The Association Between Hospital Obstetrical Volume

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OBSTETRICSThe association between hospital obstetrical volumeand maternal postpartum complicationsKathy L. Kyser, MD, MSCI; Xin Lu, MS; Donna A. Santian, !hD; Mar" K. Santian,

MD; Ste#hen K. $unter, MD, !hD; Aison G. Cahi, MD, MSCI; !eter Cra%, MD, M&A

OBJECTIVE: The purpose of this study was to examine the relationship

between delivery volume and maternal complications.STUD DESI!": We used administrative data to identify women who

had been admitted for childbirth in 2006. Hospitals were stratified intodeciles that were based on delivery volume. We compared composite

complication rates across deciles.

#ESU$TS: We evaluated1,6!,"#$ childbirths in 10$# hospitals.%ecile1 and 2 hospitals had si&nificantly hi&her rates of compositecomplicationsthan decile10'11.(and10.1(vs.#(,respectively)P

.0001*. %ecile+and

10 hospitals had modestly hi&her composite complications as compared

with decile 6 '.( and .#( vs ".6(, respectively)P .0001*. ixtypercentof decile1and2hospitalswere locatedwithin2#milesofthenearest&reatervol- umehospital.CO"C$USIO": Women who deliver at very low-volume hospitals have

hi&her complicationrates,asdowomenwhodeliveratexceedin&lyhi&h-

volume hospitals. ost women who deliver in extremely low-volumehospitalshaveahi&her volumehospitallocatedwithin2#miles./ey words complication, obstetrical volume, patient safety

ite this article as /yser /, u 3, antillan %4, et al. The association between hospital obstetrical volume and maternal postpartum complications. 4m 5bstet

7ynecol 2012)20"$2.e1-1".

ore than ' %iion wo%en gi(e

)irth annuay in the *nite+

States,

which %a"es chi+)irth the sin-the*nite+ States generay is sae with a

sa%e ti%e, there is growing

a##reciation that the (ariation in

hos#ita outco%es that ha(e )een

o)ser(e+in %any %e+icage%ost co%%on reason or

hos#itai/a-tion a%ong young wo%en. Chi+)irth in

%a0or co%#ication rate 1eg, he%or-

rhage or inection2 o 34.5-'

At the

an+ surgica +iagnoses %ay aso e6ist or

chi+)irth.More than 5 +eca+es o research has

+ocu%ente+ a reationshi# )etween8rom the %ivision of aternal-8etal edicine, %epartment of 6bstetrics and 7ynecolo&y '%rs

/yser, %. 4. antillan, . /. antillan, and Hunter*, and the %ivision of 7eneral edicine,

%epartment of 9nternal edicine 's u and %r ram*, :niversity of 9owa Hospital and linics,

and 4%;hysician 8aculty cholars >ro&ram '4.7..*)

by ?9H &rant number ;0170+01$ '%.4.. and ./.H.*) by the :niversity of 9owa 9nstitute for

linical and Translational cience /2 cholar pro&ram '?9H &rant number /2;;02$+0-2*

andby the ;eproductive cientist %evelopment >ro&ram '?9H &rant number /12 H%000$+ )

./..*) by a /2! career development award ';;01++"201* from the ?ational enter for

;esearch ;esources, ?9H '&rant number ;01 H0#!$"-0141, ?H@9, ?9H*, the ;obert Wood

5ohnson >hysician 8aculty cholars >ro&ram) and the %epartment of =eterans 4ffairs '>..*.

>.. has received consultin& fees from =an&uard Health, an operator of for-profit hospitals,

for assistance on a Auality improvement proBect and from onsumers :nion.

The views expressed in this article are those of the authors and do not necessarily reflect

the official policy or position of the %epartment of the ?avy, %epartment of %efense, the

: 7overnment '/../*, or the %epartment of =eterans 4ffairs '>..*.

The authors report no conflict of interest.

;eprints /athy /yser, %, %epartment of 6bstetrics and 7ynecolo&y, :niversity of 9owa

Hospital and linics, 200 HawCins %r., 9owa ity, 94 #22$2.Cathy-CyserDuiowa.edu.

0002-+!"EfreeF

>ublished by osby, 9nc.F

httpEEdx.doi.or&E10.1016EB.aBo&.2012.0#.010

higher hos#ita (ou%e an+ i%#ro(e+

cinica outco%es or %e+ica an+ sur-

gica +iagnoses,7-')ut +ata in the area

o %aterna chi+)irth outco%es are

sorey ac"ing. 8he #aucity o e%#iric

stu+ies o the (ou%e-outco%e rea-

tionshi# or %aterna co%#ications is

stri"ing, gi(en the cinica (ou%e an+

econo%ic i%#act o chi+)irth in the

*nite+ States. In a++ition, %etho+o-ogic i%itations o the ew #u)ishe+

stu+ies that ha(e reate+ to a (ou%e-

outco%e reationshi# or the %aterna

outco%es o chi+)irth %a"e inter#re-

tation o the conicting in+ings

+iicut.7-9

Our o)0ecti(e was to e6a%ine rigor-

ousy the reationshi# )etween hos#ita

(ou%e an+ %aterna chi+)irth out-

co%es. S#eciicay, we set out to e6a%-

ine the association )etween hos#ita

chi+)irth (ou%e an+ i%#ortant %ater-8or


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ee related editorial, pa&e1

outco%e reationshi# %ight +ier or

(agina an+ cesarean +ei(eries.

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-I!U#E (

.atients included in this stud+

8ota#o#uation

n : ,;7'

A+ei(eries

n :,;>,.96 Fn ,7'G2.

Materna chi+)irth a+%issions were

stratiie+ into cesarean +ei(eries1ICD-9 #roce+ure co+e >'2 or nor%a

s#ontaneous (agina +ei(eries 1ICD-9

+iagnosis co+es '3.6 to >.96 an+

the a)sence o a co+e or cesarean

+ei(ery2.

e e6cu+e+ #atients who +ei(ere+

ater transer ro% another acute care

hos#ita )ecause transer #atients are

%ore co%#e6 than #atients who are a+-

%itte+ through other routes an+ )ecause

a+%inistrati(e +ata +o not a+eHuatey

ca#ture this e6cess co%#e6ity that ea+sto #otentiay )iase+ resuts.

