(268) Cost-effectiveness of early vs. delayed amniotomy following transcervical balloon ripening

Objective: A recent randomized trial found a decrease in the time from balloon removal to the active phase of labor and delivery with an early amniotomy, as well as an increase in postpartum hemorrhage with delayed amniotomy among term pregnant patients undergoing labor induction. Our goal is to demonstrate the cost-effectiveness of early amniotomy (< 2 hours after balloon removal) compared to late ( >4 hours after balloon removal) amniotomy.

Study Design: A decision-analytic model was constructed using TreeAge to compare outcomes in patients with induced pregnancies undergoing transcervical balloon ripening followed by early vs. late amniotomy. Our theoretical cohort included 583,231 pregnancies, an estimate of the annual term inductions in the United States. Our outcomes include postpartum hemorrhage, chorioamnionitis, hours saved in labor, costs, and quality-adjusted life years (QALYs). We used a willingness-to-pay for the incremental cost-effectiveness ratio of $100,000/QALY. Model inputs were derived from the literature, and QALYs were generated at a discount rate of 3%. Sensitivity analyses were performed to assess the robustness of our model.

Results: In the one-year theoretical cohort of 583,231 patients, early amniotomy was found to be the dominant strategy. Early amniotomy led to 63,530 fewer cases of chorioamnionitis and 18,971 fewer cases of postpartum hemorrhage. Additionally, in the early amniotomy group, approximately 2.1 million fewer hours were spent in labor, $255 million was saved, and there were 156 additional QALYs. Univariate sensitivity analysis demonstrated that an early amniotomy is cost-saving compared to a delayed amniotomy even if the cost of labor drops to zero (Figure 1).

Conclusion: We found that the early amniotomy strategy resulted in savings of $255 million and 156 additional QALYs. Considering the significant decrease in morbidity and cost as well as the time savings associated with early amniotomy, the results of our model support early amniotomy following transcervical balloon ripening for the induction of term labor.