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Independent Pricing and Regulatory Tribunal
Case study 11 — Obstetric Delivery
Hospital costs and outcomes study for NSW Health
Other Industries
July 2010
Case study 11 – Obstetric Delivery
Hospital costs and outcomes study for NSW Health
Other Industries
July 2010
© Independent Pricing and Regulatory Tribunal of New South Wales 2010
This work is copyright. The Copyright Act 1968 permits fair dealing for study, research,
news reporting, criticism and review. Selected passages, tables or diagrams may be
reproduced for such purposes provided acknowledgement of the source is included.
ISBN 978-921628-58-0
S9-57
The Tribunal members for this review are:
Mr James Cox, Acting Chairman and Chief Executive Officer
Ms Sibylle Krieger, Part Time Member
Inquiries regarding this document should be directed to a staff member:
Alison Milne
Bee Thompson
(02) 9290 8443
(02) 9290 8496
Independent Pricing and Regulatory Tribunal of New South Wales
PO Box Q290, QVB Post Office NSW 1230
Level 8, 1 Market Street, Sydney NSW 2000
T (02) 9290 8400
F (02) 9290 2061
www.ipart.nsw.gov.au
ii
IPART Case study 11 – Obstetric Delivery
Contents
Contents
1
Introduction and executive summary
1.1 Why did we select obstetric delivery as one of the case studies?
1.2 What was the scope of the obstetric delivery case study?
1.3 What were the key findings of the obstetric delivery case study?
1.4 What are the key implications of these findings?
1.5 List of recommendations
1.6 What does the rest of this report cover?
1
4
4
5
7
8
9
2
Number and mix of patients across study hospitals
2.1 Number of obstetric delivery inpatient cases at each study hospital
2.2 Number of non-admitted occasions of service at each study hospital
2.3 Types of obstetric delivery cases at each study hospital
2.4 Comparison of casemix at the study hospitals
10
10
11
13
14
3
Length of stay across study hospitals
3.1 Comparing length of stay for caesarean sections and vaginal deliveries
3.2 Comparing length of stay by DRG
17
19
20
4
Costs of providing inpatient care
21
5
Configurations of care
5.1 Models of antenatal care
5.2 Delivery facilities
5.3 Early discharge programs
22
22
24
26
6
Outcome, safety and quality indicators
6.1 Adequacy of existing outcomes monitoring and reporting
6.2 Analysing indicators and risk-adjusting for patient characteristics
6.3 Clinical indicators for obstetrics delivery
6.4 Issues for further consideration
28
28
30
31
38
Appendices
A
List of full recommendations from main report
B
Risk-adjusted indicators provided by NSW Health
41
43
53
Glossary
55
Case study 11 – Obstetric Delivery IPART
iii
1 Introduction and executive summary
1 Introduction and executive summary
NSW Health is currently coordinating a project that ultimately aims to improve
clinical practice and efficiency consistently across the NSW hospital system. The
project involves 6 components, and is designed to enable development of a
methodology that makes better use of available data to compare patient mix, costs,
clinical practice and outcomes and which can then be applied across other hospitals
to improve performance. (See Box 1.1 for more information.)
NSW Health asked the Independent Pricing and Regulatory Tribunal of NSW
(IPART) to conduct a costs and outcomes study that encompasses 3 components of
this larger project. The aim of the study was to provide information and analysis that
can be used by clinical experts to better understand the variation in clinical practice
in NSW hospitals, and the extent to which this variation can lead to differences in
hospital costs and clinical outcomes.
IPART’s study involved comparing costs, configurations of care and outcomes in
5 selected NSW hospitals:

Royal Prince Alfred Hospital (RPAH)

Royal North Shore Hospital (RNSH)

John Hunter Hospital (JHH)

Bankstown-Lidcombe Hospital (BLH), and

Gosford Hospital (GH).
To do this, we analysed management practices at the hospital-wide level and did
detailed case studies of 11 specific clinical areas. As costs, configurations of care and
relevant indicators of outcomes vary significantly depending on the condition of the
patient and/or the procedure undertaken, these case studies allowed us to compare
the hospitals on a more like-with-like basis. This document discusses our findings in
one of these 11 clinical areas – obstetric delivery. (See Box 1.2 for the full list of
clinical areas we examined, how they were selected, and how we conducted the case
studies.)
Case study 11 – Obstetric Delivery IPART
1
1 Introduction and executive summary
Box 1.1
NSW Health Project
IPART’s hospital costs and outcomes study is part of a larger, multi-stage project NSW Health is
coordinating with the assistance of other organisations. The terms of reference for this project
set out 6 components:
1. Audit the quality of current coding and costing data.
2. Analyse differences in costs between 3 principal tertiary referral hospitals and 2 other
principal referral hospitals.
3. Describe the different configurations of care that underpin different cost profiles.
4. Analyse available data on differences in adjusted admission rates and clinical outcomes for
the 5 selected hospitals.
5. Determine whether variations in configurations of care lead to different clinical outcomes.
6. Identify the extent to which clinical variation exists, with the aim of achieving clinical best
practice and maximum efficiency.
The first component is being completed by Health Outcomes International (audit of costing)
and Pavilion Health (audit of coding). The results will assist the NSW Department of Health in
further developing episode funding, in line with the national agreement by the Council of
Australian Governments (COAG) to move to a more nationally consistent approach to activitybased funding. IPART has completed the second, third and fourth components through our
hospital costs and outcomes study. The results of this study will be used by clinical experts in
completing the fifth and sixth components.
The NSW Health project is part of its response to the findings and recommendations made in
the Report of the Special Commission of Inquiry into Acute Care Services by Commissioner
Garling.a
a Flowing from the NSW Government’s response to the Garling Inquiry (Caring Together - The Health Action Plan for
NSW (2009)), ‘four pillars’ of clinical improvement have been established – Clinical Excellence Commission (CEC),
Agency for Clinical Innovation (ACI), Bureau of Health Information (BHI) and Clinical Education and Training Institute
(CETI). IPART’s analysis on costs, clinical practice and outcomes is to be considered by the NSW Department of Health
and clinical experts in these agencies to assess whether variations in configurations of care lead to different clinical
outcomes and to identify the extent to which clinical variation exists, with the aim of achieving clinical best practice
and maximum efficiency.
2
IPART Case study 11 – Obstetric Delivery
1 Introduction and executive summary
Box 1.2
IPART’s case studies
To compare costs, configurations of care and outcomes in the 5 study hospitals, we focused on
11 specific conditions or procedures in detail (as well as undertaking a broad, hospital-wide
analysis). These conditions/procedures are:

Hip joint replacement

Major chest procedures

Breast surgery

Cholecystectomy

Appendicectomy

Stroke

Cardiology – stents, pacemakers and defibrillators

Tracheostomy, or ventilation for greater than 95 hours

Cataract/lens procedures

Hysterectomy, and

Obstetric delivery.
In selecting these conditions/procedures, and the relevant indicators to compare for each, we
were advised by a clinical consultant (Dr Paul Tridgell) and a clinical reference group (Professor
Bruce Barraclough, Dr Anthony Burrell, Dr Patrick Cregan, Professor Phillip Harris, Professor
Clifford Hughes, Professor Brian McCaughan, Professor Peter McClusky, Dr Michael Nicholl,
Professor Ron Penny, Professor Carol Pollock and Dr Hunter Watt).
The case studies were selected to provide a range of surgical procedures and a range of
medical conditions that met one or more of the following criteria:

high volumes

high reported costs

high variability in reported costs

apparent differences in clinical practice, or

a range of models of care.
To conduct the case studies, we visited each of the hospitals and spoke with a range of staff,
including clinical, nursing, management, finance, coding and administrative staff. We also
collected a range of clinical and financial data from NSW Health, relevant area health services
and hospitals. By analysing the data and speaking with clinical experts, we established the
most suitable data available for comparing hospitals on a like-with-like basis.
For further information on our methodology and broad findings on costs, outcomes and
configurations of care, see our main report, NSW Health costs and outcomes study by IPART for
selected NSW hospitals. Our detailed findings on the other case study areas can be found in our
reports on each area.
Case study 11 – Obstetric Delivery IPART
3
1 Introduction and executive summary
1.1
Why did we select obstetric delivery as one of the case studies?
Obstetric delivery was selected as one of the clinical areas for detailed study because
it involves:

high volumes1

different service models (eg, birthing units, early discharge and home support)

variation in practice between hospitals (eg, different caesarean section rates).
1.2
What was the scope of the obstetric delivery case study?
The obstetric delivery case study compared the costs, configurations of care and
outcomes related to caesarean section or vaginal delivery. We used diagnostic
related groups (DRGs) to define the case study and identify the data included in the
scope of the case study (see Table 1.1).
Table 1.1 DRGs included in the scope of the obstetric delivery case study
DRG
DRG Description
O01A
Caesarean delivery with catastrophic complication or comorbidity
O01B
Caesarean delivery with severe complication or comorbidity
O01C
Caesarean delivery without catastrophic or severe complication or comorbidity
O02A
Vaginal delivery with operating room procedure with catastrophic or severe complication
or comorbidity
O02B
Vaginal delivery with operating room procedure without catastrophic or severe
complication or comorbidity
O60A
Vaginal delivery with catastrophic or severe complication or comorbidity
O60B
Vaginal delivery without catastrophic or severe complication or comorbidity
O60C
Vaginal delivery single uncomplicated without other condition
Unless specified otherwise in this case study, the data we analysed related to the
12-month period from 1 July 2008 to 30 June 2009.
1
4
In 2007/08, there were 287,451 separations in Australian hospitals for the obstetric delivery
DRGs listed in Table 1.1. See Australian Institute of Health and Welfare, AR-DRG Data Cubes,
Separation, patient day and average length of stay statistics by Australian Refined Diagnosis Related
Group
(AR-DRG)
Version
5.0/5.1,
Australia,
1998-99
to
2007-08
(http://d01.aihw.gov.au/cognos/cgi-bin/ppdscgi.exe?DC=Q&E=/AHS/drgv5_9899-0708_v2).
IPART Case study 11 – Obstetric Delivery
1 Introduction and executive summary
1.3
What were the key findings of the obstetric delivery case study?
To compare the costs, configurations of care and outcomes of obstetric deliveries at
the study hospitals, we collected, analysed and compared data on:

the number and mix of obstetric delivery patients at each hospital

the average length of stay for these patients at each hospital

selected costs, or major clinical resources used to provide acute inpatient care for
these patients at each hospital

the configurations of care used to provide and manage obstetric delivery patients
care at each hospital

indicators of outcome, safety and quality for obstetric deliveries for each hospital.
Our key findings are summarised below.
1.3.1
Number and mix of patients
We found differences across the study hospitals in patient numbers, caesarean
section rates, obstetric delivery complexity and patient demographics.

RPAH treated the most inpatient cases, followed by JHH.

RNSH, GH and RPAH had much higher caesarean section rates than JHH and
BLH.

RPAH, RNSH and JHH had a higher percentage of patients with the more
complex DRGs (O01A, O01B, O02A and O06A2) than GH and BLH.

