荷兰16家非三级妇产科科室的学习氛围与不良产科结局之间的关联

The Association Between Learning Climate and Adverse Obstetrical Outcomes in 16 Nontertiary Obstetrics-Gynecology Departments in the Netherlands.

作者信息

Smirnova Alina, Ravelli Anita C J, Stalmeijer Renée E, Arah Onyebuchi A, Heineman Maas Jan, van der Vleuten Cees P M, van der Post Joris A M, Lombarts Kiki M J M H

机构信息

A. Smirnova is a PhD candidate, School of Health Professions Education, Department of Educational Development and Research, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, The Netherlands, and researcher, Professional Performance Research Group, Institute for Education and Training, Academic Medical Center, Amsterdam, The Netherlands. A.C.J. Ravelli is epidemiologist and assistant professor, Departments of Medical Informatics and Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands. R.E. Stalmeijer is assistant professor, Department of Educational Development and Research, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, The Netherlands. O.A. Arah is professor, Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California. M.J. Heineman is professor, Board of Directors, Academic Medical Center, Amsterdam, The Netherlands. C.P.M. van der Vleuten is professor and scientific director, School of Health Professions Education, Department of Educational Development and Research, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, The Netherlands. J.A.M. van der Post is professor, Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands. K.M.J.M.H. Lombarts is professor, Professional Performance Research Group, Institute for Education and Training, Academic Medical Center, Amsterdam, The Netherlands.

出版信息

Acad Med. 2017 Dec;92(12):1740-1748. doi: 10.1097/ACM.0000000000001964.

DOI:10.1097/ACM.0000000000001964

PMID:28953570

Abstract

PURPOSE

To investigate the association between learning climate and adverse perinatal and maternal outcomes in obstetrics-gynecology departments.

METHOD

The authors analyzed 23,629 births and 103 learning climate evaluations from 16 nontertiary obstetrics-gynecology departments in the Netherlands in 2013. Multilevel logistic regressions were used to calculate the odds of adverse perinatal and maternal outcomes, by learning climate score tertile, adjusting for maternal and department characteristics. Adverse perinatal outcomes included fetal or early neonatal mortality, five-minute Apgar score < 7, or neonatal intensive care unit admission for ≥ 24 hours. Adverse maternal outcomes included postpartum hemorrhage and/or transfusion, death, uterine rupture, or third- or fourth-degree perineal laceration. Bias analyses were conducted to quantify the sensitivity of the results to uncontrolled confounding and selection bias.

RESULTS

Learning climate scores were significantly associated with increased odds of adverse perinatal outcomes (aOR 2.06, 95% CI 1.14-3.72). Compared with the lowest tertile, departments in the middle tertile had 46% greater odds of adverse perinatal outcomes (aOR 1.46, 95% CI 1.09-1.94); departments in the highest tertile had 69% greater odds (aOR 1.69, 95% CI 1.24-2.30). Learning climate was not associated with adverse maternal outcomes (middle vs. lowest tertile: OR 1.04, 95% CI 0.93-1.16; highest vs. lowest tertile: OR 0.98, 95% CI 0.88-1.10).

CONCLUSIONS

Learning climate was associated with significantly increased odds of adverse perinatal, but not maternal, outcomes. Research in similar clinical contexts is needed to replicate these findings and explore potential mechanisms behind these associations.

摘要

目的

探讨妇产科科室的学习氛围与围产期及孕产妇不良结局之间的关联。

方法

作者分析了2013年荷兰16家非三级妇产科科室的23629例分娩情况以及103份学习氛围评估结果。采用多水平逻辑回归分析，根据学习氛围得分三分位数计算围产期及孕产妇不良结局的比值比，并对孕产妇和科室特征进行校正。围产期不良结局包括胎儿或早期新生儿死亡、5分钟阿氏评分<7分或新生儿重症监护病房入住≥24小时。孕产妇不良结局包括产后出血和/或输血、死亡、子宫破裂或会阴三度或四度裂伤。进行偏倚分析以量化结果对未控制的混杂因素和选择偏倚的敏感性。

结果

学习氛围得分与围产期不良结局的比值比显著增加相关（调整后比值比为2.06，95%置信区间为1.14 - 3.72）。与最低三分位数相比，中间三分位数的科室围产期不良结局的比值比高46%（调整后比值比为1.46，95%置信区间为1.09 - 1.94）；最高三分位数的科室比值比高69%（调整后比值比为1.69，95%置信区间为1.24 - 2.30）。学习氛围与孕产妇不良结局无关（中间三分位数与最低三分位数相比：比值比为1.04，95%置信区间为0.93 - 1.16；最高三分位数与最低三分位数相比：比值比为0.98，95%置信区间为0.88 - 1.10）。