International Journal for Quality in Health Care 1999; Volume 11, Number 4: pp.

283291
Denition and adjustment of Cesarean
section rates and assessments of hospital
performance
STEPHEN B. KRITCHEVSKY
1
, BARBARA I. BRAUN
2
, PETER A. GROSS
3
, CAROL S. NEWCOMB
2
,
CAROL ANN KELLEHER
2
AND BRYAN P. SIMMONS
4
1
Department of Preventive Medicine, University of Tennessee, Memphis,
2
Department of Research and Evaluation, Joint Commission
on Accreditation of Healthcare Organizations, Oakbrook Terrace, Illinois,
3
Department of Internal Medicine, Hackensack University
Medical Center, New Jersey, and
4
Quality Management, Methodist Health System, Memphis, Tennessee, USA
Abstract
Background. Demand is growing for comparative data such as Cesarean section rates, but little effort has been made to
develop either standardized denitions or risk adjustment approaches.
Objective. To determine to what extent a seemingly straightforward indicator like Cesarean section rate will vary when
calculated according to differing denitions used by various performance measurement systems.
Design. Retrospective data abstraction of 200 deliveries per hospital.
Setting. Fifteen acute care hospitals including two from outside the USA.
Measurements. Four widely-used performance measurement systems provided specications for their Cesarean section
indicators. Indicator specications varied on inclusion criteria (whether the population was dened using Diagnostic Related
Groups or ICD-9-CM procedure codes or ICD-9-CM diagnosis codes) and risk-adjustment methods and factors. Rates and
rankings were compared across hospitals using different Cesarean section indicator denitions and indicators with and
without risk adjustment.
Results. Calculated Cesarean section rates changed substantially depending on how the numerator and denominator cases
were identied. Relative performance based on Cesarean section rankings is affected less by differing indicator denitions
than by whether and how risk adjustment is performed.
Conclusions. Judgments about organizational performance should only be made when the comparisons are based upon
identical indicators. Research leading to a uniform indicator denition and standard risk adjustment methodology is needed.
Keywords: Cesarean section, hospitals, risk, statistics
Nearly every health care organization is asked by payers, analysis and reporting [2,3]. One of the most commonly
reported performance measures is the rate of Cesarean sec- purchasers, business coalitions, consumer groups, accrediting
bodies, and/or government agencies to provide clinical per- tions. In the USA, the Cesarean section rate rose precipitously
during the 1980s and remains much higher in this country formance measure data [1]. Hundreds of performance
measurement systems exist to help process this data into than in others [4]. Large variations in individual physicians
rates of performance suggest that a percentage of Cesarean information used to make inter-hospital comparisons. Al-
though many different systems support indicators that os- sections are done for reasons other than medical necessity.
Cesarean sections are relatively more expensive than vaginal tensibly measure the same clinical occurrence, they often use
different specications for event denition, data collection, deliveries and safely reducing the rate would be expected to
Address correspondence to Stephen B. Kritchevsky, Department of Preventive Medicine, University of Tennessee, 66 North
Pauline, Suite 633, Memphis TN 38105, USA. Tel: +1 901 448 8757. Fax: +1 901 448 7641. E-mail: skrit-
chevsky@utmem1.utmem.edu. Address requests for reprints to Barbara I. Braun, Department of Research and Evaluation,
Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd, Oakbrook Terrace IL 60181, USA.
Tel: +1 630 792 5928. Fax: +1 630 792 4928. E-mail: bbraun@jcaho.org
1999 International Society for Quality in Health Care and Oxford University Press 283
S. B. Kritchevsky et al.
yield substantial cost savings [5]. A Cesarean section rate has indicators were identical, thus four indicators are compared
herein. Measurement systems agreed to participate under high face validity and is considered easy to measure as its
determinants can be derived from administrative data. Based the condition of anonymity: therefore, the systems are not
specically identied. The sponsors of these systems included on the premise that release of Cesarean section rate in-
formation will help make providers accountable for the quality the United States government, state-hospital associations, and
a private system. Each of these systems provided spe- of care and allow users of information to compare quality
and cost across providers, comparative Cesarean section data cications for their indicator denitions and algorithms. Two
of the systems agreed to apply their risk adjustment models has been released by organizations such as the Public Citizens
Health Research Group and the New England HEDIS Co- directly to the study data. Indicator specications and risk
adjustment models used in this study may not be identical alition [6,7].
