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Keywords:

  • Economic analysis;
  • fetal pulse oximetry;
  • randomised controlled trial

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Appendix

Objective  To report an economic analysis of the Australian intrapartum fetal pulse oximetry (FPO) multicentre randomised controlled trial (the FOREMOST trial), which examined whether adding FPO to conventional cardiotocographic (CTG) monitoring (intervention group) was cost-effective in reducing operative delivery rates for non-reassuring fetal status compared with the use of CTG alone (control group).

Design  Cost-effectiveness analysis of the FOREMOST trial.

Setting  Four Australian maternity hospitals, each with more than 4000 births/year.

Population  Women in labour at ≥36 weeks of gestation, with a non-reassuring CTG.

Methods  Costs were for treatment-related expenses, incorporating diagnosis-related grouping costs and direct costs (including fetal monitoring). Incremental cost-effectiveness ratio (ICER) and cost-effectiveness plane were calculated, and sensitivity analysis was conducted. The primary outcome was that of the clinical trial: operative delivery for non-reassuring fetal status avoided in the intervention group relative to that in the control group.

Main outcome measures  The ICER.

Results  The ICER demonstrated a saving of $A813 for each operative birth for non-reassuring fetal status averted by the addition of FPO to CTG monitoring compared with the use of CTG monitoring alone.

Conclusion  The addition of FPO to CTG monitoring represented a less costly and more effective use of resources to reduce operative delivery rates for non-reassuring fetal status than the use of conventional CTG monitoring alone.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Appendix

Monitoring of fetal wellbeing during labour is undertaken to identify fetal problems, which, if left uncorrected, may result in death or morbidity. The most common form of fetal assessment during labour is through cardiotocography (CTG), which is limited by a high false-positive rate, resulting in an unnecessarily high rate of operative delivery for non-reassuring fetal status.1

Compared with spontaneous vaginal delivery, operative deliveries are more costly,2 result in greater length of stay of patients and greater posthospital discharge costs.3 Caesarean section is now one of the most common major surgical procedures in the western world, accounting for up to 27% of Australia’s 250 000 annual births,4 with similar rates reported in other industrialised countries.5,6 Reducing the economic burden of avoidable operative births for non-reassuring fetal status is therefore an important health resource consideration.

Fetal pulse oximetry (FPO) aims to improve the accuracy of evaluation of fetal wellbeing in labour and so reduce unnecessary and costly operative intervention.7 We have reported a multicentre randomised controlled trial (RCT) of intrapartum FPO (the FOREMOST trial).8

The findings of perinatal RCTs can be contextualised by an economic evaluation reporting outcomes relevant to healthcare consumers, providers and policy makers. RCTs of models of antenatal care,9 antenatal hepatitis C screening10 and induction of labour,11,12 among others, have reported economic analyses. Such economic evaluations are increasingly becoming expected. We report here the economic analysis of the FOREMOST trial. Specifically, we examined whether adding FPO to CTG monitoring was a cost-effective intervention in reducing the operative delivery rate for non-reassuring fetal status compared with the use of CTG alone.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Appendix

The FOREMOST trial

We have recently described the methodology of the FOREMOST trial, including inclusion and exclusion criteria and procedures for participants in each of the two study groups when non-reassuring fetal status was identified.8 Briefly, with ethical approval from the relevant ethics committees, the FOREMOST trial was conducted in four Australian maternity hospitals, each with more than 4000 births/year: the Royal Brisbane and Women’s Hospital, Brisbane, Queensland; the Mater Mothers’ Hospital, Brisbane, Queensland; the Royal Hospital for Women, Sydney, New South Wales and the Royal Women’s Hospital, Melbourne, Victoria, between July 1999 and September 2004. Consenting women whose fetuses showed a non-reassuring fetal heart rate pattern during labour were randomised to one of the two study groups: continued conventional CTG monitoring (control, CTG-only group) or the addition of FPO to the CTG monitoring (intervention, FPO + CTG group). In the FPO + CTG group, a sensor was placed on the fetal temple or cheek during a vaginal examination and connected to an oximeter (Nellcor OxiFirst; TYCO Inc., Pleasanton, CA, USA). There was a statistically significant 23% relative risk reduction in the primary outcome: operative delivery for non-reassuring fetal status in those allocated to the intervention group (FPO + CTG monitoring, n= 76, 25%) compared with those allocated to the control group (CTG only, n= 95 [32%]) (FPO + CTG : CTG only—relative risk 0.77, 95% CI 0.599–0.999, P=0.048, absolute risk reduction 0.07). Analyses in this study are based on the absolute risk reduction of 7%. There were no between-group differences in overall operative delivery rates or neonatal outcomes.8

