Department of Obstetrics and Gynecology, NYU Langone Hospital-Long Island, NYU Long Island School of Medicine, Mineola, NY.
Department of Obstetrics and Gynecology, NYU Langone Hospital-Long Island, NYU Long Island School of Medicine, Mineola, NY.
Am J Obstet Gynecol. 2022 Apr;226(4):556.e1-556.e9. doi: 10.1016/j.ajog.2021.10.005. Epub 2021 Oct 8.
Cesarean delivery rates have been used as obstetrical quality indicators. However, these approaches do not consider the accompanying maternal and neonatal morbidities. A challenge in the field of obstetrics has been to establish a valid outcomes quality measure that encompasses preexisting high-risk maternal factors and associated maternal and neonatal morbidities and is universally acceptable to all stakeholders, including patients, healthcare providers, payers, and governmental agencies.
This study aimed to (1) establish a new single metric for obstetrical quality improvement among nulliparous patients with term singleton vertex-presenting fetus, integrating cesarean delivery rates adjusted for preexisting high-risk maternal factors with associated maternal and neonatal morbidities, and (2) determine whether obstetrician quality ranking by this new metric is different compared with the rating based on individual crude and/or risk-adjusted cesarean delivery rates. The single metric has been termed obstetrical safety and quality index.
This was a cross-sectional study of all nulliparous patients with term singleton vertex-presenting fetuses delivered by 12 randomly chosen obstetricians in a single institution. A review of all records was performed, including a review of maternal high-risk factors and maternal and neonatal outcomes. Maternal and neonatal medical records were reviewed to determine crude and adjusted cesarean delivery rates by obstetricians and quantify maternal and neonatal complications. We estimated the obstetrician-specific crude cesarean delivery rates and rates adjusted for obstetrician-specific maternal and neonatal complications from logistic regression models. From this model, we derived the obstetrical safety and quality index for each obstetrician. The final ranking based on the obstetrical safety and quality index was compared with the initial ranking by crude cesarean delivery rates. Maternal and neonatal morbidities were analyzed as ≥1 and ≥2 maternal and/or neonatal complications.
These 12 obstetricians delivered a total of 535 women; thus, 1070 (535 maternal and 535 neonatal) medical records were reviewed to determine crude and adjusted cesarean delivery rates by obstetricians and quantify maternal and neonatal complications. The ranking of crude cesarean delivery rates was not correlated (rho=0.05; 95% confidence interval, -0.54 to 0.60) to the final ranking based on the obstetrical safety and quality index. Of note, 8 of 12 obstetricians shifted their rank quartiles after adjustments for high-risk maternal conditions and maternal and neonatal outcomes. There was a strong correlation between the ranking based on ≥1 maternal and/or neonatal complication and ranking based on ≥2 maternal and/or neonatal complications (rho=0.63; 95% confidence interval, 0.08-0.88).
Ranking based on crude cesarean delivery rates varied significantly after considering high-risk maternal conditions and associated maternal and neonatal outcomes. Therefore, the obstetrical safety and quality index, a single metric, was developed to identify ways to improve clinician practice standards within an institution. Use of this novel quality measure may help to change initiatives geared toward patient safety, balancing cesarean delivery rates with optimal maternal and neonatal outcomes. This metric could be used to compare obstetrical quality not only among individual obstetricians but also among hospitals that practice obstetrics.
剖宫产率曾被用作产科质量指标。然而，这些方法并未考虑到随之而来的母婴发病率。产科领域的一个挑战是建立一个有效的结局质量衡量标准，该标准涵盖了现有高危产妇因素以及相关的母婴发病率，并得到所有利益相关者的普遍认可，包括患者、医疗保健提供者、支付者和政府机构。
本研究旨在（1）为足月单胎头位初产妇制定一种新的产科质量改进单一指标，该指标将调整了现有高危产妇因素的剖宫产率与相关的母婴发病率相结合；（2）确定基于该新指标的产科医生质量排名是否与基于个体剖宫产率的粗值和/或风险调整值的排名不同。该单一指标被称为产科安全与质量指数。
这是一项在一家医疗机构中，对 12 名随机选择的产科医生所接生的所有足月单胎头位初产妇进行的横断面研究。对所有记录进行了回顾，包括对高危产妇因素和母婴结局的回顾。对产妇和新生儿的病历进行了审查，以确定产科医生的剖宫产率的粗值和调整值，并量化产妇和新生儿的并发症。我们通过逻辑回归模型估计了产科医生特异性的剖宫产率和调整了产科医生特异性的母婴并发症的剖宫产率。根据该模型，我们为每位产科医生计算了产科安全与质量指数。最终的排名基于产科安全与质量指数，并与基于剖宫产率的初始排名进行比较。产妇和新生儿发病率分析为≥1 例产妇和/或新生儿并发症。
这 12 名产科医生共接生了 535 名妇女；因此，共审查了 1070 份（535 份产妇和 535 份新生儿）病历，以确定产科医生的剖宫产率的粗值和调整值，并量化产妇和新生儿的并发症。剖宫产率的排名与基于产科安全与质量指数的最终排名没有相关性（rho=0.05；95%置信区间，-0.54 至 0.60）。值得注意的是，在调整高危产妇情况和母婴结局后，有 8 名产科医生的排名 quartile 发生了变化。基于≥1 例产妇和/或新生儿并发症的排名与基于≥2 例产妇和/或新生儿并发症的排名之间存在很强的相关性（rho=0.63；95%置信区间，0.08-0.88）。
在考虑高危产妇情况和相关母婴结局后，基于剖宫产率的排名有了显著变化。因此，开发了一个单一指标——产科安全与质量指数，以确定改善机构内临床医生实践标准的方法。使用这种新的质量衡量标准可能有助于改变以患者安全为导向的举措，在剖宫产率和最佳母婴结局之间取得平衡。该指标不仅可用于比较个体产科医生的产科质量，还可用于比较开展产科业务的医院的产科质量。
