Variation of a Single Physician’s Primary Cesarean Section Rate Across Multiple Hospitals

Introduction: Cesarean section is one of the most commonly performed surgical procedures. In 2020, there were over 3.6 million births in the United States, and of these, approximately 31.8% were delivered by cesarean section. In 2015, the World Health organization issued a statement in which a 10-15% population-based cesarean rate was recommended. It was noted that any increase in the cesarean section rate above this 10-15% baseline was not associated with any reduced neonatal/maternal mortality. Shortly after the WHO’s statement, a report was released noting that there was an observed improvement in maternal and neonatal mortality as cesarean section rates increased up to nearly 20%. The WHO subsequently acknowledged that there had been no standardized method for monitoring the rate of c-sections when they came to their proposed rate of 10-15%. Since their 2015 statement, the WHO has clarified their position and has explicitly stated that recommending a specific/targeted c-section rate for a hospital is inappropriate. In February of 2021, the Joint Commission began reporting hospitals’ primary cesarean section rates, giving then an “acceptable” rating if the facility’s PC-02 rate was 30% or lower, or a rating of unacceptable if their rate was higher than 30%. (The PC-02 rate consists solely of the number of deliveries for women with their first full-term, singleton pregnancy with baby in vertex presentation -head down). The Joint Commission recommends a primary c-section rate of under 30%, and as hospital accreditation and reimbursement from Medicare and Medicaid is closely tied to Joint Commission accreditation, many hospitals are now working to influence their physicians in a manner that will bring about a decrease in the number of c-sections that occur at their facilities. It is important to note that at this time neither the American Medical Association, the American Academy of Family Physicians, nor the American College of Obstetricians and Gynecologists have offered recommendations regarding what they believe the optimal c-section rate to be. The American College of Obstetricians and Gynecologists has instead taken a more epidemiological approach, and in their statement to USA Today notes, “National target c-section rates should be based on clinical data that has been risk-adjusted specifically to the hospital’s patient population, and that target rates are meant to be calculated across all births, not across hospitals.” This report is the first to our knowledge to look at a sole provider’s PC-02 rate across multiple hospitals. Methods: Clinic data was reviewed from patients who saw a single practitioner, Jonathan Faro, MD, PhD, from October 1, 2021 through September 30, 2022. This provider had maintained clinical privileges at three hospitals in the Houston metropolitan area, and when counseling his patients at where they would prefer to deliver, he simply asked them their preference. The hospitals that Dr. Faro delivered at during this period were Memorial Hermann Hospital Memorial City, The Woman’s Hospital of Texas, and Memorial Hermann Hospital Texas Medical Center. As this was a retrospective chart review and no identifying patient data were obtained, no IRB approval was requested. Patients were excluded if they were not nulliparous, were not full term, did not have a singleton pregnancy or if the fetus was not in vertex presentation. Demographic data was abstracted as well from the patient’s clinic record and included the patient’s age, gravidity, parity, BMI at delivery, ethnicity, and presence of any co-morbidities including diabetes, hypertension, and tobacco use. Results: From October 1, 2021 through September 30, 2022, a total of 105 patients were delivered by the physician. (This excludes patients that the physician delivered for any other physicians while on call.) 57 of these were delivered at Hospital A, 46 were delivered at Hospital B, and only 2 were delivered at Hospital C. Of these 105 patients, 19 met the criteria to be considered under the PC-02 criteria. Review of the demographic data revealed that there were no statistically significant differences between age, ethnicity, or presence of medical co-morbidities in either group. In Hospital A, obesity did appear to be associated with greater risk of c-section. Of the 9 patients delivered at Hospital A by the Physician, 11% resulted in c-section. Of the 8 patients delivered at Hospital B by the physician, 50% resulted in c-section. Of the 2 patients who delivered at Hospital C, none underwent c-section. Discussion: The Centers for Disease Control and Prevention established a recommended c-section rate of 23.9% as one of its healthy people 2020 goals. Shortly after, multiple organizations endorsed this, including the national Quality Forum, the Joint Commission, the Leapfrog Group, and the Centers for Medicaid and Medicare Services. This paper illustrates three very different primary c-section rates for a single provider. With rates ranging from 0%, to 11%, to 50%, one can easily see that it may be anything but the provider who is the driving force determining the primary c-section rate. This paper indirectly suggests that there are likely multiple factors separate from the provider that contribute towards a patient undergoing a primary c-section. Focusing on applying disincentives or even punishments to providers is perhaps the greatest disservice and this approach should be abandoned.