An economic analysis of patient controlled remifentanil and epidural analgesia as pain relief in labour (RAVEL trial); a randomised controlled trial.

OBJECTIVE: To compare the costs of a strategy of patient controlled remifentanil versus epidural analgesia for pain relief in labour. DESIGN: We performed a multicentre randomised controlled trial in 15 hospitals in the Netherlands, the RAVEL trial. Costs were analysed from a health care perspective alongside the RAVEL trial. POPULATION: Pregnant women of intermediate to high risk beyond 32 weeks gestation who planned vaginal delivery. METHODS: Women were randomised before the onset of labour, to receive either patient controlled remifentanil or epidural analgesia when pain relief was requested during labour. MAIN OUTCOME MEASURES: Primary outcome for effectiveness was satisfaction with pain relief, expressed as the area under the curve (AUC). A higher AUC represents higher satisfaction with pain relief. Here, we present an economic analysis from a health care perspective including costs from the start of labour to ten days postpartum. Health-care utilization was documented in the Case Report Forms and by administering an additional questionnaire. RESULTS: The costs in the patient controlled remifentanil group (n = 687) and in the epidural group (n = 671) were €2900 versus €3185 respectively (mean difference of -€282 (95% CI -€611 to €47)). The (non-significant) higher costs in the epidural analgesia group could be mainly attributed to higher costs of neonatal admission. CONCLUSION: From an economic perspective, there is no preferential pain treatment in labouring intermediate to high risk women. Since patient controlled remifentanil is not equivalent to epidural analgesia with respect to AUC for satisfaction with pain relief we recommend epidural analgesia as the method of choice. However, if appropriately counselled on effect and side effects there is, from an economic perspective, no reason to deny women patient controlled remifentanil.

Socioeconomic Deprivation and Utilization of Anesthetic Care During Pregnancy and Delivery: A Secondary Analysis of a French Prospective, Multicenter, Cohort Study.

BACKGROUND: Socioeconomic deprivation is associated with reduced use of antenatal resources and poor maternal outcomes with pregnancy. Research examining the association between socioeconomic deprivation and use of obstetric anesthesia care in a country providing universal health coverage is scarce. We hypothesized that in a country providing universal health coverage, France, socioeconomic deprivation is not associated with reduced use of anesthetic care during pregnancy and delivery. This study aimed to examine the association between socioeconomic deprivation and (1) completion of a mandatory preanesthetic evaluation during pregnancy and (2) use of neuraxial analgesia during labor. METHODS: Data were from a cohort of 10,419 women who delivered between 2010 and 2011 in 4 public teaching hospitals in Paris. We used a deprivation index that included 4 criteria: social isolation, poor housing condition, no work-related household income, and state-funded health care insurance. Socioeconomic deprivation was defined as a deprivation index greater than 1. Preanesthetic evaluation was considered completed if performed more than 48 hours before delivery. The association between socioeconomic deprivation and completion of the preanesthetic evaluation and use of neuraxial labor analgesia was assessed by multivariable logistic regression adjusting for education level, country of birth, and maternal and pregnancy characteristics. RESULTS: Preanesthetic evaluation was completed for 8142 of the 8624 women (94.4%) analyzed and neuraxial labor analgesia was used by 6258 of the 6834 women analyzed (91.6%). After adjustment, socioeconomic deprivation was associated with reduced probability of completed preanesthetic evaluation (adjusted odds ratio 0.88 [95% confidence interval, 0.79-0.98]; P = .027) but not use of neuraxial labor analgesia (adjusted odds ratio 0.97 [95% confidence interval, 0.87-1.07]; P = .540). CONCLUSIONS: In a country providing universal health care coverage, women who were socioeconomically deprived showed reduced completion of preanesthetic evaluation during pregnancy but not reduced use of neuraxial labor analgesia. Interventions should be targeted to socioeconomically deprived women to increase the completion of the preanesthetic evaluation.

Epidural analgesia during labour, routinely or on request: a cost-effectiveness analysis.

