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BackgroundThe costs of quality improvement efforts in real-world settings are often unquantified. Better understanding could guide appropriate resource utilisation and drive efficiency. Immediate postpartum contraceptive care (ie, placement of an intrauterine device or contraceptive implant during hospitalisation for childbirth) represents an excellent case study for examining costs, because recommended services are largely unavailable and adoption requires significant effort. We therefore evaluated the cost of implementing immediate postpartum contraceptive services at four academic centres and one private hospital in USA.MethodsIn this mixed-methods cost analysis, implementation activities were retrospectively identified using standardised data collection. Activities were categorised as preimplementation activities (infrastructure building, tool creation and stakeholder engagement) or execution activities (workforce training and process refinement). Costs were assigned based on national median salaries for the roles of individuals involved. Cross-case comparison and rapid qualitative analysis guided by the Consolidated Framework for Implementation Research were used to identify factors driving cost variation observed across sites.ResultsOn average, implementation activities required 204 hours (range 119–368), with this time costing $14 433.94 (range $9955.61–$23 690.49), and involving 9 (range 7–11) key team members per site. Preimplementation activities required more resources than execution activities (preimplementation: average 173 hours, $11 573.25; execution: average 31 hours, $2860.67). Sites that used lower-cost employees (eg, shifting tasks from a physician to a project manager) observed lower costs per hour for implementation activities. Implementation activities and costs were associated with local contextual factors, including stakeholder acceptance, integration of employees and infrastructure readiness for the change effort.ConclusionsOur findings provide the first estimates of health system costs for adopting recommended contraceptive care in maternity units in USA. More broadly, our findings suggest that the budget impact of improvement efforts may vary widely depending on local context.

Masson's tumor, also known as intravascular papillary endothelial hyperplasia (IPEH), is a rare and benign vascular disease in which there is a reactive hyperplasia of intravascular endothelial cells. This tumor is most commonly found in soft tissues in the head, neck and upper extremities. We report a rare case of IPEH on the vulva. A Hispanic woman in her mid-thirties presented with a painful and pruritic left vulvar mass. On physical examination, a pedunculated mass was visualized on the left labia majora. Under pathologic examination, it was concluded the lesion was IPEH and it was surgically excised. This is a rare case of IPEH located on the vulva. However, despite this rarity, a simple local excision could be used to manage IPEH.