基于人群的队列研究中医院变异与支气管肺发育不良的危险因素。

Hospital variation and risk factors for bronchopulmonary dysplasia in a population-based cohort.

机构信息

Department of Pediatrics, Stanford University School of Medicine, Stanford, California2California Perinatal Quality Care Collaborative, Stanford, California.

出版信息

JAMA Pediatr. 2015 Feb;169(2):e143676. doi: 10.1001/jamapediatrics.2014.3676. Epub 2015 Feb 2.

DOI:10.1001/jamapediatrics.2014.3676

PMID:25642906

Abstract

IMPORTANCE

Bronchopulmonary dysplasia (BPD) remains a serious morbidity in very low-birth-weight (VLBW) infants (<1500 g). Deregionalization of neonatal care has resulted in an increasing number of VLBW infants treated in community hospitals with unknown impact on the development of BPD.

OBJECTIVE

To identify individual risk factors for BPD development and hospital variation of BPD rates across all levels of neonatal intensive care units (NICUs) within the California Perinatal Quality Care Collaborative.

DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study (January 2007 to December 2011) from the California Perinatal Quality Care Collaborative including more than 90% of California's NICUs. Eligible VLBW infants born between 22 to 29 weeks' gestational age.

EXPOSURES

Varying levels of intensive care.

MAIN OUTCOMES AND MEASURES

Bronchopulmonary dysplasia was defined as continuous supplemental oxygen use at 36 weeks' postmenstrual age. A combined outcome of BPD or mortality prior to 36 weeks was used. Multivariable logistic regression accounting for hospital as a random effect and gestational age as a risk factor was used to assess individual risk factors for BPD. This model was applied to determine risk-adjusted rates of BPD across hospitals and assess associations between levels of care and BPD rates.

RESULTS

The study cohort included 15,779 infants, of which 1534 infants died prior to 36 weeks' postmenstrual age. A total of 7081 infants, or 44.8%, met the primary outcome of BPD or death prior to 36 weeks. Combined BPD or death rates across 116 NICUs varied from 17.7% to 73.4% (interquartile range, 38.7%-54.1%). Compared with level IV NICUs, the risk for developing BPD was higher for level II NICUs (odds ratio, 1.23; 95% CI, 1.02-1.49) and similar for level III NICUs (odds ratio, 1.04; 95% CI, 0.95-1.14).

CONCLUSIONS AND RELEVANCE

Bronchopulmonary dysplasia or death prior to 36 weeks' postmenstrual age affects approximately 45% of VLBW infants across California. The wide variability in BPD occurrence across hospitals could offer insights into potential risk or preventive factors. Additionally, our findings suggest that increased regionalization of NICU care may reduce BPD among VLBW infants.

摘要

重要性

支气管肺发育不良（BPD）仍然是极低出生体重（VLBW）婴儿（<1500 克）的严重发病率。新生儿照护的非区域化导致越来越多的 VLBW 婴儿在社区医院接受治疗，而这对 BPD 的发展的影响尚不清楚。

目的

确定 BPD 发展的个体风险因素，并确定加利福尼亚围产期质量护理协作会内各级新生儿重症监护病房（NICU）的 BPD 发生率的医院差异。

设计、地点和参与者：这是一项回顾性队列研究（2007 年 1 月至 2011 年 12 月），来自加利福尼亚围产期质量护理协作会，包括加利福尼亚州 90%以上的 NICU。合格的 VLBW 婴儿出生于 22 至 29 周的胎龄。

暴露因素

不同程度的重症监护。

主要结果和测量

支气管肺发育不良被定义为在 36 周的校正胎龄后持续使用补充氧气。使用 36 周前的 BPD 或死亡率的联合结局。多变量逻辑回归考虑到医院作为随机效应，胎龄作为风险因素，用于评估 BPD 的个体风险因素。该模型用于确定医院间 BPD 的风险调整后发生率，并评估护理水平与 BPD 发生率之间的关系。

结果

研究队列包括 15779 名婴儿，其中 1534 名婴儿在 36 周的校正胎龄前死亡。共有 7081 名婴儿（44.8%）满足 BPD 或 36 周前死亡的主要结局。116 个 NICU 的合并 BPD 或死亡率从 17.7%到 73.4%不等（四分位间距，38.7%-54.1%）。与 IV 级 NICU 相比，II 级 NICU 发生 BPD 的风险更高（比值比，1.23；95%置信区间，1.02-1.49），而 III 级 NICU 发生 BPD 的风险相似（比值比，1.04；95%置信区间，0.95-1.14）。