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Title: A cluster-randomized trial to reduce caesarean delivery rates in Quebec: cost-effectiveness analysis
Authors: Johri, Mira
Ng, Edmond S W
Bermudez-Tamayo, Clara
Hoch, Jeffrey S
Ducruet, Thierry
Chaillet, Nils
metadata.dc.contributor.authoraffiliation: [Johri,M] Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Québec, Canada. [Johri,M] Department of Health Management, Evaluation and Policy, School of Public Health, University of Montréal, Montréal, Québec, Canada. [Johri,M] Department of Maternal, Neonatal, Child and Adolescent Health, World Health Organization, Geneva, Switzerland. [Ng,ESW] Director's Office, London School of Hygiene and Tropical Medicine (LSHTM), London, UK. [Bermudez-Tamayo,C] Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire (CHU) de Sherbrooke, Québec, Canada. [Bermudez-Tamayo,C] Andalusian School of Public Health, Granada, Spain. [Bermudez-Tamayo,C] CIBER Epidemiologia y Salud Publica (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain. [Hoch,JS] Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. [Hoch,JS] Centre for Excellence in Economic Analysis and Research (CLEAR), Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada. [Hoch,JS] Department of Public Health Sciences, University of California, Davis, California, USA. [Ducruet,T] Department of Biostatistics, Centre hospitalier universitaire (CHU) Sainte-Justine, Université de Montréal, Montréal, Québec, Canada. [Chaillet,N] Département Obstétrique et Gynécologie, Centre Hospitalier de l’Université Laval (CHUL), Québec, Québec, Canada
Keywords: Randomized controlled trial;Cost-benefit analysis;Caesarean section/utilization;Pregnancy outcomes;Medical audit;Guideline adherence;Multilevel analysis;Female;Adult;Adolescent;Infant;Newborn;Ensayo clínico controlado aleatorio;Análisis costo-beneficio;Cesárea;Resultado del embarazo;Auditoría médica;Adhesión a directriz;Análisis multinivel;Femenino;Adulto;Adolescente;Lactante;Recién nacido
metadata.dc.subject.mesh: Medical Subject Headings::Health Care::Environment and Public Health::Public Health::Epidemiologic Methods::Epidemiologic Study Characteristics as Topic::Clinical Trials as Topic::Controlled Clinical Trials as Topic::Randomized Controlled Trials as Topic
Medical Subject Headings::Health Care::Health Care Economics and Organizations::Economics::Costs and Cost Analysis::Cost-Benefit Analysis
Medical Subject Headings::Analytical, Diagnostic and Therapeutic Techniques and Equipment::Surgical Procedures, Operative::Obstetric Surgical Procedures::Delivery, Obstetric::Cesarean Section
Medical Subject Headings::Phenomena and Processes::Reproductive and Urinary Physiological Phenomena::Reproductive Physiological Phenomena::Reproductive Physiological Processes::Reproduction::Pregnancy::Pregnancy Outcome
Medical Subject Headings::Health Care::Health Care Quality, Access, and Evaluation::Quality Assurance, Health Care::Clinical Audit::Medical Audit
Medical Subject Headings::Health Care::Health Care Quality, Access, and Evaluation::Quality of Health Care::Health Care Evaluation Mechanisms::Guideline Adherence
Medical Subject Headings::Health Care::Environment and Public Health::Public Health::Epidemiologic Methods::Statistics as Topic::Multilevel Analysis
Medical Subject Headings::Check Tags::Female
Medical Subject Headings::Persons::Persons::Age Groups::Adult
Medical Subject Headings::Persons::Persons::Age Groups::Adolescent
Medical Subject Headings::Persons::Persons::Age Groups::Infant
Medical Subject Headings::Persons::Persons::Age Groups::Infant::Infant, Newborn
Issue Date: 22-May-2017
Publisher: BioMed Central
Citation: Johri M, Ng ESW, Bermúdez-Tamayo C, Hoch JS, Ducruet T, Chaillet N. A cluster-randomized trial to reduce caesarean delivery rates in Quebec: cost-effectiveness analysis. BMC Med. 2017 May;15:96
Abstract: Background Widespread 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. Methods A 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. Results The 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. Conclusions From 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.
metadata.dc.identifier.doi: 10.1186/s12916-017-0859-8
ISSN: 1741-7015
Appears in Collections:01- Artículos - EASP. Escuela Andaluza de Salud Pública

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