Twin Vaginal Deliveries in Labor Rooms: A Cost-Effectiveness Analysis.

OBJECTIVE: Twin vaginal deliveries (VDs) are often performed in the operating room (OR) given the theoretical risk of conversion to cesarean delivery (CD) for the aftercoming twin. We aim to evaluate the cost-effectiveness of performing VDs for twin gestations in the labor and delivery room (LDR) versus OR. STUDY DESIGN: We conducted a cost-effectiveness analysis using a decision-analysis model that compared the costs and effectiveness of two strategies of twin deliveries undergoing a trial of labor: (1) intended delivery in the LDR and 2) delivery in the OR. Sensitivity analyses were performed to assess strength and validity of the model. Primary outcome was incremental cost-effectiveness ratio (ICER) defined as cost needed to gain 1 quality-adjusted life year (QALY). RESULTS: In the base-case scenario, where 7% of deliveries resulted in conversion to CD for twin B, attempting to deliver twins in the LDR was the most cost-effective strategy. For every QALY gained by delivering in the OR, 243,335 USD would need to be spent (ICER). In univariate sensitivity analyses, the most cost-effective strategy shifted to delivering in the OR when the following was true: (1) probability of successful VD was less than 86%, (2) probability of neonatal morbidity after emergent CD exceeded 3.5%, (3) cost of VD in an LDR exceeded 10,500 USD, (4) cost of CD was less than 10,000 USD, or (5) probability of neonatal death from emergent CD exceeded 2.8%. Assuming a willingness to pay of 100,000 USD per neonatal QALY gained, attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis. CONCLUSION: Twin VDs in the LDR are cost effective based on current neonatal outcome data, taking into account gestational age and associated morbidity. Further investigation is needed to elucidate impact of cost and outcomes on optimal utilization of resources. KEY POINTS: · Cost effectiveness of twin VDs in the LDR versus OR was assessed.. · Twin VDs in the LDR are cost effective based on current neonatal outcome data.. · Attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis..

[Extreme prematurity--medical and social problem].

The survival rate for extremely preterm newborns born at the threshold of viability (25 or fewer completed weeks of gestation) improved in the early 1990s, largely as the result of a greater use of assisted ventilation in the delivery room and surfactant therapy. This led WHO in 1993 to define the perinatal period as commencing at 22 completed weeks of gestation. Infants born at 22-28 weeks gestation have been termed as having "threshold viability", though in developed countries this term is more often used in reference to infants of < 26 weeks. However, this improvement in survival has not been associated with an equal improvement in morbidity The increasing potential risk of residual disability or early death associated with decreasing gestational age raises serious medical, social and ethical problems in respect to appropriate management. These include whether elective delivery for fetal indication is appropriate or whether intensive care should be provided following delivery.

Perinatal patient safety from the perspective of nurse executives: a round table discussion.

Six nurse executives across the United States discussed issues related to perinatal patient safety. Gaps in communication were identified as one of the biggest challenges facing nurse executives. Other issues included expectations of regulators and accreditors, the pressure for productivity with limited resources and staffing, and undercapitalized technology versus safety and staff competence. Each nurse executive discussed a perinatal patient safety initiative implemented recently in her organization. If costs were not an issue, construction of facilities, adoption of electronic documentation, and adding positions to help assure patient safety were at the top of their wish lists. Patient safety continues as the number one priority for nurse executives.

A Systematic Review of the State of Economic Evaluation for Health Care in India.

