Brigham and Women's Hospital and Beth Israel Deaconess Medical Center, Boston, Massachusetts.
Obstet Gynecol. 2014 Oct;124(4):697-703. doi: 10.1097/AOG.0000000000000473.
To examine the relationship between an obstetrician's delivery volume and a patient's risk for cesarean delivery.
This retrospective cohort study examined patient-level and obstetrician-level data between 2000 and 2012 at a large academic hospital. All laboring patients who delivered viable, liveborn, singleton newborns (N=58,328) were included. We measured the association of delivery volume and cesarean delivery using a multivariate logistic regression. We also assessed the association of volume by calculating adjusted cesarean delivery rates using the least squares means method. These analyses were performed on the subset of nulliparous patients with term, singleton, vertex-presenting fetuses. In addition, the association of obstetrician experience was compared against delivery volume.
There was a twofold increase in the odds of cesarean delivery for patients whose obstetricians performed fewer than the median (60) number of deliveries per year (quartile 1: odds ratio 2.00, 95% confidence interval 1.68-2.38; quartile 2: odds ratio 2.73, 95% CI 2.40-3.11) as compared with quartile 4. The adjusted cesarean delivery rate decreased from 18.2% to 9.2% from the highest to lowest volume quartile (P<.001). Compared with the volume effects, an obstetrician's experience had a smaller effect on a patient's risk of cesarean delivery.
Patients delivered by obstetricians with low delivery volume are at significantly increased risk for cesarean delivery after controlling for patient and obstetrician characteristics. In contrast, obstetrician experience had a less significant effect. These findings may prompt discussions regarding the role of volume in credentialing and practice models that direct patients to obstetricians with high delivery volume.
: II.
研究产科医生的分娩量与患者剖宫产风险之间的关系。
本回顾性队列研究在一家大型学术医院，调查了 2000 年至 2012 年期间的患者水平和产科医生水平的数据。所有分娩活产单胎新生儿的产妇（N=58328）均纳入研究。我们使用多元逻辑回归来衡量分娩量与剖宫产之间的关系。我们还通过使用最小二乘法均值法计算调整后的剖宫产率来评估容量的相关性。这些分析是在具有足月、单胎、头位胎儿的初产妇亚组中进行的。此外，我们还比较了产科医生经验与分娩量的关系。
与年分娩中位数（60）以下的产科医生相比，每年分娩量低于中位数的患者剖宫产的可能性增加了两倍（四分位 1：比值比 2.00，95%置信区间 1.68-2.38；四分位 2：比值比 2.73，95%置信区间 2.40-3.11）。调整后的剖宫产率从最高到最低的分娩量四分位从 18.2%降至 9.2%（P<.001）。与容量的影响相比，产科医生的经验对患者剖宫产风险的影响较小。
在控制患者和产科医生特征后，分娩量低的产科医生分娩的患者剖宫产风险显著增加。相比之下，产科医生的经验影响较小。这些发现可能会引发关于在认证和实践模式中，将患者引导至高分娩量产科医生的作用的讨论。
II。
