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How well do birth certificates describe the pregnancies they report? The Washington State experience with low-risk pregnancies.

Objectives: Birth certificates are a major source of population-based data on maternal and perinatal health, but their value depends on the accuracy of the data. This study assesses the validity of information recorded on the birth certificates for women in Washington State who were considered to be low risk at entry into care. Methods: Birth certificates were matched to data abstracted from prenatal and intrapartum clinic and hospital records of a sample of 1937 Washington State obstetrical patients who were considered to be low risk at the beginning of their pregnancies. Accuracy of a variety of pregnancy characteristics (e.g., complications, procedures) on the birth certificate was analyzed using percentage agreement and sensitivity with record abstracts as the “gold standard.” Next, we weighted the data from each source to produce estimates of pregnancy characteristics in the population. We compared these estimates from the two data sources to see whether they provide similar pictures of this subpopulation. Results: Missing data for specific items on the birth certificates ranged from 0% to 24%. The birth certificate accurately captured gravidity and parity, but was less likely to report prenatal and intrapartum complications. The population estimates of the two data sources were significantly different. Conclusions: Because birth certificates significantly underestimated the complications of pregnancies, number of interventions, number of procedures, and prenatal visits, use of these data for health policy development or resource allocation should be tempered with caution.

Interspecialty differences in the obstetric care of low-risk women.

OBJECTIVES This study examined differences among obstetricians, family physicians, and certified nurse-midwives in the patterns of obstetric care provided to low-risk patients. METHODS For a random sample of Washington State obstetrician-gynecologists, family physicians, and certified nurse-midwives, records of a random sample of their low-risk patients beginning care between September 1, 1988, and August 31, 1989, were abstracted. RESULTS Certified nurse-midwives were less likely to use continuous electronic fetal monitoring and had lower rates of labor induction or augmentation than physicians. Certified nurse-midwives also were less likely than physicians to use epidural anesthesia. The cesarean section rate for patients of certified nurse-midwives was 8.8% vs 13.6% for obstetricians and 15.1% for family physicians. Certified nurse-midwives used 12.2% fewer resources. There was little difference between the practice patterns of obstetricians and family physicians. CONCLUSIONS The low-risk patients of certified nurse-midwives in Washington State received fewer obstetrical interventions than similar patients cared for by obstetrician-gynecologists or family physicians. These differences are associated with lower cesarean section rates and less resource use.

Access to maternity care in rural Washington: its effect on neonatal outcomes and resource use.

OBJECTIVES This study sought to ascertain the effects of poor local access to obstetric care on the risks of having a neonate diagnosed as non-normal, a long hospital stay, and/or high hospital charges. METHODS Washington State birth certificates linked with hospital discharge abstracts of mothers and neonates were used to study 29809 births to residents of rural areas. Births to women from rural areas where more than two thirds of the women left for care were compared with births to women from rural areas where fewer than one third left for care. RESULTS Poor local access to providers of obstetric care was associated with a significantly greater risk of having a non-normal neonate for both Medicaid and privately insured patients. However, poor local access to care was consistently associated with higher charges and increased hospital length of stay only if the patient was privately insured. CONCLUSIONS These results indicate that local maternity services may help prevent non-normal births to rural women and, among privately insured women, might decrease use of neonatal resources.

The content of ambulatory medical care in the United States. An interspecialty comparison.

Ambulatory care, accounting for over half a billion visits to physicians per year, is a major component of the health-care system and is the core of primary health care. This study uses data from the National Ambulatory Medical Care Survey to describe the most common problems seen in an ambulatory-care setting, to identify the medical specialties that provide the greater part of this care, and to characterize the major specialties in terms of the diagnoses in the patients who constitute their ambulatory practice. Fifteen diagnosis clusters account for 50 per cent of all ambulatory-care visits; only 8 of the 28 specialties account for a substantial amount (more than 25 per cent) of the ambulatory care rendered to patients with any of these 15 diagnoses. General and family physicians, general internists, and general pediatricians account for 65.9 per cent of all outpatient visits to physicians for the 15 most common problems; general and family physicians alone are responsible for more than half this total. The individual specialties differ markedly in the diagnostic and demographic variety of their outpatient workload. These differences have important implications for the training of physicians and the organization of their practices.

Readmission after surgery in Washington State rural hospitals

BACKGROUND Because of concern about the quality of care in rural hospitals, we examined readmission following four surgical procedures commonly performed in Washington State rural hospitals: appendectomy, cesarean section, cholecystectomy, and transurethral prostatectomy. METHODS In a retrospective cohort study, we identified all patients discharged after receiving one of the foregoing procedures using the statewide hospital discharge database. Readmissions to any hospital in the state within 7 or 30 days of discharge were also identified. RESULTS During the 2-year period examined, there were no significant differences in readmission rates for surgeries performed in rural and urban hospitals, although the readmission rates for all four procedures were nominally lower in rural hospitals. Logistic regression analyses that controlled for factors that influence readmission did not change these results. CONCLUSIONS Investigating readmission rates following common surgeries, we found no evidence of low-quality surgical care in Washington State rural hospitals. Early readmission is an imperfect marker for poor surgical outcome, however, and other proxies for quality remain to be examined.

The regionalization of perinatal care in Wales and Washington State.

