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“Inpatient” versus “Outpatient” Induction of Labor

Case 

Ms. JA is a 26 y/o G1P0 at 41w3d who presents with an indicated induction of labor for post-term1. She has had a benign pregnancy, The fetus has been confirmed to be in the vertex presentation, and her Bishop’s score was unfavorable at closed/long/posterior/-3/soft.

Clinical Scenario A

“Outpatient” post-term induction of labor

She was placed in OB triage. A misoprostol was placed vaginally, and a non-stress test (NST) was performed for 60 min. Afterwards, the patient was taken off the monitor after a reactive NST, and she was sent home. The patient returned 3 hours later to OB triage for her 2nd round of misoprostol. This was repeated 3 times until Ms. JA was found to have a ripe cervix at 2/50/anterior/-2/soft. Ms. JA was then started on pitocin for augmentation.

Clinical Scenario B 

“Inpatient” post-term induction of labor

She was placed in a labor room. A misoprostol was placed vaginally, and a non-stress test was performed for 60 min. Afterwards, the patient was taken off the monitor. This was repeated 3 times until Ms. JA was found to have a ripe cervix at 2/50/anterior/-2/soft. Ms. JA was then started on pitocin for augmentation.

Costs

These costs were determined using “time-driven-activity-based-costing2” (TDABC), which utilizes the calculated capacity cost rate per minute for personnel, physical space and equipment for our hospital3.  

Cost Scenario A

Anticipated time required for initial round of misoprostol placement (total 130 min):

  • Patient intake (20 min)
  • Pre-misoprostol NST (20 min)
  • Waiting for personnel available + misoprostol placement (20 min)
  • Post-misoprostol NST (60 min)
  • Patient discharge (10 min)
  • Additional non-facility and non-equipment dependent time: clinical documentation for RN x 5 min, residents x 10 min, attending x 5 min)

Anticipated time required for subsequent rounds of misoprostol placement (115 min):

  • Everything is the same, other than abbreviated RN intake (5min) and abbreviated resident intake (3min), and no attending facetime

Facility Time: $0.10/min x 130 min: $13.00
Equipment: $0.03/min x 130 min (stretcher, external fetal monitor, Omnicell use): $3.90
RN: $1.44/min x 135 min

  • 100% facetime during patient intake, misoprostol placement, patient discharge, and clinical documentation (55 min): $79.20
  • 50% facetime during pre-misoprostol NST and post-misoprostol NST (80 min): $57.60

Resident $1.15/min x 20 min: $23.00

  • Patient intake x 8 min
  • Misoprostol placement x 2 min
  • Clinical documentation x 10 min

Attending: $4.26 min x 5 min: $21.30

  • Meet patient and clinical documentation x 5 min

Medication: 25 mcg of Misoprostol: $0.27
Cost for initial misoprostol placement:$198.27 
Cost for subsequent misoprostol placement: $140.47 

Total cost with 4 rounds of misoprostol: $619.68

Cost Scenario B

Anticipated time required for initial round of misoprostol placement (total 270 min)

  • Patient intake (20 min)
  • Pre-misoprostol NST (20 min)
  • Waiting for personnel available + misoprostol placement (20 min)
  • Post-misoprostol NST (60 min)
  • Patient without external fetal monitoring in labor room x 2.5 hours until next round of pre-misoprostol NST (150 min)
  • Additional non-facility and non-equipment dependent time: clinical documentation for RN x 5 min, residents x 10 min, attending x 5 min)

Anticipated time required for subsequent rounds of misoprostol placement (255 min)

  • Everything is the same, other than abbreviated RN intake (5min) and abbreviated resident intake (3min), and no attending facetime

Facility Time: $0.10/min x 270 min: $27.00
Equipment: $0.03/min x 270 min (stretcher, external fetal monitor, Omnicell use): $8.10

