Cesarean section rate variation across hospital referral regions in Texas: A claims analysis of privately insured population from 2008-2011

OBJECTIVE: With more than one-third of births delivered by cesarean section (C-section) in the U.S. and a substantial variation across states, the study assessed the rate of C-section's performed across hospital referral regions (HRR's) within Texas. METHODS: The study used 2008 – 2011 inpatient claims data from Blue Cross Blue Shield (BCBS) of Texas, largest commercial insurance provider in Texas. Of the 6,486,226 members enrolled in BCBS, about 51% were females. Delivery procedures were identified using diagnosis related groups (C-section: 765,766; Normal: 767, 768, 774, 775) and only females of child bearing age (15-44 years) at the time of admission were included in the study. Claims were mapped to twenty two Texas HRR's using the billing provider zip codes. RESULTS: A total of 108,335 delivery procedures were performed among BCBS insured females across Texas from 2008-2011. The weighted average rate of C-sections for Texas was found to be 39.30% (median: 40.28%); with the lowest rate observed for Wichita Falls at 27.11% and the highest for El Paso at 53.38%. Based on the index of variation calculations, El Paso was 35.83% higher than the state's average while Wichita Falls was 31.02% below the state's average. C-section rates increased linearly across age groups (15-19 years: 23.57%; 20-24 years: 30.81%; 25-29 years: 35.49%; 30-34 years: 41.22%; 35-39 years: 48.70%; 40-44 years: 55.03%) and were found to be stable over a period of four years. CONCLUSIONS: Overall, Texas is nearly 6% above the national average of births by C-section for commercial plans but considerable variation exists across HRR's. Further exploration is required in understanding factors that lead to such variations and high rates of C-section procedures.