Comparing rates of trial of labour attempts, VBAC success, and fetal and maternal complications among family physicians and obstetricians.

OBJECTIVES: To determine differences between family physicians and obstetricians in rates of trial of labour (TOL) attempt, vaginal birth after Caesarean section (VBAC) success, and maternal-fetal complications. METHODS: We undertook a database evaluation study in an urban Quebec secondary care hospital centre that serves a multiethnic population. Study subjects were pregnant women with at least one previous Caesarean section (CS), who delivered singletons at St. Mary's Hospital Center between January 1995 and December 2003. Outcomes were rates of TOL attempt, of VBAC success and failure, and of uterine rupture or dehiscence. RESULTS: Of 32 500 singleton deliveries, 3694 (11.4%) women met study criteria. Of these, 3493 (94.6%) were patients of obstetricians, and 201 (5.4%) were patients of family physicians. The TOL attempt rate was 50.6% (1768) and 81.1% (163) for obstetricians and family physicians, respectively (P 0.001). For women having TOL, the VBAC success rate was 64.3% for obstetricians and 76.1% for family physicians (P = 0.002). Rates of uterine rupture or dehiscence in the combined failed and successful VBAC groups were 2.9% for obstetricians and 4.3% for family physicians (P = 0.33) whereas in the failed VBAC group the rates were 7.9% versus 17.9% for the family physicians (P = 0.04). Within delivery outcomes for successful and failed VBAC there were no differences in maternal characteristics and newborn outcomes by physician group. CONCLUSION: More patients of family physicians than of obstetricians attempted TOL and had successful VBAC. Newborn outcomes were similar in the two groups, except that in the failed VBAC group, the family doctors had slightly higher uterine rupture or dehiscence rates; given the low power of this study, further studies are needed to confirm and explain this result. Also, given the similarity in patient profiles, the differences in delivery outcomes may be attributable to differences in physician practice styles.

Morbidity and mortality audits: "How to"for family practice.

PROBLEM BEING ADDRESSED: While professions hold their members responsible for self-regulation, many physicians have insufficient information about outcome measures in their practices to judge performance and are inexperienced in performing audits to gather the information they need to judge performance. OBJECTIVE OF PROGRAM: To develop a structure and process to support family doctors with little experience in doing quality improvement studies to conduct morbidity and mortality (M&M) audits. PROGRAM DESCRIPTION: A family medicine teaching group provides members on a rotating basis to an M&M review committee. The committee meets eight times a year and has done four audits, the most comprehensive on the topic of preventable hospital admissions. Both implicit and explicit criteria were incorporated into decision making. Strengths and limitations of the audit process and practice changes that resulted from the audit are discussed. CONCLUSION: Morbidity and mortality audits can vary in rigour. To promote physicians' interest in and commitment to audits, factors considered should reflect the goals, needs, skills, and time available of the physicians involved. Practical learning often results from simple projects.