RNSH and RPAH had an older patient demographic than GH, JHH and BLH.
In addition, we found that the way the hospitals counted and reported their
outpatient activity was not consistent.
1.3.2
Average length of stay
We found that the average length of stay for vaginal deliveries is lower than that for
caesarean sections. Average length of stay is lowest at GH and BLH for both
delivery types.
2
Respectively, caesarean delivery with catastrophic complication or comorbidity; caesarean
delivery with severe complication or comorbidity; vaginal delivery with operating room
procedure with catastrophic or severe complication or comorbidity; and vaginal delivery with
catastrophic or severe complication or comorbidity.
Case study 11 – Obstetric Delivery IPART
5
1 Introduction and executive summary
1.3.3
Costs of inpatient care
A significant proportion of obstetric delivery care involves outpatient activity.
Therefore, while we were able to model the costs of inpatient care, we did not
consider that this provided a reliable proxy for the total costs of obstetric delivery
care. Further, as the study hospitals do not appear to count their outpatient activity
consistently, we were unable to attribute a value to this activity in order to estimate
the total costs.
1.3.4
Configurations of care
We analysed the way the study hospitals managed and provided care for obstetric
delivery patients along a continuum, from antenatal care through obstetric delivery
and then discharge from hospital. In particular, we considered the similarities and
differences between the study hospitals in the following areas:

models of antenatal care

options regarding delivery facilities, and

early discharge programs.
Models of antenatal care
The study hospitals broadly use the same models of antenatal care, which are related
to the complexity of the patient. The antenatal clinics staffed by obstetrician
consultants and registrars are usually attended by patients with higher risk
pregnancies. Midwifery care and GP shared antenatal care are available for patients
with lower risk pregnancies.
Delivery facilities
All study hospitals have birthing suites and theatres for deliveries. RPAH and JHH
also have birth centres for low risk pregnancies. In addition, JHH has configurations
of care that support home births.
Early discharge programs
All study hospitals have some form of early discharge program. However, the study
hospitals appear to have different timeframes for patients leaving hospital under
these programs, with GH having the shortest timeframe.
To understand the impact of the early discharge programs, we analysed the time
taken from obstetric delivery to discharge from the hospital for a patient’s acute
episode. When compared to the other study hospitals, a substantially higher
percentage of patients were discharged from GH within 72 hours of delivery for
caesarean section and within 48 hours of delivery for vaginal delivery. These results
are consistent with our findings that GH patients have shorter stays on average.
6
IPART Case study 11 – Obstetric Delivery
1 Introduction and executive summary
1.3.5
Outcome, safety and quality indicators
In relation to obstetric deliveries, there is already a substantial amount of monitoring
and reporting on hospital performance against clinical indicators. Further, the
Maternity Services Inter-Jurisdictional Committee is currently developing a core set
of national maternity care performance indicators.3
As the national clinical indicators are still being finalised, we considered the
performance of the study hospitals against several commonly reported clinical
indicators. The study hospitals had broadly similar results for babies born with low
Apgar scores. However, the indicators relating to caesarean sections highlighted
significant differences between the hospitals.
GH had the highest risk-adjusted rates for caesarean sections for ‘selected
primiparas’4 and caesarean sections after induction of labour. These rates were
substantially lower at BLH and JHH.
1.4
What are the key implications of these findings?
Outpatient activity
In order to accurately assess a hospital’s total costs of providing obstetric delivery
care, both inpatient and outpatient activity at the hospital needs to be taken into
account. While costing data is available for inpatient activity, outpatient data does
not appear to be reliably measured by the study hospitals.
Outcomes monitoring
There is often a considerable lag between outcome data collection and reporting,
which does not allow hospitals to readily gauge the impact of their practices or
compare their performance with other hospitals. As an example, the latest NSW
Mothers and Babies report was released in 2009 and based on data from 2006. NSW
Health should ensure that results against clinical indicators are readily disseminated
to the clinical level.
3
4
The Maternity Services Inter-Jurisdictional Committee was established by the Australian Health
Ministers’ Advisory Council as an information sharing network of representatives from States
and Territories with the principal objective of promoting primary maternity services. See
Maternity
Services
Inter-Jurisdictional
Committee
(http://www.ahmac.gov.au/cms_documents/Maternity%20Services%20Interjurisdictional%20
Committee(1).pdf).
The ‘selected primipara’ is defined as a woman who is 20-34 years of age, giving birth for the
first time at between 37-41 weeks gestation and with a singleton pregnancy (pregnancy with
only one baby) in cephalic presentation (head-first).
Case study 11 – Obstetric Delivery IPART
7
1 Introduction and executive summary
Caesarean section rates
There were significant differences between the hospitals in relation to risk-adjusted
caesarean section rates, with GH having substantially higher rates than BLH and
JHH. This could not be easily explained by differences in configurations of care at
the study hospitals or patient complexity. Further, there was not a link between
caesarean section rates and differences in other outcome indicators in our clinical
indicator set, such as Apgar score and severe perineal trauma.
NSW Health is taking steps to address the issue of increasing caesarean section rates
and variation in rates across hospitals. It recently released a new policy directive,
Maternity – Towards Normal Birth in NSW, which outlines actions to increase the
vaginal birth rate and decrease the caesarean section rate. Area Health Services will
be required to report annually on their performance against key measures such as:

maternity services having a written normal birth policy

the percentage of women having vaginal births

maternity clinicians being informed of statistics relating to outcomes for vaginal
birth after caesarean section.
1.5
1
8
List of recommendations
That NSW Health and clinical expert groups note the variation in the following
clinical indicators relating to obstetric delivery:
39
– caesarean section rates for ‘selected primipara’
39
– vaginal delivery rates following primary caesarean section
39
– caesarean section rates after induction of labour for ‘selected primipara’
39
– repeat caesarean section rates
39
– significant tear rates
39
and monitor changes arising from the implementation of the NSW Health policy
directive, Maternity – Towards Normal Birth in NSW, to determine whether this
policy effectively addresses the variation.
39
IPART Case study 11 – Obstetric Delivery
1 Introduction and executive summary
1.6
What does the rest of this report cover?
The rest of this report discusses the findings of the obstetric delivery case study in
more detail:

Chapter 2 compares the number and mix of obstetric delivery patients at the
study hospitals.

Chapter 3 compares the length of stay for obstetric delivery patients at the study
hospitals, and describes the method we used to compare length of stay on a
consistent basis.

Chapter 4 describes the limitations associated with costing obstetric deliveries at
the study hospitals.

Chapter 5 compares the configurations of care for obstetric delivery patients at the
study hospitals.

Chapter 6 discusses the indicators of outcome, safety and quality for obstetric
deliveries we identified as clinically meaningful. It then compares the available
data on these indicators across the study hospitals.

The appendices contain the complete list of recommendations for our hospital
costs and outcomes study and additional information for risk-adjusted indicators.
A glossary is also included at the end of this report.
Case study 11 – Obstetric Delivery IPART
9
2 Number and mix of patients across study hospitals
2 Number and mix of patients across study hospitals
We identified the total number of obstetric delivery inpatient cases at each hospital
during the study period, and compared this with the outpatient activity for obstetrics
reported by the study hospitals. We also examined the proportions of inpatient cases
for each delivery type. We then compared the mix of cases by identifying the
proportion of patients within each DRG. In addition, we considered the age of
patients at the study hospitals.
We found differences across the study hospitals in patient numbers, caesarean
section rates, obstetric delivery complexity and patient demographics. We also
found that the study hospitals are not counting their outpatient activity using a
consistent methodology.
The sections below discuss our analysis of patient numbers and mix in more detail.
2.1
Number of obstetric delivery inpatient cases at each study hospital
Our data indicates that the 5 study hospitals managed a total of 15,488 obstetric
delivery cases during the study period. It also shows that there were differences
between the hospitals in the number of cases and transfers (see Table 2.1).
Table 2.1 Obstetric delivery cases at study hospitals, DRGs O01A, O01B, O01C,
O02A, O02B, O60A, O60B, O60C, 2008/09
Inpatient cases (no.)
Transfers in (%)
Transfers out (%)
RPAH
GH
RNSH
BLH
JHH
All study
hospitals
5,146
2,407
1,906
2,135
3,894
15,488
12
7
5
1
3
7
0
9
0
2
1
2
Note: See Box 2.1 for details on how we calculated the number of cases and transfers.
Source: HIE inpatient statistics, 2008/09 and IPART analysis.
The number of cases ranged from 1,906 at RNSH to 5,146 at RPAH. GH and BLH
both had a significant number of cases for hospitals of their size, with 2,407 and 2,135
cases respectively. JHH had 3,894 cases. We understand that a hospital’s volume of
cases may sometimes reflect capacity issues relating to infrastructure.
10
IPART Case study 11 – Obstetric Delivery
2 Number and mix of patients across study hospitals
RPAH had the highest percentage of patients who were transferred in (12%). The
next highest rates were at GH, RNSH and JHH, with 7%, 5% and 3% respectively.
Transfers in and out at GH reflect movement to and from nearby Wyong Hospital.
Similarly, the transfers in for RNSH and JHH include movement in from primary
models at Ryde Hospital and Belmont Hospital respectively. For the tertiary
hospitals (ie, RPAH, RNSH and JHH), some of the ‘transfers in’ may also represent
higher risk pregnancies, resulting in longer stays and greater costs than lower risk
pregnancies.
Box 2.1 provides more detail on how we calculated the number of cases and transfers
at each hospital.
Box 2.1
How we calculated the number of obstetric delivery cases and transfers
Number of cases
To calculate the number of obstetric delivery cases in study hospitals, we:

used patient episode data for 2008/09

counted adjoining episodes as part of the same stay (ie, adjoining episodes counted as one
case)

only included patient data where the whole patient stay occurred within 2008/09 (ie, all
episodes and adjoining episodes had to start on or after 1 July 2008 and end on or before
30 June 2009 to be counted)