OBJECTIVE: To assess the cost-effectiveness of routine labour epidural analgesia (EA), from a societal perspective, as compared with labour analgesia on request. STUDY DESIGN: Women delivering of a singleton in cephalic presentation beyond 36+0 weeks' gestation were randomly allocated to routine labour EA or analgesia on request in one university and one non-university teaching hospital in the Netherlands. Costs included all medical, non-medical and indirect costs from randomisation to 6 weeks postpartum. Effectiveness was defined as a non-operative, spontaneous vaginal delivery without EA-related maternal adverse effects. Incremental cost-effectiveness ratio (ICER) was defined as the ratio of the difference in costs and the difference in effectiveness between both groups. Data were analysed according to intention to treat and divided into a base case analysis and a sensitivity analysis. RESULTS: Total delivery costs in the routine EA group (n=233) were higher than in the labour on request group (n=255) (difference -€ 322, 95% CI -€ 60 to € 355) due to more medication costs (including EA), a longer stay in the labour ward, and more operations including caesarean sections. Total postpartum hospital costs in the routine EA group were lower (difference -€ 344, 95% CI -€ 1338 to € 621) mainly due to less neonatal admissions (difference -€ 472, 95% CI -€ 1297 to € 331), whereas total postpartum home and others costs were comparable (difference -€ 20, 95% CI -€ 267 to € 248, and -€ 1, 95% CI -€ 67 to € 284, respectively). As a result, the overall mean costs per woman were comparable between the routine EA group and the analgesia on request group (€ 8.708 and € 8.710, respectively, mean difference -€ 2, 95% CI -€ 1.012 to € 916). Routine labour EA resulted in more deliveries with maternal adverse effects, nevertheless the ICER remained low (€ 8; bootstrap 95% CI -€ 6.120 to € 8.659). The cost-effectiveness acceptability curve indicated a low probability that routine EA is cost-effective. CONCLUSION: Routine labour EA generates comparable costs as analgesia on request, but results in more operative deliveries and more EA-related maternal adverse effects. Based on cost-effectiveness, no preference can be given to routine labour EA as compared with analgesia on request.

Neuraxial blockade for external cephalic version: Cost analysis.

AIM: Neuraxial blockade (epidural or spinal anesthesia/analgesia) with external cephalic version increases the external cephalic version success rate. Hospitals and insurers may affect access to neuraxial blockade for external cephalic version, but the costs to these institutions remain largely unstudied. The objective of this study was to perform a cost analysis of neuraxial blockade use during external cephalic version from hospital and insurance payer perspectives. Secondarily, we estimated the effect of neuraxial blockade on cesarean delivery rates. METHODS: A decision-analysis model was developed using costs and probabilities occurring prenatally through the delivery hospital admission. Model inputs were derived from the literature, national databases, and local supply costs. Univariate and bivariate sensitivity analyses and Monte Carlo simulations were performed to assess model robustness. RESULTS: Neuraxial blockade was cost saving to both hospitals ($30 per delivery) and insurers ($539 per delivery) using baseline estimates. From both perspectives, however, the model was sensitive to multiple variables. Monte Carlo simulation indicated neuraxial blockade to be more costly in approximately 50% of scenarios. The model demonstrated that routine use of neuraxial blockade during external cephalic version, compared to no neuraxial blockade, prevented 17 cesarean deliveries for every 100 external cephalic versions attempted. CONCLUSIONS: Neuraxial blockade is associated with minimal hospital and insurer cost changes in the setting of external cephalic version, while reducing the cesarean delivery rate.

Anesthetic management of external cephalic version.

Breech presentation is common at term and its reduction through external cephalic version represents a noninvasive opportunity to avoid cesarean delivery and the associated maternal morbidity. In addition to uterine relaxants, neuraxial anesthesia is associated with increased success of version procedures when surgical anesthetic dosing is used. The intervention is likely cost effective given the effect size and the avoided high costs of cesarean delivery.

Remifentanil target-controlled infusion during second stage labour in high-risk parturients: a case series.

