Cost-effectiveness of the QUARISMA trial in Québec, Canada (2008-2017)
- mirajohri2
- May 18
- 2 min read
Updated: May 31
A caesarean section is a surgical procedure that, when undertaken for medical reasons, can save the life of a woman and her baby. As documented by the World Health Organization, caesarean section rates have been increasing worldwide over the last few decades and many procedures are not medically indicated. Potentially unnecessary caesareans may put the lives and well-being of women and their children at risk. This project tested a non-clinical intervention strategy to reduce unnecessary caesarean sections.
Project
The QUARISMA trial investigated the value of a clinician-training program to reduce unnecessary caesarean deliveries. The training program was jointly developed with the Society of Obstetricians and Gynaecologists of Canada to optimise the quality of care by reinforcing skills, fostering teamwork, and promoting self-assessment in relation to clinical best practice through local audit and feedback.
The results of the QUARISMA trial were published in 2015 in The New England Journal of Medicine.(1) The trial demonstrated a statistically significant but clinically small reduction in caesarean sections, with no adverse effects on mothers and children. Based on these results, it was unclear whether the intervention should be offered at scale.
On behalf of the QUARISMA trial group, I led a trial-based cost-effectiveness analysis using individual patient data to inform scale-up decisions.
Findings
Our analysis(2) showed that the training program for clinicians studied in the QUARISMA trial resulted in very favourable results: better quality of care for mothers and infants, and major cost savings.
Cost reductions reflected savings due to a lower need for interventions, consistent with improved quality of care in intervention group hospitals.
If the intervention were delivered at provincial scale, it would result in savings in the range of $15.8 million annually for the Province of Quebec.
Impact
These findings have immediate implications for policy and practice in Quebec, Canada and internationally as they directly support the scale-up of similar interventions.
In 2018, the World Health Organization released a landmark Guideline on non-clinical interventions to reduce unnecessary caesarean sections.(3) The QUARISMA trial was among a select number of high-quality studies included in the guidelines. Our study contributed critical evidence as it was the only economic evaluation that met criteria for inclusion.
Since 2019, the QUARISMA intervention has been scaled up in Canada through the MORE-OB Program. https://www.salusglobal.com/en_ca/solutions/ - moreob More than 80% of births in Canada occur in MORE-OB hospitals; 100% of Québec hospitals benefit from the programme. Findings from the economic evaluation played a critical role in the decision to scale the intervention.
References
Chaillet N, Dumont A, Abrahamowicz M, et al. A cluster-randomized trial to reduce cesarean delivery rates in Quebec. N Engl J Med 2015; 372(18): 1710-21. https://www.nejm.org/doi/full/10.1056/NEJMoa1407120
Mira Johri, Edmond Ng, Clara Bermudez-Tamayo*, Jeffrey S. Hoch, Thierry Ducruet, Nils Chaillet. A cluster-randomized trial to reduce caesarean delivery rates in Quebec: cost-effectiveness analysis, BMC Med 2017 15:96 https://doi.org/10.1186/s12916-017-0859-8
Opiyo N, Kingdon C, Oladapo OT, Souza JP, Vogel JP, Bonet M, et al. Non-clinical interventions to reduce unnecessary caesarean sections: WHO recommendations. Bull World Health Organ. 2020;98(1):66-8. https://doi.org/10.2471/BLT.19.236729
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