Department of Obstetrics and Gynecology, Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH.
Am J Obstet Gynecol. 2013 Nov;209(5):446.e1-446.e30. doi: 10.1016/j.ajog.2013.07.019. Epub 2013 Jul 24.
Regulatory bodies and insurers evaluate hospital quality using obstetrical outcomes, however meaningful comparisons should take preexisting patient characteristics into account. Furthermore, if risk-adjusted outcomes are consistent within a hospital, fewer measures and resources would be needed to assess obstetrical quality. Our objective was to establish risk-adjusted models for 5 obstetric outcomes and assess hospital performance across these outcomes.
We studied a cohort of 115,502 women and their neonates born in 25 hospitals in the United States from March 2008 through February 2011. Hospitals were ranked according to their unadjusted and risk-adjusted frequency of venous thromboembolism, postpartum hemorrhage, peripartum infection, severe perineal laceration, and a composite neonatal adverse outcome. Correlations between hospital risk-adjusted outcome frequencies were assessed.
Venous thromboembolism occurred too infrequently (0.03%; 95% confidence interval [CI], 0.02-0.04%) for meaningful assessment. Other outcomes occurred frequently enough for assessment (postpartum hemorrhage, 2.29%; 95% CI, 2.20-2.38, peripartum infection, 5.06%; 95% CI, 4.93-5.19, severe perineal laceration at spontaneous vaginal delivery, 2.16%; 95% CI, 2.06-2.27, neonatal composite, 2.73%; 95% CI, 2.63-2.84). Although there was high concordance between unadjusted and adjusted hospital rankings, several individual hospitals had an adjusted rank that was substantially different (as much as 12 rank tiers) than their unadjusted rank. None of the correlations between hospital-adjusted outcome frequencies was significant. For example, the hospital with the lowest adjusted frequency of peripartum infection had the highest adjusted frequency of severe perineal laceration.
Evaluations based on a single risk-adjusted outcome cannot be generalized to overall hospital obstetric performance.
监管机构和保险公司使用产科结果来评估医院质量，但有意义的比较应该考虑到现有患者的特征。此外，如果医院内的风险调整后结果一致，则需要更少的措施和资源来评估产科质量。我们的目标是建立 5 种产科结果的风险调整模型，并评估这些结果的医院绩效。
我们研究了 2008 年 3 月至 2011 年 2 月期间美国 25 家医院的 115502 名妇女及其新生儿的队列。根据静脉血栓栓塞、产后出血、围产期感染、严重会阴裂伤和新生儿不良复合结局的未调整和风险调整频率对医院进行排名。评估了医院风险调整后结局频率之间的相关性。
静脉血栓栓塞发生的频率太低（0.03%；95%置信区间[CI]，0.02-0.04%），无法进行有意义的评估。其他结局发生的频率足以进行评估（产后出血，2.29%；95%CI，2.20-2.38%，围产期感染，5.06%；95%CI，4.93-5.19%，自然分娩时严重会阴裂伤，2.16%；95%CI，2.06-2.27%，新生儿复合结局，2.73%；95%CI，2.63-2.84%）。尽管未调整和调整后的医院排名之间具有高度一致性，但个别医院的调整后排名与未调整排名有很大差异（高达 12 个排名等级）。医院调整后结局频率之间没有显著相关性。例如，围产期感染调整后频率最低的医院严重会阴裂伤的调整后频率最高。
基于单一风险调整结局的评估不能推广到医院整体产科绩效。
