Tuesday, January 31, 2012

Improving the Efficiency of Surgical Birth: Would it Make it Cost Competitive with Vaginal Birth?

One of the arguments against surgical birth - and specifically maternal request caesareans, particularly in health systems that are publicly funded - is that it imposes an unneccessary strain on the health care system. Being an economist (and more specifically one that practices in the field of health), I am quite intrigued by this argument and unable to take it at face value. The cost differences cited are frequently based on inappropriate assumptions, frequently the cost of all cesareans are lumped in together (both emergent and elective) and the cost of vaginal birth tends to exclude the cost of births that were planned vaginal but ultimately resulted in an emergent cesarean. There are many circumstances where the cost of the least expensive cesarean is far exceeded by the cost of the most expensive vaginal birth.

In a previous blog post I did a very back-of-the envelope calculation on the cost difference between planned vaginal delivery and planned caesarean delivery (I had to make some broad assumptions) - and estimated the difference to be less than $500. It is quite possible that the difference is even less than that.

This difference is not substantial. It actually is low enough that by improving the efficiency of surgical birth - that a planned cesarean might even be cost-neutral in comparison to a planned vaginal birth.

A couple of years ago, the province did a pilot project to reduce the backlog of patients waiting for hip and knee operations. It funded the "Centre for Surgical Innovation". The centre had 2 ORs and 38 inpatient beds. The ORs were specifically set up for hip and knee operations only - and completes 1600 of them a year. As a result of the surgical specialization of the facility, the centre was able to improve the OR time by 16 percent, and the length of stay per patient dropped 14 percent from 3.5 days to 3 days, and the cost per surgical case dropped 9.7 percent.

It is not hard to conceive that a similar approach applied to elective cesarean deliveries could yield vast improvements in the cost-efficiency of surgical delivery. If the cost of planned cesarean dropped by 10 percent - using the cost of a repeat c-section at $3410 as a proxy, $341 of the $471.55 difference in cost would be eliminated, leaving a cost difference of just $131.55.

Using data from C-section on request at 39 weeks: Impact on Shoulder Dystocia, Fetal Trauma, Neonatal Encephalopathy, and Intrauterine Fetal Demise. A Centre for Surgical Birth that did 2500 cesareans at 39 weeks per year would (compared to planned vaginal births) prevent approximately:

Between 1 and 12 brachial plexus injuries
8 cases of neonatal encephalopathy
5 Fetal still births

At an additional cost of $328,875 annualy over planned vaginal birth for these 2500 deliveries it would cost less than $65,775 to prevent 1 fetal still birth, less than $41,109 to prevent 1 case of neonatal encephalopathy, $54,812 to prevent on average 1 brachial plexus injury. As a composite (6 brachial plexus injuries, 8 neonatal encephalopathies, and 5 fetal still births) it would cost less than $17,310 to prevent one of these three events.

To put these numbers in perspective, it has been estimated that the cost of breast cancer screening is $13,200 and $28,000 per year of life saved. Assuming a baby who avoids a fetal still birth lives to be 75 years old, the cost per year of life saved of elective cesarean at 39 weeks is $877 per year of life saved. Even with the far more generour estimate of $500 difference between expected cost of planned cesarean and expected cost of planned vaginal birth, the cost per year of life saved would be $3,333.33.

I'm starting to think that elective cesarean at term might be a bargain in comparison to the costs of planned vaginal birth...

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