111 Budget impact analysis of aCTG in primary midwife-led care For each implementation rate scenario, the expected change in actual costs and reimbursement for the target population in the Netherlands was reported. To estimate the uncertainty surrounding the budget impact estimates, a probabilistic sensitivity analysis was conducted. In the probabilistic sensitivity analysis, a beta distribution was fitted for the prevalence of having an aCTG. Monte Carlo simulations (5000 simulations) were then used to estimate a 95% CI around the budget impact estimate of each implementation rate scenario.26 A break-even point analysis was additionally performed to estimate the number of aCTG at which actual costs and reimbursement are equal.27 The break-even point was defined as the point where the MLC-aCTG fixed costs (c_fixed: costs of equipment, training, and quality assessment) and the variable MLC-aCTG costs (c_variable: costs of performing reassuring and non-reassuring MLCaCTG) are equalled by the MLCaCTG reimbursement (r_MLC-aCTG). The equation represents the Break-even point: Fixed costs for the total estimated number of aCTGs for the Dutch population were additionally calculated as represented by the equation below: Sensitivity analyses We conducted a sensitivity analysis using the data of aCTGs performed for the indication of reduced fetal movements because, in some Dutch regional maternity care networks, aCTG is only performed for this indication. All analyses were conducted in Microsoft Excel (V.2211, 2020). RESULTS Epidemiological data In the prospective cohort study, 1795 aCTGs were performed in MLC between 2016 and 2022. Of those aCTGs, 87% and 13% were considered reassuring and nonreassuring, respectively (table 1). In the survey, 33 out of 50 healthcare professionals and 5 out 8 financial employees agreed to participate and gave informed consent. Based on the survey, we estimated the prevalence of performing aCTG for three indications to be 19.8% and for one indication to be 14.8%. We estimated that, on average, a midwife spends 2.1hours on performing a reassuring aCTG, and 1.8hours on performing a non-reassuring aCTG. Detailed information on the workload of healthcare professionals to perform an aCTG is presented in table 1. 5
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