Comparative Effectiveness in Medicine: Analysis of Episiotomy Practice Patterns

摘要

The key objective of this thesis is to provide empirical evidence to demonstrate or disprove claims that findings from a major systematic review of the outcomes of routine episiotomy published in JAMA in 2005 (Hartmann et al.) have led to further declines in the practice of episiotomy. In addition, the thesis will study the trend in episiotomy rates for the civilian population. The primary research questions addressed in this thesis are as follows: (1) Has Hartmann et al's study had any effect on episiotomy rates and practice variations; and (2) How does the study's effect on episiotomy rates vary across hospital types and patients. The study used data from the Healthcare Cost and Utilization Project: State Inpatient Databases (HCUP SID) and American Hospital Association (AHA) annual surveys. The sample consisted of 648,141 patients from 897 hospitals in eight states between 2003 and 2008. Both fixed and random effects models were specified to estimate the effects of the JAMA publication on episiotomy rates. In addition, the study analyzed variations in practice patterns to find out whether the JAMA publication has had a desirable impact on clinical practices. The results show that the declining episiotomy rate continued to decline after the JAMA publication, but only marginally. The analysis of variations in practice patterns shows that variations in episiotomy rates remain substantial. More effective strategies should be formulated to reach out to different audiences to bridge the gap between research evidence and clinical practice with regard to episiotomy.