- Email: [email protected]
Postdates pregnancy in an indigent population: The financial burden
Postdates pregnancy in an indigent population: The financial burden Linda Fonseca, MD, Manju Monga, MD, and Jeannie Silva, RDMS Houston, Tex OBJECTIVE: The objective of this study was to determine the comparative financial burden of twice-weekly fetal testing from 41 weeks of gestation until delivery, as compared with early dating ultrasound evaluation in an indigent population. STUDY DESIGN: All women who were seen for antepartum testing for postdating pregnancy at Lyndon Baines Johnson Hospital were enrolled. Patient age, parity, gestational age at initiation of prenatal care, the number of prenatal visits, gestational age at first ultrasound scan, and the number of biophysical profiles that were performed before delivery were recorded. The labor and delivery database was searched for all deliveries at >41 weeks of gestation. The charge for a single ultrasound scan at <20 weeks of gestation was compared with twice-weekly testing in the population as a whole with the use of three strategies (no dating ultrasound scans and biophysical profiles until delivery, routine dating ultrasound scan and routine induction at 41 weeks of gestation, and current practice at our institution). RESULTS: One hundred twenty-seven subjects with postdated pregnancy were enrolled (mean age, 25.2 years; median parity, 0 [range, 0-6]). The mean gestational age at the initiation of prenatal care was 21.2 ± 10.5 weeks. Forty-seven women (38.0%) initiated care at <20 weeks. The mean number of biophysical profiles performed before delivery was 1.5 ± 1.34; the mean gestational age at delivery was 42.1 ± 0.87 weeks (spontaneous labor, 39.6%; induced labor, 40.4%). The charge for a biophysical profile is $492.90 and $551.00 for a 20-week ultrasound scan; there is no difference in the charge for induced or spontaneous labor. During the 4-month study period, 1638 patients were delivered at our hospital; 341 patients were delivered at >41 weeks of gestation. The estimated financial burden of antenatal testing of 341 patients from 41 weeks to delivery was calculated to be $252,118, compared with $902,538 for a single ultrasound scan at 20 weeks for the entire population of 1638 patients. The estimated financial burden of current practice (10% of patients with no prenatal care, 38% of patients with examination at <20 weeks who were eligible for dating ultrasound scanning, and 37% of patients with examination for postdate testing) was $402,457. CONCLUSION: Patients who were seen for postdate antepartum testing in an indigent population lack early initiation of prenatal care and early ultrasound scans. Because on average only 1.5 biophysical profiles are performed per patient before delivery, routine early ultrasound scanning and routine induction at 41 weeks of gestation would add considerable financial burden to the system. (Am J Obstet Gynecol 2003;188:1214-6.)
Key words: Postdates pregnancy, biophysical profile, financial burden, ultrasound
Postterm pregnancy, pregnancy of 42 weeks (294 days) from the first day of the last menstrual period, is a common problem that is associated with increased fetal and neonatal morbidity and mortality rates because of progressive uteroplacental insufficiency with advancing gestational age.1,2 More recently, Leveno et al3 reported that increased risks to postterm fetuses were the consequence of cord compression that was associated with
From the Department of Obstetrics, Gynecology, and Reproductive Science, University of Texas Houston Medical School. Reprint requests: Manju Monga, MD, 6431 Fannin 3.268, Houston, TX 77030. E-mail: [email protected] © 2003, Mosby, Inc. All rights reserved. 0002-9378/2003 $30.00 + 0 doi:10.1067/mob.2003.287
1214
oligohydramnios. Because perinatal mortality rates gradually increase from 41 weeks of gestation, it is recommended that antenatal testing commence at 41 weeks of gestation with “postdated” pregnancy.4,5 Pregnancies may be classified incorrectly as postterm if there is uncertainty of the last menstrual period. Such misclassification may result in unnecessary antenatal fetal testing or induction of labor. Routine early ultrasound scanning has been shown to decrease the number of women who require the induction of labor for postterm pregnancies, and routine induction at 41 weeks of gestation has been shown to be less costly than twice-weekly testing.6,7 To date, no study has compared the cost of serial antenatal testing for postdated pregnancy compared with a single dating ultrasound scan and induction in an indigent population.
