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Obstetric Anesthesiology: Brief Report

A Cost Analysis of Neuraxial Anesthesia to Facilitate External Cephalic Version for Breech Fetal Presentation

Carvalho, Brendan, MBBCh, FRCA*; Tan, Jonathan M., MD, MPH; Macario, Alex, MD, MBA*; El-Sayed, Yasser Y., MD*; Sultan, Pervez, MBChB, FRCA

Author Information
doi: 10.1213/ANE.0b013e31828e5bc7

Breech fetal presentation at term occurs in 3% to 4% of pregnancies and can be managed with elective cesarean delivery, assisted vaginal delivery, or external cephalic version (ECV).1,2 ECV increases the likelihood of cephalic presentation thereby reducing the incidence of cesarean delivery and is indicated for parturients with a breech singleton fetus at ≥36 completed weeks gestational age without contraindications to vaginal delivery.3,4 Approximately 87% of breech presentations in the United States result in cesarean delivery,5 which leads to higher costs compared with vaginal delivery of cephalic presentation fetuses.

Neuraxial anesthesia can be used to facilitate ECV success rate by reducing maternal anxiety and discomfort in addition to involuntary splinting of abdominal musculature that can otherwise interfere with ECV efforts and subsequent success. The aim of this study was to use computer simulation modeling to determine the effect of neuraxial anesthesia to facilitate ECV for breech fetal presentation on overall delivery costs. We hypothesized that the additional cost of providing neuraxial anesthesia would be offset by the subsequent reduction in cesarean delivery rate.

METHODS

The cost analysis of anesthesia for a single ECV attempt was conducted using a previously published computer simulation decision cost model.6 This model considers potential outcomes, the probability of these outcomes occurring, the cost of providing ECV, and then determines associated expected overall delivery costs. The possible outcomes after ECV considered in the model are outlined in Figure 1.

Figure 1
Figure 1:
Tree diagram demonstrating possible obstetrical outcomes of breech position. ECV = external cephalic version; VD = vaginal delivery (including instrumental delivery); CD = cesarean delivery; EM = emergency; Rpt = repeat.

ECV success was defined as vertex presentation confirmed by ultrasound immediately after ECV. The probability of ECV success with and without anesthesia was obtained from published reports (6 randomized controlled studies) identified in a systematic review of all articles published in Cochrane, EMBASE, Medline, and Web of Sciences databases from January 1980 to September 2010.7–12 The average probability (and ranges) of other key outcomes were based on estimates from published literature as previously described by Tan et al. and included spontaneous reversion to breech presentation 6% (3%–10%), requirement for cesarean delivery after successful ECV 27% (9%–30%), postdural puncture headache 1% (0%–2%), successful second trial of ECV 51% (17%–71%), need for emergency cesarean delivery 0.35% (0%–1%), and adverse outcome from emergency cesarean delivery 1% (0%–1%).6,13

Costs rather than charges, as they appear on a hospital bill, were used for this societal perspective economic modeling in accordance with recommendations by the United States Panel on Cost-Effectiveness in Health and Medicine.14Table 1 summarizes the cost derivations used. The mean cost estimates of vaginal delivery, ECV, emergency, and elective cesarean deliveries are outlined in Table 2, and detailed itemized costs of ECV with and without neuraxial anesthesia are summarized in Table 3. Sensitivity analyses were conducted on costs for ECV with and without neuraxial anesthesia. Sensitivity analysis varied the probability of the mode of delivery, spontaneous reversion, vaginal delivery, emergent cesarean delivery, cesarean delivery for other indications, and costs (ECV, hospital, staff, services, and supplies) by ±10%.

Table 1
Table 1:
Cost Derivations Utilized
Table 2
Table 2:
Mean Costs (in 2010 US dollars) of External Cephalic Version With and Without Neuraxial Anesthesia, Vaginal, and Cesarean Delivery
Table 3
Table 3:
Itemized Cost (in 2010 US dollars) of External Cephalic Version With and Without Neuraxial Anesthesia

Point estimates and ranges (i.e., minimum, likely, and maximum data points) for all outcome probabilities outlined above and point estimates for costs described above were then entered into TreeAge Pro 2010 software (Tree Age Software, Inc., Williamstown, MA). For this cost model analysis, we used Monte Carlo simulation modeling to account for parameter uncertainty. We conducted Monte Carlo simulations using probabilistic sensitivity sampling with 1000 iterations from a base case for ECV with neuraxial anesthesia and 1000 iterations from a base case for ECV without anesthesia to determine expected costs. The base case was determined using cost and probability outlined in our previously published computer simulation decision ECV cost model.6 Point estimates (mean) and ranges for ECV with and without neuraxial anesthesia were derived from published ECV success rates (Table 4). We first demonstrated the distribution of costs for each strategy (ECV with or without anesthesia) separately using the TreeAge probabilistic sensitivity sampling with Monte Carlo simulations. We then used the TreeAge software with the Monte Carlo simulations to do incremental outcome comparisons between each strategy (ECV with or without anesthesia) to determine the incremental cost difference and the cost distribution between strategies. During each iteration, all samples of random variables were identical, except for whether neuraxial anesthesia was used. The cost probability distribution derived from the modeling was graphed, and the prediction intervals were computed from the 2.5th to 97.5th percentiles. To calculate the ECV success rate above baseline at which neuraxial anesthesia became cost saving (i.e., 2.5th–97.5th percentile prediction interval no longer crossed zero), we ran further simulations increasing ECV success in 1% increments from the 38% ECV base case success (see Supplemental Digital Content 1, http://links.lww.com/AA/A535, for a more detailed description of the Methods).

