Variation in Hospital Neuraxial Labor Analgesia Rates in California.

BACKGROUND: Neuraxial analgesia provides effective pain relief during labor. However, it is unclear whether neuraxial analgesia prevalence differs across US hospitals. Our aim was to assess hospital variation in neuraxial analgesia prevalence in California.

METHODS: A retrospective cross-sectional study analyzed birthing patients who underwent labor in 200 California hospitals from 2016 to 2020. The primary exposure was the delivery hospital. The outcomes were hospital neuraxial analgesia prevalence and between-hospital variability, before and after adjustment for patient and hospital factors. Median odds ratio and intraclass correlation coefficients (ICC) quantified between-hospital variability. The median odds ratio estimated the odds of a patient receiving neuraxial analgesia when moving between hospitals. The ICC quantified the proportion of the total variance in neuraxial analgesia use due to variation between hospitals.

RESULTS: Among 1,510,750 patients who underwent labor, 1,040, 483 (68.9%) received neuraxial analgesia. Both unadjusted and adjusted hospital prevalence exhibited a skewed distribution characterized by a long-left tail. The unadjusted and adjusted prevalence at the 1 st percentile were 5.4% and 6.0%; 5 th percentile were 21.0% and 21.2%; 50 th percentile were 70.6% and 70.7%; 95 th percentile were 75.8% and 76.6%; and 99 th percentile were 75.9% and 78.6%. The adjusted median odds ratio (2.3; 95% CI, 2.1 - 2.5) indicated a substantially increased odds of a patient receiving neuraxial analgesia if they moved from a hospital with a lower to higher odds of neuraxial analgesia. The hospital explained only a moderate portion of the overall variability in neuraxial analgesia (ICC=19.1%; 95% CI, 18.8 - 20.5%).

CONCLUSIONS: A long left tail in the distribution and wide variation exist in the neuraxial analgesia prevalence across California hospitals, not explained by patient and hospital factors. Addressing the low prevalence among hospitals in the left tail requires exploration of the interplay between patient preferences, staffing availability, and care providers' attitudes towards neuraxial analgesia.