Laborist model improves obstetric outcomes and is cost-effective

SAN FRANCISCO – Compared with the traditional, on-call approach to coverage of labor and delivery units, the laborist model of continuous, uninterrupted coverage yields better obstetric outcomes and is cost-effective, according to a trio of studies reported at the Pregnancy Meeting, the annual meeting of the Society for Maternal-Fetal Medicine.

Improved maternal and birth outcomes

In a cohort study, Dr. Sindhu K. Srinivas, an obstetrician-gynecologist at the University of Pennsylvania in Philadelphia, and her team assessed changes in pregnancy outcomes over a 13-year period, comparing 8 hospitals that reported implementing a laborist approach with 16 matched hospitals that reported sticking to the traditional approach.

Adjusted analyses based on nearly 550,000 patients showed that women delivering in the laborist hospitals were less likely to have labor induction (odds ratio, 0.85) and preterm birth (OR, 0.83), with similar benefit for medically indicated birth and spontaneous preterm birth.

There were no significant differences in cesarean delivery, chorioamnionitis, intensive care unit admission, or prolonged length of stay, or in a variety of neonatal outcomes, such as birth asphyxia and death.

"Our study demonstrates that implementation of laborists is a promising obstetric care delivery model, but additional studies are needed to evaluate the impact of this model in different care settings and the mechanisms by which these outcomes are improved," Dr. Srinivas commented. "If we can understand the mechanisms of these outcome improvements, these lessons may be transferrable and may assist us in achieving optimal maternal and neonatal outcomes, even in settings without laborists."

Session attendee Dr. Manuel Porto, professor and chairman of obstetrics and gynecology at the University of California, Irvine, wondered about the uniformity of the laborist approach across hospitals. "Some hospitals will call themselves a laborist hospital when they have nocturn-ists, weekend-ists, and any other variation, when we are thinking of 24-hour-a-day, 7-day-a-week dedicated services," he commented. "That might have had a great impact on your results."

There are likely two levels of effects, Dr. Srinivas replied. "One is related to the laborist who is the provider and their skill set ... and the other has to do with a model of care where you take people who might have even already worked at your institution, add a couple of people who are laborists, or hospitalists, or nocturnists, or whatever, and actually combine that and create a model of care that’s 24-hour coverage," she explained. "It’s very hard to disentangle those things. So we are now doing some qualitative interviewing of the hospitals...to better answer that question."

In another cohort study, a team led by Dr. Yvonne W. Cheng of the University of California, San Francisco, retrospectively assessed obstetric outcomes of uncomplicated singleton term live births in hospitals having at least 1,200 births a year, using birth certificates linked to hospital discharge and death data.

They compared outcomes between 274,109 deliveries at hospitals using on-call, as-needed labor and delivery coverage and 465,913 deliveries at hospitals using 24-hour coverage, with type of coverage reported by staff.

Results showed that 24-hour coverage was associated with lower adjusted odds of cesarean delivery (odds ratio, 0.87), with the same reduction seen for nulliparas and for multiparas in terms of primary cesarean. The rate of cesarean delivery among women having labor induction did not differ significantly.

Continuous coverage was also associated with higher adjusted odds of a trial of labor after cesarean (TOLAC) (OR, 2.21) but, among women having such a trial, no difference in rates of vaginal birth after cesarean (VBAC).

The odds of neonatal asphyxia and neonatal death were statistically indistinguishable between the two groups.

Dr. Cheng acknowledged that it is unclear whether the observed changes were due to the laborist model or to other factors, or some combination.

"Even though we attempted to control for patient characteristics, could there exist inherent differences between the two groups of women which we could not measure? Or could the on-call physicians make medical decisions that differ from those of around-the-clock physicians given a similar clinical scenario? Alternatively, could the hospitals that implement around-the-clock coverage have different values and culture regarding labor management?" she proposed.

"Certainly more studies are needed to address these crucial questions," she concluded.

Cost-effective for many hospitals

In a third study, Allison Allen, a medical student at Oregon Health & Science University in Portland, and colleagues used a decision analytic model to assess the cost-effectiveness of the laborist approach, looking at time-to-delivery outcomes after introducing the emergent scenarios of umbilical cord prolapse and major abruption.

