Antenatal cardiotocography in primary midwife-led care: a budget impact analysis

Introduction

Value-based healthcare has recently emerged as a prominent movement within healthcare. Value-based healthcare aims to improve patient outcomes by coordinating care around individual patients’ values, needs and preferences while efficiently using healthcare resources and eliminating (often harmful) waste.1 A basic characteristic is that care is given in the setting with the greatest value: low complex care not in expensive settings (hospitals or specific hospital departments) by expensive care providers (medical specialists and specific nurses) but in settings with lower costs outside the hospital.2 In this way, value-based healthcare can be used as a tool to provide the best quality of care for patients and address a number of important challenges for the healthcare sector as well, such as the increased demand for healthcare services and, at the same time, capacity problems in hospitals and rising healthcare costs.1 3 Policy of the Dutch government aims at moving care from in-hospital to out-of-hospital care settings, such as the home situation and primary care.4 5 An example of a value-based healthcare innovation where care is moved from a more specialised setting to a less specialised setting is the performance of an antenatal cardiotocography (aCTG) in primary midwife-led care (MLC) for specific indications.6 Until recently, aCTG was only conducted in obstetrician-led care (OLC) in a hospital setting. Recent technological developments in healthcare facilitated the performance of an aCTG in primary care by a trained midwife using a portable CTG system,7 which can be used at the pregnant woman’s home or in the midwifery practice. This is expected to decrease unnecessary referrals and resource use in women with normal aCTG outcomes because only women with a non-reassuring aCTG, who may be at high risk for adverse neonatal outcomes, will be referred to the hospital. Studies showed that referral from primary to secondary care is associated with lower satisfaction among pregnant women due to the lack of continuity of care.8 9 It is essential to ensure that the quality of care is not negatively affected when reorganising and shifting tasks and responsibilities. An important aspect of quality of care is safety. When implementing aCTG in primary care, safety and, thus, quality of care may be reduced if primary care midwives are less able to accurately classify aCTGs. However, a previous study showed excellent agreement between primary care midwives, hospital-based midwives, residents and obstetricians in the overall classification of aCTGs in healthy women.10 In a prospective study, we evaluated the process maternal and neonatal outcomes of aCTG in MLC (MLC-aCTG). A referral to secondary care was indicated after 13.0% MLC-aCTGs due to non-reassuring aCTGs, ultrasound abnormalities or other reasons, which means that 87% of these women did not need to be referred to the hospital where they normally would have received the aCTG in OLC (OLC-aCTG). The maternal and perinatal outcomes of women who had an MLC-aCTG were in the expected range for a low-risk population in MLC.11 Additionally, women were highly satisfied with the care they received.12 These outcomes together make MLC-aCTG a promising value-based healthcare innovation. Although we expect that out-of-hospital care reduces healthcare costs, evidence specific to the MLC-aCTG is lacking. Therefore, the aim of this study was to evaluate the budget impact of the implementation of MLC-aCTG for healthy pregnant women compared with OLC-aCTG in the Netherlands at a national level.

Methods

This study was conducted and reported according to the Dutch guideline for conducting economic evaluations in healthcare13 14 and the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Principles of Good Practice for Budget Impact Analysis.15

Care pathways

In the Netherlands, healthy pregnant women receive MLC from primary care midwives. In contrast, those with risk factors (eg, hypertension, diabetes) or complications receive OLC in the hospital from obstetricians, obstetric residents and hospital-based midwives.16 These women were outside the scope of this study. Figure 1 shows the process steps of the two care paths compared in this study.

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Figure 1

Process mapping care path MLC-aCTG versus OLC-aCTG. MLC-aCTG: midwife-led care antenatal cardiotocograph. OLC-aCTG: obstetrician-led care aCTG.

Usual care path: OLC-aCTG

In the usual care path, when an aCTG is indicated for a healthy pregnant woman, the primary care midwife refers the woman to OLC for consultation. The woman receives an OLC-aCTG in the hospital. Subsequently, an ultrasound scan is performed to assess fetal growth, amniotic fluid and the presentation of the fetus. Blood pressure is measured as well. When a risk factor or an abnormality arises during these examinations, the care is continued in OLC after transfer of care. If all findings of CTG, ultrasound and blood pressure are normal, the woman is referred back to MLC, where her antenatal care will continue.

