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Samuel R.g. Finlayson - One of the best experts on this subject based on the ideXlab platform.
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General surgery at Rural Hospitals: a national survey of Rural hospital administrators
Surgery, 2008Co-Authors: Brit Doty, Randall Zuckerman, Samuel R.g. Finlayson, Paul Jenkins, Nathaniel Rieb, Steven HeneghanAbstract:Background Many Rural residents have limited access to surgical care. Rural Hospitals frequently struggle to provide surgical services due to workforce shortages and financial constraints. The purpose of this study is to describe Rural hospital administrators' perceptions regarding the state of their general surgery programs and the impact that providing surgical services has on their Hospitals' financial viability. Methods A 12-item survey was mailed to a random sample of national Rural hospital administrators (n=233). One hundred and eleven surveys were completed, yielding a response rate of 48%. In addition to overall descriptive analyses, comparisons were made between Hospitals located in large versus small Rural communities. Results Eighty-three percent of Rural hospital administrators perceived their surgical program to be very important to the financial viability of their hospital and stated that they would reduce services if the hospital were to lose its surgery program. Thirty-four percent of Hospitals have a surgeon leaving within the next 2 years and more than one-third of hospital administrators are currently searching for a surgeon. Conclusions Surgical care is a vital component of the health care services delivered by Rural Hospitals. Surveyed administrators' view the ability to provide surgical services as crucial to the financial viability of their Rural Hospitals. A shortage of general surgeons is a potential major threat to these Rural Hospitals.
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small Rural Hospitals and high risk operations how would regionalization affect surgical volume and hospital revenue
Journal of The American College of Surgeons, 2006Co-Authors: Andre R Chappel, Randall Zuckerman, Samuel R.g. FinlaysonAbstract:Background Because higher hospital procedure volume is associated with better outcomes for many high-risk procedures, regionalization to higher-volume Hospitals has been proposed as a way to improve quality of surgical care. The potential impact of such policies on small Rural hospital volume and revenue is unknown. Study design We identified all hospitalizations in small Rural Hospitals (less than 50 beds) in New York State from 1998 to 2001 that included an ICD-9 procedure code for 1 of 9 procedures for which there is a documented volume-outcomes association: abdominal aortic aneurysm repair, aortic-valve replacement, carotid endarterectomy, colectomy, coronary artery bypass, cystectomy, esophagectomy, pancreatectomy, or pulmonary resection. Revenue from these procedures was estimated using gross charges and payor-specific reimbursement rates. We then compared these estimates with total hospital inpatient revenue for each Rural hospital. Results We identified 14 small Rural Hospitals where at least one of the nine procedures was performed. All included hospitalizations for colectomy. Aortic aneurysm repairs, cystectomies, and pancreatectomies were performed in three Hospitals; carotid endarterectomy in two; and esophagectomy in one. In no Hospitals were cardiac procedures or pulmonary resections performed. Estimated average contribution to hospital net revenue for all 9 procedures was approximately 2%, nearly all attributable to colectomy. Conclusions If all aortic aneurysm repairs, major cardiothoracic procedures, carotid endarterectomies, cystectomies, and pancreatectomies in New York State were regionalized to higher-volume Hospitals, no small Rural Hospitals would experience substantial impact in terms of Rural hospital procedure volume and revenue. Even regionalization of colectomy would have a small impact on inpatient volume and revenue.