53A

other cases o chi+)irth 1s#ontaneous

(agina +ei(eries, cesarean +ei(eries,

orce#s, an+ (acuu%2 were incu+e+ in

the anaysis o a +ei(eries

1igure 2. Our anaysis os#ontaneous (agina +ei(er-

ies e6cu+e+ instru%ent +ei(eries with

orce#s or (acuu%s )ecause the use osuch +e(ices suggests a %ore co%#i-

cate+ +ei(ery an+ %ay intro+uce un-

wante+ heterogeneity. A##ication o

these criteria et us with a cohort o what

we wou+ +escri)e as routine chi+)irth

a+%issions without o)(ious e(i+ence o

co%#icating actors.

8he SID +ata)ases that were use+ in

this stu+y were +e(eo#e+ )y the Agency

or $eathcare Research an+ uaity as

#art o the heath care utii/ation#ro0ect

in #artnershi# with in+i(i+ua states1htt#BLLhcu#net.ahrH.go(L2. e +ei)er-

atey acHuire+ SID +ata ro% the

states that were incu+e+ in this stu+y)e-

cause they re#resente+ a regions o the

*nite+ States, )ecause they incu+e+ a

+is#ro#ortionate #ercentage o the *S

#o#uation, an+ )ecause they co(ere+ a

%i6 o ur)an an+ rura regions. SID +ata

incu+e %any ee%ents that are incu+e+

on the *nior% &iing cai% or% 1*&-

952 hos#ita +ischarge a)stract an+ ha(e

)een use+ e6tensi(ey in #re(ious heathser(ices research, incu+ing #re(ious o)-

stetrics stu+ies.5-5=

Key +ata ee%ents in-

cu+e #atient +e%ogra#hics, a+%itting

hos#ita, #ri%ary an+ secon+ary+iagnoses
http://www.ajog.org/http://hcupnet.ahrq.gov/http://hcupnet.ahrq.gov/http://hcupnet.ahrq.gov/http://hcupnet.ahrq.gov/http://www.ajog.org/http://hcupnet.ahrq.gov/http://hcupnet.ahrq.gov/


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#re(ious stu+ies using a+%inistrati(e

+ata that incu+e+ he%orrhage, se(ere

#erinea acerations 1=r+- or 'th-+egree

acera- tions2, o#erati(e co%#ications,

inection, thro%)otic co%#ications, an+

+eath.5,=,5'

Outco%es o interest or (agina +ei(er-

ies incu+e+ a o the outco%es +e-

scri)e+, with the e6ce#tion o o#erati(e

co%#ications that are not ree(ant to

(agina +ei(ery. Outco%es o interest

or cesarean +ei(eries incu+e+ a

outco%es, e6ce#t or se(ere #erinea

acerations that are not ree(ant to

cesarean +e- i(eries. ro% an

anaytic stan+#oint, our #ri%ary

outco%e was a co%#osite %easure

that re#resente+ the occurrence o

a+(erse outco%es in a gi(en#a- tient.

e i+entiie+ co%or)i+ inesses

using the %etho+ +e(eo#e+ )y

?i6- hauser et a57

an+ su##e%ente+this )y high-ris" o)stetrica

con+itions that ha(e )een i+entiie+

#re(iousy.5

Statistical anal+sis

e use+ )i(ariate %etho+s that

incu+e+ the t-test an+ Cochran-Mante-

$aens/e statistics to co%#are the

+e%ogra#hic characteristics 1eg, age,

race2 o#atients across hos#ita (ou%e

+ecies. e use+ si%iar %etho+s to

co%#are insurance

5:2H 2012 )merican Journal o* Obstetrics&!+necolo,+%&'e&


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Research Obstetrics www . AJOG.org

co(erage an+ the inci+ence o co%or)i+

inesses across +ecies o hos#ita (o-

u%e. A anayses were con+ucte+ se#a-

ratey or s#ontaneous (agina

+ei(eries, cesarean section +ei(eries,

an+ a +ei(- eries in aggregate. e

use+ si%iar %eth- o+s to co%#are theuna+0uste+ inci+ence o in-hos#ita

%aterna co%#ications across hos#ita

(ou%e +ecies.

inay, we use+ a series o ogistic re-

gression %o+es to e(auate the associa-

tion )etween rates o chi+)irth co%#i-

cations an+ hos#ita o)stetrics (ou%e

ater a+0ust%ent or +ierences in #a-

tient +e%ogra#hics an+ co%or)i+ity.

e use+ the #atient as the unit o

anaysis; (ou%e was %easure+ at the

hos#ita e(e. 8he stan+ar+ errors,974 coni- +ence inter(as, an+

associate+ signii- cance e(es or

a+0uste+ o++s ratios)ase+ on ogistic

regression accounte+ or custering

with the use o hos#ita ran+o%-eect

%o+es. or #ur#oses o these anayses,

the outco%e 1+e#en+ent (aria)e2 was

an in+icator (aria)e that re#resente+

the occurrence o the co%- #osite

outco%e. 8he +e#en+ent (ari- a)es o

interest were a series o in+icator

(aria)es that re#resente+ the +ecie ohos#ita (ou%e, with hos#itas in the

highest (ou%e +ecie ser(ing as the re-

erence category. 8he %o+es incu+e+

9 co(ariates that incu+e+ #atient age,

race, #ayor, an+ a nu%)er o i%#ortant

co%or)i+ iness. Se#arate anayses

were #eror%e+ or 12 a chi+)irths in

aggregate, 152 s#ontaneous (agina

+ei(eries ony, an+ 1=2 cesarean

+ei(eries ony. e a##ie+ = se#arate

%o+es to each #atient cohortB 12

una+0uste+, 152 a+0ust%ent or #atient+e%ogra#hics aone, an+ 1=2 a+-

0ust%ent or #atient +e%ogra#hics #us

co%or)i+ities.

&ecause we hy#othesi/e+ that %ore

co%#e6 cases wou+ )e reerre+ seec-

ti(ey to higher (ou%e hos#itas, we

con+ucte+ a nu%)er o sensiti(ity ana-

yses. S#eciicay, we stratiie+ )oth (ag-

ina +ei(eries an+ cesarean +ei(eries

into high-ris" an+ ow-ris" cohorts.

!i"#-ris$patients were +eine+ as those

with any o the oowing con+itionsthat ty#icay are consi+ere+ a cause or

con- cern a%ong o)stetriciansB

a+(ance+ age, asth%a, cere)ra

he%orrhage, hy#erten- si(e +isor+ers,

+ia)etes %eitus, o)esity, chorioa%nionitis, congenita heart +is-

ease, i(er ano%aies, rena ano%aies,

thyroi+ +isease, %enta +isor+er, %uti-

#e gestation, #reter% gestation,#u%o-

nary e%)ois%, an+ uterine ru#ture. 8he

ow-ris" cohort incu+e+ #atients with-

out any o these con+itions. e aso re#-icate+ our anayses to e6a%ine aterna-

ti(e %etho+s or categori/ing hos#ita

(ou%e 1eg, Huinties, Huarties2 an+ +e-

ining high- an+ ow-(ou%e hos#itas.

