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Relph S, Delaney L, Melaugh A, Vieira MC, Sandall J, Khalil A, Pasupathy D, Healey A. Costing the impact of interventions during pregnancy in the UK: a systematic review of economic evaluations. BMJ Open 2020; 10:e040022. [PMID: 33127635 PMCID: PMC7604861 DOI: 10.1136/bmjopen-2020-040022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The aim of this review was to summarise the current evidence on the costing of resource use within UK maternity care, in order to facilitate the estimation of incremental resource and cost impacts potentially attributable to maternity care interventions. METHODS A systematic review of economic evaluations was conducted by searching Medline, the Health Management Information Consortium, the National Health Service (NHS) Economic Evaluations Database, CINAHL and National Institute for Health and Care Excellence (NICE) guidelines for economic evaluations within UK maternity care, published between January 2010 and August 2019 in the English language. Unit costs for healthcare activities provided to women within the antenatal, intrapartum and postnatal period were inflated to 2018-2019 prices. Assessment of study quality was performed using the Quality of Health Economic Analyses checklist. RESULTS Of 5084 titles or full texts screened, 37 papers were included in the final review (27 primary research articles, 7 review articles and 3 economic evaluations from NICE guidelines). Of the 27 primary research articles, 21 were scored as high quality, 3 as medium quality and 3 were low quality. Variation was noted in cost estimates for healthcare activities throughout the maternity care pathway: for midwife-led outpatient appointment, the range was £27.34-£146.25 (mean £81.78), emergency caesarean section, range was £1056.44-£4982.21 (mean £3508.93) and postnatal admission, range was £103.00-£870.10 per day (mean £469.55). CONCLUSIONS Wide variation exists in costs applied to maternity healthcare activities, resulting in challenges in attributing cost to maternity activities. The level of variation in cost calculations is likely to reflect the uncertainty within the system and must be dealt with by conducting sensitivity analyses. Nationally agreed prices for granular unit costs are needed to standardise cost-effectiveness evaluations of new interventions within maternity care, to be used either for research purposes or decisions regarding national intervention uptake. PROSPERO REGISTRATION NUMBER CRD42019145309.
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Affiliation(s)
- Sophie Relph
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, London, UK
| | - Louisa Delaney
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, London, UK
| | - Alexandra Melaugh
- Health Improvement: Alcohol, Drugs, Tobacco and Justice Division, Public Health England, London, UK
| | - Matias C Vieira
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, London, UK
- Department of Obstetrics and Gynaecology, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Jane Sandall
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, London, UK
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Molecular & Clinical Sciences Research Institute, St George's, University of London, Cranmer Terrace, London, UK
| | - Dharmintra Pasupathy
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, London, UK
- Discipline of Obstetrics, Gynaecology & Neonatology, Westmead Clinical School, Faculty of Medicineand Health, University of Sydney, Sydney, New South Wales, Australia
| | - Andy Healey
- Health Service and Population Research, King's College London, De Crespigny Park, London, UK
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Alfirevic Z, Keeney E, Dowswell T, Welton NJ, Medley N, Dias S, Jones LV, Gyte G, Caldwell DM. Which method is best for the induction of labour? A systematic review, network meta-analysis and cost-effectiveness analysis. Health Technol Assess 2018; 20:1-584. [PMID: 27587290 DOI: 10.3310/hta20650] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND More than 150,000 pregnant women in England and Wales have their labour induced each year. Multiple pharmacological, mechanical and complementary methods are available to induce labour. OBJECTIVE To assess the relative effectiveness, safety and cost-effectiveness of labour induction methods and, data permitting, effects in different clinical subgroups. METHODS We carried out a systematic review using Cochrane methods. The Cochrane Pregnancy and Childbirth Group's Trials Register was searched (March 2014). This contains over 22,000 reports of controlled trials (published from 1923 onwards) retrieved from weekly searches of OVID MEDLINE (1966 to current); Cochrane Central Register of Controlled Trials (The Cochrane Library); EMBASE (1982 to current); Cumulative Index to Nursing and Allied Health Literature (1984 to current); ClinicalTrials.gov; the World Health Organization International Clinical Trials Registry Portal; and hand-searching of relevant conference proceedings and journals. We included randomised controlled trials examining interventions to induce labour compared with placebo, no treatment or other interventions in women eligible for third-trimester induction. We included outcomes relating to efficacy, safety and acceptability to women. In addition, for the economic analysis we searched the Database of Abstracts of Reviews of Effects, and Economic Evaluations Databases, NHS Economic Evaluation Database and the Health Technology Assessment database. We carried out a network meta-analysis (NMA) using all of the available evidence, both direct and indirect, to produce estimates of the relative effects of each treatment compared with others in a network. We developed a de novo decision tree model to estimate the cost-effectiveness of various methods. The costs included were the intervention and other hospital costs incurred (price year 2012-13). We reviewed the literature to identify preference-based utilities for the health-related outcomes in the model. We calculated incremental cost-effectiveness ratios, expected