OBJECTIVES The purpose of this study was to compare perinatal regionalization and neonatal mortality in Wales and Washington State. METHODS The 28 hospitals in Wales and the 80 hospitals in Washington State that offered maternity services and the 218,326 births that occurred in these hospitals in 1989 and 1990 were studied. Surveys were used to identify the neonatal technology and the referral policies of each hospital, and linked data from birth and death certificates were used to examine birthweight-specific neonatal mortality rates for all babies born in these hospitals. RESULTS Welsh district general hospitals (broadly equivalent to Level II perinatal centers in the United States) have more sophisticated neonatal technology than their Washington State counterparts and appear less likely to refer small or preterm babies to regional or subregional centers. Neonatal mortality rates were quite similar in the two settings. CONCLUSIONS Perinatal care in Wales appears to be less regionalized than in a similar region in the United States. The relative lack of perinatal regionalization in Wales may contribute to duplication and underutilization of expensive neonatal technologies. National health care systems do not, in and of themselves, lead to optimal regionalization of services.

Obstetric care and payment source: do low-risk Medicaid women get less care?

OBJECTIVES This study examined whether Medicaid-insured women at low risk receive less adequate obstetrical care than privately insured women. METHODS Low-risk women who were cared for by a random sample of obstetrical providers in Washington State were randomly selected. Information on all prenatal and intrapartum services was abstracted from medical records. Service information was aggregated into standardized resource-use units. Results compared Medicaid-insured women with those who were privately insured. RESULTS Medicaid-insured women were significantly younger (22.5 years vs 26.9 years) and averaged 6% fewer visits than privately insured women. Nonetheless, Medicaid status had no meaningful association with prenatal, intrapartum, or overall resource use. Some variation occurred in individual resources received. Medicaid-insured women had 38.8% more resources expended on testing for sexually transmitted diseases. Privately insured women had more resources expended on alpha-fetoprotein testing and on amniocentesis. There were no meaningful differences in birthweight or gestational age at delivery. CONCLUSIONS In this study of women who entered obstetrical care at low risk, similar care and resources were expended on Medicaid-insured and on privately insured women.

Primary care at a crossroads: progress, problems, and future projections.

The tension between generalist and specialist roles in medical education and practice has been marked by recurrent perceived crises for many years in the United States. Primary care was at a crossroads during the 1960s. There was much turmoil within the health care system, and many in the population were unable to gain access to and afford health care. As a result of this turbulence, a major effort was mounted at state and federal levels to increase the proportion and number of primary care physicians. New initiatives included efforts to increase the total number of physicians, passage of Medicare and Medicaid legislation, new emphasis on education programs in primary care, recognition of family practice as a specialty, and emergence of the National Health Service Corps. Today, 25 years later, the health care system as a whole is unraveling and in crisis as a result of soaring costs, the difficulty of providing access to all citizens, and health care outcomes that have fallen short of those achieved in many other industrialized countries. It is ironic how many of the failings of todays health care system mirror those of the 1960s, and how parallel the approaches to address these problems are to those taken a generation ago. Primary care finds itself again at a crossroads as intense pressures mount for fundamental reform of a health care system that has an inadequate primary care base. It is timely to take stock of the progress achieved by the initiatives to expand primary care during the last 25 years. Accordingly, this report addresses the following four objectives: (1) to

Influence of Provider Characteristics and Insurance Status on Maternal Serum Alpha-Fetoprotein Screening

Background: The maternal serum alpha-fetoprotein test (MSAFP) was developed to screen for neural tube defects. Little is known about the adoption of the MSAFP test. This study examines the effect of provider specialty and geographic location and patient insurance status on MSAFP test use in Washington State. Methods: We conducted a retrospective cohort study of MSAFP use in low-risk obstetric patients of five provider groups. MSAFP use was examined for Medicaid and privately insured patients, as well as for the patients of the five provider types. Results: Patients of urban and rural obstetrician-gynecologists were most likely to have MSAFP testing (80.4 percent and 77.0 percent, respectively); patients of urban certified nurse midwives and rural family physicians were least likely to have MSAFP testing (64.2 percent and 62.2 percent, respectively). Patients of certified nurse midwives were more likely to decline MSAFP testing when offered (26.1 percent). Medicaid-insured women were significantly less likely to have MSAFP testing than privately insured women (60.5 percent versus 79.1 percent, P≤0.05). Conclusions: Providers and patients did not uniformly use MSAFP screening. Efforts should be made to ensure that all patients are adequately informed of screening tests for neural tube defects.

Neonatal Mortality Clusters: A New Tool For Classifying Neonatal Outcomes

Background: A method for assessing general hospital neonatal care performance is needed that is simple, is easy to use, and requires minimal data. Methods: All neonatal deaths in Washington State obstetric hospitals from 1980 to 1983 were assigned to 10 mutually exclusive neonatal mortality clusters, a new classification method derived from information available on the death certificate. Results: More than one-third (35.3 percent) of all neonatal deaths fell within one of the seven clusters considered to represent potentially preventable causes of death. The rate of possibly preventable deaths was much higher in level III hospitals than in level II or level I hospitals, a finding similar to that observed in other states using different analytic approaches. Conclusions: Neonatal mortality clusters offer a less complex method of classifying neonatal deaths and assessing hospital performance than other currently used techniques.