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Rural Hospitals and volume standards in surgery
Surgery, 2006Co-Authors: Samuel R.g. Finlayson, Justin B DimickAbstract:Background We sought to understand the potential impact of volume-based referral policy on Rural Hospitals by estimating the proportion of low-volume operations occurring in Rural versus urban Hospitals. Methods We performed an observational study using the national Medicare population who underwent one of 12 high-risk operations from 1999-2001. Low-volume Hospitals were considered those in the 2 lowest quintiles for each procedure. Hospitals were assigned to 1 of3 types of geographic locations on the basis of Rural-Urban Commuting Area Codes: urban areas, Rural large towns, or Rural small towns. For each of the 12 operations, we estimated the proportion of patients undergoing operation in low-volume Hospitals within each type of geographic area. Results For all 12 operations, the majority of surgical cases were performed in urban areas (ranging from a low of 76% for colectomy to 96% for heart valve operations). Evaluation of only operations performed in low-volume Hospitals showed that the majority of surgical cases were still located in urban areas (varying from a low of 55% for colectomy to a high of 94% for heart valve operations). Operations with a stronger effect of volume on outcome (eg, pancreatic and esophageal resection) were more concentrated in urban areas, compared with operations with a weaker effect (eg, colectomy). Conclusions Most low-volume operations take place in urban Hospitals. Efforts to direct patients to high-volume Hospitals can exempt Rural Hospitals and still realize most of the potential benefits.
Michelle Casey - One of the best experts on this subject based on the ideXlab platform.
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why are obstetric units in Rural Hospitals closing their doors
Health Services Research, 2016Co-Authors: Peiyin Hung, Michelle Casey, Katy B Kozhimannil, Ira MoscoviceAbstract:Objectives To understand hospital- and county-level factors for Rural obstetric unit closures, using mixed methods. Data Sources Hospital discharge data from Healthcare Cost and Utilization Project's Statewide Inpatient Databases, American Hospital Association Annual Survey, and Area Resource File for 2010, as well as 2013–2014 telephone interviews of all 306 Rural Hospitals in nine states with at least 10 births in 2010. Via interview, we ascertained obstetric unit status, reasons for closures, and postclosure community capacity for prenatal care. Study Design Multivariate logistic regression and qualitative analysis were used to identify factors associated with unit closures between 2010 and 2014. Principal Findings Exactly 7.2 percent of Rural Hospitals in the study closed their obstetric units. These units were smaller in size, more likely to be privately owned, and located in communities with lower family income, fewer obstetricians, and fewer family physicians. Prenatal care was still available in 17 of 19 communities, but local women would need to travel an average of 29 additional miles to access intrapartum care. Conclusions Rural obstetric unit closures are more common in smaller Hospitals and communities with a limited obstetric workforce. Concerns about continuity of Rural maternity care arise for women with local prenatal care but distant intrapartum care.
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the Rural obstetric workforce in us Hospitals challenges and opportunities
Journal of Rural Health, 2015Co-Authors: Katy B Kozhimannil, Michelle Casey, Peiyin Hung, Shailendra Prasad, Xinxin Han, Ira MoscoviceAbstract:Purpose The purpose of this study was to describe the types and combinations of clinicians who are delivering babies in Rural Hospitals, their employment status, the relationship between hospital birth volume and staffing models, and the staffing challenges faced by Rural Hospitals. Methods We conducted a telephone survey of 306 Rural Hospitals in 9 states: Colorado, Iowa, Kentucky, New York, North Carolina, Oregon, Vermont, Washington, and Wisconsin, from November 2013 to March 2014 to assess their obstetric workforce. Bivariate associations between Hospitals’ annual birth volume and obstetric workforce characteristics were examined, as well as qualitative analysis of workforce changes and staffing challenges. Findings Hospitals with lower birth volume (<240 births per year) are more likely to have family physicians and general surgeons attending deliveries, while those with a higher birth volume more frequently have obstetricians and midwives attending deliveries. Reported staffing challenges include scheduling, training, census fluctuation, recruitment and retention, and intrahospital relationships. Conclusions Individual Hospitals working in isolation may struggle to address staffing challenges. Federal and state policy makers, regional collaboratives, and health care delivery systems can facilitate solutions through programs such as telehealth, simulation training, and interprofessional education.
