Improving the Quality of Care for Women with Pregnancy-Induced Hypertension Reduces Costs in Tver, Russia

QUALITY

ASSURANCE

PROJECT

OPERATIONS RESEARCH RESULTS

Improving the Quality of Care for Women with Pregnancy-Induced Hypertension Reduces Costs in Tver, Russia

April 2002

Center for Human Services • 7200 Wisconsin Avenue, Suite 600 • Bethesda, MD 20814-4811 • USA • www.qaproject.org The Quality Assurance (QA) Project is funded by the U.S. Agency for International Development (USAID), under Contract Number HRN-C-00-96-90013. The QA Project serves countries eligible for USAID assistance, USAID Missions and Bureaus, and other agencies and nongovernmental organiza tions that cooperate with USAID. The QA Project team, which consists of prime contractor Center for Human Services, Joint Commission Resources, Inc., and Johns Hopkins University (including the School of Hygiene and Public Health, the Center for Communication Programs [CCP], and the Johns Hopkins Program for International Education in Reproductive Health [JHPIEGO], provides comprehen sive, leading-edge technical expertise in the design, management, and implementation of quality assurance programs in developing countries. Center for Human Services, the non-profit affiliate of University Research Co., LLC, provides technical assistance and research for the design, manage ment, improvement, and monitoring of health systems and service delivery in over 30 countries. O P E R A T I O N S R E S E A R C H R E S U L T S

Improving the Quality of Care for Women with Pregnancy-Induced Hypertension Abstract Reduces Costs in Tver, Russia The Quality Assurance Project/ Russia implemented a quality improvement (QI) demonstration project in 1998 at three hospitals in Tver Oblast, Russia. The project sought to improve the quality of care for women with pregnancy- induced hypertension (PIH), then the single largest cause of mater Table of Contents nal deaths in Tver. Central to the QI effort was the development and introduction of evidence-based ABBREVIATIONS ...... 1 clinical guidelines for the manage I. INTRODUCTION ...... 1 ment of PIH. The new guidelines rationalized admission criteria and II. THE QUALITY IMPROVEMENT INTERVENTION ...... 2 the use of drugs, reduced the num ber of PIH admissions, and called III. EFFECTS ON HEALTH OUTCOMES ...... 3 for more aggressive treatment of PIH. IV. COST STUDY DESIGN AND METHODS ...... 3 A. Inpatient Costs ...... 3 Health outcomes improved follow ing the introduction of the new B. Outpatient Costs ...... 4 guidelines. Complications in new borns of PIH mothers dropped, no V. COST STUDY FINDINGS ...... 5 PIH case progressed to eclampsia A. Number of PIH Cases ...... 5 (which is often fatal), and no B. Reduction in Direct Costs of Care for PIH Patients ...... 6 maternal deaths caused by PIH occurred in the 15 months follow Inpatient care ...... 6 ing the implementation of the new Outpatient care ...... 7 guidelines. Direct cost of hospitalization ...... 8 A before-and-after cross-sectional Direct cost of drugs for PIH inpatients ...... 8 cost study at two of the three pilot Direct cost of paraclinical care for PIH inpatients ...... 9 hospitals found that PIH admis sions decreased by 77 percent in C. Differences between Hospitals ...... 10 the six months following introduc D. Differences by Case Severity ...... 12 tion of the new guidelines com pared to the previous six months VI. ASSUMPTIONS AND POTENTIAL THREATS TO VALIDITY ...... 13 (from 47 cases before to 11 after). This decrease is consistent with the VII. CONCLUSION AND DISCUSSION ...... 14 new, more stringent guidelines and ENDNOTES ...... 15 indicates a high likelihood that compliance with the new guide- REFERENCES ...... 16

Continued on page ii Abstract Continued Acknowledgements lines caused the decrease. The cost This paper was written by Hany Abdallah, Olga Chernobrovkina, Anna study measured PIH-related direct Korotkova, Rashad Massoud, and Bart Burkhalter. The Health Depart costs for inpatient and outpatient ment of the Tver Oblast under the stewardship of Dr. Alexander N. cases. The former included the cost Zlobin, Torzhok Hospital, and the Vyshny Volochyok Hospital greatly of hospitalization (clinical services, supported and participated in the study. food), drugs, lab tests and other The staff of Torzhok Hospital and Vyshny Volochyok Hospital signifi paraclinical services. The latter in cantly facilitated the coherent and successful execution of the study. cluded antenatal care-related costs Special thanks to Marina Scheglova, Economist with the Tver Fund. and costs associated with PIH and The authors also recognize and appreciate the special effort and work other conditions: drugs, lab and other of: Dr. Valeria Gerasimova, Obstetrician-Gynecologist (Ob/Gyn), Dr. paraclinical care, and medical consul Andrey Gulin, Ob/Gyn, and Irina Kutilina, Hospital Economist, Torzhok tations. Hospital; Dr. Michail Klimov, MD and Head of Perinatal Care, Dr. Total direct inpatient-related costs Natalia Suchova, Ob/Gyn, and Olga Klueva, Hospital Economist, decreased by 86 percent, from about Vyshny Volochyok. 51,000 rubles in the Before group to Paula Tavrow and Jolee Reinke from the University Research Co., about 7,000 rubles in the After group. LLC,-Center for Human Services (URC-CHS) provided extensive This is an annualized savings of about technical input. Special thanks to Marc Oliver for his unwavering 118,000 rubles (about US$ 4,720 encouragement, and Beth Goodrich who edited this paper with at the time of the study). Direct per- diligence and a ready smile. inpatient costs decreased 41 percent. As expected, costs were higher for While we acknowledge the valuable contributions of the parties women with more severe PIH, but a mentioned above, all errors of omission and/or interpretation remain substantial decrease was evident at the sole responsibility of the authors. all severity levels following the intro duction of the new guidelines, with the larger decreases occurring in Recommended citation the more severe cases. Length of hospital stay for PIH women also Abdallah, H., O. Chernobrovkina, A. Korotkova, R. Massoud, and B. decreased, on average from 13.5 to Burkhalter. 2002. Improving the Quality of Care for Women with 11.8 days. Findings also suggest that Pregnancy-Induced Hypertension Reduces Costs in Tver, Russia. outpatient costs potentially associated Operations Research Results 2(4). Bethesda, MD: Published for the with PIH care also dropped by roughly United States Agency for International Development (USAID) by the 13,000 rubles per year, although an Quality Assurance Project. inability to separate PIH costs from regular antenatal care costs makes it difficult to pinpoint the decrease with About this series certainty. The Operations Research Results series presents the results of Although the number of cases in each country or area research that the QA Project is circulating to encour study group is small, and numerous age discussion and comment within the international development assumptions are made in the analy community. If you would like to obtain the larger research report of this sis, no substantial threats to the valid study containing all relevant data collection instruments, please ity of these findings are apparent. The contact [email protected]. unusual result of having health out comes improve at substantially lower operating costs recommends wider application of the demonstration project. Improving the Quality of Care for Women with Pregnancy-Induced Hypertension Reduces Costs in Tver, Russia

