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