134What are the models for delivering the care?

No 654Study Quality: +The costs to the NHS of maternity care: midwife-managed vs shared
Author:Young D;Lees A;Twaddle S;1997
Relevance:This paper shows that reduced costs can be incurred in postnatal care through a shared care approach as outlined in the clinical narrative. However, it does not address the clinical outcomes of the two groups of mothers.
Intervention:648 women were randomised to midwife-led care (see clinical narrative for details)
Comparison:651 women were randomised to shared care (see clinical narrative for details)
Population:1299 women from the Glasgow Royal Maternity Hospital experiencing normal pregnancy between 11 January 1993 and 25th February 1994
StudyCosting study
Methods:Not applicable
Healthvaluations:NOT APPLICABLE
Costcomponents:Clinic time and resources, tests and investigations, day-care attendances, referrals, procedures, operations, inpatient days, postnatal visits
Discount rate:Not applicable
Results cost/patient:Assuming an annual case load of 29 women per midwife per year, the cost of midwife-managed care postnatally was £470.34. The cost of shared care was £352.03. This cost saving is therefore £118.31 per mother and is statistically significant at the 5% level (p<0.01)
Results effectiveness:Not reported since study was a costing study only
Results incremental:Not applicable
Results Uncertainty:The authors looked at the effect of changing the caseload of midwives. If the midwife can adequately look after 39 mothers, the difference between the postnatal costs of the two groups narrow to £52 (still statistically significant p<0.01)
Source Funding:Public
 The paper actually looks at the costs of shared-care and midwife care antenatally, intrapartrum and postnatally. The difference in costs in the other two periods was not staistically significant (p-values of 0.48 and 0.4) respectively.