Hany Abdallah, Olga Chernobrovkina, Anna Korotkova, Rashad Massoud, and Bart Burkhalter

the maternal health priority for the demonstration project. As the single largest cause of maternal deaths in Tver, PIH accounted for seven of the 25 reported maternal deaths that I. Introduction had occurred in Tver in the previous three years (1995–97). Additionally, The Health Committee of the the diagnosis and management of U.S.-Russia Joint Commission on PIH was causing much confusion Abbreviations Economic and Technological and difficulty. Interestingly, toxemia Cooperation defined the scope of was diagnosed in 18 percent of work (SOW)1 in 1998 for cooperative pregnancies during 1997;3 the AHRQ Agency for Health activities to improve quality. The worldwide incidence of PIH is 5–6 Research and Quality, activities included the implementa percent of pregnancies (Murray and Tver Oblast Department tion of a demonstration project to Lopez 1998). of Health improve the quality of maternal and BP Blood pressure child health services in Tver Oblast. The demonstration project was Funded by the U.S. Agency for launched at three hospitals in Tver C-section Cesarean section International Development (USAID), Oblast: Tver City Maternity Hospital EBCG Evidence-Based Clinical the Quality Assurance (QA) Project #1, Vyshny Volochyok Hospital, and Guidelines provided technical assistance to Torzhok Central District Hospital. As those undertaking the SOW, includ part of the improvement in the Mg SO4 Magnesium sulfate ing the development of the demon system of care, new guidelines for Ob/Gyn Obstetrician-gynecologist stration project. A collaboration was PIH care based on evidence-based formed and included the Ministry of medicine were developed and PIH Pregnancy-induced Health of the Russian Federation implemented in these hospitals, and hypertension (RFMOH), the Central Public Health indicators were developed and QA Quality assurance Research Institute of the RFMOH, tracked monthly using time series the Tver Oblast Department of charts to show the effect of the new QI Quality improvement Health’s Agency for Health Research system on the quality of care. RFMOH Russian Federation and Quality (AHRQ), the U.S. Section II describes the quality Ministry of Health Department of Health and Human improvement effort and the effect of Services, USAID, and the QA the new evidence-based guidelines. SOW Scope of work Project. A cost study was conducted USAID United States Agency Key decision makers held a plan concurrently, during the spring of for International ning meeting in Tver that included a 2000. It quantified the economic Development review of existing data. Shortly impact of the improved system of USSR Union of Soviet Socialist thereafter, pregnancy-induced PIH care. This report documents the 2 Republics hypertension (PIH) was selected as cost study’s methodology and

Improving the Quality of Care Reduces Costs ■ 1 findings. Documenting the cost of involved in the system of PIH care from hospital records and the quality improvement is important in was formed at each hospital. The second for data from the associated part because of the paucity of such teams included obstetricians, women’s clinics. information and growing recognition gynecologists, other physicians, Phase III of the improvement of the need for evaluations of the midwives, and nurses. All team methodology was to develop economic impact of quality improve members were trained in quality interventions that the teams believed ment and evidence-based guide improvement concepts and methods would yield improvement. First, the lines (Eccles et al. 2000; Haycox et before embarking on the improve teams reviewed the available al. 1999). ment process. evidence-based literature on PIH Phase II was to analyze the existing care, using special training sessions system of toxemia/PIH care. The about the existing evidence base in II. The Quality system analysis was done at each the literature where appropriate. Improvement facility and included the referral Second, to update the clinical Intervention systems (including ambulance content in accordance with the best service) connecting the facilities. For available evidence and to achieve The QA Project/Russia team devel each hospital, the teams flowcharted agreement on clinical content oped the new system of PIH care the entire PIH care system. Next changes, several clinical review and using a quality improvement meth they documented existing clinical policy dialogue sessions were held odology (Massoud et al. 2001; practices at each step in the over a period of some six months. Langley et al. 1996) that includes a flowcharted processes, including These changes adopted recommen framework for clinical quality clinical diagnostic criteria, referral dations from the 10th International improvement (Batalden and Stoltz criteria, and treatment guidelines. Classification of Diseases (ICD-10 1993) and emphasizes the need to This analysis revealed the differ 1992). Also adopted was a radical integrate clinical content (subject ences in practice among the change to manage PIH by inducing matter knowledge) with the improve hospitals: inconsistencies in diagno early delivery and preventing ment methodology. The improvement sis and treatment, as well as eclampsia with intravenous magne methodology consists of four phases organizational problems. What had sium sulfate (Figure 1). Third, plans that integrate a systematic six-step been thought to be a standardized were developed to enhance the process for developing evidence- system of care proved to have capacity of the systems of care to based clinical guidelines (EBCG) significant variation. Importantly, the implement the updated clinical (Tula Oblast Health Care Department main strategy for treating PIH was to content. New flowcharts were drawn et al. 2001; Tver Oblast Health Care admit women to the hospital and showing the proposed changes. Department et al. 2001a and b).4 then attempt to control blood Fourth, the indicators were reviewed pressure while maintaining the and updated to ensure that they Phase I of the improvement method pregnancy. This approach contrasts measured the clinical and organiza ology was to identify the problem significantly from that of the western tional changes introduced. needing improvement. Key decision world, which stresses more stringent Phase IV was to test and implement makers had agreed at the Tver admission criteria and more aggres the changes agreed upon and to planning meeting to work on sive treatment of those admitted. show whether they actually yielded improving the system of care for The teams also developed indica improvement. This was accom women suffering from toxemia/PIH. tors to show changes that might plished using the “Shewhart Cycle They chose three hospitals repre result from their efforts. Starting with for Learning and Improvement,” also senting the different types of rural January 1998, the teams collected known as the Plan-Do-Study-Act and urban facilities that provide data retrospectively from records at (PDSA) Cycle (Shewhart 1931). The toxemia/PIH care in Tver to partici hospitals and women’s clinics. The teams pilot tested the proposed pate in the demonstration project: data were collected for the total interventions for a few months to see Tver City Maternity #1, Vyshny population (no sampling), aggre if they were feasible and worked. Volochyok Hospital, and Torzhok gated monthly, and displayed on Data from the proposed interven Rayon Hospital. A team of the time series graphs. Two different tions convinced the teams that the different professional functions databases were set up, one for data