Fonseca, Monga, and Silva 1215
Volume 188, Number 5 Am J Obstet Gynecol
The objective of this study was to compare the financial burden of a single early obstetric ultrasound scan with antenatal testing for postdated pregnancy in an indigent population. Our hypothesis was that a routine single ultrasound scan would be less expensive than serial antenatal testing in an indigent population because these women are seen for postdate testing with poor dating criteria and therefore have several unnecessary biophysical profiles before delivery. Material and methods All women who were seen for antepartum testing with an indication for “postdates” were enrolled at Lyndon Baines Johnson General Hospital between January and April 2002. The study was approved by the Committee for the Protection of Human Subjects at the University of Texas Houston. All patients were treated with twiceweekly biophysical profiles. Maternal age, parity, gestational age, first prenatal visit, first positive pregnancy test, first fetal heart rate by Doppler scan, and first ultrasound scan were recorded. The median number of biophysical profiles that were performed before delivery, gestational age at delivery, and indication for delivery were recorded. The cost of a single obstetric ultrasound scan was compared with serial biophysical profiles in the postdates population that was enrolled. The total number of deliveries and the total number of postdates deliveries at our institution during the study period were determined from the obstetric database. Three strategies were used to estimate financial burden of antenatal testing for postdates pregnancy in our population. The first strategy assumed that routine ultrasound scanning had been performed at <20 weeks of gestation and that routine induction was performed at 41 weeks of gestation. The second strategy assumed that no dating ultrasound scans had been performed and that twice-weekly biophysical profiles had been performed from 41 weeks of gestation until delivery. The third strategy represents the current practice at our institution (early ultrasound scanning in women who are seen at <20 weeks, no routine inductions at 41 weeks of gestation, and twice-weekly biophysical profiles from 41 weeks of gestation until delivery). Results One hundred twenty-seven women who were seen for postdates antenatal testing were enrolled in the study between January 4, 2002, and April 30, 2002 (mean age, 25.2 ± 5.2 years; median parity, 0 [range, 0-6]; Hispanic, 98.4%). The mean gestational age at first prenatal visit was 21.2 ± 10.6 weeks, with a median of eight prenatal visits (range, 0-16 visits). Forty-nine women (38.0%) initiated care at <20 weeks of gestation. Twenty women (15.6%) had an ultrasound scan at <20 weeks of gestation. Only 1 woman (0.7%) had a documented positive
pregnancy test for >38 weeks, and none of the women had documented fetal heart tones by Doppler scan for >32 weeks of gestation. Five women were lost to follow-up because they were delivered elsewhere. The mean gestational age at delivery was 42.1 ± 0.87 weeks. Seventy-seven women (60.6%) had induced labor. The indication for induction was oligohydramnios (50%), favorable cervix (13.8%), nonreassuring fetal heart rate tracing (7%), good dating criteria (4%), and other indications (26%). The mean number of biophysical profiles before delivery was 1.5 ± 1.34. The charge for a single biophysical profile in our unit is $492.90. The average estimated cost of antenatal testing per patient was determined to be $739.35. The charge for a single ultrasound scan at 20 weeks of gestation in our unit is $551.00. There is no charge differential for spontaneous and induced labor at our institution. The total number of deliveries for the study period was 1638. Ten percent of the women who were delivered had no prenatal care. The total number of deliveries at 41 weeks was 341 (20.6%). Of these, 127 women (37.6%) were seen for antenatal testing and were enrolled in this study. The first cost analysis strategy assumed routine ultrasound scanning for all patients at <20 weeks of gestation, with routine induction at 41 weeks of gestation. The charge of routine ultrasound scan ($551.00) for 1638 patients was $902,538. The second strategy assumed no routine ultrasound scan and twice weekly testing for all patients from 41 weeks of gestation until delivery. Because 341 patients were delivered after 41 weeks of gestation and the mean number of biophysical profiles before delivery was 1.5, the estimated charges for antenatal testing for postdates in our patient population was $252,118.35 ($492.90 1.5 341). The final strategy represents the current practice in which 10% of the women have no prenatal care, 38% of the women (n = 560) are seen for prenatal care at <20 weeks (which makes them eligible for a dating ultrasound scan), and 37% of the women with postdates pregnancy (n = 127) were seen for antenatal testing and with an average of 1.5 biophysical profiles before delivery. The financial burden of this current practice is $308,560 for ultrasound scans (560 $551.00) plus $93,897 for postdates testing (127 1.5 $492.90), for a total of $402,457. The current strategy is less expensive than routine dating ultrasound scanning and induction of labor at 41 weeks in our population. Comment Postterm pregnancies are at higher risk for meconium staining, oxytocin induction, shoulder dystocia, cesarean delivery, macrosomia, and meconium aspiration.8 A meta-analysis of 18 studies showed that routine induction at 41 weeks of gestation reduced perinatal mortality rates,9 and routine induction for postdates pregnancy has
