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

Mira Johri, Edmond S.W. Ng, Clara Bermudez-Tamayo, Jeffrey S Hoch, Thierry Ducruet, Nils Chaillet

Research output: Contribution to journalArticle

4 Citations (Scopus)

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. Trial registration: International Clinical Trials Registry Platform, ISRCTN95086407. Registered on 23 October 2007

Original languageEnglish (US)
Article number96
JournalBMC Medicine
Volume15
Issue number1
DOIs
StatePublished - May 22 2017

Fingerprint

Quebec
Cesarean Section
Cost-Benefit Analysis
Costs and Cost Analysis
Quality of Health Care
Confidence Intervals
Mothers
Labor Onset
Delivery of Health Care
Pregnancy
Cost Savings
Hospital Costs
Risk Management
Health Care Costs
Postpartum Period
Obstetrics
Uncertainty
Canada
Registries
Pregnant Women

Keywords

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

ASJC Scopus subject areas

  • Medicine(all)

Cite this

A cluster-randomized trial to reduce caesarean delivery rates in Quebec : Cost-effectiveness analysis. / Johri, Mira; Ng, Edmond S.W.; Bermudez-Tamayo, Clara; Hoch, Jeffrey S; Ducruet, Thierry; Chaillet, Nils.

In: BMC Medicine, Vol. 15, No. 1, 96, 22.05.2017.

Research output: Contribution to journalArticle

Johri, Mira ; Ng, Edmond S.W. ; Bermudez-Tamayo, Clara ; Hoch, Jeffrey S ; Ducruet, Thierry ; Chaillet, Nils. / A cluster-randomized trial to reduce caesarean delivery rates in Quebec : Cost-effectiveness analysis. In: BMC Medicine. 2017 ; Vol. 15, No. 1.
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T2 - Cost-effectiveness analysis

AU - Johri, Mira

AU - Ng, Edmond S.W.

AU - Bermudez-Tamayo, Clara

AU - Hoch, Jeffrey S

AU - Ducruet, Thierry

AU - Chaillet, Nils

PY - 2017/5/22

Y1 - 2017/5/22

N2 - 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. Trial registration: International Clinical Trials Registry Platform, ISRCTN95086407. Registered on 23 October 2007

AB - 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. Trial registration: International Clinical Trials Registry Platform, ISRCTN95086407. Registered on 23 October 2007

KW - Adolescent

KW - Adult

KW - Caesarean section/utilization

KW - Cost-benefit analysis

KW - Female

KW - Guideline adherence

KW - Infant

KW - Medical audit

KW - Multilevel analysis

KW - Newborn

KW - Pregnancy outcomes

KW - Randomized controlled trial

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DO - 10.1186/s12916-017-0859-8

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