Table 4
Table 4:
Randomized and Controlled Studies Comparing External Cephalic Version Success Rates With and Without Neuraxial Anesthesia

RESULTS

On the basis of the 6 studies identified in the systematic review, we determined an average ECV success rate of 38% for a base case (term, singleton breech presentation for attempted ECV without anesthesia; 96 of 255 patients in all the control groups combined); the ECV success rates ranged from 31% to 58% among the 6 studies. For a treatment case (attempted ECV with neuraxial anesthesia), average ECV success rate was 60% (151 of 253 patients in all the treatment groups combined); the ECV success rate ranged from 44% to 87% among the studies (Table 4). The expected cost for providing neuraxial anesthesia for ECV was $134 (Table 3). This cost included professional time of the anesthesiologist ($110) and equipment ($24).

The mean expected total delivery costs, including the cost of attempting/performing ECV with anesthesia, equaled $8931 (2.5th–97.5th percentile prediction interval $8541–$9252). The cost was $9207 (2.5th–97.5th percentile prediction interval $8896–$9419) if ECV was attempted/performed without anesthesia. The expected mean incremental difference between the total cost of delivery that includes ECV with anesthesia and ECV without anesthesia was $−276 (2.5th–97.5th percentile prediction interval $−720 to $112). The modeling revealed that neuraxial anesthesia for ECV becomes a cost-saving strategy if anesthesia increases the absolute ECV success by ≥11% above the 38% baseline ECV success expected without anesthesia. Sensitivity analysis that varied parameters (probability of spontaneous reversion, vaginal delivery, emergent cesarean delivery, cesarean delivery for other indications) and costs (ECV, hospital, staff, services, and supplies) by ±10% found that none of the parameters significantly changed our model’s final mean cost for ECV with or without anesthesia).

DISCUSSION

Neuraxial anesthesia for ECV does not appear to significantly increase the total expected costs of delivery for breech fetal presentation. The initial costs associated with providing neuraxial anesthesia ($134) were offset by subsequent savings related to fewer cesarean deliveries. Cost savings were directly related to increased probability of success of the ECV procedure. Neuraxial anesthesia adds approximately 12% more cost to providing ECV without anesthesia ($1087). The cost of neuraxial anesthesia is only a small fraction (approximately 3%) of the total delivery costs.

Using our model’s base case estimate, for the routine use of neuraxial anesthesia to be justified from a societal economic perspective, anesthesia must improve ECV success by 11% over the assumed baseline success rate of 38% derived from the control groups of published randomized studies. However, ECV success rates are dependent on various factors including timing of ECV, operator skill and experience, gestational age, and patient selection.15,16 Therefore, the “cutoff” threshold of 11% above base case success rate derived from this computer model of societal cost may not apply to all institutions.

There are large differences in reported ECV success rates with neuraxial anesthesia among studies. Some of these differences may be related to the selection of parturients suitable for ECV, timing of the ECV attempt, as well as medications (local anesthetic and opioid) and doses (anesthetic and analgesic) used. For example, the authors of a meta-analysis reported that the provision of anesthetic doses (compared with analgesic doses) for neuraxial anesthesia may increase the probability of successful ECV.17

Limitations of this computer modeling include failure to address factors such as quality of life, patient preference, and rare risks of neuraxial techniques (epidural abscess, epidural hematoma or nerve damage). We also grouped all neuraxial techniques (spinal, epidural, combined spinal–epidural) into 1 studied intervention. No studies have directly compared success rates between each neuraxial technique, and the likelihood of ECV success varies among the studies. Success rates incorporated into our model were not weighted according to quality of study.

In summary, the total cost of delivery in women with breech presentation may be decreased (up to $720) or increased (up to $112) if ECV is attempted/performed with neuraxial anesthesia compared with ECV without neuraxial anesthesia. Results suggest that the increased ECV success and subsequent reduction in breech cesarean delivery rates offset the costs of providing neuraxial anesthesia. Concern for significantly increasing total cost of delivery does not appear to be a valid reason to withhold neuraxial anesthesia for ECV.

DISCLOSURES

Name: Brendan Carvalho, MBBCh, FRCA.

Contribution: This author helped design and conduct the study, analyze the data, and write the manuscript.

Attestation: Brendan Carvalho has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Jonathan M. Tan, MD, MPH.

Contribution: This author helped design and conduct the study, analyze the data, and write the manuscript.

Attestation: Jonathan M. Tan has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Alex Macario, MD, MBA.

Contribution: This author helped design and conduct the study, analyze the data, and write the manuscript.

Attestation: Alex Macario has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Yasser Y. El-Sayed, MD.

Contribution: This author helped design and conduct the study, analyze the data, and write the manuscript.

Attestation: Yasser Y. El-Sayed has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Pervez Sultan, MBChB, FRCA.

Contribution: This author helped design and conduct the study, analyze the data, and write the manuscript.

Attestation: Pervez Sultan has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

This manuscript was handled by: Cynthia A. Wong, MD.

ACKNOWLEDGEMENTS

We thank Jeremy Goldhaber-Fiebert, PhD (Center for Health Policy/Primary Care and Outcomes Research, Stanford University School of Medicine) for his valuable input into the study analysis.

REFERENCES

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