A Simple Risk-Adjustment for Hospital-level nulliparous, Term, Singleton, Vertex, Cesarean Delivery Rates and Its Implications for Public Reporting

Background The Joint Commission uses nulliparous, term, singleton, vertex, cesarean delivery (NTSV-CD) rates to assess hospitals’ Perinatal Care (PC-02) quality. However, these rates are not risk-adjusted for maternal health factors, putting this measure at odds with the risk-adjustment paradigm of most publicly reported hospital quality measures. Here, we tested whether risk adjustment for readily documented maternal risk factors impacted hospital-level NTSV-CD rates in our large health system. Methods We included all consecutive NTSV pregnancies from January 2019 to April 2023 across ten hospitals in our health system. We used logistic regression, adjusting for age, obesity, diabetes, and hypertensive disorders to calculate hospital-level risk-adjusted NTSV-CD rates by multiplying observed versus expected ratios for each hospital by the systemwide unadjusted NTSV-CD rate. We calculated intrahospital risk differences between unadjusted and risk-adjusted rates and calculated the percentage of hospitals qualifying for different reporting status after risk adjustment using the 30% Joint Commission reporting threshold rate. Results Of 23,866 pregnancies, 6,550 (27.4%) had cesarean deliveries. Across ten hospitals, the number of deliveries ranged from 393 to 7,671, with unadjusted NTSV-CD rates ranging from 21.0% to 30.5% Risk-adjusted NTSV-CD rates ranged from 21.5% to 30.4%, with absolute intrahospital differences in risk-adjusted versus unadjusted rates ranging from -1.33% (indicating lower rate after risk-adjustment) to 3.37% (indicating higher rate after risk adjustment). Three of ten (30%) hospitals qualified for different reporting statuses after risk-adjustment. Conclusion Risk-adjustment for age, obesity, diabetes, and hypertensive disorders is feasible and resulted in meaningful changes in hospital-level NTSV-CD rates with potentially impactful consequences for hospitals near The Joint Commission reporting threshold.