Variation in Performance of Neonatal Intensive Care Units in the United States
Variation in Performance of Neonatal Intensive Care Units in the United States
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DOI：
10.1001/jamapediatrics.2016.4396
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发表时间：
2017-03-01
期刊：
影响因子：
26.1
通讯作者：
Buzas, Jeffrey S.
中科院分区：
文献类型：
--
作者：
Horbar, Jeffrey D.;Edwards, Erika M.;Buzas, Jeffrey S.
重要性医院使用最佳四分位数或十分之一的比率作为质量改进目标的基准，但这些目标的实现程度尚不确定。目的确定2014年新生儿重症监护病房(NICU)的死亡率和主要发病率的比例，以及达到这些比率所需的时间。设计、设置和参与者评估了2005年1月1日至2014年12月31日期间出生的408 164名出生体重为501至1500克的新生儿，并在美国佛蒙特州牛津大学网络成员NICU中护理了756名新生儿。带有经验贝叶斯因素的Logistic回归模型被用来估计每个NICU的标准化发病率。将每个比率乘以整个网络比率，以计算出每年缩小调整比率的第10、25、50、75和90百分位。结果在756家医院中，有695家医院提供了2014年的数据，包括出院前死亡、出生后3天以上感染、早产儿严重视网膜病变、严重脑室出血、坏死性小肠结肠炎和慢性肺部疾病。出院前未经调整的婴儿平均死亡率从2005年的14.0%下降到2014年的10.9%。2014年，在695个NICU中，689个(99.1%；95%CI，97.4%-100.0%)达到了2005年出院前死亡最佳四分位数的缩小调整率；695个NICU中，678个(97.6%；95%CI，95.8%-99.6%)达到了2005年的缩小调整率；681个严重早产儿视网膜病变中，558个(81.9%；95%CI，77.2%-86.6%)达到了2005年的缩小调整率；696例中，坏死性小肠结肠炎529例(76.0%；95%CI，71.8%-81.2%)；慢性肺部疾病286例(41.3%；95%CI，36.1%-45.6%)。445个NICU(75.0%)用3年时间达到2005年出院前死亡最佳四分位数的缩小调整率，5年后达到迟发性感染的最佳四分位数，6年后达到重度视网膜病早产儿和严重脑室出血的最佳四分位数，8年后达到坏死性小肠结肠炎的最佳四分位数。结论2005年至2014年，本研究的NICU出院前死亡率和严重发病率均下降。在8年内，75%的NICU达到了2005年基准中除慢性肺部疾病以外的所有结果的最佳四分位数。这些发现提供了一种新的方法来量化新生儿学进步的幅度和速度。
IMPORTANCE Hospitals use rates from the best quartile or decile as benchmarks for quality improvement aims, but to what extent these aims are achievable is uncertain.OBJECTIVE To determine the proportion of neonatal intensive care units (NICUs) in 2014 that achieved rates for death and major morbidities as low as the shrunken adjusted rates from the best quartile and decile in 2005 and the time it took to achieve those rates.DESIGN, SETTING, AND PARTICIPANTS A total of 408 164 infants with a birth weight of 501 to 1500 g born from January 1, 2005, to December 31, 2014, and cared for at 756 Vermont Oxford Network member NICUs in the United States were evaluated. Logistic regression models with empirical Bayes factors were used to estimate standardized morbidity ratios for each NICU. Each ratio was multiplied by the overall network rate to calculate the 10th, 25th, 50th, 75th, and 90th percentiles of the shrunken adjusted rates for each year. The proportion in 2014 that achieved the 10th and 25th percentile rates from 2005 and the number of years it took for 75% of NICUs to achieve the 2005 rates from the best quartile were estimated.MAIN OUTCOMES AND MEASURES Death prior to hospital discharge, infection more than 3 days after birth, severe retinopathy of prematurity, severe intraventricular hemorrhage, necrotizing enterocolitis, and chronic lung disease among infants less than 33 weeks' gestational age at birth.RESULTS Of the 756 hospitals, 695 provided data for 2014. The mean unadjusted infant-level rate of death before hospital discharge decreased from 14.0% in 2005 to 10.9% in 2014. In 2014, 689 of 695 NICUs (99.1%; 95% CI, 97.4%-100.0%) achieved the 2005 shrunken adjusted rates from the best quartile for death prior to discharge, 678 of 695 (97.6%; 95% CI, 95.8%-99.6%) for late-onset infection, 558 of 681 (81.9%; 95% CI, 77.2%-86.6%) for severe retinopathy of prematurity, 611 of 693 (88.2%; 95% CI, 81.7%-97.0%) for severe intraventricular hemorrhage, 529 of 696 (76.0%; 95% CI, 71.8%-81.2%) for necrotizing enterocolitis, and 286 of 693 (41.3%; 95% CI, 36.1%-45.6%) for chronic lung disease. It took 3 years before 445 NICUs (75.0%) achieved the 2005 shrunken adjusted rate from the best quartile for death prior to discharge, 5 years to achieve the rate from the best quartile for late-onset infection, 6 years to achieve the rate from the best quartile for severe retinopathy of prematurity and severe intraventricular hemorrhage, and 8 years to achieve the rate from the best quartile for necrotizing enterocolitis.CONCLUSIONS AND RELEVANCE From 2005 to 2014, rates of death prior to discharge and serious morbidities decreased among the NICUs in this study. Within 8 years, 75% of NICUs achieved rates of performance from the best quartile of the 2005 benchmark for all outcomes except chronic lung disease. These findings provide a novel way to quantify the magnitude and pace of improvement in neonatology.