2■ Improving the Quality of Care Reduces Costs Figure 1 IV. Cost Study Design Major Differences between Old and New Guidelines for Treating and Methods PIH in Hospitals The cost study used a before-and- Old New after cross-sectional design. Cost data were collected from two of the Many pregnant women diagnosed with toxemia Fewer pregnant women diagnosed with PIH three hospitals that participated in Poly-drug therapy Mono-drug therapy (magnesium sulfate: Mg SO4) the demonstration pilot: Torzhok Hospital and Vyshny Volochyok. Inpatient management of hypertension Prevention of eclampsia Data were collected retrospectively Prolonged pregnancy Early and induced delivery from medical records over a 15 month period (January 1999–March 2000). The Before data were collected for months 1 to 6 (Janu- proposed interventions worked: the women. The study team collected ary–June 1999), the new guidelines teams observed improved care for data on cases progressing to were implemented in months 7 to 9 patients admitted and managed in eclampsia and/or resulting in death (July–September 1999), and the the hospital and saw no complica over the 19 months after implemen After data were collected in months tions in those not admitted. tation of the new guidelines (Octo 10 to 15 (October 1999–March ber 1999–April 2001). Data were 5 The hospitals began implementing 2000). Cost data were not collected obtained from the monitoring system the new standards during the from Tver Maternity Hospital be developed as part of the new quality development process: Torzhok and cause it had delayed implementation assurance system for PIH care. Vyshny Volochyok hospitals started of the new guidelines. Because such data were not first, followed by Tver City Maternity. collected during the period before The director of the Tver Oblast A. Inpatient Costs the new guidelines, data on deliver Department of Health and the chief ies to PIH women and newborn To estimate inpatient costs, we obstetrician/gynecologist (Ob/Gyn) complications were obtained from reviewed medical records for all of the RFMOH officially authorized hospital records during a six-month pregnant women who were admitted the three demonstration hospitals to period before the new system was with suspected PIH of any severity implement the new system of care in implemented (January 1999–June to the two hospitals during the study September 1999. A conference in 1999). period. Data were obtained only for late September officially launched elements of maternity care that were the new system and was attended The following results were found: expected to change as a result of by all facility administrators, clinical 1. No cases progressed to eclamp the new guidelines. Elements that chiefs, and others involved in the sia among the women managed were expected to change included project (Ethier forthcoming). under the new system of care. drugs, laboratory tests, and direct This is the most important care associated with hospitalization. indicator reflecting that the new Hospitalization care included III. Effects on Health system of care is an improve physician and nursing time, and Outcomes ment. food. The cost of all these elements is referred to as “direct costs.” Several indicators of health outcome 2. No deaths occurred among the Costs not included because we did were investigated at the three women managed in the new not expect the new guidelines to demonstration hospitals. These system of PIH care. affect them included imputed rent included: (1) number of toxemia/PIH 3. Complications of newborns of for infrastructure (buildings and cases progressing to eclampsia, (2) women with PIH dropped 60 equipment), hospital supplies and number of toxemia/PIH deaths, and percent. materials, special procedures (such (3) number of newborns with as C-sections), and hospital staff complications to toxemic/PIH other than doctors and nurses.

Improving the Quality of Care Reduces Costs ■ 3 We used the following procedures to similar to the procedure used for for PIH occurred during regular estimate the direct cost of the three drugs, except that no patient-borne antenatal care visits both before and elements of inpatient care: costs were involved. We obtained after the implementation of the new data on the number of tests by type Drugs. First, we examined each PIH guidelines, under the new guide from each patient’s medical record; patient’s medical record to deter lines, no special care or attention we estimated the average cost per mine the number of doses of each was prescribed for PIH at the test in each hospital from hospital type of drug she had received. outpatient level. Patients who financial records; and we calculated Second, we estimated the average showed signs of slightly elevated total costs by summing across types cost-per-dose of a particular type of blood pressure (mild hypertension) of tests and patients. The cost per drug by finding the average price but who tested negative for protein test was based on the cost of paid for that type of drug by each in the urine (proteinuria) were materials and supplies used to hospital during the Before and After considered at risk for developing perform the tests and services. periods. The average for each PIH under the new guidelines and hospital was assumed to be the Hospitalization. Hospitalization here were typically asked to return to the midpoint between the average refers to the elements of care that outpatient facility within a few days Before price and the average After are directly associated with occupy for follow up. Any patient with this price for that hospital. Thus, for each ing a bed in the hospital’s maternity profile without easy or immediate hospital the cost per dose of a ward; their cost is roughly propor access to an emergency facility particular type of drug was assumed tional to the number of beds occu would be referred for admission to to be the same in the Before and pied. In this study, we summed the the hospital. After groups. Third, the number of cost of three elements of care Prior to the implementation of the doses was multiplied by the esti thought to be influenced by the new new guidelines, treatment at the mated average cost per dose in guidelines (physician time, nursing outpatient level for pregnant women each hospital to obtain the total cost time, and food) to obtain an indica considered at risk for toxemia/PIH to the hospital of each type of drug tor of the direct cost of hospitaliza was more intensive. In the old for each patient. tion. To obtain an estimate of the system, patients typically received direct hospitalization cost per day A special study estimated drug more attention, including more per bed, we obtained the annual costs borne by the patient (and/or monitoring and treatment (both at budget for the three elements during her family) at Vyshny Volochyok. home and in the outpatient facility). the Before and After periods from This information was used to adjust In addition, some women who were the financial records of each total drug costs in both hospitals to considered at risk also received hospital. The budget reports yielded include costs borne by the hospital referrals for hospital admission—up a total annual direct cost of hospital and patient. The adjusted costs to two or three admissions per ization for each hospital and each were summed across drug types, pregnancy. period. The total direct cost was patients, and hospitals to obtain total divided by 365 and by the number Information about outpatient care for drug costs in the Before and After of maternity beds in the hospital to women with toxemia under the old groups. The total cost of drugs in obtain the average daily hospitaliza system is mainly anecdotal, so it is each group was divided by the tion cost per bed. difficult to distinguish between care number of PIH patients in the group that was provided as part of regular to obtain the average drug cost per antenatal care visits and toxemia/ patient in each group. B. Outpatient Costs PIH care. Consequently, information Laboratory tests. Lab test costs on all elements of care received by Although the study team believed include the costs of tests and the pregnant woman at the outpa that outpatient costs for PIH patients paraclinical services such as blood tient level was collected, including would not change appreciably as a exams, urinalyses, and electrocar all regular antenatal care. Three result of the new guidelines, the diograph readings. The procedure elements of outpatient care were potential for questions about used to estimate the total cost of investigated: drugs, paraclinical outpatient costs led us to collect laboratory tests for PIH patients and services (mainly lab tests), and data on such costs. While screening the average cost per patient was medical consultations (e.g., with the

