By Christian McDonald, Assistant Professor of Practice
School of Journalism and Media, Moody College of Communication
University of Texas at Austin

This analysis looks at episiotomy rates using the Texas Health Care Information Collection’s Texas Inpatient Public Use Data File. The definition to calculate the rates comes from the 2020 Leapfrog Hospital Survey p118. I start with data filtered from the THCIC data using the Leapfrog specs. That process is explained in “01-process-lf-epi-loop”.

Setup and import

library(tidyverse)
library(janitor)
library(DT)
library(tigris)

# suppresses grouping warning
options(dplyr.summarise.inform = FALSE)
test_flag <- F

### test data
path_test <- "data-test/lf_del_vag_loop_test.rds"

### production data
path_prod <- "data-processed/lf_del_cleaned.rds"

### import based on flag
if (test_flag == T) del_vag_excl <- read_rds(path_test) else del_vag_excl <- read_rds(path_prod)

del_vag_excl %>% nrow()
## [1] 930101

Set the episiotomy cases

This creates a column for cases where episiotomy is true. We have to look through each of the surgical procedure columns to check for the code.

I’d like to refactor this method, but at least it is easy to see and understand.

# list of codes for episiotomy, which is really one: 0W8NXZZ
epi_list <- read_rds("procedures-lists/lf_epi.rds") %>% .$epi
epi_list
## [1] "0W8NXZZ"
lf_epi <- del_vag_excl %>% 
  mutate(
    EPI = case_when(
      PRINC_SURG_PROC_CODE %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_1 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_2 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_3 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_4 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_5 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_6 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_7 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_8 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_9 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_10 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_11 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_12 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_13 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_14 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_15 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_16 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_17 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_18 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_19 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_20 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_21 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_22 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_23 %in% epi_list ~ TRUE,
      OTH_SURG_PROC_CODE_24 %in% epi_list ~ TRUE,
      TRUE ~ FALSE
    )
  )

This completes the processing of the data.

Searchable table: Episiotomy rates by hospital, combined years

Hospitals with fewer than 120 deliveries excluded.

lf_epi_rate_hosp <- lf_epi %>%
  group_by(THCIC_ID, PROVIDER_NAME, EPI) %>% 
  summarise(
    EPI_CNT = n()
  ) %>% 
  pivot_wider(names_from = EPI, values_from = EPI_CNT) %>% 
  rename(
    EPIF = "FALSE",
    EPIT = "TRUE"
  ) %>% 
  mutate(
    TOTAL = EPIF + EPIT,
    EPIRATE = round_half_up((EPIT / TOTAL) * 100,1)
  ) %>% 
  select(THCIC_ID, PROVIDER_NAME, TOTAL, EPIF, EPIT, EPIRATE) %>% 
  filter(
    TOTAL >= 120
    ) %>% 
  arrange(EPIRATE %>% desc())

lf_epi_rate_hosp %>%   
    datatable()

Episiotomy rates by hospital, by year

A look at the episiotomy rates for hospitals by year. We create the rate using the EPI column we created above, then pivot to do the math. We pivot again to see the years nicely in a table. Excludes hospitals with fewer than 30 deliveries in a given year.

# pivot to crate the rate based on logical EPI column
lf_epi_rate_hosp_yr <- lf_epi %>% 
  group_by(YR, THCIC_ID, PROVIDER_NAME, EPI) %>% 
  summarise(
    EPI_CNT = n()
  ) %>% 
  pivot_wider(names_from = EPI, values_from = EPI_CNT) %>% 
  rename(
    EPIF = "FALSE",
    EPIT = "TRUE"
  ) %>% 
  mutate(
    TOTAL = EPIF + EPIT,
    EPIRATE = round_half_up((EPIT / TOTAL) * 100,1)
  )

# select, pivot to see years.
lf_epi_rate_hosp_yr_table <- lf_epi_rate_hosp_yr %>% 
  filter(TOTAL >= 30) %>% 
  select(YR, THCIC_ID, PROVIDER_NAME, EPIRATE) %>% 
  pivot_wider(names_from = YR, values_from = EPIRATE) %>% 
  arrange(`2019` %>% desc())

lf_epi_rate_hosp_yr_table %>% datatable()

Laredo hospitals

Filtering above sets for Laredo hospitals.

