path’09 u rhzdravstvo-kvaliteta.org/dokumenti/radionice/3radionica-05...hrvatski lije čni čki...

Hrvatski liječnički zbor

Hrvatsko društvo za poboljšanje kvalitete zdravstvene zaštite

3. Radionica bolničkih koordinatora

PATH’09 u RH

Zagreb, 5. svibnja 2009.Zagreb, 5. svibnja 2009.

INFORMACIJE

REGISTRACIJA BOLNICA

OPISNI LIST INDIKATORA 1. FAZE

PATIENT SURVEY?

STUFF SURVEY?STUFF SURVEY?

PRIJEDLOZI – FINANCIJSKI INDIKATOR?

TERMIN SLIJEDEĆE RADIONICE?

PATH Performance Assessment Tool for Quality Improvement in Hospital

Poštovani (PATH tim),

� šaljem vam materijale vezano za PATH' 09.

� vezano za indikatore, žutim sam označila indikatore 1. faze;

� Indikator antibiotička profilaksa smo prihvatili da nam u RH to bude indikator u 2. fazi;

� indikator (financijski) označen zelenim – o njemu nismo raspravljali, pa vas ljubazno molim da

razmislite (prijedlog) za planiranu 3. radionicu 5. svibnja;

� obrazac za registraciju bolnice (uvjet za uključivanje)

� Slobodna sam podsjetiti vas na dogovor vezano za „Patient and Staff Survey” označeno lila.

10. Travnja 2009


KBC ZagrebKB Sestre MilosrdniceKB Sveti DuhKlinika za dječje bolesti, Zagreb Klinika za tumore ZagrebSveučilišna klinika Vuk Vrhovac, ZagrebKBC RijekaKB Osijek

OB VaraždinOB ZadarOB KarlovacOB Gospić

Psihijatrijska bolnica „Sveti Ivan“ ZagrebPsihijatrijska bolnica RabPsihijatrijska bolnica Ugljan

SB za medicinsku rehabilitaciju „Kalos“, Vela LukaSB bolnica za medicinsku rehabilitaciju LipikSB za medicinsku rehabilitaciju Krapinske toplice

SB za produženo liječenje Duga Resa

SB za zaštitu djece s neurorazvojnim i motoričkimOB GospićOB VukovarOB „Dr. Tomislav Bardek“ KoprivnicaOB BjelovarOB PulaOB VinkovciOB NašiceOB ZabokOB Virovitica

PATHPerformance Assessment Tool for Quality Improvement in Hospital

SB za zaštitu djece s neurorazvojnim i motoričkim

smetnjama Goljak

20PATH’09 REGISTRACIJA BOLNICA

Istraživanje (SURVEY) o … bolesniku; …o djelatnicima

OB Karlovac Upitnik za specijalizante

Anketa bolesnika

Sveučilišna klinika Vuk Vrhovac Anketa bolesnika

Anketa za zaposlenike Klinike

OB Zabok Opažanja i primjedbe bolesnika o OB Zabok Opažanja i primjedbe bolesnika o

pruženoj zdravstvenoj skrbi

OB Bjelovar Anketa o kulturi sigurnosti pacijenata u

bolnici (HSPSC)

Ostali

CATALOGUE

Currently used patient safety culture instruments in Europe

April 14 2009April 14 2009

The ESQH-Office for Quality IndicatorsOluf Palmes Allé 13DK-8200 Aarhus N

Denmark

Name of the instrument Belgian versions of the Hospital Survey on Patient Safety Culture (1;2) by the Agency for Healthcare Research and Quality (AHRQ)

By Dr Johan Hellings, Ziekenhuis Oost-Limburg A.V. & University Hasselt (3)

Characteristic Description

Origin and year of launch USA, launched in 2004Belgium launched in 2005 in Flemish and FrenchPlease also see currently used PSCI in Scotland for more information.

Language(s) Original language: American Known translations (as the original tool and modified):- Croatian- Dutch- FinnishHealth care organizations


- Finnish- Flemish- French- Greek- Italian- Mandarin (Chinese)- Norwegian- Portuguese- Serbian- Spanish- Sweden- Swiss German- Turkish

www.ahrq.gov/qual/hospculture/

Health care organizations can use the instrument to:Assess staff’s opinion on

patient safety issues, medical error, and event reporting in the hospital Track changes in patient

safety over timeEvaluate the impact of

patient safety interventions.