The apparent simplicity of the Cesarean section rate, to those currently used by the measurement system because
the systems may have revised their specications since the however, can be deceptive. Though many performance
measurement systems include Cesarean section rates in their study was conducted.
list of indicators, there is little consistency across these systems
in the specications of how to calculate the rate. There are
Data collection
differences in how the population is dened (i.e. who is
Indicator specications from each system were consolidated
included and excluded) and in the application of risk ad-
into a single data collection form with instructions for a data
justment methodologies. For example, the overall rate re-
collection process that would accommodate the analyses
ported by the National Center for Health Statistics is not
needed for each system. Most of the data elements were
risk adjusted. On the other hand, several investigators re-
available from administrative data except for parity and a
commend the use of sophisticated risk-adjusted models which
history of Cesarean section. Sites were instructed to collect
explain a high percentage of the variation in Cesarean section
the most recent 200 deliveries, or for sites where fewer than
rates using patient factors [810]. Aron et al. have recently
200 deliveries occurred in a year, to collect the total number
used a risk adjustment algorithm developed for their study
of deliveries over the course of the study year (September
to compare hospital performance in a sample of 21 Cleveland
1994 to August 1995). Two sites used a sampling approach
area hospitals [10]; risk adjustment led to marked differences
that the project had used in its study of peri-operative
in hospital rankings.
mortality. In this approach, all Cesarean section cases were
The impact of differing denitions and risk adjustment
sampled as was a random sample of non-cases. The sampling
strategies on Cesarean section rates has not been formally
fractions for non-Cesarean section deliveries were 19% and
evaluated. The objective of this study was to determine
68% for the two hospitals.
whether Cesarean section rates as dened by different com-
parative measurement systems would lead to similar rates
Data analysis
and rankings among hospitals. If currently used denitions
are inconsistent, then judgments concerning hospital and
Separate programs were written for the indicator algorithms
health plan performance may be unreliable based on currently
according to the performance measurement systems spe-
available measures.
cications using statistical software (SAS, SAS Institute, Inc.,
Cary NC, USA). Rates at the hospitals that employed sampling
were calculated after weighting records by the inverse of their
Methods sampling fraction.
Unadjusted rates were calculated for each system. The risk
This study is part of a ongoing collaboration between the adjusted rate for systems B and D used logistic regression
Society for Healthcare Epidemiology of America (SHEA) models to calculate the ratio of the hospitals observed rate
and the Joint Commission on Accreditation of Healthcare to the hospitals predicted rate (O/P) multiplied by the overall
Organizations intended to support the effective use, de- rate for that systems measure. The systems overall rate was
velopment, understanding and continuous improvement of based on the hospitals that routinely provided data to the
clinical quality indicators [11,12]. A mailed survey was sent system, not the hospitals participating in this study. The
to a volunteer sample of SHEA hospital epidemiologists in consistency of rankings across systems was assessed using
April of 1995 asking which indicator focus areas they would Spearmans rank correlation coefcient.
prefer to study based on salience to their institution. Based For unadjusted rates, outlier hospitals were identied after
on the results of this survey, three clinical areas were identied: constructing 95% condence intervals (CI) around the sys-
Cesarean section, peri-operative mortality and mortality after tems average rate. If the hospitals overall rate was outside
coronary artery bypass graft surgery. This paper describes the of these limits, the hospital was identied as an outlier. The
ndings related to the Cesarean section indicators; in- formula used for calculating the 95% CI for proportions (p)
formation on the other two clinical areas is forthcoming. was
Before the project began, performance measurement sys-
tems with indicators of interest to the study were identied. CI=p(1.96 SE)
Five had Cesarean section indicators in current use and
consented to cooperate with the study. Two of the ve where the standard error (SE)=([p(1p)/n] [13].
