Cases in High Value Care

Office vs. outpatient surgical management of first trimester pregnancy loss

Lauren D. Demosthenes, MD
Greenville Health System
Greenville, South Carolina
laurendemosthenes@gmail.com

Scenario A:
SJ is a 28 year old woman who has been diagnosed with an early pregnancy loss at 8 weeks gestational age.  She is counseled on expectant management, medical treatment and surgical evacuation.  She prefers surgical care and is scheduled for an outpatient D&C in the operating room. Office surgical treatment is not offered. She is insured with a 10K deductible which she has not yet started. 

Scenario B: The same patient elects surgical management but is offered both outpatient and office surgical care. She prefers an office procedure and is scheduled for this with a manual vacuum aspirator and paracervical block. 

Discussion questions:
1) Discuss the treatment options for a first trimester nonviable pregnancy
2) Discuss surgical treatment options for a first trimester nonviable pregnancy?
3) What are the costs of care for surgical management of a first trimester nonviable pregnancy?

*Costs Scenario A
Ambulatory surgery center:  
Provider fee: $380.00
Facility Fee: $1665.00
Anesthesia Fee: $454.00
Total: $2,499.00

*Costs Scenario B
Office:
Provider fee  $380.00

Discussion:
Early pregnancy loss is defined as a nonviable, intrauterine pregnancy within the first 12 and 6/7 weeks of pregnancy. Approximately 10 - 25% of all clinically recognized pregnancies end as an early pregnancy loss. (1,2).
Expectant management, medical treatment and surgical evacuation of the uterine contents are all accepted options for treatment. Embracing patient centered care, options should be offered to women with this diagnosis. Surgical treatment can take place in both an office or a hospital setting.  
With more patients participating in high deductible health care plans and wanting safe and affordable choice, consideration should be given to offering surgical management in the office setting. Studies have shown that office treatment of early pregnancy loss is preferred by many women.  In a study by Dalton et al in 2006, a prospective randomized observational study was done to evaluate patient preferences, satisfaction and resource use in office evacuation of early pregnancy failure.  Among patients who reported no perception of provider bias, 68% selected an office based procedure. Although patients in the office group reported expecting and experiencing more pain with the procedure compared to the operating room  group; neither the mean total satisfaction score nor the percentage of women who rated their total level of satisfaction high was different between groups.  Patients cited “privacy” and  “avoiding going to sleep” as reasons for choosing an office procedure.  (3)
In another article by Choobun et al in 2012, a comparison was made between hospital charges, duration of in-hospital procedure, clinical course and complications between manual vacuum aspiration in the office and sharp curettage in the operating room.  In this study, there were no complications requiring repeat curettage, infection, uterine perforation or bleeding requiring transfusion in either group.  Costs were substantially less in the office setting. (4)
Lastly, cost of care is increasingly important to patients as deductibles rise.  Medical bills are a leading cause of financial strain and treatment that can lead to significant out of pocket costs for their patients (5)

Conclusion:
As part of patient centered care, women should be offered expectant management, medical treatment and surgical evacuation in both the office and outpatient hospital setting for the diagnosis of early pregnancy loss. 
In an era of increasingly high deductibles and resulting financial strain, costs of care should be part of the discussion.  

References:
1) ACOG Practice bulletin Number 150, May 2015 “Early Pregnancy Loss”
2) Jones RK, Kost K. Underreporting of induced and spontaneous abortion in the United States: any analysis of the 2002 national survey of family growth.  Stud Fam Plann 2007; 38: 187-97
3) Dalton VK, Harris L, Weisman CS, Guire K, Castleman L, Lebovic D. Patient Preferences, Satisfaction, and Resource Use in Office Evacuation of Early Pregnancy Failure. Obstetrics and Gynecology 2006; 108: 103-110
4) Choobun T, Khanuengkitkong S, Pinjaroen S.  A comparative study of cost of care and duration of management for first-trimester abortion with manual vacuum aspiration (MVA) and sharp curettage. Arch Gynecol Obstet (2012) 286: 1161-1164
5) Schoen C, Collins SR, Kriss JL, Doty MM.  How many are underinsured? Trends    among U.S. adults, 2003 and 2007.  Health Aff (Millwood). 2008;27(4):w298-w309. 

*Costs were obtained from Healthcarebluebook.com and represent “fair price” in South Carolina.  “The Fair Price is the price that you should reasonably expect a medical service to cost if you shop for care. Even in-network providers can have big cost differences for the exact same service. The most expensive can cost more than five times as much as providers that charge a Fair Price.
The Fair Price is calculated from actual amounts health plans have paid on claims. Some services show “bundled” pricing, which means there are multiple parts to the Fair Price. These usually include facility, physician and anesthesiologist fees, and can be viewed individually in the Fair Price Details. It’s always a good idea to request a price estimate from the provider and compare it to the Fair Price before your procedure”. 

Date Published: 12/28/2016

 
 
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