Cost and Quality Control Model for The Clinical Pathway of Cesarean Section

1. INTRODUCTION

Cesarean section (CS) incidence has experienced an increasing trend in various parts of the world, including Indonesia. In 2008, 54 of 137 countries had CS rates below 10%, while 69 had CS rates above 15%. However, after 2010, CS has increased globally in recent decades. In the United States, the rate of births by CS rose from 4.5% in 1970 to 32.9% in 2009 and remained at 30% until 2015 [1].

In 2015, WHO suggested that the ideal CS rate is 10% to 15% to avoid maternal deaths and improve maternal and neonatal outcomes. However, in 2008, only 10% of countries had a CS rate of 10-15%, of which 24% of countries had a CS rate of less than 5%, and 50% of countries had a CS rate of more than 15%. Therefore, the Lancet Journal calls it a global epidemic [2]. The increase in CS incidents is due to pressure on the use of new technology, which is often unbearable, increasing productive age (demographic bonus), and moral hazard (bioethics) in CS procedures [3-5]. The use of new technology often creates inefficiencies. The 2010 World Health Report estimates that 20% to 40% of all health spending is currently wasted due to inefficiency [6].

In Indonesia, the CS rate increased from 12.9% in 2012 to 17% in 2017 [7]. WHO recommends avoiding maternal deaths and improving maternal and neonatal outcomes; the ideal CS rate is 10% to 15% [8, 9]. In West Sumatra, the CS rate was 14.8% in 2013, ranking it the 6th highest in Indonesia [10]. By 2018, the rate increased significantly to 23.6% [11]. However, this rise in CSs in Indonesia did not improve hospital service quality or cost efficiency [11, 12]. This can be attributed to the use of the Indonesia-Case-Based Groups (INA-CBGs) system, which relies on discharge diagnoses and CBG codes for payment instead of billing for specific services [13]. As a result, hospitals face financial losses due to the Ministry of Health's rates for CS services not covering the actual costs [14]. Therefore, there is a need for a quality assurance program to ensure service effectiveness and cost control towards efficiency [12, 13].

The Integrated Clinical Pathway (ICP) is an established model that supports hospitals in enhancing quality and cost control [15]. This model was developed based on the Quality Care Framework model from Donabedian (1973) and aims to continuously improve cost and quality control by analyzing structural, procedural, and outcome-related components. Recent studies have shown that implementing clinical pathways can reduce hospital costs, length of stay (LOS), hospital complications, readmission, and mortality rates while improving documentation [16, 17].

This study utilized a research and development (R&D) approach to create specific products (ICP) and assess their impact on CS service. This study employed a 4-D development model, as Thiagarajan (1974:5) outlines: define, design, develop, and disseminate. The 4-D model was consistently applied to guide the entire development process. Throughout development, the researcher described the properties and functions of components at each stage and their interrelationships within the system.

Until now, no research has been related to developing an efficient and effective CS service model based on cost calculations and analysis of activity procedures within the framework of the INA-CBG's system. This research aims to develop a cost and quality control model for the clinical pathway of CS services in the INA-CBG's system.

2. MATERIALS AND METHODS

The study was conducted from August 2021 to April 2022. The study's population consists of 51 hospitals in West Sumatra. These hospitals were classified into three categories: type B (with over 200 beds), type C (with over 100 beds), and type D (with over 50 beds). This study will sample 30% of hospitals from each type of hospital category. As a result, 11 hospitals in West Sumatra that offered CS services were included. Using the Lemeshow formula (1997), it was determined that 110 CS patients would be required to complete a questionnaire [18]. We invited 10 patients from each hospital to participate, reaching a total of 110 patients. Inclusion criteria included patients registered with government health insurance and those willing to participate, while severe complications excluded patients from the study.

The study implemented a mixed-method design (quantitative and qualitative research) and followed a research and development approach, namely the 4-D model (define, design, development, dissemination) [19, 20]. The define phase consists of three stages: the first two stages (stages 1-2) feature observational analytic, as well as, quantitative research, and the third stage features qualitative research.

2.2. Design Phase

A prototype of the clinical pathway model framework for CS services was created during the design phase. This model was adjusted to ensure cost efficiency and quality effectiveness across all procedures and activities. The prototype model was developed based on the Quality Care Framework theory from Donabedian (1973) (Fig. 1) and follows a continuous improvement approach to the quality control cycle by examining the structure, process, and output/outcome [15]. The cost and quality model framework for CS are shown in Fig. (2).

3. RESULT

4. DISCUSSION

The unit cost of a CS ranges from US$ 205.81 to US$754.29, with a significant difference due to higher indirect costs at government hospitals compared to private hospitals. Several studies produced disparate results. For instance, the unit cost for government hospitals is lower in Cambodia. Using the top-down costing method, private hospitals charged USD 683.23 while government hospitals charged US$472.13 [24]. In Turkey, Aldogan (2014) also conducted unit cost calculations in private hospitals using the ABC method, which resulted in a cost of USD 358.42 or around IDR 5,370,000 but did not compare it to government hospitals [25].

