A Scoping Review of Alternative Payment Models in Maternity Care: Insights in Key Design Elements and Effects on Health and Spending.

INTRODUCTION: Although effects of alternative payment models on health outcomes and health spending are unclear, they are increasingly implemented in maternity care. We aimed to provide an overview of alternative payment models implemented in maternity care, describing their key design elements among which the type of APM, the care providers that participate in the model, populations and care services that are included and the applied risk mitigation strategies. Next to that, we made an inventory of the empirical evidence on the effects of APMs on maternal and neonatal health outcomes and spending on maternity care. METHODS: We searched PubMed, Embase and Scopus databases for articles published from January 2007 through October 2020. Search key words included 'alternative payment model', 'value based payment model', 'obstetric', 'maternity'. English or Dutch language articles were included if they described or empirically evaluated initiatives implementing alternative payment models in maternity care in high-income countries. Additional relevant documents were identified through reference tracking. We systematically analyzed the initiatives found and examined the evidence regarding health outcomes and health spending. The process was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) to ensure validity and reliability. RESULTS: We identified 17 initiatives that implemented alternative payment models in maternity care. Thirteen in the United States, two in the United Kingdom, one in New Zealand and one in the Netherlands. Within these initiatives three types of alternative payment models were implemented; pay-for-performance (n = 2), shared savings models (n = 7) and bundled payment models (n = 8). Alternative payment models that shifted more financial accountability towards providers seemed to include more strategies that mitigated those risks. Risk mitigation strategies were applied to the included population, included services or at the level of total expenditures. Of these seventeen initiatives, we found four empirical effect studies published in peer-reviewed journals. Three of them were of moderate quality and one weak. Two studies described an association of the alternative payment model with an improvement of specific health outcomes and two studies described a reduction in medical spending. CONCLUSIONS: This study shows that key design elements of alternative payment models including risk mitigation strategies vary highly. Risk mitigation strategies seem to be relevant tools to increase APM uptake and protect providers from (initially) bearing too much (perceived) financial risk. Empirical evidence on the effects of APMs on health outcomes and spending is still limited. A clear definition of key design elements and a further, in-depth, understanding of key design elements and how they operate into different health settings is required to shape payment reform that aligns with its goals.

Effects of hospital delivery during off-hours on perinatal outcome in several subgroups: a retrospective cohort study.

BACKGROUND: Studies have demonstrated a higher risk of adverse outcomes among infants born or admitted during off-hours, as compared to office hours, leading to questions about quality of care provide during off-hours (weekend, evening or night). We aim to determine the relationship between off-hours delivery and adverse perinatal outcomes for subgroups of hospital births. METHODS: This retrospective cohort study was based on data from the Netherlands Perinatal Registry, a countrywide registry that covers 99% of all hospital births in the Netherlands. Data of 449,714 infants, born at 28 completed weeks or later, in the period 2003 through 2007 were used. Infants with a high a priori risk of morbidity or mortality were excluded. Outcome measures were intrapartum and early neonatal mortality, a low Apgar score (5 minute score of 0-6), and a composite adverse perinatal outcome measure (mortality, low Apgar score, severe birth trauma, admission to a neonatal intensive care unit). RESULTS: Evening and night-time deliveries that involved induction or augmentation of labour, or an emergency caesarean section, were associated with an increased risk of an adverse perinatal outcome when compared to similar daytime deliveries. Weekend deliveries were not associated with an increased risk when compared to weekday deliveries. It was estimated that each year, between 126 and 141 cases with an adverse perinatal outcomes could be attributed to this evening and night effect. Of these, 21 (15-16%) are intrapartum or early neonatal death. Among the 3100 infants in the study population who experience an adverse outcome each year, death accounted for only 5% (165) of these outcomes. CONCLUSION: This study shows that for infants whose mothers require obstetric interventions during labour and delivery, birth in the evening or at night, are at an increased risk of an adverse perinatal outcomes.

Finding the right indicators for assessing quality midwifery care.

OBJECTIVE: To identify a set of indicators for monitoring the quality of maternity care for low-risk women provided by primary care midwives and general practitioners (GPs) in the Netherlands. DESIGN: A Project Group (midwives, GPs, policymakers and researchers) defined a long list of potential indicators based on the literature, national guidelines and expert opinion. This list was assessed against the AIRE (Appraisal of Indicators through Research and Evaluation) instrument criteria, resulting in a short list of draft indicators. In a two-round Delphi survey, a multidisciplinary group of stakeholders reviewed the elaborated draft indicators, rating both the relationship between indicator and quality of care and the feasibility. SETTING AND PARTICIPANTS: A multidisciplinary expert panel consisting of 28 midwives, 2 GPs, 3 obstetricians and 3 maternity assistants, randomly selected from different regions in the Netherlands. INTERVENTION: None. MAIN OUTCOME MEASURE: Set of quality indicators for midwifery care. RESULTS: The Project Group generated a list of 115 potential indicators which was reduced to 35 using the AIRE criteria. The 35 draft indicators were discussed by a Delphi panel. In total, 26 indicators were recommended by the participants as relevant indicators of midwifery care, representing several levels of measurement. Eight structure indicators, 12 process indicators and 6 outcome indicators were addressing the various phases of midwifery care. CONCLUSIONS: We identified a set of quality indicators concerning midwifery care provision in a low-risk population. Practicing maternity care providers adopted the large majority (83%) of the draft indicators proposed as a feasible set of indicators, describing the structure, process and outcome. The input from multidisciplinary experts in the process of identifying the right indicators showed to be essential in all phases of development.