Episiotomy rate combined years, Laredo hospitals

From combined years of the data.

lf_epi_rate_hosp %>% 
  filter(str_detect(PROVIDER_NAME, "Laredo"))

Episiotomy rates by year, Laredo hospitals

The table above, filtered for Laredo.

# filter for Laredo
lf_epi_rate_hosp_yr_table %>% 
  filter(str_detect(PROVIDER_NAME, "Laredo"))

Chart: Episiotomy rates by year, Laredo

lf_epi_rate_hosp_yr %>% 
  filter(str_detect(PROVIDER_NAME, "Laredo")) %>%
  ggplot(aes(YR, EPIRATE)) +
  geom_line(aes(group = PROVIDER_NAME, color = PROVIDER_NAME)) +
  expand_limits(y = c(0,40)) +
  theme(legend.position="bottom", legend.box = "vertical") +
  labs(title = "Episiotomy rate by year, Laredo hospitals", x = "YEAR", y = "Episiotomy rate")

Chart: Episiotomy rates by quarter, Laredo

lf_epi_rate_hosp_qr_laredo_plot <- lf_epi %>% 
  filter(str_detect(PROVIDER_NAME, "Laredo")) %>%
  group_by(DISCHARGE, PROVIDER_NAME, EPI) %>% 
  summarise(
    EPI_CNT = n()
  ) %>% 
  pivot_wider(names_from = EPI, values_from = EPI_CNT) %>% 
  rename(
    EPIF = "FALSE",
    EPIT = "TRUE"
  ) %>% 
  mutate(
    TOTAL = EPIF + EPIT,
    EPIRATE = round_half_up((EPIT / TOTAL) * 100,1)
  )

lf_epi_rate_hosp_qr_laredo_plot %>% 
  ggplot(aes(DISCHARGE, EPIRATE)) +
  geom_line(aes(group = PROVIDER_NAME, color = PROVIDER_NAME)) +
  expand_limits(y = c(0,40)) +
  theme(legend.position="bottom", legend.box = "vertical",axis.text.x=element_text(angle = -45, hjust = 0)) +
  labs(title = "Episiotomy rate by quarter, Laredo hospitals", x = "QUARTER", y = "Episiotomy rate")

Patient county

Get FIPS codes lookup for county names.

tx_fips <- fips_codes %>% 
  filter(state == "TX") %>% 
  select(county_code, county)
# peek
tx_fips %>% head(2)

Episiotomies by county, full data

This looks at rates by the patient’s county (the hospital could be elsewhere.). Currently not filtered for any minimum caseload since it is a 3+ year period.

lf_epi_rate_county <- lf_epi %>%
  group_by(PAT_COUNTY, EPI) %>% 
  summarise(
    EPI_CNT = n()
  ) %>% 
  # join for county names
  left_join(tx_fips, by=c( "PAT_COUNTY" = "county_code")) %>% 
  ungroup() %>% 
  rename(COUNTY = county) %>% 
  # pivot for mutates
  pivot_wider(names_from = EPI, values_from = EPI_CNT) %>% 
  rename(
    EPIF = "FALSE",
    EPIT = "TRUE"
  ) %>% 
  mutate(
    TOTAL = EPIF + EPIT,
    EPIRATE = round_half_up((EPIT / TOTAL) * 100,1)
  ) %>% 
  select(PAT_COUNTY, COUNTY, TOTAL, EPIF, EPIT, EPIRATE) %>% 
  # filter by total
  # filter(
  #   TOTAL >= 300
  #   ) %>% 
  arrange(EPIRATE %>% desc())

lf_epi_rate_county %>%   
    datatable()

Episiotimies by county, by year

Group by patient county. This table excludes fewer than 30 cases in a county in a given year.