BACKGROUND: Providing adequate analgesia and appropriate sedation to high-risk parturients during late second stage labour without compromising foetal safety remains a major challenge, especially in situations when neuraxial block is not applicable. Remifentanil emerged as an option for labour analgesia during the last decade but may be suitable for the facilitation of complicated vaginal deliveries as well. METHODS: A retrospective chart review of nine labouring women with significant medical and/or obstetrical risk factors was conducted. According to the assessment of an experienced obstetrician, vaginal delivery could only be achieved with profound analgesia, and neuraxial block was not possible because of contraindications, technical failure, or shortage of time. Mode of delivery, need for neonatal resuscitation, maternal and neonatal vital parameters, drug consumption, and personnel resource expenses were recorded. RESULTS: Remifentanil target-controlled infusion (TCI) facilitated vaginal delivery in eight out of nine women. No serious adverse events were observed, but three newborns needed initial respiratory support for a few minutes. The total cost of remifentanil TCI administration to facilitate vaginal delivery compared with the estimated additional cost of an emergency caesarean section was negligible. CONCLUSION: This case series suggests that remifentanil TCI may be used to facilitate vaginal delivery in high-risk parturients when other forms of analgesia are limited. However, the small number of patients studied does not allow generalisation of the results; neither can safety concerns be dispelled yet.

Coagulation testing before epidural analgesia at delivery: cost analysis.

BACKGROUND: The usefulness of coagulation tests performed before epidural analgesia for surgery or to alleviate labour pain is controversial. The aims of this study were: (1) to evaluate the prevalence of abnormal tests in a large cohort of healthy pregnant women and their association with epidural hematoma; (2) to assess the approach of the anesthesiologists to women with abnormal tests; (3) to evaluate the cost of performing coagulation tests before epidural analgesia in all healthy pregnant women. METHODS: Data regarding epidural analgesia, epidural hematoma, PT, APTT, fibrinogen and platelet count were extracted from medical charts. RESULTS: There was no case of epidural hematoma in 2546 pregnant women undergoing epidural analgesia. PT and APTT results were obtained in 2871 women; fibrinogen in 4063 women; platelet count in 5090 women. Three of them (0.1%) had a prolonged PT, 4 (0.14%) had a prolonged APTT, 27 (0.53%) had platelets ≤ 100 × 10(9)/L and 37 (0.91%) had plasma fibrinogen levels <3 g/L. No further tests were requested by the anesthesiologists in these women. Only women with platelets <80 × 10(9)/L were denied epidural analgesia. Based on the data from the literature on the frequencies of epidural hematoma after epidural analgesia, a total cost ranging from 4.5 to 40 million Euros to perform coagulation tests would be necessary to avoid one case of epidural hematoma. DISCUSSION: Unselected coagulation tests before epidural analgesia are not recommended, because epidural hematoma is extremely rare in healthy pregnant women and the cost of screening is not justified.

Focused review: ropivacaine versus bupivacaine for epidural labor analgesia.

Neuraxial analgesia is frequently administered to women in labor. For many years, bupivacaine has been used because of its long duration of action, lack of excessive motor block, and minimal fetal and neonatal effects. However, bupivacaine is one of the most cardiotoxic local anesthetics in current use and motor block is still a problem. Many local anesthetics such as bupivacaine exist in 2 forms, levorotatory and dextrorotatory. Ropivacaine, an amide local anesthetic produced in the pure levorotatory form addresses some of the concerns related to bupivacaine. In this article, we present the literature comparing ropivacaine and bupivacaine to determine whether there is an advantage to using one of these local anesthetics for labor analgesia. We found that there is no advantage to the routine use of ropivacaine for labor analgesia.

Promoting epidural analgesia for labor: 2005-2007 diffusion in Lombardia, Italy.

