Associations between Delivery Hospital Obstetric Service Level and Selected Maternal and Perinatal Outcomes for High Risk Women Public
Vanderlaan, Jennifer (2017)
Abstract
Despite recent calls for implementation of new definitions of graduated hospital levels of obstetric service to reduce maternal mortality and morbidity, associations between such an intervention and delivery outcomes remain untested. The purpose of this project is to investigate the association between the American Hospital Association's (AHA) graduated levels of obstetric service and delivery outcomes for women at high obstetric risk to provide evidence for policy makers tasked with making decisions about updating regional perinatal systems. Using the three delays framework, this project hypothesized improved outcomes at hospitals with the highest level of obstetric service.
This project first addressed the lack of a gold standard for identifying a sample of women at high obstetric risk in epidemiological data by demonstrating that a recently proposed obstetric comorbidity index allowed creation of a sample resulting in a lower likelihood of misclassification bias. The project then used a sample of women at high obstetric risk to test associations between maternal and perinatal delivery outcomes and delivering at hospitals with different levels of obstetric service as defined by the AHA.
The analyses did not provide evidence to support the hypothesis of improved outcomes for women at high risk delivering at hospitals with the highest level of obstetric service and instead found reduced odds of extended length of stay at hospitals with lower levels of obstetric service. These findings suggest the AHA system of designating levels of obstetric service may not stratify hospitals by resources that improve care and introduces questions about the validity of assumptions that the resources that provide safe care for women at high risk are limited to hospitals with the highest level of obstetric service. In addition, this project identified problems with using the metric for extended length of stay as a measure of resource use.
Table of Contents
Abstract ii
Acknowledgements iv
Contents vii
List of Figures x
List of Tables xi
Abbreviations xii
Chapter 1: Introduction 1
Background 1
Limitations and Benefits of Levels of Service 4
Importance of estimating effect of service levels 6
Purpose 8
Project Description 9
Specific Aims 9
Aim One. 9
Aim two. 9
Aim Three. 10
Setting 10
Significance 11
Theoretical Framework 11
Assessing High Obstetric Risk 13
Assessing Hospital Obstetric Service Level 15
Evaluating Effect of Delivery Hospital Obstetric Level 16
Limitations 19
Chapter Two: Net benefit analysis of obstetric high risk sample selection Methods 22
Abstract 22
Background 24
Purpose 25
Methods 25
Setting & Participants 25
Variables & Data Sources 26
High-Risk Identification Models 26
Predicted Outcome. 28
Analysis 29
Results 30
Participants 30
Model Characteristics 32
Main Results 33
Discussion 33
Limitations 34
Implications 35
Funding 36
Chapter Three: Associations between delivery hospital level of obstetric service and maternal delivery outcomes 37
Abstract 37
Background 39
Objectives 39
Methods 39
Setting 40
Participants 40
Variables and Data Sources 41
Control of Bias 43
Statistical Methods 44
Results 44
Participants 44
Descriptive Data 45
Outcome Data 45
Main Results 46
Other Analyses 46
Discussion 47
Limitations and Generalizability 49
Implications 50
Funding 51
Chapter Four: Associations between delivery hospital level of obstetric service and Neonatal delivery outcomes 52
Abstract 52
Background 54
Objectives 54
Methods 54
Setting 54
Participants 55
Variables & Data Sources 55
Predictor 57
Control Variables 57
Statistical Methods 58
Results 59
Descriptive Data 60
Outcome Data 60
Main Results 61
Discussion 63
Limitations and Generalizability 64
Implications 65
Conclusion 66
Funding 66
Chapter Five: Conclusion 68
Review of Objective and Aims 68
Aim One 68
Aim Two 69
Aim Three 70
Advances in Study 71
Interpretation 74
Limitations 77
Generalizability 78
Implications 79
Conclusion 82
Appendicies 83
Appendix 1: Georgia Regional Perinatal Centers and Perinatal Regions 83
Appendix 2: Bed size and AHA Obstetrical Service Level of Delivery Hospitals in Georgia Maternal Child Health Repository, 2008-2012 84
Appendix 3: Capabilities of Health Care Providers in Hospitals Delivering Basic, Specialty and Subspecialty Care 87
Appendix 4: ICD Codes used for conditions included in the Obstetric Comorbidity Index 90
90
Appendix 5: ICD Codes for conditions included in the New Zealand Transfer Guidelines 91
References 94
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