costs, utilities and net benefit. We represent uncertainty in the optimal intervention using cost-effectiveness acceptability curves. RESULTS We identified 1190 studies; 611 were eligible for inclusion. The interventions most likely to achieve vaginal delivery (VD) within 24 hours were intravenous oxytocin with amniotomy [posterior rank 2; 95% credible intervals (CrIs) 1 to 9] and higher-dose (≥ 50 µg) vaginal misoprostol (rank 3; 95% CrI 1 to 6). Compared with placebo, several treatments reduced the odds of caesarean section, but we observed considerable uncertainty in treatment rankings. For uterine hyperstimulation, double-balloon catheter had the highest probability of being among the best three treatments, whereas vaginal misoprostol (≥ 50 µg) was most likely to increase the odds of excessive uterine activity. For other safety outcomes there were insufficient data or there was too much uncertainty to identify which treatments performed 'best'. Few studies collected information on women's views. Owing to incomplete reporting of the VD within 24 hours outcome, the cost-effectiveness analysis could compare only 20 interventions. The analysis suggested that most interventions have similar utility and differ mainly in cost. With a caveat of considerable uncertainty, titrated (low-dose) misoprostol solution and buccal/sublingual misoprostol had the highest likelihood of being cost-effective. LIMITATIONS There was considerable uncertainty in findings and there were insufficient data for some planned subgroup analyses. CONCLUSIONS Overall, misoprostol and oxytocin with amniotomy (for women with favourable cervix) is more successful than other agents in achieving VD within 24 hours. The ranking according to safety of different methods was less clear. The cost-effectiveness analysis suggested that titrated (low-dose) oral misoprostol solution resulted in the highest utility, whereas buccal/sublingual misoprostol had the lowest cost. There was a high degree of uncertainty as to the most cost-effective intervention. FUTURE WORK Future trials should be powered to detect a method that is more cost-effective than misoprostol solution and report outcomes included in this NMA. STUDY REGISTRATION This study is registered as PROSPERO CRD42013005116. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Zarko Alfirevic
- Centre for Women's Health Research, University of Liverpool and Liverpool Women's Hospital, Liverpool, UK
| | - Edna Keeney
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Therese Dowswell
- Centre for Women's Health Research, University of Liverpool and Liverpool Women's Hospital, Liverpool, UK
| | - Nicky J Welton
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Nancy Medley
- Centre for Women's Health Research, University of Liverpool and Liverpool Women's Hospital, Liverpool, UK
| | - Sofia Dias
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Leanne V Jones
- Centre for Women's Health Research, University of Liverpool and Liverpool Women's Hospital, Liverpool, UK
| | - Gillian Gyte
- Centre for Women's Health Research, University of Liverpool and Liverpool Women's Hospital, Liverpool, UK
| | - Deborah M Caldwell
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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El Alili M, van Dongen JM, Huirne JAF, van Tulder MW, Bosmans JE. Reporting and Analysis of Trial-Based Cost-Effectiveness Evaluations in Obstetrics and Gynaecology. PHARMACOECONOMICS 2017; 35:1007-1033. [PMID: 28674846 PMCID: PMC5606992 DOI: 10.1007/s40273-017-0531-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
BACKGROUND AND OBJECTIVES The aim was to systematically review whether the reporting and analysis of trial-based cost-effectiveness evaluations in the field of obstetrics and gynaecology comply with guidelines and recommendations, and whether this has improved over time. DATA SOURCES AND SELECTION CRITERIA A literature search was performed in MEDLINE, the NHS Economic Evaluation Database (NHS EED) and the Health Technology Assessment (HTA) database to identify trial-based cost-effectiveness evaluations in obstetrics and gynaecology published between January 1, 2000 and May 16, 2017. Studies performed in middle- and low-income countries and studies related to prevention, midwifery, and reproduction were excluded. DATA COLLECTION AND ANALYSIS Reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standard (CHEERS) statement (a modified version with 21 items, as we focused on trial-based cost-effectiveness evaluations) and the statistical quality was assessed using a literature-based list of criteria (8 items). Exploratory regression analyses were performed to assess the association between reporting and statistical quality scores and publication year. RESULTS The electronic search resulted in 5482 potentially eligible studies. Forty-five studies fulfilled the inclusion criteria, 22 in obstetrics and 23 in gynaecology. Twenty-seven (60%) studies did not adhere to 50% (n = 10) or more of the reporting quality items and 32 studies (71%) did not meet 50% (n = 4) or more of the statistical quality items. As for the statistical quality, no study used the appropriate method to assess cost differences, no advanced methods were used to deal with missing data, and clustering of data was ignored in all studies. No significant improvements over time were found in reporting or statistical quality in gynaecology, whereas in obstetrics a significant improvement in reporting and statistical quality was found over time. LIMITATIONS The focus of this review was on trial-based cost-effectiveness evaluations in obstetrics and gynaecology, so further research is needed to explore whether results from this review are generalizable to other medical disciplines. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS The reporting and analysis of trial-based cost-effectiveness evaluations in gynaecology and obstetrics is generally poor. Since this can result in biased results, incorrect conclusions, and inappropriate healthcare decisions, there is an urgent need for improvement in the methods of cost-effectiveness evaluations in this field.