Economic evaluation of the FOREMOST trial

The economic analysis of the FOREMOST trial was undertaken in Australian dollars, with the base year being 2004. Readers from other countries may wish to convert our findings to local currencies: currency conversion rates at June 2004 were $A1.00 equivalent to $US0.69030 or 0.57135 Euros. We used cost-effectiveness analysis (CEA) that compared the cost and effectiveness of the new clinical strategy: adding FPO to conventional CTG monitoring versus conventional CTG monitoring alone. This method determines the ‘price’ of the additional outcome purchased by changing from current practice (CTG only) to the new strategy (FPO + CTG). The CEA examined change in resource use and outcome at the margin for the prespecified primary outcome: operative delivery for non-reassuring fetal status averted by the addition of FPO. Costs were for treatment-related expenses and included direct medical costs, such as fetal monitoring procedures, equipment, medications, delivery and postnatal stay. A social perspective, incorporating all costs that may accrue, is the preferred viewpoint in economic evaluation. However, given the uniformity of the treatment environment in which the study was undertaken, we considered a limited perspective of costs from the viewpoint of the health service appropriate for this evaluation.13

Resources used in the provision of care were predominantly measured using a top-down approach and supplemented with bottom-up estimates. Clinical records provided information on the type and nature of delivery, specifically operative delivery for non-reassuring fetal status and overall caesarean section. Case notes were matched with relevant hospital-assigned diagnosis-related group (DRG) codes to estimate costs associated with delivery and neonatal admission in each hospital. DRGs are used in Australian hospitals to categorise patients according to the nature and type of care provided in the hospital.14 Such a system is preferred to the use of International Classification Disease (ICD) codes alone as it incorporates about 10 000 ICD codes into a manageable number of broad categories. All DRG costs were adjusted for inflation to costs in 2004 using the Consumer Price Index (CPI) index for hospital and medical services.15Table 1 shows the range of maternal delivery DRGs as an example. Details of the numerous possible neonatal DRGs are available on the Foremost website.16 Although DRGs are presented as average costs per episode of care, their derivation is based on a summation of direct and indirect costs calculated across a range of cost buckets (components of costs) divided by the total number of separations for that DRG. Cost buckets used in estimates included clinical and nonclinical services (ward medical and ward nonmedical), pathology, imaging, allied, pharmacy, critical care, operating rooms, emergency room departments, hotel and depreciation.17 For example, DRG O01D is the code for a caesarean delivery without complicating diagnosis. In New South Wales, DRG O01D costs $5353, comprising $3653 in direct costs and $1699 in overhead costs. The cost bucket responsible for the greatest resource use in this code is nursing, with direct costs of $1635 and overhead costs of $102. Two features of Table 1 are worth noting. First, cost weights vary by state and across hospitals within the same state, predominantly arising through variations in state-based hospital pricing arrangements. Second, operative deliveries are generally more expensive than vaginal deliveries, with costs varying in accordance with severity of complications.

Table 1.  DRGs for birthing procedures in Australian hospitals17*
DRG codeDRG descriptionAverage cost per DRG ($A)
New South WalesVictoriaQueensland
  • Details of the numerous possible neonatal DRGs used in the analysis are available on the FOREMOST website.16

  • *

    DRG costs for this economic analysis were assigned according to the hospital and State where each woman gave birth.

O01ACaesarean delivery (multiple complicating diagnoses, at least one severe)923613 1716955
O01BCaesarean delivery (severe complicating diagnosis)619577425808
O01CCaesarean delivery (moderate complicating diagnosis)561869665830
O01DCaesarean delivery without complicating diagnosis535357865009
O02ZVaginal delivery with complicating operating room procedure547857614641
O60AVaginal delivery (multiple complicating diagnoses, at least one severe)462954773844
O60BVaginal delivery (severe complicating diagnosis)364438243167
O60CVaginal delivery (moderate complicating diagnosis)358136123225
O60DVaginal delivery without complicating diagnosis309030052422

The bottom-up approach to costing involved identifying resource use at the patient level specific to the trial and not otherwise captured within the DRGs: fetal scalp blood sampling, medications, use of oxygen and/or intravenous hydration fluid and intervention-related equipment including the FPO unit, FPO sensors, fetal blood sampling kits and fetal blood sampling analysis units.

