周末生娃更危险?BMJ新研究对其进行数据观察
来宝资讯 · 2015/11/28
所谓的“周末效应”已在许多发达国家临床上以及跨学科内被广泛地研究过。目前的研究是产科内最广泛的调查。一项发表在BMJ杂志上的新研究,证明了预产期在周末的孕妇和婴儿会有较高的并发症发生率,显示“周末效应”已到达令人担忧的程度。


所谓的“周末效应”已在许多发达国家临床上以及跨学科内被广泛地研究过。目前的研究是产科内最广泛的调查。一项发表在BMJ杂志上的新研究,证明了预产期在周末的孕妇和婴儿会有较高的并发症发生率,显示“周末效应”已到达令人担忧的程度。

这项研究在英国医院持续两年调查了超过一百万的孕妇。研究人员发现,一些预产孕妇在周六和周日去医院得到的不良健康结果显著增加。这个有争议的周末效应似乎显示了孕妇去医院的日子和产妇保健的质量和得到的医疗服务呈现负关联。

什么是“周末效应”?

简而言之,“周末效应”就是患者送往医院的日子中,周末比平时面对更多的风险。由于多因素发挥作用,研究这种效应产生出的是混杂的结果。目前已在不同的医疗保健部门进行了调查,但似乎结果越多,问题也越多。

尽管有一系列结果,但一些调查结果却令人担忧,值得进一步调查。例如,在一项老年美国人急性心肌梗死的922074例患者中,发现那些在周末住院1年之内死亡率较高。另一项研究在加拿大安大略省进行。研究人员发现,周末患者腹主动脉瘤破裂,急性会厌炎和肺栓塞死亡率比平日多。

之前“周末效应”已有研究。但目前为止,这些研究已经产生了相互矛盾的结果。

来自帝国理工学院的研究团队,在2010年4至2012年3月之间,研究了英国1332835名送至医院的孕妇以及1349599个婴儿的出生,分析了孕妇送至医院的时间和临床结果的关系,也对医疗服务质量和安全性提出分析和思考。结果中着重研究了住院期间胎儿死亡率(在出生后7天内死亡的胎儿),紧急再入院,感染和会阴撕裂。研究结果小心的排除了各种影响因素,如母亲的年龄,种族,社会经济因素,cesarians,糖尿病,高血压,先兆子痫,子痫等等。总的来看,周四的出生人数最多,而周日最少。

在周末去妇产科更危险?

研究团队发现他们调查出生指标中的四项在周末较平时要差,包括围产儿死亡率,产妇感染,出生是意外损伤和出生3天内婴儿急诊入院。其中,围产儿死亡率尤其突出。

在工作日期间,围产儿死亡率为每1000例中有6.5例末,而在周末时,这增加到每1000例中有7.1例。周末也存在更多的感染风险。工作日中每1000个新生儿感染8.2例,而周末为每1000例中有8.7例。这些数字等同于每年有770例额外的围产儿死亡(正常为4500例)以及470例额外的产妇感染。另外,因急诊入院的人数在周末也会增加。周六和周日中每1000孕妇中有12.3例,而工作日中只有11.8例。

团队的高级学术顾问,伦敦帝国大学公共卫生学院的Paul Aylin教授说:“在我们的文章中,我们试图解释在不同的日子不同的并发症发生率可能是概率原因,或是婴儿在某些特定的日子里出生在某种程度上更复杂。然而,即使排除了影响因素,我们仍然发现并发症的发生率在不同的日子也是不同的。”

是医护人员的责任吗?

该研究小组发现,医院工作人员和胎儿死亡或受伤并没有相关性。

作者也强调,他们的数据来源于2012年,所以最近几年的任何变化都未被考虑在内。他们也明确表示,这项研究是观察性的,不能用于解释这些因果关系。

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    Recent research published in The BMJ and elsewhere brings renewed attention to the “weekend effect,” suggesting higher rates of adverse outcomes associated with hospital admissions and procedures performed at weekends than on weekdays.1 2 3 Findings are not uniform among studies and fields of medicine, and persistent questions remain about whether significant findings reflect differences in case mix severity during the weekend or staffing and volume factors that are likely to influence outcomes among the patients at highest risk. The weekend effect is particularly under-studied in obstetrics, with decidedly mixed results from the small number of studies.4 5 6 7 A study by Palmer and colleagues (doi:10.1136/bmj.h5774) helps to fill this evidence gap, presenting a thoughtful analysis of adverse birth outcomes in a retrospective cohort from the United Kingdom.8

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  • Do Hospitals Provide Lower Quality Care on Weekends?

    Objective To examine the effect of a weekend hospitalization on the timing and incidence of intensive cardiac procedures, and on subsequent expenditures, mortality and readmission rates for Medicare patients hospitalized with acute myocardial infarction (AMI). Data Sources The primary data are longitudinal, administrative claims for 922,074 elderly, nonrural, fee-for-service Medicare beneficiaries hospitalized with AMI from 1989 to 1998. Annual patient-level cohorts provide information on ex ante health status, procedure use, expenditures, and health outcomes. Study Design The patient is the primary unit of analysis. I use ordinary least squares regression to estimate the effect of weekend hospitalization on rates of cardiac catheterization, angioplasty, and bypass surgery (in various time periods subsequent to the initial hospitalization), 1-year expenditures and rates of adverse health outcomes in various periods following the AMI admission. Principal Findings Weekend AMI patients are significantly less likely to receive immediate intensive cardiac procedures, and experience significantly higher rates of adverse health outcomes. Weekend admission leads to a 3.47 percentage point reduction in catheterization at 1 day, a 1.52 point reduction in angioplasty, and a 0.35 point reduction in by-pass surgery (p < 0.001 in all cases). The primary effect is delayed treatment, as weekend–weekday procedure differentials narrow over time from the initial hospitalization. Weekend patients experience a 0.38 percentage point (p < 0.001) increase in 1-year mortality and a 0.20 point (p < 0.001) increase in 1-year readmission with congestive heart failure. Conclusions Weekend hospitalization leads to delayed provision of intensive procedures and elevated 1-year mortality for elderly AMI patients. The existence of measurable differences in treatments raises questions regarding the efficacy of a single input regulation (e.g., mandated nurse staffing ratios) in enhancing the quality of weekend care. My results suggest that targeted financial incentives might be a more cost-effective policy response than broad regulation aimed at improving quality.

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