They used a hypothetical cohort of pregnant patients receiving care at hospitals that did and did not employ laborists; in base case analyses, the hospitals had 1,000 deliveries per year.

The investigators assessed a variety of costs, including the costs of delivery, of neonatal intensive care unit (NICU) care, and of caring for a child with cerebral palsy over their lifetime.

Results showed that when applied to 100,000 patients, compared with not employing laborists, employing laborists was associated with 38 fewer intrapartum stillbirths (an 83% reduction), 25 fewer cases of major neurodevelopmental injury (a 17% reduction), and 15 fewer cases of neonatal death (a 13% reduction) per year.

Employing laborists was also cost-effective, at a cost of $45,508 per quality-adjusted life-year (QALY) gained. In fact, that value is "well under our willingness-to-pay threshold of $100,000 per QALY," Ms. Allen noted.

However, employing laborists "never became the dominant model, meaning better outcomes at lower cost," she added. "Even in hospitals with up to 10,000 deliveries per year, the employment of a laborist was still not cost-saving to that hospital. This is in part due to the fact that there is an increased probability of physicians being available in hospitals without a laborist."

Sensitivity analyses showed that the model remained cost-effective down to a hospital volume of 424 deliveries per year.

"Our decision analytic model found that employment of laborists was cost-effective and produced better outcomes for moms and babies. ... Given these results, we believe that more research and discussion are necessary, not only on delineating time-to-delivery outcomes, but also on how to make 24-hour coverage of labor and delivery more feasible in small and midsized hospitals," Ms. Allen commented.

"As laborists may not generate the revenue to cover their salary, particularly in smaller hospitals, this raises an interesting dilemma: The costs of laborists must be taken on by the hospital, while the costs saved by the employment of this strategy are largely societal, being the costs of caring for neonates with major neurodevelopmental injury," she added. "However, our model did not take into account the decreased cost of litigation related to bad outcomes in hospitals without a laborist."

Attendee Dr. Michael Berman, of the Beth Israel Medical Center in New York, said, "I don’t think you should discount the importance of the litigation. Many hospitalist and laborist programs are being funded – just like patient safety programs – with funds from captive insurance companies. And it has definitely been shown to lower malpractice premiums. But on the other side of the coin, having better outcomes, even one baby a year, can really pay for a laborist program. ... I think it’s something we should all keep in mind."

And Dr. Jennifer Bailit, of the Case Western Reserve University School of Medicine in Cleveland, noted that some of the costs assessed in the study would not be ones seen by the hospital. "I just want to caution hospitals not to look at that data to say that it’s not going to be cost-effective for them to get a laborist model, because there is more to the story," she asserted.

Dr. Srinivas, Dr. Cheng, and Ms. Allen disclosed no relevant conflicts of interest.

SAN FRANCISCO – Compared with the traditional, on-call approach to coverage of labor and delivery units, the laborist model of continuous, uninterrupted coverage yields better obstetric outcomes and is cost-effective, according to a trio of studies reported at the Pregnancy Meeting, the annual meeting of the Society for Maternal-Fetal Medicine.

Improved maternal and birth outcomes

In a cohort study, Dr. Sindhu K. Srinivas, an obstetrician-gynecologist at the University of Pennsylvania in Philadelphia, and her team assessed changes in pregnancy outcomes over a 13-year period, comparing 8 hospitals that reported implementing a laborist approach with 16 matched hospitals that reported sticking to the traditional approach.

Adjusted analyses based on nearly 550,000 patients showed that women delivering in the laborist hospitals were less likely to have labor induction (odds ratio, 0.85) and preterm birth (OR, 0.83), with similar benefit for medically indicated birth and spontaneous preterm birth.

There were no significant differences in cesarean delivery, chorioamnionitis, intensive care unit admission, or prolonged length of stay, or in a variety of neonatal outcomes, such as birth asphyxia and death.

"Our study demonstrates that implementation of laborists is a promising obstetric care delivery model, but additional studies are needed to evaluate the impact of this model in different care settings and the mechanisms by which these outcomes are improved," Dr. Srinivas commented. "If we can understand the mechanisms of these outcome improvements, these lessons may be transferrable and may assist us in achieving optimal maternal and neonatal outcomes, even in settings without laborists."

