3/27/04

Q. What is the cost effectiveness for the use of cytotec or any other
induction agents?

A. Misoprostol is more cost-effective than the comparable commercial
agents

At ANMC we have a successful outpatient cervical ripening program. Our
patients really like that service, plus it saves resources on the
inpatient ward. Here are some resources that look at the cost of
misoprostol use in both inpatient and outpatient settings.

Let me know if you have any other questions. njm

Ramsey PS, Harris DY, Ogburn PL Jr, Heise RH, Magtibay PM, Ramin KD.
Comparative efficacy and cost of the prostaglandin analogs dinoprostone
and misoprostol as labor preinduction agents. Am J Obstet Gynecol. 2003
Feb;188(2):560-5.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12592272&dopt=Abstract>

OBJECTIVE: The purpose of this study was to compare the relative
efficacy and cost of three commercially available prostaglandin analogs,
misoprostol (Cytotec), dinoprostone gel (Prepidil), and dinoprostone
insert (Cervidil), as labor preinduction agents. STUDY DESIGN:
One-hundred eleven women with an unfavorable cervix who underwent labor
induction were assigned randomly to receive either misoprostol 50 microg
every 6 hours for two doses, dinoprostone gel 0.5 mg every 6 hours for
two doses, or dinoprostone insert 10 mg for one dose intravaginally.
Twelve hours later, oxytocin induction was initiated per standardized
protocol. Efficacy and cost of the labor preinduction/induction with the
study treatments were compared. RESULTS: Mean Bishop score change
(+/-SD) over the initial 12-hour interval was significantly greater in
the misoprostol group (5.2 +/- 3.1) compared with the dinoprostone
insert (3.2 +/- 2.3) or the dinoprostone gel groups (2.2 +/- 1.3, P
\<.0001). The proportion of women who reached complete dilation (68.4%,
50.0%, 51.4%, respectively; P =.14) and who were delivered (60.5%,
47.4%, 40.0%, respectively; P =.10) within 24 hours of the initiation of
induction were not significantly different between the misoprostol,
dinoprostone insert, and dinoprostone gel groups. Induction-to-delivery
intervals, however, were significantly shorter among women who treated
with misoprostol (24.0 +/- 10.8 hours) compared with either the
dinoprostone gel (31.6 +/- 13.4 hours) or the dinoprostone insert (32.2
+/- 14.7 hours, P \<.05). Overall mean cost per patient that was
incurred by labor induction was significantly less for the misoprostol
group (\$1036.13) compared with the dinoprostone insert group
(\$1565.72) or the dinoprostone gel group (\$1572.92, P \<.0001). No
significant differences were noted with respect to the mode of delivery
or to the adverse maternal/neonatal outcome. CONCLUSION: Misoprostol is
more cost-effective than the comparable commercial dinoprostone
prostaglandin preparations as an adjuvant to labor induction in women
with an unfavorable cervix.

Kaufman KE, Bailit JL, Grobman W. Elective induction: an analysis of
economic and health consequences. Am J Obstet Gynecol. 2002
Oct;187(4):858-63.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12388964&dopt=Abstract>

OBJECTIVE: Our purpose was to assess economic and health consequences of
elective induction at term. STUDY DESIGN: A decision-tree model
incorporating a Markov analysis was used to compare the decision either
to electively induce labor at term or expectantly manage the pregnancy
until 42 weeks\' gestation. Main outcome measures, stratified by parity,
cervical ripeness, and gestational age at induction, were number of
cesarean deliveries and costs to the health care system. RESULTS: By use
of baseline estimates, induction at any gestational age, regardless of
parity and cervical ripeness, required expenditures from the medical
system. Although never cost saving, inductions were less expensive at
later gestational ages, for multiparous patients, and for those women
with a favorable cervix. Sensitivity analysis demonstrated a robust
model. CONCLUSIONS: Elective induction of labor at term is not cost
saving and results in a large excess of cesarean deliveries. Costs are
significantly altered by the timing of the induction, parity, and
cervical ripeness.

Another somewhat related issue is if the cervical ripening is done as an
inpatient or outpatient.

Farmer KC, Schwartz WJ 3rd, Rayburn WF, Turnbull G. A cost-minimization
analysis of intracervical prostaglandin E2 for cervical ripening in an
outpatient versus inpatient setting. Clin Ther. 1996
Jul-Aug;18(4):747-56; discussion 702.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8879901&dopt=Abstract>

This investigation was undertaken to compare the cost impact of
prostaglandin E2 gel delivered intracervically in an outpatient versus
an inpatient setting. Eligible pregnant women with a singleton gestation
that was beyond 37 weeks gestational age and who had an unfavorable
cervix (Bishop score \< or = 4) received a single dose of 0.5 mg of
prostaglandin E2 intracervically as an outpatient or one or more doses
as an inpatient the day before a scheduled induction of labor. After gel
placement, the outpatient group was monitored for 2 hours with
electronic fetal monitoring before being sent home, while the inpatient
group was monitored for 2 hours in a labor and delivery unit and then
sent to the maternity unit overnight. The outpatient (n = 40) and
inpatient (n = 36) groups were not different in terms of maternal age,
race, parity, gestational age, maternal weight, predose Bishop score, or
indication for delivery. Patients in the outpatient group incurred
significantly less costs (\$3835.00 +/- 2172.00 vs \$5049.00 +/-
2060.00) and time (74.4 +/- 33.1 hours vs 100.3 +/- 41.6 hours) in the
hospital than did patients in the inpatient group. Multiparous patients
in the outpatient group, compared with those in the inpatient group,
spent fewer total hours in the hospital (56.6 +/- 19.3 vs 90.3 +/- 41.0
hours) and had a lower hospital cost (\$2891.00 +/- 1236.00 vs \$4704.00
+/- 2100.00). The only difference between the nulliparous groups favored
outpatient therapy because of less intrapartum expenses (\$730.00 +/-
405.00 vs \$1036.00 +/- 487.00). There were no differences between the
inpatient and outpatient groups for the frequencies of failed
inductions, abnormal fetal heart rate patterns, and cesarean sections.
No adverse maternal or neonatal effects with therapy were encountered in
either setting. Substantial cost savings were found with prostaglandin
E2 therapy in an outpatient rather than an inpatient setting for
patients who required an induction of labor and were candidates for
outpatient cervical ripening.

RE: Other outpatient misoprostol resources

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11641678&dopt=Abstract>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11271511&dopt=Abstract>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11042301&dopt=Abstract>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11728490&dopt=Abstract>