Risk-adjusted primary cesarean delivery rates for managed care plans in New York State, 1998.

OBJECTIVE: To demonstrate the effect of risk adjustment methodologies compared to crude rates in evaluating the rate of primary cesarean deliveries in managed care plans, after accounting for known demographic and clinical factors. Risk adjustment allows for a more accurate comparison of primary cesarean delivery rates among plans, eliminating potential confounding factors that could influence rates. METHODS: Data was collected from managed care plans as part of their 1998 Quality Assurance Reporting Requirements (QARR). Medicaid and commercial populations were matched to New York State Department of Health Vital Statistics birth file to produce a crude measure of cesarean deliveries per plan. Logistic regression models were then used to adjust for maternal education, age, race/ethnicity, obstetrical history, preexisting comorbid conditions, obstetrical conditions, and pregnancy-related conditions to produce adjusted rates. RESULTS: For Medicaid, the crude analysis showed four plans that were significantly lower than the statewide Medicaid managed care rate of 9.5 per 100 live births. One plan was significantly higher. The risk-adjusted results showed one plan being significantly lower than the statewide average and none being higher. For the commercial population, seven plans were significantly lower than the average of 16.3 and four plans were higher. After risk-adjusting, three plans were significantly lower and three plans were significantly higher than the statewide average. CONCLUSIONS: Risk-adjustment of primary cesarean delivery rates allows for a more accurate comparison among managed care plans. It is hoped that the generation and publication of more accurate rates will facilitate the acceptance and use of this information by clinicians in managed care plans to focus on improving health outcomes.

Commercial managed care plans leaving the Medicaid managed care program in New York State: impact on quality and access.

UNLABELLED: To develop sufficient managed care capacity to accomplish the goal of transitioning Medicaid recipients into managed care, state policymakers have relied on commercial health maintenance organizations to open their panels of providers to the Medicaid population. However, while commercial health maintenance organization involvement in Medicaid managed care was high initially, since 1996 New York State has had 14 commercial plans leave the New York State Medicaid Managed Care Program. It has been speculated that the exodus of these commercial plans would have a negative impact on Medicaid enrollees' access and quality of care. This paper attempts to evaluate the impact of this departure from the perspective of quality and access measures and plan audit performance. Univariate and multivariate analyses were performed to evaluation the effect of commercial managed care plans leaving the Medicaid program. The overall performance of plans that remained in the program was compared to that of the plans that chose to leave for the two time periods 1996-1997 and 1998-2000. Access to care, quality of care, and annual audit performance data were analyzed. The departure of commercial health plans from the New York State Medicaid Managed Care Program has not had a statistically significant negative effect on the quality of care provided to Medicaid recipients as evaluated by standardized performance measures. In addition, there were no instances when there was a negative impact of the exit of the commercial plans on access to care. Managed care plans that chose to remain in Medicaid passed the Quality Assurance Reporting Requirements audit at a significantly (P < .01) higher rate than plans that chose to leave. CONCLUSIONS: A program consisting of health plans voluntarily participating and committed to Medicaid managed care can provide Medicaid recipients with appropriate access to high-quality health care. The exodus of commercial health plans from New York's Medicaid Managed Care Program during the time periods studied did not result in a detectable adverse impact on the quality of care for enrollees.

Volume-outcome relationships in cardiovascular operations: New York State, 1990-1995.

BACKGROUND: It has been known for nearly 20 years that, in cardiovascular operations, a significant inverse relationship exists between clinical outcomes and the volume of procedures performed. Interestingly, this relationship persists 2 decades after it was recognized. OBJECTIVE: The purpose of this study was to examine the relationship between hospital volume and in-hospital deaths in 3 cardiovascular procedures: coronary artery bypass grafting, elective repair of abdominal aortic aneurysms, and repair of congenital cardiac defects. METHODS: The database includes all patients who were hospitalized in New York State during the years 1990 to 1995. Using standard logistic regression techniques, we analyzed the relationship between hospital volume and outcome. RESULTS: No correlation exists between hospital volume and in-hospital deaths in coronary artery bypass grafting. Statewide, 31 hospitals performed 97,137 operations over the 6-year period (overall mortality rate, 2. 75%). By contrast, most of the hospitals statewide (195 of 230 hospitals) performed 9847 elective abdominal aortic aneurysm repairs with an overall mortality rate of 5.5%. In abdominal aortic aneurysm operations, a significant inverse relationship between hospital volume and in-hospital deaths was determined. Sixteen hospitals performed 7199 repairs for congenital cardiac defects. A significant inverse relationship (which was most pronounced for neonates) was found between volume and death. CONCLUSIONS: The importance of these findings lies in the rather striking difference between the volume-outcome relationship found for operations for abdominal aortic aneurysms and congenital cardiac defects and the lack of such a relationship for coronary artery bypass grafting. This observation may be largely explained by the quality improvement program in New York State for bypass operations since 1989. If so, these results have important implications for expanding the scope of quality improvement efforts in New York State.

Hospital volume differences and five-year survival from breast cancer.

OBJECTIVES: The purpose of this study was to determine the effect of hospital volume on long-term survival for women with breast cancer. METHODS: Survival analysis and proportional-hazard modeling were used to assess 5-year survival and risk of death, adjusting for clinical and sociodemographic variables. RESULTS: At 5 years, patients from very low-volume hospitals had a 60% greater risk of all-cause mortality than patients from high-volume hospitals. CONCLUSIONS: Hospital volume of breast cancer surgical cases has a strong positive effect on 5-year survival. Research is needed to identify whether processes of care, especially postsurgical adjuvant treatments, contribute to survival differences.

Effect of external peer review on cesarean delivery rates: a statewide program.

OBJECTIVE: To assess the effectiveness of a joint-specialty society and health department statewide peer-review program to reduce cesarean rates. METHODS: Forty-five of the 165 hospitals with active delivery services were reviewed between 1989 and 1993. Differences in total and repeat cesarean rates and vaginal birth after cesarean (VBAC) rates were compared by hospital review status using Student t tests and linear regression for the years before and after completion of the program. RESULTS: Reviewed hospitals reduced their total cesarean rate by 3% and repeat cesarean rate by 0.7%, and increased their VBAC rate by 14.6% compared with nonreviewed hospitals, for which the respective reduction in rates was 1%, 0.6%, and 12.7%. Statistically, there was no difference between reviewed and nonreviewed hospitals in terms of rate changes. CONCLUSION: This joint-specialty society and health department peer review had no apparent impact on cesarean rates.