Hospital Variation in Costs and Outcomes of Care for Childbirth

 描述(由申请人提供)：产妇和新生儿护理是美国入院的主要原因。了解这些住院期间的护理模式可以为降低医疗成本的战略提供重要的见解。此外，尽管分娩的总成本很高，产科干预措施的使用也越来越多，但与其他工业化国家相比，美国在各种孕产妇和围产期结局指标上的排名都很低。产科专家呼吁提高分娩的成本与质量比 产妇护理服务。最近有证据表明，美国各医院的产中干预率差异很大，而且过度干预率在改善孕产妇和围产期结局方面缺乏好处，这突显了严格检查医院在产中护理价值方面的差异的必要性。因此，这项研究的目的是检查医院在分娩相关住院护理的成本和结果方面的差异，并确定与高价值护理相关的医院属性。我们假设，在对患者病例组合进行调整后，不同医院分娩住院的成本和结果有很大差异，并且医院成本与患者结果无关。我们进一步假设，医院在财务和临床综合结果的模式上各不相同，医院组织、分娩和分娩护理筹资方面的差异与不同的成本-结果模式相关。加州是美国所有州中出生人数最多的州，占全国分娩总数的12.7%。加州拥有多样化和大量的医院，以及将产妇和新生儿医院出院记录与出生证明联系起来的独特数据系统，为研究医院在产中护理中的差异提供了理想的环境。因此，我们将通过以下具体目标使用2007-2015年加州与分娩相关的住院数据来检验我们的假设：1)确定不同医院之间风险标准化成本以及孕产妇和围产期结局的差异；2)检查医院风险标准化成本与风险标准化孕产妇和围产期结局之间的关系；3)通过全州调查来描述医院组织、分娩和分娩护理筹资的特征；以及4)根据成本和孕产妇和围产期结局的组合纵向模式对医院护理价值进行分类，并确定与特定成本-结果模式相关的医院和产期护理特征。在评估医院绩效时，我们将评估产妇和围产儿结局，并使用分层广义线性模型对患者特征进行风险调整。结合临床结果评估医院成本将确定护理价值的模式。此外，使用新的潜在类别增长分析将允许通过使用纵向数据揭示时间趋势来对医院绩效进行更全面的分类。这项研究的结果可以为产科医院基准的可行性、基于价值的支付和医疗保健提供改革的设计以及促进产科保健全系统价值的战略提供参考。

 DESCRIPTION (provided by applicant): Maternal and newborn care are the leading reasons for hospital admissions in the U.S. Understanding patterns of care during these hospital stays can provide important insights for strategies to reduce health care costs. Moreover, despite the large overall cost for childbirth and increasing use of obstetric interventions, the U.S. ranks poorly in a variety of maternal and perinatal outcome measures relative to other industrialized countries. Experts in obstetrics have called for improved "cost to quality ratio in the delivery of maternity care services." Recent evidence on large variation in intrapartum intervention rates across U.S. hospitals and lack of benefit of excessive intervention rates in improving maternal and perinatal outcomes highlight the need to rigorously examine hospital differences in value of intrapartum care. Therefore, the objective of this study is to examine hospital variation in cost and outcomes of care for childbirth-related hospitalizations and to identify hospital attributes associated with high-value care. We hypothesize that cost and outcomes of childbirth hospitalizations differ substantially across hospitals after adjustment for patient case-mix and that hospital cost is not associated with patient outcomes. We further hypothesize that hospitals vary in their pattern of combined financial and clinical outcomes and that differences in hospital organization, delivery, and financing of intrapartum care are associated with distinct cost-outcome patterns. California has the largest number of births among all U.S. states, accounting for 12.7% of the country's total deliveries. With a diverse and large number of hospitals and a unique data system that links maternal and newborn hospital discharge records with birth certificates; California provides an ideal setting for studying hospital variation in intrapartum care. We will therefore test our hypotheses using data from 2007-2015 childbirth-related hospitalizations in California via the following specific aims: 1) To determine variation in risk-standardized cost and maternal and perinatal outcomes across hospitals; 2) To examine the relationship between hospital risk-standardized cost and risk- standardized maternal and perinatal outcomes; 3) To characterize hospital organization, delivery and financing of intrapartum care via a statewide survey; and 4) To classify hospital value of care based on their combined longitudinal pattern of cost and maternal and perinatal outcomes, and to identify hospital and intrapartum care characteristics associated with specific cost-outcome patterns. We will evaluate both maternal and perinatal outcomes when assessing hospital performance, and risk-adjust for patient characteristics using hierarchical generalized linear models. Evaluating hospital cost in conjunction with clinical outcomes will identify patterns in value of care. In addition, use of a novel latent class growth analysis will allow for a more comprehensive classification of hospital performance by revealing temporal trends using longitudinal data. Findings from this study can inform the feasibility of hospital benchmarking in obstetrics, design of value-based payment and health care delivery reforms, and strategies for promoting system-wide value in obstetric care.