284
Cesarean section rate variation
Table 1 Characteristics of the study hospitals associated with deliveries (370375). System B used only
procedure codes to identify cases, System C used only V
codes (V27.0V27.9) to identify deliveries and System D
Characteristic n %
............................................................................................................
used both ICD-9-CM diagnosis codes and V codes to identify
Bed size
deliveries. V codes are dened as a supplementary classi-
< 249 1 6.7
cation of factors inuencing health status and contact with
250499 6 40.0
health services to deal with occasions when circumstances
500749 5 33.3
other than a disease or injury classiable to categories 001999
7501000 3 20.0
are recorded as diagnoses or problems [15].
Location
The net effect of the differing numerator and denominator
Urban 13 86.7
denitions on Cesarean section rates for the aggregate of the
Rural 2 13.3
15 study hospitals is shown in Table 3. System Ds denition
Level of obstetrical care
was more inclusive that the other systems and identied
1 2 13.3
the greatest number of cases for both the numerator and
2 5 33.3
denominator. Compared with Systems B and A, the number
3 8 53.3
of cases had little or no net overall effect on the mean
Teaching hospital
Cesarean section rate across hospitals. The last column in
Member of Council of Teaching Hospitals 6 40.0
Table 3 shows the rates after adjustments by Systems B and
Non-member with education 1 6.7
D. Both B and D employed logistic regression models that
Not a teaching hospital 8 53.3
accounted for selected diagnosis codes, age of the mother,
Ownership
and payer. System D also included parity, race of the mother,
Government, non-federal 2 13.3
and history of Cesarean section as adjusting variables. After
Non-government, not-for-prot 9 60.0
risk adjustment the mean rates for Systems B and D showed
Investor-owned/for prot 2 13.3
different patterns. The overall adjusted rate rose with System
Government, Federal 1 6.7
B and fell with System D.
Location
Five hospitals coded fewer than 30 cases using V codes
East 4 26.7
to indicate normal deliveries; therefore their rates for System
Midwest 2 13.3
C could not be calculated. When the same subset of the
South/Southeast 7 46.7
other 10 hospitals is used to compare the other systems to
Other countries 2 13.3
System C, System C has 1314% fewer cases in the population
than other systems. Relatively more Cesarean sections were
excluded compared with vaginal births. The net effect was a
For adjusted rates, performance measurement systems B and
slightly lower Cesarean section rate in System C (20.9%
D designated hospitals as outliers as part of their processing
overall) compared with the other systems (A, 21.7%; B,
of the study data.
21.3%; D, 21.5%) in the subset.
Hospital rates and rank order
Results
Table 4 presents the unadjusted Cesarean section rates cal-
Characteristics of participating hospitals
culated using the algorithms specied by the different per-
Fifteen of 26 participating sites gathered Cesarean section formance measurement systems using the same raw data.
data. Table 1 shows the demographic characteristics of the
Though the systems rates were correlated with one another
participating hospitals. The average hospital size was 537
[all Spearman rank correlations (r
s
) between 0.91 and 0.98],
beds (SD=262) with only one considered small and most
there were differences in rates that could be attributed to
considered medium to large. Participating hospitals tended
differences in indicator specications. The last column in the
to be larger than the mean for the USA hospital population
table shows the maximum percentage difference (MPD)
[14]. They also provided more tertiary care; approximately
between the system that yields the lowest rate and the one
half the hospitals had neonatal intensive care units. The
that yields the highest rate. The MPDs ranged from 0 to
hospitals were located predominantly in the Eastern and
47.2%; the median was 4.9%. It did not appear that one
Southern USA. Two of the hospitals were located overseas.
particular system was consistently discrepant with the other
systems. The largest MPDs involved System As indicator
Overall system rates
three times, System Bs indicator twice, and Systems C and
Ds indicators once each. Each system used a different approach to dene Cesarean
The relative rankings of hospitals within indicator systems section rates (see Table 2). Systems B, C, D specied the
are shown in parentheses in Table 4. As only 10 hospitals numerator Cesarean sections using ICD-9-CM procedure
were included in System C, its rankings are not directly codes, while system A used Diagnostic Related Group (DRG)
comparable with those of the other systems. When a common categories 370 or 371 only. There was greater variety in the
specication of the denominator. System A used the DRGs subset of just these 10 hospitals was examined, System
285
S. B. Kritchevsky et al.
Table 2 Numerator and denominator specications for four Cesarean section rate indicators
Performance
measurement Patient population
system Numerator (denominator)
............................................................................................................................................................................................
