Outpatient Cervical Ripening: A Cost-Minimization and Threshold Analysis

Abstract

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.

Out-of-Hospital Cervical Ripening With a Synthetic Hygroscopic Cervical Dilator May Reduce Hospital Costs and Cesarean Sections in the United States—A Cost-Consequence Analysis

“…Figure 2 illustrates what one may expect in cost savings even for a very limited adoption of outpatient ripening. The time saved in the L&D unit alone could counteract the incremental expense for the synthetic hygroscopic cervical dilator or unexpected visits (16). Our model estimates suggest that hospitals can likely trial outpatient ripening with a very conservative set of women without expecting an increase in care costs-extending outpatient practice at a rate that is aligned with evidence from their local implementation.…”

“…With the ongoing COVID-19 pandemic, there is an additional incentive to reduce the burden on hospital resourcesand to safely keep patients out of the hospital. Furthermore, publishing on outpatient cervical ripening increased dramatically in 2020 showing a global increase in interest (7,8,16,(35)(36)(37)(38)(39).…”

“…Mean costs per woman were not significantly different, however, the outpatient balloon-catheter group experienced fewer pre-delivery inpatient hours resulting in an incremental cost per patient hour prevented of AU$57 (40). For the USA, a cost-minimization and threshold analysis comparing the cost of inpatient vs. outpatient cervical ripening with a balloon catheter was published in 2020 (16). Here, Son and colleagues reported that in most plausible scenarios, outpatient ripening is cost saving: US$228.40/patient with broad use and US$73.48/patient with limited use.…”

“…Here, Son and colleagues reported that in most plausible scenarios, outpatient ripening is cost saving: US$228.40/patient with broad use and US$73.48/patient with limited use. According to their model, outpatient ripening is no longer cost saving if time saved on L&D were <3.5 h, insertion visit cost >US$714, or facility cost/hour on L&D <US$61 (16). This study differs from the economic analysis presented here in the following aspects: (1) It compares only the balloon catheter used for both inpatient and outpatient, and (2) only the difference in ripening protocols was modeled with the assumption that there is no difference in adverse events or type of delivery.…”

Review of Evidence‐Based Methods for Successful Labor Induction

“…Key benefits of cervical balloons compared with prostaglandins are their localized action with few systemic adverse effects and their ability to be discontinued easily; for these reasons, cervical balloons are the primary cervical ripening method used in outpatient settings or among people undergoing a trial of labor after cesarean birth 41–45 . Outpatient cervical ripening for IOL can be used among select groups of people with term pregnancies, showing evidence of improved cost savings over inpatient cervical ripening 46 …”