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Use of algorithmic pathways to develop quality, cost-effective clinical care
V K Khare1, R Consonni, D C Martin
1Department of Pathology, University of Tennessee, Memphis, USA.
Insights
Analyzing diagnostic and treatment costs for hydrosalpinges and pelvic adhesions reveals that laparoscopy for adhesions and hysterosalpingogram (HSG) for hydrosalpinges are most cost-effective for achieving pregnancy. Chlamydia screening may offer further cost benefits.
Area of Science:
- Reproductive Medicine
- Health Economics
- Gynecologic Surgery
Background:
- Hydrosalpinges and pelvic adhesions are significant causes of infertility.
- Algorithmic diagnostic and treatment pathways are used to manage these conditions.
- In vitro fertilization (IVF) is a common but costly treatment option.
Purpose of the Study:
- To analyze the cost-effectiveness of various diagnostic and treatment pathways for hydrosalpinges and pelvic adhesions.
- To compare the cost per achieved pregnancy for different management strategies.
Main Methods:
- Retrospective analysis of six defined algorithmic pathways involving Chlamydia IgG titers, hysterosalpingogram (HSG), diagnostic laparoscopy, therapeutic laparoscopy, and IVF.
- Mathematical modeling was used to calculate the theoretical cost per pregnancy for each pathway.
- Data were sourced from a tertiary care practice at a university-associated hospital.
Main Results:
- The most cost-effective pathway for adhesions involved diagnosis and treatment at laparoscopy without prior screening, costing $18,883 per pregnancy.
- For hydrosalpinges, starting with an HSG was the least costly approach at $26,614 per pregnancy.
- All pathways for adhesions and screening pathways using HSG for hydrosalpinges were more cost-effective than IVF alone.
Conclusions:
- Laparoscopy for pelvic adhesions and HSG for hydrosalpinges appear to be the most cost-effective approaches to achieving pregnancy.
- The study acknowledges limitations due to assumptions and a tertiary care population.
- Primary care screening with Chlamydia trachomatis IgG antibody testing may offer a more cost-effective strategy.
Study Objectives:
To analyze the cost of diagnosis and treatment associated with hydrosalpinges and pelvic adhesions using algorithmic pathways.
Design:
Analysis of six pathways: (1) Chlamydia IgG antibody titer -> hysterosalpingogram -> diagnostic laparoscopy -> in vitro fertilization (IVF); (2) Chlamydia IgG antibody titer -> diagnostic laparoscopy -> therapeutic laparoscopy -> IVF; (3) hysterosalpingogram -> diagnostic laparoscopy -> therapeutic laparoscopy -> IVF; (4) diagnostic laparoscopy -> therapeutic laparoscopy -> IVF; (5) no treatment; and (6) IVF only.
Setting:
A tertiary care practice at a university-associated hospital.
Patients:
Patients were retrospectively chosen on the basis of availability of results of Chlamydia IgG titers, operative notes from laparoscopy, and hysterosalpingograms (HSGs). All patients identified with these three results available were included.
Interventions:
Determination of results of laparoscopic treatment, IVF, and no therapy (observation only), based on the literature.
Measurements And Main Results:
The theoretical cost to achieve pregnancy for each pathway was calculated by mathematical modeling. The greatest number of pregnancies for the least cost ($18, 883/pregnancy) was from the diagnosis and treatment of adhesions at laparoscopy with no previous screening. The least costly approach to pregnancy for blocked tubes ($26,614/pregnancy) was to start with an HSG. All pathways for adhesions and any screening pathway using HSG for hydrosalpinges were more cost effective than IVF.
Conclusions:
These pathways are limited, as they require several assumptions and are based on a tertiary care population. Although HSG and laparoscopy appeared to be the most cost-effective approaches to pregnancy, a primary care group may have a more cost-effective response to the use of Chlamydia trachomatis IgG antibody screening.
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