1216 Fonseca, Monga, and Silva
been shown to be less expensive than twice-weekly testing.7 In our study population, routine induction was not practiced routinely because our patient population lacked confirmation of gestational age by ultrasound scan or early prenatal care. In our indigent population, patients who were seen with “postdate” pregnancy were treated therefore with twice-weekly antenatal testing until delivery. To date, there has been no other study that compared the cost of serial antenatal testing for postdated pregnancy in an indigent population. Our data indicate that patients who were seen for postdates testing lacks the early initiation of prenatal care and early ultrasound confirmation of estimated delivery. However, our results reject our hypothesis that these patients had several biophysical profiles before delivery. Rather, on average only 1.5 biophysical profiles were performed before delivery. A single ultrasound scan for all women in our population would be much more expensive than our current treatment scheme and would add 1.5 million dollars per year to the cost of caring for this population. Although in other populations, routine ultrasound scans to establish the estimated date of delivery has been shown to be less expensive than serial antenatal testing for postdates pregnancy, in an indigent population, routine ultrasound scans would not be cost-effective.6,7,9
May 2003 Am J Obstet Gynecol
REFERENCES
1. Bakketeig LS, Bergsjo P. Post-term pregnancy: Magnitude of the problem. In: Chalmers I, Enkin M, Keirse M, editors. Effective care in pregnancy and childbirth. Oxford (UK): Oxford University Press; 1991. p. 765-82. 2. Freeman RK, Garite J, Modanou H, Dorchester W, Rommal C, Devaney M. Postdate pregnancy: utilization of contraction stress testing for primary fetal surveillance. Am J Obstet Gynecol 1981; 140:128-35. 3. Leveno KJ, Quirk JG, Cunningham FG, Nelson SD, SantosRamos R, Toofanian A, et al. Prolonged pregnancy, observations concerning the causes of fetal distress. Am J Obstet Gynecol 1984;150:465-73. 4. Guidetti DA, Divon MY, Langer O. Postdate fetal surveillance: is 41 weeks too early? Am J Obstet Gynecol 1989;161:91-3. 5. Bochner CJ, Williams J III, Castro L, Medearis A, Hobel CJ, Wade M. The efficacy of starting postterm antenatal testing at 41 weeks as compared with 42 weeks of gestational age. Am J Obstet Gynecol 1988;159:550-4. 6. Waldenstrom U, Nilsson S, Fall O, Axelsson O, Sclind G, Lindeberg S, et al. Effects of routine one-stage ultrasound screening in pregnancy: a randomized controlled trial. Lancet 1988;2:585-8. 7. Goeree R. Hannah M, Hewson S. Cost-effectiveness of induction of labor versus serial antenatal monitoring in the Canadian Multicentre Postterm Pregnancy Trial. Can Med Assoc J 1995; 152:1445-50. 8. Crowely P. Interventions to prevent or improve outcome of deliveries at or beyond term. The Cochrane Library. Cochrane Collaboration, Issue 4. Oxford: Update Software, 1997. 9. Eden RD, Siefert LS, Winegard A, Spellacy WN. Perinatal characteristics of uncomplicated postdate pregnancies. Obstet Gynecol 1987;32:285-6.
Key words: Postdates pregnancy, biophysical profile, financial burden, ultrasound
Postterm pregnancy, pregnancy of 42 weeks (294 days) from the first day of the last menstrual period, is a common problem that is associated with increased fetal and neonatal morbidity and mortality rates because of progressive uteroplacental insufficiency with advancing gestational age.1,2 More recently, Leveno et al3 reported that increased risks to postterm fetuses were the consequence of cord compression that was associated with
From the Department of Obstetrics, Gynecology, and Reproductive Science, University of Texas Houston Medical School. Reprint requests: Manju Monga, MD, 6431 Fannin 3.268, Houston, TX 77030. E-mail: [email protected] © 2003, Mosby, Inc. All rights reserved. 0002-9378/2003 $30.00 + 0 doi:10.1067/mob.2003.287
1214
oligohydramnios. Because perinatal mortality rates gradually increase from 41 weeks of gestation, it is recommended that antenatal testing commence at 41 weeks of gestation with “postdated” pregnancy.4,5 Pregnancies may be classified incorrectly as postterm if there is uncertainty of the last menstrual period. Such misclassification may result in unnecessary antenatal fetal testing or induction of labor. Routine early ultrasound scanning has been shown to decrease the number of women who require the induction of labor for postterm pregnancies, and routine induction at 41 weeks of gestation has been shown to be less costly than twice-weekly testing.6,7 To date, no study has compared the cost of serial antenatal testing for postdated pregnancy compared with a single dating ultrasound scan and induction in an indigent population.
