Linton Andrea, Peterson Michael R
Center for Health Care Management Studies, Office of the Assistant Secretary of Defense, Health Affairs, TRICARE Management Activity, Falls Church, VA 22041-3206, USA.
Birth. 2004 Dec;31(4):254-64. doi: 10.1111/j.0730-7659.2004.00317.x.
In response to rising cesarean rates, it is reasonable for health care organizations to look to a managed care model as a means of controlling further rate increases. However, little conclusive evidence exists to support this solution. We undertook a study of the Department of Defense health care beneficiary population to assess the impact of enrollment in TRICARE Prime, the Department's managed care health plan, on cesarean delivery rates.
Pooled hospital discharge records from 1999-2002 for live, singleton births were analyzed to calculate primary and repeat cesarean rates for TRICARE Prime and non-Prime beneficiaries in the military and civilian hospitals that comprise the Department of Defense health care network. Stepwise logistic regression was used to calculate adjusted odds ratios for clinical indicators for each combination of health plan and hospital setting using the chi2 difference(p <0.05)to eliminate nonsignificant variables from the model. Total primary and repeat cesarean rates were compared with primary and repeat cesarean rates for women with no reported clinical complications to account for differences in case mix across subgroups. Statistical significance of the differences calculated for subgroups was assessed using chi2.
Primary cesarean rates were significantly lower for TRICARE Prime enrollees relative to non-Prime beneficiaries for all race subgroups and three of five age subgroups in military hospitals and four of five age subgroups in civilian hospitals. No significant differences in repeat cesarean rates were observed between Prime and non-Prime beneficiaries within any race or age subgroup. Breech presentation followed by dystocia, fetal distress, and other complications were significant predictors for primary cesarean. Previous cesarean delivery was the leading predictor for repeat cesarean delivery. Primary and repeat cesarean rates observed for military hospitals were consistently lower than rates observed for civilian hospitals within each health plan type and age group.
Enrollment in the managed care health plan was significantly associated with lower risk of primary cesarean delivery relative to membership in other health plans offered to Department of Defense health care beneficiaries. Repeat cesarean rates in this population varied independently of health plan type. Primary cesarean delivery was generally associated with clinical complications, whereas previous cesarean delivery was the strongest indicator for a repeat cesarean delivery. A clear explanation of reduced cesarean rates for Prime enrollees remains elusive, but it is likely that factors beyond individual practitioner decision-making were at work.
为应对剖宫产率的上升，医疗保健机构寻求采用管理式医疗模式作为控制剖宫产率进一步上升的一种手段是合理的。然而，几乎没有确凿的证据支持这一解决方案。我们对国防部医疗保健受益人群进行了一项研究，以评估加入该部门的管理式医疗健康计划——“军人家属健康保险优选计划”（TRICARE Prime）对剖宫产率的影响。
分析了1999年至2002年活产单胎分娩的汇总医院出院记录，以计算在构成国防部医疗保健网络的军队医院和民用医院中，“军人家属健康保险优选计划”受益人和非优选计划受益人的初次剖宫产率和再次剖宫产率。采用逐步逻辑回归分析，使用卡方差异（p<0.05）计算每种健康计划与医院环境组合的临床指标调整优势比，以从模型中剔除无显著意义的变量。将总的初次和再次剖宫产率与未报告临床并发症的女性的初次和再次剖宫产率进行比较，以说明各亚组病例组合的差异。使用卡方检验评估各亚组计算出的差异的统计学显著性。
在军队医院中，所有种族亚组以及五个年龄亚组中的三个年龄亚组，“军人家属健康保险优选计划”参保者的初次剖宫产率相对于非优选计划受益人显著更低；在民用医院中，五个年龄亚组中的四个年龄亚组也是如此。在任何种族或年龄亚组中，优选计划和非优选计划受益人之间的再次剖宫产率均未观察到显著差异。臀位先露继之以难产、胎儿窘迫和其他并发症是初次剖宫产的重要预测因素。既往剖宫产是再次剖宫产的主要预测因素。在每种健康计划类型和年龄组中，军队医院观察到的初次和再次剖宫产率始终低于民用医院。
相对于向国防部医疗保健受益人提供的其他健康计划，加入管理式医疗健康计划与较低的初次剖宫产风险显著相关。该人群的再次剖宫产率与健康计划类型无关。初次剖宫产通常与临床并发症相关，而既往剖宫产是再次剖宫产的最强指标。对于“军人家属健康保险优选计划”参保者剖宫产率降低的原因尚无明确解释，但很可能有个体从业者决策之外的因素在起作用。
