title: Linking quality of care and training costs: cost-effectiveness in health professions education.
abstract: OBJECTIVE
  To provide a model for conducting cost-effectiveness analyses in medical education. The model was based on a randomised trial examining the effects of training midwives to perform cervical length measurement (CLM) as compared with obstetricians on patients' waiting times. (CLM), as compared with obstetricians.
  
  
  METHODS
  The model included four steps: (i) gathering data on training outcomes, (ii) assessing total costs and effects, (iii) calculating the incremental cost-effectiveness ratio (ICER) and (iv) estimating cost-effectiveness probability for different willingness to pay (WTP) values. To provide a model example, we conducted a randomised cost-effectiveness trial. Midwives were randomised to CLM training (midwife-performed CLMs) or no training (initial management by midwife, and CLM performed by obstetrician). Intervention-group participants underwent simulation-based and clinical training until they were proficient. During the following 6 months, waiting times from arrival to admission or discharge were recorded for women who presented with symptoms of pre-term labour. Outcomes for women managed by intervention and control-group participants were compared. These data were then used for the remaining steps of the cost-effectiveness model.
  
  
  RESULTS
  Intervention-group participants needed a mean 268.2 (95% confidence interval [CI], 140.2-392.2) minutes of simulator training and a mean 7.3 (95% CI, 4.4-10.3) supervised scans to attain proficiency. Women who were scanned by intervention-group participants had significantly reduced waiting time compared with those managed by the control group (n = 65; mean difference, 36.6 [95% CI 7.3-65.8] minutes; p = 0.008), which corresponded to an ICER of 0.45 EUR minute(-1) . For WTP values less than EUR 0.26 minute(-1) , obstetrician-performed CLM was the most cost-effective strategy, whereas midwife-performed CLM was cost-effective for WTP values above EUR 0.73 minute(-1) .
  
  
  CONCLUSIONS
  Cost-effectiveness models can be used to link quality of care to training costs. The example used in the present study demonstrated that different training strategies could be recommended as the most cost-effective depending on administrators' willingness to pay per unit of the outcome variable.
authors.affiliation: Centre for Clinical Education, Capital Region and University of Copenhagen, Copenhagen, Denmark.|Department of Obstetrics & Gynaecology, Nordsjaelland Hospital, Hillerød, Denmark.
authors.forename: Martin G
authors.initials: MG
authors.lastname: Tolsgaard
authors.affiliation: Department of Obstetrics, Rigshopitalet, Centre for Fetal Medicine and Pregnancy, Copenhagen University Hospital, Rigshospitalet, Denmark.
authors.forename: Ann
authors.initials: A
authors.lastname: Tabor
authors.affiliation: Department of Obstetrics, Rigshopitalet, Centre for Fetal Medicine and Pregnancy, Copenhagen University Hospital, Rigshospitalet, Denmark.
authors.forename: Mette E
authors.initials: ME
authors.lastname: Madsen
authors.affiliation: Department of Obstetrics, Rigshopitalet, Centre for Fetal Medicine and Pregnancy, Copenhagen University Hospital, Rigshospitalet, Denmark.
authors.forename: Camilla B
authors.initials: CB
authors.lastname: Wulff
authors.affiliation: Centre for Clinical Education, Capital Region and University of Copenhagen, Copenhagen, Denmark.|Department of Obstetrics, Rigshopitalet, Centre for Fetal Medicine and Pregnancy, Copenhagen University Hospital, Rigshospitalet, Denmark.
authors.forename: Liv
authors.initials: L
authors.lastname: Dyre
authors.affiliation: Faculty of Health, University of Aarhus, Aarhus, Denmark.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Ringsted
authors.affiliation: Department of Obstetrics & Gynaecology, Nordsjaelland Hospital, Hillerød, Denmark.
authors.forename: Lone N
authors.initials: LN
authors.lastname: Nørgaard
mesh_terms: D054791:Cervical Length Measurement; D003362:Cost-Benefit Analysis / Q000379:methods*; D004504:Education, Medical, Undergraduate / Q000191:economics*; D005260:Female; D006281:Health Occupations / Q000193:education*; D006801:Humans; D008880:Midwifery / Q000191:economics / Q000193:education; D009775:Obstetrics and Gynecology Department, Hospital / Q000191:economics; D011247:Pregnancy; D011787:Quality of Health Care