Cases in Cost Conscious Care

Darcy Slizewski, MD
PGY3, Greenville Health System
Mentor: Lauren Demosthenes, MD

Clinical Scenario A
18 year old G1 @ 38 weeks presented to clinic complaining of contractions every 5 minutes since the prior night.  Her pregnancy had been uncomplicated to this point.  She denies rupture of membranes and reports good fetal movement.

A nurse obtained vital signs and performed a urine dip.  She was seen by a physician in the clinic, and her cervix was found to be 25% effaced, 1 cm dilated and high.  This was unchanged from her clinic visit last week.  Fetal heart tones were obtained by Doppler.

She was counseled about latent labor and sent home after about 15 minutes.

Clinical Scenario B
18 year old G1 @ 38 weeks presents to L+D complaining of contractions every 5 minutes since the prior night.  Her pregnancy had been uncomplicated to this point.  She denies rupture of membranes and reports good fetal movement.

A nurse evaluated the patient, placed her on the external fetal monitor and tocometer.  Vital signs were obtained and a urine sample sent to the lab for urinalysis.  A physician examined the patient and found her cervix to be 25% effaced, 1 cm dilated and high.  This was unchanged from her clinic visit last week.   Her fetal heart rate tracing was category 1 with contractions every 5 minutes.

She was counseled about latent labor and discharged after about 2 hours. 

Discussion Questions:

  1. Was fetal monitoring indicated in this patient?
  2. What are the additional costs that were incurred by the patient during her visit to labor and delivery when compared to the office visit?

Costs Scenario A 
(these are charges that were obtained from the hospital billing department)
Level III Physician Visit, established patient: $140
Total Patient Charges: $140

Costs Scenario B
Evaluation in Triage Hospital Charge: $708.60
Fetal Heart Rate Monitoring Hospital Charge: $386.70
MD interpretation of fetal monitoring: $161.00
Physician Visit: $140
Urinalysis: $77.90
Total Patient Charges:  $1474.20

Teaching Moment
The patient presented in the case above is a low risk, term patient presenting for a labor assessment.  Their evaluations varied because of the place of care.  The cost to the patient of the hospital visit is also significant, as the hospital charges for simply presenting to L+D.

Fetal monitoring was not ordered on the patient in the office/outpatient setting.  Fetal monitoring was ordered in L+D Triage per unit protocol.  The performance of the NST significantly added to the cost of care for the patient evaluated in the hospital.  There is no indication for non-stress testing in this low risk patient presenting for labor assessment.

References

  1. Electronic fetal heart rate monitoring: research guidelines for interpretation. National Institute of Health and Human Development Research Planning Workshop. Am J Obstet Gynecol 1997; 177:1385.
  2. Rouse DJ, Owen J, Goldenberg RL, Cliver SP. Determinants of the optimal time in gestation to initiate antenatal fetal testing: a decision-analytic approach. Am J Obstet Gynecol 1995; 173:1357.
  3. American College of Obstetricians and Gynecologists. Antepartum Fetal Surveillance. ACOG Practice Bulletin #145 American College of Obstetricians and Gynecologists, Washington DC July 2014
  4. Grivell RM, Alfirevic Z, Gyte GM, Devane D. Antenatal cardiotocography for fetal assessment. Cochrane Database Syst Rev 2012; 12:CD007863.
  5. Parer, JT. Fetal Heart Rate. In: Maternal Fetal Medicine: Principles and Practice. Creasy and Resnik (Eds), W.B. Saunders Company, Philadelphia, 1999.

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