台灣嚴重孕產婦疾病的照護結果及影響因子分析

Abstract

背景: 孕產婦的健康一直是全球各國所重視的重要議題，針對嚴重孕產婦疾病做監測與分析，除可檢視孕產期照護品質外，亦可適時進行介入措施加以改善，著實有助於提升孕產婦的安全及促進新生兒的健康。 目的: 本研究主要以孕產婦為研究對象，首先是要了解台灣嚴重孕產婦疾病的發生率、趨勢及常見的疾病種類，進一步探討其生產住院相關醫療資源耗用與照護結果並分析可能的影響因子。接著，分析不同嚴重程度共病症的孕產婦對生產住院之醫療耗用需求差異。最後，了解不同層級別醫療院所對於嚴重孕產婦疾病案例的照護能力與結果，並探討影響照護結果的相關因子。 方法: 本研究使用衛生福利部衛生福利資料科學中心之台灣全民健康保險資料庫申報檔，進行次級資料回溯性分析比較研究。選取2011年至2021年間生產住院案例，針對嚴重孕產婦疾病的發生率、趨勢及醫療費用做測量，並以3日內非預期門急診利用及42日內再住院，做為照護結果之指標進行研究，進一步使用廣義線性迴歸模型與羅吉斯迴歸模型進行分析。 結果: 研究期間共納入2,054,010個生產案例，其中有6,961個為不含輸血之嚴重孕產婦疾病案例，估算台灣嚴重孕產婦疾病的發生率平均為3.4‰，若含輸血指標則平均達26.7‰ (53,481個案例)，且有逐年顯著上升的趨勢。高齡生產、剖腹生產及具有產科共病症等，為重要之個人風險因子。嚴重孕產婦疾病案例之生產住院醫療費用顯著較一般案例為多，且3日內非預期門急診利用與42日內再住院的風險均明顯增高。生產住院之醫療費用隨產科共病症指數上升而增加。地區醫院與基層診所對於嚴重孕產婦疾病案例的照護結果較差。提早出院雖不會導致嚴重孕產婦疾病案例之3日內非預期門急診利用上升，但卻會明顯增加再住院風險。 結論:在台灣嚴重孕產婦疾病發生率逐年上升的趨勢下，減少高齡生產及避免非醫療必要之剖腹生產將有助於降低產科相關併發症。不同層級別醫療院所對於嚴重孕產婦疾病案例的照護結果確實存在差異，至合宜之院所進行相關醫療照護，可減低到達適切醫療照護機構延遲的情形，有利於產科急重症案例照護品質的提升。再者，避免嚴重孕產婦疾病相關案例提早出院，亦有助於減少產後再住院機率。持續對嚴重孕產婦疾病進行監測與分析，將有助於降低孕產婦併發症，增進母嬰之安全與健康，為台灣日後之重要課題。

Background: Maternal health is still a major health concern worldwide nowadays. Surveillance of severe maternal morbidity(SMM) can not only investigate the quality of obstetric care but also improve maternal and neonatal safety by adequate medical intervention. Objective: The purpose of the study aimed to investigate the prevalence, trend and most common diseases among patients with severe maternal morbidity in Taiwan. The second purpose was to evaluate the medical expense, outcome of care and associated factors of SMM. Thirdly, we also analyzed the medical expense of delivery hospitalizations in women with different obstetric comorbidity index (OCI). Finally, the outcomes of obstetric care among different levels of institutions were compared as well. Methods: A population-based secondary analysis using administrative datasets released by Ministry of Health and Welfare of Taiwan from 2011 to 2021 was carried out. Women who had childbirths and delivery hospitalizations were enrolled in the study. The prevalence and trend of severe maternal morbidity were investigated. The medical expense during delivery hospitalizations was measured. The outcomes of obstetric care such as outpatient or emergency department visit within 3 days, and readmission within 42 days after discharge were also evaluated. The analysis models used in the study included generalize estimating equation model and logistic regression model. Results: A total of 2,054,010 delivery hospitalization records were identified during the study period. 6,961 subjects met the SMM indicators excluding blood transfusion, yielding an average SMM rate of 3.4 per thousand deliveries. The overall SMM rate including transfusion reached 26.7 per thousand deliveries. The trend of SMM including and excluding transfusion demonstrated significantly increasing during the study period. Advanced maternal age, cesarean delivery and obstetric comorbidity were main factors associated with SMM. The medical expense of delivery hospitalization in women with SMM was higher than non-SMM ones. The likelihood of outpatient and emergency department visit within 3 days and readmission within 42 days after discharge also increased in those with SMM. The medical expense of delivery hospitalization was positively related with the maternal OCI. The outcome of SMM care was poorer in district hospitals and maternity clinics. Finally, early discharge of SMM cases increased the risk of readmission. Conclusion: Our findings demonstrated the steadily increasing trend of SMM in the past decade from nationwide records in Taiwan. Health policies should focus on encouraging early childbearing and avoidance of unnecessary cesarean delivery to reduce maternal complications. Delivery hospitalization in adequate level of maternal institutions may reduce the delay of adequate obstetric care which may improve medical care outcomes. Avoidance of early discharge in cases with SMM also reduces the risk of readmission. Continuous surveillance of SMM is an imperative task in Taiwan in the future.