Elsevier

Midwifery

Volume 60, May 2018, Pages 20-26
Midwifery

Budget impact of a program for safely reducing caesarean sections in Canada

https://doi.org/10.1016/j.midw.2018.01.022Get rights and content

Highlights

  • Audits of indications for CS, feedback, and implementation of best practices, as compared with usual care, resulted in a significant but small reduction in the rate of CS, without adverse effects on maternal or neonatal outcomes.

  • The cost-effectiveness analysis showed that the intervention was ‘dominant’ (effective and less costly), leaving unanswered questions about the budget impact if the intervention is offered at scale.

  • Through a Budget impact analysis, we have estimated that QUARISMA led to savings of $27 million in Quebec over 4 years and extending the program to Canada could lead to savings of $150.5 million

Abstract

Introduction

audits of indications for cesarean section (CS), feedback for health professionals, and implementation of best practices, as compared with usual care (QUARISMA study), resulted in a small reduction in the rate of CS in Quebec and important cost savings from a health care payer perspective. Determining the budget impact would enable estimation of the financial consequences if the program is extended nationwide.

Material and methods

a retrospective pre-post study design was used to estimate cost prior to and after the implementation of QUARISMA in Quebec (105,351 subjects). A prospective analysis was performed to measure the budget impact in Canada’s provinces. The primary analytic perspective was that of the Minister of Health, for a 4-year time horizon. Data were taken from the trial for Quebec and extrapolated to Canada’s provinces. A sensitivity analysis was conducted by varying more than one probability at a time.

Findings

over 4 years, there was a decrease of more than $7.8 million in CS burden in Quebec, $11.9 million in vaginal birth and $9.8 million for neonatal complications. The impact on high-risk women was lower than that on low-risk. In years 1 and 2, the provinces would have to cover the cost of program implementation.

Conclusions

QUARISMA led to savings of $27 million in Quebec over 4 years. In the short to medium term, extending the QUARISMA program nationwide could lead to savings of $150.5 million.

Introduction

Considering the increasing growth in health care costs, and the budgetary constraints in many countries, it seems crucial to analyze technologies or procedures with a probable margin of inefficiency that may have a significant impact on budgets (Kneebone, 2016). Giving birth is the most common reason for hospitalization in developed countries (Torio and Andrews, 2006, Canadian Institute for Health Information, 2017). In Canada, vaginal births and CS accounted for 15% of all inpatient hospitalizations, and represents, in the aggregate, one of the most costly conditions for inpatient hospital care (Canadian Institute for Health Information, 2017). In 2015, more than one in four births in hospital was by CS, an increase of nearly 10% since 1995 (Canadian Institute for Health Information, 2015). The rapid increase in the rate of CS births without evidence of concomitant decreases in maternal or neonatal morbidity raises concerns that CS is overused (Gregory et al., 2012). Because of potential harm to mother and baby associated with medically unnecessary CS (Moore et al., 2014), and given that CS can be up to 45% more expensive than a vaginal birth (Halpern, 2009), improvements could be made to enhance efficiency.

In response to the rise in CS rates across Canada, in 2008 the Society of Obstetricians and Gynaecologists (SOGC) released a joint policy statement aimed at reducing unnecessary CS and promoting normal childbirth whenever possible (OECD, 2014). However, these recommendations have remained quite general and decisions to opt for CS continue to be discretionary and often based on non-medical factors (Chaillet et al., 2015). The QUARISMA project was designed to make progress in this area (Johri et al., 2017). It was a randomised controlled trial to reduce the rate of CS with self-assessment of practice by peers. The project hypothesises that poor adherence to clinical practice guidelines (CPGs) plays a key role in the rising CS rate. The QUARISMA program results suggest that a multifaceted intervention with clinical audit, feedback activities and best practice implementation may contribute to a small to moderate reduction in the overall cesarean delivery rate, with a marked reduction in low-risk women, and an overall improvement in neonatal outcomes (Garattini and van de Vooren, 2011). Furthermore, the cost-effectiveness analysis showed that the intervention resulted in important cost savings from a health care payer perspective (Sullivan et al., 2014).

The potential implementation of such a program by the health care system must be analyzed based on efficiency. Budget impact analysis (BIA) would enable estimation of the financial consequences of extending the program nationwide in Canada in the short to medium term (Sullivan et al., 2014).

Section snippets

Material and methods

A retrospective pre-post study design was used to estimate cost prior to and after the implementation of the QUARISMA trial in Quebec (Canada). We also performed a prospective analysis of the potential economic impact of program implementation in Canada’s other provinces. The methodology is described according to the framework proposed by the BIA good practice guidelines (Canadian Institute for Health Information CIHI, 2015).

Results

The 4-year results from the BIA in Quebec are shown in Table 2. Over 4 years, the savings to the Ministry of Health in Quebec were more than $27 million.

The total cost of deliveries was $1,088.5 million for the intervention group and $1,108.3 million for the control group. This is a reduction of more than $19 million in the deliveries budget, attributable to the QUARISMA program in Quebec.

According to the mode of birth, there was a decrease of more than $7.8 million in cesarean burden ($335.4

Discussion

One of the major debates in public funding of research is its overall return to society (Rosbash, 2011, Department of Reproductive Health and Research, 2015). Studies like this one, that link public-sponsored research to changes in clinical practice patterns, patient outcomes and costs, are uncommon. Our study findings suggest that public research investments can yield clinical and economic value when targeted to address research questions with great clinical relevance and public health impact.

Funding statement

Supported by grants from the Canadian Institutes of Health Research (200702MCT−171307-RFA-CFCF−153236 and MOP 81275), and the Spanish Ministry of Health and Consumer Affairs (FIS Exp. PI13/01340).

Conflicts of interest notification

None declared.

Ethical approval statement

The economic evaluation plan was pre-specified in the trial protocol and updated to reflect recent advances in analytic methods and reporting. On behalf of the 32 participating hospital centres, the following 32 local institutional review boards granted research ethics approval for the QUARISMA trial: (1) Comité d’éthique de la recherche du Centre intégré de santé et de services sociaux du Bas-Saint-Laurent; (2) Comité d’éthique de la recherche du Centre intégré universitaire de santé et de

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