Quality Improvement Initiatives Lead to Reduction in Nulliparous Term Singleton Vertex Cesarean Delivery Rate.
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ABSTRACT:
SUBMITTER: Vadnais MA
PROVIDER: S-EPMC5928501 | biostudies-literature | 2017 Feb
REPOSITORIES: biostudies-literature
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Quality Improvement Initiatives Lead to Reduction in Nulliparous Term Singleton Vertex Cesarean Delivery Rate.
Vadnais Mary A MA Hacker Michele R MR Shah Neel T NT Jordan JoAnn J Modest Anna M AM Siegel Molly M Golen Toni H TH
Joint Commission journal on quality and patient safety 20161115 2
<h4>Background</h4>The nulliparous term singleton vertex (NTSV) cesarean delivery rate has been recognized as a meaningful benchmark. Variation in the NTSV cesarean delivery rate among hospitals and providers suggests many hospitals may be able to safely improve their rates. The NTSV cesarean delivery rate at the authors' institution was higher than state and national averages. This study was conducted to determine the influence of a set of quality improvement interventions on the NTSV cesarean ...[more]
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Project description:OBJECTIVE:To estimate the contributions of patient and health care provider-hospital characteristics to the variation in the frequency of nulliparous, term, singleton, vertex cesarean delivery in a multi-institutional U.S. cohort. METHODS:We performed a secondary analysis of the multicenter Assessment of Perinatal Excellence cohort of 115,502 mother and neonatal pairs who were delivered at 25 hospitals between March 2008 and February 2011. Women met inclusion criteria if they were nulliparous and delivered a singleton in vertex presentation at term. Hospital ranks for nulliparous, term, singleton, vertex cesarean delivery frequency were determined after risk adjustment. The fraction of variation in nulliparous, term, singleton, vertex cesarean delivery frequency attributable to patient and health care provider-hospital characteristics was assessed using hierarchical logistic regression. RESULTS:Of the 115,502 deliveries in the initial cohort, 38,275 nulliparous, term, singleton, vertex deliveries met inclusion criteria. The median hospital nulliparous, term, singleton, vertex cesarean delivery frequency was 25.3% with a range from 15.0% to 35.2%. The majority of hospitals (16/25) changed rank quintiles after risk adjustment; overall the changes in rank were not statistically significant (P=.53). Patient characteristics accounted for 24% of the nulliparous, term, singleton, vertex cesarean delivery variation. The analyzed health care provider-hospital characteristics were not significantly associated with cesarean delivery frequency. CONCLUSION:Although patient characteristics accounted for some of the variation in nulliparous, term, singleton, vertex cesarean delivery frequency and accounting for case mix had implications for hospital cesarean delivery rankings, the majority of the variation was not explained by the characteristics evaluated. These findings emphasize the importance of continued efforts to understand aspects of obstetric care, including case mix, that contribute to cesarean delivery variation.
| S-EPMC6033063 | biostudies-literature
Project description:ImportanceCesarean birth rate among nulliparous, term, singleton, vertex (NTSV) pregnancies is a standard quality measure in obstetrical care. There are limited data on how the number and type of preexisting conditions affect mode of delivery among primigravidae, and it is also uncertain how maternal comorbidity burden differs across racial and ethnic groups and whether this helps to explain disparities in the NTSV cesarean birth rate.ObjectiveTo determine the association between obstetric comorbidity index (OB-CMI) score and cesarean delivery among NTSV pregnancies and to evaluate whether disparities in mode of delivery exist based on race and ethnicity group after adjusting for covariate factors.Design, setting, and participantsThis cross-sectional study of deliveries between January 2019 and December 2021 took place across 7 hospitals within a large academic health system in New York and included all NTSV pregnancies identified in the electronic medical record system. Exclusion criteria were fetal demise and contraindication to labor.ExposureThe OB-CMI score. Covariate factors assessed included race and ethnicity group (American Indian or Alaska Native, Asian or Pacific Islander, Hispanic, non-Hispanic Black, non-Hispanic White, other or multiracial, and declined or unknown), public health insurance, and preferred language.Main outcome and measuresCesarean delivery.ResultsA total of 30 253 patients (mean [SD] age, 29.8 [5.4] years; 100% female) were included. Non-Hispanic White patients constituted the largest race and ethnicity group (43.7%), followed by Hispanic patients (16.2%), Asian or Pacific Islander patients (14.6%), and non-Hispanic Black patients (12.2%). The overall NTSV cesarean birth rate was 28.5% (n = 8632); the rate increased from 22.1% among patients with an OB-CMI score of 0 to greater than 55.0% when OB-CMI scores were 7 or higher. On multivariable mixed-effects logistic regression modeling, there was a statistically significant association between OB-CMI score group and cesarean delivery; each successive OB-CMI score group had an increased risk. Patients with an OB-CMI score of 4 or higher had more than 3 times greater odds of a cesarean birth (adjusted odds ratio, 3.14; 95% CI, 2.90-3.40) than those with an OB-CMI score of 0. Compared with non-Hispanic White patients, nearly all other race and ethnicity groups were at increased risk for cesarean delivery, and non-Hispanic Black patients were at highest risk (adjusted odds ratio, 1.43; 95% CI, 1.31-1.55).Conclusions and relevanceIn this cross-sectional study of patients with NTSV pregnancies, OB-CMI score was positively associated with cesarean birth. Racial and ethnic disparities in this metric were observed. Although differences in the prevalence of preexisting conditions were seen across groups, this did not fully explain variation in cesarean delivery rates, suggesting that unmeasured clinical or nonclinical factors may have influenced the outcome.