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Affiliation(s)
- Mohamed El Alili
- Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands.
| | - Johanna M van Dongen
- Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands
| | - Judith A F Huirne
- Department of Obstetrics and Gynaecology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Maurits W van Tulder
- Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands
| | - Judith E Bosmans
- Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands
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Bierut A, Dowgiałło-Smolarczyk J, Pieniążek I, Stelmachowski J, Pacocha K, Sobkowski M, Baev OR, Walczak J. Misoprostol Vaginal Insert in Labor Induction: A Cost-Consequences Model for 5 European Countries-An Economic Evaluation Supported with Literature Review and Retrospective Data Collection. Adv Ther 2016; 33:1755-1770. [PMID: 27549327 PMCID: PMC5055557 DOI: 10.1007/s12325-016-0397-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Indexed: 11/24/2022]
Abstract
Introduction The present study aimed to assess the costs and consequences of using an innovative medical technology, misoprostol vaginal insert (MVI), for the induction of labor (IOL), in place of alternative technologies used as a standard of care. Methods This was a retrospective study on cost and resource utilization connected with economic model development. Target population were women with an unfavorable cervix, from 36 weeks of gestation, for whom IOL is clinically indicated. Data on costs and resources was gathered via a dedicated questionnaire, delivered to clinical experts in five EU countries. The five countries participating in the project and providing completed questionnaires were Austria, Poland, Romania, Russia and Slovakia. A targeted literature review in Medline and Cochrane was conducted to identify randomized clinical trials meeting inclusion criteria and to obtain relative effectiveness data on MVI and the alternative technologies. A hospital perspective was considered as most relevant for the study. The economic model was developed to connect data on clinical effectiveness and safety from randomized clinical trials with real life data from local clinical practice. Results The use of MVI in most scenarios was related to a reduced consumption of hospital staff time and reduced length of patients’ stay in hospital wards, leading to lower total costs with MVI when compared to local comparators. Conclusions IOL with the use of MVI generated savings from a hospital perspective in most countries and scenarios, in comparison to alternative technologies. Funding Sponsorship, article processing charges, and the open access charge for this study were funded by Ferring Pharmaceuticals Poland. Electronic supplementary material The online version of this article (doi:10.1007/s12325-016-0397-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Adam Bierut
- Ferring Pharmaceuticals Poland Sp. z o. o., Warsaw, Poland
| | | | | | | | | | - Maciej Sobkowski
- Gynecological and Obstetrics Clinical Hospital of Poznan Medical Science University, Poznan, Poland
| | - Oleg R Baev
- Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
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Alfirevic Z, Keeney E, Dowswell T, Welton NJ, Medley N, Dias S, Jones LV, Caldwell DM. Methods to induce labour: a systematic review, network meta-analysis and cost-effectiveness analysis. BJOG 2016; 123:1462-70. [PMID: 27001034 PMCID: PMC5021158 DOI: 10.1111/1471-0528.13981] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2016] [Indexed: 11/26/2022]
Abstract
Objectives To compare the clinical effectiveness and cost‐effectiveness of labour induction methods. Methods We conducted a systematic review of randomised trials comparing interventions for third‐trimester labour induction (search date: March 2014). Network meta‐analysis was possible for six of nine prespecified key outcomes: vaginal delivery within 24 hours (VD24), caesarean section, uterine hyperstimulation, neonatal intensive care unit (NICU) admissions, instrumental delivery and infant Apgar scores. We developed a decision‐tree model from a UK NHS perspective and calculated incremental cost‐effectiveness ratios, expected costs, utilities and net benefit, and cost‐effectiveness acceptability curves. Main results In all, 611 studies comparing 31 active