BACKGROUND AND OBJECTIVE: Economic evaluations are one of the important tools in policy making for rational allocation of resources. Given the very low public investment in the health sector in India, it is critical that resources are used wisely on interventions proven to yield best results. Hence, we undertook this study to assess the extent and quality of evidence for economic evaluation of health-care interventions and programmes in India. METHODS: A comprehensive search was conducted to search for published full economic evaluations pertaining to India and addressing a health-related intervention or programme. PubMed, Scopus, Embase, ScienceDirect, and York CRD database and websites of important research agencies were identified to search for economic evaluations published from January 1980 to the middle of November 2014. Two researchers independently assessed the quality of the studies based on Drummond and modelling checklist. RESULTS: Out of a total of 5013 articles enlisted after literature search, a total of 104 met the inclusion criteria for this systematic review. The majority of these papers were cost-effectiveness studies (64%), led by a clinician or public-health professional (77%), using decision analysis-based methods (59%), published in an international journal (80%) and addressing communicable diseases (58%). In addition, 42% were funded by an international funding agency or UN/bilateral aid agency, and 30% focussed on pharmaceuticals. The average quality score of these full economic evaluations was 65.1%. The major limitation was the inability to address uncertainties involved in modelling as only about one-third of the studies assessed modelling structural uncertainties (33%), or ran sub-group analyses to account for heterogeneity (36.5%) or analysed methodological uncertainty (32%). CONCLUSION: The existing literature on economic evaluations in India is inadequate to feed into sound policy making. There is an urgent need to generate awareness within the government of how economic evaluation can inform and benefit policy making, and at the same time build capacity of health-care professionals in understanding the economic principles of health-care delivery system.

Eradicating reliance on free artificial milk.

Hospitals that set forth to obtain Baby-Friendly Hospital designation often face considerable challenges in implementing the purchase of formula and supplies at a fair market rate as outlined in the International Code of Marketing of Breast-milk Substitutes. Some of the challenges include difficulty tracking products in use and volumes used and obtaining pricing information from manufacturers of artificial milk. We report on our experience with assessing these factors, with an example of calculations used to arrive at fair market pricing, which might benefit other institutions seeking Baby-Friendly Hospital designation.

Análisis con GRD: El egreso hospitalario indiferenciado de la maternidad no representa la complejidad de las pacientes con alto riesgo obstétrico / DRG analysis: undifferentiated hospital discharges of maternity does not represent the complexity of patients with high obstetric risk

INTRODUCCIÓN: La gestión actual de camas hospitalarias sigue un modelo de indiferenciación en el que existen camas quirúrgicas, médicas y de pacientes críticos. Las maternidades si bien no siguen este modelo, tienen egresos indiferenciados con pacientes que pueden egresar post parto o aún embarazadas (con patologías perinatales). OBJETIVO: Evaluar diferencias entre egresos con parto normal y aquellos con patologías de alto riesgo obstétrico (ARO) respecto a estancia media (EM) y el consumo de recursos cuantificado con el peso medio de los grupos relacionados con el diagnóstico (PMGRD). MÉTODO: Estudio transversal con egresos maternales periodo 2017-2018. Se usó Categoría Diagnóstica Mayor (CIE - 10) para definir dos grupos de egreso: 1. Con parto normal a término o 2. Con patología ARO. Se compararon 1.658 y 1.669 egresos del grupo 1 y 2 respectivamente. Las variables de resultado son EM y PMGRD. Se compararon variables cuantitativas con t de student y Kruskal Wallis. Se usó Odds Ratio con respectivo intervalo de confianza para evaluar asociación entre variables y regresión logística multivariada para ajustar asociación. RESULTADOS: La edad, proporción de gestantes tardías, EM y PMGRD fue mayor en los egresos ARO (p<0,05). Existe fuerte asociación de EM prolongada (>4 días) y PMGRD elevado (>0.3109) con los egresos ARO (ORa=3.75; IC95%=3.21-4.39 y ORa=1.28; IC95%=1.1-1.49 respectivamente). CONCLUSIONES: Es necesario diferenciar los egresos del servicio de maternidad porque los egresos de ARO muestran mayor complejidad. La evaluación del riesgo usando EM y PMGRD permite analizar con especificidad los egresos maternales para una mejor gestión de camas y del recurso humano.

