The future of obstetrics/gynecology in 2020: a clearer vision: finding true north and the forces of change

Protocol for cost-effectiveness analysis of a randomised trial of mHealth coaching (Bump2Baby and Me) compared with usual care for healthy gestational weight gain and postnatal outcomes in at-risk women and their offspring in the UK, Australia, Ireland and Spain

INTRODUCTION

Gestational diabetes mellitus and overweight are associated with an increased likelihood of complications during birth and for the newborn baby. These complications lead to increased immediate and long-term healthcare costs as well as reduced health and well-being in women and infants. This protocol presents the health economic evaluation to investigate the cost-effectiveness of Bump2Baby and Me (B2B&Me), which is a health coaching intervention delivered via smartphone to women at risk of gestational diabetes.

METHODS AND ANALYSIS

Using data from the B2B&Me randomised controlled trial, this economic evaluation compares costs and health effects between the intervention and control group as an incremental cost-effectiveness ratio. Direct healthcare costs, costs of pharmaceuticals and intervention costs will be included in the analysis, body weight and quality-adjusted life-years for the mother will serve as the effect outcomes. To investigate the long-term cost-effectiveness of the trial, a Markov model will be employed. Deterministic and probabilistic sensitivity analysis will be employed.

ETHICS AND DISSEMINATION

The National Maternity Hospital Human Research and Ethics Committee was the primary approval site (EC18.2020) with approvals from University College Dublin HREC-Sciences (LS-E-20-150-OReilly), Junta de Andalucia CEIM/CEI Provincial de Granada (2087-M1-22), Monash Health HREC (RES-20-0000-892A) and National Health Service Health Research Authority and Health and Care Research Wales (HCRW) (21/WA/0022). The results from the analysis will be disseminated in scientific papers, through conference presentations and through different channels for communication within the project.

TRIAL REGISTRATION NUMBER

ACTRN12620001240932.

The value of maternity care in Queensland, 2012-18, based on an analysis of administrative data: a retrospective observational study

OBJECTIVE

To quantify the value of maternity health care - the relationship of outcomes to costs - in Queensland during 2012-18.

STUDY DESIGN

Retrospective observational study; analysis of Queensland Perinatal Data Collection data linked with the Queensland Health Admitted Patient, Non-Admitted Patient, and Emergency Data Collections, and with the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) databases.

SETTING, PARTICIPANTS

All births in Queensland during 1 July 2012 - 30 June 2018.

MAIN OUTCOME MEASURES

Maternity care costs per birth (reported in 2021-22 Australian dollars), both overall and by funder type (public hospital funders, MBS, PBS, private health insurers, out-of-pocket costs); value of care, defined as total cost per positive birth outcome (composite measure).

RESULTS

The mean cost per birth (all funders) increased from $20 471 (standard deviation [SD], $17 513) during the second half of 2012 to $30 000 (SD, $22 323) during the first half of 2018; the annual total costs for all births increased from $1.31 billion to $1.84 billion, despite a slight decline in the total number of births. In a mixed effects linear analysis adjusted for demographic, clinical, and birth characteristics, the mean total cost per birth in the second half of 2018 was $9493 higher (99.9% confidence interval, $8930-10 056) than during the first half of 2012. The proportion of births that did not satisfy our criteria for a positive birth outcome increased from 27.1% (8404 births) during the second half of 2012 to 30.5% (9041 births) during the first half of 2018.

CONCLUSION

The costs of maternity care have increased in Queensland, and many adverse birth outcomes have become more frequent. Broad clinical collaboration, effective prevention and treatment strategies, as well as maternal health services focused on all dimensions of value, are needed to ensure the quality and viability of maternity care in Australia.

Value in maternal care: Using the Learning Health System to facilitate action

There is an increasing need to deliver high-value health care. Here, we discuss how value should be measured and implemented in maternity care through a Learning Health System. High-value maternity care will produce the highest level of benefit for women at a given cost. As pregnancy is not an illness state, and there is no cure or remission to be achieved, we believe that patient-reported outcomes should be an integral component of benefit quantification when measuring value. Furthermore, as care impacts more than just health outcomes-particularly in maternity care-there is also a need to consider patient-reported experiences as a part of defining the level of benefit. However, to move beyond traditional narrow and passive measurement of value, we need to partner with stakeholders to identify priorities for change, identify evidence for how to achieve this change, integrate measurement activities, and promote effective implementation, in a continuous, learning cycle-a Learning Health System. A robust Framework for implementing a Learning Health System has been developed, which could be applied in maternity care.

Development and Implementation of an Obstetric Milestone Pathway

To improve key discharge metrics and achieve more consistency in clinical care, a team at our large health care system developed and implemented the use of an obstetric milestone pathway (OMP). The OMP was integrated into daily multidisciplinary discharge rounds, during which nurses discussed the plan of care and progress toward discharge for each woman and her newborn. The OMP provided nursing staff with a tool for implementing a plan of care and for preparing a woman and her newborn for discharge. Use of the OMP was associated with a decrease in clinical errors, improved patient satisfaction scores, and decreased costs related to length of stay. By using Six Sigma techniques and gaining participation of front-line staff, our team developed a clinical pathway intended to improve the quality, safety, and efficiency of maternal/newborn care.