A statistica anayses were #eror%e+

with SAS sotware 1(ersion 9.5; SAS In-

stitute Inc., Cary,C2. 8he stu+y wasa#-

#ro(e+ )y the Institutiona Re(iew

&oar+ o the *ni(ersity o Iowa.

RESULTSe i+entiie+ a tota o ,7' chi+-)irths. Ater e6cu+ing transer cases

1n '9'72, our ina cohort o s#onta-

neous (agina +ei(eries, orce#s +ei(er-

ies, (acuu% e6tractions, an+ cesarean

+ei(eries incu+e+ ,>


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a+(ance+ %aterna age, hy#ertension,

an+ +ia)etes %eitus 18a)e 2.

Con(ersey, wo%en who ha+ (agina

+ei(eries in high- (ou%e hos#itas

were %ore i"ey to )e o+er an+

$is#anic or )ac" an+ to ha(e %ore

co%or)i+ iness. Resuts were si%i- ar

or cesarean +ei(eries 18a)e 52, with

ow-(ou%e hos#itas treating a higher

#ro#ortion o uninsure+ younger

white wo%en, athough high-(ou%ehos#itas treate+ %ore wo%en with

a+(ance+ age an+co%or)i+ iness.

In anayses o una+0uste+ outco%es

18a)e =; igure 52, we oun+ higher

rates o the co%#osite a+(erse

outco%e an+ %ost o the in+i(i+ua

a+(erse outco%es in the owest (ou%e

hos#itas 1+ecies an+ 52, when

co%#are+ with a other hos#itas

within a +ei(eries, (agina +e- i(eries,

or cesarean +ei(eries. or e6a%- #e,

with at a +ei(eries in aggregate, the

inci+ence o the co%#osite outco%e

in +ecie was ..-


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T)B$E (

.atient characteristics b+ annual spontaneous va,inal deliveries

Va,inal deliveries Decile ( Decile & Decile / Decile % Decile 0 Decile 1 Decile 2 Decile 3 Decile 4 Decile (5

7eneral characteristics...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Hospitals, n 10# 10$ 10$ 10# 10$ 10# 10# 10$ 10# 10$...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

;an&e of delivery volume, n 1I++ 100I!0" !0I##1 ##2I" "+I11!! 11!$I1#6" 1#6I20$ 20$+I26"# 26"6I!"2$ !"2#I12 ,$#............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

pecific characteristics...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

>atients, n 1+!0 1!,2++ 2,#0" $,10 6!,10# ,!0# 11",1!! 1#0,+$$ 210,"2! !2,"+$...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

%elivery volume, na

$$.! !!.2 16#.6 !+.$ !0+. $.6 $6$.! $!.0 6$!.0 #$.2 6.6 1. 11!+. ".+ 1$+.0 1!0 ." 2010. 16.1 !2!1.$ +1+.+...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Hi&h-risC volume, na +.1 6.6 !!." 16.1 6".1 2+.# 10"." $0.2 1##.0 #"." 21".6 "".1 !06.$ 120." $00.2 1$$.1 #$1.0 1 +$ .2 + $1 .0 $02.0...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

ow-risC volume, na !." 2".6 1!1.+ !!." 2$2." $!.! !#6.6 $+.! $.0 6.6 6#1.1 .6 !!.$ 1!#.2 10. 1#! . 1$6+. 22".! 22+0.! 6!."...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

4&e, y a 26.0 #.6 2#.+ #." 26.0 #.+ 26.$ 6.0 26. 6.1 2".2 6.1 2".$ 6.2 2".2 6.1 2".! 6.1 2".+ 6.2...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

;ace, n '(*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

W hit e 1$$# '"$.+* 0" '66.2* 1#,"0" '##. 1* 2#,!!! ' #6.2* 2,62 '$#. $* $1,$1+ '$6.+* $$,6#2 '!.1* 60,"16 '$0.2* "",+26'!".0* 11+,$0! '!6.!*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Hispanic 6! '!.!* "2 '#.#* !$"! '12.2* #62" '12 .# * 1$,0!0 '22 .2 * 1+,"6" '22.$* !!,20! '2.$* $1,#00 '2".#* 6$,$!" '!0.6* +6,110'2+.2*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

@lacC #+ '!.1* !"2 '2.* 12!" '$.!* 216# '$.* #0# '.1* 10,0!1 '11.$* 1$,1$! '12.1* 21,1!" '1$.0* 1 ," 6 ' +.0* ! 6,# #'11.1*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

ther !6! '1.* !!+2 '2#.#* 0+0 '2.$* 11,+! '26.6* 1#,!62 '2$.!* 1",0 '1+.$* 2#,1!# '21.#* 2",#+1 '1.!* $+,$$ '2!.#* "6,6+6'2!.!*...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

>ayor, n '(*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

ed icaid # '$ $.#* 66+$ ' #0. !* 1$,!2$ '#0.!* 21,10 '$6 ."* 2 ,#1 $ '$#.2* !6, 6$! '$1 .# * #$, #2 $ ' $6.6 * 66 ,01 0 '$!."* +!,202'$$.2* 1$2,+"+ '$!.#*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

>rivate 62 '$$."* #,"!$ '$!.1* 11,62 '$1.0* 21,$2 '$".6* 2,# '$#.* $#,110 '#1.1* #$,#12 '$6.#* "!,!$1 '$.6* 10#,$+!'#0.1* 1"0,0+2 '#1."*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

edicare '0.$* !6 '0.!* 200 '0."* 1"$ '0.$* 2## '0.$* !$0 '0.$* !! '0.!* #$+ '0.$* ""0 '0.$* 6$!'0.2*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

elf-pay 16$ '.#* #!1 '$.0* 10"" '!.* 1!"" '!.1* !62 '#.* !"$0 '$.2* ##"# '$.* "++# '#.!* 6""2 '!.2* +6#0'2.+*...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

omorbidities, n..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

4dvanced maternal a&e, n '(* 166 '.6* 11"" '.+* 2"10 '+.#* $+0# '10.+* ""1 '12.!* 11,+!# '1!.#* 16,#02 '1$.1* 20,!2! '1!.#* 2,!22'1! .$ * #2,611 '16.0*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Hypertension disorder, n '(* !! '1."* 2"" '1.!* 661 '2.!* # '2.0* 1!6! '2.2* 16" '2.1* 2"12 '2.!* !$## '2.!* $"+" '2.!* +210'2.*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

