Research On Medical Quality Evaluation On Obstetrics In Public Hospitals And Its Improvement Strategies Based On Risk Adjustment

[Purpose]Since the implementation of the two-child policy,the number of high-risk women in the national medical institutions has been increasing,most of them are two-child mothers.Among these puerperas,the proportion of pregnancy comorbidities and complications caused by scar uterus,elderly and other two-child factors is increasing.It also means that the probability of adverse outcomes such as cesarean section,neonatal death,postpartum hemorrhage,postpartum complications and so on will increase.For these individual factors,a more fair and effective assessment method would be introduced for obstetric quality evaluating.At the same time,how to accomplish the established clinic plan and additional contents of obstetrical department and ensure the quality of obstetric care under such a policy situation.We need to further study the factors that affect the medical quality of obstetrics so as to find the key links and management methods that can adapt to the new obstetric requirements and improve the quality of obstetrics.This study is based on the construction of the quality evaluation model of obstetric risk adjustment,and explores the theoretical model and method of obstetric evaluation,which provides practical and theoretical basis for the quality evaluation of obstetric care and the fine quality management of the hospital departments.Meanwhile,according to the results of the evaluation,the corresponding strategies for improving obstetric quality and obstetric quality evaluation are put forward.[Methods]1.Study subjects: The object of this study is the obstetrics of 135 public hospitals in Shanxi Province,2016-2017.Through the investigation of 135 hospital obstetrics and obstetrics,a total of 444920 data were obtained from the first page of the medical records of the obstetrics department in 2016-2017 years,with more than 220 items in each category.2.Based on John Hopkins' s evidence-based medicine literature analysis method,we reviewed more than 700 research papers both at home and abroad,and made systematic literature review.All indicators related to obstetric quality should be determined as an alternative index library.With consultation,21 obstetricians and experts of med-quality managerment from several provinces and municipalities were invited.Through two rounds of expert consultation,combined with one to one in-depth interview and repeated discussion,the index is screened fully to obtain the representative evaluation index of obstetric medical quality,and to construct the evaluation system of obstetric medical quality.3.According to the related individual characteristics of pregnant women,risk adjusted models of multiple obstetric outcomes in the system were constructed based on risk adjusted method.Then,to exclude the confounding factors of maternal level,the standardized rates of indicators risk adjusted was obtained.A comparative method based on benchmarking theory is applied to explore the benchmarking hospital under different obstetric quality indicators.According to the comparison between other hospitals and benchmarking hospitals,the quality indicators gap is reasonably quantified.4.According to the adjusted obstetric medical quality indexes,the latent variable model based on Bayesian project response theory was used to evaluate the medical quality of all hospitals and to carry out the comprehensive quality ranking of 135 hospitals.And confirm the theoretical model of Obstetrics medical quality evaluation.5.The linear regression model was used to analyze the factors affecting the quality of obstetric medical treatment from the aspects of hospital attributes,obstetric services and the allocation of obstetric human resources.Finally,the improvement strategy of obstetric medical quality was put forward.[Results]1.Through literature research and expert consultation,we establish the evaluation system of obstetrical quality from maternal and neonatal negative events.Indicators include cesarean section rate,postpartum hemorrhage rate,perinatal hospital infection rate,maternal birth injury rate,and the incidence of neonatal comprehensive adverse outcomes.2.Through the study of risk adjustment,it is found that:(1)The individual characteristics of maternal level have different effects on five obstetric quality indicators.(For specific results,see the sixth chapter)(2)In most of obstetrics of each hospitals,the hospital rank under five obstetric quality indicators has changed after the risk adjustment.