Outpatient Cervical Ripening: A Cost-Minimization and Threshold Analysis
29 April 2019
04 July 2019
20 August 2019 (online)
Objective To evaluate cost of outpatient (OP) versus inpatient (IP) ripening with transcervical balloons, and determine circumstances in which each strategy would be cost saving.
Study Design We created a decision model comparing OP and IP balloon ripening in term (≥37 weeks) singleton pregnancies with unfavorable cervix. We performed a cost-minimization analysis and threshold analyses comparing two OP ripening strategies (broad and limited use) to IP ripening from a health system perspective. Base case estimates of probability, utilization, and cost were derived from the literature. The primary outcome was incremental cost of OP versus IP ripening from a hospital perspective. One- and two-way sensitivity analyses explored uncertainty in the model.
Results Both OP ripening strategies were cost saving compared with IP ripening: incremental cost −$228.40/patient with broad use and −$73.48/patient with limited use. OP ripening was no longer cost saving if hours saved on labor and delivery (L&D) were <3.5, insertion visit cost >$714, or facility cost/hour on L&D <$61. Two-way sensitivity analyses showed that OP ripening was cost saving under the most plausible clinical circumstances.
Conclusion In patients with unfavorable cervix, OP transcervical balloon ripening was cost saving under a wide range of circumstances, particularly if OP ripening can shorten time spent on L&D by 3.5 hours.
Keywordscervical ripening - outpatient ripening - cost effectiveness - balloon ripening - induction of labor
These data were presented in a poster form at the Society for Maternal-Fetal Medicine Annual Pregnancy Meeting 2019 in Las Vegas, NV, on February 15, 2019.
- 1 Martin JA, Hamilton BE, Osterman MJK, Driscoll AK, Drake P. Births: final data for 2016. Natl Vital Stat Rep 2018; 67 (01) 1-55
- 2 NEJM. Labor induction versus expectant management in low-risk nulliparous women. Available at: https://www.nejm.org/doi/10.1056/NEJMoa1800566?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3D www.ncbi.nlm.nih.gov . Accessed July 4, 2019
- 3 Xenakis EM, Piper JM, Conway DL, Langer O. Induction of labor in the nineties: conquering the unfavorable cervix. Obstet Gynecol 1997; 90 (02) 235-239
- 4 Adelson PL, Wedlock GR, Wilkinson CS, Howard K, Bryce RL, Turnbull DA. A cost analysis of inpatient compared with outpatient prostaglandin E2 cervical priming for induction of labour: results from the OPRA trial. Aust Health Rev 2013; 37 (04) 467-473
- 5 Sciscione AC, Muench M, Pollock M, Jenkins TM, Tildon-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
- 6 McKenna DS, Duke JM. Effectiveness and infectious morbidity of outpatient cervical ripening with a Foley catheter. J Reprod Med 2004; 49 (01) 28-32
- 7 Dowswell T, Kelly AJ, Livio S, Norman JE, Alfirevic Z. Different methods for the induction of labour in outpatient settings. Cochrane Database Syst Rev 2010; (08) CD007701
- 8 Henry A, Madan A, Reid R. , et al. Outpatient Foley catheter versus inpatient prostaglandin E2 gel for induction of labour: a randomised trial. BMC Pregnancy Childbirth 2013; 13 (01) 25
- 9 Howard K, Gerard K, Adelson P, Bryce R, Wilkinson C, Turnbull D. Women's preferences for inpatient and outpatient priming for labour induction: a discrete choice experiment. BMC Health Serv Res 2014; 14 (01) 330
- 10 Sciscione AC, Bedder CL, Hoffman MK, Ruhstaller K, Shlossman PA. The timing of adverse events with Foley catheter preinduction cervical ripening; implications for outpatient use. Am J Perinatol 2014; 31 (09) 781-786
- 11 Kruit H, Heikinheimo O, Ulander V-M. , et al. Foley catheter induction of labor as an outpatient procedure. J Perinatol 2016; 36 (08) 618-622
- 12 Diederen M, Gommers J, Wilkinson C, Turnbull D, Mol B. Safety of the balloon catheter for cervical ripening in outpatient care: complications during the period from insertion to expulsion of a balloon catheter in the process of labour induction: a systematic review. BJOG 2018; 125 (09) 1086-1095
- 13 Policiano C, Pimenta M, Martins D, Clode N. Outpatient versus inpatient cervix priming with Foley catheter: a randomized trial. Eur J Obstet Gynecol Reprod Biol 2017; 210: 1-6
- 14 Leopold B, Sciscione A. Is there a place for outpatient preinduction cervical ripening?. Obstet Gynecol Clin North Am 2017; 44 (04) 583-591
- 15 Kuper SG, Jauk VC, George DM. , et al. Outpatient Foley catheter for induction of labor in parous women: a randomized controlled trial. Obstet Gynecol 2018; 132 (01) 94-101
- 16 Wilkinson C, Adelson P, Turnbull D. A comparison of inpatient with outpatient balloon catheter cervical ripening: a pilot randomized controlled trial. BMC Pregnancy Childbirth 2015; 15 (01) 126
- 17 Ten Eikelder M, van Baaren G-J, Oude Rengerink K. , et al. Comparing induction of labour with oral misoprostol or Foley catheter at term: cost-effectiveness analysis of a randomised controlled multi-centre non-inferiority trial. BJOG 2018; 125 (03) 375-383
- 18 Austin K, Chambers GM, de Abreu Lourenco R, Madan A, Susic D, Henry A. Cost-effectiveness of term induction of labour using inpatient prostaglandin gel versus outpatient Foley catheter. Aust N Z J Obstet Gynaecol 2015; 55 (05) 440-445