 The shared care approach applied throughout antenatal and postnatal care becomes equally costly to midwife care when the caseload of the midwife is increased to 39 per midwife per annum. Thus, below this caseload, the study shows savings in shared care for the total period (antenatal through postnatal). In postnatal care in isolation, the caseload would have to increase still further to remove the cost savings of shared care
No 651Study Quality: +Redesigning postnatal care: a randomised controlled trial of protocol-based midwifery-led care focused on individual women's physical and psychological health needs. [102 refs]
Author:MacArthur C;Winter HR;Bick DE;Lilford RJ;Lancashire RJ;Knowles H;Braunholtz DA;Henderson C;Belfield C;Gee H;2003
Intervention:Protocol-based midwife-led care. GP contact only when deemed necessary. See clinical narrative for further details
Comparison:Standard care. See clinical narrative for further details
Population:There were 1087 women allocated to the intervention group and 977 in the control. All gave birth in the West Midlands Health Region and were expected to remain within practices throughout postnatal care
Healthvaluations:NOT APPLICABLE
Costcomponents:Midwife costs, GP home visits, GP consultations, prescriptions, referrals and investigations withing Primary Care team, inpatient, outpatient and day-care days for surgery, outpatient appointments
Timehorizon:12 months
Discount rate:Not appropriate
Results cost/patient:A statistically insignificant lower cost in the intervention group was reported. The saving was £71. However, this figure is based on a slightly incorrect averaging of figures - the real cost implication of the intervention relative to the control is a cost of £31
Results effectiveness:At 4 and 12 months, the physical health score of the two groups did not differ. The mean values for the Mental Component of the SF-36 questionnaire and Edinburgh Postnatal Depression Scale showed a significantly better result in the intervention group (p<0.0003 for both scales at both 4 and 12 months)
Results incremental:Given there is no statistically significant result for differing cost levels between the intervention and the control, or for physical health parameters, the statistically significant mental health outputs at 4 and 12 months represent some evidence of cost-effectiveness in the intervention relative to the control
Results Uncertainty:A sensitivity analysis was undertaken on the conclusion, attepmting to deal with the under-recording in control group nurses. This suggested the relative difference between the two groups did not reach statistical significance
Source Funding:Public
No 641Study Quality: +A randomized trial of two public health nurse follow-up programs after early obstetrical discharge: an examination of breastfeeding rates, maternal confidence and utilization and costs of health services
Author:Steel O'Connor KO;Mowat DL;Scott HM;Carr PA;Dorland JL;Young Tai KF;2003
Intervention:The telephone screening group received a telephone call from a public health nurse on the first working day post discharge. Further interventions were provided if needs were isentified
Comparison:The home visit model provided two home visitis in the first ten days post-discharge. The first of these was provided as soon as possible post-discharge
Population:733 primiparas discharged within 48 hours postpartum at two centres in Ontario, Canada
Healthvaluations:NOT APPLICABLE
Costcomponents:Routine and unscheduled visits to family physicians and other health professionals, emergency department visits, hospital admissions, laboratory tests, public health nurse contacts, costs to parents and medication
Timehorizon:6 months
Discount rate:Not discounted
Results cost/patient:The mean cost for telephone screened infants was $152.65 compared with $243.38 for the home visit group, the difference being statistically significant at the 5% level.
Results effectiveness:At the 5% level of significancce, there was no difference between the two groups in terms of general health problems (concerns about weight, feeding difficulties, dehydration, jaundice, breathing problems, colds, congenital problems, cord concerns, gastrointestinal/colic issues, infection, injury and rash)
Furthermore, the authors tested for levels of maternal confidence (using the Maternal Confidence Scale of Carty and Bradley) and found it to be unrelated to intervention allocation
Results incremental:Since there was a lower cost in the telephone intervention group, the evidence suggesting comparable clinical outcomes means the telephone group weakly dominates the visitation group in this particular population
Results Uncertainty:Not undertaken
Source Funding:Public
No 717Study Quality: ++The Social Support and Family Health Study: a randomised controlled trial and economic evaluation of two alternative forms of postnatal support for mothers living in disadvantaged inner-city areas
Author:Wiggins M;Oakley A;Roberts I;Turner H;Rajan L;Austerberry H;2004
Relevance:Relevant. In this study, there was little evidence that either support health visitation or community group support played a cost-effective role in helping new mothers and infants.
Intervention:Two intervention groups. Respectively, these were based on support health visitation and community group support. Details of these intevrentions can be found in the clinical extraction
Comparison:Standard care
Population:This study focused on disadvantaged inner-city areas. 731 participants giving birth in 1999 were randomly assigned to one of the interventions or the control
Healthvaluations:NOT APPLICABLE
Costcomponents:Home visits, telephone calls, initial contact and ongoing costs with community groups, GP services, prescriptions, midwifery, hospital services, secondary mental health services, social services, OTC medications, transport
Timehorizon:18 months
Discount rate:Costs were discounted at 6%
Results cost/patient:At 12 months, there were no determinants of cost which were statistically significant at the 5% level. At 18 months, there was a statistically significant higher level of mean total spending per mother in the community group support wing of £26 (p=0.05)
Results effectiveness:There was little evidence to suggest differing effectiveness between the two intervention groups and the control. There were some data suggesting a less anxious experience of motherhood in the SHV intervention.
Results incremental:Since there was little evidence of differing costs or benefits, the incremental cost-effectiveness was not undertaken
Results Uncertainty:The report undertook sensitivity analysis on the costs of the interventions relative to the control. Using the non-parametric botstrapping technique, they found the cost differences between either of the interventions and the control tended to remain statistically insignificant at the 5% level. The only exception to this is that the SHV approach became statistically significantly more expensive when the assumption of constant monthly costs was relaxed
Source Funding:Public
 The cost-effectiveness impact of focusing on disadvantaged inner-city mothers is questionnable. On the one hand, they are likely to have the greater capacity to benefit (meaning the cost-effectiveness for the general population will be lower). On the other hand, they may be less likely to engage fully in the process or may have other constraints limiting the potnetial benefit of the intervention.
 The statistically significant result for cost of the community group support intervention may be the result of the extent of subdivision of costs.
 The use of the societal perspective does not affect these conclusions for the purpose of the group
No 702Study Quality: ++Costs and benefits of community postnatal support workers: a randomised controlled trial
Author:Morrell CJ;Spiby H;Stewart P;Walters S;Morgan A;2000
Relevance:Relevant. This paper shows that a role similar to that of health care assistants is not cost-effective. Indeed, the intervention group had statistically significantly higher levels of costs and poorer outcome measures.
Intervention:Up to 10 home visits in the first post natal month in support of the community midwife
Comparison:No extra visits
Population:311 women received the intervention and 312 received the control. All were recruited in postnatal wards between October 1996 and November 1997. Mothers were excluded if they could not give consent, communicate in English or had a baby in the special care baby unit for more than 48 hours.
Healthvaluations:NOT APPLICABLE
Costcomponents:Community midwifery, health visitation, child health clinics, GP contacts, prescriptions for mothers and babies, hospital contacts, secondary mental health contacts for mothers or babies
Timehorizon:6 months
Discount rate:5%
Results cost/patient:The total mean NHS cost to 6-month follow-up for the interention group was £180 per woman greater in the intervention than in the control (confidence interval £79.60–£272.40)
Results effectiveness:There was some statistically significant evidence that outcomes were better in the control group. At six weeks, this included levels of social functioning (p=0.03), physical functioning (p=0.01) and physical role limitation (p=0.008). However, there was some evidence of a higher level of satisfaction in the intervention group
Results incremental:The lack of evidence on effect, coupled with a statistically significant increase in costs in the intervention group means that the intervention is at least weakly dominated by the control. Therefore, incremental cost-effectiveness analysis was unnecessary
Results Uncertainty:These conclusions were robust. The cost of the intervention relative to the control could be reduced through shorter visits but cost-effectiveness would only occur if this were linked with positive clinical benefits
Source Funding:Public

From: Appendix D, Health Economic Extractions by Question

Cover of Postnatal Care
Postnatal Care: Routine Postnatal Care of Women and Their Babies [Internet].
NICE Clinical Guidelines, No. 37.
National Collaborating Centre for Primary Care (UK).
Copyright © 2006, National Collaborating Centre for Primary Care.

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