| S-EPMC10587795 | biostudies-literature
Project description:To compare the maternal and neonatal risks of elective repeat cesarean delivery compared with pregnancy continuation at different gestational ages, starting from 37 weeks.We analyzed the composite maternal and neonatal outcomes of repeat cesarean deliveries studied prospectively over 4 years at 19 U.S. centers. Maternal outcome was a composite of pulmonary edema, cesarean hysterectomy, pelvic abscess, thromboembolism, pneumonia, transfusion, or death. Composite neonatal outcome consisted of respiratory distress, transient tachypnea, necrotizing enterocolitis, sepsis, ventilation, seizure, hypoxic-ischemic encephalopathy, neonatal intensive care unit admission, 5-minute Apgar of 3 or lower, or death. Outcomes after elective repeat cesarean delivery without labor at each specific gestational age were compared with outcomes for all who were delivered later as a result of labor onset, specific obstetric indications, or both.Twenty-three thousand seven hundred ninety-four repeat cesarean deliveries were included. Elective delivery at 37 weeks of gestation had significantly higher risks of adverse maternal outcome (odds ratio [OR] 1.56, 95% confidence interval [CI] 1.06-2.31), whereas elective delivery at 39 weeks of gestation was associated with better maternal outcome when compared with pregnancy continuation (OR 0.51, 95% CI 0.36-0.72). Elective repeat cesarean deliveries at 37 and 38 weeks of gestation had significantly higher risks of adverse neonatal outcome (37 weeks OR 2.02, 95% CI 1.73-2.36; 38 weeks OR 1.39 95% CI 1.24-1.56), whereas delivery at 39 and 40 weeks of gestation presented better neonatal outcome as opposed to pregnancy continuation (39 weeks OR 0.79, 95% CI 0.68-0.92; 40 weeks OR 0.57, 95% CI 0.43-0.75).In women with prior cesarean delivery, 39 weeks of gestation is the optimal time for repeat cesarean delivery for both mother and neonate.
| S-EPMC4066022 | biostudies-literature
Project description:ObjectiveTo investigate whether staffing levels of maternity units affect prelabor urgent, elective, and intrapartum cesarean delivery rates.MethodsThis population-based retrospective cohort study covers the deliveries of the 11 hospitals of a French perinatal network in 2008-2014 (N = 102 236). The independent variables were women's demographic and medical characteristics as well as the type, organization, and staffing levels for obstetricians, anesthesiologists, and midwives of each maternity unit. Bivariate and multivariate analyses were conducted with multilevel logistic models.ResultsOverall, 23.9% of the women had cesarean deliveries (2.4% urgent before labor, 10% elective, and 11.5% intrapartum). Independently of individual- and hospital-level factors, the level of obstetricians, measured by the number of full-time equivalent persons (i.e., 35 working hours per week) per 100 deliveries, was negatively associated with intrapartum cesarean delivery (adjusted odds ratio, aOR 0.55, 95% confidence interval, CI 0.36-0.83, P-value = 0.005), and the level of midwives negatively associated with elective cesarean delivery (aOR 0.79, 95% CI 0.69-0.90, P-value < 0.001). Accordingly, a 10% increase in obstetrician and midwife staff levels, respectively, would have been associated with a decrease in the likelihood of intrapartum cesarean delivery by 2.5 percentage points and that of elective cesarean delivery by 3.4 percentage points. These changes represent decreases in intrapartum and elective cesarean delivery rates of 19% (from 13.1% to 10.6%) and 33% (from 10.3% to 6.9%), respectively.ConclusionStaffing levels of maternity units affect the use of cesarean deliveries. High staffing levels for obstetricians and midwives are associated with lower cesarean rates.
