背景:不必要的剖腹产导致产妇和新生儿发病率和死亡率增加。2020年,佛罗里达州的剖宫产率为35.9%,全国第三高。降低整体剖宫产率的有效质量改进策略是减少低风险分娩的原发性剖腹产(未分娩,term,单身人士,顶点;NTSV)。三种全国公认的低风险剖宫产率医院措施包括NTSV,联合委员会(JC),和母胎医学协会(SMFM)指标。比较指标是必要的,因为准确和及时的测量对于支持多医院质量改进工作以降低低风险剖宫产率和提高产妇护理质量至关重要。
目的:根据1)风险方法学-NTSV,使用五种不同的低风险剖宫产率指标评估佛罗里达州医院低危剖宫产率的差异,JC,和SMFM指标-2)仅与数据源相关的出生证明和出院记录以及出院记录。
方法:我们从2016-2019年对佛罗里达州的活产进行了一项基于人群的研究,以比较五种计算低危剖宫产率的方法。使用关联出生证明(BC)数据和住院出院(HD)数据进行分析。五种低危剖宫产措施定义为:1)NTSV-BC基于出生证明的数据,未使用相关的出院数据。指定为NTSV,它不排除其他高风险条件。第二个和第三个措施使用来自完整链接数据集的数据元素来指定NTSV,并排除了几个高风险条件:2)JC链接利用的JC排除,和3)SMFM关联的利用SMFM排除。最后两项措施仅基于出院数据的数据,而不使用关联的出生证明数据。这些措施通常反映了术语,单身人士,和顶点,因为无法在出院数据上充分评估奇偶校验:4)具有JC排除的JC-HD和5)具有SMFM排除的SMFM-HD。这五项措施之间的医院差异是通过整体和新生儿重症监护病房(NICU)水平计算得出的。
结果:总体而言,在所有措施中,医院低危剖宫产率的中位数下降,从NTSV-BC30.7%,与JC相关的29.3%,与SMFM相关的29.2%,大幅下降至JC-HD19.4%和SMFM-HD18.5%。NICU水平也有类似的趋势。对于每一项措施,II级低风险剖宫产率中位数最高(NTSV-BC:32.8%,JC关联:31.4%,SMFM链接:31.4%,SMFM-HD:19.2%),三级JC-HD除外:21.3%。总体低危分娩人数和NICU水平的比较,在相关和医院出院措施中,数字有所下降。再一次,在相关措施和出院措施之间,低危剖宫产率存在很大差距.然而,随着医院费率的增加,这一差距缩小了。
结论:使用出生证明通过NTSV指标测量的低风险剖宫产率的质量监测是相当准确的,并为佛罗里达州医院的使用提供了及时的评估。NTSV-BC率与利用链接数据源的低风险指标相当。总的来说,在同一数据源中使用的指标具有相似的比率,SMFM指标的费率最低。跨数据源,使用出院数据的指标只会导致严重低估的比率,因为包括多胎妇女,并应谨慎解释。
Unnecessary cesarean deliveries lead to increased maternal and neonatal morbidities and mortalities. In 2020, Florida had a cesarean delivery rate of 35.9%, the third highest in the nation. An effective quality improvement strategy to reduce overall cesarean delivery rates is to decrease primary cesarean deliveries in low-risk births (nulliparous, term, singleton, vertex). Of note, 3 nationally accepted hospital measures of low-risk cesarean delivery rates include the nulliparous, term, singleton, vertex; Joint Commission; and Society for Maternal-Fetal Medicine metrics. Comparing metrics is necessary because accurate and timely measurement is essential to support multihospital quality improvement efforts to reduce low-risk cesarean delivery rates and improve the quality of maternal care.
This study aimed to assess differences in hospital low-risk cesarean delivery rates in Florida using 5 different metrics of low-risk cesarean delivery rate based on (1) risk methodology, nulliparous, term, singleton, vertex; Joint Commission; and Society for Maternal-Fetal Medicine metrics, and (2) data source, linked birth certificate and hospital discharge records and hospital discharge records only.
This was a population-based study of live Florida births from 2016 to 2019 to compare 5 approaches to calculating low-risk cesarean delivery rates. Analyses were performed using linked birth certificate data and inpatient hospital discharge data. The 5 low-risk cesarean delivery measures were defined as follows: nulliparous, term,
singleton, vertex birth certificate; Joint Commission-linked used Joint Commission exclusions; Society for Maternal-Fetal Medicine-linked used Society for Maternal-Fetal Medicine exclusions; Joint Commission hospital discharge with Joint Commission exclusions; and Society for Maternal-Fetal Medicine hospital discharge with Society for Maternal-Fetal Medicine exclusions. Nulliparous, term,
singleton, vertex birth certificate was based on data from birth certificates and not using linked hospital discharge data. Designated as nulliparous, term,
singleton, vertex, it does not exclude other high-risk conditions. The second and third measures (Joint Commission-linked used Joint Commission exclusions and Society for Maternal-Fetal Medicine-linked used Society for Maternal-Fetal Medicine exclusions) use data elements from the full-linked dataset to designate nulliparous, term, singleton, vertex and excluded several high-risk conditions. The last 2 measures (Joint Commission hospital discharge with Joint Commission exclusions; and Society for Maternal-Fetal Medicine hospital discharge with Society for Maternal-Fetal Medicine exclusions) were based on data from hospital discharge data only and not using linked birth certificate data. These measures generally reflect term, singleton, and vertex because parity could not be assessed adequately on hospital discharge data. Hospital differences between these 5 measures were calculated overall and by neonatal intensive care unit level.
Overall, the median of hospital low-risk cesarean rates decreased across the measures, from NTSV-BC 30.7%, to Joint Commission linked 29.1%, and Society for Maternal Fetal Medicine hospital discharge 29.2% with a large decrease to Joint Commission hospital discharge 19.4% and Society for Maternal Fetal Medicine hospital discharge 18.1%. A similar trend was seen by neonatal intensive care unit level. For each of the measures, level II had the highest median low-risk cesarean rates (nulliparous. term, singleton, vertex birth certificate) 32.7%, Joint Commission linked (31.4%), Society for Maternal Fetal Medicine linked: 31.1%, Society for Maternal Fetal Medicine hospital discharge 19.3%), except for level III Joint Commission hospital discharge (20.0%). A comparison of the median number of low-risk births overall and by neonatal intensive care unit level showed a decreasing number across the linked and hospital discharge measures. Again, a wide gap in low-risk cesarean delivery rates was identified between linked measures and hospital discharge measures. However, this gap narrowed as hospital rates increased.
Quality monitoring of low-risk cesarean delivery rates measured by the nulliparous, term,
singleton, vertex metric using the birth certificate was fairly accurate and provided timely assessment for use by Florida hospitals. The nulliparous, term,
singleton, vertex birth certificate rates were comparable with low-risk metrics using the linked data source. Overall, metrics used within the same data source had similar rates, with the Society for Maternal-Fetal Medicine metric having the lowest rates. Across data sources, metrics using hospital discharge data only resulted in substantially underestimated rates because of the inclusion of multiparous women and should be interpreted with caution.