BACKGROUND: Since January 2005 the Regional Government of Lombardia, a large Italian region with over 1/5 of all Italian births, allocated public funds for 3 consecutive years to help provide epidural analgesia (EA) for women in labor. The aim of the present study was to evaluate the trend of diffusion of EA in the triennium 2005-2007. METHODS: Data obtained from regional Obstetric Departments, recognized by the National Health Care System, were elaborated by the Epidemiological Service of Regione Lombardia. The software looked for specific codes for vaginal deliveries, with or without EA, and Cesarean sections included in the administrative patient records. RESULTS: A substantial increase in epidurals administered in comparison to total vaginal deliveries was recorded after assignment of regional financing: from 8.2% in 2005, to 10.4% in 2006 and 12.9% in 2007 (P<0.0001). More than 60% of epidurals were performed in 8 hospitals with >2 000 births per year. The rate of EAs in these hospitals was 18% in 2005, 22% in 2006 and 24.9% in 2007. In the 69 hospitals with <2000 births per year, the rate of EAs was markedly lower: 4% in 2005, 5.5% in 2006 and 7.8% in 2007. In both cases, the increase was statistically significant (P<0.0001). At the three-year time-point, the rate of Cesarean sections did not change. CONCLUSIONS: The continuous increase of EA for labor after regional financings suggests that the low rate of pain relief procedures in Lombardia was mainly due to economic and organizational issues, rather than to cultural and psychological factors.

[Knowledge and acceptance of obstetric peridural analgesia: survey of pregnant women in Togo]. / Niveau de connaissance et acceptabilité e l'analgésie péridurale: enquête auprès des femmes enceintes au Togo.

The purpose of this study was to evaluate knowledge and acceptance of obstetric peridural analgesia among pregnant women in Togo. A prospective, descriptive survey was carried out over a period of one month. A standardized survey form was used to collect data. A total of 303 pregnant women with a mean age of 27 +/- 6 years were interviewed. A proportion of primiparous and multiparous was the same, i.e., 50%. Among multiparous women, 83.5% described labor pain during previous deliveries as severe. Twelve percent of the pregnant women interviewed claimed knowledge of techniques to control labor pain. Three pregnant women reported a detailed understanding of peridural analgesia obtained from the Internet. A total of 253 women (83.5%) replied affirmatively when asked if they would opt for peridural analgesia if it was offered free of charge for delivery at the end of the current pregnancy. Acceptance was motivated by better delivery conditions for the newborn (112 women) and comfort achieved by pain relief (130 women). Refusal was motivated by a religious belief that painful delivery was in the natural order (31 women). Among the six Moslem women that refused painless delivery, two from the Djerma ethnic group stated that pain was the best expression of their femininity. The acceptance rate fell from 83.5% to 70% if peridural analgesia was offered at extra charge. Most pregnant women in Togo expressed interest in trying peridural analgesia. It is compulsory in medical indications.

A comparison of Espocan and Tuohy needles for the combined spinal-epidural technique for labor analgesia.

UNLABELLED: When using the needle-through-needle combined spinal-epidural (CSE) technique for labor analgesia, failure to obtain cerebrospinal fluid (CSF), paresthesias, and intrathecal or intravascular migration of the catheter are of concern. Epidural needles with spinal needle apertures, such as the back-hole Espocan (ES) needles, are available and may reduce these risks. We describe the efficacy and adverse events associated with a modified epidural needle (ES) versus a conventional Tuohy needle for CSE. One-hundred parturients requesting labor analgesia (CSE) were randomized into 2 groups: 50-ES 18-gauge modified epidural needle with 27-gauge Pencan atraumatic spinal needle, 50-conventional 18-gauge Tuohy needle with 27-gauge Gertie Marx atraumatic spinal needle. Information on intrathecal or intravascular catheter placement, paresthesia on introduction of spinal needle, failure to obtain CSF through the spinal needle after placement of epidural needle, unintentional dural puncture, and epidural catheter function was obtained. No intrathecal catheter placement occurred in either group. Rates of intravascular catheter placement and unintentional dural puncture were similar between the groups. Significant differences were noted regarding spinal needle-induced paresthesia (14% ES versus 42% Tuohy needles, P = 0.009) and failure to obtain CSF on first attempt (8% ES versus 28% Tuohy needles, P < 0.02). Use of ES needles for CSE significantly reduces paresthesia associated with the insertion of the spinal needle and is associated with more frequent successful spinal needle placement on the first attempt. IMPLICATIONS: The use of modified epidural needles with a back hole for combined spinal-epidural technique significantly reduces paresthesia associated with the insertion of the spinal needle and is associated with more frequent successful spinal needle placement on the first attempt.