| S-EPMC6261590 | biostudies-literature
Project description:BackgroundOur aim was to create and validate a nomogram predicting cesarean delivery after induction of labor among nulliparous women at term.MethodsData were obtained from medical records from Nanjing Drum Tower Hospital. Nulliparous women with singleton pregnancies undergoing induction of labor at term were involved. A total of 2950 patients from Jan. 2014 to Dec. 2015 were served as derivation cohort. A nomogram was constructed by multivariate logistic regression using maternal, fetal and pregnancy characteristics. The predictive accuracy and discriminative ability of the nomogram were internal validated by 1000-bootstrap resampling, followed by external validation of a new dataset from Jan. 2016 to Dec. 2016.ResultsLogistic regression revealed nine predictors of cesarean delivery, including maternal height, age, uterine height, abdominal circumference, estimated fetal weight, indications for induction of labor, initial cervical consistency, cervical effacement and station. Nomogram was well calibrated and had an AUC of 0.73 (95% confidence interval [CI], 0.70-0.75) after bootstrap resampling for internal validation. The AUC in external validation reached 0.67, which was significantly higher than that of three models published previously (P<0.05).ConclusionsThis validated nomogram, constructed by variables that were obtained form medical records, can help estimate risk of cesarean delivery before induction of labor.
| S-EPMC8783481 | biostudies-literature
Project description:OBJECTIVE:To assess whether a multiphase, departmental quality improvement effort decreases opioid prescribing and increases multimodal analgesic use after cesarean delivery. METHODS:This is a prospective quality improvement study. In phase 1 of the protocol, discharge providers implemented counseling regarding expectations for pain, typical need for opioids, and importance of multimodal nonopioid analgesic use and used shared decision-making to determine the number of opioids prescribed. Patients could select up to a maximum of 30 tablets of 5 mg oxycodone (or equivalent opioid), lower than the previous routine discharge prescription of 40 opioid tablets. The primary outcome was the mean (SD) number of opioid tablets prescribed on discharge with secondary outcomes including opioid refill rate within 30 days of discharge and rates of nonopioid analgesic prescriptions on discharge. In phase 2, using these results, we adjusted the protocol's maximum opioid prescription to 25 opioid tablets, but no other aspects of the protocol were changed. All data were analyzed with t test and ? analyses. RESULTS:Data from 624 women who underwent cesarean deliveries were analyzed. Opioids, most commonly oxycodone, were prescribed after 95% of all cesarean deliveries. The mean (SD) number of opioid tablets prescribed decreased from 33.2 (9.3) to 26.5 (6.7; P<.01) with the implementation of phase 1 having no effect on the opioid refill rate, 8.9% vs 8.1% (P=.79). These results allowed adjustment of the maximum recommended prescription to 25 opioid tablets, introducing phase 2 of the study, during which the mean (SD) number of opioid tablets prescribed further decreased from 24.9 (7.5) to 21.5 (6.3; P<.01) with no effect on the opioid refill rate, 6.3% vs 5.1% (P=.72). Overall, this represents a 35% decrease in opioid prescribing (P<.01). Rates of ibuprofen prescribing were 98% or higher throughout the study, but rates of acetaminophen prescribing increased from 32.6% before phase 1 to 92.0% after phase 2 (P<.001). CONCLUSION:Implementation of a multiphase quality improvement protocol to decrease opioid prescribing, combined with iterative review of discharge data, resulted in a significant decrease in the number of opioid tablets prescribed after cesarean delivery.
