风险校正首次剖宫产率与产科质量的评估

1、 风险校正首次剖宫产率与产科质量的评估研究生 刘 铭导 师 马润玫 教授中文摘要目的 通过回顾性分析昆明医学院第一附属医院分娩产妇自身特征与剖宫产（Cesarean Delivery, CD）相关的影响因素，比较实际首次CD率与风险校正首次CD率的关系，评估我院产科质量。资料与方法 对2002.01.012007.04.30期间在昆明医学院第一附属医院产科住院分娩且新生儿存活符合纳入标准的7723例病历进行回顾性研究。查阅全部研究对象的住院病历，记录与CD相关因素：产次、分娩年龄、民族、职业、母亲受教育程度、孕期产检与否、分娩孕周、多胎妊娠、妊娠合并症及并发症和产时并发症。从总体数据中随机抽取

2、25的数据用逐步回归前进法筛选影响CD的高危因素并建立Logistic回归方程，以其余75的数据用ROC曲线下面积（A）法检验Logistic回归方程。以Logistic回归方程求出每例产妇CD的概率，某年所有产妇CD概率的均值即为年风险校正首次CD率，将我院年实际首次CD率与之进行比较。结果 1.初产妇、分娩年龄、母亲受教育程度、多胎妊娠、妊娠合并症及并发症和产时并发症是CD的危险因素，早产是CD的保护因素；初产妇、分娩年龄35岁、母亲高学历、多胎妊娠、中度、重度妊娠合并症及并发症、臀位或横位及前置胎盘使CD风险显著增加。2. 我院近6年内实际首次CD率与风险校正首次CD率均呈逐年降低趋势，

3、实际首次CD率由最高2003年的59.38降至最低20062007年4月的38.82，实际首次CD率和风险校正首次CD率差值在逐年缩小，至20062007年4月实际首次CD率比风险校正首次CD率95CI上限高2.81。结论 1. 初产妇、分娩年龄30岁、母亲高学历、多胎妊娠、妊娠合并症及并发症和产时并发症是CD的危险因素，早产是CD的保护因素。2. 我院实际首次CD率和风险校正首次CD率均呈下降趋势，两率逐渐接近，反映了我院产科质量稳步提升。3风险校正首次CD率是产科质量评估的可靠指标之一。关键字 剖宫产 风险校正 产科质量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