Session attendee Dr. Manuel Porto, professor and chairman of obstetrics and gynecology at the University of California, Irvine, wondered about the uniformity of the laborist approach across hospitals. "Some hospitals will call themselves a laborist hospital when they have nocturn-ists, weekend-ists, and any other variation, when we are thinking of 24-hour-a-day, 7-day-a-week dedicated services," he commented. "That might have had a great impact on your results."

There are likely two levels of effects, Dr. Srinivas replied. "One is related to the laborist who is the provider and their skill set ... and the other has to do with a model of care where you take people who might have even already worked at your institution, add a couple of people who are laborists, or hospitalists, or nocturnists, or whatever, and actually combine that and create a model of care that’s 24-hour coverage," she explained. "It’s very hard to disentangle those things. So we are now doing some qualitative interviewing of the hospitals...to better answer that question."

In another cohort study, a team led by Dr. Yvonne W. Cheng of the University of California, San Francisco, retrospectively assessed obstetric outcomes of uncomplicated singleton term live births in hospitals having at least 1,200 births a year, using birth certificates linked to hospital discharge and death data.

They compared outcomes between 274,109 deliveries at hospitals using on-call, as-needed labor and delivery coverage and 465,913 deliveries at hospitals using 24-hour coverage, with type of coverage reported by staff.

Results showed that 24-hour coverage was associated with lower adjusted odds of cesarean delivery (odds ratio, 0.87), with the same reduction seen for nulliparas and for multiparas in terms of primary cesarean. The rate of cesarean delivery among women having labor induction did not differ significantly.

Continuous coverage was also associated with higher adjusted odds of a trial of labor after cesarean (TOLAC) (OR, 2.21) but, among women having such a trial, no difference in rates of vaginal birth after cesarean (VBAC).

The odds of neonatal asphyxia and neonatal death were statistically indistinguishable between the two groups.

Dr. Cheng acknowledged that it is unclear whether the observed changes were due to the laborist model or to other factors, or some combination.

"Even though we attempted to control for patient characteristics, could there exist inherent differences between the two groups of women which we could not measure? Or could the on-call physicians make medical decisions that differ from those of around-the-clock physicians given a similar clinical scenario? Alternatively, could the hospitals that implement around-the-clock coverage have different values and culture regarding labor management?" she proposed.

"Certainly more studies are needed to address these crucial questions," she concluded.

Cost-effective for many hospitals

In a third study, Allison Allen, a medical student at Oregon Health & Science University in Portland, and colleagues used a decision analytic model to assess the cost-effectiveness of the laborist approach, looking at time-to-delivery outcomes after introducing the emergent scenarios of umbilical cord prolapse and major abruption.

They used a hypothetical cohort of pregnant patients receiving care at hospitals that did and did not employ laborists; in base case analyses, the hospitals had 1,000 deliveries per year.

The investigators assessed a variety of costs, including the costs of delivery, of neonatal intensive care unit (NICU) care, and of caring for a child with cerebral palsy over their lifetime.

Results showed that when applied to 100,000 patients, compared with not employing laborists, employing laborists was associated with 38 fewer intrapartum stillbirths (an 83% reduction), 25 fewer cases of major neurodevelopmental injury (a 17% reduction), and 15 fewer cases of neonatal death (a 13% reduction) per year.

Employing laborists was also cost-effective, at a cost of $45,508 per quality-adjusted life-year (QALY) gained. In fact, that value is "well under our willingness-to-pay threshold of $100,000 per QALY," Ms. Allen noted.

However, employing laborists "never became the dominant model, meaning better outcomes at lower cost," she added. "Even in hospitals with up to 10,000 deliveries per year, the employment of a laborist was still not cost-saving to that hospital. This is in part due to the fact that there is an increased probability of physicians being available in hospitals without a laborist."

Sensitivity analyses showed that the model remained cost-effective down to a hospital volume of 424 deliveries per year.