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birth volume and the quality of obstetric care in Rural Hospitals
Journal of Rural Health, 2014Co-Authors: Katy B Kozhimannil, Michelle Casey, Peiyin Hung, Shailendra Prasad, Maeve Mcclellan, Ira MoscoviceAbstract:Background Childbirth is the most common reason for hospitalization in the United States. Assessing obstetric care quality is critically important for patients, clinicians, and Hospitals in Rural areas. Methods The study used hospital discharge data from the Statewide Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, for 9 states (Colorado, Iowa, Kentucky, New York, North Carolina, Oregon, Vermont, Washington, and Wisconsin) to identify all births in Rural Hospitals with 10 or more births/year in 2002 (N = 94,356) and 2010 (N = 103,880). Multivariate logistic regression was used to assess the relationship between hospital annual birth volume, measured as low (10-110), medium (111-240), medium-high (241-460) or high (>460), and 3 measures of obstetric care quality (low-risk cesarean rates for term, vertex, and singleton pregnancies with no prior cesarean; nonindicated cesarean; and nonindicated induction) and 2 patient safety measures (episiotomy and perineal laceration). Results The odds of low-risk and nonindicated cesarean were lower in medium-high and high-volume Rural Hospitals compared with low-volume Hospitals after controlling for maternal demographic and clinical factors. In low-volume Hospitals, odds of labor induction without medical indication were higher than in medium-volume Hospitals, but not significantly different from medium-high or high-volume Hospitals. Odds of episiotomy were greater in medium-high or high-volume Hospitals than in low-volume Hospitals. The likelihood of perineal laceration did not differ significantly by birth volume. Conclusions Obstetric quality and safety outcomes vary significantly across Rural Hospitals by birth volume. Better performance is not consistently associated with either lower or higher volume facilities.
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the use of hospitalists by small Rural Hospitals results of a national survey
Medical Care Research and Review, 2014Co-Authors: Michelle Casey, Ira Moscovice, Peiyin Hung, Shailendra PrasadAbstract:Research on hospitalist programs has primarily focused on large, urban facilities. To fill a gap in the literature on hospitalist use in Rural Hospitals, the authors conducted a national survey of 402 Rural Hospitals with 100 or fewer beds that had reported having hospitalists. The survey examined reasons for using hospitalists, characteristics of hospitalist practices, and the impacts of hospitalist use in Rural settings. Rural Hospitals most commonly establish a hospitalist program to address medical staff requests, call coverage, and quality issues. Respondents report positive impacts of hospitalist programs on quality of care and primary care physician recruitment and retention, but mixed financial impacts. Assessments of the impact of hospitalists in Rural Hospitals need to take into account the variety of practitioner specialties functioning as hospitalists, the amount of time they spend as hospitalists, and the multiple roles they play in the Rural hospital and community.
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meaningful use of health information technology by Rural Hospitals
Journal of Rural Health, 2011Co-Authors: Jeffrey Mccullough, Ira Moscovice, Michelle Casey, Michele BurlewAbstract:Purpose: This study examines the current status of meaningful use of health information technology (IT) in Critical Access Hospitals (CAHs), other Rural, and urban US Hospitals, and it discusses the potential role of Medicare payment incentives and disincentives in encouraging CAHs and other Rural Hospitals to achieve meaningful use. Methods: Data from the American Hospital Association (AHA) Annual Survey IT Supplement were analyzed, using t tests and probit regressions to assess whether implementation rates in CAHs and other Rural Hospitals are significantly different from rates in urban Hospitals. Findings: Of the many measures we examined, only 4 have been met by a majority of Rural Hospitals: electronic recording of patient demographics and electronic access to lab reports, radiology reports, and radiology images. Meaningful use is even less prevalent among CAHs. We also find that Rural Hospitals lag behind urban institutions in nearly every measure of meaningful use. These differences are particularly large and significant for CAHs. Conclusion: The meaningful use incentive system creates many challenges for CAHs. First, investments are evaluated and subsidies determined after adoption. Thus, CAHs must accept financial risk when adopting health IT; this may be particularly important for large expenditures. Second, the subsidies may be low for relatively small expenditures. Third, since the subsidies are based on observable costs, CAHs will receive no support for their intangible costs (eg, workflow disruption). A variety of policies may be used to address these problems of financial risk, uncertain returns in a Rural setting, and limited resources.
Randall Zuckerman - One of the best experts on this subject based on the ideXlab platform.