Influence of the type of anesthesia provider on costs of labor analgesia to the Texas Medicaid program.

BACKGROUND: The Texas Medicaid Program (Medicaid) defines billable time for labor analgesia as face-to-face time; therefore, anesthesia providers determine billed time. The authors' goal was to determine the influence of anesthesia providers on labor analgesia costs billed to Medicaid. METHODS: Under the Freedom of Information Act, Medicaid provided data on claims paid for 6 months in 2001 for labor analgesia administered during the course of a vaginal delivery. Claims were either time based (codes 00946 or 00955) or a flat fee (codes 26311 or 26319). Using modifiers, the authors grouped time-based claims as either anesthesiologist group or certified registered nurse anesthetist (CRNA) group. The cost to Medicaid was based on the 2001 fee schedule. The conversion factor was 18.21 USD per American Society of Anesthesiologists unit. The flat-fee reimbursement was 152.50 USD. CRNA services were paid at 85% of the fee schedule. Average time per time claim, percent of providers with more than 4 h of billed time, and cost per claim were determined for each group. Providers with more than 120 claims (> 20 claims/month) were considered high-volume. RESULTS: The database included 21,378 claims (anesthesiologist group: 12,698 claims from 219 providers; CRNA group: 8,680 claims from 117 providers). For time-based claims, the average time per case was significantly higher in the CRNA group (146 min) than in the anesthesiologist group (105 min). The CRNA group cost to Medicaid (225.11 USD) was 19% more per claim than the anesthesiologist group (189.26 USD). The difference in cost per claim was greater among high-volume providers--213.10 USD for the CRNA group versus 168.76 USD for the anesthesiologist group. If a flat-fee program were instituted using the average cost per claim for all groups (203.81 USD), the Texas Medicaid program would save more than 500,000 USD annually. CONCLUSIONS: The costs of labor analgesia billed to Texas Medicaid were 19% to 26% less per patient when provided by anesthesiologists than by CRNAs, despite lower per-unit reimbursement of CRNAs.

Race, ethnicity, and insurance as determinants of epidural use: analysis of a national sample survey.

Despite widespread availability of pain interventions in childbirth, for most women, childbirth is associated with labor pain that exceeds expectations. Although epidural is superior to other medical interventions, the choice to use epidural still remains a matter of patient and doctor preference. Whether racial or ethnic characteristics influence preference of physician use or interact with insurance coverage is still unknown. This study used a large national sample of women to measure significant determinants of epidural use in order to discuss disparities in pain management. The findings suggest the need for nurse leaders to foster health policies that are sensitive to diversity and economics.

Costing the cascade: estimating the cost of increased obstetric intervention in childbirth using population data.

OBJECTIVE: To estimate the cost of "the cascade" of obstetric interventions introduced during labour for low risk women. DESIGN: A cost formula derived from population data. SETTING: New South Wales, Australia. POPULATION: All 171,157 women having a live baby during 1996 and 1997. METHODS: Four groups of interventions that occur during labour were identified. A cost model was constructed using the known age-adjusted rates for low risk women having one of three birth outcomes following these pre-specified interventions. Costs were based on statewide averages for the cost of labour and birth in hospital. MAIN OUTCOME MEASURES: The outcome measure is an "average cost unit per woman" for low risk women, predicted by the level of intervention during labour. Obstetric care is classified as either private obstetric care in a private or public hospital, or routine public hospital care. RESULTS: The relative cost of birth increased by up to 50% for low risk primiparous women and up to 36% for low risk multiparous women as labour interventions accumulated. An epidural was associated with a sharp increase in cost of up to 32% for some primiparous low risk women, and up to 36% for some multiparous low risk women. Private obstetric care increased the overall relative cost by 9% for primiparous low risk women and 4% for multiparous low risk women. CONCLUSIONS: The initiation of a cascade of obstetric interventions during labour for low risk women is costly to the health system. Private obstetric care adds further to the cost of care for low risk women.