A DRG 370, 371 DRG 370375
B Procedure codes: Procedure codes: 72.0, 72.1, 72.21, 72.29, 72.31, 72.39,
74.0, 74.1, 74.2, 72.4, 72.51, 72.53, 72.54, 72.6, 72.71, 72.79, 72.8, 72.9;
74.4, 74.99 73.22, 73.51, 73.59, 73.6; 74.0, 74.1, 74.4, 74.99
C Procedure codes: 74.0, Diagnosis codes: V27.0V27.9
74.1, 74.2, 74.4, 74.99
D Procedure codes: Diagnosis codes: 640.81669.92 or V27.0V27.9
74.0, 74.1, 74.2,
74.4, 74.99
Table 3 Mean Cesarean section rates by performance measurement system
Performance Unadjusted Adjusted
measurement overall rates overall rates
system Numerator Denominator Mean (range) Mean (range)
.................................................................................................................................................................
A 790 3392 23.3 (9.636.6) Not applicable
B 789 3372 23.4 (9.636.6) 25.0 (18.335.3)
C 455 2181 20.9 (9.629.6) Not applicable
D 804 3436 23.4 (9.633.7) 21.4 (18.638.5)
Table 4 Comparison of unadjusted hospital Cesarean section rates and rankings (in
parentheses) as calculated by four different Cesarean section indicators
Hospital System A System B System C System D MPD
1
............................................................................................................................................................
103 15.1 (3) 14.0 (2)
2
16.1 (3) 15.0
105 19.1 (5) 20.1 (6) 20.0 (4) 20.0 (5) 5.2
106 14.9 (2) 14.9 (3) 14.2 (3) 14.2 (2) 4.9
107 32.5 (13) 33.3 (13) 33.2 (14) 2.5
108 18.7 (4) 18.1 (4) 12.7 (2) 18.2 (4) 47.2
109 33.7 (14) 33.7 (14) 33.7 (15) 0
110 29.7 (12) 31.2 (12) 29.6 (10) 31.0 (12) 5.4
111 23.0 (6) 26.5 (9) 26.4 (9) 15.2
115 23.0 (7) 19.4 (5) 23.4 (7) 23.5 (8) 21.1
116 23.1 (8) 23.4 (8) 23.2 (6) 23.1 (7) 1.3
117 25.1 (9) 21.8 (7) 22.2 (5) 21.6 (6) 16.2
119 26.4 (10) 27.2 (10) 27.2 (8) 26.6 (10) 3.0
120 28.3 (11) 28.1 (11) 28.9 (9) 28.1 (11) 2.8
123 9.6 (1) 9.6 (1) 9.6 (1) 9.6 (1) 0
126 36.6 (15) 36.6 (15) 31.7 (13) 15.5
Overall rate 23.3 23.4 20.9 23.4 12.0
1
Maximum percentage difference was calculated as the highest rate minus the lowest rate divided
by the lowest rate for each hospital.
2
Rate not calculated because there were fewer than 30 cases in the denominator.
Cs ranks were identical to those derived from System D System C, the maximum number of differences in ranks
between systems was three (hospitals 111, 115 and 117) and (unadjusted), except that hospitals 106 and 108 were reversed.
In general, there was a fair amount of consistency in relative ve hospitals were ranked identically across the three systems.
Figure 1 shows the comparison of the unadjusted and risk- ranking of hospitals across indicator systems. Excluding
286
Cesarean section rate variation
adjustment between the two systems. For example, the hos-
pitals that experienced the biggest change in rank due to risk
adjustment in System B were not affected much by risk
adjustment in System D. Conversely, the hospital with the
largest change in rank in System D was unaffected by
adjustment in System B.