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use of locum tenens surgeons to provide surgical care in small Rural Hospitals
World Journal of Surgery, 2009Co-Authors: Brit Doty, Mark Andres, Randall Zuckerman, David C BorgstromAbstract:Too few general surgeons practice in Rural American communities, and many Hospitals in the smallest Rural areas do not have a surgeon. Therefore, it is likely that some small Rural Hospitals are using alternative arrangements to provide surgical care, including hiring locum tenens surgeons. We describe the degree to which small Rural Hospitals are using locum tenens surgeons to provide surgical services. Administrators at 129 small Rural Hospitals were surveyed by telephone. The survey instrument was comprised of questions asking whether the hospital provides surgical services, if the hospital has recruited a surgeon, whether the hospital uses locum tenens surgeons and if so for what purposes. A total of 76% of surveyed Rural Hospitals have offered surgical services during the past 5 years. In all, 56% of Hospitals providing surgical care have recruited a surgeon during the past 5 years. Of those who have been unsuccessful in their search, 30% have considered using a locum tenens surgeon, and 20% have done so. Given the difficulty of recruiting surgeons to practice in Rural America, it is critical to develop strategies to address this problem. Although using locum tenens surgeons may allow Rural Hospitals to offer surgical services, the quality of surgical care could be compromised. Other means for delivering surgical services at Rural Hospitals that cannot recruit or retain a surgeon should be explored to ensure that Rural residents have access to high quality surgical care.
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General surgery at Rural Hospitals: a national survey of Rural hospital administrators
Surgery, 2008Co-Authors: Brit Doty, Randall Zuckerman, Samuel R.g. Finlayson, Paul Jenkins, Nathaniel Rieb, Steven HeneghanAbstract:Background Many Rural residents have limited access to surgical care. Rural Hospitals frequently struggle to provide surgical services due to workforce shortages and financial constraints. The purpose of this study is to describe Rural hospital administrators' perceptions regarding the state of their general surgery programs and the impact that providing surgical services has on their Hospitals' financial viability. Methods A 12-item survey was mailed to a random sample of national Rural hospital administrators (n=233). One hundred and eleven surveys were completed, yielding a response rate of 48%. In addition to overall descriptive analyses, comparisons were made between Hospitals located in large versus small Rural communities. Results Eighty-three percent of Rural hospital administrators perceived their surgical program to be very important to the financial viability of their hospital and stated that they would reduce services if the hospital were to lose its surgery program. Thirty-four percent of Hospitals have a surgeon leaving within the next 2 years and more than one-third of hospital administrators are currently searching for a surgeon. Conclusions Surgical care is a vital component of the health care services delivered by Rural Hospitals. Surveyed administrators' view the ability to provide surgical services as crucial to the financial viability of their Rural Hospitals. A shortage of general surgeons is a potential major threat to these Rural Hospitals.
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small Rural Hospitals and high risk operations how would regionalization affect surgical volume and hospital revenue
Journal of The American College of Surgeons, 2006Co-Authors: Andre R Chappel, Randall Zuckerman, Samuel R.g. FinlaysonAbstract:Background Because higher hospital procedure volume is associated with better outcomes for many high-risk procedures, regionalization to higher-volume Hospitals has been proposed as a way to improve quality of surgical care. The potential impact of such policies on small Rural hospital volume and revenue is unknown. Study design We identified all hospitalizations in small Rural Hospitals (less than 50 beds) in New York State from 1998 to 2001 that included an ICD-9 procedure code for 1 of 9 procedures for which there is a documented volume-outcomes association: abdominal aortic aneurysm repair, aortic-valve replacement, carotid endarterectomy, colectomy, coronary artery bypass, cystectomy, esophagectomy, pancreatectomy, or pulmonary resection. Revenue from these procedures was estimated using gross charges and payor-specific reimbursement rates. We then compared these estimates with total hospital inpatient revenue for each Rural hospital. Results We identified 14 small Rural Hospitals where at least one of the nine procedures was performed. All included hospitalizations for colectomy. Aortic aneurysm repairs, cystectomies, and pancreatectomies were performed in three Hospitals; carotid endarterectomy in two; and esophagectomy in one. In no Hospitals were cardiac procedures or pulmonary resections performed. Estimated average contribution to hospital net revenue for all 9 procedures was approximately 2%, nearly all attributable to colectomy. Conclusions If all aortic aneurysm repairs, major cardiothoracic procedures, carotid endarterectomies, cystectomies, and pancreatectomies in New York State were regionalized to higher-volume Hospitals, no small Rural Hospitals would experience substantial impact in terms of Rural hospital procedure volume and revenue. Even regionalization of colectomy would have a small impact on inpatient volume and revenue.
