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Practice guidelines, consumer education, professional feedback—the verdict is still out on the best way to ensure positive outcomes and that difficult-to-define "right rate" for cesarean sections.
In Florida, for example, officials are defending their legislatively mandated guidelines for cesarean section deliveries in light of a Jan. 7, 1999, New England Journal of Medicine article calling the practice into question.
"The guidelines are flexible enough for the doctor to use medical judgment regarding medical need," says Kim Shafer, an economic analyst with the state’s Agency for Health Care Administration.
The New England Journal of Medicine article, appearing in the Journal’s "Sounding Board" section, contends the Healthy People 2000 goal of reducing the nation’s cesarean rate to 15% from the 1995 rate of 21% "may have a detrimental effect on maternal and infant health."
"There is no evidence to support this target," write four Boston researchers associated with Beth Israel Deaconess Medical Center and Massachusetts General Hospital. "Setting a target rate is an authoritarian approach to health care delivery."
Bolstering the authors’ argument is a spring 1997 analysis concluding that Florida’s guidelines "did not accelerate the consistent but gradual downward trend in cesarean births which had already been evident in the three prior years.
"[M]ere dissemination of practice guidelines by a state agency may not achieve either the magnitude or the specificity of the results desired without an explicit guideline implementation program," wrote the authors of the analysis, published in the Spring 1997 issue of the American Journal of Medical Quality. The University of South Florida researchers noted that the date of guideline implementation in Florida "was not related to any systematic changes in the observed cesarean section rates" among Florida hospitals.
Florida law implemented in 1992 required the state to develop practice parameters that address, at a minimum, the feasibility of attempting a vaginal delivery for each patient with a prior cesarean section; dystocia, including arrested dilation and prolonged deceleration phase; fetal distress; and fetal malposition. The parameters apply to physicians providing care paid for by the state’s Medicaid program.
Florida legislators also mandated that each hospital establish a peer review board to analyze every Medicaid cesarean, paying "particular attention to electronic fetal monitoring records, umbilical cord gas results, and Apgar scores in determining if the caesarean section delivery was appropriate." The board must conduct a review at least monthly and pass along its results to the attending physician.
Addressing a major concern of the New England Journal of Medicine article authors, a study of hospital deliveries during the mid-1990s suggested use of the cesarean guideline in Florida had no "detrimental impact" on newborn outcomes. However, the January report from the Agency for Health Care Administration analyzed only negative outcomes that were apparent at birth and did not include those that may show up later.
Florida officials have long analyzed how financial issues affect cesarean rates. A study of Florida’s hospital deliveries from 1990 to 1996 indicates that women classified as "self-pay"—which includes uninsured patients—are 70% as likely as commercially insured women to have a cesarean.
The 1992 law also gave physicians using the guidelines an affirmative defense in malpractice actions. There isn’t enough data to determine whether this provision has had the desired effect of reducing malpractice litigation, Ms. Shafer says.
Virginia’s approach to reducing cesareans has been less direct, focusing on educating the consumer about cesareans. The state pays for a glossy, four-color guide to obstetrical services that lists cesarean rates by hospital and physician for all providers in the state. The guide, produced by the Richmond-based nonprofit firm Virginia Health Information (VHI) under contract from the Virginia Department of Health, is careful not to say a lower rate is necessarily better and says "a cesarean rate is just one aspect among many to consider when evaluating your physician and hospital."
"VHI takes no position as to the right’ rate of cesarean delivery," says Michael Lundberg, the organization’s executive director. However, he is heartened by a University of Missouri-Columbia study in the Journal of the American Medical Association showing consumer efforts such as his can lower cesarean rates. The study gives consumer education efforts at least part of the credit for lowering the cesarean rate among hospitals where the procedure was particularly prevalent from 31.1% in 1989 to 26.7% in 1990.
VHI’s report analyzes primary and secondary rates separately and takes the unusual step of using risk-adjusted rates to compare a provider’s performance to what would be expected. Both strategies were recommended in the New England Journal of Medicine study as a way to focus attention on true overutilization of cesarean services.
Centrally issued guidelines have had "limited if any effect" in reducing the rate of cesarean deliveries, concludes an analysis in the January 1999 issue of Pediatrics. Author Elliot Main, MD, contrasts the use of guidelines with a successful program to reduce the cesarean rate among physicians in northern California using "intensive outcomes feedback."
Mr. Main, chairman of the department of obstetrics and gynecology at California Pacific Medical Center in San Francisco, says mere data about cesarean rates are unlikely to change behavior "in the absence of recognition, praise, public accord, and private admonishments."
He notes that state programs to reduce cesarean rates have had "decidedly mixed" results. Implementation of "state encouraged" practice guidelines in Minnesota, Maryland, and Massachusetts during the late 1980s and early 1990s "have had variable effects compared to the national trends," with none approaching the Healthy People 2000 goal of 15%.
"C-section rates vary greatly from country to country, from state to state, from hospital to hospital, and from doctor to doctor without any difference in neonatal outcome. We aren’t talking small differences, either," Mr. Main tells State Health Watch.
The national increase in cesarean rates has not produced improvements neonatal care, he says, noting that his study showed midwifery practices produced low cesarean rates and good infant outcomes.
Contact Ms. Shafer at (850) 922-5771, Mr. Lundberg at (804) 643-5573, and Mr. Main at (415) 750-6003.