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The American Journal of Managed Care February 2019
Impact of Hepatitis C Virus and Insurance Coverage on Mortality
Haley Bush, MSPH; James Paik, PhD; Pegah Golabi, MD; Leyla de Avila, BA; Carey Escheik, BS; and Zobair M. Younossi, MD, MPH
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The Drug Price Iceberg: More Than Meets the Eye
A. Mark Fendrick, MD; and Darrell George, BA
From the Editorial Board: Sachin H. Jain, MD, MBA
Sachin H. Jain, MD, MBA
Value-Based Arrangements May Be More Prevalent Than Assumed
Nirosha Mahendraratnam, PhD; Corinna Sorenson, PhD, MHSA, MPH; Elizabeth Richardson, MSc; Gregory W. Daniel, PhD, MPH, RPh; Lisabeth Buelt, MPH; Kimberly Westrich, MA; Jingyuan Qian, MPP; Hilary Campbell, PharmD, JD; Mark McClellan, MD, PhD; and Robert W. Dubois, MD, PhD
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Seth A. Seabury, PhD; J. Samantha Dougherty, PhD; and Jeff Sullivan, MS
Why Aren’t More Employers Implementing Reference-Based Pricing Benefit Design?
Anna D. Sinaiko, PhD, MPP; Shehnaz Alidina, SD, MPH; and Ateev Mehrotra, MD, MPH
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Does Comparing Cesarean Delivery Rates Influence Women’s Choice of Obstetric Hospital?
Rebecca A. Gourevitch, MS; Ateev Mehrotra, MD, MPH; Grace Galvin, MPH; Avery C. Plough, BA; and Neel T. Shah, MD, MPP
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Thomas E. Kottke, MD, MSPH; Jason M. Gallagher, MBA; Marcia Lowry, MS; Pawan D. Patel, MD; Sachin Rauri, MS; Juliana O. Tillema, MPA; Jeanette Y. Ziegenfuss, PhD; Nicolaas P. Pronk, PhD, MA; and Susan M. Knudson, MA
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Process Reengineering and Patient-Centered Approach Strengthen Efficiency in Specialized Care
Jesús Antonio Álvarez, PhD, MD; Rubén Francisco Flores, PhD; Jaime Álvarez Grau, PhD; and Jesús Matarranz, PhD

Does Comparing Cesarean Delivery Rates Influence Women’s Choice of Obstetric Hospital?

Rebecca A. Gourevitch, MS; Ateev Mehrotra, MD, MPH; Grace Galvin, MPH; Avery C. Plough, BA; and Neel T. Shah, MD, MPP
This randomized controlled trial finds that a hospital cesarean delivery rate comparison tool affects women’s perceptions but not where they choose to deliver.

Objectives: Despite public reporting of wide variation in hospital cesarean delivery rates, few women access this information when deciding where to deliver. We hypothesized that making cesarean delivery rate data more easily accessible and understandable would increase the likelihood of women selecting a hospital with a low cesarean delivery rate.

Study Design: We conducted a randomized controlled trial of 18,293 users of the Ovia Health mobile apps in 2016-2017. All enrollees were given an explanation of cesarean delivery rate data, and those randomized to the intervention group were also given an interactive tool that presented those data for the 10 closest hospitals with obstetric services. Our outcome measures were enrollees’ self-reported delivery hospital and views on cesarean delivery rates.

Methods: Intent-to-treat analysis using 2-sided Pearson’s χ2 tests.

Results: There was no significant difference across the experimental groups in the proportion of women who selected hospitals with low cesarean delivery rates (7.0% control vs 6.8% intervention; P = .54). Women in the intervention group were more likely to believe that hospitals in their community had differing cesarean delivery rates (66.9% vs 55.9%; P <.001) and to report that they looked at cesarean delivery rates when choosing their hospital (44.5% vs 33.9%; P <.001).

Conclusions: Providing women with an interactive tool to compare cesarean delivery rates across hospitals in their community improved women’s familiarity with variation in cesarean delivery rates but did not increase their likelihood of selecting hospitals with lower rates.