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General surgery programs in small Rural New York State Hospitals: a pilot survey of hospital administrators.
The Journal of Rural Health, 2006Co-Authors: Randall Zuckerman, Brit Doty, Paul Jenkins, Michael Gold, James Bordley, Patrick A. Dietz, Steven HeneghanAbstract:ABSTRACT: Context: Hospitals play a central role in small Rural communities and are frequently one of the major contributors to the local economy. Surgical services often account for a substantial proportion of hospital revenues. The current shortage of general surgeons practicing in Rural communities may further threaten the financial viability of Rural Hospitals and communities. Purpose: To describe hospital administrators’ perceptions regarding the current state of general surgery programs at small Rural Hospitals in New York State, including the impact that surgical services have on hospital financial viability. Methods: A list of Hospitals belonging to the Rural Hospitals group of the Healthcare Association of New York State was obtained to determine prospective survey recipients. Sixty-eight administrators at each of the identified Hospitals were subsequently surveyed and 38 respondents met all inclusion criteria. Findings: Approximately 87% of hospital administrators perceive that the general surgery program is critical to the hospital’s financial viability. Forty percent of respondents report that they would be forced to close the hospital if the surgical program was lost. Among the 42% of administrators trying to recruit a general surgeon, almost two thirds have been searching for more than 1 year. Conclusions: According to the perceptions of hospital administrators, the financial viability of Rural Hospitals in New York State depends in large part on their ability to provide surgical services. Additionally, general surgeons appear to be in high demand at a significant number of the surveyed institutions.
George H Pink - One of the best experts on this subject based on the ideXlab platform.
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Rural hospital mergers increased between 2005 and 2016 what did those Hospitals look like
Inquiry : a journal of medical care organization provision and financing, 2020Co-Authors: Dunc Williams, George H Pink, Kristin L Reiter, Mark G Holmes, Paula H SongAbstract:The objective of this study is to determine whether key hospital-level financial and market characteristics are associated with whether Rural Hospitals merge. Hospital merger status was derived from proprietary Irving Levin Associates data for 2005 through 2016 and hospital-level characteristics from HCRIS, CMS Impact File Hospital Inpatient Prospective Payment System, Hospital MSA file, AHRF, and U.S. Census data for 2004 through 2016. A discrete-time hazard analysis using generalized estimating equations was used to determine whether factors were associated with merging between 2005 and 2016. Factors included measures of profitability, operational efficiency, capital structure, utilization, and market competitiveness. Between 2005 and 2016, 11% (n = 326) of Rural Hospitals were involved in at least one merger. Rural hospital mergers have increased in recent years, with more than two-thirds (n = 261) occurring after 2011. The types of Rural Hospitals that merged during the sample period differed from nonmerged Rural Hospitals. Rural Hospitals with higher odds of merging were less profitable, for-profit, larger, and were less likely to be able to cover current debt. Additional factors associated with higher odds of merging were reporting older plant age, not providing obstetrics, being closer to the nearest large hospital, and not being in the West region. By quantifying the hazard of characteristics associated with whether Rural Hospitals merged between 2005 and 2016, these findings suggest it is possible to determine leading indicators of Rural mergers. This work may serve as a foundation for future research to determine the impact of mergers on Rural Hospitals.