“Observation period":

We suggest to measure on three years in order to be able to assess trends

(it is important to highlight the trends before comparing with other hospitals in the country

or even more before comparing internationally).

A three year observation period (3 times indicator computed) was suggested for the

indicator for which we believe that most hospitals can easily derive from computer-based administrative database. Hence, doing the work over one or over three different

years probably does not require much more. The most difficult is to define the algorithm

to retrieve the data.

If there is no electronic dsatabase for those indicators, maybe an option is to still have 3 years, but only on a sample. I would prefer 3 times 1 month or 2 monthsobservation over three different years than one time 3 or 6 months observation over one

signe year.


Ann-Lise, WHO, May 4

What financial indicator could be included?

This is very locally-grounded and we cannot suggest one from the international side. It

depends really on what is regularly being monitored and what managers are held accountable for.

But even if we will not have any international comparisons, it is extremely relevant to include such indicators in the PATH framework, to cover performance in a

comprehensive way.

So that would be nice if you could have a discussion on that or if you could agree that

the PATH coordinators will get suggestions from their financial managers for next meeting.



“Psychiatric and rehabilitation hospitals”

We called for interest through the minutes of Ljubjana meeting. Maybe the Internatinal

Secretariat can send an email to country cooridnator to assess their interest in

participating to a working group on this and to collect their previous experience with

indicators in such type of facilities.



Indikatori 1. faze: definicija, logistika prikupljanja podataka


Indicator Wave for data

collection

Deadline for

providing data

to the

coordinator in

the country

“Observation”

period

Source Responsible

for extraction

or collection of

data

Retrospective

(use previously

available data)

or prospective

(collect data

over a period

after

implementatio

n of data

collection tool)

Comments

C-section use wave 1 provide data by

July’09

2006, 2007,

2008 or the

three last

available years

Discharge

abstract

extraction by

hospitals or

centrally by

coordinator

retrospective

Case fatalities

for AMI and

Stroke

wave 1 provide data by

July’09

2006, 2007,

2008 or the

three last

available years

Discharge

abstract

extraction by

hospitals or

centrally by

coordinator

retrospective


available years coordinator

Post-

operative

pulmonary

embolism


July’09

2006, 2007,

2008 or the

three last

available years

Discharge

abstract

extraction by

hospitals or

centrally by

coordinator

retrospective

Length of

stay


July’09

2006, 2007,

2008 or the

three last

available years

Discharge

abstract

extraction by

hospitals or

centrally by

coordinator

retrospective

Day surgery wave 1 provide data by

July’09

2006, 2007,

2008 or the

three last

available years

Discharge

abstract

extraction by

hospitals or

centrally by

coordinator

retrospective

Needle

injuries

wave 1, might

be

complemented

with specific

ad-hoc data

collection

during wave 2

Provide data

by July’09

2006, 2007,

2008

Occupational

medicine

database

(repository of

all injuries

reported)

Extraction by

hospitals

Retrospective

(note: might be

complemented

with ad-hoc

prospective

data collection

through the

staff survey or

through

specific study

during wave 2)

Staff smoking Might be wave

1 (to be

discussed)

To be

discussed

Month to

perform the

auto-audit does

not matter

much as pretty

stable in time

Self-audit

using standard

tool (see

European

Network for

Smoke Free

Current

practices and

policies


Hospitals,

Barometer tool

available in

several

languages)

Financial

indicator(s)

To be decided

nationally

To be decided

nationally

2006, 2007,

2008

Financial

balance

Extraction by

hospital (or

centrally??)

retrospective It is suggested that each

country includes one or

two financial indicator

(“classical financial

ratios”) that is currently

widely used and that

CEO closely monitor in

the country

OPISNI LIST INDIKATORA

• Naziv indikatora

• Kratka definicija indikatora

• Logička osnova za korištenje (uključujući opravdanje, jakost i ograničenje)

• Radna definicija (opis numeratora i denominatora)

• Izvor podataka

• Domena PATH modela i vrsta indikatora• Domena PATH modela i vrsta indikatora

• Podešavanje – stratifikacija

• Povezanost indikatora s drugim indikatorima

• Interpretacija, cilj indikatora, aktivnosti za poboljšanje

• Preporuke

• Reference


PATH’09 indicators – draftApril 2009/ag

Short name C-section rate

Detailed name Rate of c-section after exclusion of deliveries with high risk of c-section (pre-term, multiple, breech, abnormal presentation)


Short definition Number of c-section over the total number of live births, expressed as a percentage.

