Departments of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; Northwestern University, Chicago, Illinois; MetroHealth Medical Center-Case Western Reserve University, Cleveland, Ohio; Columbia University, New York, New York; the University of Utah Health Sciences Center, Salt Lake City, Utah; the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; the University of Texas Southwestern Medical Center, Dallas, Texas; the University of Pittsburgh, Pittsburgh, Pennsylvania; The Ohio State University, Columbus, Ohio; the University of Texas Medical Branch, Galveston, Texas; Wayne State University, Detroit, Michigan; Brown University, Providence, Rhode Island; the University of Texas Health Science Center at Houston, McGovern Medical School-Children's Memorial Hermann Hospital, Houston, Texas; Oregon Health & Science University, Portland, Oregon; the George Washington University Biostatistics Center, Washington, DC; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland.
Obstet Gynecol. 2018 Jun;131(6):1039-1048. doi: 10.1097/AOG.0000000000002636.
To estimate the contributions of patient and health care provider-hospital characteristics to the variation in the frequency of nulliparous, term, singleton, vertex cesarean delivery in a multi-institutional U.S. cohort.
We performed a secondary analysis of the multicenter Assessment of Perinatal Excellence cohort of 115,502 mother and neonatal pairs who were delivered at 25 hospitals between March 2008 and February 2011. Women met inclusion criteria if they were nulliparous and delivered a singleton in vertex presentation at term. Hospital ranks for nulliparous, term, singleton, vertex cesarean delivery frequency were determined after risk adjustment. The fraction of variation in nulliparous, term, singleton, vertex cesarean delivery frequency attributable to patient and health care provider-hospital characteristics was assessed using hierarchical logistic regression.
Of the 115,502 deliveries in the initial cohort, 38,275 nulliparous, term, singleton, vertex deliveries met inclusion criteria. The median hospital nulliparous, term, singleton, vertex cesarean delivery frequency was 25.3% with a range from 15.0% to 35.2%. The majority of hospitals (16/25) changed rank quintiles after risk adjustment; overall the changes in rank were not statistically significant (P=.53). Patient characteristics accounted for 24% of the nulliparous, term, singleton, vertex cesarean delivery variation. The analyzed health care provider-hospital characteristics were not significantly associated with cesarean delivery frequency.
Although patient characteristics accounted for some of the variation in nulliparous, term, singleton, vertex cesarean delivery frequency and accounting for case mix had implications for hospital cesarean delivery rankings, the majority of the variation was not explained by the characteristics evaluated. These findings emphasize the importance of continued efforts to understand aspects of obstetric care, including case mix, that contribute to cesarean delivery variation.
评估患者和医疗保健提供者-医院特征对美国多机构队列中初产妇、足月、单胎、头位剖宫产频率的变化的影响。
我们对 2008 年 3 月至 2011 年 2 月期间在 25 家医院分娩的 115502 对母婴对进行了多中心卓越围产期评估队列的二次分析。符合纳入标准的产妇为初产妇且分娩足月、头位、单胎。在风险调整后确定初产妇、足月、单胎、头位剖宫产频率的医院等级。使用分层逻辑回归评估患者和医疗保健提供者-医院特征对初产妇、足月、单胎、头位剖宫产频率变化的贡献比例。
在最初的队列中，有 115502 例分娩，其中 38275 例为初产妇、足月、单胎、头位分娩，符合纳入标准。中位数医院初产妇、足月、单胎、头位剖宫产频率为 25.3%，范围为 15.0%至 35.2%。大多数医院（25 家医院中的 16 家）在风险调整后改变了等级五分位数；总体而言，等级变化没有统计学意义（P=0.53）。患者特征占初产妇、足月、单胎、头位剖宫产变化的 24%。分析的医疗保健提供者-医院特征与剖宫产频率无显著相关性。
尽管患者特征解释了初产妇、足月、单胎、头位剖宫产频率变化的一部分，并且考虑病例组合对医院剖宫产排名有影响，但大多数变化无法用评估的特征来解释。这些发现强调了继续努力了解导致剖宫产率变化的产科护理方面（包括病例组合）的重要性。