INTRODUCTION: The current management of hospital beds in Chile follows an undifferentiation model in which there are surgical, medical and critical patient bed. Maternity hospitals although they do not follow this model, have undifferentiated discharges with patients who may leave poatpartum or still pregnant (with perinatal pathologies) OBJECTIVE: To assess differences between discharges with normal delivery and those with high obstetric risk pathologies (HOR) with respect to mean stay (MS) and the resource spending quantified with the average weight of the diagnosis related group (AWDRG). METHOD: Cross-sectional study with maternal discharges between 2017-2018 period. Major Diagnostic Category (ICD - 10) was used to define two discharge groups: 1. With normal term birth or 2. With HOR pathology. 1,658 and 1,669 egress from group 1 and 2 were compared respectively. The outcome variables are EM and AWDRG. Quantitative variables were compared with student t and Kruskal Wallis. Odds Ratio and respective confidence interval were used to evaluate association between variables and multivariate logistic regression to adjust association. RESULTS: Age, proportion of late pregnant women, MS and AWDRG was higher in HOR discharges (p <0.05). There is a strong association of prolonged MS (> 4 days) and elevated AWDRG (> 0.3109) with HOR discharges (ORa = 3.75; 95% CI 3.21-4.39 and ORa = 1.28; 95% CI 1.1-1.49 respectively). CONCLUSIONS: It is necessary to differentiate medical discharge of the maternity service because the HOR egress show greater complexity. The risk assessment using MS and AWDRG allows to analyze with specificity the maternal discharge for a better management of beds and human resources.

Strategies for Providing Low-Cost Water Immersion Therapy With Limited Resources.

At our university-affiliated medical center, a major renovation of the women's health and birthing unit resulted in the temporary loss of the permanent tub used for water immersion therapy during labor. Because 40 percent of the women in the nurse-midwifery practice utilize hydrotherapy, we undertook a rigorous search for an interim solution. We developed a safe and cost-effective strategy that can be easily replicated and utilized by others to provide hydrotherapy for laboring women.

Implementing the Use of Chemical-Free Products in a Perinatal Unit.

OBJECTIVE: To develop a process to identify, adopt, and increase individual awareness of the use of chemical-free products in perinatal hospital units and to develop leadership skills of the fellow/mentor pair through the Sigma Theta Tau International Maternal-Child Health Nurse Leadership Academy (STTI MCHNLA). DESIGN: Pretest/posttest quality improvement project. SETTING: Tertiary care 80-bed perinatal unit. PATIENTS: Mothers and newborns on perinatal unit. INTERVENTIONS/MEASUREMENTS: The chemical hazard ratings of products currently in use and new products were examined and compared. Chemical-free products were selected and introduced to the hospital system, and education programs were provided for staff and patients. We implemented leadership tools taught at the STTI MCHNLA to facilitate project success. Pre- and postproject evaluations were used to determine interest in the use of chemical-free products and satisfaction with use of the new products. Cost savings were measured. RESULTS: Products currently in use contained potentially harmful chemicals. New, chemical-free products were identified and adopted into practice. Participants were interested in using chemical-free products. Once new products were available, 71% of participants were positive about using them. The fellow and mentor experienced valuable leadership growth throughout the project. CONCLUSIONS: The change to chemical-free products has positioned the organization and partner hospitals as community leaders that set a health standard to reduce environmental exposure for patients, families, and staff. The fellow and mentor learned new skills to assist in practice changes in a large organization by using the tools shared in the STTI MCHNLA.

Are cuts to health expenditure in Victoria compromising quality of care?

Separate state-wide surveys of women who had recently given birth in Victoria were conducted in 1989 and 1993. The first survey was conducted in conjunction with the Victorian Ministerial Review of Birthing Services. The second survey occurred three years after the release of the Review's final report and three months after the introduction of casemix funding. It coincided with a period of substantial cutbacks to expenditure on Victorian public hospitals. In both studies, surveys were mailed to women 6 to 9 months after the birth. Response rates were 71.4% (n = 790) in 1989 and 62.5% (n = 1336) in 1993. Between the two surveys, the proportion of women giving critical feedback about caregivers, more than doubled. The survey findings suggest that standards of care are being compromised in the current economic and policy environment.

Strategies for change: nursing implementation of the birthing room.

