July 25, 2013 — Summary of "Costs of Unnecessary Admissions and Treatments for 'Threatened Preterm Labor,'" Lucovnik et al., American Journal of Obstetrics & Gynecology, 6/25.
Proposals to lower health care costs in the U.S. have focused too little on reducing the use of tests, admissions and treatments that are not supported by evidence but are still common in clinical practice, Miha Lucovnik of the Department of Obstetrics and Gynecology at St. Joseph's Hospital and Medical Center and colleagues wrote in the study. "Physicians could play a major role in reducing health care costs by adopting protocols centered on evidence based medicine," they added.
One of these unnecessary practices occurs during the diagnosis of preterm labor, according to the study. In the past, physicians have diagnosed preterm labor based on a patient's perception of contractions, even though that perception has a low predictive value. By contrast, fetal fibronectin (FFN) and transvaginal cervical length (CL) have shown high negative predictive values for the possibility of preterm labor and thus could help physicians avoid needless treatment. In addition, if a woman's CL is at least three centimeters, preterm delivery is not likely regardless of FFN.
The researchers developed the study to assess how often patients with a cervical length greater than or equal to three centimeters were admitted and treated for preterm labor, as well as the cost of caring for them.
The researchers examined hospital charges for women admitted to St. Joseph's Hospital and Medical Center in Phoenix, Ariz., between July 1, 2009, and June 30, 2010, for preterm labor with intact membranes at fewer than 34 weeks of pregnancy. Women were included in the study if they also were found to have a CL greater than or equal to three centimeters. The researchers noted that hospital charges are not synonymous with a patient's final bill and do not incorporate other costs, such as care at a referring facility, transportation and physician fees.
Patients were diagnosed as experiencing preterm labor if they were having uterine contractions assessed by tocodynamometry and/or if the patient perceived contractions, as well as changes in cervical dilatation or effacement assessed by a digital cervical examination.
The researchers found that during the one-year study period, 139 patients were admitted and treated for preterm labor. Of those patients, 36% had a CL of at least three centimeters. None of the patients who had a CL of at least three centimeters delivered preterm.
All of the women admitted and treated for preterm labor were pregnant with one fetus. The median age of the patients was 27, 18% were smokers and 20% had previously experienced a preterm birth.
Total hospital charges for women admitted and treated for preterm labor whose cervical length was at least three centimeters were $1,018,589.
The researchers commented that unwarranted admissions and treatments for potential preterm labor "are still part of everyday clinical practice and contribute to exploding healthcare costs," even though there is considerable evidence that measuring CL via transvaginal ultrasound can help avoid "needless interventions."
The analysis demonstrated that diagnosing preterm labor frequently relies on the presence of contractions, even though contractions commonly occur during a normal pregnancy and relying on the patient and/or TOCO to detect them has little predictive value for preterm labor, the researchers wrote.
They also noted that manual examinations of cervical "dilation, effacement, consistency, position, and station of the presenting part" as a means to determine the likelihood of preterm labor are subjective, with low predictive values.
By contrast, there is "substantial evidence that measuring the CL by transvaginal ultrasound can help to avoid unnecessary treatment due to the high negative predictive value of this test."
"Implementing and adhering to evidence-based protocols, such as one utilizing CL measurement to rule out 'false' preterm labor, would contribute to controlling the costs of healthcare significantly," the researchers wrote.
"[C]linicians have a major responsibility" to reduce health care costs without jeopardizing outcomes, they continued, concluding, "[I]f providers are not willing to embrace evidence-based medicine to reduce costs, then someone else will find a different way to reduce them. And in that case, physicians will no longer be the ones deciding how their patients are treated."