"Our decision analytic model found that employment of laborists was cost-effective and produced better outcomes for moms and babies. ... Given these results, we believe that more research and discussion are necessary, not only on delineating time-to-delivery outcomes, but also on how to make 24-hour coverage of labor and delivery more feasible in small and midsized hospitals," Ms. Allen commented.

"As laborists may not generate the revenue to cover their salary, particularly in smaller hospitals, this raises an interesting dilemma: The costs of laborists must be taken on by the hospital, while the costs saved by the employment of this strategy are largely societal, being the costs of caring for neonates with major neurodevelopmental injury," she added. "However, our model did not take into account the decreased cost of litigation related to bad outcomes in hospitals without a laborist."

Attendee Dr. Michael Berman, of the Beth Israel Medical Center in New York, said, "I don’t think you should discount the importance of the litigation. Many hospitalist and laborist programs are being funded – just like patient safety programs – with funds from captive insurance companies. And it has definitely been shown to lower malpractice premiums. But on the other side of the coin, having better outcomes, even one baby a year, can really pay for a laborist program. ... I think it’s something we should all keep in mind."

And Dr. Jennifer Bailit, of the Case Western Reserve University School of Medicine in Cleveland, noted that some of the costs assessed in the study would not be ones seen by the hospital. "I just want to caution hospitals not to look at that data to say that it’s not going to be cost-effective for them to get a laborist model, because there is more to the story," she asserted.

Dr. Srinivas, Dr. Cheng, and Ms. Allen disclosed no relevant conflicts of interest.

SAN FRANCISCO – Compared with the traditional, on-call approach to coverage of labor and delivery units, the laborist model of continuous, uninterrupted coverage yields better obstetric outcomes and is cost-effective, according to a trio of studies reported at the Pregnancy Meeting, the annual meeting of the Society for Maternal-Fetal Medicine.

Improved maternal and birth outcomes

In a cohort study, Dr. Sindhu K. Srinivas, an obstetrician-gynecologist at the University of Pennsylvania in Philadelphia, and her team assessed changes in pregnancy outcomes over a 13-year period, comparing 8 hospitals that reported implementing a laborist approach with 16 matched hospitals that reported sticking to the traditional approach.

Adjusted analyses based on nearly 550,000 patients showed that women delivering in the laborist hospitals were less likely to have labor induction (odds ratio, 0.85) and preterm birth (OR, 0.83), with similar benefit for medically indicated birth and spontaneous preterm birth.

There were no significant differences in cesarean delivery, chorioamnionitis, intensive care unit admission, or prolonged length of stay, or in a variety of neonatal outcomes, such as birth asphyxia and death.

"Our study demonstrates that implementation of laborists is a promising obstetric care delivery model, but additional studies are needed to evaluate the impact of this model in different care settings and the mechanisms by which these outcomes are improved," Dr. Srinivas commented. "If we can understand the mechanisms of these outcome improvements, these lessons may be transferrable and may assist us in achieving optimal maternal and neonatal outcomes, even in settings without laborists."

Session attendee Dr. Manuel Porto, professor and chairman of obstetrics and gynecology at the University of California, Irvine, wondered about the uniformity of the laborist approach across hospitals. "Some hospitals will call themselves a laborist hospital when they have nocturn-ists, weekend-ists, and any other variation, when we are thinking of 24-hour-a-day, 7-day-a-week dedicated services," he commented. "That might have had a great impact on your results."

There are likely two levels of effects, Dr. Srinivas replied. "One is related to the laborist who is the provider and their skill set ... and the other has to do with a model of care where you take people who might have even already worked at your institution, add a couple of people who are laborists, or hospitalists, or nocturnists, or whatever, and actually combine that and create a model of care that’s 24-hour coverage," she explained. "It’s very hard to disentangle those things. So we are now doing some qualitative interviewing of the hospitals...to better answer that question."

In another cohort study, a team led by Dr. Yvonne W. Cheng of the University of California, San Francisco, retrospectively assessed obstetric outcomes of uncomplicated singleton term live births in hospitals having at least 1,200 births a year, using birth certificates linked to hospital discharge and death data.

They compared outcomes between 274,109 deliveries at hospitals using on-call, as-needed labor and delivery coverage and 465,913 deliveries at hospitals using 24-hour coverage, with type of coverage reported by staff.

