896: Quality improvement projects to reduce decision to incision time: A cost-effective approach to improve neonatal outcomes

Abstract

Obstetric emergencies such as fetal bradycardia, uterine rupture, abruption, and cord prolapse require prompt recognition and expeditious delivery to avoid fetal hypoxia, acidemia, and the related short and long-term sequelae. Several studies have shown quality improvement projects to be successful in decreasing decision to incision intervals with a recent study demonstrating subsequent improvement in neonatal outcomes. We aimed to determine if a quality improvement project was a cost effective approach for improving neonatal outcomes in labor and delivery units of varying sizes. A decision-analytic model was built using TreeAge software and inputs derived from the literature. The model compared the outcomes with or without an educational program to reduce the decision-to-incision time at small, medium, and large volume institutions. Long-term outcomes included stillbirth, neonatal death, and cerebral palsy. The cost-effectiveness threshold was set to $100,000 per quality adjusted life year (QALY). Univariate sensitivity analyses were used to vary model inputs to investigate the robustness of the model results. In our model, an educational quality improvement project was the dominant strategy (greater effectiveness, lower costs) when compared to the current state. Program implementation and improved decision to incision intervals resulted in a reduction of stillbirths, neonatal deaths, and cases of cerebral palsy regardless of institutional volume. Furthermore it would save $65,516 and result in 2.87 additional QALYs per emergent cesarean delivery. In a medium volume hospital, performing approximately 50 emergent deliveries/year, this equates to a savings of $6.8 million dollars and more than two surviving neonates annually. Sensitivity analyses demonstrated that the model was robust even with variation in program cost and probability of adverse neonatal outcomes in the post-education group. Multidisciplinary quality improvement programs to improve decision to incision intervals are both effective and cost saving in improving neonatal outcomes regardless of obstetric volume. Translation of such programs broadly into obstetric units requires further implementation and research.