The effect of hospital acuity on severe maternal morbidity in high-risk patients
The effect of hospital acuity on severe maternal morbidity in high-risk patients
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DOI：
10.1016/j.ajog.2018.04.015
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发表时间：
2018-07-01
影响因子：
9.8
通讯作者：
Kaimal, Anjali J.
中科院分区：
文献类型：
--
作者：
Clapp, Mark A.;James, Kaitlyn E.;Kaimal, Anjali J.
背景：2015年，母胎医学学会和美国妇产科医师学会发布了建立孕产妇护理水平的指南。这些指导方针概述了被指定为分娩中心的医院的护理、提供者和设施要求或4级护理中的1级。迄今为止，这些水平的孕产妇保健尚未得到广泛采用；目前，没有数据存在这些名称如何影响产妇或新生儿的结局。目的：由于产妇护理水平试图反映医院治疗与并发症风险增加相关的某些疾病患者的能力，我们的目的是比较高、低视力医院中高、低风险患者的结局。我们假设，那些照顾高风险病人的医院，我们认为是“高敏锐度”中心，与低敏锐度中心相比，高风险病人中严重产妇发病率的风险更低。研究设计：在2013年全国再入院数据库中确定分娩情况。患者的合并症指数根据诊断和程序代码分配，并使用先前验证的方法；合并症指数>= 3与严重产妇发病率增加有关。根据患者的合并症指数将患者分为低、中、高风险进行分析。患者在医院= 3。构建对数二项回归模型，评估患者合并症指数组对高、低视力医院重症发病风险的影响。这些模型控制了可用的患者和医院因素。回归使用具有稳健标准误差的患者水平数据，这些数据在医院水平上聚类。采用Wald检验评价合并症指数组与医院视敏度之间的效应改变。结果：1203家医院有1,656,659例分娩患者符合纳入标准。总体样本中低危患者占58.7%，中危患者占39.0%，高危患者占2.3%，重度产妇总体发病率为1.2%。在低视力医院分娩的患者中，只有不到3.7%的患者有高危情况。相比之下，在高敏度中心，bb0.7.1%的患者有高风险状况。在调整后的分析中，与低风险患者相比，中危患者在低视力中心和高视力中心的发病风险均略有增加（调整后的风险比为1.53[95%可信区间，1.33-1.77]vs 1.57[95%可信区间，1.49-1.65]）。但高危人群孕产妇重症发病的调整风险比存在显著差异，低锐度医院的调整风险比为9.55(95%可信区间6.83 ~ 13.35)，高锐度医院的调整风险比为6.50（95%可信区间5.94 ~ 7.09）。结论：低锐度医院高危患者发生严重孕产妇发病的风险高于高锐度医院。这些发现支持区域化产科护理的概念，以改善高危患者的预后。
BACKGROUND: In 2015, the Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists published guidelines that established levels of maternal care. These guidelines outlined the nursing, provider, and facility requirements for hospitals to be designated a birthing center or 1 of 4 levels of care. To date, these levels of maternal care have not been adopted widely; currently, no data exist on how these designations may affect maternal or neonatal outcomes.OBJECTIVE: Because the levels of maternal care attempt to reflect a hospital's ability to treat patients with certain conditions that are associated with increased risk of complications, our objective was to compare outcomes among high-and low-risk patients between high-and low-acuity hospitals. We hypothesized that hospitals that cared for a high rate of high-risk patients, which we considered "high-acuity" centers, would have a lower risk of severe maternal morbidity among high-risk patients compared with low-acuity centers.STUDY DESIGN: Deliveries were identified in the 2013 Nationwide Readmission Database. A patient's comorbidity index was assigned based on diagnosis and procedure codes with the use of previously validated methods; a comorbidity index of >= 3 has been associated with increased odds of severe maternal morbidity. Patients were classified as low, intermediate, or high risk by their comorbidity index for analysis. Patients at hospitals with = 3. Log-binomial regression models were constructed to assess the effects of a patient's comorbidity index group on the risk of severe morbidity in high-and low-acuity hospitals. The models controlled for available patient and hospital factors. The regression used patient-level data with robust standard errors that were clustered at the level of the hospital. The Wald test was used to assess for the effect modification between comorbidity index group and hospital acuity.RESULTS: From 1203 hospitals, 1,656,659 delivering patients met the inclusion criteria. There were 58.7% low-risk, 39.0% intermediate-risk, and 2.3% high-risk patients in the overall sample, and the overall rate of severe maternal morbidity was 1.2%. Less than 3.7% of delivering patients in low-acuity hospitals had a high-risk condition. In comparison, >7.1% patients in high-acuity centers had a high-risk condition. In the adjusted analysis, intermediate-risk patients had a slightly increased risk of morbidity in both low-acuity and high-acuity centers compared with low-risk patients (adjusted risk ratios, 1.53 [95% confidence interval, 1.33-1.77] vs 1.57 [95% confidence interval, 1.49-1.65]). However, there was a notable difference in the adjusted risk ratios for severe maternal morbidity in the high-risk population: the adjusted risk ratio was 9.55 (95% confidence interval, 6.83-13.35) in low-acuity hospitals compared with 6.50 (95% confidence interval, 5.94-7.09) in high-acuity hospitals.CONCLUSION: High-risk patients have a higher risk of severe maternal morbidity at low-acuity hospitals compared with high-acuity centers. These findings support the concept of regionalization of maternity care to improve outcomes for high-risk patients.