風(fēng)險(xiǎn)校正首次剖宮產(chǎn)率與產(chǎn)科質(zhì)量的評(píng)估

1、 風(fēng)險(xiǎn)校正首次剖宮產(chǎn)率與產(chǎn)科質(zhì)量的評(píng)估研究生 劉 銘導(dǎo) 師 馬潤(rùn)玫 教授中文摘要目的 通過(guò)回顧性分析昆明醫(yī)學(xué)院第一附屬醫(yī)院分娩產(chǎn)婦自身特征與剖宮產(chǎn)（Cesarean Delivery, CD）相關(guān)的影響因素，比較實(shí)際首次CD率與風(fēng)險(xiǎn)校正首次CD率的關(guān)系，評(píng)估我院產(chǎn)科質(zhì)量。資料與方法 對(duì)2002.01.012007.04.30期間在昆明醫(yī)學(xué)院第一附屬醫(yī)院產(chǎn)科住院分娩且新生兒存活符合納入標(biāo)準(zhǔn)的7723例病歷進(jìn)行回顧性研究。查閱全部研究對(duì)象的住院病歷，記錄與CD相關(guān)因素：產(chǎn)次、分娩年齡、民族、職業(yè)、母親受教育程度、孕期產(chǎn)檢與否、分娩孕周、多胎妊娠、妊娠合并癥及并發(fā)癥和產(chǎn)時(shí)并發(fā)癥。從總體數(shù)據(jù)中隨機(jī)抽取

2、25的數(shù)據(jù)用逐步回歸前進(jìn)法篩選影響CD的高危因素并建立Logistic回歸方程，以其余75的數(shù)據(jù)用ROC曲線(xiàn)下面積（A）法檢驗(yàn)Logistic回歸方程。以L(fǎng)ogistic回歸方程求出每例產(chǎn)婦CD的概率，某年所有產(chǎn)婦CD概率的均值即為年風(fēng)險(xiǎn)校正首次CD率，將我院年實(shí)際首次CD率與之進(jìn)行比較。結(jié)果 1.初產(chǎn)婦、分娩年齡、母親受教育程度、多胎妊娠、妊娠合并癥及并發(fā)癥和產(chǎn)時(shí)并發(fā)癥是CD的危險(xiǎn)因素，早產(chǎn)是CD的保護(hù)因素；初產(chǎn)婦、分娩年齡35歲、母親高學(xué)歷、多胎妊娠、中度、重度妊娠合并癥及并發(fā)癥、臀位或橫位及前置胎盤(pán)使CD風(fēng)險(xiǎn)顯著增加。2. 我院近6年內(nèi)實(shí)際首次CD率與風(fēng)險(xiǎn)校正首次CD率均呈逐年降低趨勢(shì)，

3、實(shí)際首次CD率由最高2003年的59.38降至最低20062007年4月的38.82，實(shí)際首次CD率和風(fēng)險(xiǎn)校正首次CD率差值在逐年縮小，至20062007年4月實(shí)際首次CD率比風(fēng)險(xiǎn)校正首次CD率95CI上限高2.81。結(jié)論 1. 初產(chǎn)婦、分娩年齡30歲、母親高學(xué)歷、多胎妊娠、妊娠合并癥及并發(fā)癥和產(chǎn)時(shí)并發(fā)癥是CD的危險(xiǎn)因素，早產(chǎn)是CD的保護(hù)因素。2. 我院實(shí)際首次CD率和風(fēng)險(xiǎn)校正首次CD率均呈下降趨勢(shì)，兩率逐漸接近，反映了我院產(chǎn)科質(zhì)量穩(wěn)步提升。3風(fēng)險(xiǎn)校正首次CD率是產(chǎn)科質(zhì)量評(píng)估的可靠指標(biāo)之一。關(guān)鍵字 剖宮產(chǎn) 風(fēng)險(xiǎn)校正 產(chǎn)科質(zhì)量Risk-adjusted primary cesarean deli

4、very rates and quality assessment of obstetric careM.Phil student Liu Ming Supervisor Prof. Ma Run-mei AbstractObjective: The purpose of this study was to explore the risk factors of cesarean delivery (CD) using a logistic regression model, and to calculate risk-adjusted primary CD rates comparing w

5、ith observed primary CD rates, to evaluate the quality of obstetric care in our obstetrics unit.Material and methods: The study population consists of all live births in the First Affiliated Hospital of Kunming Medical College between 1 January 2002 and 30 April 2007.During the study period, 8155 in

6、fants were delivered, after exclusion (432 births), remaining 7723 births for final analysis. The independent variables which would likely be important in determining the risk for a CD were maternal age, nulliparity, maternal race, maternal occupation, maternal education, and the trimester that pren

7、atal care began, multiple pregnancy, gestational age, maternal medical conditions and intrapartum complications. A multivariate logistic regression model of characteristics independently associated with CD was developed with the use of a random 25% sample of the data, the model was validated on the

8、75% portion of the data that were not used to build the model and an A statistic was calculated, the A statistic refers to the area under the receiver operating characteristic curve, A statistic above 0.7 indicate acceptable discrimination. Using the model, the probability of a CD was determined for

9、 every patient in the database. The risk-adjusted primary CD rate for a hospital in each year was calculated by an average of the CD probabilities of each patient who delivered at the hospital in each year. We then compare the two rates.Results: 1. Nulliparity, maternal age, multiple pregnancy, mate

10、rnal medical conditions and intrapartum complications were the risk factors of CD, preterm was protective against CD; nulliparity, maternal age35 age, multiple pregnancy, moderate and severe maternal medical conditions, placental previa and breech/malpresentation, were increased CD risk. 2. Both the

11、 observed primary CD rates and the risk-adjusted primary CD rates were decreased over the past 6 years, in 20062007, the observed primary CD rate was in the upper of the 95% CI of the risk-adjusted primary CD rate, the observed primary CD rate was 38.82% .Conclusions: 1. Nulliparity, maternal age30a

12、ge, maternal education, multiple gestation, maternal medical conditions and intrapartum complications were the risk factors of CD, preterm was protective against CD. 2. Both the observed primary CD rates and the risk-adjusted primary CD rates were decreased over the past 6 years, reflecting quality of obstetric care of