only included patient data where the first episode in the year in the study hospital was
coded as a DRG for an obstetric delivery (ie, episode sequence number had to be 1).
The approach prevented double counting. It excluded cases where the patient was admitted
for a different procedure and later reclassified to an obstetric delivery DRG.
Note that our approach means that the number of cases we identified will be less than the
number of separations in 2008/09.
Transfers
Due to data quality issues with the transfer in and transfer out fields in the admitted patient
data, transfers in and out were calculated using a linkage key developed by the Australian
Institute of Health and Welfare.
2.2
Number of non-admitted occasions of service at each study hospital
A significant proportion of obstetric delivery care involves outpatient activity. Table
2.2 sets out the number of non-admitted patient occasions of service (NAPOOS)
reported by the study hospitals during the case study period.
Case study 11 – Obstetric Delivery IPART
11
2 Number and mix of patients across study hospitals
Table 2.2 Non-admitted patient occasions of service by provider type
RPAH
GH
RNSH
BLH
JHH
no.
no.
no.
no.
no.
4,427
542
9,406
-
7,688
13,914
4,157
-
-
-
17,514
14,505
13,468
22,313
54,244
Individual sessions
Provider type
Setting type
Medical or
surgical
specialist
Hospital
Multidisciplinary Hospital
team
Nurse or allied
health
professional
Hospital
Community
Health Centre
Home
Group sessions Hospital
Total sessions
-
6,965
-
-
5,106
5,502
5,457
1,941
-
14,421
181
118
19
-
185
41,538
31,744
24,834
22,313
81,644
Note: The multidisciplinary team figure for RPAH include 1,682 outpatient occasions of service for assisted
reproductive technology.
Source: NSW Department of Health, 2008/09 and IPART analysis.
The outpatient activity reported by the study hospitals does not correlate with their
inpatient activity, as would be expected. For example, JHH reported almost double
the number of NAPOOS than RPAH, even though JHH had fewer inpatient obstetric
delivery patients than RPAH (see Table 2.1). This indicates that the study hospitals
are not counting their outpatient activity using a consistent methodology.
Study hospitals also seem to be classifying their NAPOOS differently. As an
example, all of BLH’s NAPOOS are reported as being managed by nurses (or allied
health professionals) in a hospital setting. In contrast, the other hospitals reported
their NAPOOS as being managed by a number of provider types across several
settings.
12
IPART Case study 11 – Obstetric Delivery
2 Number and mix of patients across study hospitals
2.3
Types of obstetric delivery cases at each study hospital
There was substantial variation in the rates of caesarean section at the study hospitals
(see Table 2.3).
Table 2.3 Obstetric delivery types
RPAH
GH
RNSH
BLH
JHH
All study
hospitals
%
%
%
%
%
%
Caesarean section
32
34
35
20
23
29
Vaginal delivery
68
66
65
80
77
71
Source: HIE inpatient statistics, 2008/09 and IPART analysis.
RNSH, GH and RPAH all had similar caesarean section rates, with 35%, 34% and
32% respectively. In comparison, JHH and BLH had much lower caesarean rates, at
23% and 20% respectively.
The caesarean section rate is higher among private patients than public patients at
the study hospitals (see Table 2.4).
Table 2.4 Caesarean section rates by patient type, 2008/09
RPAH
GH
RNSH
BLH
JHH
%
%
%
%
%
Public patients
51
98
97
91
84
Private patients
49
2
3
9
16
Public patients
29
33
35
19
22
Private patients
35
64
61
31
26
Patient mix
Caesarean section rate
Source: HIE inpatient statistics, 2008/09 and IPART analysis.
Only RPAH and JHH have significant proportions of private patients for obstetric
deliveries, with 49% and 16% respectively. GH and RNSH have the lowest
proportions of private patients, with 2% and 3% respectively. As such, the higher
caesarean section rates at these hospitals cannot be explained by them having a
higher intake of private patients.
Clinicians at most study hospitals indicated that they were trying to reduce
caesarean section rates. For example, RPAH clinicians conducted an audit of their
caesarean section rates to understand the factors affecting them. The audit has led to
RPAH placing a greater emphasis on one-on-one midwifery care and midwives
looking after women in labour. In addition, the Northern Sydney Central Coast Area
Health Service (which includes RNSH and GH) is planning to implement an area
wide program encouraging more women to attempt vaginal delivery for their next
Case study 11 – Obstetric Delivery IPART
13
2 Number and mix of patients across study hospitals
birth following a caesarean section. Caesarean section rates at the study hospitals are
discussed in more detail in section 6.2.
2.4
Comparison of casemix at the study hospitals
Our data indicated that there was variation in the relative proportions of cases in
each DRG across study hospitals. Further, there were differences in the proportion of
patients in different age groups.
2.4.1
DRG complexity
The obstetric delivery case study contains eight DRGs. Table 2.5 shows the
percentage of cases ‘coded’ in each DRG, divided into the more complex and less
complex categories of patient.
Table 2.5 Percentage of cases coded in each obstetric delivery DRG
DRG
RPAH
GH
RNSH
BLH
JHH
All study
hospitals
%
%
%
%
%
%
O01A – caesarean delivery with catastrophic CC
3
2
2
0
3
2
O01B – caesarean delivery with severe CC
7
5
7
3
5
6
O02A – vaginal delivery with O.R. procedure
with catastrophic or severe CC
1
1
2
0
1
1
O60A – vaginal delivery with catastrophic or
severe CC
9
7
8
5
10
8
20
14
19
9
20
17
22
27
26
16
15
21
1
1
3
1
3
2
49
48
46
56
51
50
8
9
6
17
12
10
80
86
81
91
80
83
More complex DRGs
Total more complex DRGs
Less complex DRGs
O01C – caesarean delivery without catastrophic
or severe CC
O02B – vaginal delivery with O.R. procedure
without catastrophic or severe CC
O60B – vaginal delivery without catastrophic or
severe CC
O60C – vaginal delivery single uncomplicated
without other condition
Total less complex DRGs
Note: “CC”= complication or comorbidity; “O.R.”=operating room.
Source: HIE inpatient statistics, 2008/09 and IPART analysis.
RPAH, JHH and RNSH had the highest proportion of patients with the more
complex DRGs, with 20%, 20% and 19% respectively. In contrast, GH and BLH only
had 14% and 9% respectively of their patients with the more complex DRGs.
14
IPART Case study 11 – Obstetric Delivery
2 Number and mix of patients across study hospitals
In order to help assess if the coders in each hospital are coding patients similarly,
IPART compared the average number of diagnosis codes per obstetric delivery in the
five hospitals5 (see Table 2.6).
Table 2.6 Average number of diagnosis codes per patient in study hospitals by DRG
DRG
RPAH
GH
RNSH
BLH
JHH
no.
no.
no.
no.
no.
O01A – caesarean delivery with catastrophic CC
8.5
8.5
9.0
7.3
9.0
O01B – caesarean delivery with severe CC
6.3
6.8
6.9
5.3
6.9
O01C – caesarean delivery without catastrophic or
severe CC
4.2
4.2
4.4
3.5
4.5
O02A – vaginal delivery with O.R. procedure with
catastrophic or severe CC
6.4
6.1
7.2
5.7
7.1
O02B – vaginal delivery with O.R. procedure without
catastrophic or severe CC
4.0
4.3
4.5
4.2
4.3
O60A – vaginal delivery with catastrophic or severe CC
6.3
6.2
7.3
5.1
6.5
O60B – vaginal delivery without catastrophic or severe
CC
3.8
4.1
4.1
3.4
4.0
O60C – vaginal delivery single uncomplicated without
other condition
2.5
2.7
2.4
2.6
2.6
Note: “CC”= complication or comorbidity; “O.R.”=operating room.
Source: HIE inpatient statistics, 2008/09 and IPART analysis.
We found that the number of diagnosis codes in the inpatient data was fairly similar
across the hospitals.
5
This provides a rough guide to help assess whether there is a significant difference in coding
practice between hospitals. If one hospital is coding cases in higher complexity categories, we
would expect that there were more diagnosis codes used on average. Likewise, if hospitals were
paying little attention to coding complexity, we would expect few diagnosis codes to be
included.
Case study 11 – Obstetric Delivery IPART
15
2 Number and mix of patients across study hospitals
2.4.2
Age of patients
We considered the age of patients at the study hospitals (see Table 2.7).
Table 2.7 Age of patients
RPAH
GH
RNSH
BLH
JHH
All study
hospitals
All cases
33
29
32
29
29
31
Caesarean section
34
30
33
31
30
31
Vaginal delivery
32
29
32
29
29
30
1
5
1
2
5
3
20-34 years
62
75
63
80
75
70
35 years and over
38
20
36
18
20
28
Average age (years)
% of patients in different age groups
under 20 years
Note: Age at date of admission.
Source: HIE inpatient statistics, 2008/09 and IPART analysis.
The average age of patients for caesarean section was 31 years old, ranging from an
average of 30 years for GH and JHH to 34 years for RPAH. In relation to vaginal
delivery, the average age of patients was 30 years old, ranging from an average of
29 years for GH, JHH and BLH to 32 years for RPAH and RNSH.
The small difference in average age for caesarean section and vaginal delivery
implies that patient age is not an important factor in hospitals’ caesarean section
rates. However, there appears to be some correlation between hospitals with older
demographics and higher caesarean section rates.
RPAH and RNSH had the highest proportion of patients aged 35 years and over,
with 38% and 36% respectively, as well as relatively high caesarean section rates. In
contrast, BLH and JHH had the lowest proportion of patients aged 35 years and over,
with 18% and 20% respectively, as well as relatively low caesarean section rates.
16
IPART Case study 11 – Obstetric Delivery
3 Length of stay across study hospitals
3 Length of stay across study hospitals
We examined the average length of stay of obstetric delivery inpatients because it is
one of the factors that influence the cost of an individual’s hospital care. This is
because a large component of this cost is nursing care (and this cost increases with
the length of stay). In addition, differences in length of stay can point to differences
in casemix or clinical practice between hospitals.
We calculated the average length of stay across all study hospitals for obstetric
delivery cases using 3 different measures:

episode length of stay in study hospital (LOS1)

total length of stay in study hospital (LOS2)

total length of stay in study hospital and 2 other hospitals – one transfer in and
one transfer out (LOS3).
Box 3.1 provides more detail on these measures. The sections below set out our
analysis of length of stay for caesarean section and vaginal delivery cases, as well as
for each obstetric delivery DRG, with a focus on LOS1 and LOS3.
Case study 11 – Obstetric Delivery IPART
17
3 Length of stay across study hospitals
Box 3.1
The 3 measures of length of stay we used for obstetric delivery patients
1. Episode length of stay in study hospital (LOS1)
This is the average number of days a patient stayed in the study hospital for a single acute
episode. This measure is often used in DRG benchmarking analyses.
2. Total length of stay in study hospital (LOS2)
This is the total number of days a patient stayed in the study hospital from admission to
discharge. It includes all consecutive episodes including acute, rehabilitation and any other
types of care. However, for some conditions/procedures, patients can be:

transferred to the study hospital from another hospital, and/or

transferred from the study hospital to another.
LOS2 does not include the length of stay in such other hospitals, so does not provide a
consistent basis for comparing average length of stay required to care for certain
conditions/procedures.
3. Total length of stay in study hospital plus up to 2 other hospitals – one transfer in and
one transfer out (LOS3)
The third measure is the total length of stay in the study hospital (ie, LOS2), plus the total
length of stay at 2 other hospitals – one ‘transfer in’, and one ‘transfer out’. Ideally all related
hospital stays would be linked, but we have only added up to one additional hospital stay at
either end of the stay in the study hospital. We used the linkage key developed by the
Australian Institute of Health and Welfare (AIHW) for use between all public and private
hospitals. This step is not routinely done in hospital comparisons.
We consider that LOS3 is a more consistent basis for comparing average length of stay for
certain conditions/procedures because it takes account of differences in hospital:
18

administrative practices for reclassifying patients between their acute care and other phases
of care (type changes)

access to rehabilitation facilities (transfers out)

patterns of referral from other hospitals (transfers in).
IPART Case study 11 – Obstetric Delivery
3 Length of stay across study hospitals
3.1
Comparing length of stay for caesarean sections and vaginal
deliveries
Table 3.1 compares the average length of stay for caesarean sections and vaginal
deliveries across the study hospitals, using the LOS1 and LOS3 measures.
Table 3.1 Average length of stay by delivery type
RPAH
GH
RNSH
BLH
JHH
days
days
days
days
days
LOS1
5.6
3.8
5.3
4.4
6.3
LOS3
5.5
3.8
5.2
4.3
6.8
LOS1
3.5
2.2
3.1
2.8
2.9
LOS3
3.4
2.4
3.0
2.7
3.0
LOS1
2.1
1.7
2.2
1.6
3.4
LOS3
2.1
1.4
2.2
1.6
3.8
Caesarean section
Vaginal delivery
Difference in LOS
Note: Numbers may not add due to rounding. In a few instances LOS3 will be slightly shorter than LOS1, because LOS1
is calculated using hours on the ward while LOS3 is calculated using days. For example, if a patient is admitted in the
morning for surgery and discharged early afternoon of the next day, the average length of stay would be 30 hrs or 1.25
days: under LOS3 this would be 1 day and under LOS1 this would be 1.25 days.
Source: HIE inpatient statistics, 2008/09 and IPART analysis.
The average total number of days in hospital for caesarean sections ranges from
3.8 days at GH to 6.8 days at JHH. For vaginal deliveries, the range was from
2.4 days at GH to 3.4 days at RPAH. The difference in length of stay between
caesarean sections and vaginal deliveries ranges from 1.4 days at GH to 3.8 days at
JHH using the LOS3 measure.
Patient mix may partially explain the differences in average length of stays at the
study hospitals. For example, GH has a relatively young patient mix (see Table 2.7),
a factor which is typically associated with shorter stays. In addition, a hospital’s
average length of stay may be affected by capacity issues relating to infrastructure.
Clinicians at GH indicated that their shorter stays partly reflect the high numbers of
deliveries at the hospital. Staff proactively check wards to see whether patients are
ready for discharge.
The approach of study hospitals to discharging patients is discussed further in
Chapter 5 on configurations of care. We note that some hospitals provide
considerable support for patients at home after their discharge. As such, a shorter
length of stay may be partially offset by care in the home.
Case study 11 – Obstetric Delivery IPART
19
3 Length of stay across study hospitals
3.2
Comparing length of stay by DRG
Table 3.2 compares the average length of stay for caesarean section and vaginal
delivery patients by DRG across the study hospitals using the LOS3 measure.
Table 3.2 Average length of stay by DRG
RPAH
GH RNSH
BLH
JHH
days
days
days
days
days
10.2
7.4
13.1
5.0
12.9
O01B – caesarean delivery with severe CC
6.5
4.7
7.0
5.3
9.6
O01C – caesarean delivery without catastrophic or severe
CC
4.6
3.5
4.0
4.1
4.7
O02A – vaginal delivery with O.R. procedure with
catastrophic or severe CC
4.6
4.3
6.5
4.1
5.6
O02B – vaginal delivery with O.R. procedure without
catastrophic or severe CC
3.9
2.7
3.0
3.5
2.9
O60A – vaginal delivery with catastrophic or severe CC
5.3
3.6
6.4
4.5
5.7
O60B – vaginal delivery without catastrophic or severe CC
3.3
2.3
2.5
2.7
2.7
O60C – vaginal delivery single uncomplicated without
other condition
2.2
1.6
1.7
2.1
1.6
Caesarean section
O01A – caesarean delivery with catastrophic CC
Vaginal delivery
Note: “CC”= complication or comorbidity; “O.R.”=operating room.
Source: HIE inpatient statistics, 2008/09 and IPART analysis.
Average length of stay for the less common, more complex DRGs can be significantly
influenced by a few outlier cases. As such, there is a large difference between the
study hospitals for these DRGs.
In relation to the more common, less complex DRGs, GH generally had the shortest
stays. For example, the average total number of days in hospital for:

DRG O01C ranges 3.5 days at GH to 4.7 days at JHH, and

DRG O60B ranges 2.3 days at GH to 3.3 days at RPAH.
These DRGs comprise over 70% of obstetric deliveries at the study hospitals (see
Table 2.5).
20
IPART Case study 11 – Obstetric Delivery
4 Costs of providing inpatient care
4 Costs of providing inpatient care
We were unable to compare obstetric delivery costs at the study hospitals, mainly
due to a lack of data on outpatient costs.
Outpatient activity represents a significant proportion of obstetric delivery care (see
Table 2.2). However, as study hospitals do not count their outpatient activity using a
consistent methodology, we were unable to accurately cost it.
While we did model the costs of inpatient care at the study hospitals, we did not
consider that this provided a reliable proxy for the total costs of obstetric delivery
care.
As an example, a hospital may provide an early discharge program to patients for the
week following their deliveries. This program is an alternative to the patients
remaining in hospital for that week. By only focusing on inpatient costs, the early
discharge program appears to lower the hospital’s costs. However, the outpatient
costs that the hospital incurs – namely, the costs of home visits by the midwives –
need to be taken into account to understand the hospital’s total costs.
Case study 11 – Obstetric Delivery IPART
21
5 Configurations of care
5 Configurations of care
The term ‘configurations of care’ refers to the way that hospitals choose to manage
and provide patient care, including their clinical practices.
The particular
configurations of care within a hospital can be influenced by a complex array of
factors, including national or state-wide guidelines or protocols, the culture, practices
and controls of the individual hospital, the culture and practices of each clinical unit
and its leadership and the preferences of each clinician. Differences in the way
hospitals manage and provide patient care can also lead to differences in the costs
and outcomes of that care.
We have considered configurations of care along a continuum, from antenatal care
through obstetric delivery and then discharge from hospital. The section below
describes the similarities and differences between the study hospitals in the
following areas:

