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

Abstract

Objective: Out-of-hospital (outpatient) cervical ripening prior to induction of labor (IOL) is discussed for its potential to decrease the burden on hospital resources. We assessed the cost and clinical outcomes of adopting an outpatient strategy with a synthetic hygroscopic cervical dilator, which is indicated for use in preinduction cervical ripening. Methods: We developed a cost-consequence model from the hospital perspective with a time period from IOL to post-delivery discharge. A hypothetical cohort of women to undergo IOL at term with an unfavorable cervix (all risk levels) were assessed. As the standard of care (referred to as IP-only) all women were ripened as inpatients using the vaginal PGE2 insert or the single-balloon catheter. In the comparison (OP-select), 50.9% of low-risk women (41.4% of the study population) received outpatient cervical ripening using a synthetic hygroscopic cervical dilator and the remaining women were ripened as inpatients as in the standard of care. Model inputs were sourced from a structured literature review of peer-reviewed articles in PubMed. Testing of 2,000 feasible scenarios (probabilistic multivariate sensitivity analysis) ascertained the robustness of results. Outcomes are reported as the average over all women assessed, comparing OP-select to IP-only. Results: Implementing OP-select resulted in hospital savings of US$689 per delivery, with women spending 1.48 h less time in the labor and delivery unit and 0.91 h less in the postpartum recovery unit. The cesarean-section rate was decreased by 3.78 percentage points (23.28% decreased to 19.50%). In sensitivity testing, hospital costs and cesarean-section rate were reduced in 91% of all instances. Conclusion: Our model analysis projects that outpatient cervical ripening has the potential to reduce hospital costs, hospital stay, and the cesarean section rate. It may potentially allow for better infection-prevention control during the ongoing COVID-19 pandemic and to free up resources such that more women might be offered elective IOL at 39 weeks.

Keywords: cervical ripening; cesarean section; cost-consequence analysis; health economics; induction of labor; mechanical dilator; outpatient; prostaglandins.

Figure 1

Decision trees for (A) flow of women from hospital admission to assigning women to inpatient or outpatient for preinduction cervical ripening and (B) cervical ripening/IOL to delivery care pathway. For (A), internal nodes (white boxes) describe patient characteristics and leaves (gray/black boxes) represent the type of ripening agent administered and whether women are ripened in the inpatient (gray) or outpatient (black) setting. (B) The internal nodes (white boxes) represent events or interventions, and the leaves (gray boxes) represent vaginal (dark gray) or cesarean birth (light gray) as the two possible outcomes. CR, cervical ripening; C-section, cesarean section; PGE, prostaglandin.

Figure 2

Illustrating the cost-saving potential by increasing the number of low-risk women for outpatient cervical ripening with the synthetic hygroscopic cervical dilator (SHCD) from 0 to 100%. The dashed line represents the model base case at 50.9%.

Figure 3

Scenario analyses comparing per-delivery cost savings (A) and cesarean sections (B) in IP-only vs. OP-select strategies. Scenario analyses: (1) model base case, (2) women for TOLAC are ripened in the hospital only, (3) all non-significant relative risks for clinical events are set to 1.0, and (4) only primiparous women are assessed. TOLAC, trial of labor after cesarean section.