1. A multifaceted intervention involving audit and feedback significantly reduced the rates of cesarean delivery in 32 hospitals in Quebec, Canada.
2. These findings were consistent at different levels of care (i.e., community, regional, tertiary hospitals).
Evidence Rating Level: 1 (Excellent)
Study Rundown: The rates of cesarean delivery have been steadily rising in developed countries for decades. This is concerning given that unnecessary cesarean delivery exposes both mother and baby to significant risk of harm, while also contributing to rising health care costs. Various initiatives have been studied to reduce the rate of unnecessary cesarean delivery with previous studies supporting the effectiveness of strategies involving audit of indications linked with provision of feedback. There is a paucity of evidence, however, from large randomized trials to support these interventions. The Quality of Care, Obstetrics Risk Management, and Mode of Delivery (QUARISMA) trial sought to determine whether a multifaceted intervention involving audit and feedback to encourage professional training would be effective in reducing rates of cesarean delivery in hospitals in Quebec, Canada. In the audit and feedback group, which included nurses and obstetricians deployed to each hospital to help train the staff, there were significantly less cesarean deliveries as opposed to the standard care group.
In-Depth [randomized controlled trial]: This cluster-randomized trial randomized hospitals in Quebec, Canada to either the intervention group or the control group, with randomization being stratified by level of care (i.e., community, regional, or tertiary hospital). Individual women were the unit of analysis. A 1-year preintervention phase assessed baseline rates of cesarean delivery. The intervention was 1.5 years in length – the first 6 months involved selecting an opinion leader and local audit committee (i.e., 1-2 obstetricians, 1-2 general practitioners, 1 nurse) at each hospital, developing local expertise in audit and feedback through a 1-day training course, and another day of training in monitoring indications for cesarean and managing intra-partum care. A 1-year postintervention period was implemented to allow intervention groups to continue performing audits without supervision to assess sustainability. The primary outcome was the overall rate of cesarean delivery.
A total of 32 hospitals (4 community, 22 regional, 6 tertiary) were randomized as part of this study. The baseline rate of cesarean delivery was slightly higher in the control group compared to the intervention group (23.2% vs. 22.5%). There was a significant reduction in the rate of cesarean delivery in the intervention group as compared to the control group (adjusted OR 0.90, 95%CI 0.80-0.99, p = 0.04; adjusted absolute risk difference -1.8%, 95%CI -3.8 to -0.2). The intervention effect did not vary significantly with different levels of care (p = 0.86). When looking specifically at low-risk pregnancies, the cesarean delivery rate decreased significantly in the intervention group when compared with the control group (adjusted OR 0.80, 95%CI 0.65-0.97, p = 0.03; adjusted risk difference -1.7%, 95%CI -3.0 to -0.3).
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