Fonseca, Monga, and Silva 1215
Volume 188, Number 5 Am J Obstet Gynecol
The objective of this study was to compare the financial burden of a single early obstetric ultrasound scan with antenatal testing for postdated pregnancy in an indigent population. Our hypothesis was that a routine single ultrasound scan would be less expensive than serial antenatal testing in an indigent population because these women are seen for postdate testing with poor dating criteria and therefore have several unnecessary biophysical profiles before delivery. Material and methods All women who were seen for antepartum testing with an indication for “postdates” were enrolled at Lyndon Baines Johnson General Hospital between January and April 2002. The study was approved by the Committee for the Protection of Human Subjects at the University of Texas Houston. All patients were treated with twiceweekly biophysical profiles. Maternal age, parity, gestational age, first prenatal visit, first positive pregnancy test, first fetal heart rate by Doppler scan, and first ultrasound scan were recorded. The median number of biophysical profiles that were performed before delivery, gestational age at delivery, and indication for delivery were recorded. The cost of a single obstetric ultrasound scan was compared with serial biophysical profiles in the postdates population that was enrolled. The total number of deliveries and the total number of postdates deliveries at our institution during the study period were determined from the obstetric database. Three strategies were used to estimate financial burden of antenatal testing for postdates pregnancy in our population. The first strategy assumed that routine ultrasound scanning had been performed at <20 weeks of gestation and that routine induction was performed at 41 weeks of gestation. The second strategy assumed that no dating ultrasound scans had been performed and that twice-weekly biophysical profiles had been performed from 41 weeks of gestation until delivery. The third strategy represents the current practice at our institution (early ultrasound scanning in women who are seen at <20 weeks, no routine inductions at 41 weeks of gestation, and twice-weekly biophysical profiles from 41 weeks of gestation until delivery). Results One hundred twenty-seven women who were seen for postdates antenatal testing were enrolled in the study between January 4, 2002, and April 30, 2002 (mean age, 25.2 ± 5.2 years; median parity, 0 [range, 0-6]; Hispanic, 98.4%). The mean gestational age at first prenatal visit was 21.2 ± 10.6 weeks, with a median of eight prenatal visits (range, 0-16 visits). Forty-nine women (38.0%) initiated care at <20 weeks of gestation. Twenty women (15.6%) had an ultrasound scan at <20 weeks of gestation. Only 1 woman (0.7%) had a documented positive
pregnancy test for >38 weeks, and none of the women had documented fetal heart tones by Doppler scan for >32 weeks of gestation. Five women were lost to follow-up because they were delivered elsewhere. The mean gestational age at delivery was 42.1 ± 0.87 weeks. Seventy-seven women (60.6%) had induced labor. The indication for induction was oligohydramnios (50%), favorable cervix (13.8%), nonreassuring fetal heart rate tracing (7%), good dating criteria (4%), and other indications (26%). The mean number of biophysical profiles before delivery was 1.5 ± 1.34. The charge for a single biophysical profile in our unit is $492.90. The average estimated cost of antenatal testing per patient was determined to be $739.35. The charge for a single ultrasound scan at 20 weeks of gestation in our unit is $551.00. There is no charge differential for spontaneous and induced labor at our institution. The total number of deliveries for the study period was 1638. Ten percent of the women who were delivered had no prenatal care. The total number of deliveries at 41 weeks was 341 (20.6%). Of these, 127 women (37.6%) were seen for antenatal testing and were enrolled in this study. The first cost analysis strategy assumed routine ultrasound scanning for all patients at <20 weeks of gestation, with routine induction at 41 weeks of gestation. The charge of routine ultrasound scan ($551.00) for 1638 patients was $902,538. The second strategy assumed no routine ultrasound scan and twice weekly testing for all patients from 41 weeks of gestation until delivery. Because 