Models of antenatal care

Options regarding delivery facilities, and

Early discharge programs.
5.1
Models of antenatal care
The study hospitals broadly use the same models of antenatal care, which are related
to the complexity of the patient. The antenatal clinics staffed by obstetrician
consultants and registrars are usually attended by patients with higher risk
pregnancies. Midwifery care and GP shared antenatal care are available for patients
with lower risk pregnancies.
The study hospitals use a similar approach to ascertain which model of antenatal
care is appropriate for each patient. Typically, patients have their first visit with an
obstetrician, where they are screened for risk factors. If there are no significant risk
factors regarding the pregnancy, the patient can choose to attend the midwives clinic.
If there are risks, the patient attends the antenatal clinic.
22
IPART Case study 11 – Obstetric Delivery
5 Configurations of care
5.1.1
Antenatal clinic
At RNSH, the antenatal clinic offers a ‘one-stop shop’ for high risk patients (eg, with
complications like diabetes or hypertension). These patients visit the obstetric
specialist at the clinic, who can then consult with the anaesthetist or haematologist as
needed. Alternatively, the patients may meet directly with the appropriate clinician
for their complication (eg, renal clinician).
The majority of obstetric delivery patients at RNSH attend its antenatal clinic. In
contrast, only 40% of patients at GH attend the antenatal clinic.
RPAH has a high risk obstetrician consultant and registrar clinic on site. Registrar
clinics are the usual points of contact where women come for set visits to review their
care.
RNSH, BLH and GH have Day Assessment Units. This enables high risk pregnancies
to be monitored without a hospital admission.
5.1.2
Midwifery care
RNSH and GH both have midwifery group practices providing continuity of care to
patients. Under this model, each patient has a particular midwife within the
midwifery group who provides the majority of care throughout the pregnancy, birth
and after the birth. Each midwife looks after around 40 women.
GH also has a community midwifery practice. This is a team of midwives with no
dedicated patients that assist with antenatal and post partum care as needed. Over
45% of patients choose a combination of midwifery group practice and community
midwifery services.
Similar to RNSH and GH, JHH has a continuity of care model where the midwife is
the primary carer throughout the patient’s antenatal and post-partum care.
However, JHH is also aiming to provide more midwifery care to higher risk
pregnancies. As such, there is a major initiative in place at the hospital to improve
midwife skills to handle high risk cases.
RNSH, GH and JHH introduced their midwifery models of care to help meet the
demands of an increasing number of patients, as well as provide greater patient
choice.
At BLH, midwives handle around 50% of patients. While there is no community
midwifery program at BLH, it is a model of care they are considering adopting.
Case study 11 – Obstetric Delivery IPART
23
5 Configurations of care
5.1.3
GP shared care
Under this model, a patient’s care is shared between a GP and antenatal or midwives
clinics. Typically, the GP will conduct most of the patient’s check-ups over the
course of the pregnancy.
5.2
Delivery facilities
All study hospitals have birthing rooms. Several also have dedicated obstetric
theatres. A birth centre is available for patients at RPAH and JHH. In addition, JHH
has configurations of care that support home birth.
5.2.1
Birthing rooms
The study hospitals have similar number of birthing rooms. For example:

BLH has 7 birthing rooms.

RPAH has 9 birthing rooms.

GH has 8 birthing rooms and 1 pregnancy loss room.
As RPAH has significantly more obstetric deliveries than the other study hospitals,
there have been access issues for its birthing rooms. In the last 18 months in
particular, clinicians have needed to transfer early labouring women who are low
risk to Canterbury Hospital.
5.2.2
Theatre
Several of the study hospitals have full-time obstetric theatres. For example, RPAH
has 2 dedicated theatres. Further, RNSH has a maternity theatre in the birthing unit.
While BLH has one dedicated theatre, it is closed between 10pm and 8am. As such,
clinicians cannot perform emergency caesarean sections during these times at this
theatre. Instead, caesarean sections at these times are performed in the gynaecology
ward for surgery.
24
IPART Case study 11 – Obstetric Delivery
5 Configurations of care
5.2.3
Birth centre
Around 2.8% of births in NSW occur in birth centres.6 Birth centres offer both
antenatal care and care during birth to women with low risk pregnancies. They are
separate from the hospital and managed by midwives. Birth centres are generally
characterised by a commitment to normality of pregnancy and birth, and a homelike
environment.7
They have established links to a hospital referral service. As such, women intending
to give birth in a birth centre may be transferred during pregnancy or labour
depending on their risk factors.8
RPAH and JHH both administer birth centres:

The birth centre at RPAH has midwives, lead consultants and guidelines that are
separate from the main hospital. Staff estimate that the birth centre has around
800 cases a year. This represents around 16% of obstetric delivery cases at RPAH
in 2008/09.

The birth centre at JHH is located on the grounds of Belmont Hospital. Access to
JHH’s birth centre is based on risk categorisation, with only low risk pregnancies
able to access this service.
While RNSH does not have a physical birth centre, it provides the birth centre
philosophy through its midwifery care model.
5.2.4
Home births
Planned home births represent around 0.3% of births in Australia.9 JHH offers a
publicly funded home birthing service. Clinicians at JHH noted that they managed
around 50 home births each year.
Clinicians indicated there was a fairly high transfer rate into hospital from home
births. However, they thought this was a good outcome as it meant midwives were
managing risks appropriately.
6
7
8
9
Australian Institute of Health and Welfare, Australia’s mothers and babies 2007, December 2009,
p 24 (http://www.aihw.gov.au/publications/per/per-48-10972/per-48-10972.pdf).
Australian Institute of Health and Welfare, Australia’s mothers and babies 2007, December 2009,
p 81 (http://www.aihw.gov.au/publications/per/per-48-10972/per-48-10972.pdf).
Ibid.
Australian Institute of Health and Welfare, Australia’s mothers and babies 2007, December 2009,
p 24 (http://www.aihw.gov.au/publications/per/per-48-10972/per-48-10972.pdf).
Case study 11 – Obstetric Delivery IPART
25
5 Configurations of care
5.3
Early discharge programs
All study hospitals have some form of early discharge program. However, the study
hospitals appear to have different timeframes for patients leaving hospital under
these programs, with GH having the shortest timeframe.

At BLH, the midwifery support program is available for patients who want an
early discharge from hospital. Midwives visit the patients in their home at
regular intervals during the initial post-partum period. While the midwifery
support program can cater for patients from as early as four hours after obstetric
delivery, clinicians indicated that most patients under this program leave hospital
on day 3.

At GH, the midwifery support program aims to return patients to their homes
within 24 hours of obstetric delivery. Around 85% of patients have follow-up
visits in the home, either by phone or in person within 7 days of birth.

At JHH, clinicians estimated that around 50% of patients go home under the early
discharge model. Most of these patients are discharged within 24 hours of
obstetric delivery, with a further one-third of these patients discharged on day 2.
A home maternity service is offered for up to 5 days. Women who need an
assessment for complications such as a breast abscess or newborn jaundice will be
readmitted to hospital.

At RNSH, early discharge depends on the level of patient risk. If patients are low
risk, clinicians indicated that they are usually discharged within 48 hours.

One program which complements RPAH’s early discharge model is the ‘bili‘ bed
at home. If a newborn has mild jaundice, they can be managed at home.
To understand the impact of the early discharge programs, we analysed the time
taken from obstetric delivery to discharge from the hospital for a patient’s acute
episode (ie, LOS1) (see Table 5.1).
26
IPART Case study 11 – Obstetric Delivery
5 Configurations of care
Table 5.1 Time from obstetric delivery to discharge, acute episode LOS1
RPAH
GH
RNSH
BLH
JHH
%
%
%
%
%
3
14
4
6
17
25-48 hours
11
24
17
15
16
49-72 hours
16
25
27
37
19
>73 hours
71
36
52
42
49
<24 hours
0
1
0
0
0
25-48 hours
0
5
1
1
2
49-72 hours
4
25
10
14
11
96
69
89
85
87
5
21
6
8
21
25-48 hours
16
34
26
19
20
49-72 hours
21
25
37
42
21
>73 hours
59
20
31
31
37
All cases
<24 hours
Caesarean section
>73 hours
Vaginal delivery
<24 hours
Source: HIE inpatient statistics, 2008/09 and IPART analysis.
When compared to the other study hospitals, a substantially higher percentage of
patients were discharged from GH within 72 hours of delivery for caesarean section
and within 48 hours of delivery for vaginal delivery. These results are consistent
with our findings of GH having shorter average length of stays (see Table 3.1).

For caesarean section, 31% of patients at GH were discharged within 72 hours of
delivery. At the other hospitals, the figure ranged from 4% at RPAH to 15% at
BLH.

For vaginal delivery, 55% of patients at GH were discharged within 48 hours of
delivery. At the other hospitals, the figure ranged from 21% at RPAH to 41% at
JHH.
Case study 11 – Obstetric Delivery IPART
27
6 Outcome, safety and quality indicators
6 Outcome, safety and quality indicators
The terms of reference for this study required us to analyse available data on
differences in clinical outcomes across the 5 study hospitals. In relation to obstetric
deliveries, there is already a substantial amount of monitoring and reporting hospital
performance against clinical indicators. Further, the Maternity Services InterJurisdictional Committee is currently developing a core set of national maternity care
performance indicators.10
As the national clinical indicators are still being finalised, we considered the
performance of the study hospitals against several commonly reported clinical
indicators. The study hospitals had broadly similar results for babies born with low
Apgar scores. However, the indicators relating to caesarean sections highlighted
significant differences between the hospitals.
6.1
Adequacy of existing outcomes monitoring and reporting
There is a large amount of publicly reported data on maternity outcomes:

At the state level, Australia’s mothers and babies11 includes indicators such as
method of birth, birth weight and gestational age.

At the area level, Quality of Healthcare in NSW12 includes indicators such as infant
well being at birth and rates of unassisted vaginal deliveries.

At the area and hospital level, NSW Mothers and Babies13 includes indicators such
as induction of labour and perineal tear.
10
The Maternity Services Inter-Jurisdictional Committee was established by the Australian Health
Ministers’ Advisory Council as an information sharing network of representatives from States
and Territories with the principal objective of promoting primary maternity services. See
Maternity Services Inter-Jurisdictional Committee
(http://www.ahmac.gov.au/cms_documents/Maternity%20Services%20Interjurisdictional%20
Committee(1).pdf).
11 Australian Institute of Health and Welfare, Australia’s mothers and babies 2007, December 2009,
pp 37, 64 & 67 (http://www.aihw.gov.au/publications/per/per-48-10972/per-48-10972.pdf).
12 Clinical Excellence Commission, Quality of Healthcare in NSW, Chartbook 2007, pp 110 & 112
(http://www.cec.health.nsw.gov.au/files/chartbook/chartbook-2007_revised.pdf).
13 NSW Health, New South Wales Mothers and Babies 2006, March 2009, pp 38 & 47
(http://www.health.nsw.gov.au/pubs/2009/pdf/mothers_babies.pdf).
28
IPART Case study 11 – Obstetric Delivery
6 Outcome, safety and quality indicators
There are also a number of entities that have developed clinical indicators for
obstetrics. For example, Women's Hospitals Australasia provides benchmarking
data to its member hospitals on their performance against clinical indicators such as
post partum haemorrhage rates and episiotomy rates.14 It reviews its indicator set
annually, with indicators chosen on the basis that they:

are readily collectible

have a significant degree of clinical relevance

are capable of identifying a process or outcome that is capable of modification

are able to be benchmarked with comparable facilities.
In addition:

The Australian Council on Healthcare Standards, in conjunction with the Royal
Australian and New Zealand College of Obstetricians and Gynaecologists, has
developed a recognised set of clinical indicators for obstetric deliveries.15 These
indicators are included in NSW Mothers and Babies.

The Australian Institute of Health and Welfare has proposed a number of
indicators relating to obstetric deliveries to be included in a national set of clinical
indicators.16

The Maternity Services Inter-Jurisdictional Committee is currently developing a
core set of national maternity care performance indicators.17
Despite this, the data could be improved in the following ways:

Hospitals collecting data on a consistent basis and in a systematic way.