RN: $1.44/min x 275 min

  • 100% facetime during patient intake, misoprostol placement, and clinical documentation (45 min): $64.80
  • 50% facetime during pre-misoprostol NST and post-misoprostol NST (80 min): $57.60
  • 30% facetime while in-between rounds of misoprostol (150min): $64.80

Resident $1.15/min x 20 min: $23.00

  • Patient intake x 8 min
  • Misoprostol placement x 2 min
  • Clinical documentation x 10 min

Attending: $4.26min x 5 min: $21.30

  • Meet patient and clinical documentation x 5 min 

Medication: 25mcg of Misoprostol: $0.27
Total cost for initial misoprostol placement: $263.87 
Cost for subsequent misoprostol placement: $216.27 
4 rounds of misoprostol total: $912.68

Discussion Questions

  • Should patients undergoing induction remain in the hospital, or can they leave the hospital after reassuring fetal testing?
  • What is the relative cost of the patient staying at home vs. occupying a labor room and the utilization of a nurse’s time?
  • How would you change your decision based on the patient’s parity or indication for induction?
  • Where is the most cost effective place for labor inductions?
  • What is the value to the patient in spending a greater amount of time at home, versus in the hospital?  Is this measurable?

Teaching Moment

At Beth Israel Medical Center, we performed misoprostol cervical ripening in 810 patients over a year. 60% of these were managed as an outpatient with patients returning home between doses. 

As demonstrated in Table 1, the absolute cost difference between “inpatient” and “outpatient” induction of labor (IOL) is $293 calculated with the TDABC method. While the cost per minute of facility is quite low given the durability and sustainability of physical space and infrastructure, the single factor that drove up total cost is personnel4.  In Scenario B, while the patient spent 2.5 hrs without monitoring, nursing care is still required, albeit with lesser facetime. Another cost not presented here is opportunity cost. In scenario B, the 30% facetime that nursing provided could have been used to start an initial induction of labor, or even care for a woman in active labor. Furthermore, the physical occupation of a labor room precludes the admittance of another patient. The final outcome in both settings is the same with a favorable Bishop score, yet there is an absolute cost difference and non-measured opportunity cost for personnel and physical space. 

“Outpatient” IOL may not be suitable for patients who do require interval monitoring between misoprostol, such as in the case of pre-eclampsia, non-reassuring fetal testing, placental abruption or any indication as determined by the healthcare team5. Lastly, patient satisfaction is paramount; even though “outpatient” IOL may be cost-saving, if a patient is uncomfortable with the plan, then potential low patient satisfaction may be encountered. In summary, in properly selected patients, an outpatient approach to induction of labor may be cost saving.

References

  1. American College of Obstetricians and Gynecologists. Practice Bulletin 146: Management of Late-Term and Postterm Pregnancies. https://www.acog.org/-/media/Practice-Bulletins/Committee-on-Practice-Bulletins----Obstetrics/pb146.pdf?dmc=1&ts=20160324T2213316209. Accessed March 25, 2016.
  2. Kaplan RS, Anderson SR. Time-Driven Activity-Based Costing. Harvard Business Review. https://hbr.org/2004/11/time-driven-activity-based-costing. Published November 1, 2004. Accessed April 20, 2016.
  3. Schon Klinik: Measuring Cost and Value - Harvard Business Review. https://hbr.org/product/schon-klinik-measuring-cost-and-value/112085-PDF-ENG. Accessed December 30, 2014.
  4. Shah N, Golen, TH, Kim J, Mistry B, Kaplan R, Gawande A. A Cost Analysis of Hospitalization for Vaginal and Cesarean Deliveries. Obstet Gynecol. May 2015.
  5. American College of Obstetricians and Gynecologists. Practice Bulletin 107: Induction of Labor. https://www.acog.org/-/media/Practice-Bulletins/Committee-on-Practice-Bulletins----Obstetrics/pb107.pdf?dmc=1&ts=20160324T2213504179. Accessed March 25, 2016.