Categories of deliveries with a high risk of c-section are excluded (pre-term,multiple, breech, abnormal presentation)

Rationale (including

justification,

strengths and limits)

Why monitor c-section rate?

Rationale:

1) C-section is the most common operative procedure in many industrialized countries. In

2002, in Europe, c-section rate ranged from 6.2 to 36% with an average of 19% (1) and

those rates are steadily rising in most countries in the European Region. Those figures

are well above the WHO recommendations to maintain rates no higher than 10-15% (2). Though the optimal rate of c-section remains controversial, in developed

countries with a rate substantially higher to 15%, the attention has focused on

strategies to reduce use due to the concern that higher c-section rates do not bring

additional health gain but may increase maternal risks, have implications for future

pregnancies and have resources implications for health services (1). This indicator may

address large potential for quality improvement in a number of settings.

1) The burden of data collection is low. This indicator is built on data readily available

in administrative database (discharge abstract) in most country and is already regularly

being monitored. There is a high consensus on use.

This indicator is multidimensional as it addresses


- Clinical effectiveness: appropriateness of medical care

- Patient safety: maternal and infant risks related to inappropriate (over and under) use of

c-section, physician defensive practice

- Efficiency: higher utilization of resources for C-section than vaginal deliveries.

- Responsive governance: Access, availability

- Patient centeredness: patient informed choice, physician responsibility in providing

balanced information and honouring patient choice for elective c-section

Limit: Because of the numerous factors that affect the rate of C-section and because there is

no “gold standard” on optimal C-section rate, this indicator is difficult to interpret.

Both very low rates and very high rates should be scrutinized to understand thereasons for variations.

Operational definition Numerator:

Total number of deliveries at the denominator with c- section as procedure Code

(see appendix A)

Denominator:

Total number of deliveries

Exclusion: delivery before the 37th week of gestation, abnormal presentation, foetal death, multiple gestation and breech procedure


presentation, foetal death, multiple gestation and breech procedure

(see appendix B)

Appendix A:

Name

INCLUDE - ICD-9-CM Cesarean delivery procedure codes:

CLASSICAL C-SECTION 740

CESAREAN SECTION NEC 744


CESAREAN SECTION NEC 744

LOW CERVICAL C-SECTION 741

CESAREAN SECTION NOS 7499

EXTRAPERITONEAL C-SECT 742

Exclude:

HYSTEROTOMY TO TERMIN PG 7491

Appendix B

Name WHO´s "International Statistical

Classification of Diseases and

Related Health Problems (ICD-9)