Hospitals receiving more timely data. There is often a considerable lag between
data collection and reporting, which does not allow hospitals to readily gauge the
impact of their practices or compare their performance with other hospitals. As
an example, the latest NSW Mothers and Babies report was released in 2009 and
based on data from 2006.
14
Women’s Hospitals Australasia, Clinical Indicators in Women’s Health, WHA's Benchmarking
Maternity Care Indicators (http://www.wcha.asn.au/index.cfm/spid/1_46.cfm).
15 Australian Council on Healthcare Standards, Obstetrics Version 6, ACHS Clinical Indicator Users’
Manual 2008.
16 Australian Institute of Health and Welfare, Towards national indicators of safety and quality in
health care, September 2009 (http://www.aihw.gov.au/publications/hse/hse-75-10792/hse-7510792.pdf).
17 The Maternity Services Inter-Jurisdictional Committee was established by the Australian Health
Ministers’ Advisory Council as an information sharing network of representatives from States
and Territories with the principal objective of promoting primary maternity services. See
Maternity
Services
Inter-Jurisdictional
Committee
(http://www.ahmac.gov.au/cms_documents/Maternity%20Services%20Interjurisdictional%20
Committee(1).pdf).
Case study 11 – Obstetric Delivery IPART
29
6 Outcome, safety and quality indicators
6.2
Analysing indicators and risk-adjusting for patient characteristics
It’s important to recognise that hospitals’ performance against many outcome
indicators is not simple to interpret and, when considered in isolation, can be
misleading. Therefore, this performance needs to be analysed within the appropriate
context.
To make meaningful and fair comparisons of the performance of the study hospitals
on some outcome indicators, the analyses were risk-adjusted for factors outside the
control of the hospitals. As such, the obstetric indicators were adjusted for hospitalbased care group18 and socio-economic status.19 Appendix B provides further details
for each risk-adjusted indicator provided by NSW Health, including the data sources
used, the relevant time period for the data and the adjustment factors applied.
Most of the clinical indicators measure rates for the ‘selected primipara’ (ie, rather
than for all women giving birth). The Australian Council on Healthcare Standards
has noted that the selected primipara represents an uncomplicated pregnancy
whereby intervention and complication rates should be low and consistent across
hospitals.20 In this case study, the ‘selected primipara’ is defined as a woman who:

is 20-34 years of age at the time of giving birth

is giving birth for the first time at greater than 20 weeks gestation

has a singleton pregnancy (pregnancy with only one baby)

has cephalic presentation (head-first), and

is giving birth at term (between 37 to 41 weeks gestation).
18
That is, hospital based medical or midwife care (not transferred in or other type).
The ABS Index of Relative Socio-Economic Disadvantage (IRSD) was used to estimate socioeconomic status. The IRSD was assigned at Local Government Area level and grouped into
quintiles from least disadvantaged to most disadvantaged for analysis.
20 Australian Council on Healthcare Standards, Obstetrics Version 6, ACHS Clinical Indicator Users’
Manual 2008.
19
30
IPART Case study 11 – Obstetric Delivery
6 Outcome, safety and quality indicators
6.3
Clinical indicators for obstetrics delivery
As the national set of clinical indicators is still being finalised, we analysed data from
the study hospitals against 8 clinical indicators (see Table 6.1), with the results
reported below.
Table 6.1 Clinical indicators for obstetric delivery and data availability
No.
Indicator
Available?
1.
Caesarean section rates (risk
adjusted)
Yes – data provided by NSW Health (see Appendix B)
2.
Vaginal deliveries following
primary caesarean section (risk
adjusted)
Yes – data provided by NSW Health (see Appendix B)
3.
Vaginal deliveries with third or
fourth degree perineal tears (risk
adjusted)
Yes – data provided by NSW Health (see Appendix B)
4.
Caesarean section after induction
of labour (risk adjusted)
Yes – data provided by NSW Health (see Appendix B)
5.
Babies born with an Apgar score of Yes – data provided by NSW Health (see Appendix B)
4 or below at 5 minutes (risk
adjusted)
6.
Repeat caesarean section rates
(risk adjusted)
Yes – data provided by NSW Health (see Appendix B)
7.
Administration of VTE prophylaxis
No – data collected at hospital-wide level for VTE
prophylaxis assessment
8.
Administration of antibiotic
prophylaxis
No – data collected at hospital-wide level for
antibiotic prophylaxis assessment
6.3.1
Caesarean section rates
This indicator measures the caesarean section rate for selected primipara. While there
is no agreed optimal rate for caesarean sections, there is concern that the current rates
are too high for low risk pregnancies. This view has been expressed by bodies such
as the Clinical Excellence Commission.21 It was also raised by clinicians at all the
study hospitals. NSW Health has noted that the rate of caesarean section operations
(both elective and emergency) in NSW hospitals was 28.8% in 2006, a rise of almost
10% above the rate in 1998.22
21
Clinical Excellence Commission, Quality of Healthcare in NSW, Chartbook 2007, p 102
(http://www.cec.health.nsw.gov.au/files/chartbook/chartbook-2007_revised.pdf).
22 NSW Health, Policy Directive, Maternity – Towards Normal Birth in NSW, June 2010, p 1
(http://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_045.pdf).
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6 Outcome, safety and quality indicators
While caesarean sections can be lifesaving, the Clinical Excellence Commission notes
that it exposes women to anaesthesia and surgery, with their associated risks.23
Further, Chapter 3 indicates that caesarean sections generally lead to longer stays
than vaginal deliveries. NSW Health has noted that there is growing evidence of
increasing maternal mortality and morbidity associated with multiple caesarean
operations, such as more difficult surgery, increased blood loss, abdominal organ
injury and hysterectomy.24
At the 5 study hospitals, there were 2,159 caesarean sections from 9,189 births, giving
an overall rate of 23.5% (see Table 6.2).
Table 6.2
Caesarean section for selected primipara, 2007 & 2008
Hospital
Risk-adjusted odds ratio
95% confidence interval
RPAH
1.74
1.42-2.14
GH
3.31
2.61-4.20
RNSH
2.40
1.86-3.08
JHH
1.38
1.08-1.76
BLH
1
Note: Analysis was based on mothers (using the first birth where the mother had a multiple birth), and was adjusted for
socio-economic status and type of hospital-based care group (ie, hospital based medical/midwife, not transferred in/
other). For an explanation of the odds ratio, see Box 6.1. The odds ratio used in this table only compares the odds at the
5 study hospitals. It does not provide an indication of how these study hospitals compare with other hospitals.
Source: Midwives Data Collection (HOIST), Centre for Epidemiology and Research, NSW Department of Health.
There were statistically significant differences between hospitals, with the odds of
caesarean section lowest at BLH. See Box 6.1 for an explanation of the adjusted odds
ratio.
23
24
32
Ibid.
NSW Health, Policy Directive, Maternity – Towards Normal Birth in NSW, June 2010, p 1
(http://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_045.pdf).
IPART Case study 11 – Obstetric Delivery
6 Outcome, safety and quality indicators
Box 6.1
Risk-adjusted odds ratios
Risk-adjusted odds ratios were calculated for hospitals in order to highlight differences in rates
between the hospitals.a The ‘odds ratio’ is the ratio of the odds of an event occurring at one
hospital to the odds of it occurring at another hospital.b
If the odds ratio between two hospitals is:

1 – the event is equally likely to occur at both hospitals

>1 – the event is more likely to occur at the first hospital

<1 – the event is less likely to occur at the first hospital.
As an example, assume Hospital A has 15 infections and Hospital B has 10 infections, out of
1,000 patients at each hospital. The odds of infection at Hospital A and Hospital B are 15/985
and 10/990 respectively. The odds ratio of infection between Hospital A and Hospital B is
(15/985) / (10/990) or 1.51. This odds ratio indicates that the odds of infection at Hospital A are
around 50% higher than at Hospital B.
a Odds ratios are widely used in medical literature to examine the effects of other variables on the relationship
between two binary variables, using logistic regression (J Bland “The odds ratio”, British Medical Journal, 320, 2000, p
1468; S Simon “Understanding the Odds Ratio and the Relative Risk”, Journal of Andrology, 22, 2001, p 533). The odds
ratios were risk-adjusted for patient characteristics using the approach discussed in Box 6.1.
b The ‘odds of an event occurring’ is equal to the probability that the event occurs divided by the probability that it
does not occur.
As the selected primipara represents the patient subgroup likely to have the least
complicated pregnancies, we would expect their caesarean section rates to be
substantially lower than caesarean section rates for all patients (see Table 2.3). This is
the case for the study hospitals, except for GH where it was lower by only 1%.25
6.3.2
Vaginal births following primary caesarean section
This indicator measures the rate of women aged 20 to 34 years delivering vaginally
following a primary caesarean section in the previous pregnancy. Due to the current
high rates of caesarean sections, clinicians are exploring whether it is safe to have a
vaginal birth after caesarean section (VBAC). The Australian Council on Healthcare
Standards notes that repeat caesarean section can be associated with significant
morbidity for women. However, it also points out that VBAC carries increased risks
for the baby when compared with repeat elective caesarean section. As such, the
correct rate for VBAC is unknown.26
At the 5 study hospitals, there were 489 vaginal births following 2,521 primary
caesarean sections, giving an overall rate of 19.4% (see Table 6.3).
25
26
Note that the data in Table 6.2 is for 2007 & 2008 and the data in Table 2.2 is for 2008/09.
Australian Council on Healthcare Standards, Obstetrics Version 6, ACHS Clinical Indicator Users’
Manual 2008.
Case study 11 – Obstetric Delivery IPART
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6 Outcome, safety and quality indicators
Table 6.3
Vaginal births following primary caesarean section among women aged
20-34 years, 2007 & 2008
Hospital
Risk-adjusted odds ratio
95% confidence interval
BLH and RPAH
0.39
0.28-0.55
GH and RNSH
0.22
0.17-0.30
JHH
1
Note: Analysis was based on mothers (using the first birth where the mother had a multiple birth), and was adjusted for
socio-economic status and hospital-based care group (ie, hospital based medical/midwife, not transferred in/ other).
For an explanation of the odds ratio, see Box 6.1. The odds ratio used in this table only compares the odds at the 5
study hospitals. It does not provide an indication of how these study hospitals compare with other hospitals.
Source: Midwives Data Collection (HOIST), Centre for Epidemiology and Research, NSW Department of Health.
On adjustment, there was no statistically significant difference between:

