A cluster-randomized trial to reduce caesarean delivery rates in Quebec: cost-effectiveness analysis

BMC Medicine

Research Article

Mira Johri¹  Thierry Ducruet²  Clara Bermudez-Tamayo³  Edmond S. W. Ng⁴  Nils Chaillet⁵  Jeffrey S. Hoch⁶ 

[1] Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Tour Saint-Antoine, Porte S03-910, 850, rue St-Denis, H2X 0A9, Montréal, Québec, Canada;Department of Health Management, Evaluation and Policy, School of Public Health, University of Montreal, Montréal, Québec, Canada;Department of Maternal, Neonatal, Child and Adolescent Health, World Health Organization, Geneva, Switzerland;Department of Biostatistics, Centre hospitalier universitaire (CHU) Sainte-Justine, Université de Montréal, Montréal, Québec, Canada;Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire (CHU) de Sherbrooke, Sherbrooke, Québec, Canada;Andalusian School of Public Health, Granada, Spain;CIBER Epidemiologia y Salud Publica (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain;Director’s Office, London School of Hygiene and Tropical Medicine (LSHTM), London, UK;Département Obstétrique et Gynécologie, Centre Hospitalier de l’Université Laval (CHUL), Québec, Québec, Canada;Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada;Centre for Excellence in Economic Analysis and Research (CLEAR), Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada;Department of Public Health Sciences, University of California, Davis, California, USA;

关键词: Randomized controlled trial;    Cost-benefit analysis;    Caesarean section/utilization;    Pregnancy outcomes;    Medical audit;    Guideline adherence;    Multilevel analysis;    Female;    Adult;    Adolescent;    Infant;    Newborn;   

DOI  :  10.1186/s12916-017-0859-8

 received in 2016-12-11, accepted in 2017-04-20,  发布年份 2017

来源: Springer

【 摘 要 】

BackgroundWidespread increases in caesarean section (CS) rates have sparked concerns about risks to mothers and infants and rising healthcare costs. A multicentre, two-arm, cluster-randomized trial in Quebec, Canada assessed whether an audit and feedback intervention targeting health professionals would reduce CS rates for pregnant women compared to usual care, and concluded that it reduced CS rates without adverse effects on maternal or neonatal health. The effect was statistically significant but clinically small. We assessed cost-effectiveness to inform scale-up decisions.MethodsA prospective economic evaluation was undertaken using individual patient data from the Quality of Care, Obstetrics Risk Management, and Mode of Delivery (QUARISMA) trial (April 2008 to October 2011). Analyses took a healthcare payer perspective. The time horizon captured hospital-based costs and clinical events for mothers and neonates from labour onset to 3 months postpartum. Resource use was identified and measured from patient charts and valued using standardized government sources. We estimated the changes in CS rates and costs for the intervention group (versus controls) between the baseline and post-intervention periods. We examined heterogeneity between clinical subgroups of high-risk versus low-risk pregnancies and estimated the joint uncertainty in cost-effectiveness over 20,000 trial simulations. We decomposed costs to identify drivers of change.ResultsThe intervention group experienced per-patient reductions of 0.005 CS (95% confidence interval (CI): −0.015 to 0.004, P = 0.09) and $180 (95% CI: −$277 to − $83, P < 0.001). Women with low-risk pregnancies experienced statistically significant reductions in CS rates and costs; changes for the high-risk subgroup were not significant. The intervention was “dominant” (effective in reducing CS and less costly than usual care) in 86.08% of simulations. It reduced costs in 99.99% of simulations. Cost reductions were driven by lower rates of neonatal complications in the intervention group (−$190, 95% CI: −$255 to − $125, P < 0.001). Given 88,000 annual provincial births, a similar intervention could save $15.8 million (range: $7.3 to $24.4 million) in Quebec annually.ConclusionsFrom a healthcare payer perspective, a multifaceted intervention involving audits and feedback resulted in a small reduction in caesarean deliveries and important cost savings. Cost reductions are consistent with improved quality of care in intervention group hospitals.Trial registrationInternational Clinical Trials Registry Platform, 10.1186/ISRCTN95086407. Registered on 23 October 2007

【 授权许可】

CC BY   
© The Author(s). 2017