Innovative care path: MLC-aCTG

In the innovative care path, when an aCTG is indicated for a healthy pregnant woman, the woman is offered an aCTG that is performed and assessed by a primary care midwife either at home, in the midwifery practice, or at a community healthcare centre nearby, using a portable CTG system. If the MLC-aCTG is classified as non-reassuring or of insufficient quality, the woman is immediately referred to OLC for additional evaluation, including a new aCTG. After a reassuring MLC-aCTG, an ultrasound scan is performed in primary care to assess fetal growth, amniotic fluid and presentation of the fetus. Blood pressure is measured as well. If aCTG, ultrasound and blood pressure findings are normal, antenatal care is continued in MLC.

Results

Base-case analysis

The estimated number of MLC-aCTGs performed in the Netherlands in 2020 was 28 597. Shifting aCTG from secondary OLC to primary MLC would lead to an incremental budget impact in terms of actual costs between €311 763 (95% CI €188 574 to €426 072) to 1 247 052 (95% CI €754 296 to €1 704 290) for implementation rates of 25% and 100%, respectively. Reimbursement would decrease by −€7 538 335 (95% CI −€10 302 306 to −€4 559 661) and −€30 153 342 (95% CI −€41 209 225 to −€18 238 645) for implementation rates of 25% and 100%, respectively (table 3, online supplemental material 1, worksheet ‘base-case analysis’). An overview of the costs for 50% and 75% implementation rates is reported in table 3.

Table 3

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Budget impact results according to different implementation rates of MLC-aCTG

The break-even analysis shows that the actual costs of implementing the MLC-aCTG per year in midwifery practices in the three regional maternity care networks together would be €423 741, and the reimbursement would be €316 400. The break-even point in the three regional maternity care networks together at which actual costs and reimbursement are equal was 1799 CTGs, as shown in figure 2 (online supplemental material 1, worksheet ‘costing tool’).

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Figure 2

Break-even point actual costs versus reimbursement. The orange line represents the actual costs of MLC-aCTG per year, the blue line represents reimbursed costs of MLC-aCTG per year and black lines represent the number of aCTG at which actual and reimbursed costs are equal. MLC-aCTG, midwife-led care antenatal cardiotocograph; OLC-aCTG, obstetrician-led care aCTG.

