Obstetric services and quality among critical access, rural, and ...

Policy Brief June 2013

Obstetric Services and Quality among Critical Access, Rural, and Urban Hospitals in Nine States Katy Kozhimannil PhD, MPA; Peiyin Hung MSPH; Maeve McClellan BS; Michelle Casey MS; Shailendra Prasad MBBS, MPH; and Ira Moscovice PhD Key Findings • Women who gave birth in Critical Access Hospitals (CAHs) and other rural hospitals in 2010 were younger on average and had lower rates of clinical complications than those who gave birth in urban hospitals. • CAHs compared favorably with other rural and urban hospitals on obstetric care quality measures including cesarean delivery among low-risk women, cesarean delivery without medical indication, and labor induction with medical indication. • Medicaid covered 49 percent of births in CAHs and 56 percent of births in other rural hospitals, compared to 41 percent of births in urban hospitals. • The percentage of CAHs, other rural hospitals, and urban hospitals providing obstetric services in 2010 varied significantly across states, with the greatest variation among CAHs. • Half of the CAHs in this study’s sample provided obstetric services in 2010, likely a higher rate than all CAHs nationwide due to the selection criteria for the sample.

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Background

Motivated by concerns about the closure of obstetric units in rural hospitals and limited availability of obstetric care providers in rural areas, much contemporary research on rural obstetric care has focused on access and workforce issues.1-4 Increasingly, health policy is focused on measurement and improvement of obstetric care quality in U.S. hospitals, including an obstetric care patient safety initiative by the National Partnership for Patients. The Joint Commission adopted a new set of perinatal care measures in 2011, and the National Quality Forum endorsed 14 perinatal measures in 2012. State interest in obstetric care quality measurement is growing as the percentage of births covered by Medicaid (currently 47 percent) continues to rise.5 Despite these trends, questions about the quality of childbirth-related care in different types of hospital settings (e.g., development of maternity care quality measures, reducing primary cesarean rates, and increasing access to vaginal birth after cesarean) have remained unexamined.6-9 Understanding how obstetric care is currently provided in CAHs and other rural hospitals is important for assessing the quality of maternity services and quantifying implications for maternal and child health.

Purpose

The goal of this research was to assess and compare the characteristics and quality of obstetric care in CAHs, other rural hospitals, and their urban counterparts.

Approach

The study measured obstetric care quality related to delivery mode, elective procedures, and perinatal safety in CAHs, other rural hospitals, and their urban counterparts using 2010 discharge data from Colorado, Iowa, Kentucky, New York, North Carolina, Oregon, Vermont, Washington, and Wisconsin State Inpatient Databases (SID), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality.10 The data set included all births occurring in 623 hospitals in the nine states (N=686,703 births). These hospitals comprise a census of all rural hospitals providing obstetric services in the nine states we studied. These nine states were chosen based on the size of their rural population, number of rural hospitals (including CAHs) providing obstetric care, U.S. regional distribution, and because they permitted linkage with American Hospital Association (AHA) Annual Survey data on hospital characteristics and location.11

Obstetric Services and Quality among Critical Access, Rural, and Urban Hospitals in Nine States Outcomes measured were the low- Table 1.Critical Access Hospitals, Rural Hospitals, and Urban Hospitals with risk cesarean rate (among full term, Ten or More Births in 2010 vertex, singleton pregnancies with no CAHsa Other Rural Hospitalsb Urban Hospitalsb prior cesarean deliveries), labor in% of % of state’s duction without medical indication, n ≥ 10 n ≥ 10 n ≥ 10 % of state’s state’s Other Rural cesarean delivery without medical inbirths births births Urban Hospitals CAHs Hospitals dication, episiotomy, and 3rd- or 4thdegree perianal laceration. Medical Colorado 12 41% 12 92% 28 93% indications used in the calculation of Iowa 45 55% 14 100% 20 95% non-indicated induction and cesarean Kentucky 2 7% 31 78% 19 61% delivery outcomes were defined based on the Joint Commission National North Carolina 7 30% 38 90% 39 80% Quality Measure, “Perinatal Care New York 1 8% 27 90% 104 77% Measure PC-01: Elective Delivery.”12 Oregon 19 76% 7 100% 25 96% Vermont 6 75% 4 100% 2 100% Limitations Washington 22 59% 6 100% 35 83% The rural designation we used is based on the hospital where a birth Wisconsin 38 64% 18 100% 42 84% occurred, not on the residence of the Total 152 50% 157 90% 314 82% mother. Hospital discharge data do a not contain clinical notes or informa- The number of CAHs in each state is from a CAH dataset maintained by the Flex Monitoring Team and all CAHs open as of 12/31/2010. tion on prenatal care, parity, or gesta- includes b The number of other rural and urban hospitals in each state are from the AHA Annual Survey Database tional age at birth. The 623 hospitals 2010. in the study come from nine states distributed across all four US Census vided obstetric services varied across gories included some hospitals with a regions, but the results may not be states. CAHs were much less likely to low volume of births, most other rurepresentative of all hospitals nation- provide obstetric services than other ral hospitals and urban hospitals had ally. rural hospitals or urban hospitals. many more births than CAHs. Only 7 percent of CAHs in KenResults tucky had at least 10 births in 2010, Differences Among Hospitals Providing Hospital Characteristics compared to 76 percent of CAHs in and Not Providing Obstetric Services Overall, 50 percent of CAHs, 90 per- Oregon. Among other rural hospitals On average, CAHs that provided cent of other rural hospitals, and 82 (not CAHs), rates varied from 78 obstetric services had significantly percent of urban hospitals provided percent in Kentucky to 100 percent higher annual inpatient admissions obstetric services (defined by having in five states. Urban hospitals shared (1,060) and surgeries (249) than 10 or more births) in 2010 in these similar variability across states, with CAHs that did not provide obstetric nine states (Table 1). The rate of Kentucky at 61 percent compared to services (583 and 83, respectively) CAHs doing obstetrics is higher than a rate of 100 percent in Vermont. (p