USE OF ALGORITHMIC PATHWAYS TO DEVELOP QUALITY, COST-EFFECTIVE CLINICAL CARE

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 Ige antibody titer -> hysterosalpingogram -> diagnostic laparoscopy -> in vitro fertilization (IVF); (2) Chlamydia Ige 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.