Abstract
A high cesarean delivery rate in US hospitals indicates the potential overuse of this procedure; however, underlying causes of the excessive use of cesarean procedures in the US have not been fully understood. To investigate the association between the probability of cesarean delivery at the patient-level and profit per procedure from cesarean deliveries. This observational, cross-sectional study used a nationally representative sample of hospital discharge data from women at low risk for cesarean birth who delivered newborns between 2010 and 2014 in the US. Data were gathered from the Nationwide Readmissions Database from the Healthcare Cost and Utilization Project, compiled by the Agency for Healthcare Research and Quality. Data cleaning and analyses were conducted between August 2019 and May 2020. Hospital-level median value of profits from cesarean deliveries, defined as the difference between the charge and the cost for cesarean delivery calculated for each hospital. Our primary outcome was the individual-level probability of undergoing a cesarean delivery. We examined the association with the hospital-level median value of profits per procedure for cesarean delivery (defined as the difference between the charge and the cost for cesarean delivery) using hierarchical regression models adjusted for patient and hospital characteristics and year-fixed effects. A total of 13 215 853 deliveries were included in our analyses (mean [SE] age, 27.4 [0] years), of which 2 202 632 (16.7%) were cesarean deliveries. After adjusting for potential confounders, pregnant women were more likely to have a cesarean birth when they delivered at hospitals with higher profits per procedure from cesarean deliveries. Women cared for at hospitals with the highest (adjusted odds ratio, 1.08; 95% CI, 1.02-1.14; P = .005) and second-highest profit quartiles (adjusted odds ratio, 1.07; 95% CI, 1.02-1.13; P = .007) had higher probabilities of a cesarean delivery compared with those cared for at hospitals in the lowest profit quartile. In this cross-sectional study of US nationally representative hospital discharge data, hospitals with higher profits per cesarean procedure were associated with an increased probability of delivering newborns through cesarean birth. These findings highlight the potential influence financial incentives play in determining a high cesarean delivery rate in the US.
Highlights
Cesarean delivery is the most frequent surgical procedure performed in the US.[1,2,3] Nationally, the procedure accounts for 1 in 3 births.[1,4,5,6] Cesarean delivery is a potentially lifesaving intervention that is necessary in some cases to protect the lives and health of the mother and newborn
We found that individual patients cared for at hospitals with high profits per procedure from cesarean deliveries were older, more likely to be covered by public health insurance (1 545 055 deliveries [45.9%] vs 987 009 deliveries [41.9%]), less likely to have delivery complications (465 247 deliveries [13.8%] vs 355 827 deliveries [15.1%]), and more likely to have postpartum complications (80 677 deliveries [2.4%] vs 51 405 deliveries [2.2%]) compared with patients cared for at low-profit hospitals (Table 2)
Hospital Profit and Cesarean Delivery Rate After adjusting for potential confounders, we found that delivering at the highest and the second-highest profit quartiles was associated with increased odds of a cesarean delivery compared with delivering at hospitals in the lowest profit quartile (Table 3)
Summary
Cesarean delivery is the most frequent surgical procedure performed in the US.[1,2,3] Nationally, the procedure accounts for 1 in 3 births.[1,4,5,6] Cesarean delivery is a potentially lifesaving intervention that is necessary in some cases to protect the lives and health of the mother and newborn. Healthy People 2020—a framework designed to address health disparities across the US—calls for a 10% relative decrease in primary cesarean deliveries among low-risk women, with the goal of lowering the cesarean rate to 23.9%.21. While an official midprogram review is not yet available, it is estimated that the US will not meet this goal.[1,3,4,5,6,22] According to the World Health Organization, cesarean delivery rates above 10% to 15% are generally not associated with improvements in maternal, neonatal, and infant mortality rates,[23] though a previous study suggested a cesarean rate of 19% to be more attainable.[24] A high rate of cesarean deliveries in the US indicates a potential overuse of this procedure; underlying causes of the excessive use of cesarean delivery in the US have not been fully understood
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