To ensure that resource use data could be legitimately compared across the four trial sites, a standardised methodology was applied, which involved the application of uniform data collection procedures and valuation techniques. Resource use was predominantly ascertained using clinical records and specific data collected as part of the trial. Resources were valued according to local prices. Medications were valued using the Australian Pharmaceutical Benefit Scheme.18 The annuitised cost of intervention-specific equipment was valued from the source.

Consistent with guidelines for conducting economic evaluation,19 results are presented in terms of an incremental cost-effectiveness ratio (ICER) to ascertain the additional cost per unit of benefit associated with moving to the new assessment technique. The ICER is calculated using the following formula:

  • image

where i is the intervention group (FPO + CTG), co is the control group (CTG only), cost is the average cost of resources used in the treatment and effect is the proportion of operative deliveries for non-reassuring fetal status averted by the addition of FPO to CTG monitoring (primary outcome). The difference between effect in the intervention group and that in the control group is the absolute risk reduction. Results of the ICER are presented in two complementary ways: numerically, in terms of a point estimate, with 95% confidence intervals, and diagrammatically, in terms of a cost-effectiveness plane, constructed by plotting the incremental costs and incremental effects of an intervention on a two-dimensional graph.20

Statistical uncertainty arises when a variable includes a range of estimates within which the true value is likely to be found. In economic analyses, the uncertainty surrounding the ICER is presented in a cost-effectiveness plane (Figure 1). This contains four quadrants representing four possible outcomes related to the costs and effects of the control and intervention groups. The first outcome, where an intervention is less costly but more effective than the control (CostsI < CostsC [CI > CC] and EffectsI > EffectsC [EI > EC]), is located in the southeast quadrant; the second outcome (CI > CC and EI < EC) in the northwest quadrant; the third outcome (CI > CC and EI > EC) in the northeast quadrant and the fourth outcome (CI < CC and EI < EC) in the southwest quadrant.

image

Figure 1. Cost-effectiveness plane. The point estimate of the ICER falls into the southeast quadrant. This represents the intervention (addition of FPO to conventional CTG monitoring) being more effective and less expensive than the control (CTG only).

Download figure to PowerPoint

To present the ICER on a cost-effectiveness plane, the point estimate of the change in costs is plotted on the y-axis, while the point estimate from the change in effects is plotted on the x-axis.

Sensitivity analysis, an important component of determining uncertainty,13 was also undertaken to examine the robustness of results when a key cost driver was varied. Throughout the trial, it was assumed that the FPO unit was used at full capacity. The sensitivity analysis explored the cost implications of varying the levels of capacity. Based on the 2402 fetal heart rate traces identified as being eligible for trial inclusion8 and the lengths of time the trial was conducted at each hospital, we estimated that there were approximately 282 non-reassuring fetal heart rate traces per hospital per year. It was therefore assumed that an FPO unit would be required for 5.4 births/week (per hospital), varied from four births to seven births/week for the purposes of the sensitivity analysis.

The location and spread of baseline demographic data were summarised using proportions, mean and SD or using median and interquartile range, as appropriate. Chi-square test/Fisher’s exact test, t tests or Mann–Whitney U test were used, as appropriate, to compare baseline patient characteristics for factors that may have influenced maternal or fetal morbidity. We planned to use regression modelling to address any differences in baseline patient characteristics, which may have influenced costings.21

As parametric assumptions do not necessarily hold for the ICER, bootstrap resamples were used to explore the statistical inferences of ICERs.20 Bootstrap resampling is based on repeated random sampling with replacement from an original sample to provide a collection of new pseudoreplicate samples, from which sampling variance can be estimated. In keeping with accepted practice, a total of 2000 replicates were taken from each sample and the bias-corrected accelerated method22 used to calculate 95% confidence intervals about the sample estimate of the ICER.