Nurses were primary participants in introducing the birthing room for maternity care in their respective institutions. Based on tape-recorded interviews, this paper is a report on how the idea of a birthing room was initiated, the resistance it encountered, the eight strategies used to implement the idea, and appropriation of the idea by physicians. Although the examples are specific to the development of a birthing room, the strategies can be used by nurses to initiate other changes in perinatal health care delivery. In addition, increased collaboration between nurses and physicians may make some strategies obsolete.

Equipment costs. The neonatal intensive care unit and the modern obstetric unit.

In summary, the cost of equipment depends on a plethora of factors. In purchasing equipment, while cost is a major consideration, it should not be the sole determinant. Other major concerns include prepurchase evaluation opportunity, repair capabilities, breakdown frequency, capability for emergency repair, self-monitoring systems built into equipment, personnel education on the use of the equipment, other services offered by the company, trade-in capability, reliability of the company, and restrictions established by the Hospital's Standardization committee. The Emergency Care Research Institute is considered to be the "consumer's guide" for sophisticated hospital equipment and issues a publication called Health Devices, which reviews the results of their findings. Also the Medical Device Register is a single source of information on medical equipment and suppliers.

Single room maternity care: perinatal outcomes, economic costs,and physician preferences.

OBJECTIVES: (1) To compare perinatal outcomes and costs of care among women giving birth in a single room maternity care (SRMC) setting versus a traditional delivery suite or postpartum setting; and (2) to report on physicians' responses to the SRMC environment. METHODS: Among women who were determined to be at "low risk" for intrapartum complications through the use of a triage tool, the outcomes of those receiving care in the new SRMC unit were compared to the outcomes of those cared for in the traditional delivery suite and postpartum modules. Total costs of the entire maternity service before and after implementation of SRMC were also compared. Physicians were surveyed about the adequacy of the physical environment. RESULTS: Rates of intrapartum interventions and adverse outcomes were similar in both groups, with the exception of less frequent electronic fetal monitoring in the SRMC setting. Caesarean section rates were lower than expected in both groups. Length of stay was significantly shorter in the SRMC group (55.1 +/- 26.5 days vs. 61.0 +/- 24.3 days; <.001). Staff positions in the hospital were reduced from 206 to 193.7. Direct costs for women of similar acuity (resource intensity weightings) were reduced by 24% (1809 dollars vs. 2377 dollars). The proportion of physicians preferring SRMC to the traditional setting increased from 45.8% at 6 months to 78.7% at 12 months after implementation of the SRMC model (P =.003). CONCLUSION: SRMC is a model of obstetric care for women at low risk for intrapartum complications, offering cost savings without affecting perinatal outcomes, and is well accepted by physicians.

Costs of intrapartum care in a midwife-managed delivery unit and a consultant-led labour ward.

OBJECTIVE: to investigate whether there are differences between the cost of intrapartum care for women at low obstetric risk in a midwife-managed labour and delivery unit and that in a consultant-led labour and delivery ward. DESIGN: cost analysis based on the findings of a randomised controlled trial comparing two alternative types of intrapartum care. SETTING: Aberdeen Maternity Hospital, Grampian. SUBJECTS: the number of women 'booked' for care in the Midwives' Unit in a standard year and a comparable group of women cared for in the consultant-led labour ward. PRIMARY OUTCOME MEASURE: the cost 'outcome' is the extra (or reduced) cost per woman resulting from the introduction of a midwife-managed delivery unit. FINDINGS: the baseline extra cost of the introduction of the Midwives' Unit was found to be 40.71 pounds per woman. Depending on the scenario used, this ranged from a cost saving of 9.74 pounds per woman to an additional cost of 44.23 pounds per woman. CONCLUSIONS: this study has shown that, in terms of costs incurred during the intrapartum period, the marginal cost of caring for women at low obstetric risk alongside women at high obstetric risk in a standard labour ward is small. However, the impact of establishing a separate midwife-managed delivery unit, requiring an increase in midwifery staffing levels, can be significant.

Women's choice? The impact of private health insurance on episiotomy rates in Australian hospitals.

