Objective
Cervical length (CL) of 3 cm or greater has been shown to have a 97-99% negative predictive value for preterm delivery in women with threatened preterm labor. Consequently, hospitalization and treatment are not indicated in these patients. We analyzed how often patients with a CL of 3 cm or greater are still being admitted and treated for preterm labor and how much this contributes to the economic burden of preterm labor hospitalizations.
Study Design
Twelve month hospitalizations for preterm labor at less than 34 weeks at a single institution were reviewed and patients with a CL of 3 cm or greater were identified. We chose to use patients’ hospital charges as a surrogate for health care costs, recognizing that charges are not synonymous with the final patient bill and also do not reflect additional costs such as the cost of treatment at the referring facility, transportation, physician fees, and other such costs as lost wages, need for additional child care, etc.
Results
Between July 2009 and June 2010, 139 patients were admitted and treated for preterm labor at our level III center. Fifty of these patients (36%) had a CL of 3 cm or greater. None of them delivered preterm. Total hospital charges for the management of these patients were $1,018 589 (mean, $20,372; median, $14,444).
Conclusion
Unnecessary admissions and treatments for threatened preterm labor are part of clinical practice and contribute to exploding health care costs. Using currently available diagnostics, these costs could be lowered significantly without jeopardizing outcome.
The cost of health care in the United States is a major concern for patients, insurers, employers, and policy makers. The United States spends more per capita on publicly funded health care than just about every other developed country, including spending more than those countries with universal publicly funded health care systems. In 2011, employers paid an average of $15,073 per employee for family coverage, and the ability to be able to afford health care insurance for new employees is a major factor in the decision to hire more workers.
Several proposals to reduce health care costs exist: prevention, health information technology, changing Medicare rules, etc. However, there is an aspect of cost control that has not received enough attention: unnecessary tests, admissions, and treatments, not supported by evidence, are part of everyday clinical practice. Physicians could play a major role in reducing health care costs by adopting protocols centered on evidence-based medicine.
Diagnosis of preterm labor previously relied on patient’s perception of contractions, despite their poor predictive value. Fetal fibronectin (FFN) and transvaginal cervical length (CL) have been demonstrated to have high negative predictive values for preterm delivery and can help avoid unnecessary treatment. Moreover, if the CL is 3 cm or greater, preterm delivery is unlikely, regardless of FFN.
The objective of our analysis was to determine how often patients with a CL of 3 cm or greater are still being admitted and treated for preterm labor at our level III center and how much this contributes to the economic burden of preterm labor hospitalizations.
Materials and Methods
The St. Joseph’s Hospital and Medical Center Institutional Review Board approved the study.
We analyzed hospital charges for the management of women admitted at our institution (St. Joseph’s Hospital and Medical Center, Phoenix, AZ) between July 1, 2009, and June 30, 2010, for preterm labor with intact membranes at less than 34 weeks of gestation, who were subsequently found to have a CL of 3 cm or greater.
The diagnosis of preterm labor was based on the presence of uterine contractions assessed by tocodynamometry (TOCO) and/or maternal perception of contractions and on change in cervical dilatation or effacement assessed by digital cervical examination. Digital examination was performed by 1 of 26 obstetrical-gynecological resident physicians involved in the care of the patients included in the study. The CL was measured after admission by one of 4 certified ultrasound technicians. The ultrasound images were reviewed and the measurement confirmed by 1 of 5 maternal-fetal medicine specialists.
The estimated gestational age (EGA) was based on the last menstrual period, a review of prior ultrasound images, and outside records if available. If there were no previous ultrasound images or no outside records, the EGA was determined by the admitting ultrasound. If the admitting ultrasound EGA differed by more than 2 weeks from the last menstrual period in the second trimester or 3 weeks into the third trimester, the ultrasound EGA was selected.
Results
During the 12 month period analyzed, 139 patients were admitted and treated for preterm labor at our level III center. Of these, 50 patients (36%) had a CL of 3 cm or greater. None of the patients with a CL of 3 cm or greater delivered preterm. All were pregnant with singletons, median maternal age was 27 years (range, 18–43 years), 9 (18%) were smokers, and 10 (20%) had had a previous preterm birth. Total hospital charges for threatened preterm labor management in patients with a CL of 3 cm or greater were $1,018,589 (range, $6915–63,212; mean, $20,372; median, $14,444) ( Figure ).
Results
During the 12 month period analyzed, 139 patients were admitted and treated for preterm labor at our level III center. Of these, 50 patients (36%) had a CL of 3 cm or greater. None of the patients with a CL of 3 cm or greater delivered preterm. All were pregnant with singletons, median maternal age was 27 years (range, 18–43 years), 9 (18%) were smokers, and 10 (20%) had had a previous preterm birth. Total hospital charges for threatened preterm labor management in patients with a CL of 3 cm or greater were $1,018,589 (range, $6915–63,212; mean, $20,372; median, $14,444) ( Figure ).