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predicting financial distress and closure in Rural Hospitals
Journal of Rural Health, 2017Co-Authors: George M Holmes, Brystana G Kaufman, George H PinkAbstract:Purpose Annual rates of Rural hospital closure have been increasing since 2010, and Hospitals that close have poor financial performance relative to those that remain open. This study develops and validates a latent index of financial distress to forecast the probability of financial distress and closure within 2 years for Rural Hospitals. Methods Hospital and community characteristics are used to predict the risk of financial distress 2 years in the future. Financial and community data were drawn for 2,466 Rural Hospitals from 2000 through 2013. We tested and validated a model predicting a latent index of financial distress (FDI), measured by unprofitability, equity decline, insolvency, and closure. Using the predicted FDI score, Hospitals are assigned to high, medium-high, medium-low, and low risk of financial distress for use by practitioners. Findings The FDI forecasts 8.01% of Rural Hospitals to be at high risk of financial distress in 2015, 16.3% as mid-high, 46.8% as mid-low, and 28.9% as low risk. The rate of closure for Hospitals in the high-risk category is 4 times the rate in the mid-high category and 28 times that in the mid-low category. The ability of the FDI to discriminate Hospitals experiencing financial distress is supported by a c-statistic of .74 in a validation sample. Conclusion This methodology offers improved specificity and predictive power relative to existing measures of financial distress applied to Rural Hospitals. This risk assessment tool may inform programs at the federal, state, and local levels that provide funding or support to Rural Hospitals.
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medicaid expansion affects Rural and urban Hospitals differently
Health Affairs, 2016Co-Authors: Brystana G Kaufman, George H Pink, Kristin L Reiter, George M HolmesAbstract:Rural Hospitals differ from urban Hospitals in many ways. For example, Rural Hospitals are more reliant on public payers and have lower operating margins. In addition, enrollment in the health insurance Marketplaces of the Affordable Care Act (ACA) has varied across Rural and urban areas. This study employed a difference-in-differences approach to evaluate the average effect of Medicaid expansion in 2014 on payer mix and profitability for urban and Rural Hospitals, controlling for secular trends. For both types of Hospitals, we found that Medicaid expansion was associated with increases in Medicaid-covered discharges. However, the increases in Medicaid revenue were greater among Rural Hospitals than urban Hospitals, and the decrease in the proportion of costs for uncompensated care were greater among urban Hospitals than Rural Hospitals. This preliminary analysis of the early effects of Medicaid expansion suggests that its financial impacts may be different for Hospitals in urban and Rural locations.
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to what extent do community characteristics explain differences in closure among financially distressed Rural Hospitals
Journal of Health Care for the Poor and Underserved, 2016Co-Authors: Sharita R Thomas, George M Holmes, George H PinkAbstract:From January 2005 through December 2015, 105 Rural Hospitals closed. This study examined associations between community characteristics and Rural hospital closure. Compared with other Rural Hospitals that were at high risk of financial distress but remained open over the same time period, closed Rural Hospitals had a smaller market share (p < .0001) despite being in areas with higher population density (p < .05), were located nearer to another hospital (p < .0001), and were located in markets that had a higher rate of unemployment (p < .05) and a higher percentage of Black (p < .05) and Hispanic (p < .01) residents. These results have three implications for Rural health policy: Rural hospital closures may disproportionately affect racial and ethnic minorities, community characteristics in combination with other factors make it likely that Rural hospital closures will continue, and Rural hospital closures illuminate the need for new models of reimbursement and health care delivery to meet the needs of Rural communities.
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uncompensated care burden may mean financial vulnerability for Rural Hospitals in states that did not expand medicaid
Health Affairs, 2015Co-Authors: Kristin L Reiter, Marissa Noles, George H PinkAbstract:The implementation of the Affordable Care Act has led to a large decrease in the number of uninsured people. Yet uncompensated care will still occur, particularly in states where eligibility for Medicaid is not expanded. We compared Rural Hospitals in Medicaid expansion and nonexpansion states in terms of the amount of uncompensated care they provided and their profitability and market characteristics in 2013. We found that Rural Hospitals in expansion states provided more dollars of uncompensated care than those in nonexpansion states and that the difference was at least partly driven by greater uncompensated costs associated with public programs such as Medicaid. We found higher dollar values of unrecoverable debt and charity care among non-critical access Rural Hospitals in nonexpansion states than among those in expansion states. Compared to Hospitals in expansion states, those in nonexpansion states provided greater amounts of uncompensated care as a percentage of revenues and appeared to be more financially vulnerable; thus, these Hospitals may be more likely to experience financial pressure or losses. Policy makers need to formulate strategies for maintaining access to care for Rural populations residing in nonexpansion states.
