婦產科低效益照護指標之建立及影響催生或剖腹產之相關因素

Abstract

研究背景與目的：低效益照護/過度使用漸受關注，如何衡量低效益照護是重要的問題，過去研究發展低效益照護清單多以文獻或臨床醫師凝聚共識，針對台灣婦產科低效益照護清單及影響因素研究闕如，因此，本研究有兩個目的：(一)本研究參考過去研究發展低效益照護清單方法，以德菲法邀請相關專家共同擬定臺灣婦產科低效益照護清單；(二)以衛生福利部資料科學中心之健康保險研究資料庫，探討人口、醫師、院所與醫療區特性對39週前無醫學適應症進行催生或剖腹產使用之影響。 研究方法：針對研究目的一，參考美國、英國、加拿大及澳洲和紐西蘭之明智選擇建議和專家意見，發展婦產科低效益照護問卷。納入醫師為邀請台灣婦產科學會從北中南東醫療院所推薦醫師名單，最終再以德菲法產生婦產科低效益照護代表性清單，同意尺度為1分（非常不同意）至9分（非常同意），專家共識定義為中位數≧7且評≧7之比例至少75%，再依評≧7之比例排序，結果排名前5名為最終推薦低效益照護清單。德菲法專家共識結果，是以IQR進行描述性統計，若IQR≦3，則表示達成專家共識；另以魏克生符號檢定(Wilcoxon Signed Ranks Test)檢定二回合專家共識改變程度。研究目的二，資料取自衛生福利資料科學中心全民健康保險資料檔、政府資料開放平台、醫師聯合會與內政部戶政司人口統計資料等，研究對象為2018年全國健康保險對象，有健保申報紀錄者之懷孕週數為37-39週，且以廣義估計方程式，探討人口、醫師、院所與醫療區特性與39週前無醫學適應症進行催生或剖腹產使用情形之關係。 研究結果：本研究共有12名專家參與，兩回合問卷從38項項目中，最終推薦清單共有6項，因排序同名次，7分以上人數比例為91.7%，包括3項檢查（若無妊娠併發症，不建議將臍動脈都普勒超音波作為評估胎兒生長的常規性檢查、在妊娠全程，不建議以D-Dimer作為排除靜脈血栓栓塞的檢查、妊娠期間，不建議以紅血球沉降率作為發炎反應的檢測方式）、2項處置（妊娠39週前，無醫學適應症的孕婦不建議進行催生或剖腹產、子宮內膜增生症不建議進行子宮切除術治療）及1項藥品（妊娠期間B型鏈球菌感染，在有產兆前不建議使用抗生素治療）。懷孕37-39週婦女無醫學適應症進行催生或剖腹產低效益照護情形者為48.80%。居住在鄉村者，39週前無醫學適應症進行催生或剖腹產情形較高；有工作婦女，39週前無醫學適應症進行催生或剖腹產情形較低；男醫師，婦女39週前無醫學適應症進行催生或剖腹產情形較高；醫師服務量愈高，婦女39週前無醫學適應症進行催生或剖腹產情形較低；地區醫院及診所，婦女39週前無醫學適應症進行催生或剖腹產情形較高。 結論：本研究以德菲法選出6項適合我國國情的婦產科低效益照護清單。居住鄉村、男醫師、地區醫院及診所，39週前無醫學適應症進行催生或剖腹產之產婦，使用情形較高；有工作、醫師服務量愈高，39週前無醫學適應症進行催生或剖腹產產婦，使用情形較低。

Objectives: The problem of low-value care/overuse has become a focal point among the medical community. Determining how to identify and measure low-value care is a central concern. Previous studies have formulated lists of low-value care practices based on earlier literature or the consensus of clinicians, but no study has yet to focus on low-value care and its influencing factors in obstetrics and gynecology in Taiwan. There were two objectives in this study: (1)we used the Delphi method to compile a list of low-value care practices in obstetrics and gynecology in Taiwan; (2) we explored the association of maternal, physician, hospital and regional characteristics with the use of induced labor or cesarean section without medical indication before 39 weeks . Methods: With regard to the first objective, by referring to recommendations from international Choosing Wisely lists and expert opinion, we developed a questionnaire about low-value care practices in obstetrics and gynecology. The Taiwan Association of Obstetrics and Gynecology recommended a list of suitable doctors for inclusion from the medical institutions in the northern, central, southern and eastern regions of Taiwan, and the Delphi method was then used to produce a representative list of low-value care practices. The agreement scale ranged from 1 (strongly disagree) to 9 (strongly agree). Expert consensus was defined as a median ≥ 7 with at least 75% scoring ≥ 7. All recommendations were ranked by percentage of score ≥ 7 to determine a list of the top five low-care practices. The expert consensus results of the Delphi method are descriptive statistics based on interquartile range (IQR). The items with an IQR ≤ 3 on the 9-point scales in the Delphi method were considered as having an acceptable level of consensus. In addition, the Wilcoxon Signed Ranks Test is the degree of change between the second round and the first round of expert consensus. With regard to the second objective, the database derived from Taiwan National Health Insurance Research Database, which was provide by the Health and Welfare Data Science Center in Taiwan, the government Open Data, the data of Taiwan Medical Association and the demographic data of Department of Household Registration.The study population was the national health insurance subjects in 2018. The pregnancy weeks of those with health insurance declaration records were 37-39 weeks’ gestation. Generalized estimation equation(GEE) was used to explore the characteristics of population, physicians, hospital and regional with the use of induced labor or cesarean section without medical indication before 39 weeks . Results: A total of 12 experts completed in two rounds of questionnaires from which six lists of options were selected from a total of 38 recommendations because the rankings were identical. The lists with 91% scoring ≥ 7 included three examinations (Don’t perform umbilical artery Doppler studies as a routine screening test in uncomplicated pregnancies with normal fetal growth, Do not perform a D-Dimer test for the exclusion of venous thromboembolism during any trimester of pregnancy, Do not measure erythrocyte sedimentation rate (ESR) in pregnancy), two procedures (Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks 0 days gestational age, Endometrial hyperplasia can often be managed without surgery), and one drug (Avoid use of antibiotics for group B Streptococcus carriage until labour starts). 48.80% of women in 37-39 weeks’ gestation had no medical indications to induced labor or caesarean section with low-value care. People living in rural areas have a higher incidence of induction or caesarean section without medical indication before 39 weeks. Employment less likely to have induction or caesarean section without medical indication before 39 weeks.Physicians who were male were more likely to induction or caesarean section without medical indications for women before 39 weeks. The physicians with higher volume, women who had no medical indication before 39 weeks had a lower rate of induction or caesarean section. In regional hospitals and clinics, women who had no medical indication before 39 weeks had a higher rate of induction or caesarean section. Conclusion: In this study, the Delphi method yielded six lists suitable for conditions in Taiwan. Women who live in rural areas, male doctors, regional hospitals and clinics, had no medical indication before 39 weeks had a higher rate of induction or caesarean section. Women who have jobs, the higher of physician volume, and the women who have no medical indications before 39 weeks had a lower rate of induction or caesarean section.