(3)According to the point of view of the benchmarking theory,it is found that in most obstetrics and gynecology department,there is a difference in the comparison with the benchmarks.3.Based on Bayes item response theory,the evaluation model of Obstetrics was established,and the comprehensive coefficients and ranking results of obstetric medical quality were obtained.From the results of weight index of obstetric quality indicators,the weight of all obstetric indexes of postpartum evaluation is higher: postpartum hemorrhage(2.115),perinatal nosocomial infection(1.927),neonatal comprehensive adverse outcome(1.885),maternal birth trauma(1.434),however,the weight of cesarean section was only 0.260.4.Among the selected variables,the p value is at a significant level of 0.1.A total of 6 variables are considered to be statistically significant: hospital level(p=0.035,coef:0.42)?annual average hospitalization of obstetrics(p=0.001,coef: 2.16*10-6)?annual operative volume of obstetrics(p=0.000,coef:-1.58*10-6),Annual average obstetric operation ratio in 3-4 level(p=0.042,coef:0.13),maternity beds than midwives(p=0.069,coef:0.21),bachelor degree or above in obstetrical nursing(p=0.061,coef:1.06)[Conclusions]1.The quality of obstetric medical treatment is influenced by many factors of the patient(parturient)and the medical side.By means of risk adjustment,the miscellaneous factors of the patients(parturients)can be excluded,and the quality of obstetric medical treatment can be evaluated more scientifically and fairly.2.In obstetrics evaluation,we should set up evaluation indicators from multiple angles to evaluate the medical quality of different departments according to the characteristics of the actual clinical work of departments.According to the situation of obstetric department under different indicators,we set up benchmarking to carry out targeted medical quality improvement.3.The comprehensive evaluation of a number of obstetric quality indicators should be based on the objective reality and the subjective opinion of the obstetric experts.The latent variable model based on the Bayesian project response theory can achieve this requirement.4.The improvement of the quality of obstetric care at the medical level should be improved from reducing the rate of non medical indication of caesarean section,improving the proportion of the 3-4 levels of Obstetrics,improving the knowledge and business level of the medical staff,increasing the allocation of midwives and improving the training and incentive mechanism of the related midwives.[Innovation and deficiency]1.The Innovation of this study(1)The risk adjusted model constructed by this study not only excludes the confounding factors of maternal level,but also considers the aggregation problem of patients.Based on the perspective of benchmarking,the benchmarking group under the provincial level is set up in the provincial area.By comparing the other hospital obstetrics with the benchmarking group,the gap between the medical quality and the medical quality is reflected,which provides the direction for the improvement and promotion of quality.Based on the theory of Bayesian project reaction,the idea of priori probability and posterior probability is adopted to fully synthesize the subjective and objective evaluation of power and comprehensive evaluation,and the evaluation is in accordance with the actual situation.At the same time,using the Bayesian project to reflect the characteristics of the theoretical model,we have solved the problems related to each other in the traditional comprehensive evaluation,and provide a reference for the comprehensive evaluation of medical quality.(2)In the domestic research area,this study first adopted such a large maternal sample to build a multi risk obstetric quality evaluation system based on risk adjustment.The influence factors from patients and doctors are to find medical quality,and put forward the corresponding improvement strategy.On the one hand,it has a good guiding significance to the quality evaluation of the domestic obstetrics,on the other hand,it provides a good reference for the follow-up of the fine quality management of the Department as a unit,and has a good promotion and value.In addition,this study also combined with the status of newborns to evaluate the quality of obstetrical obstetrics,the comprehensive adverse outcome of the newborn as a evaluation index to broaden the visual field of the quality of obstetric care evaluation,and also provide a more solid empirical basis for the research of maternal and child related medical health management.2.The deficiencies of this study(1)Although more than a hundred samples of Obstetrics have been collected in the study,there is still some lack of efforts in improving the quality of obstetric care as a reasonable strategy.The selected samples are all biased towards one province,and their scope and actual effect still have some limitations.(2)Although there are many variables in this study,there are still some data such as social and epidemiological variables,such as patients' past history,living habits and hobbies,as well as prenatal pregnancy and maternity test,health care and other data.Due to the limitation of data acquisition,there will be some deviations in the model.At the same time,the obstetrics medical equipment,technology and other variables are not complete,so it is difficult to obtain more information to carry out more medical level improvement strategies.