1. Differential misclassification of confounders in comparative evaluation of hospital care quality: caesarean sections in Italy.
- Author
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Di Martino M, Fusco D, Colais P, Pinnarelli L, Davoli M, and Perucci CA
- Subjects
- Adult, Confounding Factors, Epidemiologic, Female, Hospitalization, Hospitals statistics & numerical data, Humans, Italy epidemiology, Logistic Models, Middle Aged, Models, Theoretical, Pregnancy, Prevalence, Cesarean Section statistics & numerical data, Hospitals standards, Obstetric Labor Complications surgery, Quality of Health Care statistics & numerical data
- Abstract
Background: Despite extensive studies on exposure and disease misclassification, few studies have investigated misclassification of confounders. This study aimed to identify differentially misclassified confounders in a comparative evaluation of hospital care quality and to quantify their impact on hospital-specific risk-adjusted estimates, focusing on the appropriateness of caesarean sections (CS)., Methods: We gathered data from the Hospital Information System in Italy for women admitted in 2005-2010. We estimated adjusted proportions of CS with logistic regression models. Among several confounders, we focused on high fetal head at term (HFH), which is seldom objectively documentable in medical records., Results: A total of 540 maternity units were compared. The median HFH prevalence was 0.9%, ranging from 0 to 70%. In some units, HFH was coded so frequently that it was unlikely to reflect a natural heterogeneity. This "over-coding" was conditional on the outcome because it occurred more frequently for women that underwent CS. This suggested an opportunistic coding to justify the choice of a CS. HFH misclassification was not randomly distributed over Italy; it had an excess in the Campania region where, in some units, the proportion of HFHs gradually increased from 2005 to 2010 (e.g., from 0 to 26%), but the national average remained constant (2.5%). The inclusion of the misclassified diagnosis in the models favored those hospitals that codified in a less-than-fair manner., Conclusions: Our findings emphasized the importance of rigorously inspecting for differential misclassification of confounders. Their validity may be subject to substantial heterogeneity over hospitals, over time and geographical areas.
- Published
- 2014
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