4■ Improving the Quality of Care Reduces Costs Ob/Gyn). The cost of each element Table 1 was obtained in the same manner as Number of Hospitalized PIH Cases Included in the Cost Study, the corresponding elements of by Severity and Hospital inpatient costs. The cost of medical consultation was assumed to be Before After Total proportional to the number of outpatient visits, with the cost per Vyshny Vyshny (Percentage visit equal to the per unit cost used Severity Torzhok Volochyok Total Torzhok Volochyok Total Reduction) in the hospital budget reports. Other Mild 19 14 33 1 5 6 39 (82%) outpatient costs were not estimated, including costs associated with Moderate 8 3 11 0 3 3 14 (73%) undetected PIH cases, if there were Severe 3 0 3 1 1 2 5 (33%) any, that were not admitted under either set of guidelines. We assumed Total 30 17 47 2 9 11 58 (77%) that all of these unmeasured costs were constant in the Before and After periods. allocating costs to the elements of received outpatient care, 47 in the The outpatient medical records of all care. Data were analyzed using Before period and 9 in the After women were screened to identify Microsoft Access and Excel soft- period (Table 2). Twelve patients (9 cases with a toxemia/PIH diagnosis ware. Before and 3 After) diagnosed with in the Before and After periods. This PIH were not hospitalized. These 12 included women admitted to the included patients with mild forms of hospital, those treated only as V. Cost Study Findings PIH. Note that some women admit- outpatients, and those who were referred to a hospital as possible A. Number of PIH Cases PIH cases but classified as not Table 2 Inpatient cases. In the two study being at risk following referral. Number of Cases with PIH Women in the After period who were hospitals combined, 47 PIH cases not diagnosed with PIH, but who were admitted in the six months prior Seen as Outpatients, would have been treated for toxemia to the implementation of the new Including Cases Not under the old guidelines, were not guidelines and only 11 in the six Admitted included as a PIH case. We as months after, a 77 percent drop. This reduction in admissions indicates sumed that PIH had no effect on the PIH Patients Seen the degree to which the new outpatient treatment and cost of as Outpatients Before After cases not identified by this screen guidelines were successfully [1] [2] ing. We abstracted and analyzed implemented (see Section VI on Admitted for hospital care 38 6 assumptions and threats to validity). outpatient cost data for the PIH Not admitted for hospital care 9[3] 3 cases identified in this screening. As As shown in Table 1, a larger Total 47 9 with the inpatient analysis, the proportion of the admitted cases in analysis of the outpatient data the After group presented with Notes: assumed that the number and moderate to severe cases of PIH (5 1. No records of outpatient care were found for 9 of severity of cases was the same in of 11: 45 percent) than in the Before the 47 hospitalized women in the hospitalized the Before and After periods, and Before group (reported in Table 1). These group (14 of 47: 30 percent). We patients were most likely hospital walk-ins. that the pattern of regular antenatal hypothesized that the increased 2. Similarly, no records were found for 5 of the 11 care visits was the same. proportion of severe cases would hospitalized patients in the After group. A team made up of an Ob/Gyn increase the average cost and 3. It is a coincidence that in the Before period, the responsible for treating the admitted examine our hypothesis below. number of women admitted for PIH who had not received outpatient care (9) equals the number women and a hospital economist Outpatient cases. We found 56 diagnosed with PIH receiving outpatient care but was responsible for measuring and records of women with PIH who not admitted for PIH.

Improving the Quality of Care Reduces Costs ■ 5 ted with PIH do not appear to have Table 3 received any outpatient care for PIH Direct Cost of Inpatient PIH Care in Two Tver Hospitals before or for any other reason: 9 of the 47 [1] women admitted with PIH in the and after New PIH Guidelines Before period and 5 of the 11 Percentage Change women in the After period did not Before (n = 47) After (n = 11) (n decreased 76.6%) receive outpatient care. Average Total Average Total Average Total B. Reduction in Direct Costs cost / direct cost / direct cost / direct [1] [1] [1] of Care for PIH Patients Elements of Care patient cost patient cost patient cost Inpatient care Hospitalization 744.4 34,987 457.1 5,028 - 38.6% - 85.6% The total economic burden of Drugs 223.8[2] 10,517 83.7 921 - 62.6% - 91.2% treating pregnant women admitted to Paraclinical care (tests) 122.2 5,743 102.0 1,122 - 16.5% - 80.4% the hospital for PIH decreased following the implementation of Total inpatient care 1,090.4 51,247 642.8 7,071 - 41.0% - 86.2% clinical guidelines for PIH (Figure 2 and Table 3). Total direct inpatient Notes: costs for six months decreased from 1. All costs are in rubles. Total costs are for a six-month period in the Before and After columns and are subject to rounding error. 51,247 rubles in the Before period to 2. Average is based on 46 patients for whom drug data were collected; this average was projected to the 47th 7,071 rubles in the After period or 83 patient for whom data were missing. percent of Before costs in the two hospitals.6 Recall that the direct inpatient costs reported here reflect The distribution of inpatient costs only the costs likely to change as a Figure 2 among the three elements did not result of the new guidelines and not Change in Total Cost of vary significantly between the two all the costs incurred by the hospital Inpatient Maternal Care for groups (Table 4). Hospitalization accounted for the largest portion of to treat PIH patients. Thus the PIH Patients (Rubles) over savings of 44,176 rubles is likely to direct inpatient costs in both the be a reasonable estimate of the PIH 6-Month Periods Before and After groups (69 percent and 71 percent, respectively). The costs saved by the two hospitals as Million Rubles variation in the distribution of costs a result of the new guidelines, but 55 total costs for treating PIH inpatients by case severity is discussed in a would not decrease by 83 percent 50 later section. because the total costs include 45 costs not affected by the guidelines. Table 4 40 The large drop in the cost of PIH Test Distribution of the Total inpatient care was driven by two 35 Drugs Direct Inpatient Cost of factors: a 76.6 percent decrease in 30 PIH Treatment in the Two the number of patients admitted for Hospitalization PIH, and a 41.0 percent decrease in 25 Hospitals Combined the cost per inpatient (Table 3). The 20 decrease in average-per-inpatient Elements of Care Before After 15 cost resulted from decreases in all Hospitalization 69% 71% three elements of inpatient care; the 10 decreases in drug and hospitaliza Drugs 20% 13% 5 tion costs were much larger than the Paraclinical care (tests) 11% 16% decrease in paraclinical services 0 Total inpatient cost 100% 100% costs. Before After

