Gregory K D, Hackmeyer P, Gold L, Johnson A I, Platt L D
Cedars Sinai Medical Center, Department of Obstetrics and Gynecology, Los Angeles, CA 90048, USA.
Jt Comm J Qual Improv. 1999 Dec;25(12):619-29. doi: 10.1016/s1070-3241(16)30476-x.
In 1994 a five-year prospective observational study (including 38,541 singleton live-born deliveries) based on maternal and neonatal hospital administrative discharge data for DRGs 370-375 was launched at Cedars Sinai Medical Center (CSMC) in Los Angeles. In 1993 a cesarean section (C-section) reduction task force was first convened and several interventions were conducted and monitored during a two-year period. In 1995 CSMC joined the Institute for Healthcare Improvement's (IHI's) national collaborative on lowering C-section rates.
The first intervention involved physician education (grand rounds) and occurred during the preintervention baseline period. Providing physician-specific data had been implemented before participation in the IHI collaborative. Two other interventions were implemented before the collaborative versus 13 interventions after. The C-section rate decreased from 26.0% in the baseline period in 1993 to 20.5% in 1997, a 21.2% reduction. During the postintervention period, the C-section rate increased to 23.5%. There was no statistically or clinically significant increase in clavicular fractures, brachial plexus injuries, or cerebral hemorrhage in the four study years, compared to the baseline period.
It is possible to safely reduce C-section delivery rates. Activities are now under way to involve additional private physician leaders in the continuous quality improvement effort. Although the small increase in the C-section rate during the postintervention period may represent statistical variation, and in itself may not be clinically significant, it supports the thesis that ongoing, continuous organizational support is required to achieve and maintain gains.
1994年，基于洛杉矶西达赛奈医疗中心（CSMC）370 - 375疾病诊断相关分组（DRGs）的母婴医院行政出院数据，开展了一项为期五年的前瞻性观察研究（包括38,541例单胎活产分娩）。1993年首次召集了剖宫产（C-section）率降低特别工作组，并在两年期间进行了多项干预措施并进行监测。1995年，CSMC加入了医疗改进研究所（IHI）降低剖宫产率的全国合作项目。
首次干预是针对医生的教育（学术大查房），发生在干预前的基线期。在参与IHI合作项目之前就已经实施了提供医生特定数据的措施。另外两项干预措施在合作之前实施，而在合作之后实施了13项干预措施。剖宫产率从1993年基线期的26.0%降至1997年的20.5%，降低了21.2%。在干预后期间，剖宫产率上升至23.5%。与基线期相比，在四个研究年份中，锁骨骨折、臂丛神经损伤或脑出血在统计学或临床上均无显著增加。
安全降低剖宫产分娩率是可能的。目前正在开展活动，让更多的私人医生领导者参与到持续质量改进工作中来。尽管干预后期间剖宫产率的小幅上升可能代表统计差异，其本身可能在临床上并不显著，但它支持了这样一个论点，即需要持续的组织支持来实现并维持所取得的成效。
