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.