Grand Rounds

Neuraxial Analgesia: What is the Statewide Variation in Usage?

BACKGROUND AND PURPOSE:

Butwick et al. (JAMA Network Open, 2018) examined variability in the use of neuraxial analgesia (epidural, spinal, or combined spinal-epidural blockade) across US states

Retrospective, population-based, cross-sectional analysis
Participants
- Women who underwent labor in 2015
Study design and data analysis
- US birth certificate data
- Variation evaluated by state
- Neuraxial prevalence was adjusted for antepartum, obstetric, and intrapartum factors
Primary outcomes
- State-specific prevalence of neuraxial analgesia per 100 women who underwent labor
- Variability in neuraxial analgesia use among states

Data based on 2,625,950 women | Neuraxial analgesia was used by 73.1%
Age distribution
- <15 years: 0.1% | 15 to 19 years: 7.0% | 20 to 24 years: 23.6% | 25 to 29 years: 29.6% | 30 to 34 years: 26.0% | 35 to 39 years: 11.4% | 40 to 44 years: 2.2% | 45 and 54 years: 0.1%
>90% of the study participants were privately insured or insured with Medicaid
Neuraxial analgesia prevalence
- Lowest neuraxial analgesia prevalence: Maine: 36.6%
- Highest neuraxial analgesia prevalence: Nevada: 80.1%
If the same patient received neuraxial analgesia in a high-use vs a low-use state, her odds of receiving neuraxial analgesia were 1.5-fold higher
- Adjusted median odds ratio: 1.5 (95% CI, 1.4 to 1.6)
The state where a woman obtained her care accounted for 5.4% of the overall variation in neuraxial analgesia
- Intraclass correlation coefficient: 5.4% (95% CI, 4.0% to 7.9%)

Only a small portion of variation in the use of neuraxial analgesia could be attributed to the state where a laboring patient received her care
- Patient-level and hospital-level factors (not analyzed in this current study) may further explain the variation seen between states

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