Am J Manag Care. 2019;25(2):e33-e38
Takeaway Points

Many states and consumer-focused organizations publicly report hospital cesarean delivery rates, but few women know where to access these data. We conducted a randomized controlled trial of 18,293 Ovia Health mobile app users to evaluate whether directly giving women access to cesarean delivery rates of local hospitals affected their choice of hospital. We found that providing women with this information improved their familiarity with these data but did not change their choice of hospital.
  • Cesarean deliveries are believed to be overused in the United States, and rates vary widely across hospitals.
  • Many organizations have begun publicly reporting cesarean delivery rates to help guide women’s choice of hospital.
  • Giving women an interactive tool on a mobile app to compare the hospitals in their community did not increase use of hospitals with low cesarean delivery rates.
  • This study illustrates the potential and limitations of using a modern method of communicating with the public to engage women in considering variation in quality of care among hospitals.
Across the United States, hospital cesarean delivery rates vary dramatically, independent of women’s health status, demographic characteristics, or personal preferences.1,2 Although cesarean deliveries are often clinically necessary, as many as 45% may be unindicated.3 More than three-fourths of women would prefer not to have an unindicated cesarean delivery.4 Compared with vaginal deliveries, cesarean deliveries are associated with 3-fold higher rates of maternal complications and 50% higher costs.5-8

In recent years, consumer advocates such as The Leapfrog Group and Consumer Reports, as well as more than 20 state departments of public health, have begun to publicly report hospital-level cesarean delivery rates. However, research has found that few women know where to access these data. Furthermore, women prioritize the selection of their obstetrician or midwife over selection of their hospital and believe that a hospital’s cesarean delivery rate will not affect the care that they receive.4,9,10

We hypothesized that making cesarean delivery rate data easily accessible to women who either are trying to conceive or are early in their pregnancy, and then pairing these data with an explanation of how their choice of hospital may affect their odds of having a cesarean delivery, would increase the likelihood of women selecting a hospital with a low cesarean delivery rate. A hospital with a low cesarean delivery rate was defined as one that meets the Healthy People 2020 target of a 23.9% (or lower) cesarean delivery rate for nulliparous term singleton vertex (NTSV) deliveries.11


Trial Platform and Recruitment

We conducted this trial using 2 mobile apps, Ovia Fertility and Ovia Pregnancy, from the Ovia Health mobile app suite. Trial recruitment and retention are outlined in the CONSORT diagram (eAppendix A [eAppendices available at]). We presented advertisements in the in-app information feeds of Ovia Fertility users who indicated they were trying to conceive and Ovia Pregnancy users in their first trimester (eAppendix B, Figure 1). The advertisements linked to a short article that explained the potential risks of unnecessary cesarean deliveries and the variation in hospital-level cesarean delivery rates (eAppendix B, Figure 2). Women who clicked on a hyperlink at the end of the article offering the opportunity to learn more were randomized 1:1 through the app to the control or intervention group.

Women randomized to the control group were shown a short article that encouraged considering cesarean delivery rates when selecting an obstetric hospital and explained where to find publicly reported data (text available in eAppendix B, Figure 3). Women in the intervention group were shown the same article plus an interactive tool presenting NTSV cesarean delivery rate data for the 10 hospitals closest to their location. Women could also enter another zip code in the tool to see a different set of hospitals. The cesarean delivery rates were self-reported by hospitals to The Leapfrog Group. On the interactive tool, hospitals were color-coded green if they met the Healthy People 2020 target NTSV cesarean delivery rate (23.9%), red if they did not meet the target, and yellow if they did not report their cesarean delivery rate to The Leapfrog Group.11 A screenshot of the tool is in eAppendix B, Figure 4.

Primary and Secondary Outcomes

Our primary outcome was the proportion of women who selected a hospital that met the Healthy People 2020 cesarean delivery rate target. Women enrolled in the trial were shown an advertisement in their feed incentivizing them to report their chosen hospital in the app for the opportunity to enter a lottery for a gift card (eAppendix B, Figure 5). Because any user of the app could report their hospital in their app settings, a small fraction of women in the trial entered their hospital choice before they enrolled in the trial. Our secondary outcomes were responses to 3 survey questions about cesarean delivery rates. The survey was delivered to women enrolled in the trial as another advertisement in their feed (eAppendix B, Figure 6).

Demographic and Other Data

Limited demographic data were available through Ovia, including enrollees’ age, zip code of residence, and pregnancy risk status, which was calculated by Ovia Health based on their age, body mass index, number of gestations, and a structured, self-reported medical history (eAppendix C). Using each woman’s zip code, we linked our data set with data from the US Census on median annual household income, the proportion of residents with a bachelor’s degree, and the urban or rural status of the county. We characterized a woman as having “hospital choice” if there was at least 1 hospital that met the target (green) and at least 1 hospital that did not meet the target or did not report (red or yellow) among hospitals that she saw or would have seen (if she was randomized to the control group) based on her zip code.

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