%iabetes mellitus, n '(* 22 '1.1* 222 '1."* #00 '1.* +1 '2.0* 1$!6 '2.!* 2016 '2.!* !11$ '2."* $0$! '2."* #1$ '2.* 10,126'!.1*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

besity, n '(* 10 '0.#* +$ '0."* 1+$ '0."* !# '0.* $"6 '0.* " '0.+* 12" '1.1* 1#6# '1.0* !06 '1.#* 2"#'0.*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

ultiple &estation, n '(* 2 '0.1* 11 '0.1* 21 '0.01* #+ '0.1* "2 '0.1* 161 '0.2* 222 '0.2* !06 '0.2* $+$ '0.2* 10!2'0.!*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

>reterm &estation, n '(* 1 '0.+* 1# '1.$* $#2 '1.6* "2" '1.6* 120+ '1.+* 101 '2.0* 26"$ '2.!* !"+ '2.6* #"! '2."* 10,6++'!.!*............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

a %ata are &iven as mean %.

Kyser. Obstetrical volume andpostpartum complications.AmJ Obstet Gynecol 2012.
http://www.ajog.org/http://www.ajog.org/http://www.ajog.org/http://www.ajog.org/http://www.ajog.org/http://www.ajog.org/http://www.ajog.org/http://www.ajog.org/http://www.ajog.org/http://www.ajog.org/http://www.ajog.org/http://www.ajog.org/http://www.ajog.org/


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.atient characteristics b+ annual cesarean deliveries

Cesarean deliveries Decile ( Decile & Decile / Decile % Decile 0 Decile 1 Decile 2 Decile 3 Decile 4 Decile (5

7eneral characteristics...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Hospitals, n 10# 10$ 10$ 10# 10$ 10# 10# 10$ 10# 10$...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

;an&e of delivery volume, n 1I++ 100I!0" !0I##1 ##2I" "+I11!! 11!$I1#6" 1#6I20$ 20$ +I2 6"# 26"6I! "2 $ !"2 #I1 2, $ #............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

pecific characteristics...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

>atients, n +22 6006 1$,1"# 20,""+ !0,22+ $#,$!# 60,6#+ "+,00" 102,$1 1"",00...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

=olume, na

1!.2 11. 6$.1 1".! 1!#.# 21. 20.1 1+.+ 2+1.1 !!.+ $22.1 $#.! #"#.2 $#.6 "$+.# #1.0 +++. +.# 1"#2.6 #61.$...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Hi&h-risC volume, na #.1 $.! 2!.1 12.0 #2.+ 16.0 !.# 2$.0 11+.0 !!.$ 1".! #!.0 2#!.6 6".# !##.1 .$ $66. 10+.0 +1.2 !!2.6...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

ow-risC volume, na 10.$ . $1.0 12.! 2.6 1+.$ 12$.6 2$.0 1"2.1 !1.6 2!$." #6.# !21.6 61.$ !+$.$ #.+ #!!.0 11+.2 61.# !0....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

4&e, y a 26." #." 2".2 6.0 2".$ 6.2 2".+ 6.2 2.# 6.! 2+.0 6.! 2+.! 6.$ 2+.1 6.! 2+.! 6.! 2+.+ 6.!...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

;ace, n '(*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

White 6#! '"0.* !$2 '6$.0(* "##2 '#!.!* 1 1, ' #".2* 1 !,6 " ' $# .! * 21 ,# " ' $ .1 * 2 $,+ 0 ' $1 .2 * !2 ,+ 6 ' $1 . * $ 0,"$ # ' !+ . * 6 ",!+ 2'!.1*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Hispanic #+ '6.$* $1 '".0* 1+! '1!."* 26!# '12."* 6+$0 '2!.0* 1 0,## $ ' 2! .2 * 1 6,1 ## ' 26 .6* 2 1,10 2 ' 26 ." * 2 +,# #+ ' 2 . * $ +,01 '2"."*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

@lacC $! '$."* 22" '!.* ""# '#.#* 10+! '#.!* 2"$ '+.1* #606 '12.!* 000 '1!.2* 11,#1 '1#.0* +6" '+.#* 22,1$"'12.#*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

ther 16" '1.1* 1#1+ '2#.!* !+10 '2".6* #16! '2$.+* 6#$ '22."* "$1 '16.!* 1 1,# 2$ ' 1+ .0* 1 !,06 ' 16 .# * 2 2,$ +0 ' 22 .0 * ! ,#2 !'21.*...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

>ayor, n '(*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

edicaid !66 '!+."* 2+! '$.2* 6#0 '$.!* +11+ '$!.+* 1 2,# + ' $1 ." * 16 ,"" 1 ' !6 .+ * 2 #,## + ' $2 .1 * !1 ,10 $ ' !+ .$ * $ 0,10 ' !+ .1 * 6 #,21 6'!6.*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

>rivate $$+ '$."* 2"!! '$#.#* 62!" '$$.0* 10,#!# '#0."* 1#,22# '#0.$* 2#,! '#6.+* !1,#!0 '#2.0* $ 2,"! ! ' #$ .1 * # 6,+6 # ' ## .6 * 1 0$ ," 6!'#+.2*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

edicare " '0.* !" '0.6* 1! '0.1* 112 '0.#* 20$ '0."* 20 '0.#* 26+ '0.$* !" '0.#* $## '0.$* ##2'0.!*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

elf-pay 2 '.+* 22# '!.* $$$ '!.1* #2$ '2.#* 1$$! '$.* 1##+ '!.$* 21!# '!.#* !1+ '$.1* 2## '2.* !!1'2.2*...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

omorbidities, n '(*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

4dvanced maternal a&e +! '10.1* "+ '1!.!* 212$ '1#.0* !#$6 '1".1* #!2 '1+.!* +62 '21 ." * 1!," '22 .+ * 1",$0 '22 .0 * 2!,11#' 22 .6 * $ #, 6# + ' 2# . *..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Hypertension disorder $+ '#.!* !0 '6.!* ++# '".0* 1!6 '6."* 212! '".0* !01+ '6.6* $2 '".1* #+22 '".#* ""!1 '".#* 1#,!!0'."*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

%iabetes mellitus ## '6.0* !2" '#.$* 6 '6.!* 1$2$ '6.+* 22$0 '".$* !16# '".0* $#6$ '".#* 620$ '".+* 6!! '.$* 1#,!!#'."*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

besity 1" '1.* 16# '2.* !!1 '2.!* #$ '2.6* "!+ '2.$* 11!" '2.#* 1#1 '2.6* 22"# '2.+* !6## '!.6* $10'2."*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

ultiple &estations # '0.#* !$ '0.6* 112 '0.* 1"+ '0.+* 2"! '0.+* #1# '1.1* ""$ '1.!* 11# '1.#* 1+1# '1.+* !"20'2.1*..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

>reterm &estation 2$ '2.6* 22$ '!."* #!" '!.* +2 '$.#* 1622 '#.$* 2#"0 '#."* !#1 '6.$* ##2 '".0* !+ '.2* 16,2"+'+.2*............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

a %ata are &iven as mean %.