341 patients were delivered after 41 weeks of gestation and the mean number of biophysical profiles before delivery was 1.5, the estimated charges for antenatal testing for postdates in our patient population was $252,118.35 ($492.90 1.5 341). The final strategy represents the current practice in which 10% of the women have no prenatal care, 38% of the women (n = 560) are seen for prenatal care at <20 weeks (which makes them eligible for a dating ultrasound scan), and 37% of the women with postdates pregnancy (n = 127) were seen for antenatal testing and with an average of 1.5 biophysical profiles before delivery. The financial burden of this current practice is $308,560 for ultrasound scans (560 $551.00) plus $93,897 for postdates testing (127 1.5 $492.90), for a total of $402,457. The current strategy is less expensive than routine dating ultrasound scanning and induction of labor at 41 weeks in our population. Comment Postterm pregnancies are at higher risk for meconium staining, oxytocin induction, shoulder dystocia, cesarean delivery, macrosomia, and meconium aspiration.8 A meta-analysis of 18 studies showed that routine induction at 41 weeks of gestation reduced perinatal mortality rates,9 and routine induction for postdates pregnancy has
1216 Fonseca, Monga, and Silva
been shown to be less expensive than twice-weekly testing.7 In our study population, routine induction was not practiced routinely because our patient population lacked confirmation of gestational age by ultrasound scan or early prenatal care. In our indigent population, patients who were seen with “postdate” pregnancy were treated therefore with twice-weekly antenatal testing until delivery. To date, there has been no other study that compared the cost of serial antenatal testing for postdated pregnancy in an indigent population. Our data indicate that patients who were seen for postdates testing lacks the early initiation of prenatal care and early ultrasound confirmation of estimated delivery. However, our results reject our hypothesis that these patients had several biophysical profiles before delivery. Rather, on average only 1.5 biophysical profiles were performed before delivery. A single ultrasound scan for all women in our population would be much more expensive than our current treatment scheme and would add 1.5 million dollars per year to the cost of caring for this population. Although in other populations, routine ultrasound scans to establish the estimated date of delivery has been shown to be less expensive than serial antenatal testing for postdates pregnancy, in an indigent population, routine ultrasound scans would not be cost-effective.6,7,9
May 2003 Am J Obstet Gynecol
REFERENCES
1. Bakketeig LS, Bergsjo P. Post-term pregnancy: Magnitude of the problem. In: Chalmers I, Enkin M, Keirse M, editors. Effective care in pregnancy and childbirth. Oxford (UK): Oxford University Press; 1991. p. 765-82. 2. Freeman RK, Garite J, Modanou H, Dorchester W, Rommal C, Devaney M. Postdate pregnancy: utilization of contraction stress testing for primary fetal surveillance. Am J Obstet Gynecol 1981; 140:128-35. 3. Leveno KJ, Quirk JG, Cunningham FG, Nelson SD, SantosRamos R, Toofanian A, et al. Prolonged pregnancy, observations concerning the causes of fetal distress. Am J Obstet Gynecol 1984;150:465-73. 4. Guidetti DA, Divon MY, Langer O. Postdate fetal surveillance: is 41 weeks too early? Am J Obstet Gynecol 1989;161:91-3. 5. Bochner CJ, Williams J III, Castro L, Medearis A, Hobel CJ, Wade M. The efficacy of starting postterm antenatal testing at 41 weeks as compared with 42 weeks of gestational age. Am J Obstet Gynecol 1988;159:550-4. 6. Waldenstrom U, Nilsson S, Fall O, Axelsson O, Sclind G, Lindeberg S, et al. Effects of routine one-stage ultrasound screening in pregnancy: a randomized controlled trial. Lancet 1988;2:585-8. 7. Goeree R. Hannah M, Hewson S. Cost-effectiveness of induction of labor versus serial antenatal monitoring in the Canadian Multicentre Postterm Pregnancy Trial. Can Med Assoc J 1995; 152:1445-50. 8. Crowely P. Interventions to prevent or improve outcome of deliveries at or beyond term. The Cochrane Library. Cochrane Collaboration, Issue 4. Oxford: Update Software, 1997. 9. Eden RD, Siefert LS, Winegard A, Spellacy WN. Perinatal characteristics of uncomplicated postdate pregnancies. Obstet Gynecol 1987;32:285-6.