Hospitalization Duration Following Uncomplicated Cesarean Delivery: Predictors, Facility Variation, and Outcomes

Abstract

Objectives This study was designed to: (1) characterize stay duration following cesarean delivery, (2) ascertain whether facility variation exists, and (3) determine whether shorter stays are associated with rates of readmission or costs.

Study Design The 2017 Nationwide Readmissions Database was used to identify uncomplicated cesarean deliveries. Hierarchical logistic regression was used to assess for facility variation in percentage of patients discharged within 2 days. Similar models were used to assess for associations between probability of readmission within 30 days and facility-level rates of discharge within 2 days.

Results In total, 456,312 patients from 1,535 hospitals were included. The median facility discharged 46.8% of patients within 2 days, with the 25th percentile of hospitals 23.7% and the 75th percentile 71.2%. In adjusted regression, there was significant facility heterogeneity (p < 0.0001). The overall readmission rate was 1.7%, and proportion of patients discharged within 2 days of cesarean delivery was not associated with readmission probability (adjusted relative risk: 1.02, confidence interval: 0.90–1.16), but was associated with lower inpatient costs (adjusted incremental cost: $111, confidence interval: −181 to −41).

Conclusion Unexplained facility variation in percentage of patients discharged within 2 days of cesarean delivery was not associated with differences in readmissions.

Key Points

• We find significant facility-level variation in outcomes following uncomplicated cesarean delivery in the United States.

• High rates of early (postoperative day 2) discharge was not associated with differences in readmission rates in adjusted analyses but was associated with lower inpatient costs.

Keywords

cesarean section/economics - cesarean section/utilization - pregnancy - cesarean delivery - length of stay - readmission - facility variation

Note

A preliminary version of this report was presented in poster form at the 38th Annual Society for Maternal-Fetal Medicine Annual Pregnancy Meeting (January 29–February 3, 2018 in Dallas, TX).

This research was funded by a Kelly Resident Research Award from the Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine. The funding source was not involved in the conduct of this research or preparation of this report.

• References

• 1 Cowper PA, DeLong ER, Hannan EL. , et al. Trends in postoperative length of stay after bypass surgery. Am Heart J 2006; 152 (06) 1194-1200
• 2 Doll KM, Dusetzina SB, Robinson W. Trends in inpatient and outpatient hysterectomy and oophorectomy rates among commercially insured women in the United States, 2000-2014. JAMA Surg 2016; 151 (09) 876-877
• 3 Mennuti MT. The shrinking postpartum hospital stay. Hosp Pract (1995) 1995; 30 (08) 11-12
• 4 Lord M. Check in, deliver, go home. US News World Rep 1994; 117 (22) 98-100
• 5 Dahlke JD, Mendez-Figueroa H, Rouse DJ, Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for cesarean delivery: an updated systematic review. Am J Obstet Gynecol 2013; 209 (04) 294-306
• 6 Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med 2003; 138 (04) 273-287
• 7 HCUP Nationwide Readmissions Database (NRS). Healthcare Cost and Utilization Project (HCUP). 2017. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/nrdoverview.jsp
• 8 Bateman BT, Mhyre JM, Hernandez-Diaz S. , et al. Development of a comorbidity index for use in obstetric patients. Obstet Gynecol 2013; 122 (05) 957-965
• 9 Armstrong JC, Kozhimannil KB, McDermott P, Saade GR, Srinivas SK. ; Society for Maternal-Fetal Medicine Health Policy Committee. Comparing variation in hospital rates of cesarean delivery among low-risk women using 3 different measures. Am J Obstet Gynecol 2016; 214 (02) 153-163
• 10 Henry OA, Gregory KD, Hobel CJ, Platt LD. Using ICD-9 codes to identify indications for primary and repeat cesarean sections: agreement with clinical records. Am J Public Health 1995; 85 (8 Pt 1): 1143-1146
• 11 Blumenfeld YJ, El-Sayed YY, Lyell DJ, Nelson LM, Butwick AJ. Risk factors for prolonged postpartum length of stay following cesarean delivery. Am J Perinatol 2015; 32 (09) 825-832
• 12 Nilsson IM, Kronborg H, Knight CH, Strandberg-Larsen K. Early discharge following birth - what characterises mothers and newborns?. Sex Reprod Healthc 2017; 11: 60-68
• 13 Brown S, Small R, Faber B, Krastev A, Davis P. Early postnatal discharge from hospital for healthy mothers and term infants. Cochrane Database Syst Rev 2002; 3 (03) CD002958
• 14 Bayoumi YA, Bassiouny YA, Hassan AA, Gouda HM, Zaki SS, Abdelrazek AA. Is there a difference in the maternal and neonatal outcomes between patients discharged after 24 h versus 72 h following cesarean section? A prospective randomized observational study on 2998 patients. J Matern Fetal Neonatal Med 2016; 29 (08) 1339-1343
• 15 Liu S, Heaman M, Kramer MS, Demissie K, Wen SW, Marcoux S. ; Maternal Health Study Group of the Canadian Perinatal Surveillance System. Length of hospital stay, obstetric conditions at childbirth, and maternal readmission: a population-based cohort study. Am J Obstet Gynecol 2002; 187 (03) 681-687
• 16 Clapp MA, Little SE, Zheng J, Kaimal AJ, Robinson JN. Hospital-level variation in postpartum readmissions. JAMA 2017; 317 (20) 2128-2129
• 17 Campbell OM, Cegolon L, Macleod D, Benova L. Length of stay after childbirth in 92 countries and associated factors in 30 low- and middle-income countries: compilation of reported data and a cross-sectional analysis from nationally representative surveys. PLoS Med 2016; 13 (03) e1001972
• 18 Gazmararian JA, Koplan JP. Length-of-stay after delivery: managed care versus fee-for-service. Health Aff (Millwood) 1996; 15 (04) 74-80
• 19 Krieger N, Chen JT, Waterman PD, Soobader MJ, Subramanian SV, Carson R. Geocoding and monitoring of US socioeconomic inequalities in mortality and cancer incidence: does the choice of area-based measure and geographic level matter? The Public Health Disparities Geocoding Project. Am J Epidemiol 2002; 156 (05) 471-482