| S-EPMC6105442 | biostudies-literature
Project description:BackgroundPreterm birth remains a common cause of neonatal mortality, with a disproportionately high burden in low-income and middle-income countries. Meta-analyses of low-dose aspirin to prevent pre-eclampsia suggest that the incidence of preterm birth might also be decreased, particularly if initiated before 16 weeks of gestation.MethodsASPIRIN was a randomised, multicountry, double-masked, placebo-controlled trial of low-dose aspirin (81 mg daily) initiated between 6 weeks and 0 days of pregnancy, and 13 weeks and 6 days of pregnancy, in nulliparous women with an ultrasound confirming gestational age and a singleton viable pregnancy. Participants were enrolled at seven community sites in six countries (two sites in India and one site each in the Democratic Republic of the Congo, Guatemala, Kenya, Pakistan, and Zambia). Participants were randomly assigned (1:1, stratified by site) to receive aspirin or placebo tablets of identical appearance, via a sequence generated centrally by the data coordinating centre at Research Triangle Institute International (Research Triangle Park, NC, USA). Treatment was masked to research staff, health providers, and patients, and continued until 36 weeks and 7 days of gestation or delivery. The primary outcome of incidence of preterm birth, defined as the number of deliveries before 37 weeks' gestational age, was analysed in randomly assigned women with pregnancy outcomes at or after 20 weeks, according to a modified intention-to-treat (mITT) protocol. Analyses of our binary primary outcome involved a Cochran-Mantel-Haenszel test stratified by site, and generalised linear models to obtain relative risk (RR) estimates and associated confidence intervals. Serious adverse events were assessed in all women who received at least one dose of drug or placebo. This study is registered with ClinicalTrials.gov, NCT02409680, and the Clinical Trial Registry-India, CTRI/2016/05/006970.FindingsFrom March 23, 2016 to June 30, 2018, 14?361 women were screened for inclusion and 11?976 women aged 14-40 years were randomly assigned to receive low-dose aspirin (5990 women) or placebo (5986 women). 5780 women in the aspirin group and 5764 in the placebo group were evaluable for the primary outcome. Preterm birth before 37 weeks occurred in 668 (11·6%) of the women who took aspirin and 754 (13·1%) of those who took placebo (RR 0·89 [95% CI 0·81 to 0·98], p=0·012). In women taking aspirin, we also observed significant reductions in perinatal mortality (0·86 [0·73-1·00], p=0·048), fetal loss (infant death after 16 weeks' gestation and before 7 days post partum; 0·86 [0·74-1·00], p=0·039), early preterm delivery (<34 weeks; 0·75 [0·61-0·93], p=0·039), and the incidence of women who delivered before 34 weeks with hypertensive disorders of pregnancy (0·38 [0·17-0·85], p=0·015). Other adverse maternal and neonatal events were similar between the two groups.InterpretationIn populations of nulliparous women with singleton pregnancies from low-income and middle-income countries, low-dose aspirin initiated between 6 weeks and 0 days of gestation and 13 weeks and 6 days of gestation resulted in a reduced incidence of preterm delivery before 37 weeks, and reduced perinatal mortality.FundingEunice Kennedy Shriver National Institute of Child Health and Human Development.
| S-EPMC7168353 | biostudies-literature
Project description:BACKGROUND:Phenylephrine is the most commonly used vasopressor for prophylaxis against maternal hypotension during cesarean delivery; however, the best regimen for its administration is not well established. Although variable infusion protocols had been suggested for phenylephrine infusion, evidence-based evaluation of variable infusion regimens are lacking. The aim of this work is to compare variable infusion, fixed on-and-off infusion, and intermittent boluses of phenylephrine for prophylaxis against maternal hypotension during cesarean delivery. METHODS:A randomized controlled study was conducted, including full-term pregnant women scheduled for elective cesarean delivery. Participants were divided into three groups which received phenylephrine by either intermittent boluses (1.5 mcg/Kg phenylephrine), fixed on-and-off infusion (with a dose of 0.75 mcg/Kg/min), or variable infusion (with a starting dose of 0.75 mcg/Kg/min). The three groups were compared with regard to frequency of: maternal hypotension (primary outcome), second episode hypotension, reactive hypertension, and bradycardia. Other outcomes included heart rate, systolic blood pressure, physician interventions, and neonatal outcomes. RESULTS:Two-hundred and seventeen mothers were available for final analysis. The 2 infusion groups showed less incidence of maternal hypotension {26/70 (37%), 22/71 (31%), and (51/76 (67%)} and higher incidence of reactive hypertension compared to the intermittent boluses group without significant differences between the two former groups. The number of physician interventions was highest in the variable infusion group compared to the other two groups. The intermittent boluses group showed lower systolic blood pressure and higher heart rate compared to the two infusion groups; whilst the two later groups were comparable. CONCLUSION:Both phenylephrine infusion regimens equally prevented maternal hypotension during cesarean delivery compared to intermittent boluses regimen. Due to higher number of physician interventions in the variable infusion regimen, the current recommendations which favor this regimen over fixed infusion regimen might need re-evaluation.