interventions were included. Intravenous oxytocin with amniotomy and vaginal misoprostol (≥50 μg) were most likely to achieve VD24. Titrated low‐dose oral misoprostol achieved the lowest odds of caesarean section, but there was considerable uncertainty in ranking estimates. Vaginal (≥50 μg) and buccal/sublingual misoprostol were most likely to increase uterine hyperstimulation with high uncertainty in ranking estimates. Compared with placebo, extra‐amniotic prostaglandin E2 reduced NICU admissions. There were insufficient data to conduct analyses for maternal and neonatal mortality and serious morbidity or maternal satisfaction. Conclusions were robust after exclusion of studies at high risk of bias. Due to poor reporting of VD24, the cost‐effectiveness analysis compared a subset of 20 interventions. There was considerable uncertainty in estimates, but buccal/sublingual and titrated (low‐dose) misoprostol showed the highest probability of being most cost‐effective. Conclusions Future trials should be designed and powered to detect a method that is more cost‐effective than low‐dose titrated oral misoprostol. Tweetable abstract New study ranks methods to induce labour in pregnant women on effectiveness and cost. New study ranks methods to induce labour in pregnant women on effectiveness and cost.
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Affiliation(s)
- Z Alfirevic
- Centre for Women's Health Research, University of Liverpool and Liverpool Women's Hospital, Liverpool, UK
| | - E Keeney
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - T Dowswell
- Centre for Women's Health Research, University of Liverpool and Liverpool Women's Hospital, Liverpool, UK
| | - N J Welton
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - N Medley
- Centre for Women's Health Research, University of Liverpool and Liverpool Women's Hospital, Liverpool, UK
| | - S Dias
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - L V Jones
- Centre for Women's Health Research, University of Liverpool and Liverpool Women's Hospital, Liverpool, UK
| | - D M Caldwell
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Beckmann M, Merollini K, Kumar S, Flenady V. Induction of labor using prostaglandin vaginal gel: cost analysis comparing early amniotomy with repeat prostaglandin gel. Eur J Obstet Gynecol Reprod Biol 2016; 199:96-101. [PMID: 26914400 DOI: 10.1016/j.ejogrb.2016.01.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Accepted: 01/29/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND In a randomized controlled trial of two policies for induction of labor (IOL) using Prostaglandin E2 (PGE2) vaginal gel, women who had an earlier amniotomy experienced a shorter IOL-to-birth time. OBJECTIVE To report the cost analysis of this trial and determine if there are differences in healthcare costs when an early amniotomy is performed as opposed to giving more PGE2 vaginal gel, for women undergoing IOL at term. STUDY DESIGN Following an evening dose of PGE2 vaginal gel, 245 women with live singleton pregnancies, ≥37+0 weeks, were randomized into an amniotomy or repeat-PGE2 group. Healthcare costs were a secondary outcome measure, sourced from hospital finance systems and included staff costs, equipment and consumables, pharmacy, pathology, hotel services and business overheads. A decision analytic model, specifically a Markov chain, was developed to further investigate costs, and a Monte Carlo simulation was performed to confirm the robustness of these findings. Mean and median costs and cost differences between the two groups are reported, from the hospital perspective. RESULTS The healthcare costs associated with IOL were available for all 245 trial participants. A 1000-patient cohort simulation demonstrated that performing an early amniotomy was associated with a cost-saving of $AUD289 ($AUD7094 vs $AUD7338) per woman induced, compared with administering more PGE2. Propagating the uncertainty through the model 10,000 times, early amniotomy was associated with a median cost savings of $AUD487 (IQR -$AUD573, +$AUD1498). CONCLUSIONS After an initial dose of PGE2 vaginal gel, a policy of administering more PGE2 when the Modified Bishop's score is <7 was associated with increased healthcare costs compared with a policy of performing an amniotomy, if technically possible. Length of stay was the main driver of healthcare costs.
