Induced labor may be cost-effective for patients with unfavorable cervical exams

Compared with expectant management, inducing labor at 39 weeks’ gestation may be cost-effective for nulliparas with unfavorable cervical exams, according to data published in the American Journal of Obstetrics & Gynecology.

“Induction of labor is time- and resource-intensive,” Alison C. Fitzgerald, MD, a resident in the department of OB/GYN at Brigham and Women’s Hospital in Boston, and colleagues wrote. “In the ARRIVE trial, patients in the induction group spent an average of 20 hours on labor and delivery vs. 14 hours for patients in the expectant management group. This difference contributes to concerns that offering induction of labor at 39 weeks without a medical indication will further tax already strained labor and delivery units.”

Fitzgerald and colleagues developed a model to evaluate the cost of 39-week induction vs. expectant management for nulliparas with unfavorable cervical exams, and another model to evaluate the same among those with favorable exams.

The primary outcome was cost-effectiveness with a willingness-to-pay threshold of $100,000 per quality-adjusted life-year. The researchers also evaluated the number of cases with cesarean section, hypertensive disorders of pregnancy and stillbirth.

Among patients with unfavorable cervical exams, the incremental cost-effectiveness ratio (ICER) for elective induction at 39 weeks’ gestation vs. expectant management was $2,152 per QALY. Among patients with favorable exams, the ICER was $115,100 per QALY, which exceeds the willingness-to-pay threshold by $15,100.

Evaluating QALY discounts revealed that with a 0% discount per year, 39-week induction was more cost-effective for patients with unfavorable (ICER = $1,473 per QALY) and favorable (ICER = $75,820 per QALY) cervical exams. However, with a 5% QALY discount per year, 39-week induction was more cost-effective for patients with unfavorable cervical exams (ICER = $2,913 per QALY) and expectant management was more cost-effective for patients with favorable exams (ICER = $156,400 per QALY).

Further analyses showed that 39-week induction was cost-effective for 64.1% of patients with unfavorable cervical exams and expectant management was cost-effective for 55.4% of patients with favorable cervical exams.

Both elective induction groups had fewer cesarean deliveries and hypertensive disorders of pregnancy compared with the expectant management groups. Also, neither elective induction group had stillbirths, while the expectant management groups had 48 stillbirths per 100,000 patients among those with favorable exams and 58 stillbirths per 100,000 patients among those with unfavorable exams.

“Our analysis suggests that elective induction of labor at 39 weeks may be cost-effective for patients with unfavorable cervical exams,” Fitzgerald and colleagues wrote. “This result may be counterintuitive given patients with unfavorable cervical exams may require more resources and time for elective induction of labor at 39 weeks, and aids in decision-making for health systems with busy labor and delivery units regarding which patients should be prioritized for elective induction if desired.”

Moving forward, the researchers said, more study is needed on the cost of induction across health systems and the current landscape and patient preferences with regard to elective induction.