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Comparing Methods of Identifying Outlying Nurses in Audits of Low-Risk Cesarean Delivery Rates
Joyce K Edmonds1, Samuel R Woodbury, Stuart R Lipsitz
1Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts (Dr Edmonds); Science and Technology, Ariadne Labs, Boston, Massachusetts (Mr Woodbury and Drs Lipsitz, Weiseth, and Shah); Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, and the Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts (Dr Farrell); Division of Maternal Fetal Medicine (Dr Gregory), Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California (Dr Greene).
Background:
The low-risk cesarean delivery (CD) rate is an established performance indicator for providers in maternity care for quality improvement purposes.
Purpose:
Our objectives were to assess nurse performance using adjusted nurse-level CD rates and to compare methods of identifying nurse outliers.
Methods:
We conducted a retrospective, cohort study of 6970 births attended by 181 registered nurses in one hospital's maternity unit. Adjusted and unadjusted nurse-level CD rates were compared and agreement between 3 definitions (statistical, top decile, over a benchmark) of outliers calculated.
Results:
Adjusted nurse-level CD rates varied from 5.5% to 53.2%, and the unadjusted rates varied from 5% to 50%. Risk adjustment had little impact on the ranking of nurses, and outliers were consistently identified by 3 definitions.
Conclusions:
Trade-offs between statistical certainty and feasibility need to be considered when classifying nurse outliers. Findings can help target interventions to improve nurse performance.
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