9/55

Resea

rch

Obstetrics

www.AJOG.o

rg

T)B$E /

Total population: unad6usted percent complications b+ hospital decile and route o* deliver+

Variable Decile ( Decile & Decile / Decile % Decile 0 Decile 1 Decile 2 Decile 3 Decile 4 Decile (5 P value

4ll deliveries...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

? !011 20,6" $#,$$6 6+,6+ ++,6#$ 1$1,$$ 1,22" 2$!,$"# !!1,01 #!$,0$...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Hemorrha&e, n '(* 2$1 '.0* 1!! '6."* 2#2" '#.6* !6$$ '#.2* $$+ '$.+* 6!" '$.#* " '$."* 12,!$2 '#.1* 1",#!+ '#.(* 26,210 '$.+* .0001...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

9nfection, n '(* 26 '0.+* 102 '0.#* 212 '0.#* 2#2 '0.$* $## '0.#* 6+! '0.#* 11" '0.6* 2061 '0.+* 2$#0 '0."* $"0+ '0.+* .0001...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

aceration, n '(* $ '2.* #2 '2.6* +2" '2.0* 1#0 '2.2* 21#2 '2.2* 2#+ '2.0* !$0$ '1.* #00# '2.1* "161 '2.2* 10,+10 '2.0(* .0001...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Thrombotic, n '(* 26 '0.+* 2#2 '1.2* #$2 '1.2* "$ '1.!* 116 '1.2* 16"$ '1.2* 22"0 '1.2* 2,2! '1.2* $!66 '1.!* "116 '1.!* .0001...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

perative, n '(* + '0.!* # '0.!* 121 '0.!* 22" '0.!* !!+ '0.!* $26 '0.!* #"6 '0.!* +21 '0.$* 1,!#0 '0.$* 2$1! '0.#* .0001...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

ortality, n '(* 1 '0.0!* 2 '0.01* 2 '0.00* # '0.01* $ '0.00* 1! '0.01* 1" '0.01* 20 '0.01* 2" '0.01* #6 '0.01* .#$$+...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

om posi te, n '( * !#$ ' 11.* 202 '10.1* !0 '.#* #$ '.$* 021 '.1* 10," '". 6* 1$,#!1 '"."* 20,6#1 '.#* 2+, 1#1 '.* $#,2 '.#* .0001............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

=a&inal deliveries...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

? 1+ 1!,!01 2,#11 $#,112 6!,10 ,!0+ 11",1!" 1#0,+$ 210,"2" !2,"+"...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Hemorrha&e, n '(* 1!6 '".2* 06 '6.1* 1,$# '#.1* 2,2!2 '#.0* 2,"$0 '$.!* !,"!2 '$.2* $,+"2 '$.2* 6,#"1 '$.$* +,2#$ '$.$* 1!,#$0 '$.1* .0001...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

9nfection, n '(* 1! '0."* !2 '0.2* + '0.!* 121 '0.!* 11 '0.!* 26 '0.!* $"2 '0.$* 6+" '0.#* +#0 '0.#* 1"0" '0.#* .0001...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

aceration, n '(* #0 '2.6* !#$ '2."* #+6 '2.1* 102# '2.!* 1!"+ '2.2* 1+22 '2.2* 2202 '1.+* !!" '2.2* $"0" '2.2* "016 '2.1* .0001...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Thrombotic, n '(* 6 '0.!* $1 '0.!* +! '0.!* 16 '0.$* 22 '0.$* !12 '0.$* !" '0.!* $"0 '0.!* 6+2 '0.!* 106! '0.!* .#0"!...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

ortality, n '(* 0 '0.00* 0 '0.00* 0 '0.00* 0 '0.00* 0 '0.00* $ '0.00* 6 '0.01* " '0.00* ! '0.00* 21 '0.01* .06...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

om posi te, n '( * 1+$ ' 10.2* 1, 1#0 '."* 2,12! '".#* !, !"+ '".#* $,2! '6. * #,+!# '6. "* ",61" '6.#* 10,##1 '".0* 1$, ""1 '".0* 22,126 '6."* .0001............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

esarean deliveries...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

? +22 6006 1$,1"# 20,""+ !0,22+ $#,$!# 60,6#+ "+,00" 102,$1 1"",00...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Hemorrha&e, n '(* 6 '+.!* $! '".!* $1 '#.+* 110! '#.!* 166# '#.#* 211# '$."* !26$ '#.$* $+# '6.!* "1$0 '".0* 10,1+ '6.1* .0001...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

9nfection, n '(* 12 '1.!* ## '0.+* 102 '0."* 111 '0.#* 2$6 '0.* !#1 '0.* 6!! '1.0* 12!1 '1.6* 1!60 '1.!* 2""+ '1.6* .0001...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

perative, n '(* + '1.0* # '1.0* 121 '0.+* 22" '1.1* !!+ '1.1* $26 '0.+* #"6 '1.0* +21 '1.2* 1!#0 '1.!* 2$1! '1.$(* .0001...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Thrombotic, n '(* 11 '1.2* "0 '1.2* 12 '1.!* 2$+ '1.2* !6! '1.2* $+! '1.1* 0! '1.!* 11#2 '1.#* 1#" '1.#* 21 '1.6* .0001...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

ortality, 'n* 1 '0.11* 2 '0.0!* 2 '0.01* ! '0.01* $ '0.01* + '0.02* 11 '0.02* 1! '0.02* 22 '0.02* !$ '0.02* ."2$0...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

omposite, n '(* 10! '11.2* #!# '.+* 10$! '".$* 1$12 '6.* 2166 '".2* 20+ '6.2* $!$2 '".2* 610 '.6* +!" '+.2* 1#,!0$ '.6* .0001............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................



