a recommendation to improve consistency in the number of casesaudited as part of the Time Out process relative to the number of separations.

39 That NSW Health speci�es the number or proportion of patient cases that should be audited as part of the Time Out process.

Next steps - wider application of this study

40 That NSW Health re�nes and develops useful aspects of this study for application more widely to other hospitals, other health settings and other clinical conditions.

B Risk-adjusted indicators provided by NSW Health



Table B.1 includes the data sources and risk adjustment factors used for risk-adjusted indicators provided by NSW Health.



Table B.1 Risk-adjusted indicators provided by NSW Health

No. Indicator Data source

Numerator & denominator Risk-adjustment

1 Caesarean section rates

MDC 2007-2008

Numerator – Number of caesarean sections

Denominator – Number of selected primipara

Care group (hospital based medical or midwife not transferred in; residual group - other), and socio-economic status

2 Vaginal births following primary caesarean section

MDC 2007-2008

Numerator – Number of vaginal births

Denominator – Number of women aged 20-34 years giving birth who have had a previous primary caesarean section


3 Vaginal births with 3rd or 4th degree perineal tears

MDC 2007-2008

Numerator – Vaginal births with significant tears (3rd or 4th degree)

Denominator – Number of selected primipara


4 Caesarean section after induction of labour

MDC 2007-2008

Numerator– Number of caesarean sections

Denominator– Number of inductions among selected primipara


5 Apgar score of 4 or below at 5 minutes among selected primipara

MDC 2007-2008

Numerator – Number of babies born with an Apgar score of 4 or below at 5 minutes

Denominator – Number of term babies born to selected primipara


6 Repeat caesarean section rates (following primary caesarean section)

MDC 2007-2008

Numerator – Number of caesarean sections

Denominator – Number of women aged 20-34 years giving birth who have had a previous primary caesarean section

Care group (hospital based medical or midwife not transferred in; residual group - other), and socio-economic status.

Notes: APDC - NSW Admitted Patient Data Collection. RBDM - Registry of Births, Deaths and Marriages. MDC - NSW Midwives Data Collection. A case represents a hospital admission for a specified condition. DRG - Diagnosis Related Group v 5.1. A ‘selected primipara’ is a woman who: is 20-34 years of age at the time of giving birth; is giving birth for the first time at greater than 20 weeks gestation; has a singleton pregnancy (pregnancy with only one baby); has cephalic presentation (head-first), and is giving birth at term (between 37 to 41 weeks gestation). The ABS Index of Relative Socio-Economic Disadvantage (IRSD) was used to estimate socio-economic status. The IRSD was assigned at Local Government Area level and grouped into quintiles from least disadvantaged to most disadvantaged for analysis.

Source: NSW Health.

Glossary


Glossary

Term Abb. Definition

95% confidence interval

A statistical term describing a range of values within which we are 95% certain that the true population value lies.

Activity-based funding

ABF Funding that is based on the projected amount and type of work of a facility, where standard prices are set for similar work undertaken. This has also been referred to as casemix or episode funding.

Acute care Clinical services provided to admitted or non-admitted patients, including managing labour, curing illness or treating injury, performing surgery, relieving symptoms and/or reducing the severity of illness or injury, and performing diagnostic and therapeutic procedures. Most patients have acute or temporary ailments. The average length of stay is relatively short.

Admission The process by which a person commences a period of residential care in a health facility.

Admitted Patient Data Collection

APDC A database that covers all inpatient separations (discharges, transfers and deaths) from all Public (including Psychiatric), Private, and Repatriation Hospitals, Private Day Procedures Centres and Public Nursing Homes in NSW.

Agency for Clinical Innovation

ACI A board-governed statutory health corporation that reports to the NSW Minister for Health and the Director-General of NSW Health.

Antenatal clinic A special clinic staffed by obstetricians, registrars, residents and midwives to cater for women progressing through pregnancy.

Apgar score Apgar A numerical score used to indicate a baby’s condition at one minute and five minutes after birth. Between 0 and 2 points are given for each of five characteristics: heart rate, breathing, colour, muscle tone and reflex irritability. The total score is between 0 and 10. Apgar stands for Activity, Pulse, Grimace, Appearance, and Respiration.

Appendicectomy Surgical excision of the patient's appendix.

Assistant In Nursing AIN An employee that is not a registered nurse, enrolled nurse or trainee nurse, who assists the Enrolled Nurses and Registered Nurses by providing basic nursing care, working within a plan of care under the supervision and direction of a Registered Nurse.

Average length of stay

ALOS The average number of days each admitted patient stays in hospital. This is calculated by dividing the total number of occupied bed days for the period by the number of actual separations in the period.

Glossary



Bankstown-Lidcombe Hospital

BLH One of the study hospitals included in the review.

Bureau of Health Information

BHI An independent, board-governed organisation established by the NSW Government to be the leading source of information on the performance of the public health system in NSW.

Casemix The range and types of episodes of care of patients (the mix of cases) treated by a hospital. This provides a way of describing and comparing hospitals and other services for planning and managing health care. Casemix classifications put patients into DRGs with similar conditions that use similar health-care resources, so that the activity and cost-efficiency of different hospitals can be compared.

Casemix funding See Activity-based funding.

Cholecystectomy Excision of the gallbladder.

Clinical Excellence Commission

CEC A board-governed statutory health corporation with the CEO reporting directly to the NSW Minister for Health. A key role of the Clinical Excellence Commission is building capacity for quality and safety improvement in Health Services.

Clinical Nurse Specialist

CNS A Registered Nurse/Midwife who applies a high level of clinical nursing knowledge, experience and skills in providing complex nursing/midwifery care directed towards a specific area of practice, a defined population or defined service area, with minimum direct supervision.

