纽约州产科出血质量改进项目与孕产妇结局

原文

OBJECTIVE: The New York State Safe Motherhood Initiative, a statewide quality-improvement effort, developed a bundle to optimize management of obstetric hemorrhage that was then disseminated and implemented by many hospitals in New York State. The purpose of this study was to evaluate trends in statewide outcomes related to postpartum hemorrhage (PPH) before, during, and after Safe Motherhood Initiative obstetric hemorrhage bundle implementation. METHODS: Delivery hospitalizations in the 2007-2022 New York State Inpatient Database were analyzed for this repeated ecologic cross-sectional analysis that evaluated outcomes before and after implementation of the Safe Motherhood Initiative obstetric hemorrhage bundle from 2013 to 2015. The New York State Inpatient Database includes discharge data for all inpatient acute care hospitalizations in New York. Trends analysis of PPH diagnoses among all delivery hospitalizations over the study period was first performed. Then, among deliveries complicated by PPH, the rate of the following adverse outcomes was determined by year: 1) transfusion, 2) nontransfusion severe maternal morbidity (SMM), 3) disseminated intravascular coagulation (DIC), and 4) hysterectomy. Analyses were performed with joinpoint regression to determine the average annual percent change (AAPC). Adjusted logistic regression models were additionally performed for each of the adverse outcomes. RESULTS: Among 3,563,885 delivery hospitalizations, PPH increased continuously from 22 per 1,000 in 2007 to 59 per 1,000 in 2022 (AAPC 6.9%, 95% CI, 6.5-7.5%). In joinpoint analysis, transfusion among delivering patients with PPH increased from 192 per 1,000 in 2007 to 212 per 1,000 in 2013 (AAPC 2.1%, 95% CI, 0.6-6.6%) but then decreased to 174 per 1,000 in 2016 (AAPC -6.8%, 95% CI, -9.5% to -2.1%) before increasing again to 212 per 1,000 in 2022 (AAPC 2.8%, 95% CI, 1.2-8.1%). Severe maternal morbidity increased from 88 per 1,000 in 2007 to 122 per 1,000 in 2014 (AAPC 2.8%, 95% CI, 0.7-7.6%) before decreasing to 76 per 1,000 in 2017 (AAPC -16.3%, 95% CI, -20.8% to -8.4%) before rising again to 88 per 1,000 in 2022 (AAPC 4.4%, 95% CI, 0.1-18.5%). Disseminated intravascular coagulation increased from 54 per 1,000 in 2007 to 90 per 1,000 in 2014 (AAPC 4.5%, 95% CI, 1.3-12.6%), decreased to 53 per 1,000 in 2017 (AAPC -19.3%, 95% CI, -25.3% to -8.9%), and increased without a significant statistical association to 88 per 1,000 in 2022 (AAPC 4.2%, 95% CI, -2.0% to 24.5%). Hysterectomy decreased significantly from 26 per 1,000 in 2013 to 9 per 1,000 in 2022 (AAPC -10.2%, 95% CI, -14.3% to -8.7%). In logistic regression analysis, adjusted odds of severe morbidity from 2016 to 2022 were decreased compared with 2007 after accounting for patient- and hospital-level factors. CONCLUSION: The initiation of the New York Safe Motherhood Initiative obstetric hemorrhage bundle coincided with decreased risk for a range of adverse outcomes among deliveries complicated by PPH. Decreases in risk continued for approximately 3-4 years after initiation of the program for SMM, DIC, and transfusion. In comparison, hysterectomy decreased continuously until the end of the study period. Case mix and worsening comorbidity may have accounted for later study trends given that adjusted regression models for SMM demonstrated decreased odds of peripartum hysterectomy over the later portion of the study.