Comparative effectiveness in medicine: analysis of episiotomy practice patterns

This thesis provides empirical evidence to demonstrate or disprove claims that findings from a major systematic review published in 2005, have led to further declines in practices of episiotomy. The study uses data from the Healthcare Cost and Utilization Project: State Inpatient Databases (HCUP SID) and American Hospital Association (AHA) annual surveys. The sample consists of 648,141 patients from 897 hospitals between 2003 and 2008. Both fixed and random effects models are specified to estimate the effects of the JAMA publication, hospital characteristics including interaction terms and patient compositions on episiotomy rates. In addition the study analyzes variation of practice patterns to examine whether the JAMA publication has the desirable impact on clinical practices. The results show that the declining episiotomy trends accelerate marginally after the JAMA publication. Hospitals do not also appear to respond differentially to the JAMA publication for most hospital characteristics, except for hospital sizes, maternity ward turnover and ownership structure. The analysis of practice pattern variation suggests that practice variations by volumes are declining but variances of episiotomy rates remain substantial. More effective strategies should be formulated to reach out to different audiences to bridge the gap between research evidences and clinical practices on episiotomy. ; Approved for public release; distribution is unlimited. ; Outstanding Thesis ; Republic of Singapore Navy author ; http://archive.org/details/comparativeeffec1094510582