6 ■ Improving the Quality of Care Reduces Costs Outpatient care Table 5 Table 5 gives total outpatient care Total Direct Cost of All Outpatient Care During Six-Month costs for all women treated for PIH Before and After Periods for Patients Diagnosed with PIH (from Table 2) during the study periods. The outpatient costs reflect Percentage regular antenatal care plus PIH- Before After Change related and other outpatient care Average Number Total Average Number Total Average received during the six-month Cost/ of Direct Cost/ of Direct Cost/ Before and After study periods. The Category of patient Patient Patients Cost Patient Patients Cost Patient costs of outpatient care for women who received such care and were Admitted patients 409.3 38 15,553 334.0 6 2,004 -18.4% admitted for PIH averaged 409 Patients not admitted 621.0 9 5,588 266.5 3 800 -57.1% rubles per patient before the new guidelines and 334 rubles after. The Overall average 449.8 47 21,142 311.5 9 2,804 -30.7% average per-patient costs of outpa Notes: Costs include all outpatient costs whether or not related to PIH for women diagnosed with PIH and who tient care for women who were not received outpatient care in the Before or After period. All figures are in rubles and subject to rounding error. hospitalized dropped from 621 rubles to 266. This difference is statistically significant at the 0.01 the new guidelines. This finding is about 6,500 rubles over the six level. However, the differences consistent with the expected impact months in the Before group. This is between the 409 and 334 figures of the new guidelines on outpatient an annualized saving of 13,000 and between the 334 and 266 care. In the Before group, women rubles for the two hospitals. When figures are not statistically significant diagnosed with toxemia received the direct PIH-related outpatient using a 2-tailed t-test. Overall there more intensive attention and costs are combined with the inpa was a decrease of 30.7 percent in treatment as outpatients (including tient costs in Table 3, total costs in the per-patient cost of outpatient home-based care) than those in the the six-month Before period equal care for patients with a toxemia/PIH After group where the new guide 57,747 rubles (51,247+6,500) diagnosis.7 lines redefined the disease classifi compared to 7,071 in the After cation for PIH and hence the period. This is an 87.7 percent drop. Because of the difficulty of separat treatment provided. In the After ing costs associated with regular The distribution of the cost of group, only “border” PIH cases, i.e., antenatal care from costs that are outpatient care changed only those women with elevated blood specifically related to treatment for slightly following the implementation pressure (BP) and no protein in their PIH, it is difficult to project what of the new guidelines (Table 6). The urine, received any “special” proportion of the decrease in the cost of consultations became outpatient attention. They were cost of outpatient care is due to the relatively more important (45 percent typically asked to return sooner than implementation of the new guide of total per patient costs versus 41 their next scheduled antenatal visit lines. However, in the absence of percent in the Before group), while to receive BP and urine protein tests. any information on change in the the cost of drug treatments became The rest, i.e., women diagnosed with antenatal care program for women8 slightly less important (from 37 PIH including proteinuria during an during the period of the study, and percent to 24 percent of total per antenatal visit, immediately became because the data on outpatient patient costs). The relative cost of inpatients. drugs and lab tests among the 38 paraclinical care did not change admitted patients who received Based on the above findings and from the Before to the After period. outpatient care in the Before period assuming that the cost of PIH- show PIH-related treatment, it is related outpatient care is zero in the likely that a large part or all of the After group, the cost of PIH-related 30.7 percent decrease in per-patient care at the outpatient level in the cost was due to the introduction of Before group is estimated to be

Improving the Quality of Care Reduces Costs ■ 7 Table 6 group. The average per-patient cost Average Cost per PIH Patient of Outpatient Care, dropped 63 percent (from 224 rubles by Element of Care and Group, in Rubles and as a before to 84 rubles after). Percentage of Total Average Cost per Patient A special study of patient-paid inpatient drug costs at Vyshny Group Drug Cost Paraclinical Cost Consultation Cost Total Cost Volochyok found that a higher proportion of inpatients in the After Before (n = 47) 122.5 (27%) 140.7 (31%) 186.6 (41%) 449.8 (100%) group (i.e., including both hospitals) After (n = 9) 75.6 (24%) 95.5 (31%) 140.5 (45%) 311.5 (100%) paid for part of their own drugs than in the Before group. In the After Note: The total outpatient care cost by element and group was obtained first, and the average cost per patient by group 6 of the 11 inpatients (55 element and group was then obtained by dividing the total cost for each cell by the number of patients (n) in that group. percent) paid 59 percent of their

Direct cost of hospitalization (from 13.5 to 11.8 days). Length of Figure 3 Total PIH inpatient days dropped stay varies significantly by case Reduction in the Average from 635 before the implementation severity, as is addressed in a later Direct Cost per PIH Inpatient section. of the new guidelines to 130 after- of Hospitalization, Drugs, ward (a 79 percent reduction), largely as a result of the decrease in and Paraclinical Care for the total direct cost of hospitalization Direct cost of drugs for Both Hospitals Combined in both hospitals combined from PIH inpatients (Rubles) 34,987 rubles to 5,028 rubles.9 The To analyze drug costs, we combined average direct cost of hospitalization the cost of drugs provided by the Rubles per Patient per PIH inpatient decreased from hospital and those purchased by the 1200 744 rubles to 457 rubles, a drop of patient and her family. The total cost Before 39 percent (Table 7 and Figure 3). dropped from 10,517 rubles in the After The drop in inpatient days was Before group to 921 in the After 1000 caused by the 77 percent reduction group (Table 3). This large decrease in the total number of inpatients and was driven by the combination of a 13 percent reduction in the fewer admissions for PIH and lower average length of stay per inpatient drug costs per inpatient in the After 800

Table 7 Average Direct Cost of PIH Hospitalization per Day and per Stay 600 for Both Hospitals Combined, before and after New Guidelines (Rubles) 400 Before After Percentage Change Average cost per day 55.1 38.7 -29.8 %

Average days per stay 13.5 11.8 -12.6 % 200 Average cost per stay 744 457 -38.6 %

Note: The average cost per day is based on the combined average cost of hospitalization in the two hospitals. Vyshny Volochyok has a lower per-day cost than Torzhok. While the average cost per inpatient in each hospital 0 was assumed to stay constant during the course of the study, the change in average cost per day reported here Hospital- Medication Tests Total reflects the relatively larger proportion of patients being admitted in Vyshny Volochyok hospital in the After group ization as compared to the Before group (Table 1).