BLH and RPAH

GH and RNSH,
so results for these hospitals were grouped. The odds of vaginal birth following
primary caesarean section were highest at JHH. Rates were substantially lower at the
remaining hospitals.
6.3.3
Vaginal deliveries with third or fourth degree perineal tears
This indicator measures the rate of vaginal deliveries with third or fourth degree
perineal tears27 for selected primipara. According to the Australian Institute of
Health and Welfare, in the short term, such tears can increase hospital stays and
readmissions. In the long term, they can have a significant impact on a woman’s
quality of life.
It also notes that there are practices clinicians can use to reduce or minimise the risk
of severe perineal tears. These include antenatal determination of the baby’s weight,
monitoring the position of the baby’s head throughout the labour, and maternal
positioning during the second stage of labour.28
At the 5 study hospitals, there were 512 significant tears among 9,189 births, giving
an overall rate of 5.6% (see Table 6.4).
27
A third degree tear is an injury to the perineum involving the anal sphincter or recto-vaginal
septum. A fourth degree tear is an injury to the perineum involving the anal sphincter complex
and the anal epithelium (Australian Council on Healthcare Standards, Obstetrics Version 6,
ACHS Clinical Indicator Users’ Manual 2008).
28 Australian Institute of Health and Welfare, Towards national indicators of safety and quality in
health care, September 2009, p 142, (http://www.aihw.gov.au/publications/hse/hse-7510792/hse-75-10792.pdf).
34
IPART Case study 11 – Obstetric Delivery
6 Outcome, safety and quality indicators
Table 6.4
Vaginal births with third or fourth degree perineal tears for selected
primipara, 2007 & 2008
Hospital
Risk-adjusted odds ratio
95% confidence interval
GH and RPAH
2.48
1.60-3.86
RNSH and JHH
3.68
2.31-5.89
BLH
1
Note: Analysis was based on mothers (using the first birth where the mother had a multiple birth), and was adjusted for
socio-economic status and hospital-based care group (ie, hospital-based medical/midwife, not transferred in/other).
For an explanation of the odds ratio, see Box 6.1. The odds ratio used in this table only compares the odds at the 5
study hospitals. It does not provide an indication of how these study hospitals compare with other hospitals.
Source: Midwives Data Collection (HOIST), Centre for Epidemiology and Research, NSW Department of Health.
On adjustment there were no statistically significant differences between RPAH and
GH, and between RNSH and JHH, so results for these hospitals were grouped. BLH
had the lowest odds of vaginal birth with significant tear.
6.3.4
Caesarean section after induction of labour
This indicator measures the caesarean section rate after induction of labour for
selected primipara. The Australian Council on Healthcare Standards notes that
interventions in obstetric deliveries frequently ‘cascade’.29 That is, having one
intervention increases the risks of additional interventions. This indicator is looking
at how often inducing labour then leads to a caesarean section.
At the 5 study hospitals, 931 of 2,773 mothers had a caesarean section following
induction of labour, giving an overall rate of 33.6% (see Table 6.5).
Table 6.5
Hospital
Caesarean section after induction of labour for selected primipara, 2007
& 2008
Risk-adjusted odds ratio
95% confidence interval
RPAH
1.71
1.33-2.21
GH
3.47
2.72-4.43
RNSH
2.36
1.70-3.28
BLH and JHH
1
Note: Analysis was based on mothers (using the first birth where the mother had a multiple birth), and was adjusted for
socio-economic status and hospital-based care group (ie, hospital based medical/midwife, not transferred in/ other).
For an explanation of the odds ratio, see Box 6.1. The odds ratio used in this table only compares the odds at the 5
study hospitals. It does not provide an indication of how these study hospitals compare with other hospitals.
Source: Midwives Data Collection (HOIST), Centre for Epidemiology and Research, NSW Department of Health.
29
Australian Council on Healthcare Standards, Obstetrics Version 6, ACHS Clinical Indicator Users’
Manual 2008).
Case study 11 – Obstetric Delivery IPART
35
6 Outcome, safety and quality indicators
On adjustment, no statistically significant difference was found between BLH and
JHH, so results for these 2 hospitals were grouped. The odds of caesarean section
after induction of labour at the remaining 3 hospitals were significantly higher than
at BLH and JHH.
6.3.5
Babies born with a low Apgar score
This indicator measures the proportion of babies born with an Apgar score of 4 or
below at 5 minutes after birth for selected primipara. The Apgar score gives an
indication of the baby’s condition shortly after birth. It is determined by
5 characteristics of the baby (heart rate, respiratory effort, muscle tone, reflex
irritability and colour). Each characteristic is rated from zero to 2. The sum of the
above five characteristics is the total Apgar score of the baby (out of 10).30 A low
Apgar score at 5 minutes after birth is considered to be an indicator of complications
and compromise for the baby.31
At the 5 study hospitals, 61 of 9,198 babies were born with an Apgar score of less
than 4 at 5 minutes, giving an overall rate of 0.7%.32 On adjustment, there were no
statistically significant differences between the hospitals for this indicator.33
6.3.6
Repeat caesarean section
This indicator measures the caesarean section rate for women aged 20 to 34 years
whose previous (and only) obstetric delivery was by caesarean section.
At the 5 study hospitals, there were 1,256 repeat caesarean sections among 1,563
mothers, giving an overall repeat caesarean section rate of 80.4%. (See Table 6.6.)
Table 6.6
Repeat caesarean section among women aged 20-34 years, 2007 & 2008
Hospital
RPAH, GH, RNSH and BLH
JHH
Risk-adjusted odds ratio
95% confidence interval
2.75
2.01-3.75
1
Note: Analysis was based on mothers (using the first birth where the mother had a multiple birth), and was adjusted for
socio-economic status and hospital-based care group (ie, hospital based medical/midwife, not transferred in/ other).
For an explanation of the odds ratio, see Box 6.1. The odds ratio used in this table only compares the odds at the 5
study hospitals. It does not provide an indication of how these study hospitals compare with other hospitals.
Source: Midwives Data Collection (HOIST), Centre for Epidemiology and Research, NSW Department of Health.
30
Ibid.
Australian Institute of Health and Welfare, Australia’s mothers and babies 2007, December 2009, p
75 (http://www.aihw.gov.au/publications/per/per-48-10972/per-48-10972.pdf).
32 The analysis based on babies, and included both stillborn and live born babies. It was carried
out using the NSW Midwives Data Collection for the 2007 and 2008 calendar years.
33 The analysis was adjusted for socio-economic status and hospital-based care group (ie, hospital
based medical/midwife, not transferred in/other).
31
36
IPART Case study 11 – Obstetric Delivery
6 Outcome, safety and quality indicators
On adjustment, there were no statistically significant differences between RPAH,
GH, RNSH and BLH, so results for these hospitals were grouped.
6.3.7
Administration of VTE prophylaxis
This indicator measures the proportion of patients who are administered venous
thrombo-embolism (VTE) prophylaxis. The Australian Institute of Health and
Welfare notes that VTE can cause pain, loss of function and sometimes death.
Further, the incidence of VTE is an indicator of the quality of postoperative care, and
can reflect inappropriate or inadequate medical and nursing care. VTE invariably
prolongs the duration of hospitalisation and requires additional medical
intervention.34
The study hospitals do not systematically collect this data at the clinical level.
Instead, they conduct hospital-wide audits to see whether VTE prophylaxis
assessments are being conducted. Refer to Chapter 16 of our main report for further
information.35
6.3.8
Administration of prophylaxis
This indicator measures the proportion of patients who are administered antibiotic
prophylaxis. The Australian Council of Healthcare Standards has noted that an
appropriate prophylactic antibiotic at the time of caesarean section significantly
reduces maternal post operative infectious morbidity.36
The study hospitals do not systematically collect this data at the clinical level.
Instead, they conduct hospital-wide audits to see whether antibiotic prophylaxis
assessments are being conducted. Refer to Chapter 16 of our main report for further
information.37
34
Australian Institute of Health and Welfare, Towards national indicators of safety and quality in
health care, September 2009, p 155, (http://www.aihw.gov.au/publications/hse/hse-7510792/hse-75-10792.pdf).
35 IPART, NSW Health costs and outcomes study by IPART for selected NSW hospitals, July 2010.
36 Australian Council on Healthcare Standards, Obstetrics Version 6, ACHS Clinical Indicator Users’
Manual 2008).
37 IPART, NSW Health costs and outcomes study by IPART for selected NSW hospitals, July 2010.
Case study 11 – Obstetric Delivery IPART
37
6 Outcome, safety and quality indicators
6.4
Issues for further consideration
There are significant differences between the hospitals in relation to caesarean section
rates, with GH having substantially higher rates than BLH and JHH. This cannot be
easily explained by differences in configurations of care at the study hospitals or
patient complexity. Further, there is not a link between caesarean section rates and
differences in other outcome indicators in our clinical indicator set, such as Apgar
score and significant perineal trauma.38
NSW Health is taking steps to address the issue of increasing caesarean section rates
and variation in rates across hospitals. It recently released a new policy directive,
Maternity – Towards Normal Birth in NSW. The document aims to provide direction to
NSW maternity services regarding actions to increase the vaginal birth rate and
decrease the caesarean section rate. It outlines 10 principles of providing woman
centred labour and birth care (see Box 6.2).
Box 6.2
NSW Health policy directive, Maternity – Towards Normal Birth in NSW
The 10 principles of providing woman centred labour and birth care are:
1. Have a written normal birth policy that is routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Facilitate access to midwifery continuity of carer programs in collaboration with GPs and
obstetricians for all women with appropriate consultation, referral and transfer guidelines in
place.
4. Inform all pregnant women about the benefits of normal birth and factors that promote
normal birth.
5. Have a written policy on pain relief in labour that includes the use of water immersion in
labour and birth.
6. Have a written postdates policy that is routinely communicated to all health care staff.
7. Facilitate access to vaginal birth after caesarean section operation that is supported by a
written vaginal birth after caesarean section operation policy and health care staff with the
skills necessary to implement this policy.
8. Facilitate access to external cephalic version (where a clinician turns the baby from breech
to head-first presentation in late pregnancy).
9. Provide one to one care to all women experiencing their first labour or undertaking a
vaginal birth after caesarean section operation, vaginal breech or vaginal twin birth.
10. Provide formal debriefing in the immediate postpartum period for all women requiring
primary caesarean section operation or instrumental birth with the opportunity for further
discussion and information transfer.
Source: NSW Health, Policy Directive, Maternity – Towards Normal Birth in NSW, June 2010, p 8,
(http://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_045.pdf).
38
38
For example, RNSH and JHH both had similar significant tear rates, but RNSH had a
substantially higher caesarean section rate than JHH.
IPART Case study 11 – Obstetric Delivery
6 Outcome, safety and quality indicators
The policy directive outlines key measures to facilitate Area Health Services in
adopting these 10 principles. The key measures include:

maternity services having a written normal birth policy (target 100% by 2015)

the percentage of women having vaginal births (target >80% by 2015)

