Obstetric delivery volume, regionalization, and maternal and infant outcomes

摘要 美国的婴儿和产妇死亡率和发病率远远高于世界其他地区 发达国家。这些糟糕结果的一个潜在驱动因素是医院的特点 女性接生，尤其是每年的接生量。有证据表明，交货量 影响产妇结局(死亡率和严重发病率)，但这一证据并不适用于所有人 或所有类型地点的孕产妇结局，并经常遗漏胎儿死亡 分析。此外，还没有仔细研究产科容量对关节的影响。 母婴结局二元体，或产科容量如何改变观察到的新生儿改善 NICU的死亡率和发病率。最后，这些研究中的许多只关注于 早产儿，忽略总产量、慢性疾病或共存的并发症， 和低风险的送货。两项规模较小的欧洲研究发现， 足月、低风险婴儿的分娩和新生儿结局，而不检查产妇结局。 医院接生量可能是导致美国生育结果不佳的原因之一 具有重大的政策影响。产科服务的一些整合可能会带来好处， 但在整合和访问之间存在权衡，两者都没有相应的数据 阈值，或当常规医疗机会有限时，如农村地区，这些阈值如何变化 区域。20世纪90年代，葡萄牙关闭了所有快递服务，每年送货量为1500人次， 孕产妇死亡率从9.2/10万降至5.3/100,000。葡萄牙同时 关闭了所有小型NICU，因此导致新生儿和围产儿人数大幅下降(8.1/1000)和围产儿 死亡率(16.4/1000至6.6/1000)可能是NICU和产科容量变化所致。而当 这样的数据是令人信服的，患者风险和在美国接生婴儿的医院之间的较大差异 美国需要创新的研究，为美国和国家政策提供关于如何组织产科护理的信息。 拟议的研究将涉及以下具体目标： 目标1：产科服务量与母婴有什么关系 发病率和死亡率(包括胎儿死亡)？这些影响非常受患者风险的影响吗？ 目标2：农村和城市地区的接生量对产量-结果的影响是否存在差异？ 我们将使用相关的生命统计数据-1995年CA、MA、MO、PA、SC和WA的患者出院数据- 2020年。我们将利用数据的小组性质(每家医院随时间的重复观察)来 控制未观察到的、特定于医院的影响预后的因素。目标是确定交付 为优化孕妇及其婴儿的结局所需的体积，允许证据- 以州和国家一级的政策为基础，指导围产期分娩系统的发展。

Abstract The US infant and maternal mortality and morbidity rates are far above those for the rest of the developed world. One potential driver of these poor outcomes is the characteristics of hospitals where women deliver, especially the annual delivery volume. There is some evidence that the volume of deliveries affects maternal outcomes (mortality and serious morbidity), but this evidence is not consistent for all maternal outcomes or across all types of locations and has frequently omitted fetal deaths from the analyses. Further, there has not been a careful examination of the effect of obstetric volume on joint maternal-infant outcomes dyad, or how obstetric volume modifies the observed improvements in neonatal mortality and morbidity at NICUs. Finally, many of these studies have focused only on the volume of preterm infants, ignoring overall delivery volume, chronic medical conditions or co-existing complications, and low-risk deliveries. Two smaller European studies have found and association between the volume of the deliveries of term, low-risk infants and newborn outcomes, without examining maternal outcomes. That hospital delivery volume could be a contributor to the poor US reproductive outcomes could have significant policy implications. There could be benefits from some consolidation of obstetric services, but there are trade-offs between consolidation and access, with no data on either the appropriate thresholds, or how such thresholds change when routine access to medical care is limited, such as rural areas. In the 1990s Portugal closed all deliveries services with a volume <1500 deliveries/year and experienced a decrease in the maternal mortality rate from 9.2 to 5.3/100,000. Portugal simultaneously closed all small NICUs, so the resulting very large decrease in neonatal (8.1 to 2.9/1000) and perinatal (16.4 to 6.6/1000) mortality could have resulted from either changes in NICU and obstetric volume. While such data is compelling, the larger variation in both patient risk and hospitals that deliver infants in the United States requires innovative studies to inform US and state policy about how organize obstetric care. The proposed study will address the following specific aims: Aim 1: What are the relationships between the volume of obstetric services and maternal and infant morbidity and mortality (including fetal deaths)? Do these effects very by patient risk? Aim 2: Are there differences in the volume-outcome effects of delivery volume for rural vs. urban areas? We will use linked vital statistics-patient discharge data from CA, MA, MO, PA, SC and WA for 1995- 2020. We will exploit the panel nature of the data (repeated observations of each hospital over time) to control for unobserved, hospital-specific factors that affect outcomes. The objective is to identify the delivery volumes needed to optimize the outcomes for pregnant women and their babies, allowing for evidence- based policies at the state and national-level to guide the development of perinatal delivery systems.