Faculty of Health, University of Technology Sydney, Centre for Midwifery, Child and Family Health, Sydney, Australia; Level 11, Room 131, Building 10, City Campus, PO Box 123 Broadway NSW 2007.
School of Women's and Children's Health, UNSW Medicine, UNSW, Australia; Department of Women's and Children's Health, St George Hospital, Sydney, Australia; The George Institute for Global Health, UNSW Medicine, Australia.
Midwifery. 2021 Jul;98:102988. doi: 10.1016/j.midw.2021.102988. Epub 2021 Mar 15.
Variation in practice in relation to indications and timing for both induction of labour (IOL) and planned caesarean section (CS) clearly exists. However, the extent of this variation, and how this variation is explained by clinicians remains unclear. The aim of this study was to map the variation in IOL and planned CS at eight Australian hospitals, and understand why variation occurs from the perspective of clinicians at these hospitals. Our ultimate aim was to identify opportunities for improvement as evidenced by hospital data, clinician experiences, and feedback.
A two-phased mixed method study using sequential explanatory study design. The first phase consisted of an analysis of routinely collected patient data to map variation between hospitals. The second phase consisted of focus groups with clinicians to gain their perspectives on the reasons for variation.
Patient data consisted of routine data from 19,073 women giving birth at eight Sydney hospitals between November 2017 and October 2018. Focus groups were attended by a total of 61 medical staff and 121 midwives.
Hospital data analysis found substantial variation, before and after adjustment for case-mix, in rates of both IOL (adjusted rates 27.6%-42%) and planned CS (adjusted rate 15.4%-22.6%). Planned CS by gestation also showed variation, although after restricting analysis to term (≥37 weeks gestation) births, variation was reduced. At focus groups, five main themes explaining variation emerged: local guidelines, policies and procedures (inconsistency and ambiguity); uncertainty of the evidence/what is best practice (contradictory research and different interpretations of evidence); clinician preferences, beliefs and values; the culture of the unit; and organisational influences (access to specialised clinics, theatre time).
Considerable variation in IOL and planned CS, even after case-mix adjustment, was found in this sample of Australian hospitals. Engagement with hospital clinicians identified likely sources of this variation and enabled clinicians at each hospital to consider appropriate local responses to address variation, such as more detailed review of their planned birth cases.
At a macro level, measures to reduce unwarranted variation should initially focus on consistent national guidelines, while supporting equitable access to operating theatres for optimal CS timing, and shared decision-making training to reduce influence of clinician preference.
在引产（IOL）和计划剖宫产（CS）的适应证和时机方面，实践中的差异显然存在。然而，这种差异的程度以及临床医生如何解释这种差异尚不清楚。本研究的目的是绘制澳大利亚 8 家医院 IOL 和计划 CS 的差异图，并从这些医院的临床医生的角度了解差异产生的原因。我们的最终目的是通过医院数据、临床医生的经验和反馈，确定改进的机会。
采用两阶段混合方法研究，采用顺序解释性研究设计。第一阶段是对常规收集的患者数据进行分析，以绘制医院之间的差异。第二阶段是对临床医生进行焦点小组讨论，以了解他们对差异产生原因的看法。
患者数据包括 2017 年 11 月至 2018 年 10 月期间，8 家悉尼医院 19073 名分娩妇女的常规数据。共有 61 名医务人员和 121 名助产士参加了焦点小组。
医院数据分析发现，在调整病例组合后，IOL（调整率 27.6%-42%）和计划 CS（调整率 15.4%-22.6%）的发生率存在很大差异。按胎龄计划的 CS 也存在差异，但将分析限制在足月（≥37 周妊娠）分娩后，差异减少。在焦点小组中，出现了五个主要的主题来解释差异：当地的指南、政策和程序（不一致和模糊）；证据/最佳实践的不确定性（相互矛盾的研究和对证据的不同解释）；临床医生的偏好、信念和价值观；单位文化；组织影响（获得专业诊所、手术室时间）。
在本研究中，澳大利亚的这些医院发现 IOL 和计划 CS 存在相当大的差异，即使在调整病例组合后也是如此。与医院临床医生的接触确定了这种差异的可能来源，并使每个医院的临床医生能够考虑对差异做出适当的本地反应，例如更详细地审查他们计划的分娩病例。
在宏观层面上，减少不必要差异的措施应首先侧重于国家指南的一致性，同时支持公平获得手术室以优化 CS 时机，并进行共同决策培训，以减少临床医生偏好的影响。