EARLY ONSET DELIV-UNSPEC 64420

EARLY ONSET DELIVERY-DEL 64421

TWIN PREGNANCY-UNSPEC 65100

TWIN PREGNANCY-DELIVERED 65101

TWIN PREGNANCY-ANTEPART 65103

TRIPLET PREGNANCY-UNSPEC 65110

TRIPLET PREGNANCY-DELIV 65111

TRIPLET PREG-ANTEPARTUM 65113


QUADRUPLET PREG-UNSPEC 65120

QUADRUPLET PREG-DELIVER 65121

QUADRUPLET PREG-ANTEPART 65123

TWINS W FETAL LOSS-UNSP 65130

TWINS W FETAL LOSS-DEL 65131

TWINS W FETAL LOSS-ANTE 65133

TRIPLETS W FET LOSS-UNSP 65140

TRIPLETS W FET LOSS-DEL 65141

TRIPLETS W FET LOSS-ANTE 65143

QUADS W FETAL LOSS-UNSP 65150

QUADS W FETAL LOSS-DEL 65151

QUADS W FETAL LOSS-ANTE 65153

MULT GES W FET LOSS-UNSP 65160

MULT GES W FET LOSS-DEL 65161

MULT GES W FET LOSS-ANTE 65163

MULTI GESTAT NEC-UNSPEC 65180

MULTI GESTAT NEC-DELIVER 65181

MULTI GEST NEC-ANTEPART 65183

MULTI GESTAT NOS-UNSPEC 65190

MULT GESTATION NOS-DELIV 65191

MULTI GEST NOS-ANTEPART 65193

BREECH PRESENTAT-UNSPEC 65220

BREECH PRESENTAT-DELIVER 65221

BREECH PRESENT-ANTEPART 65223


TRANSV/OBLIQ LIE-UNSPEC 65230

TRANSVER/OBLIQ LIE-DELIV 65231

TRANSV/OBLIQ LIE-ANTEPAR 65233

FACE/BROW PRESENT-UNSPEC 65240

FACE/BROW PRESENT-DELIV 65241

FACE/BROW PRES-ANTEPART 65243

MULT GEST MALPRESEN-UNSP 65260

MULT GEST MALPRES-DELIV 65261

MULT GES MALPRES-ANTEPAR 65263

INTRAUTERINE DEATH-UNSP 65640

INTRAUTER DEATH-DELIVER 65641

INTRAUTER DEATH-ANTEPART 65643

LOCKED TWINS-UNSPECIFIED 66050

LOCKED TWINS-DELIVERED 66051

LOCKED TWINS-ANTEPARTUM 66053

DELAY DEL 2ND TWIN-UNSP 66230

DELAY DEL 2ND TWIN-DELIV 66231

DELAY DEL 2 TWIN-ANTEPAR 66233

BREECH EXTR NOS-UNSPEC 66960

BREECH EXTR NOS-DELIVER 66961

MULT PREGNANCY AFF NB 7615

DELIVER-SINGLE STILLBORN V271

DELIVER-TWINS, BOTH LIVE V272


DELIVER-TWINS, BOTH LIVE V272

DEL-TWINS, 1 NB, 1 SB V273

DELIVER-TWINS, BOTH SB V274

DEL-MULT BIRTH, ALL LIVE V275

DEL-MULT BRTH, SOME LIVE V276

DEL-MULT BIRTH, ALL SB V277

ICD-9-CM breech procedure codes

PART BRCH EXTRAC W FORCP 7253 TOT

BRCH EXTRAC W FORCEP 7251

PART BREECH EXTRACT NEC 7254 TOT

BREECH EXTRAC NEC 7252

International results and discussion on this indicator can be found in the PATH Newsletter 4.

The definition of the c-section indicator is identical for PATH-pilot, PATH-II and PATH’09. However, in PATH-II,

the codes for inclusion and exclusion criteria were not specified. In PATH-II, it was suggested to complement

the c-section indicator with measures of repeat c-section (number of vaginal deliveries over number of

deliveries with previous c-section) and primary c-section (number of c-section over number of primary

deliveries). Those two tailored indicators were measured by only few hospitals, on an ad-hoc data collection for

a limited time period (and hence limited number of cases that make) and reliability of data was low because of

poor understanding of the definition. Hence, it was decided not to include those two tailored indicator in

PATH’09.

In PATH’09, extremely seldom did hospitals present c-section rates below 10%. Countries 2, 3, and 5 (figure 4,

Lessons learnt from PATH-pilot and PATH-II and adaptation to the definition in PATH’09


In PATH’09, extremely seldom did hospitals present c-section rates below 10%. Countries 2, 3, and 5 (figure 4,

red) tended to have a higher rate (median and mean) as well as a wider dispersion (inter-quartile and standard

deviation) compared to countries 1 and 4 (figure 4, blue). This might signal generally better practices in

countries 1 and 4 with more homogeneity in the process around a more accepted median or mean rate. If

socio-cultural factors (mother-induced c-section for non clinical reasons) can contribute to higher rates in some

countries, it does not explain wider variations in those same countries. However, the seemingly better results

in countries 1 and 4 might also be explained by homogeneous patient populations in both countries and

question the reliability of exclusion criteria identified from administrative database and coding practices in

countries 2, 3, and 5. In PATH-II, some hospitals indicated that they were not able to identify the exclusion

criteria and some relied on other sources (ward medical document).

In PATH-II, mother-induced demand was repeatedly cited in several countries as the main driver for high c-

section rates, especially in primary deliveries.

22

68

55

23

30

2028

3333

40

60

80

100

Lessons learnt from PATH-pilot and PATH-II and adaptation to the definition in PATH’09


18

22

12

21

12

2320

17

81011

11 1517

0

20

country 1 country 2 country 3 country 4 country 5

Figure 1: International comparison on average

c-section rate within country (min, quartile 1, quartile 3, max, in %)

Data source Retrospective data collection on administrative database (discharge abstracts).

This indicator is computed for the last 3 years available (2006, 2007, 2008). If the data is

retrieved manually from paper database, the indicator can be computed based on asample (all deliveries meeting the inclusion criteria for the months of October andFebruary 2006, 2007, 2008).The PATH Coordinator in the Country should be informed of the sampling procedure.