maternity clinicians being informed of statistics relating to outcomes for vaginal
birth after caesarean section (target 100% by 2015).
From June 2011, Area Health Services will be required to report annually on their
performance against these key measures.39
We consider that NSW Health and clinical expert groups should note the variation in
caesarean section rates and monitor changes arising from the implementation of
NSW Health’s new policy directive, Maternity – Towards Normal Birth in NSW, to
determine whether the policy effectively addresses the variation.
Recommendation
1
That NSW Health and clinical expert groups note the variation in the following clinical
indicators relating to obstetric delivery:
– caesarean section rates for ‘selected primipara’
– vaginal delivery rates following primary caesarean section
– caesarean section rates after induction of labour for ‘selected primipara’
– repeat caesarean section rates
– significant tear rates
and monitor changes arising from the implementation of the NSW Health policy
directive, Maternity – Towards Normal Birth in NSW, to determine whether this policy
effectively addresses the variation.
39
NSW Health, Policy Directive, Maternity – Towards Normal Birth in NSW, June 2010, pp 7-14,
(http://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_045.pdf).
Case study 11 – Obstetric Delivery IPART
39
6 Outcome, safety and quality indicators
Appendices
Case study 11 – Obstetric Delivery IPART
41
6 Outcome, safety and quality indicators
42
IPART Case study 11 – Obstetric Delivery
A
List of full recommendations from main report
A List of full recommendations from main report
Consistency of DRG groupings
Our recommendations in this area are mainly aimed at making users of hospital data
aware of some of the limitations of using DRG groupings for hospital comparisons in
certain clinical areas.
1
That users of hospital cost and outcome data note that DRGs may contain a range of
patient types with varying clinical resource requirements, costs of care and expected
clinical outcomes. Therefore DRGs may not always provide the optimal basis for
comparing costs and outcomes among hospitals.
2
In light of Recommendation 1, that the NSW Department of Health, and other health
research bodies at both the state and national level, consider whether DRGs are a
suitable basis for determining funding and comparing performance among hospitals
(for various different types of hospital activity). Where they are not suitable, continue
research to develop better approaches for these areas.
Consistency of patient numbers
Our recommendations on patient numbers are aimed at making users of hospital
data aware of differences in patient counting practices and patient datasets between
hospitals that can affect hospital comparisons, to improve consistency of patient
counting practices between hospitals and lead to better integration of patient
datasets.
3
That users of hospital data note that there are differences in practices relating to
counting of patients that can affect hospital patient numbers and average cost
comparisons eg, counting differences relating to admission status, billing status,
location of care and collaborative care arrangements.
4
In light of Recommendation 3, that NSW Health clarifies and standardises
administrative procedures including guidelines for recording of non-inpatients of
various types, as well as ‘collaborative care’ patients.
5
That NSW Health considers ways of better integrating patient information held locally
by hospital clinical units (such as eye clinics and cardiac catheter labs) with the HIE
data set.
Case study 11 – Obstetric Delivery IPART
43
A
List of full recommendations from main report
Consistency of lengths of stay
Our recommendations aim to improve consistency between hospitals on length of
stay measures, and to make users of hospital data aware of the limitations of
measures based on ‘acute episodes’.
6
That NSW Health monitors hospital practices relating to the classification of episodes
into care types and type-changing practices (eg, timing of type changes from acute to
rehabilitation care) and provide clear and consistent guidelines to hospitals, so
episode measures are more consistent among hospitals.
7
That users of hospital data note that 'acute episodes' often only represent a part of a
patient's hospital stay. Therefore, comparisons among hospitals using acute length of
stay measures or acute costs may produce misleading results. This is particularly
important for conditions that involve both acute and sub-acute care and/or transfers
between facilities.
Coding
We have made recommendations aimed at improving the quality of medical records
documentation and clinical coding in hospitals to both improve the quality of data
for clinical research as well as to more accurately reflect casemix complexity.
8
That NSW Health should continue to improve the quality of medical record
documentation and the accuracy and consistency of coding.
9
That hospitals should encourage consistent education on coding and facilitate
communication between clinical staff and coders regarding both the coding process
and the documentation required to code common clinical conditions, diagnoses or
complications, such as AMI, angina and chest pain.
10 Where pathology test information can be readily extracted (eg, Cerner sites), that
systems be developed so this information can be used to validate coding and support
work on variation in clinical practice and measuring clinical quality.
11 That NSW Health considers undertaking further analysis to identify pathology or
imaging tests that can be used to help target audits of coding and support work on
variation in clinical practice and measuring clinical quality – such as identifying types
of pathology tests that correspond closely with diagnosis coding.
44
IPART Case study 11 – Obstetric Delivery
A
List of full recommendations from main report
Clinical costing
Our recommendations are aimed at improving the quality and consistency of clinical
costing data, and helping to ensure that quality costing data and clinical inputs to the
costing process (such as data from prosthesis, pathology and imaging systems) can
be used to inform hospital management about resource use, and clinicians about
clinical practice.
12 That the NSW Department of Health works with the area health services and hospitals
to apply a consistent set of rules for clinical costing covering cost centres and IFRACs
so that data are consistent and comparable between the hospitals.
13 That NSW Health regularly audits the accuracy of cost centres and IFRACs used for
clinical costing.
14 That NSW Health uses standard clinical data feeds (actual patient data) for clinical
costing where this is feasible and useful.
15 That the data used for clinical costing purposes be available to hospitals and clinicians
so they can undertake comparative analysis on clinical practices and performance.
Medical staff costs
Given our finding that there was a lack of consistency in the treatment of medical
staff costs and the difficulty this created in estimating medical staff costs for our
case study areas, we recommend:
16 That further work be undertaken to strengthen the quality and consistency of
available information on medical staff costs.
Prosthesis costs
Our recommendations on prosthesis costs are aimed at improving prosthesis
purchasing and making cost savings in this area. These should be considered in
conjunction with our recommendation that clinical experts should review the
appropriateness of clinical variation in prosthesis use and address this variation (see
Recommendation 31).
17 That NSW Health notes the variation in prostheses use among the study hospitals
including:
– drug-eluting stents versus bare metal stents
– single chamber pacemakers versus dual chamber pacemakers
– different types of components for hip replacement procedures.
18 That NSW Health notes the range of approaches to prosthesis controls and the
variation in prices currently paid for prostheses, including for exactly the same
models.
Case study 11 – Obstetric Delivery IPART
45
A
List of full recommendations from main report
19 That NSW Health facilitates sharing of information on purchase prices for prostheses
to assist price negotiations with suppliers.
20 That NSW Health optimises prosthesis cost savings through tenders, supplier price
agreements and controlled approaches to prosthesis purchasing, noting that clinical
consultation and cooperation is essential as is retaining some flexibility to allow for
special orders when clinically indicated.
Imaging and pathology costs
Our recommendations are aimed at encouraging better use of imaging and
pathology data, and consideration of whether there should be standard treatment of
imaging and pathology within clinical costing and whether internal charges should
reflect actual costs. These recommendations should be considered in conjunction
with our clinical case studies, which include comparisons of imaging use, and
Recommendation 31, relating to clinical variation in imaging use for diagnosing
appendicitis.
21/25 That NSW Health notes that imaging and pathology data can be used to monitor
changes in imaging use and inform clinical practice, and that:
– All hospitals obtain detailed reports from pathology and imaging services on their
test ordering patterns, including the number of tests by major test type and the
cost of these tests.
– Hospitals routinely provide data to heads of clinical units to help inform them on
resource use and provision of care to improve patient outcomes and discuss
trends at management meetings – for example, summary reports that include
both the number of tests by test type, and the value (or preferably cost) of these
tests.
– NSW Health develops reports comparing the use of imaging and pathology tests
for clinical groupings and circulates these to area health services and hospitals.
22. That NSW Health considers whether, for clinical costing purposes, it is appropriate for
hospitals and area health services to base the value of imaging tests on the MBS rate
for these tests and, if so, what standard percentage of this rate is appropriate for use
by all hospitals given the actual costs of providing the test.
23 That NSW Health seeks to obtain detailed information from the pathology services on
the number and type of tests and the actual cost of undertaking a range of typical
tests for future comparisons of pathology costs.
24 That NSW Health addresses issues that prevent the actual costs associated with
specific pathology tests and ordering patterns being disclosed by pathology services.
26. That NSW Health considers whether the detailed cost estimates that pathology
services prepare as part of the benchmarking pathology project could be used for
more accurate pricing between pathology services and hospitals, to enable clinicians
to consider the actual cost of their clinical decisions.
46
IPART Case study 11 – Obstetric Delivery
A
List of full recommendations from main report
Operating theatre costs
Our recommendations in relation to operating theatres aim to facilitate
improvements in theatre management arrangements, and the quality and consistency
of theatre data.
27 That NSW Health notes the differences in approaches to theatre management among
hospitals and consider if there is scope to share information about how the better
theatre arrangements are organised.
28 That NSW Health notes the issues regarding theatre data and work with the hospitals
to improve the completeness of datasheets and apply a consistent set of rules for
recording operating theatre times.
29 That NSW Health considers routine auditing of the quality of data on returns to
theatre and considers the best way for achieving accuracy and consistency in this
indicator.
Pharmacy costs
As we were not able to undertake a detailed comparison of pharmacy services and
costs, our recommendations focus on encouraging further analysis in this area.
30 That NSW Health:
– Notes the wide variation in the proportion of drugs dispensed versus held on
imprest across the study hospitals.
– Monitors the value of expired pharmacy stock and compares this among hospitals.
– Considers standardised guidelines for the return of unused medication, principally
to ensure patient safety but also to minimise wastage and reduce costs.
– Considers whether antimicrobial stewardship programs should be implemented at
the major hospitals where such programs are not currently in place. The purpose
of these programs would be to help prevent antimicrobial resistance and reduce
costs by preventing inappropriate use of antimicrobials.
Case study 11 – Obstetric Delivery IPART
47
A
List of full recommendations from main report
Configurations of care – Review of clinical variations during Stages 5 and 6 of the
wider NSW Department of Health study
Our case studies identified a number of differences in the way care is provided
among study hospitals in specific clinical areas. We recommend that clinical experts
consider these clinical differences or clinical issues as part of Stages 5 and 6 of the
wider health study. This recommendation should be dealt with in conjunction with
Recommendation 36, relating to variation in indicators of safety, quality and
outcomes.
31 That NSW Health arranges for appropriate clinical expert groups to consider the
following clinical issues identified in our case studies; and that where appropriate,
NSW Health and the expert groups take steps to address clinical differences.
– Hip joint replacement:
o Note that separation of planned and emergency cases may reduce lengths of
stay for planned (arthritis) cases.
o Address the variation in the selection of hip prosthesis components (including
press fit, cementless hip stems versus cemented hip stems and ceramic femoral
heads versus metal femoral heads) among study hospitals.
– Major chest procedure:
o Note the different clinical pathways and high day of surgery admission rates for
thoracic surgery patients at RPAH compared with other study hospitals.
o Consider whether aspects of the model of care at RPAH are suitable to be used
in other hospitals.
– Breast surgery:
o Note the early discharge models at RNSH for breast surgery patients having
mastectomies and
o Consider whether such models should be followed more widely in NSW
hospitals and the types of patient cases they should be used for (eg, simpler,
unilateral cases or younger patients).
– Cholecystectomy:
o Note the variation in the proportion of patients with cholelithiasis or
cholecystitis who are operated on acutely as emergency admissions.
o Consider whether this variation has significant quality of care implications.
o Consider the relative costs and benefits of an emergency surgical services team
model for ensuring early diagnosis and treatment of conditions like
cholecystectomy and whether it should be more widely applied.
o Note that costing of cholecystectomy should take into account the costs of
prior related emergency department attendances. A similar approach should
be adopted for other clinical conditions that are likely to involve multiple prior
emergency department attendances.
48
IPART Case study 11 – Obstetric Delivery
A
List of full recommendations from main report
o Consider the relative costs and benefits of cholecystectomies with and without
the use of fluoroscopy.
– Appendicectomy
o Note the variation in the use of imaging tests for diagnosing appendicitis.
o Consider establishing standard protocols for diagnosing appendicitis,
indicating when it is appropriate to use CT scans, MRIs and ultrasounds.
o As part of establishing standard protocols for diagnosing appendicitis, consider
whether CT scans, MRIs and ultrasounds should only be used for certain patient
groups (eg, older patients who are more likely to be suffering from other
conditions with symptoms similar to appendicitis).
o Consider the relative costs and benefits of laparoscopic versus open surgery for
appendicitis.
– Stroke
o Consider ways to reduce the proportion of stroke patients coded with a
principal diagnosis of 'stroke, not specified as haemorrhage or infarction'
(ICD10 code I64).
o Consider developing consistent guidelines for the administration of tPA.
o Consider including tPA administration as a procedure in coding standards.
o Consider ways to improve transfers of suspected stroke patients to stroke units
with minimum delay, including consultation with the Ambulance Service and
Emergency Departments.
o Investigate whether it is useful and possible to combine Ambulance Service
data on response time with hospital patient data to monitor time from call to
ambulance to arrival at an appropriate hospital.
o Consider the costs and benefits of providing more rehabilitation care in the
home.
o Pursue the collection of the data on outcome indicators from the National
Stroke Research Institute.
– Cardiology – Stents, Pacemakers and Defibrillators:
o Address the variation in the use of drug-eluting stents versus bare metal stents
among study hospitals.
o Address the variation in the types of pacemakers used among study hospitals.
o Investigate whether there are differences in treatment procedures, or waiting
times between presentation and procedure, for patients who present to
hospitals without a 24 hour cardiac catheter laboratory, compared to patients
who present to hospitals with a 24 hour cardiac catheter laboratory, and
whether any differences in procedure or waiting times have implications for
clinical outcomes.
Case study 11 – Obstetric Delivery IPART
49
A
List of full recommendations from main report
o Consider ways of better integrating information held in cardiac catheter
laboratories with the HIE data set.
– Tracheostomy or ventilation greater than 95 hours:
o Note that at BLH, clinicians tend to perform surgical tracheostomies, whereas at
the other hospitals, these are usually performed percutaneously.
– Cataract/lens procedure:
o Assess the costs and benefits of toric lenses and develop guidelines for their
use in public hospitals.
– Hysterectomy:
o That any future studies of hysterectomy compare the costs and outcomes for
hysterectomies with the costs and outcomes of other procedures such as
endometrial ablation and uterine artery embolisation.
Improving outcome, safety and quality indicators
While current Commonwealth and State initiatives will improve outcomes data, we
have made recommendations that will assist this process.
32 That NSW Health enhances understanding and use of mortality, survival, unplanned
