Variations in risk-adjusted cesarean delivery rates according to race and health insurance
Variations in risk-adjusted cesarean delivery rates according to race and health insurance
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DOI：
10.1097/00005650-200001000-00005
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发表时间：
2000-01-01
期刊：
影响因子：
3
通讯作者：
Rosenthal, GE
中科院分区：
文献类型：
--
作者：
Aron, DC;Gordon, HS;Rosenthal, GE
客观的。在调整增加剖腹产可能性的临床风险因素后，评估种族、保险和剖腹产率之间的关联。设计。在俄亥俄州东北部 21 家医院进行的回顾性队列研究。 1993 年 1 月至 1995 年 6 月期间，有 25,697 名没有剖腹产史的妇女入院分娩。 方法。人口统计和临床数据是从患者的医疗记录中提取的。剖宫产风险根据 39 个孕产妇和新生儿风险因素进行了调整，这些因素包含在先前使用嵌套逻辑回归分析开发的风险调整模型中。主要结果指标。非白人患者相对于白人、有政府保险或没有保险的患者相对于有商业保险的患者剖宫产的比值比。结果。白人和非白人患者的剖宫产率总体相似（分别为 15.8% 和 16.1%），但根据保险的不同，剖宫产率有所不同（P < 0.001）（有商业保险、政府保险和无保险的患者分别为 17.0%、14.2%、10.7%）。然而，调整临床因素后，非白人患者剖宫产的调整后比值比 (OR) 较高（OR = 1.34；95% CI：1.14-1.57；P < 0.001），但有政府保险的患者相似（OR = 1.01；95% CI：0.90-1.14；P = 0.84），无保险患者则较低（OR = 0.65；95% CI，0.41，1.03；P = 0.067），尽管没有统计学意义。在根据剖宫产预测风险五分位进行分层的分析中，种族差异主要限于风险较低五分位的患者。然而，尽管比值比不具有统计学显着性，但未投保患者的比值比在风险五分位中存在差异。结论。调整临床因素后，种族和保险状况可能会独立影响剖腹产的使用。非白人的较高比率和未投保的较低比率可能反映了患者偏好或期望的差异、医生实践的差异或未测量的风险因素。未参保妇女（尤其是高危妇女）剖宫产率较低，可能会引发服务利用不足的问题，值得进一步研究。
OBJECTIVE. To assess the association between race and insurance and Cesarean delivery rates after adjusting for clinical risk factors that increase the likelihood of cesarean delivery.DESIGN. Retrospective cohort study in 21 hospitals in northeast Ohio.SUBJECTS. 25,697 women without prior cesarean deliveries admitted for labor and delivery January 1993 through June 1995.METHODS. Demographic and clinical data were abstracted from patients' medical records. The risk of cesarean delivery was adjusted for 39 maternal and neonatal risk factors that were included in a previously developed risk-adjustment model using nested logistic regression analysis.MAIN OUTCOME MEASURES. Odds ratios for cesarean delivery in nonwhite patients relative to whites and for patients with government insurance or who were uninsured relative to patients with commercial insurance.RESULTS. The overall rate of cesarean delivery was similar in white and nonwhite patients (15.8% and 16.1%, respectively), but rates varied (P < 0.001) according to insurance (17.0%, 14.2%, 10.7% in patients with commercial insurance, government insurance, and without insurance, respectively). However, after adjusting for clinical factors, the adjusted odds ratio (OR) of cesarean delivery was higher in nonwhite patients (OR = 1.34; 95% CI: 1.14-1.57; P < 0.001), but similar for patients with government insurance (OR = 1.01; 95% CI: 0.90-1.14; P = 0.84) and lower for uninsured patients (OR = 0.65; 95% CI, 0.41, 1.03; P = 0.067), albeit not statistically significant. In analyses stratified according to quintiles of predicted risk of cesarean delivery, racial differences were largely limited to patients in the lower risk quintiles. However, differences in odds ratios for uninsured patients were seen across the risk quintiles, although odds ratios were not statistically significant.CONCLUSION. After adjusting for clinical factors, race and insurance status may independently influence the use of cesarean delivery. The higher rates in nonwhites and lower rates in the uninsured may reflect differences in patient preferences or expectations, differences in physician practice, or unmeasured risk factors. The lower adds of cesarean delivery in uninsured women, particularly women at high risk, may raise the issue of underutilization of services and warrants further study.