The cost-effectiveness of a program to reduce intrapartum and neonatal mortality in a referral hospital in Ghana

Objective To evaluate the cost-effectiveness of a systems strengthening program intended to reduce intrapartum and neonatal mortality in Accra, Ghana
Design Quasi-experimental, time-sequence intervention, retrospective cost-effectiveness analysis
Methods A program integrating leadership development, clinical skills and quality improvement training was piloted at the Greater Accra Regional Hospital from 2013 to 2016. The number of intrapartum and neonatal deaths prevented were estimated using the hospital’s 2012 stillbirth and neonatal mortality rates as a steady-state assumption. The cost-effectiveness of the intervention was calculated as cost per disability-adjusted life year (DALY) averted. In order to test the assumptions included in this analysis, it was subjected to probabilistic and one-way sensitivity analyses.
Main outcome measures Incremental cost-effectiveness ratio (ICER), which measures the cost per disability-adjusted life-year averted by the intervention compared to status quo
Results From 2012 to 2016, there were 45,495 births at the Greater Accra Regional Hospital, of whom 5,734 were admitted to the newborn intensive care unit. The budget for the systems strengthening program was US $1,716,976. Based on program estimates, 307 (±82) neonatal deaths and 84 (±35) stillbirths were prevented, amounting to 12,342 DALYs averted. The systems strengthening intervention was found to be highly cost effective with an ICER of US $139 (±$44), an amount significantly lower than the established threshold of cost-effectiveness of the per capita gross domestic product, which averaged US $1,649 between 2012-2016. The results were found to be sensitive to the following parameters: DALYs averted, number of neonatal deaths, and number of stillbirths.
Conclusion An integrated approach to system strengthening in referral hospitals has the potential to reduce neonatal and intrapartum mortality in low resource settings and is likely to be cost-effective. Sustained change can be achieved by building organizational capacity through leadership and clinical training.

研究目标：评估加纳阿克拉地区一项旨在降低产时及新生儿死亡率的系统强化项目的成本效果。
研究设计：准实验性时间序列干预、回顾性成本效果分析。
方法：2013年至2016年，在大阿克拉区域医院试点了一项融合领导力发展、临床技能与质量改进培训的项目。以该医院2012年的死胎率与新生儿死亡率作为稳态假设，估算了本次干预避免的产时及新生儿死亡例数。本研究以每避免1个伤残调整寿命年（disability-adjusted life year, DALY）所需的成本作为干预的成本效果测算指标。为验证本分析中所采用的各项假设，研究开展了概率敏感性分析与单因素敏感性分析。
主要结局指标：增量成本效果比（Incremental cost-effectiveness ratio, ICER），即相较于现状，本干预每避免1个伤残调整寿命年所需的成本。
结果：2012年至2016年间，大阿克拉区域医院共计接生45495例新生儿，其中5734例收入新生儿重症监护病房。本系统强化项目的总预算为1716976美元。根据项目估算，本次干预共避免了307例（±82）新生儿死亡与84例（±35）死胎，累计避免12342个伤残调整寿命年。经测算，本系统强化干预的增量成本效果比为139美元（±44美元），远低于2012-2016年间加纳人均国内生产总值（年均1649美元）这一公认的成本效果阈值，表明该干预具备极高的成本效果性。敏感性分析结果显示，研究结果对以下参数较为敏感：避免的伤残调整寿命年数、新生儿死亡例数以及死胎例数。
结论：在转诊医院开展一体化系统强化干预，有望在资源有限的环境中降低新生儿及产时死亡率，且具备成本效果性。通过领导力与临床培训强化组织能力，可实现可持续的改变。