Statistical analyses were performed using SPSS for Windows, version 13 (SPSS Inc., Chicago, IL, USA) and @Risk software (Palisade Corporation, New York, NY, USA).

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Appendix

Baseline demographics, clinical characteristics and non-reassuring CTG features that allowed for study entry were similar for each group (Table 2).8 Total and mean costs for the intervention and control groups are reported in Table 3, with the ICER. The majority of participant costs accrued due to hospital DRGs (about 99% for both groups). Other costs of intrapartum resource use are shown in Table 4.

Table 2.  Baseline characteristics. Reproduced with permission from East et al. Am J Obstet Gynecol 2006;194:606, e1–16.8
CharacteristicsIntervention (FPO + CTG) (n= 305)Control (CTG only) (n= 295)P value*
  • VE, vaginal examination. Data for the two study groups are given as mean (SD), number of patients (%) or median (interquartile range).

  • *

    Chi-square test unless otherwise indicated.

  • T test.

  • Mann–Whitney U test.

  • §

    Fisher’s exact test.

  • One or more of chronic hypertension, pregnancy-induced hypertension, eclampsia, pre-pregnancy diabetes, glucose intolerance in pregnancy, no prenatal care, maternal cardiac disease, maternal renal disease.

  • One or more of small for dates/intrauterine growth restriction, polyhydramnios, oligohydramnios, >42 weeks of gestation, <37 weeks of gestation, maternal substance use (alcohol, drugs, smoking).

  • #

    Birthweight categories that influence DRGs.

  • **

    Birthweight >4000 g could suggest increased risk for shoulder dystocia and therefore affect neonatal morbidity and DRG.

  • ††

    All were prerandomisation.

Maternal age (years)29.72 (5.806)28.92 (5.620)0.087
Hospital status, n (%)
Public288 (94.4)276 (93.6)0.655
Private17 (5.6)19 (6.4)
Nulliparous247 (81.0)226 (76.6)0.190
Cervical dilatation on first VE (cm)3 (2, 3.9)3 (2, 4)0.775
Station on first VE−2 (0.8)−2 (0.8)0.538
Previous caesarean—overall, n (%)19 (6.2)16 (5.4)0.674
Previous caesarean for dystocia/failure to progress3 (1.0)3 (1.0)0.817
Previous caesarean for non-reassuring fetal status8 (2.6)5 (1.7)0.508
Previous caesarean for non-reassuring fetal status + dystocia/failure to progress0 (0)2 (0.7)0.202§
Maternal risk factors ≥ 1, n (%)110 (36.1)117 (39.7)0.364
Fetal risk factors ≥ 1, n (%)84 (27.5)86 (29.2)0.661
Birthweight (g)3435.3 (500.88)3440.9 (510.27)0.893
1500–1999, n (%)#2 (0.6)0 (0)0.499§
2000–2499, n (%)#9 (3.0)15 (5.1)0.182
>2499, n (%)#294 (96.4)280 (94.9)0.374
>4000, n (%)**33 (10.8)35 (11.9)0.687
Induction of labour, n (%)140 (45.9)144 (48.8)0.475
Artificial rupture of membranes, n (%)††162 (53.1)171 (58.0)0.232
Meconium liquor, n (%)116 (38.0)115 (39.0)0.811
Epidural analgesia, n (%)274 (89.8)254 (86.1)0.159
Table 3.  Cost increment and ICER
 Intervention group (FPO + CTG) (n= 305)Control group (CTG only) (n= 295)
  • *

    Costs per person in the intervention group comprised an average of $105.50 in diagnostics, $2.60 in medications and $7273.30 in DRGs. Costs per person in the control group comprised an average of $26.60 in diagnostics, $2.50 in medications and $7411.60 in DRGs.

  • **

    Change in effect: absolute risk reduction of operative delivery for non-reassuring fetal status.

  • ***

    Saving per operative delivery averted for non-reassuring status in the intervention group compared with the control group.

Total cost ($)2 251 3412 194 997
Mean cost* (SD) ($)7381 (2229)7441 (2334)
Change in cost per person (intervention—control) ($)−59.25
Change in effect** (intervention—control) (%)7
ICER*** (%)−813.25
Table 4.  Intrapartum resource use* and unit cost data
ItemUnit cost ($A)Intervention group (FPO + CTG)Control group (CTG only)
Number of participants**Number of units**Total cost ($A)Number of participantsNumber of unitsTotal cost ($A)
  • NRFS, non-reassuring fetal status.

