Background

Cesarean delivery rates have been used as obstetrical quality indicators. However, these approaches do not consider the accompanying maternal and neonatal morbidities. A challenge in the field of obstetrics has been to establish a valid outcomes quality measure that encompasses preexisting high-risk maternal factors and associated maternal and neonatal morbidities and is universally acceptable to all stakeholders, including patients, healthcare providers, payers, and governmental agencies.

Objective

This study aimed to (1) establish a new single metric for obstetrical quality improvement among nulliparous patients with term singleton vertex-presenting fetus, integrating cesarean delivery rates adjusted for preexisting high-risk maternal factors with associated maternal and neonatal morbidities, and (2) determine whether obstetrician quality ranking by this new metric is different compared with the rating based on individual crude and/or risk-adjusted cesarean delivery rates. The single metric has been termed obstetrical safety and quality index.

Study Design

This was a cross-sectional study of all nulliparous patients with term singleton vertex-presenting fetuses delivered by 12 randomly chosen obstetricians in a single institution. A review of all records was performed, including a review of maternal high-risk factors and maternal and neonatal outcomes. Maternal and neonatal medical records were reviewed to determine crude and adjusted cesarean delivery rates by obstetricians and quantify maternal and neonatal complications. We estimated the obstetrician-specific crude cesarean delivery rates and rates adjusted for obstetrician-specific maternal and neonatal complications from logistic regression models. From this model, we derived the obstetrical safety and quality index for each obstetrician. The final ranking based on the obstetrical safety and quality index was compared with the initial ranking by crude cesarean delivery rates. Maternal and neonatal morbidities were analyzed as ≥1 and ≥2 maternal and/or neonatal complications.

Results

These 12 obstetricians delivered a total of 535 women; thus, 1070 (535 maternal and 535 neonatal) medical records were reviewed to determine crude and adjusted cesarean delivery rates by obstetricians and quantify maternal and neonatal complications. The ranking of crude cesarean delivery rates was not correlated (rho=0.05; 95% confidence interval, −0.54 to 0.60) to the final ranking based on the obstetrical safety and quality index. Of note, 8 of 12 obstetricians shifted their rank quartiles after adjustments for high-risk maternal conditions and maternal and neonatal outcomes. There was a strong correlation between the ranking based on ≥1 maternal and/or neonatal complication and ranking based on ≥2 maternal and/or neonatal complications (rho=0.63; 95% confidence interval, 0.08–0.88).

Conclusion

Ranking based on crude cesarean delivery rates varied significantly after considering high-risk maternal conditions and associated maternal and neonatal outcomes. Therefore, the obstetrical safety and quality index, a single metric, was developed to identify ways to improve clinician practice standards within an institution. Use of this novel quality measure may help to change initiatives geared toward patient safety, balancing cesarean delivery rates with optimal maternal and neonatal outcomes. This metric could be used to compare obstetrical quality not only among individual obstetricians but also among hospitals that practice obstetrics.

中文翻译：

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产科安全和护理质量的新指标：将剖宫产率与孕产妇和新生儿结局相结合

背景

剖宫产率已被用作产科质量指标。然而，这些方法没有考虑伴随的孕产妇和新生儿发病率。产科领域的一个挑战是建立一个有效的结果质量衡量标准，该衡量标准包括先前存在的高危孕产妇因素以及相关的孕产妇和新生儿发病率，并为所有利益相关者（包括患者、医疗保健提供者、支付者和政府机构）普遍接受。

客观的

本研究旨在 (1) 建立一个新的单一指标，用于改善足月单胎初生胎儿的产科质量，将剖宫产率根据先前存在的高危母体因素与相关的母体和新生儿发病率进行调整，以及 (2)确定此新指标的产科医生质量排名与基于个人粗产和/或风险调整剖宫产率的评级相比是否不同。单一指标被称为产科安全和质量指数。

学习规划

这是一项横断面研究，研究对象为由 12 名随机选择的产科医生在一个机构中分娩的所有足月单胎顶点先露胎儿的未产患者。对所有记录进行了审查，包括对产妇高危因素以及产妇和新生儿结局的审查。审查了产妇和新生儿的医疗记录，以确定产科医生的粗略和调整剖宫产率，并量化产妇和新生儿并发症。我们根据逻辑回归模型估计了产科医生特异性粗剖宫产率和针对产科医生特异性孕产妇和新生儿并发症调整的比率。从这个模型中，我们得出了每个产科医生的产科安全和质量指数。将基于产科安全和质量指数的最终排名与初步剖宫产率排名进行比较。产妇和新生儿发病率被分析为≥1和≥2产妇和/或新生儿并发症。

结果

这12名产科医生共接生了535名妇女；因此，审查了 1070 份（535 名产妇和 535 名新生儿）医疗记录，以确定产科医生的粗略和调整剖宫产率，并量化产妇和新生儿并发症。粗剖宫产率的排名与基于产科安全和质量指数的最终排名无关（rho=0.05；95% 置信区间，-0.54 至 0.60）。值得注意的是，12 名产科医生中有 8 名在对高危产妇状况和产妇和新生儿结局进行调整后改变了他们的四分位数。基于≥1 名产妇和/或新生儿并发症的排名与基于≥2 名产妇和/或新生儿并发症的排名之间存在很强的相关性（rho=0.63；95% 置信区间，0.08-0.88）。

结论

在考虑了高危产妇状况以及相关的产妇和新生儿结局后，基于粗剖宫产率的排名存在显着差异。因此，制定了产科安全和质量指数这一单一指标，以确定提高机构内临床医生实践标准的方法。使用这种新颖的质量措施可能有助于改变以患者安全为目标的举措，平衡剖宫产率与最佳孕产妇和新生儿结局。该指标不仅可用于比较个别产科医生之间的产科质量，也可用于比较从事产科的医院之间的产科质量。