Results showed that 24-hour coverage was associated with lower adjusted odds of cesarean delivery (odds ratio, 0.87), with the same reduction seen for nulliparas and for multiparas in terms of primary cesarean. The rate of cesarean delivery among women having labor induction did not differ significantly.

Continuous coverage was also associated with higher adjusted odds of a trial of labor after cesarean (TOLAC) (OR, 2.21) but, among women having such a trial, no difference in rates of vaginal birth after cesarean (VBAC).

The odds of neonatal asphyxia and neonatal death were statistically indistinguishable between the two groups.

Dr. Cheng acknowledged that it is unclear whether the observed changes were due to the laborist model or to other factors, or some combination.

"Even though we attempted to control for patient characteristics, could there exist inherent differences between the two groups of women which we could not measure? Or could the on-call physicians make medical decisions that differ from those of around-the-clock physicians given a similar clinical scenario? Alternatively, could the hospitals that implement around-the-clock coverage have different values and culture regarding labor management?" she proposed.

"Certainly more studies are needed to address these crucial questions," she concluded.

Cost-effective for many hospitals

In a third study, Allison Allen, a medical student at Oregon Health & Science University in Portland, and colleagues used a decision analytic model to assess the cost-effectiveness of the laborist approach, looking at time-to-delivery outcomes after introducing the emergent scenarios of umbilical cord prolapse and major abruption.

They used a hypothetical cohort of pregnant patients receiving care at hospitals that did and did not employ laborists; in base case analyses, the hospitals had 1,000 deliveries per year.

The investigators assessed a variety of costs, including the costs of delivery, of neonatal intensive care unit (NICU) care, and of caring for a child with cerebral palsy over their lifetime.

Results showed that when applied to 100,000 patients, compared with not employing laborists, employing laborists was associated with 38 fewer intrapartum stillbirths (an 83% reduction), 25 fewer cases of major neurodevelopmental injury (a 17% reduction), and 15 fewer cases of neonatal death (a 13% reduction) per year.

Employing laborists was also cost-effective, at a cost of $45,508 per quality-adjusted life-year (QALY) gained. In fact, that value is "well under our willingness-to-pay threshold of $100,000 per QALY," Ms. Allen noted.

However, employing laborists "never became the dominant model, meaning better outcomes at lower cost," she added. "Even in hospitals with up to 10,000 deliveries per year, the employment of a laborist was still not cost-saving to that hospital. This is in part due to the fact that there is an increased probability of physicians being available in hospitals without a laborist."

Sensitivity analyses showed that the model remained cost-effective down to a hospital volume of 424 deliveries per year.

"Our decision analytic model found that employment of laborists was cost-effective and produced better outcomes for moms and babies. ... Given these results, we believe that more research and discussion are necessary, not only on delineating time-to-delivery outcomes, but also on how to make 24-hour coverage of labor and delivery more feasible in small and midsized hospitals," Ms. Allen commented.

"As laborists may not generate the revenue to cover their salary, particularly in smaller hospitals, this raises an interesting dilemma: The costs of laborists must be taken on by the hospital, while the costs saved by the employment of this strategy are largely societal, being the costs of caring for neonates with major neurodevelopmental injury," she added. "However, our model did not take into account the decreased cost of litigation related to bad outcomes in hospitals without a laborist."

Attendee Dr. Michael Berman, of the Beth Israel Medical Center in New York, said, "I don’t think you should discount the importance of the litigation. Many hospitalist and laborist programs are being funded – just like patient safety programs – with funds from captive insurance companies. And it has definitely been shown to lower malpractice premiums. But on the other side of the coin, having better outcomes, even one baby a year, can really pay for a laborist program. ... I think it’s something we should all keep in mind."

And Dr. Jennifer Bailit, of the Case Western Reserve University School of Medicine in Cleveland, noted that some of the costs assessed in the study would not be ones seen by the hospital. "I just want to caution hospitals not to look at that data to say that it’s not going to be cost-effective for them to get a laborist model, because there is more to the story," she asserted.

Dr. Srinivas, Dr. Cheng, and Ms. Allen disclosed no relevant conflicts of interest.