Outlier status
Table 5 shows which hospitals were identied as low or high
outliers on the calculated rates. For two of the four systems
(A and B), there was very good consistency in determining
outlier status using the unadjusted data. System C agged
two additional hospitals as outliers due to the lower overall
Cesarean section rate calculated. System D failed to ag two
hospitals that were agged by systems A and B, and also
agged one of the additional hospitals agged by system C
(hospital 120). More than one-half of the hospitals were
agged by at least one system when using unadjusted data.
Using adjusted data, System B identied two high outliers
and three low outliers. Four of these had similar status using
unadjusted data, but one hospital (105) was identied as a
low outlier only after risk adjustment. The risk-adjusted data
for system D agged four high outliers and no low outliers.
Three of the four high outliers had been agged in the
unadjusted data as well. Using risk-adjusted data, Systems B
and D identied only two hospitals in common out of the
seven agged by either system.
Figure 1 A comparison of the effect of risk adjustment on
reported Cesarean section rates between two performance
Discussion measurement systems. Solid lines connect unadjusted to
adjusted rates for a hospital. Dashed lines connect the un-
Our study calculated Cesarean section rates for 15 hospitals. adjusted rates between the systems.
We processed the same data through the numerator and
denominator specications used by ve different performance
measurement systems. The differences in specications led
adjusted rates for the two systems, B and D, that provided
to differences in rates of up to 47.2%. Risk adjustment used
risk-adjusted Cesarean section rates. Within systems the
by two of the ve systems led to larger differences in both
adjusted rates were moderately correlated with the unadjusted
rates and relative rankings. Risk adjustment did not affect all rates (r
s
=0.69 and 0.65 for Systems B and D, respectively).
hospitals in the same direction or to the same degree. The In both systems, more than 25% of the hospitals changed
overall study Cesarean section rate varied between 21.0% at least 4 ranks following adjustment. For System B, two
and 25.0%, depending on denition. These rates are slightly hospitals changed 7 ranks and one changed 6. For System
higher than the national statistics. The Centers for Disease D, risk adjustment caused one hospital to change 9 ranks
Control and Prevention report the national rate for 1995 to and another to change 7 ranks.
be 20.8 per 100 deliveries from the 1995 National Hospital Because adjusted rates are calculated relative to the average
Discharge Survey [16]. The national rate is based on primary Cesarean section rate for all the hospitals submitting data to
medical record abstraction of a nationally representative that system and not to the hospitals in this study, the absolute
sample of 29 000 inpatients discharged from 466 participating values of the risk-adjusted rates cannot be strictly compared
hospitals. between systems. However, given the similarities in risk
The differences in unadjusted rates can be attributed to adjustment methodologies used by Systems B and D, it is
differences in numerator and denominator denitions and to interesting to compare the rankings after risk adjustment
differences in coding practices by the individual hospitals. between the two systems. Overall, the adjusted rates from
According to the U.S. Department of Health and Humans the two systems were moderately correlated (r
s
=0.61), but
Services, guidelines for coding and reporting using the Inter- there was more disparity in relative rankings after risk ad-
national Classication of Diseases, 9th Revision, Clinical Modication justment than before. Eight hospitals differed by 1 rank or
(ICD-9-CM), codes in the chapter Complications of Preg- less, ve hospitals differed by 35 ranks and two hospitals
nancy, Childbirth and the Puerperium (630677) are required differed by 8 or more ranks after risk adjustment. Important
inconsistencies were noted in the relative effect of risk for every delivery. A V code for the outcome, V27.0V27.9,
287
S. B. Kritchevsky et al.
Table 5 Comparison of outlier status across Cesarean section indicators
Before risk adjustment After risk adjustment
............................................................................................................. ......................................................
Hospital System A System B System C System D System B System D
.......................................................................................................................................................................................................
103 L L N I I I
105 I I I I L I
106 L L L L I I
107 H H N H I I
108 L L L I L I
109 H H N H I H
110 H H H H H H
111 I I N I I I
115 I I I I I I
116 I I I I I I
117 I I I I I I
119 I I H I I I
120 I I H H I H
123 L L L L L I
126 H H N H H H
H, High outlier; L, low outlier; I, inlier; N, insufcient data.
should also be included on every maternal record when a system, the specications for the Cesarean section rate in-
dicator provide different options for identifying the de- delivery has occurred [15]. Our ndings, albeit from a small
group of hospitals, suggest that this coding convention is nominator population, thus leaving the approach to the
discretion of health care organizations. Since the choice of not universally followed.
