Proactive management — the surprising driver of C-section variation: 4 questions with Harvard researcher Dr. Neel Shah

Variation in hospital cesarean delivery rates can be partially explained by the way labor and delivery units are managed, according to new research out of Harvard's Ariadne Labs, published in Obstetrics and Gynecology.

The number of C-sections is up 500 percent over the last generation — so much so that 1 in 3 babies are born by major surgery. This means a third of mothers in the U.S. are at risk of surgical complications, longer hospital stays and increased delivery costs. However, C-section rates can vary 10-fold across hospitals, and this variation cannot be fully explained by mothers' health or preferences.

Ariadne Labs researchers set out to determine if management influenced this variation. They interviewed 118 nurse and physician managers across 53 hospitals about how their labor and delivery units were managed. Their findings indicated hospitals with more "proactive" management styles were associated with greater risk of C-sections, postpartum hemorrhage, blood transfusion and prolonged inpatient stay.

The study provided insight into one of Ariadne Lab's key areas of focus: finding a safe, scalable way to decrease unnecessary C-sections. To discuss the implications of this research, Becker's caught up with Neel Shah, MD, senior author of the study, and director of the Delivery Decisions Initiative at Ariadne Labs. Dr. Shah also founded the NGO Costs of Care and serves as an assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School in Boston.

Editor's note: This interview has been edited for length and clarity.

Question: What are the key findings of your team's new research?

Dr. Neel Shah: We've been trying to understand why hospital C-section rates are so different from place to place. It's this idea that your biggest risk factor for getting the most common major surgery could be where you go, not your medical risks. We spent a lot of time visiting different hospitals with different C-section rates and trying to find out what makes them different.

A lot of places said different hospitals have different cultures, but it's really hard to measure what they mean by that. So we looked at way the labor and delivery units were managed as a way to operationalize what people meant by "culture." We looked at a couple different dimensions of management: the way nursing staff were managed, including how they assigned each nurse to a patient; unit culture management, essentially the way the teams communicated with each other and how they collaborated across disciplines; and how they managed patient flow, or what do you do when there's a bottleneck and you are running out of beds, that kind of thing.

The bottom line of the study is after you account for every fixed, observable characteristic of a woman that goes to a labor floor, and every fixed, observable characteristic of the hospital, the last and final thing that determines whether she'll get a C-section or have a hemorrhage seems to be how the labor and delivery unit is managed.

Q: The findings are a bit counterintuitive — if labor and delivery units are more proactive, it can lead to a higher risk of C-sections. Did that surprise you?

NS: It did, definitely. We looked at a range of management practices that we scored from being reactive to proactive. Generally being proactive in life is good thing. And the places that were really proactive valued that they had all these policies and practices in place that allowed them to anticipate issues before they came up. So we thought that would run with good outcomes.

The thing is we really focused on the mom, but in the labor and delivery unit, there are a bunch of different goals and sometimes these goals compete. One of the things this study underscores is the goals you have for management are as important as the practices. For example, if the main goal of the labor and delivery unit is financial performance, you are going to turn over patients very quickly. If the main goal of the labor and delivery unit is to do a lot of surveillance for the fetus or the baby, then you are going to err on the side of doing more C-sections. I think that might explain what we saw.

There are really two possible explanations. One is that people have goals other than the mom's wellbeing. Which sounds crazy for a labor and delivery unit, but when you really think about it, you are primarily focused on keeping afloat financially, which means moving people through quicker, and making sure none of the babies are compromised, which means doing more C-sections. But if you do more C-sections, you will see more hemorrhage.

The other possible explanation is it might be that the places with the worst outcomes needed the best management. It's sort of like a chicken-egg thing. You don't know which came first. But just from our observations — we did a lot of site visits along the way — I doubt it's that. My gut says it's probably more of the former.

Q: So does this challenge conventional management practices? Are most hospitals striving to be proactive?

NS: Running a labor and delivery unit is one of the hardest jobs in all of healthcare. You can't really anticipate when your customers are going to show up, you don't know how long they are going to be in labor, you don't know if one of them is going to become sick enough to need resources. Every labor and delivery unit seems to meet those challenges in different ways.

Management is definitely a modifiable risk factor. We look at that in epidemiology all the time. We saw there was huge variation in the way these units are managed, and the way they are managed predicts the outcomes of moms independently.

We looked at 220,000 deliveries; we controlled for everything that we can observe. But I don't think we got to the point where we could say you should definitely [do this]. There's no prescription to manage this way versus that way. It's more like everybody is doing it really differently, and it's more an opportunity to learn about what your neighbors are doing or what people across the country are doing. It's more like opening up a big Pandora's Box of opportunity.

Q: What are the implications for hospitals?

NS: The No. 1 message to the hospital is management matters. I wouldn't go as far as saying you should be more reactive or more proactive because I can't prove causality. But I can say that your management systems definitely matter.

When people look at making care better, they often say, 'Well if we just change payments or we just tweak incentives, everything would be fine.' What this shows is after you've created the incentives, you've got to look at how people are setting up their systems. It's probably a call back into the C-suite of a hospital to start looking at management at a service line level, which is not something that's been traditionally prioritized. We think a lot about clinical management, and we think a lot about hospital-level management. But thinking specifically about the policies and practices by service line seems like a huge opportunity where there is tremendous variation and probably some people who do it better than others.


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