Cesarean Delivery Rates Vary Tenfold Among US Hospitals; Reducing Variation May Address Quality and Cost Issues

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Cesarean delivery (CD) is the most common operation in US hospitals, with rates increasing from 20.7% to 32.8% between 1996 and 2011 and often attributed to a higher incidence of conditions requiring CD and physicians’ concerns about liability and malpractice. Cesarean delivery is much more costly than vaginal delivery, and the adverse outcomes and complications have large implications for delivery systems and health insurers. The Healthy People 2020 initiative recommends a 10% reduction in both primary and repeat CD rates, from 26.5% to 23.9% and from 90.8% to 81.7%, respectively. An approach to reaching these goals might focus on hospitals with exceptionally high CD rates. Because no prior study has reported hospital-level variations in CD rates using recent, nationally representative data, this analysis was undertaken using 2009 data from 1050 hospitals in 44 states.

A total of 675 hospitals reported 1 or more discharges with neonatal or maternal diagnoses and procedures; 82 hospitals with less than 100 deliveries were excluded. The final data set included 817,318 deliveries at 593 hospitals. The main outcomes were overall CD rates and CD rates for lower-risk deliveries. Each hospital’s CD rate was calculated as the percentage of all deliveries that were CDs. The lower-risk CD rate represented the rate of CDs for women with term, singleton, vertex pregnancies, and no history of CD. The rates of CDs and lower-risk CDs across all hospitals were stratified by hospital bed size, teaching status, and geographic location. For each stratum, minimum, maximum, and mean rate values and interquartile ranges were determined.

The mean hospital-level rate of CD was 32.8% with a range from 7.1% to as high as 69.9%. The mean rate of CD in lower-risk women was 12.0% also with a wide range from as low as 2.4% to as high as 36.4%. Small (n = 131; 22%), medium (n = 179; 30%), and large hospitals (n = 270; 48%) averaged 581, 1151, and 1926 deliveries, respectively. The mean hospital-level overall CD rates were 32.0%, 32.3%, and 33.4% for small, medium, and large hospitals, respectively; however, rates varied widely within each category. The mean lower-risk CD rates followed a similar pattern with comparable mean rates across all hospital categories (12.1%, 11.9%, and 12.0%, respectively) with a wide range.

This wide range in rate of cesarean indicates that there may be a way to reduce such variability. The methods to do this are unclear and require further investigation.

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