readmission and wound infection indicators and their risk adjustment by:
– continuing to contribute to the development of ACSQHC’s safety and quality
standards for these indicators
– refining the methodology used for standardising or risk-adjusting these indicators
– continuing to consult with clinicians regarding the agreed presentation of
mortality, survival unplanned readmission and wound infection information
– reporting this information on a more routine and regular basis consistent with
ACSQHC data sets.
33 That NSW Health encourages hospitals to put in place systems to facilitate accurate
coding of comorbidities and ensures that coding practices are consistent across
hospitals.
34 That NSW Health works with ACSQHC to negotiate more streamlined arrangements
for access to data held by third parties (such as clinical registries) for clinical analysis,
and makes these data available to hospitals and clinicians.
35 That NSW Health explores the possibility of providing outcomes information to
clinicians in a more systematic way as an aid to clinical improvement and a key
indicator of performance.
50
IPART Case study 11 – Obstetric Delivery
A
List of full recommendations from main report
Indicators of safety, quality or outcomes, - review of clinical variations during stages
5 and 6 of the wider NSW Department of Health project
We have also made a number of findings relating to variations in indicators of safety,
quality or outcomes. Where we have observed apparent differences among
hospitals, these should be considered by clinical expert groups in completing stages 5
and 6 of the Department of Health’s wider project. These differences should be
considered in conjunction with differences in clinical practice (Recommendation 31).
36 That clinical expert groups consider the following clinical issues; and where
appropriate, NSW Health and clinical expert groups take steps to address clinical
variations as part of Stages 5 and 6 of the broader NSW Health review:
– Review the variations in outcome, safety and quality indicators among study
hospitals, including their:
o unplanned readmission rates
o wound infection rates for selected surgical procedures.
– Review the variation in mortality and survival rates for all major chest surgery
patients and consider whether to recommend changes to clinical practice or
conduct further investigation involving:
o a larger sample of hospitals, and
o more detailed analyses for ‘like patients’ (ie, lung cancer, infection-related
abscess/pyothorax and collapsed/punctured lung patients).
– Review the variation in the following clinical indicators for hip joint replacement
surgery at the study hospitals:
o wound infection rates
o unplanned readmission rates.
– Review the variation in wound infection rates for appendicectomy and
cholecystectomy surgery at the study hospitals.
– Note the variation in the following clinical indicators relating to obstetric delivery:
o caesarean section rates for ‘selected primipara’
o vaginal delivery rates following primary caesarean section
o caesarean section rates after induction of labour for ‘selected primipara’
o repeat caesarean section rates
o significant tear rates
and monitor changes arising from the implementation of the NSW Health policy
directive, Maternity – Towards Normal Birth in NSW, to determine whether this
policy effectively addresses the variation.
Case study 11 – Obstetric Delivery IPART
51
A
List of full recommendations from main report
Additional outcome indicators
We made recommendations to consider the costs and benefits of collecting data for
the following areas where indicators are not commonly used.
37 That NSW Health considers the costs and benefits of collecting data and monitoring
performance against the following indicators:
– warfarin management
– visual outcomes for patients undergoing lens procedures.
We also made a recommendation to develop a set of standard indicators for
measuring care and/or outcomes in ICUs.
38 That NSW Health undertakes further work to develop a set of standard indicators for
measuring care and/or outcomes in ICUs.
Time Out audits
Finally, we made a recommendation to improve consistency in the number of cases
audited as part of the Time Out process relative to the number of separations.
39 That NSW Health specifies the number or proportion of patient cases that should be
audited as part of the Time Out process.
Next steps - wider application of this study
40 That NSW Health refines and develops useful aspects of this study for application
more widely to other hospitals, other health settings and other clinical conditions.
52
IPART Case study 11 – Obstetric Delivery
B Risk-adjusted indicators provided by NSW Health
B Risk-adjusted indicators provided by NSW Health
Table B.1 includes the data sources and risk adjustment factors used for risk-adjusted
indicators provided by NSW Health.
Case study 11 – Obstetric Delivery IPART
53
B Risk-adjusted indicators provided by NSW Health
Table B.1 Risk-adjusted indicators provided by NSW Health
No.
Indicator
Data
Numerator & denominator
source
1
Caesarean
section rates
MDC
20072008
Numerator – Number of caesarean Care group (hospital based
sections
medical or midwife not
Denominator – Number of selected transferred in; residual group other), and socio-economic
primipara
status
2
Vaginal
births
following
primary
caesarean
section
MDC
20072008
Numerator – Number of vaginal
births
3
Vaginal
MDC
births with
20073rd or 4th
2008
degree
perineal tears
Numerator – Vaginal births with
significant tears (3rd or 4th
degree)
4
Caesarean
section after
induction of
labour
Numerator– Number of caesarean
sections
5
6
MDC
20072008
Risk-adjustment
Care group (hospital based
medical or midwife not
Denominator – Number of women transferred in; residual group aged 20-34 years giving birth who other), and socio-economic
status
have had a previous primary
caesarean section
Care group (hospital based
medical or midwife not
transferred in; residual group Denominator – Number of selected other), and socio-economic
status
primipara
Denominator– Number of
inductions among selected
primipara
Care group (hospital based
medical or midwife not
transferred in; residual group other), and socio-economic
status
Apgar score MDC
of 4 or below 2007at 5 minutes 2008
among
selected
primipara
Numerator – Number of babies
born with an Apgar score of 4 or
below at 5 minutes
Repeat
caesarean
section rates
(following
primary
caesarean
section)
Numerator – Number of caesarean Care group (hospital based
sections
medical or midwife not
Denominator – Number of women transferred in; residual group aged 20-34 years giving birth who other), and socio-economic
status.
have had a previous primary
MDC
20072008
Denominator – Number of term
babies born to selected primipara
Care group (hospital based
medical or midwife not
transferred in; residual group other), and socio-economic
status
caesarean section
Notes: APDC - NSW Admitted Patient Data Collection. RBDM - Registry of Births, Deaths and Marriages. MDC - NSW
Midwives Data Collection. A case represents a hospital admission for a specified condition. DRG - Diagnosis Related
Group v 5.1. A ‘selected primipara’ is a woman who: is 20-34 years of age at the time of giving birth; is giving birth for
the first time at greater than 20 weeks gestation; has a singleton pregnancy (pregnancy with only one baby); has
cephalic presentation (head-first), and is giving birth at term (between 37 to 41 weeks gestation). The ABS Index of
Relative Socio-Economic Disadvantage (IRSD) was used to estimate socio-economic status. The IRSD was assigned at
Local Government Area level and grouped into quintiles from least disadvantaged to most disadvantaged for analysis.
Source: NSW Health.
54
IPART Case study 11 – Obstetric Delivery
Glossary
Glossary
Term
Abb.
95% confidence
interval
Activity-based
funding
Definition
A statistical term describing a range of values within which we
are 95% certain that the true population value lies.
ABF
Funding that is based on the projected amount and type of
work of a facility, where standard prices are set for similar work
undertaken. This has also been referred to as casemix or
episode funding.
Acute care
Clinical services provided to admitted or non-admitted patients,
including managing labour, curing illness or treating injury,
performing surgery, relieving symptoms and/or reducing the
severity of illness or injury, and performing diagnostic and
therapeutic procedures. Most patients have acute or temporary
ailments. The average length of stay is relatively short.
Admission
The process by which a person commences a period of
residential care in a health facility.
Admitted Patient
Data Collection
APDC
A database that covers all inpatient separations (discharges,
transfers and deaths) from all Public (including Psychiatric),
Private, and Repatriation Hospitals, Private Day Procedures
Centres and Public Nursing Homes in NSW.
Agency for Clinical
Innovation
ACI
A board-governed statutory health corporation that reports to
the NSW Minister for Health and the Director-General of NSW
Health.
Antenatal clinic
Apgar score
A special clinic staffed by obstetricians, registrars, residents and
midwives to cater for women progressing through pregnancy.
Apgar
Appendicectomy
A numerical score used to indicate a baby’s condition at one
minute and five minutes after birth. Between 0 and 2 points are
given for each of five characteristics: heart rate, breathing,
colour, muscle tone and reflex irritability. The total score is
between 0 and 10. Apgar stands for Activity, Pulse, Grimace,
Appearance, and Respiration.
Surgical excision of the patient's appendix.
Assistant In Nursing
AIN
An employee that is not a registered nurse, enrolled nurse or
trainee nurse, who assists the Enrolled Nurses and Registered
Nurses by providing basic nursing care, working within a plan of
care under the supervision and direction of a Registered Nurse.
Average length of
stay
ALOS
The average number of days each admitted patient stays in
hospital. This is calculated by dividing the total number of
occupied bed days for the period by the number of actual
separations in the period.
Case study 11 – Obstetric Delivery IPART
55
Glossary
Term
Abb.
Definition
BankstownLidcombe Hospital
BLH
One of the study hospitals included in the review.
Bureau of Health
Information
BHI
An independent, board-governed organisation established by
the NSW Government to be the leading source of information
on the performance of the public health system in NSW.
Casemix
The range and types of episodes of care of patients (the mix of
cases) treated by a hospital. This provides a way of describing
and comparing hospitals and other services for planning and
managing health care. Casemix classifications put patients into
DRGs with similar conditions that use similar health-care
resources, so that the activity and cost-efficiency of different
hospitals can be compared.
Casemix funding
See Activity-based funding.
Cholecystectomy
Excision of the gallbladder.
Clinical Excellence
Commission
CEC
A board-governed statutory health corporation with the CEO
reporting directly to the NSW Minister for Health. A key role of
the Clinical Excellence Commission is building capacity for
quality and safety improvement in Health Services.
Clinical Nurse
Specialist
CNS
A Registered Nurse/Midwife who applies a high level of clinical
nursing knowledge, experience and skills in providing complex
nursing/midwifery care directed towards a specific area of
practice, a defined population or defined service area, with
minimum direct supervision.
Comorbidity
Computed
tomography
CT scan
A non-invasive medical imaging method using X-rays and
computer processing.
Diagnosis Related
Group
DRG
A system used to classify hospital admissions into groups with
similar clinical conditions (related diagnoses) and similar
resource usage (hospital services). There are approximately 500
coding classes. In Australian acute hospitals, Australian refined
DRGs are used (AR-DRGs). The classification categorises
episodes into groups with similar conditions and similar usage
of hospital resources, using information in the hospital
morbidity record such as the diagnoses, procedures and
demographic characteristics.
Enrolled Nurse
EN
A person holding an Enrolled Nurse qualification who works
under the supervision of a Registered Nurse to provide nursing
care for patients in hospitals, nursing homes and a variety of
other health care organisations.
Episode funding
See Activity-based funding.
Fluoroscopy
An imaging technique that provides real-time moving images
of the internal structures of a patient through the use of a
fluoroscope.
Gosford Hospital
56
When a person has two or more health problems at the same
time.
GH
One of the study hospitals included in the review.
IPART Case study 11 – Obstetric Delivery
Glossary
Term
Abb.
Definition
Health Information
Exchange
HIE
A database maintained by the NSW Department of Health that
contains a range of financial, patient and clinical information
from hospitals and area health services.
High dependency
unit
HDU
An area or environment in a hospital that provides a higher
level of critical care and monitoring than is provided in a
general ward, but a lower level of care provided by an intensivecare unit.
Hysterectomy
Surgical removal of the uterus.
Independent Pricing
and Regulatory
Tribunal of NSW
IPART
The independent economic regulator for NSW that is
undertaking this hospital study.
Inpatient fraction
IFRAC
A measure used in casemix costing. The proportion of total (or
operating) costs that are attributed to admitted patients.
Intensive care unit
ICU
An area or environment in a hospital that provides the highest
level of critical care and monitoring.
John Hunter Hospital
JHH
One of the study hospitals included in the review.
Length of stay 1
LOS1
LOS1 is the episode length of stay in study hospital, ie, from the
start of the episode to the end of the episode of care.
Length of stay 2
LOS2
LOS2 is the total length of stay in study hospital, ie, from
admission to discharge at the study hospital.
Length of stay 3
LOS3
LOS3 is the total length of stay in study hospital plus up to 2
other hospitals - one transfer in and one transfer out.
Maternity Services
Inter-Jurisdictional
Committee
MSIJC
An information sharing network of health representatives with
the objective of promoting maternity services and consistent
approaches to maternity care.
Medical resonance
imaging
MRI
A medical imaging technique most commonly used in
radiology to visualise detailed internal structures of the body
using a magnetic field.
Medicare Benefits
Schedule
MBS
A listing of the Medicare services subsidised by the Australian
government.
Midwife
National Hospital
Cost Data Collection
A nurse with specific training to assist mothers throughout
pregnancy, childbirth and postnatal care.
NHCDC
Newborn jaundice
Non-admitted
patient occasions of
service
NSW Health
The NHCDC contains component costs per DRG based on
patient-costed and cost-modelled information. The NHCDC
enables DRG Cost Weights and average costs for DRGs for acute
in-patients to be produced.
A condition affecting the colour of the baby's skin colour and
skin tissue primarily due to relatively high levels of bilirubin.
NAPOOS
Outpatient care provided in a hospital, community health
centre or home setting by specialists and nurses.
The broad term encompassing operational and other structures
including the NSW Department of Health, Area Health Services,
the Agency for Clinical Innovation, the Clinical Excellence
Commission and a range of clinical taskforces.
Case study 11 – Obstetric Delivery IPART
57
Glossary
Term
Abb.
Definition
Odds ratio
OR
The odds of an event occurring. This is equal to the probability
that the event occurs divided by the probability that it does not
occur.
Open Surgery
An invasive medical procedure where an incision is required for
direct surgical access to the organs.
Perineal tears
Tears of the tissues around the vaginal opening during
childbirth.
Post-partum period
The time period immediately after the birth and can extend to
several weeks.
Principal referral
hospital
Hospital within peer group (principal referral hospitals 1b)
classified as an acute hospital, treating 25,000 or more acute
casemix weighted separations per annum, with an average cost
weight greater than 1 and 1 or fewer specialty services.
Principal tertiary
referral hospital
Hospital within peer group (principal referral hospitals 1a)
classified as an acute hospital, treating 25,000 or more acute
casemix weighted separations per annum, with an average cost
weight greater than 1 and having more than 1 specialty service.
Prophylaxis
Disease prevention, also called preventive treatment.
Registered midwife
Registered midwives provide care for women and their families
through the cycle of pregnancy and birth.
Registered nurse
RN
A qualified nurse who provides care for patients in a variety of
healthcare settings. These include public and private hospitals,
community and home-based services, nursing homes and
industry.
Royal North Shore
Hospital
RNSH
One of the study hospitals included in the review.
Royal Prince Alfred
Hospital
RPAH
One of the study hospitals included in the review.
Selected primipara
(for this case study)
The ‘selected primipara’ is defined as a woman who is 20-34
years of age, giving birth for the first time at between 37-41
weeks gestation and with a singleton pregnancy (pregnancy
with only one baby) in cephalic presentation (head-first).
The Australian
Council on
Healthcare Standards
An independent organisation dedicated to improving the
quality of health care through performance reviews, assessment
and accreditation.
The Royal Australian
and New Zealand
College of
Obstetricians and
Gynaecologists
Tracheostomy
58
RANZCOG
An organisation dedicated in maintaining the highest standards
in obstetrics and gynaecology in Australia and New Zealand.
A surgical procedure to cut an opening into the trachea
(windpipe) so that a tube can be inserted into the opening to
assist breathing.
IPART Case study 11 – Obstetric Delivery
Glossary
Term
Abb.
Definition
Venous Thromboembolism
VTE
The process by which blood clots occur and travel through the
veins. It is the collective term for deep vein thrombosis (the
formation of a blood clot in one of the deep veins within the
body, such as in the leg or pelvis) and pulmonary embolism
(condition in which the arteries leading from the heart to the
lungs becomes blocked).
Case study 11 – Obstetric Delivery IPART
59