Indicators of healthcare performance have progressed to the point where hospitals and employers know providers' Caesarean-section rate, their inpatient mortality rate and other measures that spell success or distress in specific areas of care.
Those rates increasingly are used for comparisons among healthcare organizations, but their capacity to improve care within the delivery system is limited. And simple rates can't explain to payers or governments why C-section occurrences are going up or down.
For example, is one hospital's rate higher than others because it's getting more pressure to deliver at a physician's convenience, or because the physicians are seeing more fetal distress? Is a teaching hospital seeing more low-birthweight deliveries, or is it trying to turn out more obstetrics residents who are proficient in C-sections?
These are some of the "why" questions that may be tackled in the next phase of the Maryland Quality Indicator Project, a quality-evaluation initiative of the Maryland Hospital Association. Started in 1985, the project now has 850 participating hospitals in 48 states.
Its 21 measurements of clinical performance in inpatient, ambulatory/emergency and pediatric care (See chart) have netted hospitals a final tally in all of these areas that are comparable across similar institutions in the project's data base as well as within an institution over time.
But now the project is aiming to find out what events and decisions went into the final score, said Vahe Kazandjian, the project's vice president for research. "We're at the point where once we have the outputs analyzed, it's time to go back and have the reasons analyzed," he said. "It needs to pass the so-what test."
Without that extra dimension, he said, healthcare decisionmakers are left to assume generally that when it comes to such measures as C-section or mortality rates, lower is better and reduction over time is progress-good assumptions but not the whole picture.
For example, a hospital under pressure to reduce C-section rates eventually could drive the rate too low-holding out for natural birth long after the situation calls for surgical intervention, and putting mother and child at more risk instead of less.
This is called the "breaking point" in a clinical rate, said Mr. Kazandjian, "where you stop doing the right thing" in pursuit of a benchmark goal. "If you stop C-sections for people who need it, that's the point."
Knowing what drives the rate down, or having an explanation for an uptick, will bolster the understanding and usefulness of a quality indicator, he said. "In some ways you can say that the process (of care delivery) is more important than the outcome."
Mr. Kazandjian said the project is "just starting to have a good feel for what's involved." The new initiative will be calling for volunteers among the project's membership starting next week to test components that could help explain the results of three indicators: C-section, inpatient mortality and unscheduled returns to a special-care unit.
The tracking process will be organized into five categories of variables:
Demographics. Factors include the age of a patient, source of payment and whether an expectant mother received prenatal care.
Clinical factors. In C-section analysis, for example, possible considerations include attempts at a vaginal birth after a previous C-section, lack of progress in delivery and fetal distress.
Use of technology. In one example affecting C-section rates, fetal monitors may or may not be providing false positives for fetal distress.
Routines and patterns. Some say the day of the week or time of day may be predictive of decisions, Mr. Kazandjian said. For instance, availability of anesthesia may dictate how long a physician waits to go for a C-section. If anesthesia isn't a 24-hour service, a C-section may be done earlier in the day to be safe.
Also, arrival of new residents at a teaching hospital may dictate a change in clinical patterns to fit the expectations of the residency program, he said.
Patient preference. How many times does a physician do a C-section because the patient demanded one?
Mr. Kazandjian expects the testing to start in about two months, and he said it's possible that a number of explanatory measures will be available in 1995.
The process questions are something any hospital can implement on its own, he added, but the scope of the Quality Indicator Project will provide clues about where to focus attention. That's because it will develop prevailing rates from the experiences of the hospitals in its data base.