McKinley Lilian P, Wen Timothy, Gyamfi-Bannerman Cynthia, Wright Jason D, Goffman Dena, Sheen Jean-Ju, D'Alton Mary E, Friedman Alexander M
Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York.
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York.
Am J Perinatol. 2021 Aug;38(S 01):e359-e366. doi: 10.1055/s-0040-1710544. Epub 2020 May 5.
This study aimed to analyze whether hospital safety-net burden status is associated with increased risk for severe maternal morbidity (SMM) and postpartum readmissions.
The 2010 to 2014 Nationwide Readmissions Database was utilized for this retrospective cohort study. Hospitals were categorized as high-burden hospitals (25% of hospitals with the highest safety-net burden), medium-burden hospitals (50% of hospitals with intermediate safety-net burden), and low-burden hospitals (25% of hospitals with the lowest safety-net burden) based on the proportions of Medicaid or uninsured patients. Risk for (1) SMM, (2) 60-day postpartum readmissions, and (3) SMM during postpartum readmissions was analyzed. Unadjusted and adjusted log-linear regression models were performed, respectively, for these outcomes with unadjusted risk ratio (RR) and adjusted RR (aRR) as measures of effect. Adjusted models included demographic, hospital, and clinical factors.
High-burden safety-net status was associated with increased risk for SMM compared with low-burden safety-net status in both unadjusted (RR: 1.51, 95% confidence interval [CI]: 1.50-1.53) and adjusted analyses (aRR: 1.27, 95% CI: 1.25-1.30). High-burden status was also associated with increased risk for readmissions in unadjusted analyses (RR: 1.42, 95% CI: 1.40-1.44), although this risk was attenuated in adjusted analyses (aRR: 1.07, 95% CI: 1.06-1.08). High-burden status was associated with significantly increased risk for readmission for uterine infections, hypertensive diseases of pregnancy, and psychiatric diagnoses. High-burden status was not associated with severe morbidity during readmissions in adjusted or unadjusted analyses (RR: 1.02, 95% CI: 0.98-1.05; aRR: 0.95, 95% CI: 0.92-0.99).
This study found that high safety-net burden hospitals may be a higher risk setting for obstetric care. Improvement of outcomes in high-burden settings may be important in overall efforts to reduce maternal risk.
本研究旨在分析医院安全网负担状况是否与严重孕产妇发病率（SMM）及产后再入院风险增加相关。
本回顾性队列研究使用了2010年至2014年的全国再入院数据库。根据医疗补助或未参保患者的比例，医院被分为高负担医院（安全网负担最高的25%的医院）、中等负担医院（安全网负担中等的50%的医院）和低负担医院（安全网负担最低的25%的医院）。分析了（1）SMM、（2）产后60天再入院以及（3）产后再入院期间SMM的风险。分别针对这些结果进行未调整和调整后的对数线性回归模型分析，以未调整风险比（RR）和调整后RR（aRR）作为效应指标。调整后的模型纳入了人口统计学、医院和临床因素。
与低负担安全网状况相比，在未调整分析（RR：1.51，95%置信区间[CI]：1.50 - 1.53）和调整分析（aRR：1.27，95%CI：1.25 - 1.30）中，高负担安全网状况均与SMM风险增加相关。在未调整分析中，高负担状况也与再入院风险增加相关（RR：1.42，95%CI：1.40 - 1.44），不过在调整分析中该风险有所减弱（aRR：1.07，95%CI：1.06 - 1.08）。高负担状况与子宫感染、妊娠期高血压疾病和精神疾病诊断的再入院风险显著增加相关。在调整或未调整分析中，高负担状况与再入院期间的严重发病率均无关联（RR：1.02，95%CI：0.98 - 1.05；aRR：0.95，95%CI：0.92 - 0.99）。
本研究发现，高安全网负担医院可能是产科护理风险较高的环境。改善高负担环境下的结局对于降低孕产妇风险的整体努力可能很重要。
