Impact of surgeon annual volume on short-term maternal outcome in cesarean delivery

Background The annual procedure volume is an accepted marker for quality of care and has been documented in various medical fields. Surgeon volume has been shown to correlate with morbidity and mortality in surgical and high risk medical procedures. Though cesarean delivery is one of the most common surgical procedures in the USA, the link between surgeon's annual cesarean delivery volume and maternal outcome has never been tested. Objective To evaluate the impact of surgeons' annual volume on short term maternal outcome in cesarean deliveries. Study Design Retrospective cohort study in a single tertiary center between 2006 and 2013. Cesarean deliveries were categorized into two groups based on the annual volume of cesarean delivery of the attending obstetrician. LOW group included low annual volume obstetricians, whose annual volume of cesarean delivery was lower than median. HIGH group comprised high annual volume obstetricians whose annual volume was median and above. Further analyses were done for quartiles and for four clinical relevant groups according to the annual number of cesarean delivery performed/supervised by the attending (20 or less, 21-60 , 61-120 and more than 120) The primary outcome was a composite adverse maternal outcome including one or more of the following: urinary or gastrointestinal tract injuries, hemoglobin drop &gt; three gm/dL, blood transfusion, re-laparotomy, puerperal fever, prolonged maternal hospitalization and readmission. Secondary outcomes were operative times (skin incision to delivery and overall). Results A total of 11,954 cesarean deliveries were included, the median annual number of cesarean delivery performed/supervised by one obstetrician was 48. Unadjusted analysis suggested that HIGH group patients, had fewer urinary and gastrointestinal injuries 18/9278 (0.2%) vs. 16/2676 (0.6%), P&lt;0.001, less blood loss as measured by hemoglobin drop &gt; three gm/dL 1053/9278 (11.5%) vs. 366/2676 (13.8%), P&lt;0.001 and fewer cases of prolonged maternal hospitalization: 80/9278 (0.9%) vs. 39/2676 (1.5%), P=0.006. The rate of blood transfusion, re-laparotomy, puerperal febrile morbidity and readmission to hospital did not differ between groups. Multivariable regression analysis showed that cesarean delivery performed/supervised by HIGH group resulted in a significantly lower composite adverse maternal outcome (15.8% vs. 18.9%, OR 0.86; 95%CI 0.78–0.95, p=0.004). This was primarily related to a decreased frequency of urinary and gastrointestinal injuries, lower likelihood of hemoglobin drop &gt; three gm/dL and lower incidence of prolonged maternal hospitalization. Operative times were significantly shorter for HIGH group. Composite adverse maternal outcome ranged from 21.8% in the lowest quartile , to 17.9% in Q2, to 17.4% in Q3, and 15.6% in Q4. With Q4 defined as the reference, Q3 had an OR of 1.14 95%CI[1.01-1.29] , p=0.029, Q2 had an OR 1.18 95%CI[1.02-1.36] , p=0.021 and Q1 had an – OR 1.51 95%CI[1.14-1.99], p=0.004 for composite adverse maternal outcome. Composite adverse maternal outcome ranged from 21.5% in clinical group 1, to 17.5% in clinical group 2 to 17.9% in clinical group 3, and 15.2% in clinical group 4, p value=0.001). Cesarean delivery performed/supervised by clinical groups 2, 3 and 4 in compare to clinical group 1 were associated with a statistically significant risk reduction, (23%, 25% and 34% respectively). Conclusion Maternal composite morbidity is decreased as the volume of cesarean deliveries performed or supervised by obstetricians increases.</p

Impact of surgeon annual volume on short-term maternal outcome in cesarean delivery

Background The annual procedure volume is an accepted marker for quality of care and has been documented in various medical fields. Surgeon volume has been shown to correlate with morbidity and mortality in surgical and high risk medical procedures. Though cesarean delivery is one of the most common surgical procedures in the USA, the link between surgeon's annual cesarean delivery volume and maternal outcome has never been tested. Objective To evaluate the impact of surgeons' annual volume on short term maternal outcome in cesarean deliveries. Study Design Retrospective cohort study in a single tertiary center between 2006 and 2013. Cesarean deliveries were categorized into two groups based on the annual volume of cesarean delivery of the attending obstetrician. LOW group included low annual volume obstetricians, whose annual volume of cesarean delivery was lower than median. HIGH group comprised high annual volume obstetricians whose annual volume was median and above. Further analyses were done for quartiles and for four clinical relevant groups according to the annual number of cesarean delivery performed/supervised by the attending (20 or less, 21-60 , 61-120 and more than 120) The primary outcome was a composite adverse maternal outcome including one or more of the following: urinary or gastrointestinal tract injuries, hemoglobin drop > three gm/dL, blood transfusion, re-laparotomy, puerperal fever, prolonged maternal hospitalization and readmission. Secondary outcomes were operative times (skin incision to delivery and overall). Results A total of 11,954 cesarean deliveries were included, the median annual number of cesarean delivery performed/supervised by one obstetrician was 48. Unadjusted analysis suggested that HIGH group patients, had fewer urinary and gastrointestinal injuries 18/9278 (0.2%) vs. 16/2676 (0.6%), P three gm/dL 1053/9278 (11.5%) vs. 366/2676 (13.8%), P three gm/dL and lower incidence of prolonged maternal hospitalization. Operative times were significantly shorter for HIGH group. Composite adverse maternal outcome ranged from 21.8% in the lowest quartile , to 17.9% in Q2, to 17.4% in Q3, and 15.6% in Q4. With Q4 defined as the reference, Q3 had an OR of 1.14 95%CI[1.01-1.29] , p=0.029, Q2 had an OR 1.18 95%CI[1.02-1.36] , p=0.021 and Q1 had an – OR 1.51 95%CI[1.14-1.99], p=0.004 for composite adverse maternal outcome. Composite adverse maternal outcome ranged from 21.5% in clinical group 1, to 17.5% in clinical group 2 to 17.9% in clinical group 3, and 15.2% in clinical group 4, p value=0.001). Cesarean delivery performed/supervised by clinical groups 2, 3 and 4 in compare to clinical group 1 were associated with a statistically significant risk reduction, (23%, 25% and 34% respectively). Conclusion Maternal composite morbidity is decreased as the volume of cesarean deliveries performed or supervised by obstetricians increases.</p