Patient-level data (one record for each patient) is to be sent to the PATH Coordinator in

the Country (PCC). For each patient, it includes relevant data for the calculation of the

numerator and denominator

(specification of inclusion/exclusion criteria) and may also include fields on age of themother, day/time of delivery, obstetrician, assurance status, etc. Those additionalfields are to be discussed at the national level depending on availability of the data

?


fields are to be discussed at the national level depending on availability of the data(ease to retrieve) and relevance in the context of the country.

The coding practices should be discussed among participating hospitals to assess

how much the exclusion criteria are specified in the discharge abstracts or if alternative

sources of information need to be retrieved on an ad-hoc basis.

Domain Clinical Effectiveness and Safety. But also efficiency, patient centeredness and

responsive governance. This indicator is truly multidimensional.

Type of indicator Process measure

Adjustment/stratification Not relevant

It is suggested to compare the % of deliveries excluded at the denominator out of the

total number of deliveries. This measure might reflect differences in case-mix or

differences in how exclusion criteria are identified and coded in the dischargeabstracts or from alternative sources. Hence, it is advisable to compare this measurefor different level of care (e.g. university hospital with neonatal intensive care vs.community hospital). It should then be discussed among the group of participatinghospitals if the differences do indeed represent differences of case-mix (complex

deliveries oriented to higher level of care).

?


Sub-indicators - By age categories of the mother (less 20, 20-35, more 35)

- By assurance status of the mother (if relevant to the country)

- By elective vs. emergency or proxy: day of the week, time of the day

- By categories for BMI of the mother

- By categories for weight of the newborn

- By parity

Guidelines

References RCOG Clinical Effectiveness Support Unit. The National Sentinel Caesarean Section Audit Report..

Eds: Royal College of Obstetricians and Gynecologists, London, UK, 2001. 118 p. Available on

www.rcog.org.uk

Main EK. Reducing cesarean birth rates with data driven quality improvement activities. Pediatrics

1999;103(1supp.E):374-383.

Kazandjian VA, Lied TR. Cesarean section rates: effects of participation in a performance measurement

project. Joint commission Journal on Quality Improvement 1998;24(4):187-196.

Yeast JD, Jones A, Poskin M. Induction of labor and the relationship to cesarean section delivery: a

review of 7001 consecutive inductions. American Journal of Obtestrics and Gynecology 1999;180:628-

633.

Seyb St, Berbka RJ, Socol ML et al. Risk of cesarean delivery with elective induction of labor at term in

nulliparous women. Obstetrics and Gynecology 1999;94:600-607.

Aaron DC, Harper DL, Shepardson LB, Rosenthal GE. Journal of the American Medical Association

1998;279:1968-1972.

DiGiuseppe DL, Aron DC, Payne SMC, Snow RJ, Dierker L, Rosenthal GE. Risk adjusting cesarean


DiGiuseppe DL, Aron DC, Payne SMC, Snow RJ, Dierker L, Rosenthal GE. Risk adjusting cesarean

delivery rates: a comparison of hospital profiles based on medical record and birth certificate data.

Health Services Research 2001;65(5):959-977.

Pasternak DP, Pine M, Nolan K, French R. Risk-adjusted measurement of primary cesarean sections:

reliable assessment of the quality of obstetrical services. Quality Management in Health Care

1999;8(1):47-54. 1999

Peaceman AM, Feinglass J, Manheim LM. Risk-adjustment of cesarean delivery rates: a practical

method for use in quality improvement. American Journal of Medical Quality 2002;17(3):113-117.

Naiditch M, Levy G, Chale JJ, Cohen H, Colladon B, Maria B, Nisand I, Papiernik E, Souteyrand P.

Cesearean sections in France: impactof organizational factors on different utilization rates (French).

Journal de Gynécologie, Obstétrique et Biologie de la Reproduction 1997;26(5):484-495.

Di Lallo D, Perucci DA, Bertollini R, Mallone S. Cesarean section rates by type of maternity unit and

level of obstetric care: an area-based study in central Italy. Preventive Medicine 1996;25(2):178-185.

Gregory KD. Monitoring, risk adjustment and strategies to decrease cesarean rates. Current Opinion in

Obstetrics and Gynecology 2000,12:481-486.

