Cases in Cost Conscious Care

John Van Deman, MD
Greenville Health System
Mentor: Lauren Demosthenes, MD


Clinical Scenario A
A 30-year-old G1 at 40 weeks presents to the office for a routine appointment.  Her pregnancy has been uncomplicated and she had a negative GBS screen at 36 weeks.  On exam her cervix is found to be fingertip, 25% effaced, and -3 station.  Plans for a post dates induction are made if she has not spontaneously gone into labor by 41 weeks.  She is counseled that she will be admitted to the hospital when she is 40 weeks and 6 days for overnight cervical ripening with hopes of delivering later the following day.

Clinical Scenario B A 30-year-old G1 at 40 weeks presents to the office for a routine appointment.  Her pregnancy has been uncomplicated and she had a negative GBS screen at 36 weeks.  On exam her cervix is found to be fingertip, 25% effaced, and -3 station.  Plans for a post dates induction are made if she has not spontaneously gone into labor by 41 weeks.  She is counseled that she will come to the office when she is 40 weeks and 6 days.  Her cervix will be checked and if her bishop score is not favorable she will have a Foley bulb placed in the office after a reactive NST is obtained.  She will then be placed back on continuous fetal monitoring for at least 30 minutes and then hopefully sent home to continue the ripening process with clear instructions on what should prompt her to return to the hospital prior to the next morning when she would be admitted to continue her induction.

Discussion Questions

1. At what point in labor is inpatient admission warranted?
2. What are the benefits to decreasing the length of stay for an induction of labor?

Costs Scenario A (obtained from actual patient billing data)

Room and Board: $850
Foley Bulb: $94.47
Total: $944.47

Costs Scenario B (obtained from outpatient office charge sheet) 

Insertion of Cervical Dilator (device included): $235
Non-stress Test:$161
Total: $396

Discussion
Induction of labor is an increasingly common practice in this country with 23% of all pregnancies being induced in 2013.  In women with an unfavorable cervix induction is usually preceded by cervical ripening with either mechanical or pharmacologic methods.  Traditionally these women are admitted to the hospital the evening prior to the day they would be induced to undergo cervical ripening, but studies have investigated the safety and efficacy of outpatient mechanical ripening with a foley bulb.  In fact, the ACOG practice bulletin on induction of labor states that outpatient cervical ripening, particularly mechanical methods may be appropriate in select patients.   A study by Sciscione and colleagues has demonstrated the safety of outpatient ripening with a foley bulb after reviewing more than 1,900 records of women who underwent ripening and not identifying any adverse events.  Previously there has also been shown to be no difference in mean change in Bishop score between inpatient and outpatient ripening.  As we have evolved to providing care that is both more evidence based and patient centered we should provide options that are demonstrated to be safe and allow for arguably more comfort in addition to better utilization of healthcare resources.

References

  1. ACOG Committee on Practice Bulletins—Obstetrics. Induction of Labor: ACOG Practice Bulletin No. 107. Obstet Gynecol. 2009;114(2 Pt 1):386–397.
  2. Sciscione AC, Muench M, Pollack M, Jenkins TM, Tidlon-Burton J, Colmorgen GH. Transcervical Foley catheter for preinduction cervical ripening in an outpatient versus inpatient setting. Obstet Gynecol. 2001;98(5, Pt 1):751–756.
  3. Sciscione AC, Bedder C, Hoffman MK, Ruhstaller K, Sholssman PA. The timing of adverse events with Foley catheter preinduction cervical ripening: implications for outpatient use. Am J Perinatol. 2014;31:781–786.

Published: 04/15/16

American Congress of Obstetricians and Gynecologists
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