Impact of a Physician Dashboard on Episiotomy Utilization at William P. Clements Jr. University Hospital
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OBJECTIVE: Third and fourth degree vaginal lacerations following delivery are associated with long-term pelvic floor complications including pain and incontinence. Routine performance of episiotomy in a spontaneous vaginal delivery increases the likelihood of a severe perineal laceration and routine utilization of episiotomy is discouraged. High provider variation in adherence to this recommendation is known. The objective of this study was to determine if the adoption of a physician dashboard that reported individual and group rates of episiotomy utilization could reduce both institutional and individual rates to below the national benchmark of 5.5%. STUDY DESIGN: Baseline data extracted from records of patients delivering between January 1, 2015 and July 15, 2015 were entered into a green-yellow-red dashboard that listed all generalist obstetricians performing deliveries at Clements University Hospital (CUH). Physician identities were blinded on the dashboard; individual physicians were provided their code in written and email communications. Data on episiotomy utilization were collected prospectively following distribution of the dashboard. RESULTS: The baseline rate for episiotomy performance was 9.5% at CUH prior to the development of the physician dashboard, with individual rates ranging from 0.0% to 55.6%. Following implementation of the dashboard there was a significant reduction in the institutional rate of episiotomy (9.5% pre-intervention vs. 0.52% post-intervention, p<0.001) and all providers met the target rate of <5.5%. Our analysis of data also validated the increased risk of severe perineal lacerations with the performance of episiotomy at CUH (Table below). Pre-Intervention No episiotomy Episiotomy Total deliveries 458 52 3rd/4th degree laceration 9 (1.97%) 4 (7.69%) p=0.01; Odds ratio 4.1 (1.2, 14.0) Despite the reduction in episiotomy utilization we were unable to demonstrate a reduction in the frequency of severe perineal lacerations (2.42% pre-intervention vs. 1.55% post-intervention, p=0.48), suggesting that multiple factors contribute to these events. CONCLUSION: When variation in physician performance exists, utilization of a physician dashboard comparing individual provider behavior to peers can result in a significant improvement in provider and institutional performance on specific metrics.