Facility-Level Cesarean Section and VBAC Rates for Canada
By Romy McMaster
The Canadian Institute for Health Information (CIHI) just released a new online resource on their website called the Canadian Hospital Reporting Project. CIHI has been releasing various health indicator and specialized health care reports for a long time in Canada and they’re well recognized and respected for their high quality data standards and reports. But this is the very first time they’ve released, at least for public ‘consumption’, facility-level data for a number of clinical and financial indicators (30 to be exact), with the intention of allowing hospitals across the country to compare their performance with their peers (in terms of hospital size and community vs teaching) and to learn from leading practices. Normally, public reports available from CIHI report by region (nationally or by province/territory/health region), so this represents a huge step towards increasing the transparency of public reporting of facility-level data.
If you’re wondering if anyone is interested at looking at facility-level data, I’d say the interest is pretty high: shortly after its release, the website crashed due to incredibly higher-than-expected traffic. It’s working now and believe me when I tell you that it’s very much worth your time to check it out. Why? Aside from being a data-lover’s dream, two of the indicators have immediate relevance to visitors to CesareanRates.com: Cesarean rate and VBAC rate by facility (Canada only).
The VBAC indicator is defined as the rate of women delivering vaginally after having had a previous cesarean section. The Cesarean rate is defined as the number of cesarean sections/number of deliveries x 100. It includes both live and stillbirths and for this project, it excludes preterm and multiple gestations. Their rationale for including only term (and post-term) singletons in the c-section rate is that the inclusion of preterm and multiple gestations may have shown bias towards facilities that are more likely to deliver these types of gestations. And yes, I agree with those of you who might be thinking that it may be a bit of a crude adjustment as not all pre-term and multiple gestations are high-risk, but it does allow for a fairer comparison across hospitals.
On that note, CIHI has also risk-adjusted the indicators to help account for possible differences in patient mix and to improve hospital comparability. You might still hear the argument that Hospital X “only births ‘older wealthier women’ and that’s why their CS rate is so high” or “this region has a large number of homebirths so a lower-risk population is excluded from the Hospital Y rate”, but the risk adjustment that has been done and the comparison groups used does help nullify those arguments. It’s true that the adjustment doesn’t (nor can it) account for every factor that effects patient mix, but it definitely opens the door for a discussion about variations between hospital that are more likely due to differences in hospital practice and provider practice and NOT about differences among women. In my opinion, a refreshing change. Could it be that it’s not all about women getting old and big?
For these two indicators, most hospitals have four years of data reported (2007/2008 to 2010/2011) with facilities in Quebec only reporting two years of data. You can check out the complete technical specifications through the website, but briefly: you can compare data across Canada, within a province or territory, across different regions of Canada, and you can compare facilities with their peer-group (facilities are grouped according to whether they are ‘teaching’, ‘community-large’, ‘community-medium’, and ‘community-small’). You can scroll around a map of Canada to check out current rates and you can produce peer-group or facility reports. You can download the entire dataset so you can re-work the data yourself. You can also focus in on just one or two facilities where you might be thinking about birthing and educate yourself on their indicator rates.
The intention of CIHI in releasing this report is to give facilities a tool to start the process of improvement at the local level, a process which has been shown to demonstrate some of the largest strides in improving care and outcomes. A facility can compare its own rate to that of any other facility in the country and can discuss differences in a local context. It’s meant to serve as a first step in determining what could be done to improve rates, or how to continue success in improving rates, or to initiate more analysis into what extreme rate variation at a facility might mean. Although these rates aren’t intended for a women to assess her own individual risk when birthing at a specific facility, it does go a long way in increasing transparency of maternity care in Canada and does help to better inform our choices when it comes time to birth.