Unexpected term NICU admissions: a marker of obstetrical care quality?
Unexpected term NICU admissions: a marker of obstetrical care quality?
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DOI：
10.1016/j.ajog.2019.02.001
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发表时间：
2019-04
影响因子：
9.8
通讯作者：
Kaimal AJ
中科院分区：
文献类型：
--
作者：
Clapp MA;James KE;Bates SV;Kaimal AJ
足月新生儿意外入住新生儿重症监护病房和意外产后并发症已被提议作为以新生儿为中心的产时护理质量指标。之前的研究已经注意到，医院新生儿重症监护病房的整体入院率存在显着差异；然而，人们对产科实践对这些比率的影响知之甚少，也不知道低风险足月新生儿意外入院的差异是否可以归因于系统性医院实践。该研究的目的是检查患者特征和产时事件对意外新生儿重症监护病房入院的相对影响，并量化该组新生儿新生儿重症监护病房入院率的医院间差异。我们使用安全劳动联盟研究中收集的数据进行了一项回顾性横断面研究。分娩足月（≥37周）、单胎、非异常、活产婴儿且无新生儿重症监护病房先验风险的妇女被纳入研究。主要结果是该人群中新生儿入住重症监护室。使用多级混合效应模型计算人口统计学（年龄、种族、保险公司）、妊娠特征（产次、胎龄、烟草使用、出生体重）、孕产妇合并症（慢性和妊娠诱发高血压）、医院特征（分娩量、医院和新生儿重症监护病房水平、学术背景）和产时事件（第二产程延长、引产、剖腹产后试产、绒毛膜羊膜炎、胎粪污染的羊水和早剥）。组内相关系数用于估计一系列分层模型中医院间的方差。在符合所有患者和医院纳入标准的 143,951 名婴儿中，7995 名（5.6%）在出生后被送入新生儿重症监护室。在完全调整的模型中，与新生儿重症监护病房入院最高几率相关的因素包括：未产（调整后的比值比，1.62 [95% 置信区间，1.53–1.71]）、大胎龄（调整后的比值比，1.59 [95% 置信区间，1.47–1.71]）和小胎龄（调整后的比值比， 1.60 [95% 置信区间，1.47–1.73]）。与自然分娩的妇女相比，引产（调整后的优势比，0.95 [95% 置信区间，0.89-1.01]）与新生儿重症监护病房入住的几率增加无关。与新生儿重症监护病房入院几率较高相关的事件包括： 第二阶段延长（调整后的优势比，1.66 [95% 置信区间，1.51–1.83]）；绒毛膜羊膜炎（调整后的比值比，3.89 [95% 置信区间，3.42–4.44]）、胎便染色羊水（调整后的比值比，1.96 [95% 置信区间，1.82–2.10]）和早剥（调整后的比值比，2.64 [95% 置信区间，2.16–.21]）。与未临产的女性相比，临产的女性入住新生儿重症监护病房的几率较低：无子宫疤痕和调整后的比值比为 0.48（95% 置信区间，0.45-0.52），有子宫疤痕的女性为 0.83（95% 置信区间，0.73-0.94）。不同医院的新生儿重症监护病房入院率存在显着差异，范围为 2.9% 至 11.2%。考虑到病例组合和医院特征后，医院间差异为 1.9%，表明医院的影响几乎无法解释差异。这项研究有助于目前对足月新生儿重症监护病房入院率作为产科护理质量标志的有限理解。我们证明，医院意外新生儿重症监护病房入院率存在显着差异，并且某些产时事件与分娩后新生儿重症监护病房入院风险增加相关。然而，医院之间的差异很小。未测量的混杂因素和外部因素（例如新生儿重症监护病房床位可用性）可能会限制意外足月新生儿重症监护病房入院有意义地反映产科护理质量的能力。
Unexpected admissions of term neonates to the neonatal intensive care unit and unexpected postnatal complications have been proposed as neonatal-focused quality metrics for intrapartum care. Previous studies have noted significant variation in overall hospital neonatal intensive care unit admission rates; however, little is known about the influence of obstetric practices on these rates or whether variation among unanticipated admissions in low-risk, term neonates can be attributed to systemic hospital practices. The objective of the study was to examine the relative effects of patient characteristics and intrapartum events on unexpected neonatal intensive care unit admissions and to quantify the between-hospital variation in neonatal intensive care unit admission rates among this group of neonates. We performed a retrospective cross-sectional study using data collected as part of the Consortium for Safe Labor study. Women who delivered term (≥37 weeks), singleton, nonanomalous, liveborn infants without an a priori risk for neonatal intensive care unit admission were included. The primary outcome was neonatal intensive care unit admission among this population. Multilevel mixed-effect models were used to calculate adjusted odds ratios for demographics (age, race, insurer), pregnancy characteristics (parity, gestational age, tobacco use, birthweight), maternal comorbidities (chronic and pregnancy-induced hypertension), hospital characteristics (delivery volume, hospital and neonatal intensive care unit level, academic affiliation), and intrapartum events (prolonged second stage, induction of labor, trial of labor after cesarean delivery, chorioamnionitis, meconium-stained amniotic fluid, and abruption). Intraclass correlation coefficients were