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Affiliation(s)
- Michael Beckmann
- Mater Health Services, Department of Obstetrics and Gynecology, Brisbane, Queensland, Australia; Mater Research Institute - The University of Queensland, Brisbane, Queensland, Australia; School of Medicine - The University of Queensland, Brisbane, Australia.
| | - Katharina Merollini
- Institute of Health and Biomedical Innovation, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Sailesh Kumar
- Mater Research Institute - The University of Queensland, Brisbane, Queensland, Australia; Mater Health Services, Department of Obstetrics and Gynecology, Brisbane, Queensland, Australia; School of Medicine - The University of Queensland, Brisbane, Australia
| | - Vicki Flenady
- Mater Research Institute - The University of Queensland, Brisbane, Queensland, Australia
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Draycott T, van der Nelson H, Montouchet C, Ruff L, Andersson F. Reduction in resource use with the misoprostol vaginal insert vs the dinoprostone vaginal insert for labour induction: a model-based analysis from a United Kingdom healthcare perspective. BMC Health Serv Res 2016; 16:49. [PMID: 26864022 PMCID: PMC4750172 DOI: 10.1186/s12913-016-1278-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 01/22/2016] [Indexed: 11/16/2022] Open
Abstract
Background In view of the increasing pressure on the UK’s maternity units, new methods of labour induction are required to alleviate the burden on the National Health Service, while maintaining the quality of care for women during delivery. A model was developed to evaluate the resource use associated with misoprostol vaginal inserts (MVIs) and dinoprostone vaginal inserts (DVIs) for the induction of labour at term. Methods The one-year Markov model estimated clinical outcomes in a hypothetical cohort of 1397 pregnant women (parous and nulliparous) induced with either MVI or DVI at Southmead Hospital, Bristol, UK. Efficacy and safety data were based on published and unpublished results from a phase III, double-blind, multicentre, randomised controlled trial. Resource use was modelled using data from labour induction during antenatal admission to patient discharge from Southmead Hospital. The model’s sensitivity to key parameters was explored in deterministic multi-way and scenario-based analyses. Results Over one year, the model results indicated MVI use could lead to a reduction of 10,201 h (28.9 %) in the time to vaginal delivery, and an increase of 121 % and 52 % in the proportion of women achieving vaginal delivery at 12 and 24 h, respectively, compared with DVI use. Inducing women with the MVI could lead to a 25.2 % reduction in the number of midwife shifts spent managing labour induction and 451 fewer hospital bed days. These resource utilisation reductions may equate to a potential 27.4 % increase in birthing capacity at Southmead Hospital, when using the MVI instead of the DVI. Conclusions Resource use, in addition to clinical considerations, should be considered when making decisions about labour induction methods. Our model analysis suggests the MVI is an effective method for labour induction, and could lead to a considerable reduction in resource use compared with the DVI, thereby alleviating the increasing burden of labour induction in UK hospitals.
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Affiliation(s)
- T Draycott
- Spire Bristol Hospital, The Glen, Redland Hill, Durdham Down, Bristol, BS6 6UT, UK
| | - H van der Nelson
- Spire Bristol Hospital, The Glen, Redland Hill, Durdham Down, Bristol, BS6 6UT, UK
| | - C Montouchet
- Covance Inc., Clove Building, 4 Maguire Street, London, SE1 2NQ, UK
| | - L Ruff
- Covance Inc., Clove Building, 4 Maguire Street, London, SE1 2NQ, UK.