8■ Improving the Quality of Care Reduces Costs drug costs, while in the Before group quently used drugs in the Table 8 10 of the 47 patients (21 percent) Before group were used Most Frequently Used Drugs to paid 67 percent of their drug costs. significantly less fre- Treat PIH: Percentage Receiving The total cost of inpatient drugs quently or not at all in the borne by the patients represented After group. But other Drug, by Group 13 percent of total inpatient drug drugs (magnesium sulfate costs in the Before group (both [Mg SO4], clofellini, and Percentage of PIH Inpatients hospitals) and 28 percent in the Ringer solution) were used Receiving the Drug After group (both hospitals).10 The more frequently in the Drug Before (n=47) After (n=11) average cost of drugs borne by a After group, in accordance Papaverine hydrochloride 78% 8% patient in Vyshny Volochyok fell 68 with the new clinical percent (from 131 rubles Before to guidelines. For example, Glucose (40%) 69% 8% 42 rubles After: Figure 4). The most the new guidelines Methylogobrevin 64% 23% important factor in reducing the cost recommend using Mg SO4 to the patient was a 60 percent drop to control convulsions. In Dibasol 56% Dis in the average number of drugs paid the After group, a propor Novocaine 50% Dis for by patients: from five to two. tionately higher percentage of severe PIH cases— Diazepam 50% Dis which are the cases most Magnesium sulfate 42% 46% Figure 4 likely to need Mg SO4— was admitted. We present Clofellini 30% 31% Average Inpatient Drug Cost an analysis of costs by Ringer solution 23% 43% Borne by Patients at case severity below. Vyshny Volochyok (Rubles) Notes: Frequently prescribed drugs are defined as those given to 50% or more of the PIH patients in either or both the Before and 131 After groups. “Dis” means discontinued for PIH use under new Direct cost of guidelines, or 0%. paraclinical care for PIH inpatients The total direct cost of paraclinical factors contributed to usage, care including tests decreased from including the type of test, the 5,743 rubles to 1,122, a drop of 80 frequency of use per patient, and 42 percent (Table 3). The decrease in the unit cost of the test. the number of women admitted for As illustrated in Table 9, frequently PIH accounted for most of this used tests in the Before group were decrease. The average direct cost of also frequently used in the After Before After all tests per inpatient also de- group, although most dropped off a creased (Table 3 and Figure 3), but little, including electrocardiographs, not as dramatically as the costs of a relatively expensive test. On the Fewer types of drugs were used other elements. Direct costs other hand, several tests infre following the introduction of the new dropped from 122 rubles per patient quently used in the Before group guidelines: 72 different types were to 102, a 16 percent decrease. became more popular after imple- used across all severity levels in the The average number of tests per mentation, especially relatively Before group and 32 in the After inpatient increased by about two expensive specialty consultations group. The average Before group following the implementation of the with ophthalmologists and thera- inpatient received ten different new guidelines. This pattern held for pists. The increased use of the drugs, and the average After group mild and severe PIH, but not for proteinuria test was likely the result inpatient received six. moderate, where the average of increased monitoring of PIH Table 8 illustrates the decreased number of tests per inpatient inpatients according to the new polypharmacy. The six most fre dropped from nine to five. Several guidelines.

Improving the Quality of Care Reduces Costs ■ 9 Table 9 the different factors contributing to Frequently Used and Other Selected Tests and Consultations cost, thereby according confidence in the results. This hospital-by- Percentage of Patients in Group Receiving Test hospital analysis brings understand ing about the cost savings that are Before (n=47) After (n=11) likely to be achieved if the new Most Frequently Used guidelines are scaled up.

Urinalysis 100% 100% Duration and change in length of Total blood count 98% 45% stay varied between hospitals. In Blood platelet and coagulation 91% 73% Torzhok, average length of stay per patient dropped from 14.7 days Blood biochemistry 85% 82% Before to 7.0 After. In Vyshny Electrocardiograph 42% 27% Volochyok it increased from 11.8 Other Selected Tests days Before to 12.9 After. Most of the increase at Vyshny Volochyok was Ophthalmologist 2% 45% due to an outlier who was admitted Therapist 4% 36% in the After period with a moderate Proteinuria 2% 18% severity level.

Notes: These represent the five most frequently used tests. In Torzhok only, tests for AIDS (moderately expensive In both hospitals, use of certain compared to other tests) were administered to 63% of patients in the Before group and 18% of patients in the drugs appears to have increased in After group. frequency, although the type of drugs differed between the two hospitals (Table 11), and the small C. Differences between the average cost per admission, Hospitals causing higher reductions there. Another difference between the two An analysis of the direct inpatient hospitals was the range of per- Figure 5 costs by hospital found large patient variation in direct costs in Range and Average Direct differences between them. Direct the Before period, with Torzhok costs were substantially higher at Cost per PIH Inpatient showing a much larger spread than (Before Period; in Rubles) Torzhok than at Vyshny Volochyok Vyshny Volochyok (Figure 5). before the new guidelines, and the Rubles per Inpatient reduction in direct costs was also Although the analysis suffers from 3500 larger at Torzhok (Table 10). Torzhok small sample sizes at the individual had strikingly larger decreases in hospital level, the pattern between 3000 both the number of admissions and the hospitals is consistent across 2500 Table 10 2000 Comparison of Direct Costs of PIH Inpatients in the Two Hospitals (Rubles) 1500

Torzhok Hospital Vyshny Volochyok Hospital 1000 Before After Change Before After Change 500 PIH admissions 30 2 - 93% 17 9 - 47% Average direct cost 1,342 760 - 43% 618 617 - 0% 0 Torzhok Vyshny Volochyo per PIH inpatient High-Low Range Average Total direct cost 40,272 1,520 - 96% 10,503 5,551 - 49%

10■ Improving the Quality of Care Reduces Costs Table 11 Percentage of PIH Cases Using Frequently Prescribed Drugs,[1] before and after Clinical Guidelines, by Case Severity and by Hospital

Torzhok[2] Vyshny Volochyok[3] Mild Severe Mild Moderate Before n = 19 After n = 1 Before n = 3 After n = 1 Before n = 14 After n = 5 Before n = 3 After n = 3 Glucose (40%) 100% 100% Methylogobrevin 100% 100% 100% 100% Papaverine hydrochloride 89% 100% 100% Dis 54% 20% Folliculin 58% Dis Oxytocin 53% 100% 100% Dis Dibasol 47% Dis 100% Dis 54% 20% Novocaine 100% Dis 69% Dis 67% Dis Magnesium sulfate 100% 100% 23% 60% 100% 67% Gendevit tablets 100% Dis 0% 40% Reopolyglucine 100% Dis 0% 40% 67% Dis Ringer solution 100% 100% 20% 67% Euphyline 100% Dis 77% 20% 67% 33% Glucose (5%) 0% 100% Diazepam 100% 100% Buxopan 0% 100% Neostigmine methylsulfate 0% 100% 0% 100% Relanium 100% Dis Curantil 67% Dis Ascorbic acid 67% Dis Promedol 0% 100% Glucose (20%) 77% 20% 67% 33%

Notes: 1. Frequently prescribed drugs are defined as those given to 50% or more of the PIH patients in either or both the Before and After groups. 2. This analysis could not be conducted for cases with moderate PIH in Torzhok because no moderate cases were found in the After group. 3. Similarly, no severe cases were found in the Before group in Vyshny Volochyok. “Dis” means discontinued (from use for PIH under new guidelines) or 0%.

