DNP Assignment 835 Value based Healthcare Delivery
DNP Assignment 835 Value based Healthcare Delivery
Value-based Healthcare Delivery – Develop a 15 slide
PowerPoint presentation. Be thorough and include rational and references for
Imagine you have been asked to present your recommendation
on implementing value-based healthcare delivery with a focus on the role of
nursing in the development of the delivery model. You will develop the project as if to present
the PowerPoint to the healthcare systems board of directors. Be sure to include
specific roles and how the changes will improve healthcare delivery and
Healthcare costs have substantially increased in recent years, threatening the population health. Obstetric care is a significant contributor to this scenario since it represents 20% of healthcare. The rate of cesarean sections (C-sections) has escalated worldwide. Evidence shows that cesarean delivery is not only more expensive, but it is also linked to poorer maternal and neonatal outcomes. This study assesses which type of delivery is associated with a higher healthcare value in low-risk pregnancies.
A total of 9345 deliveries were analyzed. The C-section group had significantly worse rates of breastfeeding in the first hour after delivery (92.57% vs 88.43%, p < 0.001), a higher rate of intensive unit care (ICU) admission both for the mother and the newborn (0.8% vs 0.3%, p = 0.001; 6.7% vs 4.5%, p = 0.0078 respectively), and a higher average cost of hospitalization (BRL14,342.04 vs BRL12,230.03 considering mothers and babies).
Cesarean deliveries in low-risk pregnancies were associated with a lower value delivery because in addition to being more expensive, they had worse perinatal outcomes.
Healthcare costs are a growing concern. They have rapidly risen and constitute a threatening to health access throughout the world. To discuss how to solve this problem is essential by also reviewing the financing model of the various fields of healthcare.
According to a report by the World Health Organization (WHO), health expenditure is growing more rapidly than the global economy and represents 10% of the global Gross Domestic Product (GDP) .
In Brazil, there is a private and a public healthcare system, the latter is called the Unified Health System (SUS). Between 2010 and 2017 the ratio of health spending to GDP has grew from 8% to 9,2% . The majority of this value is paid by households in the private sector. While government expenditure decreased from 5,3% of the GDP in 2010 to 3,9% in 2017, household disbursement increased from 4,3% to 5,3% for the same period . This context generated a transition of more than 3 million users of the supplementary health system to the SUS between 2015 and 2017, according to data from the National Association of Private Hospitals (ANHAP) .
The rise in health costs affects all spheres of care; however, the maternal-perinatal represent a large share of these expenditures. In Brazil, maternal and neonatal hospitalizations represented almost 12% of all hospital admissions in 2020, whereas in 2019 they accounted for 9,4% . In the United States, according to the Agency for Healthcare Research and Quality, maternal and neonatal hospitalizations represent more than 20% of all hospital admissions. They also represent the largest isolated category of hospital expenses, reaching more than a quarter of the amount transferred from health insurance companies [6, 7]. Besides that, the costs related to maternal and neonatal care grew about 90% between 2003 and 2013, they reached more than 127 billion dollars annually in that country [8, 9].
Cesarean deliveries are associated with a higher rate of newborn admissions to neonatal intensive care units (NICU), longer hospital stay, and greater use of human resources for assistance . Also, unnecessary C-sections seem to increase the risk of parturient as their inadvertent practice may increase in 3.7 times the chances of maternal death, and approximately 5 times of those of amniotic embolism, along with being related to a higher future incidence of abnormal placental insertion .
For Medicaid, the average costs involved in cesarean delivery including prenatal care, childbirth, and postnatal care are US$13,590.00 per event. On the other hand, for vaginal deliveries this cost is about 30% lower, i.e., US$9,131.00 .
Despite all these issues mentioned, C-section rates have risen in some countries. Although the ideal and safe rate for cesareans should be around 15–18%, there was an increase from just over 20% in 1996 to almost 33% in 2011 in the United States [7, 15]. In Brazil, the situation is even more critical. Considering both the public and private systems, there was an increase from 40% to nearly 55% in the same period, with the private system accounting for values exceeding 80% .
This means that less value has been delivered since poorer outcomes are associated with a higher cost.
To establish what led to the current scenario of indiscriminate use of C-sections is complex, especially in Brazil, but some factors have been listed, such as: judicialization of health (not only due to the demand for access to new technologies, but also due to questioning of unexpected outcomes such as childbirth anoxia), patient’s pain-related fear, lack of training for health professionals in vaginal delivery.