| | - F Andersson
- Ferring Pharmaceuticals A/S, HEOR, Kay Fiskers Plads 11, DK-2300, Copenhagen S, Denmark.,Center for Medical Technology Assessment (CMT), Linköping University, SE-581 83, Linköping, Sweden
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8
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Austin K, Chambers GM, de Abreu Lourenco R, Madan A, Susic D, Henry A. Cost-effectiveness of term induction of labour using inpatient prostaglandin gel versus outpatient Foley catheter. Aust N Z J Obstet Gynaecol 2015; 55:440-5. [PMID: 26173911 DOI: 10.1111/ajo.12348] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 04/10/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Evaluating cost-effectiveness of induction of labour (IOL) using outpatient mechanical cervical ripening using a Foley catheter (OFC) compared to inpatient chemical ripening using prostin gel (IPG). STUDY DESIGN Cost-effectiveness analysis from a hospital perspective alongside a RCT. Women in a metropolitan Australian maternity hospital with an unfavourable cervix requiring IOL at term were randomised to IPG (n = 51) or OFC (n = 50). Primary economic measures were mean patient costs, incremental cost per predelivery inpatient hour prevented, and incremental cost per vaginal delivery within 12 h of admission to the birthing unit. Bootstrapping estimates were used to construct 95% confidence intervals. Estimates of net monetary benefit were calculated to aid interpretation of the results. RESULTS Mean hospital costs per woman were nonsignificantly higher ($6524 OFC vs $5876 IPG) and mean difference $643; 95% CI -$366 to $1652. OFC group experienced fewer predelivery inpatient hours, resulting in an incremental cost per inpatient hour prevented of $57 (95% CI -$79.44 to $190.65). However, OFC patients were less likely to deliver vaginally within 12 h of admission to birthing unit. Other cost influencing clinical outcomes, including caesarean section rates and total inpatient hours, were not statistically different. Results were not sensitive to changes in costs or the cost-effectiveness thresholds. CONCLUSION OFC had fewer inpatient hours and costs prior to birth. However, OFC did not reduce overall inpatient hours and failed to achieve comparable rates of vaginal delivery within 12 h of birthing unit admission. Therefore, OFC is unlikely to be considered cost-effective compared to IPG in current hospital settings.
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Affiliation(s)
- Kathryn Austin
- Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Georgina M Chambers
- National Perinatal Epidemiology and Statistics Unit, School of Women's and Children's Health, University of New South Wales (UNSW), Sydney, New South Wales, Australia
| | - Richard de Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology, Ultimo, New South Wales, Australia
| | - Arushi Madan
- School of Women's and Children's Health, UNSW Medicine, University of New South Wales (UNSW), Randwick, New South Wales, Australia
| | - Daniella Susic
- Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Amanda Henry
- Royal Hospital for Women, Randwick, New South Wales, Australia.,School of Women's and Children's Health, UNSW Medicine, University of New South Wales (UNSW), Randwick, New South Wales, Australia.,Women's and Children's Health, St George Hospital, Kogarah, New South Wales, Australia
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9
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Thomas J, Fairclough A, Kavanagh J, Kelly AJ. Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term. Cochrane Database Syst Rev 2014; 2014:CD003101. [PMID: 24941907 PMCID: PMC7138281 DOI: 10.1002/14651858.cd003101.pub3] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Prostaglandins have been used for induction of labour since the 1960s. This is one of a series of reviews evaluating methods of induction of labour. This review focuses on prostaglandins given per vaginam, evaluating these in comparison with placebo (or expectant management) and with each other; prostaglandins (PGE2 and PGF2a); different formulations (gels, tablets, pessaries) and doses. OBJECTIVES To determine the effects of vaginal prostaglandins E2 and F2a for third trimester cervical ripening or induction of labour in comparison with placebo/no treatment or other vaginal prostaglandins (except misoprostol). SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2014) and bibliographies of relevant papers. SELECTION CRITERIA Clinical trials comparing vaginal prostaglandins used for third trimester cervical ripening or labour induction with placebo/no treatment, with each other, or other methods listed above it on a predefined list of labour induction methods. DATA COLLECTION AND ANALYSIS We assessed studies and extracted data independently. MAIN RESULTS Seventy randomised controlled trials (RCTs) (11,487 women) are included. In this update seven new RCTs (778 women) have been added. Two of these new trials compare PGE2 with no treatment, four compare different PGE2 formulations (gels versus tablets, or sustained release pessaries) and one trial compares PGF2a with placebo. The majority of trials were at unclear risk of bias for most domains.Overall, vaginal prostaglandin E2 compared with placebo or no treatment probably reduces the likelihood of vaginal delivery not being achieved within 24 hours. The risk of uterine hyperstimulation with fetal heart rate changes is increased (4.8% versus 1.0%, risk ratio (RR) 3.16, 95% confidence interval (CI) 1.67 to 5.98, 15 trials, 1359 women). The caesarean section rate is probably reduced by about 10% (13.5% versus 14.8%, RR 0.91, 95% CI 0.81 to 1.02, 36 trials, 6599 women). The overall effect on improving maternal and fetal outcomes (across a variety of measures) is uncertain.PGE2 tablets, gels and pessaries (including sustained release preparations) appear to be as effective as each other, small differences are detected between some outcomes, but these maybe due to chance. AUTHORS' CONCLUSIONS Prostaglandins PGE2 probably increase the chance of vaginal delivery in 24 hours, they increase uterine hyperstimulation with fetal heart changes but do not effect or may reduce caesarean section rates. They increase the likelihood of cervical change, with no increase in operative delivery rates. PGE2 tablets, gels and pessaries appear to be as effective as each other, any differences between formulations are marginal but may be important.