Improving the Quality of Care Reduces Costs ■ 11 number of cases in the After groups Table 12 in each hospital makes before and Average Direct Cost per PIH Inpatient in Rubles, after comparisons speculative. In for Both Hospitals Combined by Case Severity Vyshny Volochyok, the drugs clofellini, gendevit tablets, Before After reopolyglucine, and Ringer solution were used more frequently in the Mild Moderate Severe Mild Moderate Severe After group, mostly for mild cases, Element of Care n = 33 n = 11 n = 3 n = 6 n = 3 n = 2 and Ringer solution for moderate Hospitalization 654 810 1,412 430 563 379 cases. In Torzhok, the drugs neostigmine methylsulfate, buxopan, Medication 139 349 625 74 76 125 and promedol were used in the After Paraclinical care (tests) 95 146 335 80 86 191 group for mild cases where they had not been used in the Before group. Total 888 1,294 2,372 584 726 695 Neostigmine methylsulfate was also used in severe cases in the After group where it had not been used in pected. Table 12 shows that in the very tentative because of the small the Before group. Use of Mg SO4 for Before group, direct inpatient costs sample sizes. convulsions did not change at for PIH were progressively higher in Torzhok. Overall, Vyshny Volochyok Moderate and severe cases of PIH more severe cases in all three used fewer drugs on average and had larger reductions in medication elements of inpatient care. The achieved a more significant reduc cost than mild cases (Table 13). An average direct costs for mild, tion in number and types of drugs important driver of this reduction moderate, and severe PIH were 888; used (50 percent reduction overall in was the decrease in the average 1,294; and 2,372 rubles, respec number and type) than Torzhok. number of different types of drugs tively. The average costs for mild, administered per patient (Table 14). Unit costs of inputs were generally moderate, and severe PIH were While patients with severe cases of higher at Torzhok than Vyshny roughly equal in the After group toxemia/PIH received the largest Volochyok, owing generally to a (584, 726, and 695 rubles, respec number of different types of drugs, higher cost of living in the Torzhok tively). Clearly, the average direct these patients also had the largest region. Torzhok prices were higher inpatient cost dropped substantially reduction in different types of drugs for hospital staff and food, drugs, for all severity levels following the used. Significant reductions also and clinical tests. For example, the introduction of the new guidelines, appeared in the moderate cases. cost of meals per hospital day was with larger decreases in the more 10 rubles at Torzhok compared to 6 severe cases. rubles at Vyshny Volochyok. Simi Prior to the study we thought that the Table 13 larly, the most frequently used new guidelines might lead to higher test—urine analysis—cost 5 rubles Average Cost of Medication average per-patient costs because at Torzhok and 4 at Vyshny the new guidelines recommended per PIH Inpatient for Volochyok. The guideline-recom- admitting fewer, higher-severity PIH Both Hospitals Combined, mended drug Mg SO4 cost 1.42 patients, who were expected to cost rubles per unit at Torzhok and 0.30 by Case Severity more. The data do not support this rubles at Vyshny Volochyok. expectation. No significant cost Mild Moderate Severe difference exists under the new Before 139 349 625 guidelines among the severity D. Differences by Case levels, and although a greater After 74 76 125 Severity proportion of the admitted cases are Percentage - 47% - 78% - 80% more severe than before the new Average direct cost per inpatient change varied according to the severity of guidelines, costs did not increase PIH in the Before group, as ex- (Table 3). These conclusions are

12■ Improving the Quality of Care Reduces Costs Reduced polypharmacy was present Table 14 at all severity levels (Table 15). For Number of Different Types of Drugs Used to Treat PIH by Case example, mild PIH cases reduced usage of all five of the most fre Severity (Both Hospitals Combined) quently used drugs, from roughly Mild Moderate Severe Overall one out of two patients receiving the drug Before to one out of three or Total number of different types of drugs used for all patients one out of six receiving it After. The Before 55 51 33 72 one exception is Mg SO4, which increased from one out of six Before After 21 15 14 32 to one out of two After, reflecting Percentage change - 62% - 70% - 42% - 55% compliance with the new guidelines. Similarly, among moderately severe Average number of different types of drugs used per patient cases, the most frequently used Before 8 14 23 10 drugs Before were less frequently used or discontinued After. All of After 5 6 8 6 these findings about the polyphar- Percentage change - 38% - 57% - 65% - 40% macy trends are based on very small sample sizes. Table 15 Percentage of PIH Cases Using Frequently Prescribed Drugs in VI. Assumptions and Before and After Groups, by Case Severity Potential Threats to (Both Hospitals Combined) Validity Mild PIH Moderate PIH Severe PIH Several necessary assumptions Before After Before After Before After related to factors that potentially n = 32 n = 6 n = 11 n = 3 n = 3 n = 2 weaken the study design are Papaverine hydrochloride 75% 33% 82% Dis 100% 50% discussed below: Glucose (40%) 69% 17% 73% Dis Decline in fertility rate. If the number of pregnancies in the Methylogobrevin 59% 17% 73% 33% 100% 50% population served by hospitals Dibasol 50% 17% 100% Dis declined between the Before and After periods (the population or the Novocaine 50% Dis 100% Dis fertility rate may have dropped), the Magnesium sulfate 16% 50% 100% 67% 100% 100% decline may have caused a drop in the number or severity of PIH cases. Reopolyglucine 73% Dis 100% Dis Changes in the fertility rate may Relanium 82% 33% have been due to a long-term trend, seasonality, or monthly fluctuations. Clofellini 18% 50% In fact, the fertility rate in Russia has Ringer solution 9% 67% 100% 100% been declining since before the fall of the USSR, which mandated an Euphyline 100% Dis expanded role for women outside Glucose 100% Dis the home (Da Vanzo et al. 2000; Zakharov et al. 1996). However, the Oxytocin 100% 50% size of this trend is very small over Diazepan 100% Dis the study period, so its effect on our findings is probably inconsequential. Notes: Frequently prescribed drugs are defined as those given to 50% or more of the PIH patients in either or both the Before and After group. “ Dis” means discontinued for PIH use under new guidelines, or 0%.

