Obstetric delivery volume, regionalization, and maternal and infant outcomes

产科分娩量、区域划分以及母婴结局

• 批准号: 10612824
• 负责人: CIARAN S. PHIBBS
• 金额: $ 64.3万
• 依托单位: STANFORD UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-06-15 至 2025-03-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10612824
• 关键词: Affect; Birth; California; Caring; Cesarean section; Characteristics; Chronic; Complex; Data; Developed Countries; Dimensions; Discipline of obstetrics; Ethnic Origin; European; Fetal Death; First Births; Geography; Guidelines; Hemorrhage; Hospitals; Income; Infant; Infant Mortality; Infection; Insurance; Joints; Link; Literature; Location; Maternal Health; Maternal Mortality; Measures; Medical; Morbidity - disease rate; Nature; Neonatal; Neonatal Intensive Care; Neonatal Mortality; Newborn Infant; Nulliparity; Obstetric Delivery; Operative Surgical Procedures; Outcome; Outcome Study; Patient Discharge; Patient risk; Patients; Perinatal; Policies; Policy Maker; Population Density; Portugal; Pregnant Women; Premature Infant; Quality of Care; Race; Research Personnel; Rest; Risk; Rural; Rural Hospitals; Sample Size; Sampling; System; Term Birth; Time; United States; Urban Hospitals; Variant; Very Low Birth Weight Infant; Vital Statistics; Woman; data resource; evidence base; experience; experimental study; extreme prematurity; high risk; improved; infant death; infant morbidity/mortality; infant outcome; innovation; maternal morbidity; maternal outcome; mortality; neonatal morbidity; obstetric care; obstetric services; perinatal development; placenta previa; policy implication; reproductive outcome; rural area; service delivery; trauma care; urban area

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.

摘要 美国的婴儿和产妇死亡率和发病率远远高于其他国家。 发达世界。这些不良结果的一个潜在驱动因素是医院的特点， 妇女分娩，特别是年分娩量。有证据表明， 影响孕产妇结局（死亡率和严重发病率），但这一证据并不适用于所有人 产妇的结果或所有类型的地点，并经常忽略胎儿死亡的 分析。此外，还没有仔细检查产科体积对关节炎的影响。 母婴结局二分体，或产科容量如何改变新生儿的观察改善 NICU的死亡率和发病率。最后，其中许多研究仅关注 早产儿，忽略总分娩量、慢性疾病或共存并发症， 低风险的交付。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的结果，而不检查产妇的结果。 医院分娩量可能是导致美国生育结果不佳的一个因素， 具有重大的政策意义。对产科服务进行某种程度的整合可能会有好处， 但在整合和访问之间存在权衡， 阈值，或当常规医疗服务受到限制时，如农村地区， 地区在1990年代，葡萄牙关闭了所有交付量<1 500次/年的交付服务， 孕产妇死亡率从每100 000人9.2人降至5.3人。葡萄牙同时 关闭了所有小型NICU，因此新生儿（8.1至2.9/1000）和围产期 (16.4至6.6/1000）死亡率可能是由于NICU和产科容量的变化。而 这些数据是令人信服的，病人风险和医院的差异越大， 美国需要创新的研究，以告知美国和国家政策如何组织产科护理。 拟议的研究将针对以下具体目标： 目的1：产科服务量与母婴的关系 发病率和死亡率（包括胎儿死亡）？这些影响对患者的风险很大吗？ 目标2：农村与城市地区的分娩量对分娩量结果的影响是否存在差异？ 我们将使用1995年CA、MA、MO、PA、SC和WA的相关生命体征-患者出院数据- 2020.我们将利用数据的面板性质（随着时间的推移对每家医院进行重复观察）， 控制未观察到的、影响结果的医院特定因素。目标是确定交付 为孕妇及其婴儿优化结果所需的数量，考虑到证据- 在州和国家一级制定政策，指导围产期分娩系统的发展。

项目成果

Perinatal Care Measures Are Incomplete If They Do Not Assess The Birth Parent-Infant Dyad As A Whole.

如果不从整体上评估出生亲子二元关系，围产期护理措施就是不完整的。

• DOI: 10.1377/hlthaff.2023.00398
• 发表时间: 2023
• 期刊: Health affairs (Project Hope)
• 作者: Handley,SaraC;Formanowski,Brielle;Passarella,Molly;Kozhimannil,KatyB;Leonard,StephanieA;Main,ElliottK;Phibbs,CiaranS;Lorch,ScottA
• 通讯作者: Lorch,ScottA

A Comprehensive Analysis of the Costs of Severe Maternal Morbidity.

• DOI: 10.1016/j.whi.2021.12.006
• 发表时间: 2022-07
• 期刊: WOMENS HEALTH ISSUES
• 影响因子: 3.2
• 作者: Phibbs, Claire M.;Kozhimannil, Katy B.;Leonard, Stephanie A.;Lorch, Scott A.;Main, Elliott K.;Schmitt, Susan K.;Phibbs, Ciaran S.
• 通讯作者: Phibbs, Ciaran S.

The effect of severe maternal morbidity on infant costs and lengths of stay.

• DOI: 10.1038/s41372-022-01343-3
• 发表时间: 2022-05
• 期刊: JOURNAL OF PERINATOLOGY
• 影响因子: 2.9
• 作者: Phibbs, Claire M.;Kozhimannil, Katy B.;Leonard, Stephanie A.;Lorch, Scott A.;Main, Elliott K.;Schmitt, Susan K.;Phibbs, Ciaran S.
• 通讯作者: Phibbs, Ciaran S.