The Application of the Ten Group Classification System (TGCS) in Caesarean Delivery Case Mix Adjustment. A Multicenter Prospective Study

Gianpaolo Maso, Salvatore Alberico, Lorenzo Monasta, Luca Ronfani, Marcella Montico, Caterina Businelli, Valentina Soini, Monica Piccoli, Carmine Gigli, Daniele Domini, Claudio Fiscella, Sara Casarsa, Carlo Zompicchiatti, Michela De Agostinis, Attilio D'Atri, Raffaela Mugittu, Santo La Valle, Cristina Di Leonardo, Valter Adamo, Silvia SmiroldoGiovannil De Frate, Monica Olivuzzi, Silvio Giove, Maria Parente, Daniele Bassini, Simona Melazzini, Secondo Guaschino, Francesco De Seta, Sergio Demarini, Laura Travan, Diego Marchesoni, Alberto Rossi, Giorgio Simon, Sandro Zicari, Giorgio Tamburlini

Research output: Contribution to journalArticlepeer-review


Background:Caesarean delivery (CD) rates are commonly used as an indicator of quality in obstetric care and risk adjustment evaluation is recommended to assess inter-institutional variations. The aim of this study was to evaluate whether the Ten Group classification system (TGCS) can be used in case-mix adjustment.Methods:Standardized data on 15,255 deliveries from 11 different regional centers were prospectively collected. Crude Risk Ratios of CDs were calculated for each center. Two multiple logistic regression models were herein considered by using: Model 1- maternal (age, Body Mass Index), obstetric variables (gestational age, fetal presentation, single or multiple, previous scar, parity, neonatal birth weight) and presence of risk factors; Model 2- TGCS either with or without maternal characteristics and presence of risk factors. Receiver Operating Characteristic (ROC) curves of the multivariate logistic regression analyses were used to assess the diagnostic accuracy of each model. The null hypothesis that Areas under ROC Curve (AUC) were not different from each other was verified with a Chi Square test and post hoc pairwise comparisons by using a Bonferroni correction.Results:Crude evaluation of CD rates showed all centers had significantly higher Risk Ratios than the referent. Both multiple logistic regression models reduced these variations. However the two methods ranked institutions differently: model 1 and model 2 (adjusted for TGCS) identified respectively nine and eight centers with significantly higher CD rates than the referent with slightly different AUCs (0.8758 and 0.8929 respectively). In the adjusted model for TGCS and maternal characteristics/presence of risk factors, three centers had CD rates similar to the referent with the best AUC (0.9024).Conclusions:The TGCS might be considered as a reliable variable to adjust CD rates. The addition of maternal characteristics and risk factors to TGCS substantially increase the predictive discrimination of the risk adjusted model.

Original languageEnglish
Article numbere62364
JournalPLoS One
Issue number6
Publication statusPublished - Jun 5 2013

ASJC Scopus subject areas

  • Agricultural and Biological Sciences(all)
  • Biochemistry, Genetics and Molecular Biology(all)
  • Medicine(all)


Dive into the research topics of 'The Application of the Ten Group Classification System (TGCS) in Caesarean Delivery Case Mix Adjustment. A Multicenter Prospective Study'. Together they form a unique fingerprint.

Cite this