The role of race in cesarean rate case mix adjustment Jennifer L. Bailit, MD, MPH and Department of Obstetrics and Gynecology Division of Maternal Fetal Medicine and Center for Health Care Research and Policy, MetroHealth Medical Center, Case Western Reserve University Thomas E. Love, Ph.D. Center for Health Care Research and Policy, MetroHealth Medical Center, Case Western Reserve University Introduction It has been well established that perinatal outcomes vary by the race and ethnicity of the mother. Prematurity, cesarean delivery, infant death, and maternal death are higher in the black population than in the white population. 1,2 The causes of these differences have been of great interest to the obstetric community. 3,4 There are many possible causes of racial disparities in obstetrics, including economics, biology, and discrimination. 5 There is likely overlap in these categories and it is unclear whether a lucid answer will ever be delineated. Despite this uncertainty regarding the mechanism by which race and ethnicity influence perinatal outcomes, perinatal outcomes are used as a measure of the quality of obstetric care. Outcomes are often measured at the hospital level. Case mix adjustment is a technique used to account for differences in baseline patient characteristics that influence outcomes. This is done so that hospitals caring for sicker patients who are more likely to have poor outcomes are not penalized in the evaluation of quality. 6 Risk-adjusted primary cesarean rates are a promising new measure of obstetrical quality that can be used to effectively identify hospitals with poorer outcomes. 789 A risk-adjustment model is first developed to predict the probability of a cesarean delivery for each patient associated with the institution, using a series of well-accepted risk factors for cesarean delivery that were developed by practicing obstetricians 10, 11 . The estimated probabilities of cesarean delivery for each patient are then summed across the institution in order to create an institutional predicted primary cesarean rate. These rates are then directly compared to actual observed rates of primary cesarean delivery. Risk-adjusted primary cesarean rates are particularly appealing because they are associated with both maternal and neonatal outcomes. 12 Hospitals that have risk-adjusted primary cesarean rates that are below expected have higher rates of poor maternal and neonatal outcomes. 13121415 Risk-adjusted cesarean rates do not provide a “target” cesarean rate. They do not pass judgment as to whether any particular cesarean was appropriate, and they do not attempt to assess the quality of surgical technique. The model simply predicts Corresponding author: Jennifer Bailit MD, MPH, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, 2500 MetroHealth Dr., Cleveland, OH 44109, Phone: 216-778-7341, Fax: 216-778-8847, jbailit@metrohealth.org. Reprints will not be available Presented at the Society for Maternal-Fetal Medicine Annual meeting in San Francisco on Feb 9, 2007 Condensation: The addition of race and ethnicity to standard risk adjustment models for primary cesarean deliveries does not improve their performance. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. NIH Public Access Author Manuscript Am J Obstet Gynecol. Author manuscript; available in PMC 2009 January 1. Published in final edited form as: Am J Obstet Gynecol. 2008 January ; 198(1): 69.e1–69.e5. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript