Vermont Oxford Network, Burlington2Department of Pediatrics, College of Medicine, University of Vermont, Burlington.
Vermont Oxford Network, Burlington3Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, University of Vermont, Burlington.
JAMA Pediatr. 2017 Mar 6;171(3):e164396. doi: 10.1001/jamapediatrics.2016.4396.
Hospitals use rates from the best quartile or decile as benchmarks for quality improvement aims, but to what extent these aims are achievable is uncertain.
To determine the proportion of neonatal intensive care units (NICUs) in 2014 that achieved rates for death and major morbidities as low as the shrunken adjusted rates from the best quartile and decile in 2005 and the time it took to achieve those rates.
DESIGN, SETTING, AND PARTICIPANTS: A total of 408 164 infants with a birth weight of 501 to 1500 g born from January 1, 2005, to December 31, 2014, and cared for at 756 Vermont Oxford Network member NICUs in the United States were evaluated. Logistic regression models with empirical Bayes factors were used to estimate standardized morbidity ratios for each NICU. Each ratio was multiplied by the overall network rate to calculate the 10th, 25th, 50th, 75th, and 90th percentiles of the shrunken adjusted rates for each year. The proportion in 2014 that achieved the 10th and 25th percentile rates from 2005 and the number of years it took for 75% of NICUs to achieve the 2005 rates from the best quartile were estimated.
Death prior to hospital discharge, infection more than 3 days after birth, severe retinopathy of prematurity, severe intraventricular hemorrhage, necrotizing enterocolitis, and chronic lung disease among infants less than 33 weeks' gestational age at birth.
Of the 756 hospitals, 695 provided data for 2014. The mean unadjusted infant-level rate of death before hospital discharge decreased from 14.0% in 2005 to 10.9% in 2014. In 2014, 689 of 695 NICUs (99.1%; 95% CI, 97.4%-100.0%) achieved the 2005 shrunken adjusted rates from the best quartile for death prior to discharge, 678 of 695 (97.6%; 95% CI, 95.8%-99.6%) for late-onset infection, 558 of 681 (81.9%; 95% CI, 77.2%-86.6%) for severe retinopathy of prematurity, 611 of 693 (88.2%; 95% CI, 81.7%-97.0%) for severe intraventricular hemorrhage, 529 of 696 (76.0%; 95% CI, 71.8%-81.2%) for necrotizing enterocolitis, and 286 of 693 (41.3%; 95% CI, 36.1%-45.6%) for chronic lung disease. It took 3 years before 445 NICUs (75.0%) achieved the 2005 shrunken adjusted rate from the best quartile for death prior to discharge, 5 years to achieve the rate from the best quartile for late-onset infection, 6 years to achieve the rate from the best quartile for severe retinopathy of prematurity and severe intraventricular hemorrhage, and 8 years to achieve the rate from the best quartile for necrotizing enterocolitis.
From 2005 to 2014, rates of death prior to discharge and serious morbidities decreased among the NICUs in this study. Within 8 years, 75% of NICUs achieved rates of performance from the best quartile of the 2005 benchmark for all outcomes except chronic lung disease. These findings provide a novel way to quantify the magnitude and pace of improvement in neonatology.
医院使用来自最佳四分位数或十分位数的比率作为质量改进目标的基准，但这些目标的可实现程度尚不确定。
确定 2014 年新生儿重症监护病房（NICU）达到 2005 年最佳四分位数和十分位数缩小调整死亡率和主要发病率的比例，以及达到这些比率所需的时间。
设计、地点和参与者：共评估了 2005 年 1 月 1 日至 2014 年 12 月 31 日期间在美国 756 个 Vermont Oxford Network 成员 NICU 接受治疗的出生体重为 501 至 1500 g 的 408164 名婴儿。使用具有经验贝叶斯因子的逻辑回归模型来估计每个 NICU 的标准化发病率比。每个比率乘以整个网络的比率，以计算每年缩小调整后的第 10、第 25、第 50、第 75 和第 90 百分位数。估计了 2014 年达到 2005 年第 10 和第 25 百分位数的比例，以及 75%的 NICU 达到最佳四分位数 2005 年的比率所需的年数。
出院前死亡、出生后 3 天以上感染、早产儿重度视网膜病变、严重脑室出血、坏死性小肠结肠炎和胎龄小于 33 周的婴儿慢性肺病。
在 756 家医院中，695 家提供了 2014 年的数据。未调整的婴儿出院前死亡率从 2005 年的 14.0%下降到 2014 年的 10.9%。2014 年，695 个 NICU 中有 689 个（99.1%；95%CI，97.4%-100.0%）达到了 2005 年最佳四分位数的出院前死亡率缩小调整率，695 个中有 678 个（97.6%；95%CI，95.8%-99.6%）达到了晚发性感染的缩小调整率，681 个中有 558 个（81.9%；95%CI，77.2%-86.6%）达到了早产儿重度视网膜病变的缩小调整率，693 个中有 611 个（88.2%；95%CI，81.7%-97.0%）达到了严重脑室出血的缩小调整率，696 个中有 529 个（76.0%；95%CI，71.8%-81.2%）达到了坏死性小肠结肠炎的缩小调整率，693 个中有 286 个（41.3%；95%CI，36.1%-45.6%）达到了慢性肺病的缩小调整率。达到最佳四分位数的出院前死亡率的缩小调整率需要 3 年，达到最佳四分位数的晚发性感染率需要 5 年，达到最佳四分位数的早产儿重度视网膜病变和严重脑室出血率需要 6 年，达到最佳四分位数的坏死性小肠结肠炎率需要 8 年。
从 2005 年到 2014 年，本研究中 NICU 的出院前死亡率和严重发病率有所下降。在 8 年内，除慢性肺病外，75%的 NICU 达到了 2005 年基准的最佳四分位数的所有结果的性能水平。这些发现为量化新生儿学改善的程度和速度提供了一种新方法。