Combined spinal epidural analgesia is the preferred technique for labour analgesia.

To justify its place as the preferred method of pain relief in labour, CSE must demonstrated a clear superiority over epidural analgesia. Looking at the relative efficacy of the two techniques failure rates appear to be equal. Speed of onset may be faster with an initial spinal injection although perhaps only clinically relevant in advanced labour where the quality of analgesia may sometimes be better. CSE would not seem to offer significant advantage in terms of mode of delivery or the ability to ambulate. The side effects of the technique are somewhat more concerning as CSE would appear to carry slightly greater risk than epidural analgesia, most notably in neurological sequelae and the effects of intrathecal opioids. Certainly CSE confers no benefit in terms of cost. What then is the place of CSE in labour analgesia? Its potential benefit makes it a reasonable option when there is a clear clinical advantage such as requests for analgesia in late labour or where maternal distress is extreme or where epidural analgesia has been ineffective. However even in such situations the slight increase in risk must be weighed against the possible advantage. Consequently the CSE cannot at the present time be recommended as the preferred option for labour analgesia.

Economic considerations related to providing adequate pain relief for women in labour: comparison of epidural and intravenous analgesia.

Epidural analgesia and intravenous analgesia with opioids are two techniques for providing pain relief for women in labour. Labour pain is comparable to surgical pain in its severity, and epidural analgesia provides better relief from this pain than intravenous analgesia; a meta-analysis quantified this improvement to be 40 mm on a 100mm pain scale during the first stage of labour. Epidural analgesia also has fewer adverse effects. However, providing epidural analgesia for labour pain costs more. The full cost of providing epidural analgesia can be divided into two components: a baseline-cost component, which captures the costs of hospital care to parturients receiving intravenous analgesia for labour pain; and an incremental-cost component, which estimates the costs arising from incremental care specific to epidural analgesia. The baseline component may be constructed using hospital cost-accounting data pertaining to actual obstetric patients. The incremental component is constructed from a set of recognised complications of epidural and intravenous analgesia, associated incidence rates and estimates of the costs involved, from society's perspective. The incremental expected cost per patient to society of providing epidural analgesia was calculated to be approximately $US338 (1998 values). This cost difference results primarily from increased professional costs (and is particularly sensitive to the method used to estimate the cost of anaesthesia professional services) and increased complication costs associated with epidural analgesia. A rational social policy for providing labour analgesia must weigh the value of improved pain relief from epidural analgesia against the increased cost of epidural analgesia.

Cost-effectiveness of analgesia after Caesarean section. A comparison of intrathecal morphine and epidural PCA.

BACKGROUND: Patient-controlled analgesia (PCA) techniques and intrathecal morphine are the most widely used treatments for post-Caesarean section pain. However these methods have not been compared with respect to analgesic quality and cost differences. METHODS: Fifty-three patients scheduled for elective or semi-urgent Caesarean section were randomized to receive for postoperative analgesia either epidural PCA with a mixture containing bupivacaine 0.06% and sufentanil 1 microg x ml(-1) or intrathecal morphine 0.15 mg together with the spinal anaesthetic and to be supplemented with paracetamol and tramadol. Analgesic efficacy, side-effects and costs were calculated during 48 h. RESULTS: VAS pain scores both at rest and during mobilization were lower in the PCA group, more particularly during the second postoperative day. Nausea and vomiting were more frequently registered in the morphine treated patients. PCA treated patients stayed longer in the recovery room but required fewer nurse interventions on the surgical ward. Manpower and drug costs were equal in both groups. The differences in total costs (Euro) amounted to euros 33 and were mainly caused by the more expensive equipment required for epidural PCA. Satisfaction and hospital discharge were similar for both treatments. CONCLUSIONS: It was concluded that epidural PCA induced better pain relief, caused less nausea/vomiting but was more expensive than intrathecal morphine.