Phototherapy use in jaundiced newborns in a large managed care organization: Do clinicians adhere to the guideline?
Phototherapy use in jaundiced newborns in a large managed care organization: Do clinicians adhere to the guideline?
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DOI：
10.1542/peds.111.5.e555
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发表时间：
2003-05-01
期刊：
影响因子：
8
通讯作者：
Newman, TB
中科院分区：
文献类型：
--
作者：
Atkinson, LR;Escobar, GJ;Newman, TB
客观的。 1994 年，美国儿科学会 (AAP) 发布了针对患有高胆红素血症的健康足月新生儿进行光疗的特定年龄阈值的实践指南。本研究的目的是检查大型管理式医疗组织对指南的遵守情况。方法。我们对北加州 11 家 Kaiser Permanente 医疗护理计划医院的链接计算机数据库进行了回顾性横断面分析。纳入的新生儿妊娠期至少为 37 周，出生体重至少为 2500 克，出生日期为 1995 年 1 月 1 日至 1996 年 12 月 31 日。该研究的主要结果变量是根据指南接受光疗。根据AAP指南，使用血清总胆红素（TSB）和测量胆红素时的婴儿年龄（小时）将婴儿分为3组：推荐光疗（R）、考虑光疗（C）和不推荐光疗（N）。 R 组包括 48 小时前 TSB 水平至少 15 mg/dL、72 小时前至少 18 mg/dL 或 72 小时后至少 20 mg/dL 的婴儿。 C 组包括不属于 R 组的婴儿，48 小时前 TSB 水平至少为 12 mg/dL，72 小时前为 15 mg/dL，或 72 小时后至少为 17 mg/dL。 N 组包括既不属于 R 组也不属于 C 组且在 24 小时前也没有明显黄疸的婴儿。电子数据库中的光疗代码通过图表审查对 550 名婴儿的子集进行了验证。结果。与图表审查相比，数据库中的光疗代码敏感性为 94.4%（95% 置信区间 [CI]：89.1%-97.5%），特异性为 100%（95% CI：99.25%-100%）。在 47 801 名符合资格的婴儿中，2.3% 接受了光疗。 R组1194名婴儿中的54%（跨医院范围：27%-77%）、C组2245名婴儿中16%（范围：5%-37%）和N组44362名婴儿中0.2%（范围：0.1%-0.6%）接受了光疗。 R组（建议进行光疗的组）的光疗预测因素是通过逻辑回归确定的，TSB水平增加（比值比[OR]：1.6/mg/dL；95% CI：1.4-1.7），与48小时或更长的年龄相比，在24至47.9小时时达到AAP阈值（OR：7.1；95% CI：4.3-11.9），孕龄为 37 周与 38 周或以上相比（OR：1.6；95% CI：1.1-2.3）、首次建议光疗时的年龄（OR：0.7/d；95% CI：0.6-0.8）以及出生设施（OR：0.2-2.7）。出生条件是所有组（R、C 和 N）光疗使用的强有力预测因素。结论。临床医生仅对 54% 患有高胆红素血症的足月儿提供了 AAP 推荐的光疗。在这个大型管理式医疗系统中，光疗的使用存在明显的院际差异。如果同时减少对 TSB 水平较低的婴儿的不必要的使用，则提高对指南的遵守率只需要稍微增加光疗使用的总比率。
Objective. In 1994, the American Academy of Pediatrics (AAP) published a practice guideline with age-specific thresholds for phototherapy for healthy term newborns with hyperbilirubinemia. The purpose of this study was to examine adherence to the guideline in a large managed care organization.Methods. We conducted a retrospective cross-sectional analysis of linked computerized databases from 11 Northern California Kaiser Permanente Medical Care Program hospitals. Newborn infants included were at least 37 weeks of gestation, had birth weights of at least 2500 g, and were born between January 1, 1995, and December 31, 1996. The primary outcome variable for the study was receipt of phototherapy according to the guideline. Total serum bilirubin (TSB) and infant age in hours at the time of bilirubin measurement were used to classify infants into 3 groups according to the AAP guideline: recommend phototherapy (R), consider phototherapy (C), and did not recommend phototherapy (N). Group R included infants with TSB levels of at least 15 mg/dL before 48 hours of age, at least 18 mg/dL before 72 hours, or at least 20 mg/dL after 72 hours. Group C included infants not in group R, with TSB levels of at least 12 mg/dL before 48 hours, 15 mg/dL before 72 hours, or at least 17 mg/dL after 72 hours. Group N included infants who were in neither group R nor group C and also did not have significant jaundice before 24 hours of age. Phototherapy codes from electronic databases were validated by chart review for a subset of 550 infants.Results. Compared with chart review, phototherapy codes in the database were 94.4% sensitive (95% confidence interval [CI]: 89.1%-97.5%) and 100% specific (95% CI: 99.25%-100%). Among the 47 801 infants eligible, 2.3% received phototherapy. Phototherapy was administered to 54% of 1194 infants in group R (range across hospitals: 27%-77%), 16% of 2245 infants in group C (range: 5%-37%), and 0.2% of 44 362 infants in group N (range: 0.1%-0.6%). The predictors of phototherapy for group R, the group for whom phototherapy was recommended, determined by logistic regression were increasing TSB levels (odds ratio [OR]: 1.6/mg/dL; 95% CI: 1.4-1.7), reaching the AAP threshold at 24 to 47.9 hours of age compared with 48 hours or more (OR: 7.1; 95% CI: 4.3-11.9), gestational age of 37 weeks compared with 38 weeks or more (OR: 1.6; 95% CI: 1.1-2.3), age when phototherapy was first recommended (OR: 0.7/d; 95% CI: 0.6-0.8), and facility of birth (OR: 0.2-2.7). The facility of birth was a strong predictor of phototherapy use in all groups (R, C, and N).Conclusions. Clinicians provided phototherapy to only 54% of term infants with hyperbilirubinemia for whom it was recommended by the AAP. There is marked interhospital variation in phototherapy use in this large managed care system. Improved adherence to the guideline would require only a slight increase in the total rate of phototherapy use if unnecessary use for infants with lower levels of TSB were simultaneously decreased.