  • *

    Pre- and postrandomisation.

  • **

    One participant could use several units during the trial, i.e. have the procedure repeated or have it interrupted with later recommencement.

  • ***

    Sensor placement was not attempted in 11 participants; more than one sensor placement occurred in 24 participants due to unsuccessful placement on the first attempt.

Fetal scalp blood sampling
pH103241410991451450
Lactate4.64121778.885574343.36
Sampling kits31418927591552096479
FSpO2 sensor***9029431828 620 
Antibiotics (various)0.0016–0.0686/mg110214895.5898168633.09
Intravenous fluid bolus for NRFS1.52/l394117.00373718.16
Maternal administration of oxygen for NRFS0.000005/l80930.1366710.15
Neonatal naloxone19.3301119.33

ICER data are shown in Table 3. Using (i) the decrease in average cost per patient for the intervention group compared with that for the control group and (ii) the incremental (absolute risk) reduction in operative delivery for non-reassuring fetal status for the intervention group compared with that for the control group, the point estimate of ICER was −$813.25, indicating a saving of $813.25 per operative delivery averted for non-reassuring fetal status, compared with the control group. The upper limit of the 95% confidence interval of the ICER was $191 198. The lower limit was dominant as a result of the intervention being both less expensive and more effective than the conventional methods and is therefore not reported since it is a meaningless number. In this situation, the cost-effectiveness plane provides a visual and more meaningful estimate of uncertainty.20

The point estimate of the ICER falls in the southeast quadrant of the cost-effectiveness plane (Figure 1), the quadrant where the intervention (FPO + CTG) is less costly but more effective than the control (CTG only).

After varying the assumptions regarding the number of births per day involving the FPO unit, the sensitivity analysis showed that the ICER varied from −$770 (when four births/week were assumed) to −$840 (when seven births/week were assumed).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Appendix

This economic evaluation of the FOREMOST trial found that the addition of FPO to conventional CTG monitoring was cost-effective in reducing the operative delivery rate for non-reassuring fetal status, compared with the use of CTG alone. The ICER of −$813 represents a saving of $813 for each operative delivery averted, with little variance between the upper and lower limits for the key assumptions of the FPO unit usage, thereby allowing confidence in the estimation of the ICER.

In understanding the possible policy and clinical implications of this finding, it is important to reflect on some of the key features of this economic evaluation. First, data came from a randomised clinical trial conducted at four hospitals in three Australian states. A common protocol was followed, and uniform data collection instruments were implemented; hence, consistency of data was ensured. Second, a CEA was deemed the most appropriate type of economic appraisal for comparison of two strategies for the same clinical indication. Third, while the economic analyst may adopt a number of perspectives, with the societal perspective considered the most comprehensive, such a viewpoint was considered beyond the scope and purpose of the present analysis. This analysis was therefore conducted from the viewpoint of the treatment provider, excluding costs to the patients, family, carers and other postdischarge treatment costs. Fourth, effect was prespecified as the primary outcome of operative delivery for non-reassuring fetal status since this is the purpose of FPO monitoring. Would effect on overall caesarean section (or any of the other outcomes reported8) have been more appropriate? Post hoc selection of outcomes is subject to bias and lacks the logic argued below for the a priori selection of operative delivery for non-reassuring fetal status, that is considering the purpose of FPO and the impact of indication for operative delivery on other costs. If we had retrospectively selected the nonsignificant difference in overall caesarean section rates as the measure of effect, we could have argued that the ICER favoured FPO, or, conversely, using overall operative delivery as the measure of effect, we would find an ICER that favoured CTG only. Such post hoc selection of a measure of effect is clearly biased in that it allows the investigators to pursue their preferred interpretation of findings. Therefore, we remain confident in the appropriateness of the measure of effect being the trial’s primary outcome, specified before results of the RCT were known.