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Affiliation(s)
- Jane Thomas
- The University of LiverpoolC/o Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Anna Fairclough
- University of OxfordWorcester CollegeWalton StreetOxfordUKOX1 2HB
| | - Josephine Kavanagh
- The University of LiverpoolC/o Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Anthony J Kelly
- Brighton and Sussex University Hospitals NHS TrustDepartment of Obstetrics and GynaecologyRoyal Sussex County HospitalEastern RoadBrightonUKBN2 5BE
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van Baaren GJ, Jozwiak M, Opmeer BC, Oude Rengerink K, Benthem M, Dijksterhuis MGK, van Huizen ME, van der Salm PCM, Schuitemaker NWE, Papatsonis DNM, Perquin DAM, Porath M, van der Post JAM, Rijnders RJP, Scheepers HCJ, Spaanderman M, van Pampus MG, de Leeuw JW, Mol BWJ, Bloemenkamp KWM. Cost-effectiveness of induction of labour at term with a Foley catheter compared to vaginal prostaglandin E₂ gel (PROBAAT trial). BJOG 2013; 120:987-95. [PMID: 23530729 DOI: 10.1111/1471-0528.12221] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the economic consequences of labour induction with Foley catheter compared to prostaglandin E2 gel. DESIGN Economic evaluation alongside a randomised controlled trial. SETTING Obstetric departments of one university and 11 teaching hospitals in the Netherlands. POPULATION Women scheduled for labour induction with a singleton pregnancy in cephalic presentation at term, intact membranes and an unfavourable cervix; and without previous caesarean section. METHODS Cost-effectiveness analysis from a hospital perspective. MAIN OUTCOME MEASURES We estimated direct medical costs associated with healthcare utilisation from randomisation to 6 weeks postpartum. For caesarean section rate, and maternal and neonatal morbidity we calculated the incremental cost-effectiveness ratios, which represent the costs to prevent one of these adverse outcomes. RESULTS Mean costs per woman in the Foley catheter group (n = 411) and in the prostaglandin E₂ gel group (n = 408), were €3297 versus €3075, respectively, with an average difference of €222 (95% confidence interval -€157 to €633). In the Foley catheter group we observed higher costs due to longer labour ward occupation and less cost related to induction material and neonatal admissions. Foley catheter induction showed a comparable caesarean section rate compared with prostaglandin induction, therefore the incremental cost-effectiveness ratio was not informative. Foley induction resulted in fewer neonatal admissions (incremental cost-effectiveness ratio €2708) and asphyxia/postpartum haemorrhage (incremental cost-effectiveness ratios €5257) compared with prostaglandin induction. CONCLUSIONS Foley catheter and prostaglandin E2 labour induction generate comparable costs.
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Affiliation(s)
- G J van Baaren
- Department of Obstetrics, Academic Medical Centre, Amsterdam, the Netherlands.
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Melamed N, Yariv O, Hiersch L, Wiznitzer A, Meizner I, Yogev Y. Labor induction with prostaglandin E2: characteristics of response and prediction of failure. J Matern Fetal Neonatal Med 2012; 26:132-6. [PMID: 22928537 DOI: 10.3109/14767058.2012.722729] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To characterize the response to labor induction with prostaglandin E2 (PGE2) and to identify risk factors for induction failure. METHODS A prospective controlled study of women admitted for labor induction with PGE2. Maternal characteristics, Bishop score and sonographic cervical length were documented at admission. The change in cervical characteristics and the emergence of uterine contractions following each application of PGE2 were analyzed. RESULTS Of the 88 women who were included in the study, 19 (21.6%) failed to response to PGE2. The following factors were independently associated with induction failure: nulliparity (odds ratio [OR] = 5.9, 95% confidence interval (CI): 1.2-30.2), pre-pregnancy body mass index >25 kg/m2 (OR = 5.4, 95% CI: 1.1-26.5), Bishop score <4 (OR = 2.3, 95% CI: 1.05-14.4), cervical length <25 mm (OR = 0.2, 95% CI: 0.1-0.8) and the development of uterine contractions in response to the first application of PGE2 (OR = 0.4, 95% CI: 0.1-0.93). Overall, most women required only one (60.9%) or two (85.5%) applications of PGE2 to achieve successful induction. The number of applications of PGE2 required to achieve successful induction was related to parity and cervical status at presentation. CONCLUSIONS Overall, most women who eventually respond to PGE2 do so following the first two applications of PGE2, and the contribution of subsequent applications is relatively small and related to cervical status at admission.
