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University hospital-based prenatal care decreases the rate of preterm delivery and costs, when compared to managed care |
Bienstock J L, Ural S H, Blakemore K, Pressman E K |
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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 The health interventions examined in the study were inner city hospital house staff (HC) and inner city managed care organisation (MCO) used for the management of women of low socio-economic status at risk for preterm pregnancy.
Economic study type Cost-effectiveness analysis.
Study population The study population comprised women with low socio-economic status who had previously had a preterm pregnancy (less than 37 weeks). Women with a history of spontaneous preterm birth and those with a history of induced preterm deliveries were included. Only women with singleton pregnancies in the current and prior pregnancies were considered eligible. Patients cared for by a private attending physician group and women who did not receive any prenatal care were excluded.
Setting The setting was a major inner-city university hospital. The economic study was conducted at the Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Dates to which data relate Data on effectiveness and resource use were gathered from January 1994 to December 1996. No price year was reported.
Source of effectiveness data A single study was used as the source of the effectiveness evidence.
Link between effectiveness and cost data The costing was conducted retrospectively on the same patient sample as that used in the effectiveness analysis.
Study sample Power calculations were not performed in the effectiveness study. All eligible patients who were delivered at The Johns Hopkins Hospital during the study period were enrolled in the study and were grouped according to whether they had their prenatal care for current pregnancy at the university obstetrics HS or the hospital's Medicaid-accepting MCO. An overall sample of 260 women was included in the study: 96 patients (mean maternal age: 26.6+/-6 years; proportion of non-white patients: 90%) were selected for the HS group and 164 patients (mean maternal age: 26.0+/-5.7 years; proportion of non-white patients: 96%) were selected for the MCO group.
Study design This was a retrospective case-control study, carried out in a single centre. The method of allocation to study groups was not reported. Patients were not followed after discharge. Data on effectiveness were derived from chart abstraction, examination of computerised discharge summaries, and computerised scheduling information. Patient management was similar, as women who delivered prematurely were cared for by the house staff once hospitalised, regardless of the source of prenatal care.
Analysis of effectiveness All patients included in the study were accounted for in the analysis of effectiveness. The primary health outcome used in the analysis was the rate of recurrent preterm delivery (less than 37 weeks). Secondary health outcomes were gestational age for preterm deliveries, number of prenatal visits, number of antepartum admissions, cervical dilatation on presentation to labour and delivery ward, total Caesarean section rate, and several neonatal outcome variables, such as neonatal intensive care unit (NICU) admissions, NICU length of stay, and perinatal mortality rate. Study groups were shown to be comparable at baseline in terms of maternal age, proportion of non-white patients, and parity characteristics.
Effectiveness results The effectiveness results were as follows:
The rate of recurrent preterm delivery was 24% in the HS group and 26% in the MCO group, (p=0.04);
the gestational age for preterm deliveries was 32.6+/-3.8 years in the HS group and 32.1+/-4.2 years in the MCO group, (not significant);
the median number of prenatal visits was 7 (range: 1 - 27) in the HS group and 8 (range: 1 - 21) in the MCO group, (not significant);
the percentage of antepartum admissions was 30% in the HS group and 15% in the MCO group, (p=0.002);
cervical dilatation on presentation to labour and delivery ward was 1.2+/-1.03 cm in the HS group and 2.6+/-2.7 cm in the MCO group, (p=0.005);
total Caesarean section rate was 25% in the HS group and 18% in the MCO group, (p=0.16);
NICU admissions were 11% in the HS group and 36% in the MCO group, (p=0.01);
NICU length of stay was 3.1+/-11.5 days in the HS group and 7.6+/-20 days in the MCO group, (p=0.02); and
perinatal mortality rate was 2.0% in the HS group and 3.7% in the MCO group, (p=0.48).
Clinical conclusions The effectiveness analysis showed that the rate of recurrent preterm delivery was significantly lower in the HS group. Several secondary outcomes (both neonatal and antepartum/peripartum variables) proved to be better in the HS group.
Measure of benefits used in the economic analysis Health outcomes were left disaggregated and no summary benefit measure was used, thus a cost-consequences analysis was conducted.
Direct costs No discounting was performed as costs were incurred over a period of time shorter than one year. Unit costs were not reported separately from quantities of resources. The health services included in the analysis were mother and infant costs of care, such as antepartum admissions, labour and delivery postpartum, and neonatal hospital care. A breakdown of costs was not reported. The cost/resource boundary adopted in the study was that of the hospital. Charges rather than costs were used in the economic evaluation. The estimation of quantities of resources and costs was based on hospital charges and professional fees, derived from the medical centre's financial office. Resource use was estimated over the period 1994-1996. No price year was reported.
