基于风险调整的三级综合医院剖宫产率评价

Evaluation of cesarean delivery rate at tertiary general hospitals based on risk adjustment

目的基于风险调整思想,通过考虑产妇的个体特征来计算标准化剖宫产率,合理评价医院产科的医疗质量。方法收集山西省33家三级综合医院2016年1—12月入院的69406例产妇的病历资料,采用logistic回归模型构建产妇剖宫产的风险调整模型,利用ROC曲线下面积评价模型的拟合优度。结果69406例产妇中,采用剖宫产分娩者30881例,剖宫产率为44.49%。不同年龄、民族、入院情况、是否参与临床路径、双胎或多胎、新生儿体重、产妇孕周以及合并症严重程度产妇的剖宫产率差异均有统计学意义(P<0.001)。logistic模型结果显示,年龄越大、有剖宫产史、双胎或多胎、新生儿体重大、胎位不正、前置胎盘以及有各类妊娠合并症的产妇进行剖宫产手术的概率较大,模型的拟合优度达0.82。风险调整后,各医院的实际剖宫产率和标准化剖宫产率排序不一致。结论调整产妇因素后的标准化剖宫产率能够剔除产妇自身危险因素,科学合理地评价医院产科的剖宫产开展情况。

Objective To calculate the standardized cesarean delivery rate by considering the individual characteristics of puerprae, and to evaluate the medical quality of obstetrics in the hospital. Methods Medical records of 69 406 puerprae from January to December in 2016 were collected from 33 tertiary general hospitals in Shanxi province. A logistic regression model was used to construct a maternal risk adjustment model of cesarean delivery, with the area under the ROC curve (AUC) used to evaluate the goodness of fit of the model. Results Of the 69 406 puerprae, 30 881 used caesarean delivery, accounting to 44. 37%. The cesarean section rate difference was statistically significant among those of different age, nationality, conditions upon admission, whether to participate in a clinical pathway, fetus number, birth weight and maternal gestational age, as well as the severity of complications (P < 0. 001). According to the logistic model, those of older age, history of cesarean delivery, twins or triplet births, neonatal overweight, malposition, placenta previa, and those with various pregnancy complications tend to use maternal cesarean section surgery, with a goodness-of-fit of 0. 82. With risk adjusted, the ranking of actual cesarean section rate and standardized cesarean section rate varies among the hospitals. Conclusions With the factor of puerprae factor adjusted, the standardized cesarean delivery rate can eliminate risk factors of the puerprae, it is feasible to scientifically evaluate the cesarean delivery rate of the hospital′s obstetric department.