Discussion

As far as we know, this is the first study in which the budget impact has been assessed of implementing aCTG in primary care. The results of the base-case analysis suggest that, based on the best information available, implementing MLC-aCTG would result in an increase in actual costs of €311 763 and €1 247 052 for implementation rates of 25% and 100%, respectively, and a decrease in reimbursement of almost €7 538 335 and €30 153 342 million per year, for implementation rates of 25% and 100%, respectively. Our study focused on healthy pregnant women with a specific aCTG indication who received the aCTG in primary care as an alternative to temporary hospital admission during which an aCTG is conducted. Several studies of other innovations in maternity care focussing on out-of-hospital care for high-risk pregnancies had evaluated similar interventions. The trial of Bekker et al suggests that home telemonitoring of CTG and blood pressure measurements in pregnancy care is an acceptable alternative to monitoring selected women with complications in hospital, and therefore, has the potential to reduce admissions and costs in obstetric care.4 van den Heuvel et al reported that using a digital platform for blood pressure and symptom monitoring in antenatal care for high-risk women is associated with lower costs than conventional care while observed maternal and neonatal outcomes are similar.5 Our findings showed that the reimbursement of implementing the MLC-aCTG care path might be substantially lower than those of the OLC-aCTG care path and concord with the studies that conclude that out-of-hospital care reduces healthcare costs. However, the cost savings are not reflected in the actual costs incurred by midwifery practices. Compared with obstetrician led, the actual costs of performing an aCTG are higher in MLC. This difference can be explained by the fact that MLC professionals spend more time in attendance during the aCTG, as shown by the time-driven activity-based costing calculation. The break-even analysis shows that income would increase for midwifery practices by performing aCTGs, although at high expenses (eg, in three regional maternity care networks, on average 1799 aCTGs need to be performed together to break even). Hence, midwifery practices must perform sufficient aCTGs to cover costs adequately. The hospital would lose income, but overhead costs like housing costs, personal staff and equipment in obstetrician-led would initially not decrease.28 29 The expectation is that hospitals would use the freed-up capacity to provide more care for pregnant women at increased risk. This will further improve the specialised care for those pregnant women who need it most while providing additional revenue for hospitals given the more specialised procedures needed.28 However, in the short term, task-shifting aCTG from OLC to MLC would result in a financial burden for hospitals. This means the current reimbursement policy does not support the proposed care path change for maternity care networks.29–33 As healthcare costs and hospital capacity problems continue to increase worldwide to unsustainable levels, innovations that reduce costs and increase hospital capacity are urgently needed.3 Besides, in terms of women’s satisfaction levels, performing aCTGs in primary MLC, thereby improving continuity of care, seems to be a valuable change in the organisation of maternity care in the Netherlands.12 However, a fee-for-service payment model is an important barrier to implementing innovations such as MLC-aCTG.29 32 33 Within this traditional payment, all maternity care providers (such as gynaecologists and midwives) are paid separately, which hinders collaboration between disciplines. Moreover, fee-for-service models are known to incentivise healthcare professionals to increase the number of medical diagnostic tests and interventions (as long as the price is above marginal costs) and increase overtreatment and low-value care, which is not contributing to the integration of MLC and OLC.34 35 Stakeholders in Dutch maternity care agree that a different payment model is needed.33 Within the traditional payment model, all maternity care providers (such as obstetricians and midwives) are paid separately, which hinders collaboration between the different disciplines. However, opinions differ about a new payment model’s preferred design and the conditions it should meet.35 In terms of further research, it is important to explore the facilitators and barriers for healthcare professionals in MLC and OLC regarding the implementation of MLC-aCTG and explore the possibilities of improving payment models in integrated maternity care. This study has several strengths. First, we analysed the actual costs and reimbursement both at a national level. Second, for the cost calculation, we used time-driven activity-based costing, which helps care providers understand the major cost drivers and find points of action for lowering costs.3 36 Third, we performed a probabilistic sensitivity analysis to estimate the uncertainty surrounding our budget impact estimates.37 However, some limitations need to be addressed. We used different data sources to estimate the actual costs of MLC-aCTG and OLC-aCTG, including a specifically conducted survey, prospective cohort data and national registry data. Although we tried to be as precise as possible in estimating costs, actual costs in clinical practice may differ from our estimations. Unfortunately, we do not have data for training and CTG equipment costs in OLC, and we assumed in our study equal costs for these components in OLC-aCTG and MLC-aCTG. However, these costs are expected to be lower in OLC, given that the volume of CTGs is higher. This may lead to a lower rate of actual costs of OLC-aCTG. In our analyses, we only focused on the actual costs of performing the aCTG in MLC or OLC without considering a possible impact on the percentage of women that remain in MLC in either of the two care models. Since we expect that more women will stay in MLC when the aCTG is conducted in MLC than in OLC, where the chance of medical interventions is lower,38 we expect total childbirth costs to be lower for MLC-aCTG. Future research should address this, for example, in a large prospective cohort study. We chose to focus on the direct material costs, which comprise the majority of expenses incurred in clinical practice. We did not consider the costs of sterilisation, housekeeping, finance, and information and communication technology. Although this might have impacted the costs, we do not expect this would alter our conclusion as this difference will be minimal compared with the costs we have included.

Finally, in this study, we performed a budget impact analysis considering the financial consequences of implementing MLC-aCTG. It was not possible to perform a cost-effectiveness analysis that included outcomes such as safety and women’s satisfaction with the data we had available. However, we have assessed quality of care and women’s satisfaction in separate publications and have shown that there are no differences in the quality of aCTG assessment between primary care midwives, hospital-based midwives, residents and obstetricians.10 In addition, our previous work has shown reassuring maternal and perinatal outcomes after MLC-aCTG and high levels of women’s satisfaction with this care.11 12 Considering the impact of costs, quality and satisfaction together is crucial when implementing a value-based healthcare innovation such as MLC-aCTG.