The disparity between adjusted and unadjusted rates and denominator can lead to noticeable differences in reported
rates, consumers and other users of this information cannot resultant rankings was expected and has been observed by
others looking at a variety of patient outcomes including be assured of fair, meaningful comparisons.
There remains controversy regarding the scientic validity Cesarean section rates [10]. Iezzoni et al. demonstrated that
the application of differing algorithms for risk adjustment and usefulness of report cards in general [2326]. One popular
feature of many report cards is the identication of statistical also effects rankings [1719]. Hartz et al. [20] found that
inaccurate coding practices can articially raise risk-adjusted outliers. The theory behind outliers is that the outlying rates
are unlikely to be due to random variation, and therefore mortality rates. Romano and Mark found that errors in the
elds of admission source and type biased the estimation of reect some real difference in practice of the outlying or-
ganization compared with other institutions. By implication, risk adjusted mortality more than underreporting of com-
orbidities [21]. Coding issues are a particular problem for hospitals and the physicians practicing at them are held
accountable. Risk adjustment is intended to make this process public hospitals whose reimbursement may be minimally
affected by coding practices. fairer by allowing for differences in patient populations that
both determine the Cesarean section risk and cannot be The fact that variation in indicator specications leads to
differences in calculated rates suggests that standardization controlled by the organization. In the current study, risk
adjustment led to the identication of fewer outliers than of denitions for commonly used performance indicators
should be a high priority. To our knowledge, no national did unadjusted rates. However, there were inconsistencies
between the hospitals agged by the two risk-adjusted in- standardized specications for calculating a Cesarean section
rate exist. The National Center for Health Statistics reports dicators.
The ndings of this project also demonstrate that the their methodology for calculating Cesarean section rates as
including procedure codes 74.074.2, 74.4 and 74.99 in the decision to compare performance based on outliers as op-
posed to rankings will affect the judgments about hospital numerator and the denominator as V27.0V27.9, though the
codes and algorithm have not been widely distributed to date performance. The use of statistically signicant outlier status
is affected both by sample size and by effect size (e.g. how [22].
The need for standardization is even more urgent when different the rate was from the overall mean). Rankings, on
the other hand, may overestimate the magnitude of differences one realizes that current clinical performance comparisons
are based on any number of denitions of Cesarean section between organizations. For example, hospitals with similar
rates (e.g. 20.0, 20.3, 20.4 and 20.5) may be ranked 6, 7, 8 rates. For example, in at least one comparative indicator
288
Cesarean section rate variation
Figure 2 Examples of factors that affect indicator rates.
and 9 with a difference in rank of 3 but a difference in rate that the data came from a relatively small number of hospitals.
Differences among hospitals in data collection procedures of 0.5.
It is important to remember that this study was not may have affected indicator rates. Future studies should
evaluate the additional contribution to the indicator variation designed to judge the participating performance measurement
systems, their indicators or the hospitals participating in the introduced by data collection practices.
This study focused on variation in indicator specications, study. Since there are no consensus-based external criteria
for the validity of indicators or performance measurement but there are many other factors that inuence a given
indicator rate. These include organization-related factors (e.g. systems, one cannot conclude that one indicator is superior
to another (except perhaps, to the extent that one is more equipment, systems of care, practitioner skill, completeness
and accuracy of data collection) and external factors such as in concert with coding guidelines) or that certain hospitals
were good or poor performers. The data further suggest that severity of illness and random variation (Figure 2). For an
indicator to be a useful guide in quality improvement activities, using an outlier criteria based on unadjusted data may be
of little use in identifying improvement opportunities. Thus, it must reliably index organizational factors, i.e. those that
can be controlled by the organizations being compared. the ndings support the need for additional research and
consensus on criteria for establishing the validity of indicators Additional research needs to be done to examine both the
organizational factors and external factors that inuence in order to judge which measures are best. For example, a
study could be designed to test which indicator specications Cesarean section rates.