Guild interests: an insidious threat to professionalism in obstetrics and gynecology

Powerful incentives now exist that could subordinate professionalism to guild self-interest. How obstetrician-gynecologists respond to these insidious incentives will determine whether guild self-interests will define our specialty. We provide ethically justified, practical guidance to obstetrician-gynecologists to prevent this ethically unacceptable outcome. We describe and illustrate 2 major incentives to subordinating professionalism to guild self-interest: demands for productivity; and compliance and regulatory pressures. We then set out the professional responsibility model of ethics in obstetrics and gynecology to guide obstetrician-gynecologists in responding to these incentives so that they preserve professionalism. Obstetrician-gynecologists should identify guild interests affecting their group practices, set ethically justified limits on self-sacrifice, and prevent incremental drift toward dominance of guild self-interests over professionalism. Guild self-interests could succeed in undermining professionalism, but only if obstetrician-gynecologists allow this to happen. When guild self-interest becomes the deciding factor in patient care, professionalism withers and insidious incentives flourish.

Reduction of Peripartum Racial and Ethnic Disparities: A Conceptual Framework and Maternal Safety Consensus Bundle

Racial and ethnic disparities exist in both perinatal outcomes and health care quality. For example, black women are 3 to 4 times more likely to die from pregnancy-related causes and have more than a 2-fold greater risk of severe maternal morbidity than white women. In an effort to achieve health equity in maternal morbidity and mortality, a multidisciplinary workgroup of the National Partnership for Maternal Safety, within the Council on Patient Safety in Women's Health Care, developed a concept article for the bundle on reduction of peripartum disparities. We aimed to provide health care providers and health systems with insight into racial and ethnic disparities in maternal outcomes, the etiologies that are modifiable within a health care system, and resources that can be used to address these etiologies and achieve the desired end of safe and equitable health care for all childbearing women.

Achieving higher-value obstetrical care

Obstetrical care in the United States is unnecessarily costly. Birth is 1 of the most common reasons for healthcare use in the United States and 1 of the top expenditures for payers every year. However, compared with other Organization for Economic Cooperation and Development countries, the United States spends substantially more money per birth without better outcomes. Our team at the Clinical Excellence Research Center, a center that is focused on improving value in healthcare, spent a year studying ways in which obstetrical care in the United States can deliver better outcomes at a lower cost. After a thoughtful discovery process, we identified ways that obstetrical care could be delivered with higher value. In this article, we recommend 3 redesign steps that foster the delivery of higher-value maternity care: (1) to provide long-acting reversible contraception immediately after birth, (2) to tailor prenatal care according to women's unique medical and psychosocial needs by offering more efficient models such as fewer in-person visits or group care, and (3) to create hospital-affiliated integrated outpatient birth centers as the planned place of birth for low-risk women. For each step, we discuss the redesign concept, current barriers and implementation solutions, and our estimation of potential cost-savings to the United States at scale. We estimate that, if this model were adopted nationally, annual US healthcare spending on obstetrical care would decline by as much as 28%.

Roles of Obstetrician-Gynecologist Hospitalists with Changes in the Obstetrician-Gynecologist Workforce and Practice

Obstetrician-gynecologists (OB-GYNs) are the fourth largest group of physicians and the only specialty dedicated solely to women's health care. The specialty is unique in providing 24-hour inpatient coverage, surgical care and ambulatory preventive health care. This article identifies and reviews changes in the OB-GYN workforce, including more female OB-GYNs, an increasing emphasis on work-life balance, more sub-specialization, larger group practices with more employed physicians and, finally, an emphasis on quality and performance improvement. It then describes the evolution of the OB-GYN hospitalist movement to date and the role of OB-GYN hospitalists in the future with regard to these workforce changes.

The future of obstetrics/gynecology in 2020: a clearer vision. Transformational forces and thriving in the new system

Revamping the delivery of women's health care to meet future demands will require a number of changes. In the first 2 articles of this series, we introduced the reasons for change, suggested the use of the 'Triple Aim' concept to (1) improve the health of a population, (2) enhance the patient experience, and (3) control costs as a guide post for changes, and reviewed the transformational forces of payment and care system reform. In the final article, we discuss the valuable use of information technology and disruptive clinical technologies. The new health care system will require a digital transformation so that there can be increased communication, availability of information, and ongoing assessment of clinical care. This will allow for more cost-effective and individualized treatments as data are securely shared between patients and providers. Scientific advances that radically change clinical practice are coming at an accelerated pace as the underlying technologies of genetics, robotics, artificial intelligence, and molecular biology are translated into tools for diagnosis and treatment. Thriving in the new system not only will require time-honored traits such as leadership and compassion but also will require the obstetrician/gynecologist to become comfortable with technology, care redesign, and quality improvement.