10/55


-I!U#E &

Unad6usted composite morbidit+ and mortalit+ ratesb+hospital decile7 strati*ied b+ route o* deliver+

Kyser. Obstetrical volume andpostpartum complications.Am JObstet Gynecol 2012.

u%e hos#ita, which is a in+ing that, i

not reate+ to un%easure+ +ierence in

co%or)i+ity, wou+ gi(e one #ause.

8hir+, we oun+ %ar"e+ (ariation in ce-

sarean +ei(ery rates across hos#itas.

8he in+ing o higher rates o a+(erse

outco%es at ow-(ou%e hos#itas has)een we-+ocu%ente+ in %e+ica an+

surgica iterature7-'

)ut has not )een

we-stu+ie+ in o)stetrics. !re(ious

stu+- ies that e(auate+ the (ou%e-

outco%e reationshi# in o)stetrics ha(e

)een i%- ite+ to stu+ies ro% singe

state #o#ua- tions, to +ata that are

now +eca+e o+, an+ to conicting

resuts a)out the (ou%e-outco%e

reationshi#.7-9

In a++ition, %any

#re(ious o)stetrics (o- u%e-outco%e

stu+ies ocuse+ e6cu- si(ey onneonata outco%es without in-

(estigating %aternaco%#ications.5>-==

Our stu+y #ro(i+es i%#ortant new e(i-

+ence o higher %aterna co%#ication

rates at (ery ow-(ou%e hos#itas.

8he in+ing o higher o)stetrics co%-

#ication rates in ow-(ou%e hos#itas

is not necessariy une6#ecte+. 8he

%eaneries that were cesarean sections across

(ou%e +ecies.

In anayses that a+0uste+ or #atient+e%ogra#hics an+ co%or)i+ities 18a)e

'2, we again oun+ higher ris" o

a+(erse outco%es in owest (ou%e

hos#itas 1+ecie an+ 52. S#eciicay,

o++s o e6- #eriencing the co%#osite

outco%e were )etween '=4 an+ 34

higher or +ecie hos#itas 1with

+ecie 3 ser(ing as the reerence

category2 e(en ater a+0ust%ent or

#atient +e%ogra#hics an+ co%or)i+ity

1% .372. Aternati(ey, the o++s o a+-

(erse outco%es a##eare+ %o+esty owerorinter%e+iate (ou%e hos#itas1+ecie

7 an+ 2, with the eect #articuary

nota)e or cesarean +ei(eries.

8o ensure the ro)ustness o our in+-

ings, we con+ucte+ a++itiona su##e-

%enta anayses. irst, we re#eate+ our

una+0uste+ an+ a+0uste+ anayses e6a%-

ining outco%es across +ecies o

hos#ita (ou%e ater stratiying

#atients into high- an+ ow-ris"

su)grou#s. *na+- 0uste+ anayses

#ro+uce+ si%iar resuts to our %ainanayses, with higher co%- #ication

rates in the owest (ou%e hos- #itas

or )oth the high- an+ ow-ris"#a- tient

strata, irres#ecti(e o +ei(ery route

1A##en+i6; Su##e%entary 8a)es -

=2.

A+0uste+ resuts in the high- an+ ow-

ris" su)grou#s were aso si%iar to the

%ain anayses, with higher o++s o e6#e-riencing the co%#osite outco%es in

the owest (ou%e hos#itas 1A##en+i6;

Su##e%entary 8a)es '-2. A++itiona

resuts were signiicant or high-ris" #a-

tients who ha+ higher o++s o a+(erse

outco%es co%#are+ with ow-ris" su)-

grou#s in the owest (ou%e hos#itas

1% .372. Interestingy, in our su##e-

%entary anayses high-(ou%e hos#itas

again a##eare+ to ha(e %arginay

higher rates o a+(erse outco%es in)oth

the high- an+ ow-ris" strata. e asocon+ucte+ a++itiona anayses using a-

ternati(e %etho+s or the stratiication

o hos#itas accor+ing to (ou%e 1eg,

Huarties, Huinties2, an+ the resuts were

again si%iar.

COMMENTIn an anaysis o . %iion %aterna

hos#itai/ations or chi+)irth, we i+en-

tiie+ a nu%)er o i%#ortant in+ings.

irst, we oun+ %ar"e+y higher rates o

%aterna co%#ications or +ei(eries inow-(ou%e hos#itas. Secon+, we oun+

%o+esty higher rates o co%#ications

or +ei(eries at e6cee+ingy high-(o-
http://www.ajog.org/http://www.ajog.org/


11/55

o(era chi+)irth (ou%e or +ecie

hos#itas was =. #er year an+ or

+ecie

5 hos#itas 53'.< #er year. Moreo(er,

the %ean cesarean section (ou%es or

+e- cie an+ 5 hos#itas were =.5 an+

'., res#ecti(ey. ith such ow

(ou%es, it see%s ogica that

co%#ication rates wou+ )e high,

es#eciay gi(en the i%- #ortance o

)oth e6#erience an+ tea%- wor" in theheath care setting. Se(era hos#itas in

our stu+y ha+ ony or 5 a+%issions

or chi+)irth +uring 533, which

suggests that such +ei(eries re#-

resente+ e%ergent cases that were

treate+ at hos#itas without an e6#eri-

ence+ #hysician or o)stetrics tea%.

Aternati(ey, it is interesting to

thin" a)out how the heath care

syste% %ight )e change+ in a way

that %ight re+uce the nee+ or

%others to gi(e )irth at e6- tre%eyow-(ou%e hos#itas. In su#-

#e%entary anayses, we e6#ore+ the

roe o +istance in wo%en gi(ing )irth

at +ecie an+ 5 hos#itas. ota)y,

we oun+ 34 o +ecie an+ 5

hos#itas were ocate+ within 57 %ies

o a higher o)stetrics (ou%e hos#ita

1+ecie '; %ean +istance, 57.9 %ies2.

!racticay s#ea"ing, our resuts wou+

suggest that a certain #ercentage o

+ei(eries at (ery

%&'e2 )merican Journal o* Obstetrics& !+necolo,+ 5:2H 2012


12/55


T)B$E %

Unad6usted and ad6usted odds o* composite adverse outcome b+ volume decile

$owestvolume

)dverse outcomes

Decile (

O# 8409 CI

Decile &

P value O# 8409 CI

Decile /

P value O# 8409 CI

Decile %

P value O# 8409 CI

Decile 0

P value O# 8409 CI

4ll deliveries.......................................................................................................................................................................................................................................................................................................................................................................

