Risk-adjusted cesarean section rates for the assessment of physician performance in Taiwan: a population-based study

BACKGROUND: Over the past decade, about one-third of all births nationwide in Taiwan were delivered by cesarean section (CS). Previous studies in the US and Europe have documented the need for risk adjustment for fairer comparisons among providers. In this study, we set out to determine the impact that adjustment for patient-specific risk factors has on CS among different physicians in Taiwan. METHODS: There were 172,511 live births which occurred in either hospitals or obstetrics/gynecology clinics between 1 January and 31 December 2003, and for whom birth certificate data could be linked with National Health Insurance (NHI) claims data, available as the sample for this study. Physicians were divided into four equivalent groups based upon the quartile distribution of their crude (actual) CS rates. Stepwise logistic regressions were conducted to develop a predictive model and to determine the expected (risk-adjusted) CS rate and 95% confidence interval (CI) for each physician. The actual rates were then compared with the expected CS rates to see the proportion of physicians whose actual rates were below, within, or above the predicted CI in each quartile. RESULTS: The proportion of physicians whose CS rates were above the predicted CI increased as the quartile moved to the higher level. However, more than half of the physicians whose actual rates were higher than the predicted CI were not in the highest quartile. Conversely, there were some physicians (40 of 258 physicians) in the highest quartile who were actually providing obstetric care that was appropriate to the risk. When a stricter standard was applied to the assessment of physician performance by excluding physicians in quartile 4 for predicting CS rates, as many as 60% of physicians were found to have higher CS rates than the predicted CI, and indeed, the CS rates of no physicians in either quartile 3 or quartile 4 were below the predicted CI. CONCLUSION: Overall, our study found that the comparison of unadjusted CS rates might not provide a valid reflection of the quality of obstetric care delivered by physicians, and may ultimately lead to biased judgments by purchasers. Our study has also shown that when we changed the standard of quality assessment, the evaluation results also changed

Cervical Screening within HIV Care: Findings from an HIV-Positive Cohort in Ukraine

HIV-positive women have an increased risk of invasive cervical cancer but cytologic screening is effective in reducing incidence. Little is known about cervical screening coverage or the prevalence of abnormal cytology among HIV-positive women in Ukraine, which has the most severe HIV epidemic in Europe

Organization of interest groups

Insight into the internal organization of interest groups is crucial for understanding their representative function and intermediary role in contemporary democracies. The particular organizational features of groups shape their ability to fulfill their potential as “transmission belts” between society and the state. Given these important repercussion of organizational choices, it is not surprising that decisions about the specific mission of the organization, the type of members, and their precise role in decision-making processes are often strongly contested when a new interest group is being established. Once these choices have been made, however, an organization’s mission and structure tend to be rather inert and mostly evolve in a path-dependent, incremental manner (Fraussen, 2014).This chapter defines interest groups as membership-based formal organizations, who seek to represent the interests of a particular constituency or advocate for a particular cause in the political arena. This chapter first clarifies the importance of the internal organization of interest groups and subsequently addresses the use and value of different group typologies. The last two sections focus on clarifying feature- and identity-based approaches for identifying variation in organizational form and explore how digital technologies might alter the organizational design of interest groups and how they conceive and involve their constituency.The politics and administration of institutional chang

Peasant federations and rural development policies in the andes

This chapter focuses on a special type of structural social capital embedded in second-tier indigenous peasant federations in the Andean countries. It first examines the manifestations of this social capital and then goes on to analyze the strategies of the various social actors for its use, mainly to further the interests of poor and oppressed members, but often in the service of broader societal or narrower partisan purposes. Cases are presented to illustrate how such a social capital resource, once created, can be used or transformed for other than the original purposes. Sometimes these spillovers are socially beneficial, confirming the mutability thesis of Hirschman (1984); but in other cases the diversions can be harmful and disempowering. The authors conclude that even considering these varied uses, meso-level peasant federations, when incorporated into rural development policies, can help to achieve equity and sustainability