used to estimate the between-hospital variance in a series of hierarchical models. Of the 143,951 infants meeting all patient and hospital inclusion criteria, 7995 (5.6%) were admitted to the neonatal intensive care unit after birth. In the fully adjusted model, the factors associated with the highest odds for neonatal intensive care unit admission included: nulliparity (adjusted odds ratio, 1.62 [95% confidence interval, 1.53–1.71]), large for gestational age (adjusted odds ratio, 1.59 [95% confidence interval, 1.47–1.71]), and small for gestational age (adjusted odds ratio, 1.60 [95% confidence interval, 1.47–1.73]). Induction of labor (adjusted odds ratio, 0.95 [95% confidence interval, 0.89–1.01]) was not associated with increased odds of neonatal intensive care unit admission compared with women who labored spontaneously. The events associated with higher odds of neonatal intensive care unit admission included: prolonged second stage (adjusted odds ratio, 1.66 [95% confidence interval, 1.51–1.83]); chorioamnionitis (adjusted odds ratio, 3.89 [95% confidence interval, 3.42–4.44]), meconium-stained amniotic fluid (adjusted odds ratio, 1.96 [95% confidence interval, 1.82–2.10]), and abruption (adjusted odds ratio, 2.64 [95% confidence interval, 2.16–.21]). Compared with women who did not labor, the odds of neonatal intensive care unit admission were lower for women who labored: adjusted odds ratio, 0.48 (95% confidence interval, 0.45–0.52) for women with no uterine scar and adjusted odds ratio, 0.83 (95% confidence interval, 0.73–0.94) for women with a uterine scar. There was significant variation in neonatal intensive care unit admission rates by hospital, ranging from 2.9% to 11.2%. After accounting for case mix and hospital characteristics, the between-hospital variance was 1.9%, suggesting that little of the variation was explained by the effect of the hospital. This study contributes to the currently limited understanding of term, neonatal intensive care unit admission rates as a marker of obstetrical care quality. We demonstrated that significant variation exists in hospital unexpected neonatal intensive care unit admission rates and that certain intrapartum events are associated with an increased risk for neonatal intensive care unit admission after delivery. However, the between-hospital variation was low. Unmeasured confounders and extrinsic factors, such as neonatal intensive care unit bed availability, may limit the ability of unexpected term neonatal intensive care unit admissions to meaningfully reflect obstetrical care quality.
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DOI：
10.1377/hlthaff.2012.1030
发表时间：
2013-03
期刊：
Health affairs (Project Hope)
影响因子：
--
作者：
Kozhimannil KB;Law MR;Virnig BA
通讯作者：
Virnig BA
影响因子：
9.8
作者：
Gerten, KA;Coonrod, DV;Chambliss, LR
通讯作者：
Chambliss, LR
影响因子：
9.8
作者：
Cheng, Yvonne W.;Hopkins, Linda M.;Caughey, Aaron B.
通讯作者：
Caughey, Aaron B.
影响因子：
9.8
作者：
Cheng, YW;Hopkins, LM;Caughey, AB
通讯作者：
Caughey, AB
DOI：
10.1056/nejmoa1800566
发表时间：
2018-08-09
期刊：
The New England journal of medicine
影响因子：
--
作者：
Grobman WA;Rice MM;Reddy UM;Tita ATN;Silver RM;Mallett G;Hill K;Thom EA;El-Sayed YY;Perez-Delboy A;Rouse DJ;Saade GR;Boggess KA;Chauhan SP;Iams JD;Chien EK;Casey BM;Gibbs RS;Srinivas SK;Swamy GK;Simhan HN;Macones GA;Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network
通讯作者：
Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network