| S-EPMC6827237 | biostudies-literature
Project description:BackgroundThe preventable premature mortality achievable by improvement in dietary quality at a global level is unclear.ObjectiveThe aim of this study was to assess dietary quality globally, and to quantify the potential global impact of improving dietary quality on population health.MethodsWe applied the Alternate Healthy Eating Index (AHEI, potential range 0-100) to a global dietary database to assess dietary quality among adults in 190 countries/territories. The relation of AHEI score to risks of major chronic disease was estimated from 2 large cohorts of men and women for whom many repeated dietary assessments during up to 30 years were available. We calculated the preventable premature deaths achievable by shifting from current national diets to a reference healthy diet.ResultsThe global mean AHEI score in 2017 was 49.5 for males and 50.5 for females. Large differences between current and target intakes existed for whole grains, sodium, long-chain n-3 polyunsaturated fats, polyunsaturated fats, and fruits. From 1990 to 2017, the global mean AHEI score increased modestly from 45.4 to 50.0. Diet quality varied substantially across the world. Coastal Mediterranean nations, the Caribbean region, and Eastern Asia (except China and Mongolia) had a higher AHEI score, whereas Central Asia, the South Pacific, and Eastern and Northern Europe had a lower score. An improvement in dietary quality from the current global diet to the reference healthy diet could prevent >11 million premature deaths, ?24% of total deaths in 2017. These included 1.6 million cancer deaths, 3.9 million coronary artery disease deaths, 1.0 million stroke deaths, 1.7 million respiratory disease deaths, 0.4 million neurodegenerative disease deaths, 0.5 million kidney disease deaths, 0.6 million diabetes deaths, and 1.2 million digestive disease deaths.ConclusionsGlobal dietary quality is slowly improving, but remains far from optimal and varies across countries. Improvements in dietary quality have the potential to reduce mortality rates substantially.
| S-EPMC6543201 | biostudies-literature
Project description:ObjectiveChina has a high cesarean delivery (CD) and low labor epidural analgesia (LEA) rate. This online survey was conducted to explore the reasons behind this phenomenon and potential solutions.MethodsA voluntary, anonymous survey was distributed via both WeChat and professional websites for 4 months amongst groups of Chinese perinatal professionals. Data was collected and analyzed using a Chi-square test and presented as percentages of respondents.Results1412 respondents were recorded (43% anesthesiologists, 35% obstetricians, 15.5% midwives or labor and delivery nurses, and 6.5% others), and 1320 respondents were care providers. It was found that 82.7% (1092/1320) of the provider respondents used CD per patient request in fear of lawsuits or yinao/yibao and 63.4% (837/1320) used CD for respecting superstitious culture. The number one reason (noted by 60.2% (795/1320) of all the three specialties) for low LEA use was lack of anesthesia manpower without statistical difference among specialties. The most recommended solution was increasing the anesthesia workforce, proposed by 79.8% (1053/1320) of the three specialties. However, the top solution provided by the two non-anesthesia specialties is different from the one proposed by anesthesiologists. The later (83%, 504/606) suggested increasing the incentive to provide the service is more effective. The answers to questions related to medical knowledge about CD and LEA, and unwillingness of anesthesiologists, parturients and their family members to LEA were similar for the most part, while the opinions regarding low LEA use related to poor experiences and unwillingness of obstetricians and hospital administrators were significantly divided among the three specialties. In the providers' point of view, the unwillingness to LEA from parturient's family members was the most salient (26.1%, 345/1320), which is more than all care providers, hospital administrators, and parturients themselves (16.8%, 222/1320).ConclusionThe reasons for high CD rate and low LEA use are multifactorial. The sociological issues (fear of yinao/yibao and superstitious culture) were the top two contributing factors for the high CD rate in China, while lack of anesthesia manpower was the top response for the low LEA use, which contributes to its being the most recommended solution overall from the three specialties. An incentive approach to providers is a short-term solution while training more perinatal care providers (especially among anesthesiologists and midwives), improving billing systems, and reforming legal systems are 3 systemic approaches to tackling this problem in the long-term.
| S-EPMC8139447 | biostudies-literature