Risk-adjusted models for adverse obstetric outcomes and variation in risk-adjusted outcomes across hospitals

Jennifer L. Bailit, William A. Grobman, Madeline Murguia Rice, Catherine Y. Spong, Ronald J. Wapner, Michael W. Varner, John M. Thorp, Kenneth J. Leveno, Steve N. Caritis, Phillip J. Shubert, Alan T. Tita, George Saade, Yoram Sorokin, Dwight J. Rouse, Sean C. Blackwell, Jorge E. Tolosa, J. Peter Van Dorsten

Research output: Contribution to journalArticlepeer-review

81 Scopus citations


Objective Regulatory bodies and insurers evaluate hospital quality using obstetrical outcomes, however meaningful comparisons should take preexisting patient characteristics into account. Furthermore, if risk-adjusted outcomes are consistent within a hospital, fewer measures and resources would be needed to assess obstetrical quality. Our objective was to establish risk-adjusted models for 5 obstetric outcomes and assess hospital performance across these outcomes. Study Design We studied a cohort of 115,502 women and their neonates born in 25 hospitals in the United States from March 2008 through February 2011. Hospitals were ranked according to their unadjusted and risk-adjusted frequency of venous thromboembolism, postpartum hemorrhage, peripartum infection, severe perineal laceration, and a composite neonatal adverse outcome. Correlations between hospital risk-adjusted outcome frequencies were assessed. Results Venous thromboembolism occurred too infrequently (0.03%; 95% confidence interval [CI], 0.02-0.04%) for meaningful assessment. Other outcomes occurred frequently enough for assessment (postpartum hemorrhage, 2.29%; 95% CI, 2.20-2.38, peripartum infection, 5.06%; 95% CI, 4.93-5.19, severe perineal laceration at spontaneous vaginal delivery, 2.16%; 95% CI, 2.06-2.27, neonatal composite, 2.73%; 95% CI, 2.63-2.84). Although there was high concordance between unadjusted and adjusted hospital rankings, several individual hospitals had an adjusted rank that was substantially different (as much as 12 rank tiers) than their unadjusted rank. None of the correlations between hospital-adjusted outcome frequencies was significant. For example, the hospital with the lowest adjusted frequency of peripartum infection had the highest adjusted frequency of severe perineal laceration. Conclusion Evaluations based on a single risk-adjusted outcome cannot be generalized to overall hospital obstetric performance.

Original languageEnglish (US)
Pages (from-to)446.e1-446.e30
JournalAmerican journal of obstetrics and gynecology
Issue number5
StatePublished - Nov 2013
Externally publishedYes


  • obstetrics
  • performance improvement
  • quality
  • risk adjustment

ASJC Scopus subject areas

  • Obstetrics and Gynecology


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