Johri, MiraNg, Edmond S WBermudez-Tamayo, ClaraHoch, Jeffrey SDucruet, ThierryChaillet, Nils2018-06-152018-06-152017-05-22Johri M, Ng ESW, Bermúdez-Tamayo C, Hoch JS, Ducruet T, Chaillet N. A cluster-randomized trial to reduce caesarean delivery rates in Quebec: cost-effectiveness analysis. BMC Med. 2017 May;15:96http://hdl.handle.net/10668/2890Background Widespread increases in caesarean section (CS) rates have sparked concerns about risks to mothers and infants and rising healthcare costs. A multicentre, two-arm, cluster-randomized trial in Quebec, Canada assessed whether an audit and feedback intervention targeting health professionals would reduce CS rates for pregnant women compared to usual care, and concluded that it reduced CS rates without adverse effects on maternal or neonatal health. The effect was statistically significant but clinically small. We assessed cost-effectiveness to inform scale-up decisions. Methods A prospective economic evaluation was undertaken using individual patient data from the Quality of Care, Obstetrics Risk Management, and Mode of Delivery (QUARISMA) trial (April 2008 to October 2011). Analyses took a healthcare payer perspective. The time horizon captured hospital-based costs and clinical events for mothers and neonates from labour onset to 3 months postpartum. Resource use was identified and measured from patient charts and valued using standardized government sources. We estimated the changes in CS rates and costs for the intervention group (versus controls) between the baseline and post-intervention periods. We examined heterogeneity between clinical subgroups of high-risk versus low-risk pregnancies and estimated the joint uncertainty in cost-effectiveness over 20,000 trial simulations. We decomposed costs to identify drivers of change. Results The intervention group experienced per-patient reductions of 0.005 CS (95% confidence interval (CI): −0.015 to 0.004, P = 0.09) and $180 (95% CI: −$277 to − $83, P < 0.001). Women with low-risk pregnancies experienced statistically significant reductions in CS rates and costs; changes for the high-risk subgroup were not significant. The intervention was “dominant” (effective in reducing CS and less costly than usual care) in 86.08% of simulations. It reduced costs in 99.99% of simulations. Cost reductions were driven by lower rates of neonatal complications in the intervention group (−$190, 95% CI: −$255 to − $125, P < 0.001). Given 88,000 annual provincial births, a similar intervention could save $15.8 million (range: $7.3 to $24.4 million) in Quebec annually. Conclusions From a healthcare payer perspective, a multifaceted intervention involving audits and feedback resulted in a small reduction in caesarean deliveries and important cost savings. Cost reductions are consistent with improved quality of care in intervention group hospitals.enRandomized controlled trialCost-benefit analysisCaesarean section/utilizationPregnancy outcomesMedical auditGuideline adherenceMultilevel analysisFemaleAdultAdolescentInfantNewbornEnsayo clínico controlado aleatorioAnálisis costo-beneficioCesáreaResultado del embarazoAuditoría médicaAdhesión a directrizAnálisis multinivelFemeninoAdultoAdolescenteLactanteRecién nacidoMedical Subject Headings::Health Care::Environment and Public Health::Public Health::Epidemiologic Methods::Epidemiologic Study Characteristics as Topic::Clinical Trials as Topic::Controlled Clinical Trials as Topic::Randomized Controlled Trials as TopicMedical Subject Headings::Health Care::Health Care Economics and Organizations::Economics::Costs and Cost Analysis::Cost-Benefit AnalysisMedical Subject Headings::Analytical, Diagnostic and Therapeutic Techniques and Equipment::Surgical Procedures, Operative::Obstetric Surgical Procedures::Delivery, Obstetric::Cesarean SectionMedical Subject Headings::Phenomena and Processes::Reproductive and Urinary Physiological Phenomena::Reproductive Physiological Phenomena::Reproductive Physiological Processes::Reproduction::Pregnancy::Pregnancy OutcomeMedical Subject Headings::Health Care::Health Care Quality, Access, and Evaluation::Quality Assurance, Health Care::Clinical Audit::Medical AuditMedical Subject Headings::Health Care::Health Care Quality, Access, and Evaluation::Quality of Health Care::Health Care Evaluation Mechanisms::Guideline AdherenceMedical Subject Headings::Health Care::Environment and Public Health::Public Health::Epidemiologic Methods::Statistics as Topic::Multilevel AnalysisMedical Subject Headings::Check Tags::FemaleMedical Subject Headings::Persons::Persons::Age Groups::AdultMedical Subject Headings::Persons::Persons::Age Groups::AdolescentMedical Subject Headings::Persons::Persons::Age Groups::InfantMedical Subject Headings::Persons::Persons::Age Groups::Infant::Infant, Newbornresearch article28528578Acceso abierto10.1186/s12916-017-0859-81741-7015