Another contributor to the increase of C-section is the physician-centered care models, which is common in Brazil, mainly in the private sector. These models are associated with a remuneration system that pays equally for vaginal and cesarean deliveries and inadequately privilege dedication to the hours of labor, regardless of the associated complications. Thereby, the prolonged assistance needed in vaginal deliveries ends up making the intervention a convenience one in order to end the birth process without financial losses .
These factors explain the lower cesarean rates in the public system, where medical and nursing pay is per shift, compared to the private system, whose medical payment usually occurs per event. Nevertheless, cesarean rates in the public sector are also high due to the other factors mentioned: judicialization of health, patient’s pain-related fear and lack of training for health professionals in vaginal delivery.
In this context, the adoption of a value-based remuneration model is advocated as one of the alternatives to shift this scenario. The Brown’s team defined Value-Based Medicine (VBM) as “the practice of medicine incorporating the highest level of evidence-based data with the patient-perceived value conferred by healthcare interventions for the resources expended” . Consequently, it encompasses three main components: evidence-based decision, patient value-based data and cost-effectiveness in selecting an intervention .
Therefore, value may be defined by the quality of the care provided divided by its cost, that is, the clinical result achieved by the amount spent . Clinical result is understood not as the quantity of services to which the patient is submitted, but as the quality of these services in terms of safety and efficiency [21, 22]. This quality needs to be measured objectively, considering processes, which must be based on scientific evidence, or clinical outcomes . This measurement allows a better comparison of the assistance provided by services and professionals.
In summary, VBM is considered to be the search for health deliveries, or interventions, based on scientific and economically sustainable evidence, in which patients perceive benefit, either by greater satisfaction or by reducing complications. This reduction is intrinsically related to satisfaction .
Based on the above, the value in health would be greater the better the results measured and the lower the costs.
As value-based medicine clearly involves an economic aspect, it is crucial to establish the ideal remuneration model. To adopt one paying strategy that can encourage the best practices while avoiding waste is advised, as well as considering better outcomes and technically adequate practice [23, 24].
A new question is raised at this point: what exactly better results mean? Since they are related to the values perceived by the patients, which need to be measured, in the same way as costs. Therefore, several measurable factors have been proposed: the percentage of C-section rate; the percentage of births at full-term (over 39 weeks); NICU admission rate; breastfeeding rate; the rate of newborns with an Apgar score less than 7 in the fifth minute of life; maternal readmission rate, among many others [25, 26].
There is still a debate as to whether vaginal deliveries would be associated with higher value delivery in all settings. Consequently, this study proposes to assess which mode of delivery is associated with a greater value delivery in low-risk pregnancies considering clinical results and related costs in a private hospital in Brazil.
Primary outcome: To determine whether C-section or vaginal birth is associated with a greater value delivery in low-risk pregnancies considering clinical results and related costs in a private hospital in Brazil.
Secondary outcome: To compare in both mode of delivery the rate of breastfeeding in the first hour after delivery, the rate of ICU admission both for the mother and the newborn, the average cost of hospitalization, and the hospital readmission up to 30 days after delivery.
This study was approved by the ethical committee and conducted in a private hospital. A hospital database (Excel) was used for the analysis, and the data was extracted from the birth record book and validated with information from the electronic medical record. A filter was applied to select the low-risk pregnancies deliveries from this basis, defined as singleton pregnancies at term with cephalic presentation without previous C-section. A retrospective analysis was made from 2016 to 2019.
The average costs per patient (fixed and variable) involved in the overall hospital care of the maternal-fetal binomial were calculated for vaginal and cesarean deliveries considering the period of hospitalization related to that delivery. Costs were calculated based on direct and indirect expenses, which make up tables with extensive items. Direct costs are given by the average value of all items (drugs and materials) posted to the patients’ hospital bill during the hospitalization period. The average indirect costs, on the other hand, are based on the fraction of use of human resources and the contribution to the depreciation of equipment cared for by assistance, according to the time of use and useful life of the equipment. Besides that, the results related to the value delivery for this binomial were compared using the following indicators:
- Breastfeeding rate in the first hour of life;
- NICU admission rate;
- Maternal ICU admission rate.
- Maternal hospital readmission rate within 30 days from delivery;
- Deliveries at a selected hospital from 2016 to 2019;
- Single pregnancies;
- Term pregnancies;
- Cephalic presentation at the time of delivery;
- Absence of previous C-section.