Statistical analysis of costs Standard statistical analyses were conducted to test for statistically significant differences between the study groups. Preliminary power calculations showed that 100 patients in each group were required to detect a 20% reduction in costs of delivery of care with an alpha error of 0.05 and a beta error of 0.20. However, interim statistical analysis indicated that the sample size used in the effectiveness analysis was powered to detect statistically significant differences in costs.
Indirect Costs Indirect costs were not included.
Sensitivity analysis No sensitivity analyses were conducted.
Estimated benefits used in the economic analysis Please refer to the effectiveness analysis.
Cost results The cost results were as follows:
Mother costs were $6,480 in the HS group and $5,721 in the MCO group, (p=0.08).
Infant costs were $2,614 in the HS group and $7,843 in the MCO group, (p=0.005).
Overall costs were $9,082 in the HS group and $13,565 in the MCO group, (p=0.02).
Synthesis of costs and benefits Combination of costs and benefits was not relevant as no summary benefit measure was used in the analysis. Although the authors did not express the intention to combine costs and benefits in a cost-effectiveness ratio, a combination of costs and benefits would have shown that the HS intervention dominated MCO as it led to lower costs and higher effectiveness (as estimated using the primary outcome measure).
Authors' conclusions The authors concluded that an MCO approach led to greater total expenditures and less effective clinical outcomes in the population of indigent women with a history of preterm delivery. The authors commented that such results were likely to have been affected by shorter prenatal office visits resulting in decreased ascertainment of conditions and symptoms associated with recurrent preterm delivery and decreased amount of time available for patient education. The authors also stated that MCO usually does not have focused obstetric high-risk clinics.
CRD COMMENTARY - Selection of comparators The rationale for the choice of the comparators was clear. The two approaches to patient management represent possible alternatives for pregnant women in the USA. You, as a user of this database, should decide whether they are widely used approaches in your own setting.
Validity of estimate of measure of effectiveness The analysis of effectiveness was based on a case-control study, which was appropriate for the study question. However, the retrospective nature of the study design and the lack of randomisation in the allocation of patients to study groups may have limited the internal validity of the analysis. Study groups were shown to be comparable at baseline, but power calculations were not conducted in the effectiveness study and no evidence was provided that the initial study sample was appropriate for the study question.
Validity of estimate of measure of benefit No summary benefit measure was used in the economic analysis. The analysis was therefore categorised as a cost-consequences study (see validity of effectiveness comments above).
Validity of estimate of costs The analysis of costs was conducted from the perspective of the hospital. However, a breakdown of costs included in the economic evaluation was not given and unit costs were not reported separately from quantities of resources. No price year was given, thus making reflation exercises in other settings difficult. The source of data on costs and resource use was reported. Although charges were used to approximate true costs of the services, relative differences between the study groups were likely to be valid as hospital bills were used for both patient groups. Standard statistical analyses of costs were conducted and power calculations were also performed.
Other issues The authors did not compare their findings with those from other studies and did not address the issue of the generalisability of the study results to other settings, thus the external validity of the analysis was quite low. The study included patients at risk of preterm pregnancy and this was reflected in the conclusions of the analysis. The authors commented on the possible limitation of using charges rather than true costs in the economic analysis.
Implications of the study The main implication of the study is that managed care organisations might not provide the appropriate care for pregnant women at risk for preterm pregnancy. Future studies should aim to identify the factors which contribute to, and increase the costs, of preterm delivery.
Bibliographic details Bienstock J L, Ural S H, Blakemore K, Pressman E K. University hospital-based prenatal care decreases the rate of preterm delivery and costs, when compared to managed care. Journal of Maternal-Fetal Medicine 2001; 10(2): 127-130 Indexing Status Subject indexing assigned by NLM MeSH Adult; Baltimore /epidemiology; Cohort Studies; Fee-for-Service Plans /economics; Female; Health Care Costs /statistics & Hospitals, University /economics; Hospitals, Urban /economics; Humans; Infant, Newborn; Intensive Care Units, Neonatal /economics; Length of Stay /economics; Managed Care Programs /economics; Obstetric Labor, Premature /economics /epidemiology; Outpatient Clinics, Hospital /economics; Patient Admission /economics; Pregnancy; Pregnancy Outcome; Prenatal Care /economics /organization & Retrospective Studies; administration; numerical data AccessionNumber 22001006755 Date bibliographic record published 30/06/2003 Date abstract record published 30/06/2003 |
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