:nadBusted 1.!" '1.0"I1."#* .0112 1.1" '0.+I1.!+* .0+01 0.+2 '0."I1.10* .!"12 0.+6 '0.1I1.1$* .66$1 0." '0."!I1.0!*.......................................................................................................................................................................................................................................................................................................................................................................

4dBusted for demo&raphicsa 1.! '1.0I1."6* .0100 1.1" '0.+I1.$0* .061 0.+2 '0.""I1.10* .!!!! 0.+6 '0.1I1.1$* .6$1 0." '0."!I1.02*.......................................................................................................................................................................................................................................................................................................................................................................

4dBusted for demo&raphicsand selectedcomorbiditiesb

1.$! '1.1!I1.2* .00!# 121 '1.02I1.$$* .0!2 0.+# '0.0I1.12* .#!0$ 0.++ '0.!I1.1"* .6#2 0.+ '0."#I1.0#*

................................................................................................................................................................................................................................................................................................................................................................................

=a&inal deliveries.......................................................................................................................................................................................................................................................................................................................................................................

:nadBusted 1.#1 '1.16I1.+6* .002$ 1.2 '1.0I1.#!* .00## 1.0# '0.I1.2$* .6006 1.10 '0.+!I1.!0* .22# 0.+$ '0."+I1.11*.......................................................................................................................................................................................................................................................................................................................................................................

4dBusted for demo&raphicsa 1.#" '1.1!I1.+2* .0001 1.!2 '1.10I1.#"* .0001 1.0# '0.+I1.2$* .0002 1.11 '0.+$I1.!2* .0001 0.+2 '0."I1.0+*.......................................................................................................................................................................................................................................................................................................................................................................

4dBusted for demo&raphicsand selectedcomorbidities

1.60 '1.!I1.6* .0001 1.!! '1.2#I1.$2* .0001 1.12 '1.0"I1.1"* .0001 1.1! '1.0I1.1"* .0001 1.02 '0.++I1.06*................................................................................................................................................................................................................................................................................................................................................................................

esarean deliveries.......................................................................................................................................................................................................................................................................................................................................................................

:nadBusted 1.!" '0.+6I1.+#* .02 1.01 '0."+I1.2+* .+#0" 0."+ '0.62I1.00* .0$6+ 0."6 '0.60I0.+#* .01"# 0."! '0.#I0.+1*.......................................................................................................................................................................................................................................................................................................................................................................

4dBusted for demo&raphicsa 1.! '0.+"I1.+"* .0"60 1.02 '0.0I1.!1* .$1 0."+ '0.62I1.00* .0$62 0."6 '0.61I0.+6* .022$ 0."! '0.#I0.+1*.......................................................................................................................................................................................................................................................................................................................................................................

4dBusted for demo&raphicsand selectedcomorbidities

b 1.$# '1.01I2.0$* .0$!6 1.06 '0.!I1.!6* .626 0.2 '0.6#I1.0!* .0"1 0."+ '0.6!I0.++* .0$02 0."# '0.60I0.+$*

................................................................................................................................................................................................................................................................................................................................................................................

Kyser. Obstetrical volume andpostpartum complications.AmJ Obstet Gynecol 2012. &continued'

ow-(ou%e hos#itas reasona)y %ight

)e transitione+ to higher (ou%e hos#i-

tas with itte incon(enience to #atients

or their a%iies. It is aso i%#ortant to

consi+er our in+ings in the conte6t o

e6isting gui+eines that are reate+ tochi+)irth. 8he A%erican Congress o

O)stetrics an+ Gynecoogy rea+iy rec-

o%%en+s that wo%en who are i"ey to

+ei(er#reter% )e transerre+ to tertiary

centers,='

yet there is no

eHui(aent gui+eine or esta)ishing

%ini%u% hos#ita +ei(ery (ou%e an+

tiere+ %a- terna reerras )ase+ on

#atient saety.

Secon+, it is interesting that we

consis- tenty oun+ %o+esty higher

rates o co%#ications or +ei(eries ate6cee+- ingy high-(ou%e hos#itas.

8here are se(era #otentia

e6#anations or our in+ings. It is

#ossi)e, an+ in+ee+ highy i"ey, that

the higher rates o a+(erse outco%es

in the highest (ou%e hos#i- tas

re#resent the higher ris" o the #o#-

uation that our highest (ou%e hos#i-

tas ser(e. !atients who are reerre+ to

high-(ou%e hos#itas or chi+)irth

ha(e a greater i"eihoo+ o ha(ing

%e+- ica con+itions with an increase+

se(erity o iness that is #oory

re#resente+ in cai%s +ata.53 8he

in+ing that the higher rates o a+(erse

outco%es #ersiste+ ater

a+0ust%ent or #atient +e%ogra#hics

an+ co%or)i+ities %ay %erey reect

un%easure+ +ierences in co%or)i+ity

that are not ca#ture+ we in a+%inistra-

ti(e +ata. Aternati(ey, it is #ossi)e

that e6tre%ey high-(ou%e hos#itastruy +o ha(e higher co%#ication rates

or chi+)irth. S#eciicay, i our

highest (ou%e hos#itas were too

)usy, stae+ )y trainees without

a+eHuate su#er(i- sion, an+ un+er

e6tre%e inancia #res- sure, higher

co%#ication rates %ight we )e

e6#ecte+. urther stu+y is nee+e+ to

e6a%ine this issue in greater +etai.

8hir+, we oun+ %ar"e+ (ariation in

%ean hos#ita cesarean +ei(ery rates

across hos#itas 1=.3-9.>42. 8hese re-suts are consistent with se(era

#re(ious stu+ies that oun+ highy

(aria)e rates o cesarean +ei(eries

with signiicant re- giona (ariation.=7-

=>8he reasons or these +ierences

re%ain un"nown an+ ar e6cee+e+ the

e6#ecte+ (ariationthat can)e e6#aine+

)y +ierences in #atient ris" actors

aone. 8hese in+ings suggest that there

is insuicient outco%es-)ase+ e(i+ence

to gui+e eecti(e cinica +eci- sion-

%a"ing. uture research is nee+e+ tourther e6#ain the un"nown (aria-

tion inrates o cesarean +ei(eries, es#e-

ciay gi(en our in+ing o higher rates

o

%aterna co%#ications ater cesarean

+ei(ery co%#are+ with (agina +ei(ery.

