Hospital variation and cesarean delivery: Studies of contemporary practice patterns in Canada and the United States
Notice bibliographique
Résumé
In Canada, 27% of deliveries were performed by cesarean in 2013, making Cesarean delivery the most commonly performed surgery in Canadian women.Given that high rates of cesarean have not been shown to be associated with better maternal and perinatal outcomes, there have been recommendations to reduce the overall rate of cesarean delivery, with a focus on preventing the first ("primary") cesarean.To best determine how to reduce the rate of primary cesarean delivery, an understanding of indication-specific patterns of cesarean is needed.The goal of this thesis was to advance our understanding of indication-specific cesarean delivery rates through the use of inter-institutional practice variation.To explore contemporary practice patterns in Canada, this thesis used data across three provincial birth registries, and focused on low-risk nulliparous women delivered following the onset of labour.Practice patterns in the timing of cesarean delivery by indication are illustrated, and an examination of adherence to clinical guidelines on the management of labour is presented.We find that many cesarean deliveries are performed early during labour and demonstrate substantial variation across hospitals in their compliance with clinical guidelines on the management of labour.Next, inter-hospital variation in the rates of cesarean delivery for labour dystocia is examined.After stabilization for hospital size and adjustment for maternal, fetal, and hospital characteristics, variability in rates across hospitals remained high.Together, these findings suggest that hospitals with the highest rates may benefit from conducting internal reviews and examining adherence to best practice guidelines on the management of labour dystocia.This thesis then examines women who had a previous cesarean delivery using data from the United States' Nationwide Inpatient Sample.We find that the occurrence of a uterine rupture at a hospital is associated with a subsequent reduction to the hospital's trial of labour success rate (that is, the rate of women having a successful vaginal delivery, in those who underwent labour) and a short-term increase in the rate of repeat cesarean delivery.These findings suggest that obstetrical decision-making is impacted by the occurrence of rare, adverse events.My thesis has been shaped and guided by two wonderful co-supervisors, Dr. Jay Kaufman and Dr. Jennifer Hutcheon.Together, these expert epidemiologists have provided me with superb guidance, methodological and substantive.I'd like to thank Jay for being the apostle who relayed Modern Epidemiology in mostly bite-sized pieces, and from whom I've learned a great deal about epidemiologic methods, in particular multi-level modeling with an econometric flair and the critical issues about analyses concerning race as a causal factor.You've been an excellent mentor, and I am very grateful for the countless e-mail exchanges, and meetings during walks through the Plateau that helped to bring this document to fruition.I was also very fortunate that Jenn agreed to take me on as a trainee, and provide such excellent inter-provincial guidance.I have learned a great deal about how to tailor my papers for a clinical readership and my thesis benefitted considerably from your focus on the practical conclusions of this work.Beyond the scope of this thesis, you strived to include me in important side-projects that encouraged me to step out of my research silo (more accurately, my research basement) and enhance my understanding beyond the textbook and journal article to support the goal of clinically meaningful work.My thesis committee was made complete by Dr. Erin Strumpf
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,003 | 0,017 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,001 | 0,001 |
| Bibliométrie | 0,003 | 0,015 |
| Études des sciences et des technologies | 0,003 | 0,002 |
| Communication savante | 0,002 | 0,001 |
| Science ouverte | 0,002 | 0,002 |
| Intégrité de la recherche | 0,001 | 0,001 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,001 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».