In summary, there is a need for standardization of the best identify organizations or individual patient records in
which the care needs to be improved. This may be where specications for calculating Cesarean section rates, par-
ticularly when these rates are used for comparative purposes. the benets of risk adjustment on patient factors are most
apparent, e.g. not agging cases which received appropriate It is essential to dene carefully how to identify cases for
the numerator and denominator and whether or not risk care or those in which practitioners and organizations could
not have inuenced the mode of delivery. adjustment is required. If risk adjustment is required, it will
be important to establish which factors are appropriate to Strengths of this demonstration project include the in-
volvement of hospital epidemiologists in the data collection include in risk adjustment models. Despite the inconsistencies
between measurement systems demonstrated here, the in- process and the variety of hospital sizes and locations in-
cluded. This study is unique in being able to disentangle dicators as currently dened may well be useful to or-
ganizations for monitoring and improving their own differences due to indicator denition versus those due to
risk adjustment. A limitation of the project includes the fact performance over time [27].
289
S. B. Kritchevsky et al.
11. Kritchevsky SB, Simmons BP, Braun BI. The project to monitor
Our results suggest that health care organizations should
indicators: a collaborative effort between the Joint Commission
carefully consider indicator-related factors when selecting a
on Accreditation of Healthcare Organizations and the Society
performance measurement system and when comparing
for Healthcare Epidemiology of America. Infect Control Hosp
results across organizations. The indicator specications for
Epidemiol 1995; 16: 3335.
something as simple as a Cesarean section rate need to be
articulated and carefully implemented before the results can
12. Simmons BP, Schyve PM. SHEA and JCAHO: Partners in
be used appropriately for making comparative judgments of
science. Infect Control Hosp Epidemiol 1995; 15: 56.
health care provider performance. Given the widespread
demand for external release of outcome data from hospitals
13. Sempos CT, Kahn HA. Statistical Methods in Epidemiology. New
by insurers, employers, legislators, consumer advocates, regu-
York: Oxford University Press, 1989.
latory agencies, accrediting bodies and many others, there is
a serious need for further education on factors that inuence 14. American Hospital Association. Hospital Statistics: Emerging Trends
in Hospitals, 199596 Edition. Chicago: American Hospital As-
and potentially confound the reported rates.
sociation, 1995.
15. Illustrated ICD-9-CM Code Book, Volumes 1,2,3, 1998. Reston VA:
Acknowledgments
St. Anthony Publishing, Inc., 1997.
This study received nancial support from the Methodist
16. Curtin SC, Kozak LJ. Cesarean delivery rates in 1995 continue
Hospitals Foundation, Memphis, TN, USA. The authors
to decline in the United States. Birth 1997; 24: 194196.
gratefully acknowledge PMI executive committee members
Jerod Loeb PhD, Alfred Buck MD, Paul Schyve MD and 17. Iezzoni LI, Ash AS, Schwartz M et al. Judging hospitals by
severity-adjusted mortality rates: the inuence of the severity- Ronald Shorr MD for their advice during the study and for
adjustment method Am J Public Health 1996; 86: 13791387.
manuscript review. Thanks also to Mary Ellen Baruch for
assistance with algorithm programming and data analysis.
18. Iezzoni LI, Schwartz M, Ash AS et al. Using severity-adjusted
stroke mortality rates to judge hospitals. Int J Qual Health Care
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Cesarean section rate variation
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Appendix
J. John Weems Jr. MD, Richard Rose III, MD, John Adams
MD, Fred Barrett MD, William Scheckler MD, Michael Climo
Society for Healthcare Epidemiology of America (SHEA)
MD, Kenji Kono MD, Ziad Memish MD and Z. Ahmed
member epidemiologists from hospitals participating in the
Quraishi, PhD.
PMI Study Group included: Brian Cooper MD, Maureen
Theroux EdD, RN, James Steinberg MD, Louis Katz MD,
Sharon Welbel MD, August Valenti MD, Mark Keroack MD,
Jo Wilson MD, Peter Gross MD, Isabel Guererro MD, Larry Accepted for publication 7 April 1999
291