# pivot to crate the rate based on logical EPI column
lf_epi_rate_county_yr <- lf_epi %>% 
  group_by(YR, PAT_COUNTY, EPI) %>% 
  summarise(
    EPI_CNT = n()
  ) %>% 
  # Join to add county names
  left_join(tx_fips, by=c( "PAT_COUNTY" = "county_code")) %>% 
  ungroup() %>% 
  rename(COUNTY = county) %>% 
  pivot_wider(names_from = EPI, values_from = EPI_CNT) %>% 
  rename(
    EPIF = "FALSE",
    EPIT = "TRUE"
  ) %>% 
  mutate(
    TOTAL = EPIF + EPIT,
    EPIRATE = round_half_up((EPIT / TOTAL) * 100,1)) %>% 
    # filter caseload
    filter(TOTAL >= 30)

# select, pivot to see years.
lf_epi_rate_county_yr_table <- lf_epi_rate_county_yr %>% 
  select(YR, COUNTY, EPIRATE) %>% 
  pivot_wider(names_from = YR, values_from = EPIRATE) %>% 
  arrange(`2019` %>% desc())

lf_epi_rate_county_yr_table %>% datatable()

Summaries

Statewide episiotomy rate

We combine all years of data to compare the percentage of episiotomy cases. The TRUE value is the percentage of cases where an episiotomy is performed.

lf_epi %>% 
  tabyl(EPI) %>% 
  rename(count = n) %>% 
  adorn_pct_formatting()

Creating a summary table in case we want it.

lf_epi_rate_tx_summary <- lf_epi %>% 
  group_by(EPI) %>% 
  summarize(CNT = n()) %>% 
  pivot_wider(names_from = EPI, values_from = CNT) %>% 
  rename(
    EPIF = "FALSE",
    EPIT = "TRUE"
  ) %>% 
  mutate(
    SUMMARY = "TX",
    CATEGORY = "EPISIOTOMY",
    MEASUREMENT = "RATE",
    TOTAL = EPIF + EPIT,
    VALUE = round_half_up((EPIT / TOTAL) * 100,1) # EPIRATE
  ) %>% 
  select(SUMMARY, CATEGORY, MEASUREMENT, VALUE)

lf_epi_rate_tx_summary

Episiotomy rate statewide by year

lf_epi_rate_tx_yr_summary <- lf_epi %>%
  group_by(YR, EPI) %>% 
  summarise(
    EPI_CNT = n()
  ) %>% 
  pivot_wider(names_from = EPI, values_from = EPI_CNT) %>% 
  rename(
    EPIF = "FALSE",
    EPIT = "TRUE"
  ) %>% 
  mutate(
    SUMMARY = "TX",
    CATEGORY = "EPISIOTOMY",
    MEASUREMENT = "RATE",
    TOTAL = EPIF + EPIT,
    VALUE = round_half_up((EPIT / TOTAL) * 100,1) # EPIRATE
  ) %>% 
  select(
    YR, SUMMARY, CATEGORY, MEASUREMENT, VALUE
  )

lf_epi_rate_tx_yr_summary

Episiotomy rate by hospital: Averaged, by year

lf_epi_rate_hosp_yr_summary <- lf_epi_rate_hosp_yr %>% 
  ungroup() %>% 
  group_by(YR) %>% 
  summarize(
    SUMMARY = "HOSPITAL",
    CATEGORY = "EPISIOTOMY",
    MEASUREMENT = "MEAN_OF_RATE",
    # MEDIAN = median(EPIRATE),
    VALUE = round_half_up(mean(EPIRATE, na.rm = TRUE),1) #MEAN
  )

lf_epi_rate_hosp_yr_summary

Write files

Writing out aggregate files. Here is a list of CSVs exports:

Plus some data outputs for 03-analysis-summaries.

# lf_epi %>% write_rds("data-processed/epi.rds")

if (test_flag == F) lf_epi_rate_tx_yr_summary %>%
  write_rds("data-processed/lf_epi_rate_tx_yr_summary.rds")

if (test_flag == F) lf_epi_rate_hosp_yr_summary %>%
  write_rds("data-processed/lf_epi_rate_hosp_yr_summary.rds")

if (test_flag == F) lf_epi_rate_hosp_yr %>%
  write_rds("data-processed/lf_epi_rate_hosp_yr.rds")

if (test_flag == F) lf_epi_rate_county_yr %>%
  write_csv("exports/lf_epi_rate_county_yr.csv")

beepr::beep(4)