8here are a nu%)er o i%itations to

our stu+y. irst, our stu+y reie+ on a+-

%inistrati(e +ata an+ thus %ay ha(e

)een su)0ect to )ias i +iagnoses or#ro-ce+ures were syste%aticay %isco+e+

%ore oten )y grou# o hos#itas. e

ha(e, howe(er, no reason to)eie(e that

this ha##ene+; #re(ious stu+ies ha(e

shown that there is reia)e co+ing o

o)- stetrics +iagnoses an+ #roce+ures.=. aternal and perinatal infection.

9n 7abbe , ?iebyl 5;, impson 5, eds.

bstetrics normal and problem

pre&nancies. ?ew orC hurchill

ivin&stone) 200212!+-$2.

/' 4merican olle&e of bstetricians and

7yne- colo&ists. 467 practice bulletin

clinical man- a&ement &uidelines for

obstetrician-&ynecolo- &ists, no. "6

postpartum hemorrha&e. bstet 7ynecol2006)1010!+-$".

%' Heron , Hoyert %, urphy , 3u

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SU..$E sub,roups

b

Spontaneousva,inal

deliveries

:nadBusted

$owestvolume

Decile (

O# 8409 CI PvalueDecile &

O# 8409CI

PvalueDecile /

O# 8409CI

PvalueDecile %

O# 8409CI

PvalueDecile 0

O# 8409 CI

.......................................................................................................................................................................................................................................................................................................................................................................

Hi&h risC 2.0 '1.$#I2.+"* .0001 1.$ '1.22I1."* .0001 1.1!$ '0.+6I1.!$* .1!2 1.16'1.00I1.!6* .0#$0 1.02 '0.I1.1+*.......................................................................................................................................................................................................................................................................................................................................................................

ow risC 1.#0 '1.12I1.++* .00#" 1.!0 '1.0I1.#"* . 00 ## 1.0 '0.+0I1.2+* .$12# 1.12 '0.+$I1.!!* .212! 0.+# '0.0I1.1!*................................................................................................................................................................................................................................................................................................................................................................................

4dBusted fordemo&raphics

a

.......................................................................................................................................................................................................................................................................................................................................................................

Hi&h risC 2.1! '1.$+I!.0$* .0001 1.$ '1.2!I1."* .0001 1.12 '0.+6I1.!2* .1#+0 1.16'1.00I1.!$* .0#!" 1.02 '0.+I1.1*.......................................................................................................................................................................................................................................................................................................................................................................

ow risC 1.#0 '1.22I1.++* .0060 1.!0 '1.0I1.#"* . 00 61 1.06 '0.+I1.2"* .$+#1 1.11 '0.+!I1.!2* .2#11 0.+$ '0."I1.1+*................................................................................................................................................................................................................................................................................................................................................................................

8ully adBusted.......................................................................................................................................................................................................................................................................................................................................................................

Hi&h risC 2.21 '1.##I!.16* .0001 1.#2 '1.2"I1.!* .0001 1.16 '0.++I1.!6* .06$2 1.1+'1.02I1.!* .02$6 1.06 '0.+1I1.22*.......................................................................................................................................................................................................................................................................................................................................................................

ow risC 1.#0 '1.12I1.++* .0060 1.!0 '1.0I1.#"* . 00 61 1.06 '0.+I1.2"* .$+#1 1.11 '0.+!I1.!2* .2#11 0.+$ '0."I1.12*................................................................................................................................................................................................................................................................................................................................................................................

Kyser. Obstetrical volume andpostpartum complications.AmJ Obstet Gynecol 2012. &continued'

5:2H 2012 )merican Journal o* Obstetrics&!+necolo,+%&'e(%


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Decile 1 Decile 2 Decile 3 Decile 4 volumeP value O# 8409 CI P value O# 8409 CI P value O# 8409 CI P value O# 8409 CI P value Decile(5


SU..$E sub,roups

b(continued)

$owestvolume

;i,hest

;eference.................................................................................................................................................................................................................................................................................................................................................................................""# 0.++ '0.6I1.1#* .+!2+ 1.01 '0."I1.16* .+26" 1.0! '0.+0I1.1* .6+2+ 1.02 '0.+I1.1"* ."##$................................................................................................................................................................................................................................................................................................................................................................................

.#!#2 0.+ '0."#I1.06* .12# 0.+1 '0.""I1.0* .2"21 1.00 '0.$I1.1* .+#10 0.+ '0.!I1.1"* .##!

................................................................................................................................................................................................................................................................................................................................................................................

;eference................................................................................................................................................................................................................................................................................................................................................................................

."6$# 1.00 '0."I1.1#* .+"1" 1.0# '1.00I1.10* ."" 1.01 '0.I1.16* ."""# 1.02 '0.+I1.1"* .#++

................................................................................................................................................................................................................................................................................................................................................................................

.$0" 0.+ '0."#I1.06* .1""6 0.+1 '0."6I1.0* .2#"$ 0.++ '0.!I1.1"* .+0!$ 0.+" '0.2I1.1#* ."$6"

................................................................................................................................................................................................................................................................................................................................................................................

;eference................................................................................................................................................................................................................................................................................................................................................................................

.$6! 1.0! '0.+0I1.1* .6"0 1.0! '0.+0I1.1* .6!0 1.0$ '0.+1I1.1+* .#$! 1.0! '0.+0I1.1"* ."202

................................................................................................................................................................................................................................................................................................................................................................................

.$0" 0.+ '0."#I1.06* .1""6 0.+1 '0."6I1.0* .2#"$ 0.++ '0.!I1.1"* .+0!$ 0.+" '0.2I1.1#* ."$6"

................................................................................................................................................................................................................................................................................................................................................................................

CI, confidence interval) OR, odds ratio.a

4dBusted for race, a&e, and payor)b

4dBusted for race, a&e, payor, advanced a&e, herpes, asthma, cerebral hemorrha&e, chorioamnionitis,diabetes mellitus, hypertensive disorders, con&enitalheart disease, liver anomalies, renal anomalies, thyroid disease, mental disorder,multiple &estation, preterm &estation, obesity, pulmonary embolism, uterine rupture.


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Decile 1 Decile 2 Decile 3 Decile 4 volume

P value O# 8409 CI P value O# 8409 CI P value O# 8409 CI P value O# 8409 CI P value Decile(5


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8/13/2019 The Association Between Hospital

Documents

The Association Between Hospital Obstetrical Volume