Cost of Unnecessary Hospitalization
Abstract & Commentary
By John C. Hobbins, MD
Professor, Department of Obstetrics and Gynecology,
University of Colorado School of Medicine, Aurora
Dr. Hobbins reports no financial relationships relevant to this field of study.
Synopsis: A new study shows that using cervical length as an arbiter of whom to admit for suspected preterm labor is a safe and cost-effective method to decrease health care costs.
Source: Lucovnik M, et al. Costs of unnecessary admissions and treatments for threatened preterm labor. Am J Obstet Gynecol 2013;209:217.e1-3. [Epub ahead of print].
One of the hottest and, perhaps, most polarizing top-
ics today is the upward spiraling cost of health care. In the United States, health care consumes about 17% of the gross national product, which is more than double the average of other developed countries. One can certainly argue (from our outcome statistics) that we are not getting our money's worth. Although everyone agrees that the cost is way too high, there is little agreement regarding how to bring it down.
A group from a tertiary hospital in Phoenix has offered one particular way to bring down some costs — by eliminating unnecessary hospital admissions for patients with preterm contractions (PTC) who are not in preterm labor (PTL). Lucovnik et al reviewed the records of patients presenting with painful PTC prior to 34 weeks.1 Their protocol called for patients to have a digital exam by a resident and a cervical length (CL) obtained by a sonographer using transvaginal sonography (TVS). Between July 2009 and June 2010, 139 patients were admitted and treated for PTL, 50 of whom had CLs of ≥ 3 cm. None of these patients delivered preterm, which is in line with previous studies that have shown a very high negative predictive value (NPV) in ruling out true PTL with a cervix length ≥ 3 cm. The authors calculated the hospital charges for these patients during their stays. Charges ranged from $6915 to $63,212, and the total cost was $1,018,589. Although these charges do not represent reimbursements (which vary greatly according to the payer and never completely match up to the amount charged), these reimbursed costs are dwarfed by a combination of charges for separate physicians services, some treatment expenditures, loss of patient income, child care expenses, and even, perhaps, the cost generated from hospital-acquired infections.
The authors' conclusion was that "unnecessary admissions and treatments for treatment of PTL contributed to exploding health care costs, and by using currently available diagnostic methods, these costs could be lowered significantly without jeopardizing outcome." Amen.
Commentary
Tsoi was the first to show that in 132 patients with PTC and CL of > 1.5 cm, only one delivered within 7 days, yielding an NPV of 99%.2 Fuchs also showed a 99% NPV in a group of similar patients with CL > 1.5 cm.3 Fetal fibronectin (fFN) is another method that has been used successfully to identify patients presenting with uterine contractions who are actually in false labor. In a collaborative study from the United States and Chile, 215 patients with PTC between 24 and 34 weeks were evaluated with fFN and CL.4 Twenty percent delivered < 35 weeks and CL outperformed fFN in predicting this event. If both were positive, 81.3% delivered prior to 35 weeks. If both were negative only, 2.2% delivered prior to 35 weeks. Most importantly, in the 60% of patients with CL > 3.0 cm, fFN added nothing to the diagnostic predictability.
Most studies show that about four in five patients presenting with PTC are not in labor. Yet, even when tests are available to rule out true PTL, there still is a great tendency to commit these patients to many days of hospitalization with almost constant monitoring and, often, exposure to various tocolytics, which have questionable efficacy but unquestionable side effects. Much of this fruitless wheel-spinning is initiated because of the fear of being second-guessed if one of these (rare) patients will return soon after discharge, fully dilated.
It has been suggested that the result of a fFN test may be affected by a lubricant or gel used in a digital exam or TVS. It has also been shown that adequate information can be obtained by placing a swab in the posterior fornix, rather than in the external cervical os (without the need for a speculum). With this in mind, here is a simple protocol for patients suspected of being in PTL:
- Before any other vaginal exam is done, gently guide a swab into the posterior fornix and reserve the fFN specimen until the CL has been ascertained by TVS.
- If CL > 3.0 cm, discharge the patient after a short period of monitoring to make sure that contractions do not increase in intensity or frequency.
- If CL < 1.5 cm, then admit the patient.
- If CL is 1.5-3.0 cm, then send fFN off for testing.
- If positive, admit and observe the patient as long as contractions persist.
- If negative, discharge the patient to home with instructions for follow-up.
By utilizing this type of protocol, we can do our part, along with other initiatives, to diminish the cost of obstetrical care in the United States.
References
- Lucovnik M, et al. Am J Obstet Gynecol 2013;209:217.e1-3.
- Tsoi E, et al. Ultrasound Obstst Gynecol 2003;21:552-555.
- Fuchs IB, et al. Ultrasound Obstet Gynecol 2004;24:554-557.
- Gomez R, et al. Am J Obstet Gynecol 2005;92:350-359.