The indication for operative intervention does not influence DRGs and was therefore not incorporated into this CEA. There are cost implications to the health service of a caesarean section performed for non-reassuring fetal status, which, in Australian maternity hospitals, could be expected to be performed a median 42 minutes from the time of decision.23 Staffing costs may be considerably higher if additional personnel are called in or staff work overtime to accommodate the emergency, than for a less urgent caesarean section performed for other indications, which may have a longer decision to delivery interval without compromising fetal wellbeing. The statistically significant finding of operative births avoided (specifically birth by caesarean section) for non-reassuring fetal status in the intervention group may therefore have had a greater impact on cost reduction than this analysis demonstrates and may be explored in future studies.

A second major impact on maternal DRG differences is caesarean section (compared with vaginal birth), which may be further impacted upon by complicating diagnoses (maternal morbidity) as sequelae. Neonatal DRGs are influenced by birthweight (for example 2000–2499 g or ≥2499 g), death or transfer to another hospital at <5 days of age, significant operative procedures and/or major problems.17 Given these considerations, could the cost difference between the two study groups have been influenced by an imbalance of factors other than the intervention (or lack of intervention)? We found no difference in baseline characteristics of maternal risk factors (including chronic hypertension, pregnancy-induced hypertension, eclampsia, diabetes, no prenatal care, maternal cardiac disease or maternal renal disease) between the two study groups. There was no statistically significant difference between the proportion of babies in birthweight categories (Table 2), postrandomisation CTG patterns or of those requiring admission to the neonatal intensive care unit.8 There were no between-group differences in lengths of maternal or neonatal hospital stay.8 Therefore, our data do not reveal any potential influence on hospital-assigned DRGs of between-group differences in maternal or neonatal complications that would explain the between-group cost differences.

There are no reports of economic evaluation of FPO in the peer-reviewed literature, despite the desirability of economic analysis in perinatal clinical trials.9–12 However, the conduct of an economic analysis is appropriate, from the viewpoint of childbearing women, clinicians, administrators and policy makers, to identify both the costs and the effectiveness of alternative forms of treatment/monitoring/models of service delivery. Future studies may address the potential limitations of our study, including approaching the analysis from a societal perspective and a priori selection of a less intermediate outcome.

Having now satisfied the emergent standards of demonstrating both the cost-effectiveness and the clinical effectiveness of the addition of FPO to conventional CTG monitoring to reduce operative delivery for non-reassuring fetal status, is it now appropriate to introduce FPO to the clinical setting?

Stakeholders (childbearing women, clinicians and administrators) at individual hospitals will need to determine whether or not the saving of $813 per operative delivery avoided warrants the introduction of FPO to their perinatal setting. The pragmatic nature of the FOREMOST trial, particularly the indication for operative delivery being as documented by the clinician, rather than retrospectively assigned according to an algorithm by the researchers, suggests that the findings would be generalisable outside the trial setting. In Australia, the use of FPO outside the trial setting is limited. Its’ future introduction is limited by the current unavailability of the product from the manufacturer. Should that alter, units introducing FPO would need to make a moderate investment in training: midwives and doctors with varying levels of Birth Suite experience rated ease of sensor placement favourably.24 Childbearing women rated their experience with FPO favourably during the trial, suggesting that the addition of technology when there was concern about fetal wellbeing did not negatively impact their birth experience.25 The introduction of FPO units would not require substantial financial outlay since (i) the addition of FPO did not result in increased costs for the primary outcome or for caesarean section and (ii) the equipment was estimated to be used between four and seven times per week, implying that only one FPO unit would be required per hospital.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Appendix

The addition of FPO to CTG monitoring represents a less costly and more effective use of resources to reduce operative delivery rates for non-reassuring fetal status than the use of conventional CTG monitoring alone.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Appendix

We thank the childbearing women and their babies who participated in the FOREMOST trial, and the midwifery and medical staff at the respective Birth/Delivery Suites who actively assisted in recruitment to and conduct of the trial. We also thank the health information services personnel at the participating hospitals for providing details of DRGs.

Funding

This research was funded by the Australian National Health and Medical Research Council (grant #142936 and #301050), Queensland Health, TYCO Inc. (Nellcor) and the University of Queensland.