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Affiliation(s)
- Nir Melamed
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
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Basu A, Elgey S, Haran M. Outcome of induction of labour in nulliparous women following replacement of Cervidil with Prostin. ScientificWorldJournal 2012; 2012:325968. [PMID: 22666106 PMCID: PMC3361173 DOI: 10.1100/2012/325968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Accepted: 12/22/2011] [Indexed: 11/17/2022] Open
Abstract
This study at the Logan Hospital, Australia, compared the outcome of induction of labour (IOL) in nulliparous women following replacement of Cervidil with Prostin. Eighty-two nulliparous women were identified for this retrospective cohort study over a period of three months on either side of the changed practice. Forty-four women received Prostin and 38 received Cervidil. Baseline characteristics were similar amongst the groups including maternal age, mean gestational age, and modified Bishop's score at the commencement of IOL. The incidence of amniotomy, oxytocin augmentation of labour, and rate of epidural use did not differ significantly between the groups. The mean time to delivery (vaginally or abdominally) showed a significant difference, with women receiving Prostin delivering earlier than those having Cervidil (P = 0.018). Women receiving Prostin were more likely to have assisted vaginal delivery compared to the Cervidil group (P = 0.04).
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Affiliation(s)
- Abhijit Basu
- Department of Obstetrics and Gynaecology, Logan Hospital, Cnr Armstrong and Loganlea Road, Meadowbrook, QLD 4131, Australia.
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Kelly AJ, Malik S, Smith L, Kavanagh J, Thomas J. Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term. Cochrane Database Syst Rev 2009:CD003101. [PMID: 19821301 DOI: 10.1002/14651858.cd003101.pub2] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Prostaglandins have been used for induction of labour since the 1960s. Initial work focused on prostaglandin F2a as prostaglandin E2 was considered unsuitable for a number of reasons. With the development of alternative routes of administration, comparisons were made between various formulations of vaginal prostaglandins. OBJECTIVES To determine the effects of vaginal prostaglandins E2 and F2a for third trimester cervical ripening or induction of labour in comparison with placebo/no treatment or other vaginal prostaglandins (except misoprostol). SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (May 2009) and bibliographies of relevant papers. SELECTION CRITERIA Clinical trials comparing vaginal prostaglandins used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods. DATA COLLECTION AND ANALYSIS We assessed studies and extracted data independently. MAIN RESULTS Sixty-three (10,441 women) have been included.Vaginal prostaglandin E2 compared with placebo or no treatment reduced the likelihood of vaginal delivery not being achieved within 24 hours (18.1% versus 98.9%, risk ratio (RR) 0.19, 95% confidence interval (CI) 0.14 to 0.25, two trials, 384 women). The risk of the cervix remaining unfavourable or unchanged was reduced (21.6% versus 40.3%, RR 0.46, 95% CI 0.35 to 0.62, five trials, 467 women); and the risk of oxytocin augmentation reduced (35.1% versus 43.8%, RR 0.83, 95% CI 0.73 to 0.94, 12 trials, 1321 women) when PGE2 was compared to placebo. There was no evidence of a difference between caesarean section rates, although the risk of uterine hyperstimulation with fetal heart rate changes was increased (4.4% versus 0.49%, RR 4.14, 95% CI 1.93 to 8.90, 14 trials, 1259 women).PGE2 tablet, gel and pessary appear to be as efficacious as each other and the use of sustained release PGE2 inserts appear to be associated with a reduction in instrumental vaginal delivery rates (9.9 % versus 19.5%, RR 0.51, 95% CI 0.35 to 0.76, NNT 10 (6.7 to 24.0), five trials, 661 women) when compared to vaginal PGE2 gel or tablet. AUTHORS' CONCLUSIONS PGE2 increases successful vaginal delivery rates in 24 hours and cervical favourability with no increase in operative delivery rates. Sustained release vaginal PGE2 is superior to vaginal PGE2 gel with respect to some outcomes studied.Further research is needed to assess the best vehicle for delivering vaginal prostaglandins and this should, where possible, include some examination of the cost-analysis.
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Affiliation(s)
- Anthony J Kelly
- Department of Obstetrics and Gynaecology, Brighton and Sussex University Hospitals NHS Trust, Royal Sussex County Hospital, Eastern Road, Brighton, UK, BN2 5BE
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