Patient-, Hospital-, and Neighborhood-Level Factors Associated with Severe Maternal Morbidity During Childbirth: A Cross-Sectional Study in New York State 2013-2014
Patient-, Hospital-, and Neighborhood-Level Factors Associated with Severe Maternal Morbidity During Childbirth: A Cross-Sectional Study in New York State 2013-2014
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DOI：
10.1007/s10995-018-2596-9
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发表时间：
2019-01-01
影响因子：
2.3
通讯作者：
Li, Guohua
中科院分区：
文献类型：
--
作者：
Guglielminotti, Jean;Landau, Ruth;Li, Guohua
背景在美国，分娩期间严重孕产妇发病率（SMM）的发生率正在增加。更好地描述SMM的风险因素可能会确定改善孕产妇结局的目标。本研究旨在描述分娩期间与SMM相关的患者，医院和社区水平因素。方法在2013-2014年纽约州住院患者数据库中确定分娩期间的SMM。从美国医院协会和地区卫生资源档案中提取医院和社区的特征。多层次模型被用来确定与SMM相关的因素，有和没有输血，以及其医院间的变化。结果分析了来自139家医院的403，116例与分娩相关的出院; 1557例（0.39%）记录了SMM，未输血。在最终的多水平模型中，7个患者水平的因素与SMM风险增加4倍以上相关：肺动脉高压、产后出血、胎盘植入、慢性肾脏疾病、心脏传导障碍、紧急剖宫产和先兆子痫。三个医院层面的因素与SMM相关：非白人患者的比例，医疗补助受益人的比例和编码强度。没有邻里水平的因素预测SMM。模型解释的SMM变异比例为23.5%，其中23.2%与患者水平因素相关。该模型解释了55%的医院间差异，主要与患者水平的因素有关。SMM与输血观察到类似的结果。结论本研究证实了患者层面的因素与SMM之间的关联。它确定了患者层面的因素作为SMM医院间变化的主要驱动因素。改善孕产妇结局的努力应针对患者层面的因素。
Background The incidence of severe maternal morbidity (SMM) during childbirth is increasing in the United States. A better characterization of risk factors for SMM may identify targets for improving maternal outcomes. This study aims to characterize patient-, hospital-, and neighborhood-level factors associated with SMM during childbirth. Methods SMM during childbirth was identified in the 2013-2014 State Inpatients Database for New York. Hospital and neighborhood characteristics were abstracted from the American Hospital Association and the Area Health Resources files. Multilevel modeling was used to identify factors associated with SMM, with and without blood transfusion, and its between-hospital variation. Results 403,116 delivery-related discharges from 139 hospitals were analyzed; 1557 (0.39%) recorded SMM without blood transfusion. In the final multilevel model, 7 patient-level factors were associated with a greater than fourfold increase in the risk of SMM: pulmonary hypertension, postpartum hemorrhage, placenta accreta, chronic kidney disease, cardiac conduction disorders, emergent cesarean delivery, and preeclampsia. Three hospital-level factors were associated with SMM: proportion of non-White patients, proportion of Medicaid beneficiaries, and coding intensity. No neighborhood-level factors were predictive of SMM. The proportion of variation in SMM explained by the model was 23.5 with 23.2% related to patient-level factors. The model explained 55% of the between-hospital variation, primarily related to patient-level factors. Similar results were observed for SMM with blood transfusion. Conclusions This study confirms the association between patient-level factors and SMM. It identifies patient-level factors as the major driver of between-hospital variation in SMM. Efforts to improve maternal outcomes should target patient-level factors.