Goyert G L, Bottoms S F, Treadwell M C, Nehra P C
Department of Obstetrics and Gynecology, Wayne State University-Hutzel Hospital, Detroit.
N Engl J Med. 1989 Mar 16;320(11):706-9. doi: 10.1056/NEJM198903163201106.
To investigate the influence of physicians' practice styles on the rate of deliveries by cesarean section, we studied 1533 affluent women at low risk of obstetrical complications who were cared for by 11 obstetricians in a single community hospital. The mean rate of delivery by cesarean section was 26.9 percent, but the rate ranged from 19.1 to 42.3 percent, according to the physician. The mean rate of primary cesarean section (i.e., the rate for women without previous cesarean deliveries) was 17.2, with a range of 9.6 to 31.8 percent. A stepwise logistic-regression model of the determinants of primary cesarean section, including the individual physician, parity, birth weight, and maternal age and excluding specific medical indications, showed that only nulliparity (P less than 0.0001) was more important than the identity of the physician (P less than 0.001) in its influence on the rate of cesarean section. Variation in cesarean-section rates among physicians was not attributable to the practice setting, the patient population, the degree of obstetrical risk, or the physician's recent medicolegal experience, and it was not accompanied by corresponding differences in neonatal outcome. We conclude that individual practice style may be an important determinant of the wide variations in the rates of cesarean delivery among obstetricians. Our data do not permit us to say with certainty whether the procedure is overused by some obstetricians or underused by others, but we found no obvious differences in neonatal outcome associated with differences in the cesarean-section rate.
为了研究医生的执业风格对剖宫产率的影响，我们对一家社区医院的11位产科医生所护理的1533名低产科并发症风险的富裕女性进行了研究。剖宫产的平均发生率为26.9%，但根据医生的不同，发生率在19.1%至42.3%之间。首次剖宫产的平均发生率（即此前未进行过剖宫产的女性的发生率）为17.2%，范围在9.6%至31.8%之间。一个关于首次剖宫产决定因素的逐步逻辑回归模型，包括个体医生、产次、出生体重、产妇年龄且排除特定医学指征，结果显示，在对剖宫产率的影响方面，只有初产（P<0.0001）比医生的身份（P<0.001）更重要。医生之间剖宫产率的差异并非归因于执业环境、患者群体、产科风险程度或医生近期的医疗法律经历，并且也未伴随新生儿结局的相应差异。我们得出结论，个体执业风格可能是产科医生剖宫产率广泛差异的一个重要决定因素。我们的数据无法让我们确定该手术是否被一些产科医生过度使用或被另一些产科医生使用不足，但我们发现剖宫产率的差异与新生儿结局之间没有明显差异。