OBJECTIVE: To assess the extent to which variations in episiotomy rates in Australian hospitals are justified by clinical variables and to further explore the relationships between episiotomy, insurance status, perineal trauma and outcomes for babies. DESIGN: A retrospective analysis of anonymous medical record data using logistic regression models, aimed at identifying factors influencing both episiotomy rates and outcomes for babies. SETTING: A large regional public hospital, New South Wales, Australia. PARTICIPANTS: The study sample consisted of 2028 women who delivered vaginally during a 12 month period during 1996-1997. RESULTS: After controlling for clinical and other factors privately insured women were estimated to be up to twice as likely to experience episiotomy as publicly insured women. This difference most plausibly reflects differences in labour management styles between obstetricians and midwives. Other significant contributors to episiotomy were instrumental delivery, indications of possible fetal distress and lower parity. Severe perineal trauma (third degree tear) was found to be positively associated with episiotomy. Furthermore, the incidence of additional tears requiring suture was also substantially higher among privately insured women, the net effect being that these women had a substantially lower chance of achieving an intact perineum. Neither episiotomy nor insurance status had any significant effect on the well-being of babies. IMPLICATIONS FOR PRACTICE: Private health insurance appears to deny many women the opportunity of achieving normal vaginal delivery with intact perineum. Episiotomy rates amongst privately insured women in Australia may be higher than is clinically appropriate, and severe perineal trauma within this study was associated with this practice.

Creating a unit-specific charging system.

A totally nurse-dependent charging system developed specifically for the labor and delivery suite at the University of Maryland Medical System is described in the article. This easy and effective method of charging was incorporated into an already existing patient census and classification system. The number of relative value units has increased by more than 30%, and the amount of revenue billed has increased by more than $800,000 in the first 10 months after implementation.

A comparative analysis of newborn outcome in a hospital-based birthing center.

Medical records of babies born in a hospital-based birthing center were reviewed to determine whether a birthing center alternative to traditional hospital care of the newborn is safe and cost-effective. A cohort of 123 hospital-based birthing center low-risk deliveries was compared to 100 control low-risk deliveries born in the traditional setting at the medical center during the same time period. Morbidity was assessed using the Hollister Classification as reference and was based on treatment need. The analysis of the babies' status at birth, 24 hours, and 72 hours revealed no difference in immediate morbidity. Cost of hospitalization was reduced by $340.00 per cohort baby. These data suggest that this alternative can be safe and cost-effective. This study applies only to hospital-based birthing centers, because the safety of free-standing birthing centers has not been established and because screening for low risk can not eliminate morbidity.

Medicare program; inclusion of labor/delivery room days in the calculation of inpatient days--HCFA. Notice of HCFA ruling.

This notice announces a Ruling concerning the disposition of provider claims pending in court or that could be filed within the jurisdictions of the courts of appeals for the Sixth, Eighth, Ninth, and District of Columbia Circuits with respect to the treatment of labor/delivery room days in the apportionment of general routine services costs. Since all providers ordinarily can obtain judicial review in the DIstrict of Columbia, this ruling has broad application.

Cost-effectiveness analysis: birth center vs. hospital care.

Increasingly nursing will need to prove the cost effectiveness of alternative models of care. A cost-effectiveness analysis, using a decision analysis format, compared a birthing center to a hospital for low-risk deliveries. Results indicate that a birth center is a cost-effective model of nursing care.

Exploring cost and quality: community-based versus traditional hospital delivery systems.

This article presents two approaches for comparison studies of cost and quality outcomes between community-based and traditional hospital systems of care. Two methodologies are used specifically to compare midwifery practice in a free-standing birth center to traditional obstetric practice with hospital deliveries. Findings from both studies reinforce the potential cost savings of community-based care without compromising quality. The methodologies used here can be applied to other settings. These approaches are also relevant for comparison studies of cost and quality outcomes between physicians and other nonphysician providers such as physician assistants and nurse practitioners, who frequently staff emerging models of community-based care. Issues related to obtaining comparable clinical and cost data versus reimbursement for both community-based and hospital care will be highlighted.