Improving the Quality of Care Reduces Costs ■ 13 Seasonality might also be a concern Cost of non-included hospital patients and their families), they because three of the six months in services. The cost of other hospital could increase the direct costs, the Before and After periods are the services provided to women, which might alter the reported same month of the year and three specifically the cost of medical savings. are not. We cannot estimate the procedures, such as deliveries and potential magnitude of a seasonality C-sections, was not expected to effect, but we do not believe it had change significantly following the VII. Conclusion and an important effect in this situation. implementation of the guidelines and was therefore excluded from our Discussion Decline in the incidence of measures of cost. Several points toxemia/PIH. If the incidence of When the new guidelines for PIH support this assumption: (a) the cost toxemia/PIH per pregnancy declined care were introduced in the pilot of a delivery, which will occur in all during the study period for some hospitals in Tver, health outcomes admitted cases, is in large part reason, this could account for at improved and hospital costs accounted for in the cost of drugs least part of the decline in admitted decreased. This result seems almost and hospitalization already calcu PIH cases. However, there is no too good to be true. However, the lated in the study for all severity evidence that this is the case. Given logic of the new guidelines supports types, and (b) the rate of C-sections current understanding of risk factors these results. The new guidelines among women with PIH does not for PIH in populations—mainly focus inpatient resources on fewer appear to have changed signifi positive family history, underlying and more severe cases of PIH, treat cantly: one case was observed in vascular disease, and first preg those cases more aggressively, and each group. nancy especially among adolescent rely on systematic outpatient care for mothers—no major changes Other interventions for inpatient identifying and triaging the PIH affecting these risk factors were care. We assumed that the ob cases that need close attention. detected. Related to this assumption served changes in PIH inpatient Three factors contributed most to the is the assumption that the incidence treatment patterns were all due to reduction in inpatient costs: reduc of pregnancies that were not carried the new guidelines. We know of no tion in the number of hospitalized to term in this population has not other intervention that influenced cases, reduction in length of changed. No specific data were PIH treatment. Further, it is plausible hospitalizations, and more rational found to contend this assumption. that the new guidelines caused the use of drugs. While the relatively observed changes because they Change in the definition of PIH. In small number of cases analyzed in were implemented with a high effect, the new guidelines changed the study makes it difficult to draw degree of compliance. the definition of PIH. We have firm conclusions, the findings corrected for this by assuming that Patient-borne costs. We measured strongly suggest that using the new the same number of suspected PIH patient-borne PIH drug costs in one guidelines is associated with patients presented in the After hospital in both the Before and After significant economic benefits. period as presented (and were periods and assumed that the same In the short run, further analysis of admitted) in the Before period for the pattern of patient-borne costs the effect of using clinical guidelines cost study. This could also influence applied in the second hospital. on costs at the outpatient level may the measured health outcome These costs were added to the be valuable. Preliminary results indicators, because some of the hospital-borne drug costs to obtain suggest that outpatient costs have women not admitted in the After total drug costs. On one hand, these been rationalized following the period (but who would have been patient-borne drug costs overstate implementation of the guidelines, admitted in the Before period) may the amount actually paid by the probably resulting in a small have had deliveries with negative hospital. On the other hand, if there decrease in costs. However, more health outcomes that were not are other patient-borne costs that we information on the patterns of care counted in the After period. As far as have not accounted for (e.g., for PIH outpatients is needed to we know, this was not the case, but informal payments to providers for determine the nature and magnitude we were unable to identify and track services and the provision of of the effects of the guidelines on the care of these women. medical supplies and foods by

14■ Improving the Quality of Care Reduces Costs care. Still, findings are encouraging should be considered and better and on future social and economic and consistent with expected results understood to make projections benefits would help position this of using the new guidelines. realistic. Also, the benefits obtained intervention in relation to other from improved health outcomes for proposed programs. Analysis of More data and analysis are needed women with PIH and their newborns factors that influence care practices, to confidently project the potential remain to be further studied and and by extension the extent of use economic benefit of the new quantified. For example, additional or non-use of guidelines, would also guidelines to the oblast level or on information on the impact of the new help to strengthen future analyses the long-term costs. Differences in guidelines on reduced drug interac (e.g., factors related to the charac the existing and potential patterns of tions from reduced polypharmacy, teristics of patients, providers, or treatment in different hospitals on potentially reduced sequelae, hospitals).

Endnotes

1 The Scope of Work included the following tasks: (a) Reach ment methodology are: (a) study the existing system of care for consensus on concepts and terminology in quality of health the improvement under consideration, (b) document existing care and publish a glossary, (b) Train a team of senior Russian clinical practices and content at each step, (c) review evi- health care professionals in quality improvement, (c) Develop dence-based literature on content of care, (d) update clinical two demonstration projects that introduce quality improvement content of care, (e) enhance system capability to accommo methods in the Russian Federation (one in primary care in Tula date updated content, and (f) review and update indicators to Oblast; the other in maternal and child health in Tver Oblast), fit updated content. (d) Develop indicators of quality to measure improvements in 5 The cost study data were not collected for as long as the quality of care, (e) Publish a Russian language quality “Health Outcomes” data described in Section III. improvement guide, and (f) Disseminate success stories of 6 quality improvement in Russia. At the time of this study, the exchange rate for $1.00 U.S. ranged from 21.5 to 28.6 rubles. 2 PIH is a complication of pregnancy characterized by elevated 7 There are two other groups of women who delivered during the blood pressure and sometimes by protein in the urine and edema after the 20th week of gestation. Its causes are not well study periods: those who were hospitalized with PIH but did understood. During pregnancy, PIH can progress to pre not receive outpatient care of any sort, and those who were not hospitalized with PIH and did not receive any outpatient care. A eclampsia, characterized by headaches, vomiting, impaired vision, abdominal pain, and further increases in blood much larger proportion of admitted women in the After group pressure, urine protein, and edema. In the most severe cases, did not receive outpatient care of any sort (5 of 11 or 45 percent) than in the Before group (9 of 47 or 19 percent). We pre-eclampsia progresses to eclampsia, characterized by convulsions. If untreated, eclampsia can result in death from do not know the reason for this. brain hemorrhage or from failure of the heart, liver, or kidney. 8 Including access to antenatal care services. Pre-eclampsia is associated with increased perinatal deaths 9 At each hospital the estimated cost per inpatient day is and increased newborn complications, especially if untreated. assumed to be constant throughout the study, and therefore the Risk factors for PIH include first pregnancy especially among change in total direct cost between the Before and After adolescents, overweight, family history, and underlying groups is proportional to the change in the number of PIH vascular diseases including diabetes. inpatient days (Total cost = inpatient days x cost per day). 3 “Toxemia” is the diagnostic classification generally used in However, the average cost per day is not the same in the two Russia in place of PIH. Toxemia typically includes all PIH cases hospitals, and therefore the total cost in both hospitals plus others. In this paper, the term “toxemia/PIH” refers to combined did not drop by the same proportion as the number women classified as having toxemia prior to the new guidlines of days. and women classified as having PIH after the guidelines were 10 Looking at only Vyshny Volochyok patients, total inpatient drug implemented. costs borne by patients represent about 56 percent of total 4 These references present examples of how this integrated inpatient drug costs in the Before group and about 30 percent methodology was applied in different clinical areas, including of inpatient drug costs in the After group. PIH, by the QA Project. The six steps in the EBCG develop

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