Comorbidity When a person has two or more health problems at the same time.

Computed tomography

CT scan A non-invasive medical imaging method using X-rays and computer processing.

Diagnosis Related Group

DRG A system used to classify hospital admissions into groups with similar clinical conditions (related diagnoses) and similar resource usage (hospital services). There are approximately 500 coding classes. In Australian acute hospitals, Australian refined DRGs are used (AR-DRGs). The classification categorises episodes into groups with similar conditions and similar usage of hospital resources, using information in the hospital morbidity record such as the diagnoses, procedures and demographic characteristics.

Enrolled Nurse EN A person holding an Enrolled Nurse qualification who works under the supervision of a Registered Nurse to provide nursing care for patients in hospitals, nursing homes and a variety of other health care organisations.

Episode funding See Activity-based funding.

Fluoroscopy An imaging technique that provides real-time moving images of the internal structures of a patient through the use of a fluoroscope.

Gosford Hospital GH One of the study hospitals included in the review.

Glossary



Health Information Exchange

HIE A database maintained by the NSW Department of Health that contains a range of financial, patient and clinical information from hospitals and area health services.

High dependency unit

HDU An area or environment in a hospital that provides a higher level of critical care and monitoring than is provided in a general ward, but a lower level of care provided by an intensive-care unit.

Hysterectomy Surgical removal of the uterus.

Independent Pricing and Regulatory Tribunal of NSW

IPART The independent economic regulator for NSW that is undertaking this hospital study.

Inpatient fraction IFRAC A measure used in casemix costing. The proportion of total (or operating) costs that are attributed to admitted patients.

Intensive care unit ICU An area or environment in a hospital that provides the highest level of critical care and monitoring.

John Hunter Hospital JHH One of the study hospitals included in the review.

Length of stay 1 LOS1 LOS1 is the episode length of stay in study hospital, ie, from the start of the episode to the end of the episode of care.

Length of stay 2 LOS2 LOS2 is the total length of stay in study hospital, ie, from admission to discharge at the study hospital.

Length of stay 3 LOS3 LOS3 is the total length of stay in study hospital plus up to 2 other hospitals - one transfer in and one transfer out.

Maternity Services Inter-Jurisdictional Committee

MSIJC An information sharing network of health representatives with the objective of promoting maternity services and consistent approaches to maternity care.

Medical resonance imaging

MRI A medical imaging technique most commonly used in radiology to visualise detailed internal structures of the body using a magnetic field.

Medicare Benefits Schedule

MBS A listing of the Medicare services subsidised by the Australian government.

Midwife A nurse with specific training to assist mothers throughout pregnancy, childbirth and postnatal care.

National Hospital Cost Data Collection

NHCDC The NHCDC contains component costs per DRG based on patient-costed and cost-modelled information. The NHCDC enables DRG Cost Weights and average costs for DRGs for acute in-patients to be produced.

Newborn jaundice A condition affecting the colour of the baby's skin colour and skin tissue primarily due to relatively high levels of bilirubin.

Non-admitted patient occasions of service

NAPOOS Outpatient care provided in a hospital, community health centre or home setting by specialists and nurses.

NSW Health The broad term encompassing operational and other structures including the NSW Department of Health, Area Health Services, the Agency for Clinical Innovation, the Clinical Excellence Commission and a range of clinical taskforces.

Glossary



Odds ratio OR The odds of an event occurring. This is equal to the probability that the event occurs divided by the probability that it does not occur.

Open Surgery An invasive medical procedure where an incision is required for direct surgical access to the organs.

Perineal tears Tears of the tissues around the vaginal opening during childbirth.

Post-partum period The time period immediately after the birth and can extend to several weeks.

Principal referral hospital

Hospital within peer group (principal referral hospitals 1b) classified as an acute hospital, treating 25,000 or more acute casemix weighted separations per annum, with an average cost weight greater than 1 and 1 or fewer specialty services.

Principal tertiary referral hospital

Hospital within peer group (principal referral hospitals 1a) classified as an acute hospital, treating 25,000 or more acute casemix weighted separations per annum, with an average cost weight greater than 1 and having more than 1 specialty service.

Prophylaxis Disease prevention, also called preventive treatment.

Registered midwife Registered midwives provide care for women and their families through the cycle of pregnancy and birth.

Registered nurse RN A qualified nurse who provides care for patients in a variety of healthcare settings. These include public and private hospitals, community and home-based services, nursing homes and industry.

Royal North Shore Hospital

RNSH One of the study hospitals included in the review.

Royal Prince Alfred Hospital

RPAH One of the study hospitals included in the review.

Selected primipara (for this case study)

The ‘selected primipara’ is defined as a woman who is 20-34 years of age, giving birth for the first time at between 37-41 weeks gestation and with a singleton pregnancy (pregnancy with only one baby) in cephalic presentation (head-first).

The Australian Council on Healthcare Standards

An independent organisation dedicated to improving the quality of health care through performance reviews, assessment and accreditation.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists

RANZCOG An organisation dedicated in maintaining the highest standards in obstetrics and gynaecology in Australia and New Zealand.

Tracheostomy A surgical procedure to cut an opening into the trachea (windpipe) so that a tube can be inserted into the opening to assist breathing.

Glossary



Venous Thrombo-embolism

VTE The process by which blood clots occur and travel through the veins. It is the collective term for deep vein thrombosis (the formation of a blood clot in one of the deep veins within the body, such as in the leg or pelvis) and pulmonary embolism (condition in which the arteries leading from the heart to the lungs becomes blocked).

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Case study 11 Obstetric Delivery - IPART · PDF fileContents Case study 11 – Obstetric Delivery IPART iii Contents 1 Introduction and executive summary 1 1.1 Why did we select obstetric