Definition and adjustment of Cesarean section rates and assessments of hospital performance.

BACKGROUND: Demand is growing for comparative data such as Cesarean section rates, but little effort has been made to develop either standardized definitions 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 definitions 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 specifications for their Cesarean section indicators. Indicator specifications varied on inclusion criteria (whether the population was defined 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 definitions and indicators with and without risk adjustment. RESULTS: Calculated Cesarean section rates changed substantially depending on how the numerator and denominator cases were identified. Relative performance based on Cesarean section rankings is affected less by differing indicator definitions 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 definition and standard risk adjustment methodology is needed.

A randomized, controlled trial of an attending staff service in general internal medicine.

This study, a prospective, randomized trial comparing two inpatient staffing models, was undertaken to compare clinical and financial outcomes for general medicine inpatients assigned to resident (teaching) or staff (nonteaching) service. Key outcome measures included: 1) length of stay; 2) total charges; 3) laboratory, radiology, pharmacy, and supplies charges; 4) in-hospital mortality and mortality within 6 months of admission; and 5) 15-day readmission rate. The study took place at Henry Ford Hospital, a 937-bed urban teaching hospital in Detroit, Michigan; the subjects included all general internal medicine patients admitted to a single nursing unit of Henry Ford Hospital between October 1, 1987 and September 30, 1988. When the unit was fully staffed and operational, patients admitted to the Staff Service had a 1.7-day lower average length of stay than patients admitted to the Resident Service (P greater than 0.005), lower average total charges of $1,681 (P greater than 0.01), and significantly lower laboratory and pharmacy charges. No statistically significant differences in mortality rates or readmission rates were found. Even though personnel costs are invariably higher on an attending service, this staffing arrangement can be financially viable because of more efficient patterns of care. Shorter length of stay may be translated either into cost savings or increased revenues in order to offset higher salary costs. Teaching hospitals may wish to consider an attending service as one way to reduce house officer work loads, offer more opportunities for training in ambulatory settings, and adjust to a smaller pool of applicants for residency positions.