In Indonesia, Asjanti (2021) conducted qualitative research using a case study approach in Indonesia and found that the direct cost was US$89.2 (46%), the indirect cost was US$282.6 (64%), and the total cost was US$371.9 [26]. These findings are consistent with the results of the present study. Additionally, research conducted at class C hospitals in Indonesia showed that private hospitals have a higher unit cost than government hospitals. The unit costs in government hospitals range from US$158.79 to US$860.66, while private hospitals range from US$411.98 to US$1988.13 [27]. The differences in cost can be attributed to the use of different cost calculation methodologies, differences in human resources related to operating time, total patient care or non-total patient care, and high and low depreciation of equipment and buildings or indirect costs [24, 25]

According to our study, 40 patients (36%) who underwent both effective and efficient CS do not incur costs (cost control) and have also succeeded in achieving established service standards (quality control). Nonetheless, these findings indicate that the CS service performed in this study is still below 50% in applying the principles of quality control and cost control. However, the results imply that there is room for improvement in applying both quality and cost control principles, as the CS service performed below 50%.

Previous studies related to adherence to the clinical pathway for CS services obtained high (effective) adherence to the implementation of CS procedures in 686 patient cases (98%), and 14 patients (2%) had low (ineffective) adherence rates [28]. These findings reflect this study. Another study found that the number of patients according to the clinical pathway (effective) was only 1 patient (1.35%), and not according to the clinical pathway (ineffective), it was 98.65% [29]. Other findings found that 43 patients (83.6%) implemented clinical pathways according to (effective) [30]. The findings of these two studies were very different; the first study showed very low adherence to procedures, and the second showed fairly good adherence to procedures.

According to a recent study, the cost of CS rate >15% has increased by 313% since 2008, resulting in a $7 billion surplus since 2008. This study stated that the reallocation of CS funds would result in $9 billion in savings for the global economy. Global disparities in CS costs have escalated since 2008, leading to an unequal allocation of resources [31]. Therefore, it is necessary to implement a cost-effective clinical pathway for CS [31].

The ICP for CS clinical pathways in this study is a well-organized planning document structured as a map and model of various clinical and non-clinical care activities from different CS service units within the framework. Clinical pathways have several advantages, including enhancing medical services and providing patient-centered care. Patients are encouraged to take an active role in planning, offer feedback on the outcomes achieved, receive education about their care, and collaborate with multidisciplinary teams in medical and nursing services [17, 22]. This model was developed based on the Quality Care Framework model from Donabedian (1973), which emphasizes continuous improvement of the quality control cycle of cost control by examining structure, process, and output/outcome [15].

In this study, researchers have developed a model in the form of an integrated clinical pathway (ICP). This model was developed based on a thorough cost and activity analysis of effective and efficient CS services in 40 cases. The main focus of this model is the workflow of mild CS services, analyzed within the accounting and quality management framework. Here is an overview of the model:

(a) The main part of this model is the CS service activity procedure, carried out from the initial admission to the hospital until discharge.

(b) There are 14 service activities divided into three major groups: pre-operation, operation, and post-operation.

(c) Within the cost control framework, there is 1 module and one program, namely the indirect cost calculation module using the Activity Based Costing (ABC) method and the efficiency analysis program using the Break Even Point method.

(d) Within the quality control framework, there is one program, namely the effectiveness analysis program, which analyses the activity procedures and outcomes of CS services.

(e) The output of all the modules and programs above, within the framework of the INA-CBG's system of CS services, is carried out in the hospital into a module called the module for quality control and cost control for CS services in hospitals.

LIMITATIONS

First, hospital cost data is complicated as each hospital has a different cost structure. Additionally, the terminology and designations used to describe these cost structures can differ significantly from one hospital to another. This can make it challenging for researchers to accurately match the fee structure created by their team with the cost structure provided by the hospital. To overcome this hurdle, hospitals must break down their cost structure and adjust it to align with the structure established by researchers. A standardized cost structure for hospitals that adhere to national accounting standards will be necessary to calculate indirect costs accurately.

Second, the grouping of CS services uses ASA criteria set by anesthesiologists, thus confirming whether the ASA criteria are suitable for diagnosis grouping is necessary. In this study, the grouping of CS services was not carried out by incorporating coding, considering that observations were made directly from when the patient entered until discharge without waiting for the coding process. Still, we used the physical status classification system according to the ASA (American Society of Anesthesiologists) set by the anaesthetist during preoperative assessment. ASA 1 and 2 were considered mild CS services, ASA 3 moderate, and ASA 4 and 5 severe. However, it remains unclear whether the ASA criteria align with diagnosis grouping as no research has been conducted on this topic.

CONCLUSION

The study identified significant costs and customs associated with CS services. Mild CS services range from US$205.81 to US$754.29 per unit, while moderate CS services cost between US$305.22 and US$755.62. Regarding tariffs, mild CS services cost between US$246.97 and US$754.29, while moderate ones fall between US$320.64 and US$755.62. The Integrated Clinical Pathway model is obtained as a cost and quality control model for CS services at the hospital with two modules: one for cost quality control and one for calculating indirect costs using the Activity Based Costing (ABC) method in hospitals. Hospitals should consider implementing the ICP model for CS service to avoid financial losses resulting from changes in health financing policies.

REFERENCES