The FOREMOST study group

The FOREMOST study group included the following: Andrews K (research midwife, Mater Mothers’ Hospital, Brisbane); Aziz R (research midwife, Mater Mothers’ Hospital, Brisbane); Barr K (research midwife, Royal Brisbane and Women’s Hospital, Brisbane); Beller E (statistician, final analysis); Chan FY (investigator, Mater Mothers’ Hospital, Brisbane); Cleary K (research midwife, Mater Mothers’ Hospital, Brisbane); Crowther C (data monitoring committee member); Davies J (research midwife, Mater Mothers’ Hospital, Brisbane); Dunster K (establishment and maintenance of the randomisation system); Everding D (research midwife, Royal Brisbane and Women’s Hospital, Brisbane); Healy G (data management); Henderson-Smart D (data monitoring committee member); Hockey R (statistician, interim analysis; data monitoring committee member); Leader L (collaborator, Royal Hospital for Women, Sydney); Henshall N (research midwife, Royal Hospital for Women, Sydney); Moroney L (research midwife, Royal Brisbane and Women’s Hospital, Brisbane) and Stewart M (research midwife, Royal Women’s Hospital, Melbourne).

Neonatal DRGs

Also available on the Foremost website.16

  1. Adm, admission; g, grams; Multi, multiple; O.R., operating room; Proc, procedure; Tfer, transferred; W, with; W/O’, without; Wt, weight.

  2. Source: Australian Government Department of Health and Ageing. National Hospital Cost Data Collection: Cost Report Round 7. Canberra, Australia: Commonwealth Department of Health and Ageing, 2004

P01Z—Neonate, Died or Tfer <5 days of Admission W Significant O.R. Procedure
P02Z—Cardiothoracic/Vascular Procedures for Neonates
P03Z—Neonate, Adm Wt 1000–1499 g W Significant O.R. Procedure
P04Z—Neonate, Adm Wt 1500–1999 g W Significant O.R. Procedure
P05Z—Neonate, Adm Wt 2000–2499 g W Significant O.R. Procedure
P06A—Neonate, Adm Wt >2499 g W Significant O.R. Procedure W Multi Major Problems
P06B—Neonate, Adm Wt >2499 g W Significant O.R. Proc W/O Multi Major Problems
P60A—Neonate Died or Tfer <5 days of Adm, W/O Significant O.R. Proc, Born Here
P60B—Neonate Died/Tfer <5 days of Adm, W/O Significant O.R. Proc, Not Born Here
P61Z—Neonate, Adm Wt <750 g
P62Z—Neonate, Adm Wt 750–999 g
P63Z—Neonate, Adm Wt 1000–1249 g W/O Significant O.R. Procedure
P64Z—Neonate, Adm Wt 1250–1499 g W/O Significant O.R. Procedure
P65A—Neonate, Adm Wt 1500–1999 g W/O Significant O.R. Proc W Multi Major Problems
P65B—Neonate, Adm Wt 1500–1999 g W/O Significant O.R. Procedure W Major Problem
P65C—Neonate, Adm Wt 1500–1999 g W/O Significant O.R. Procedure W Other Problem
P65D—Neonate, Adm Wt 1500–1999 g W/O Significant O.R. Procedure W/O Problem
P66A—Neonate, Adm Wt 2000–2499 g W/O Significant O.R. Proc W Multi Major Problems
P66B—Neonate, Adm Wt 2000–2499 g W/O Significant O.R. Procedure W Major Problem
P66C—Neonate, Adm Wt 2000–2499 g W/O Significant O.R. Procedure W Other Problem
P66D—Neonate, Adm Wt 2000–2499 g W/O Significant O.R. Procedure W/O Problem
P67A—Neonate, Adm Wt >2499 g W/O Significant O.R. Procedure W Multi Major Problems
P67B—Neonate, Adm Wt >2499 g W/O Significant O.R. Procedure W Major Problem
P67C—Neonate, Adm Wt >2499 g W/O Significant O.R. Procedure W Other Problem
P67D—Neonate, Adm Wt >2499 g W/O Significant O.R. Procedure W/O Problem

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Appendix
  • 1
    Umstad MP. The predictive value of abnormal fetal heart rate patterns in early labour. Aust N Z J Obstet Gynaecol 1993;33:1459.
  • 2
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Appendix

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Appendix

The FOREMOST website (http://www.som.uq.edu.au/research/prc/foremosttrial.asp). The figure includes a eligibility criteria, randomisation and numbers included in the intention-to-treat analysis. Reproduced with permission from East et al. Am J Obstet Gynecol 2006;194:606, e1–16.8