On the third Thursday of every month, we speak to a recent graduate about their thesis and their studies. This month’s guest is Dr Christopher Yau who has a PhD from the University of Bristol. If you would like to suggest a candidate for an upcoming Thesis Thursday, get in touch.
Better care costs less: a system-based approach in maternity
Erik Lenguerrand, Timothy Draycott, Elena Pizzo
What are some of the main avoidable costs in obstetrics and maternity care?
The human and financial costs associated with preventable harm. Any error in obstetrics, particularly during childbirth, has the potential to have a lifelong impact on the baby, mother and their family. Maternity litigation can therefore be very costly (sometimes millions of pounds) as settlements are made to help support families over a lifetime. Unfortunately, preventable harm within obstetrics does still occur and maternity litigation costs continue to rise. In England, the NHS spent £3.1 billion on maternity litigation in a decade (2000-2010). More recently, the value of obstetric claims in 2018/19 alone is expected to be worth £2.5 billion. In the context of the NHS, where money for patient care and litigation are sourced from the same funds, such worrying increases in litigation costs could threaten the financial stability of the health system.
What kind of ‘system-based’ approaches are available?
There are several classifications for the different levels of a health system. Ferlie and Shortell identified four levels: the individual, the team, the organisation and the environment. This model was subsequently adapted into a nested model with each level incorporated by the next level and the ‘individual’ was replaced with the ‘patient’. The levels of a health system could also be described using social science terminology such as micro, meso and macro. Regardless of the chosen classification, any system-based approach will engage with each level of a health system. For my thesis, I decided to adopt a ‘bottom-up’ and ‘top-down’ approach to improving maternity care and tackling the rising cost of litigation in obstetrics. For my ‘bottom-up’ approach, I started by assessing the quality of life of individuals and families affected by an important birth injury (obstetric brachial plexus injury) and then investigated the health economics behind training to prevent such injuries. For my ‘top-down’ approach, I explored the role of the medical indemnifier in influencing and improving patient care, and consequently reducing litigation costs. I felt that a bi-directional approach would give me a better understanding of how a health system functions.
Were the necessary data for your analyses easy to come by?
I wanted to conduct a cost-utility analysis of multi-professional training for obstetric emergencies, with a focus on its impact on reducing and preventing obstetric brachial plexus injuries. During my literature searches, it became clear that training interventions in obstetrics (and in general) were very rarely economically evaluated. As a result, there were no comprehensive cost data for any recognised training programmes. Obstetric brachial plexus injuries (permanent injuries to nerves in a baby’s neck) can arise after the mismanagement of a shoulder dystocia (obstetric emergency where the baby’s head is delivered but the shoulder is trapped behind the mother’s pelvic bone). These injuries can have significant implications for the affected individual/family and are important causes of litigation in obstetrics. They are also relatively rare so there were limited quality of life data or utility scores for these cohorts.
The only way I could get the data for the cost-utility analysis was to generate them myself. I therefore investigated the quality of life associated with permanent obstetric brachial plexus injuries and conducted a micro-costing analysis of a training programme for obstetric emergencies.
Can training programmes improve outcomes?
Although there are an increasing number of studies evaluating the clinical effectiveness of multi-professional training for obstetric emergencies, the evidence for improving outcomes and clinical results remains mixed. Some training programmes appeared to offer no benefit whereas some counterintuitively led to worse outcomes. However, there has been some evidence that training in obstetric emergencies does lead to improvements in clinical outcomes. For example, PROMPT (PRactical Obstetric Multi-Professional Training) has been associated with a 49% reduction in the number of babies with low 5-minute Apgar scores (the higher the score the better the condition at birth) and a similar reduction in the number of babies with brain injuries due to oxygen starvation. It has also appeared to avoid permanent obstetric brachial plexus injuries following sustained training.
What would be your key recommendation for reducing litigation costs in this context?
There are many factors that can influence and reduce the cost of maternity litigation. One way is to improve patient safety and reduce preventable harm during childbirth. My thesis adopted a system-level perspective to try and help achieve this. More investment to support maternity units in training their staff is crucial. The studies from my thesis have shown that training is not free but can be cost saving in the long run. However, the key will be to invest in evidence-based training programmes that have demonstrated improvements in clinical outcomes and not to waste resources on training with no or negative effects.
Medical indemnifiers have the financial resources and administrative capacity to support clinical staff in their pursuit for safer care. They can also help to coordinate the health system by using incentives and their system-wide contacts. We stand a better chance of making the widespread improvements in obstetric care that are required to reduce maternity litigation costs when the healthcare objectives are aligned through all levels of the health system.
There are some more general recommendations for reducing preventable harm and litigation costs in our recent BMJ analysis.
As a medical doctor, how did you come to study health economics?
I studied economics at school and considered studying it at university, so my interest has been longstanding. The longer I worked in the NHS, the more I realised that the care that I was providing was shaped and influenced by cost, from the type of surgical equipment that we used or the medication that we prescribed through to the commissioning of services. Almost every aspect of patient care was determined by its value for money. As a frontline clinician, I was aware of this but had limited knowledge of the underlying decision-making processes. I decided to include a health economics component in my thesis as I wanted to learn about economic evaluations in healthcare, utility scores and QALYs. After completing my PhD, I feel that I have a better understanding of health economics and I hope this will enable me to contribute to conversations and decision-making regarding provision of healthcare services in future.