|
Cost-effectiveness of a delayed pushing policy for patients with epidural anesthesia |
Petrou S, Coyle D, Fraser W D |
|
|
Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology A delayed pushing policy for patients with epidural anesthesia.
Economic study type Cost-effectiveness analysis.
Study population Nulliparous women with full dilatation and under epidural anesthesia.
Setting Hospital. The study was carried out in Canada.
Dates to which data relate Effectiveness and resource use data were collected from a randomised controlled trial published in 2000. Cost data were collected from 1998 sources. The price year was 1997.
Source of effectiveness data Effectiveness data were derived from a single study.
Link between effectiveness and cost data The costing was undertaken on the same patient sample as that used in the effectiveness study and was carried out prospectively alongside the effectiveness study.
Study sample 1,862 women were randomly allocated to the delayed pushing group (n=936) or the early pushing group (n=926). The sample size was determined by a clinically important difference in the number of difficult deliveries at conventional levels of statistical significance.
Study design This was a multi-centre randomised controlled trial. Patients were followed up from random assignment to discharge from the hospital. There was no loss to follow-up.
Analysis of effectiveness The analysis of the clinical study was based on intention to treat. The primary health outcomes studied included duration between random assignment and start of pushing, duration between random assignment and delivery, number of difficult deliveries, number of spontaneous vaginal deliveries, maternal and neonatal morbidity. There were no significant differences between the groups with respect to gestational age, maternal age, weight, height, or level of education at time of random assignment.
Effectiveness results The duration between random assignment and start of pushing was 9.5 minutes in the early pushing group and 105 in the delayed pushing group. The duration between random assignment and delivery was 134 minutes in the early pushing group and 188 in the delayed pushing group. The policy of delayed pushing was effective in reducing difficult deliveries (RR=0.79; 95% CI: 0.66 - 0.95) and at increasing the number of spontaneous vaginal deliveries (RR=1.09; 95% CI: 1 - 1.18). Maternal and neonatal morbidity were similar in the two groups.
Clinical conclusions The policy of delayed pushing was more clinically effective.
Measure of benefits used in the economic analysis Two measures of benefits were used: the number of difficult deliveries and the number of spontaneous vaginal deliveries.
Direct costs Costs were not discounted given the short time frame of the study (less than 1 year). Quantities were reported separately. Item costs were not reported. Direct costs included all costs related to intrapartum and postnatal care provided to the mother and infant. The quantity/cost boundary adopted was that of the health service. The estimation of quantities and costs was based on actual data. Fetal heart rate monitor costs were obtained from the Ottawa General Hospital. Physician and anaesthetist fees were obtained from the Ontario Health Insurance Plan. Nursing costs were obtained from the Ontario Nursing Association. The costs of medications are those paid by the Public Insurance Scheme. All other costs were obtained from cost models derived for the Ottawa Civic Hospital and the Children's Hospital for Eastern Ontario by the Clinical Epidemiology Unit of the University of Ottawa. The price year was 1997.
Statistical analysis of costs Student's t test was used to analyse costs. Fieller's theorem was used to calculate 95% confidence intervals for incremental cost-effectiveness ratios.
Sensitivity analysis A sensitivity analysis was conducted on nursing support during the second stage of labour, staff costs, and delivery suite overheads.
Estimated benefits used in the economic analysis The policy of delayed pushing was effective in reducing difficult deliveries (RR=0.79; 95% CI: 0.66 - 0.95) and at increasing the number of spontaneous vaginal deliveries (RR=1.09; 95% CI: 1 - 1.18).
Cost results Significant differences were found in terms of fetal heart monitor, epidural analgesia, vaginal examination, complication, staff and overhead costs. The costs per patient amounted to Can$2,772.53 (+/- 1,818.40) in the delayed pushing group and to Can$2,691.18 (+/- 1,739.33) in the early pushing group, (p=0.324).
Synthesis of costs and benefits The incremental cost per difficult delivery prevented was Can$1,743.06 (95% CI: -Can$5,565.71 - Can$17,067.70). The incremental cost per spontaneous delivery was Can$1,702.29 (95% CI: -Can$6,076.38 - Can$53,800.46). These ratios fell when assumptions about nursing support, staff costs, and delivery suite overheads were relaxed.
Authors' conclusions A policy of delayed pushing increases the cost of care during the second stage of labour and intrapartum care costs, but is more clinically effective.
CRD COMMENTARY - Selection of comparators A justification was given for the comparator used. You, as a user of the database, should decide if these health technologies are relevant to your setting.
Validity of estimate of measure of benefit The analysis was based on a randomised controlled trial, which was appropriate for the study question. The study sample was representative of the study population. Patient groups were shown to be comparable at analysis. Appropriate analyses of the effectiveness data were undertaken. The estimation of benefits was obtained directly from the effectiveness analysis.
Validity of estimate of costs All categories of costs relevant to the perspective adopted were included in the analysis. Item costs were not reported separately. A sensitivity analysis of resources and prices was conducted. Charges were used in some cases to proxy prices. The price year was reported.
Other issues The authors did not make appropriate comparisons of their findings with those from other studies. However, the issue of generalisability to other settings was addressed. The authors did not present their results selectively. The study examined nulliparous women with epidural anesthesia and this was reflected in the authors' conclusions. The authors did not measure non-medical costs, indirect or intangible costs. Another limitation of the study is the limited time frame of the clinical trial.
Implications of the study Before accepting a policy of delayed pushing, decision makers should consider the implications that a shift in practice would have in terms of increased staff and material requirements and increased pressure placed on obstetric facilities.
Bibliographic details Petrou S, Coyle D, Fraser W D. Cost-effectiveness of a delayed pushing policy for patients with epidural anesthesia. American Journal of Obstetrics and Gynecology 2000; 182(5): 1158-1164 Indexing Status Subject indexing assigned by NLM MeSH Anesthesia, Epidural; Cost-Benefit Analysis; Delivery, Obstetric /economics /methods; Female; Health Care Costs; Humans; Labor Stage, Second; Obstetric Labor Complications /prevention & Pregnancy; Time Factors; control AccessionNumber 22000000984 Date bibliographic record published 31/12/2000 Date abstract record published 31/12/2000 |
|
|
|