AHRQ Quality/Patient safety indicators http://www.qualityindicators.arhq.gov

Related indicators - Median length of stay for patient (mother) at numerator, median length of stay for patient (mother) at

denominator with vaginal delivery, median length of stay for all patient (mother) at denominator

- Deep Vein Thrombosis

The following indicators are not computed in the frame of PATH’09 but if monitored in the hospital, it might be

relevant to relate to the rate of c-section

- AGPAR score at birth

- Antibioprophylaxis before elective c-section

Interpretation and actions for

improvement

As indicated above, the indicator is difficult to interpret because of the numerous drivers for c-section (clinical

factors but also cultural and socio-economic factors) and because there is little consensus on optimal c-section

rate. This indicator is bi-directional. It means that both high and low rate should be scrutinized. Selection bias is

expected (high risk pregnancies concentrated in some facilities, mother choosing their physician to fit their

preference in terms of c-section or vaginal delivery). Hence, the best reference point is oneself; it is crucial to

look at the evolution over time and understand what factors might affect the trends. Comparison between

hospitals within a same country might be relevant to identify some best practice; understand why c-section rate is

stable in some hospital while the general trend is a (sharp) in crease in c-section. International comparisons are

of less value because of the numerous external factors (cultural, socio-economic) that might affect the outcome

and which contributions are very difficult to isolate or make explicit.

?


Complementary measures for further scrutiny – to investigate outliers:

-Proportion by category of urgency (immediate threat to the life of the mother or foetus, maternal or foetal

compromise that is not immediately life threatening, mother need early delivery but no maternal or foetal

compromise, delivery timed to suit the mother and the staff) (classification according to the National Confidential

Enquiry into Perioperative Deaths NCEPOD)

Background measures to better understand practice type:

- Proportion of failed vaginal delivery after C-section

- Epidural use

- Labour induction

Guidelines

References RCOG Clinical Effectiveness Support Unit. The National Sentinel Caesarean Section Audit Report.. Eds:

Royal College of Obstetricians and Gynecologists, London, UK, 2001. 118 p. Available on www.rcog.org.uk

Main EK. Reducing cesarean birth rates with data driven quality improvement activities. Pediatrics

1999;103(1supp.E):374-383.

Kazandjian VA, Lied TR. Cesarean section rates: effects of participation in a performance measurement

project. Joint commission Journal on Quality Improvement 1998;24(4):187-196.

Yeast JD, Jones A, Poskin M. Induction of labor and the relationship to cesarean section delivery: a review of

7001 consecutive inductions. American Journal of Obtestrics and Gynecology 1999;180:628-633.

Seyb St, Berbka RJ, Socol ML et al. Risk of cesarean delivery with elective induction of labor at term in

nulliparous women. Obstetrics and Gynecology 1999;94:600-607.

Aaron DC, Harper DL, Shepardson LB, Rosenthal GE. Journal of the American Medical Association

1998;279:1968-1972.

DiGiuseppe DL, Aron DC, Payne SMC, Snow RJ, Dierker L, Rosenthal GE. Risk adjusting cesarean delivery

rates: a comparison of hospital profiles based on medical record and birth certificate data. Health Services

Research 2001;65(5):959-977.


Research 2001;65(5):959-977.

Pasternak DP, Pine M, Nolan K, French R. Risk-adjusted measurement of primary cesarean sections: reliable

assessment of the quality of obstetrical services. Quality Management in Health Care 1999;8(1):47-54. 1999

Peaceman AM, Feinglass J, Manheim LM. Risk-adjustment of cesarean delivery rates: a practical method for

use in quality improvement. American Journal of Medical Quality 2002;17(3):113-117.

Naiditch M, Levy G, Chale JJ, Cohen H, Colladon B, Maria B, Nisand I, Papiernik E, Souteyrand P.

Cesearean sections in France: impactof organizational factors on different utilization rates (French). Journal

de Gynécologie, Obstétrique et Biologie de la Reproduction 1997;26(5):484-495.

Di Lallo D, Perucci DA, Bertollini R, Mallone S. Cesarean section rates by type of maternity unit and level of

obstetric care: an area-based study in central Italy. Preventive Medicine 1996;25(2):178-185.

Gregory KD. Monitoring, risk adjustment and strategies to decrease cesarean rates. Current Opinion in

Obstetrics and Gynecology 2000,12:481-486.

AHRQ Quality/Patient safety indicators http://www.qualityindicators.arhq.gov

path’09 u rhzdravstvo-kvaliteta.org/dokumenti/radionice/3radionica-05...hrvatski lije čni čki...

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