Bjarke Lund Sorensen - One of the best experts on this subject based on the ideXlab platform.
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disclosing doubtful indications for emergency cesarean sections in Rural Hospitals in tanzania a retrospective criterion based audit
Acta Obstetricia et Gynecologica Scandinavica, 2012Co-Authors: Nanna Maaloe, Ib C Bygbjerg, Rwakyendela Onesmo, N J Secher, Bjarke Lund SorensenAbstract:Objective. To investigate in depth to what extent indications for emergency cesarean sections followed evidence-based audit criteria for realistic best practice. Design. A quality assurance analysis based on a retrospective criterion-based audit. Setting. Two Rural Hospitals in Tanzania. Population. From 2009, 400 cesarean section instances were investigated. Of these, 303 were emergency cesarean sections and therefore included. Methods. Documented indications for and management preceding the emergency cesarean sections were compared with the audit criteria. Main outcome measures. Prevalence of suboptimal care. Results. Of the emergency sections, 26% appeared to be decided based on inappropriate indications, and in an additional 38%, the indications were unclear. Prolonged labor was the leading indication; in 36% of these, labor progressed timely and/or the membranes were still intact. In 26%, previous cesarean section was the indication, half of these with one previous section only. Fetal distress was an indication in 14%, but for 84% of these the fetal heart rate was either reassuring or not documented. For nine women, section was decided upon because of intrauterine fetal death; none had a trial of forceps/vacuum extraction or destructive surgery. Conclusion. A considerable number of the audited emergency cesarean sections were performed on doubtful indications. In the light of the rising trend in global cesarean section rates, there seems to be a need to ensure quality of management preceding cesarean sections. This is particularly called for in Rural sub-Saharan Africa where cesarean rates are still low and health risks of emergency surgery not negligible.
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prolonged labour as indication for emergency caesarean section a quality assurance analysis by criterion based audit at two tanzanian Rural Hospitals
British Journal of Obstetrics and Gynaecology, 2012Co-Authors: Nanna Maaloe, N J Secher, Bjarke Lund Sorensen, R Onesmo, Ib C BygbjergAbstract:Please cite this paper as: Maaloe N, Sorensen B, Onesmo R, Secher N, Bygbjerg I. Prolonged labour as indication for emergency caesarean section: a quality assurance analysis by criterion-based audit at two Tanzanian Rural Hospitals. BJOG 2012;119:605–613. Objective To audit the quality of obstetric management preceding emergency caesarean sections for prolonged labour. Design A quality assurance analysis of a retrospective criterion-based audit supplemented by in-depth interviews with hospital staff. Setting Two Tanzanian Rural mission Hospitals. Population Audit of 144 cases of women undergoing caesarean sections for prolonged labour; in addition, eight staff members were interviewed. Methods Criteria of realistic best practice were established, and the case files were audited and compared with these. Hospital staff were interviewed about what they felt might be the causes for the audit findings. Main outcome measures Prevalence of suboptimal management and themes emerging from an analysis of the transcripts. Results Suboptimal management was identified in most cases. Non-invasive interventions to potentially avoid operative delivery were inadequately used. When deciding on caesarean section, in 26% of the cases labour was not prolonged, and in 16% the membranes were still intact. Of the women with genuine prolonged labour, caesarean sections were performed with a fully dilated cervix in 36% of the cases. Vacuum extraction was not considered. Amongst the hospital staff interviewed, the awareness of evidence-based guidelines was poor. Word of mouth, personal experience, and fear, especially of HIV transmission, influenced management decisions. Conclusion The lack of use and awareness of evidence-based guidelines led to misinterpretation of clinical signs, fear of simple interventions, and an excessive rate of emergency caesarean sections.
