UCLA Clinical Translational Science Institute

项目摘要 美国妇产科学院提出了产妇风险适当的护理 （ACOG），产妇胎儿医学协会（SMFM），疾病控制中心（CDC）和其他 作为一项全国性的全系统建议， 产妇发病率和死亡率上升。ACOG、SMFM和其他各种利益相关者都主张 根据医院资源，采用一级至四级系统， 为低风险妇女提供资源和护理，二级和三级护理中等风险妇女， IV级是一个区域中心，可全天候访问现场多学科顾问和重症监护资源。 作为对NIH IMPROVE倡议的回应，该补充提案的重点是出血-第四大 产妇死亡的原因。报告显示，66-93%以上可能是可以避免的，使其成为领先的 可预防的孕产妇死亡原因。异常胎盘形成（胎盘植入谱（PAS）疾病和 前置胎盘）是出血的主要原因。由于剖宫产率的增加， 分娩和剖宫产的风险因种族/民族而异。许多研究人员、临床医生和患者的拥护者 团体支持对PAS妇女的区域化护理，由卓越中心协调护理，或 “accreta中心”设有指定的小组和标准化的协议。然而，到目前为止，还没有一个 基于医院层面的风险适当护理，对医院的结局进行系统评价，甚至 专门的“accreta中心”没有提供数据表明健康差距有所改善。在 作为对NIH IMPROVE倡议的回应，目前的提案使用了加州的排放数据（2013-2016年）， 提出以下研究目的：（1）描述胎盘形成异常（PAS）妇女的妊娠结局 或前置胎盘）;（2）评估 孕产妇护理和种族/民族对PAS女性重度孕产妇发病率（SMM）的影响;（3）评价 产妇护理水平和种族/民族对胎盘前置妇女SMM的相互作用 可能受母体风险影响的替代条件适当的护理。本研究将首先 基于风险适当的护理，评估PAS或前置胎盘女性的结局是否更好， 护理水平减轻了在这些高风险状况中观察到的SMM差异。此外，这项研究提供了 一个框架，研究不同的临床条件，其中转介风险适当的护理可以进行评估。

Project Summary Maternal risk appropriate care has been proposed by the American College of Obstetricians & Gynecologists (ACOG), Society of Maternal Fetal Medicine (SMFM), the Centers for Disease Control (CDC) and other stakeholders as a national system-wide recommendation to improve safety in childbirth and to decrease the rising rate of maternal morbidity and mortality. ACOG, SMFM, and various other stakeholders have advocated for certifying hospitals based on hospital resources with a system ranked from I-IV where Level I has essential resources and provides care for low risk women, Level II and III takes care of intermediate risk women, and Level IV is a regional center with 24/7 access to onsite multidisciplinary consultants and critical care resources. In response to the NIH IMPROVE initiative, this supplement proposal focuses on hemorrhage--the 4th leading cause of maternal mortality. Reports suggest that upwards of 66-93% may be avoidable making it the leading cause of preventable maternal death. Abnormal placentation (placenta accreta spectrum (PAS) disorders and placenta previa) is a leading cause of hemorrhage. Rates are increasing due to increasing rates of cesarean delivery, and risk of cesarean varies by race/ethnicity. Many researchers, clinicians, and patient advocacy groups support regionalizing care for women with PAS with care coordinated by centers of excellence or "accreta centers” with designated teams and standardized protocols. However, to date, there has not been a systematic evaluation of outcomes by hospitals based on risk appropriate care at the hospital level, and even the specialized “accreta centers” have not provided data demonstrating improvement in health disparities. In response to the NIH IMPROVE initiative, the current proposal uses California discharge data (2013-2016), to address the following study aims: (1) describe maternal outcomes in women with abnormal placentation (PAS or placenta previa) by level of maternal care and race/ethnicity; (2) evaluate the interactions of levels of maternal care and race/ethnicity on severe maternal morbidity (SMM) for women with PAS; and (3) evaluate the interaction of levels of maternal care and race/ethnicity on SMM for women with placenta previa—an alternate condition that likely could be influenced by maternal risk appropriate care. This study will be the first to evaluate if outcomes are better for women with PAS or placenta previa based on risk appropriate care and if level of care mitigates observed disparities in SMM for these high-risk conditions. Further, this study provides a framework to study different clinical conditions where referral to risk appropriate care can be evaluated.