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Impact of risk-adjusting cesarean delivery rates when reporting hospital performance.

CONTEXT
Hospitals and health plans are often ranked on rates of cesarean delivery, under the assumption that lower rates reflect more appropriate, more efficient care. However, most rankings do not account for patient factors that affect the likelihood of cesarean delivery.


OBJECTIVE
To compare hospital cesarean delivery rates before and after adjusting for clinical risk factors that increase the likelihood of cesarean delivery.


DESIGN
Retrospective cohort study.


SETTING
Twenty-one hospitals in northeast Ohio.


PATIENTS
A total of 26127 women without prior cesarean deliveries admitted for labor and delivery from January 1993 through June 1995.


MAIN OUTCOME MEASURES
Hospital rankings based on observed and risk-adjusted cesarean delivery rates.


RESULTS
The overall cesarean delivery rate was 15.9% and varied (P<.001) from 6.3% to 26.5% in individual hospitals. Adjusted rates varied from 8.4% to 22.0%. The correlation between unadjusted and adjusted hospital rankings (ie, 1-21) was only modest (R=0.35, P=.12). Whereas 7 hospitals were classified as outliers (ie, had rates higher or lower [P<.05] than overall rate) on the basis of both unadjusted and adjusted rates, outlier status changed for 5 hospitals (24%), including 2 that changed from outliers to nonoutliers, 2 that changed from nonoutliers to outliers, and 1 that changed from a high outlier to a low outlier.


CONCLUSIONS
Cesarean delivery rates varied across hospitals in a single metropolitan region. However, rankings that fail to account for clinical factors that increase the risk of cesarean delivery may be methodologically biased and misleading to the public.