Alice Goodman

May 20, 2011

May 20, 2011 (Washington, DC) — Adhesions from previous Caesarean deliveries severe enough to require adhesiolysis during repeat Caesarean delivery have clinical and economic implications, according to a retrospective review of a large database with discharge data from 60 hospitals in the United States. The data were reported here at the American Congress of Obstetricians and Gynecologists 59th Annual Clinical Meeting.

The matched cohort study found that for patients who required adhesiolysis, the cost per patient was $300 more, operative length was longer, hospital stay was longer, and postoperative complications were more frequent.

"Adhesions are a significant complication of surgery. C-sections are increasingly common in the United States, and anywhere from 30% to 50% of patients have adhesions," explained Michael Broder, MD, from the University of California at Los Angeles School of Medicine. He estimated that treating complications of adhesions related to Caesarean deliveries that are severe enough for adhesiolysis costs $25 million to $30 million per year.

The study identified 167,000 patients who underwent repeat caesarean delivery. Of these, 10,261 (6%) had adhesiolysis. These patients were matched in a 1:1 ratio with 10,261 control subjects for age, race, and indication for Caesarean delivery. The mean age of the case and control groups was 29.9 years, and 39% of the cohort was white. About 68% of all Caesarean deliveries were elective, he noted.

"For every outcome measured, outcomes differed substantially between those who underwent adhesiolysis and those who did not," Dr. Broder told meeting attendees.

For patients who underwent adhesiolysis, compared with those who did not, the extra cost was $300 per patient ($5739 vs $5448), the operative procedure was 10 minutes longer, hospital stay was several hours longer, and postoperative complications were more common (hemorrhage [1.7% vs 1.2%], wound complications [1.4% vs 0.7%], pelvic organ damage [1.0% vs 0.1%], and hysterectomy [0.3% vs 0.1%]).

In an interview with Medscape Medical News, Dr. Broder said that the study implies that surgical technique should be improved for primary caesarean deliveries to avoid adhesions.

David Archer, MD, from Eastern Virginia Medical School, in Norfolk, disagreed. "Meticulous surgery will not decrease the adhesion rate," he said. "Many C-sections are for emergencies, and emergency surgery increases the chance of adhesions."

"One strategy to approach this problem would be to decrease the number of C-sections we perform, but that probably is not going to happen," noted Robert Kauffman, MD, from the Texas Tech University School of Medicine in Amarillo.

"The 800-pound gorilla in the room is that doctors get paid more for performing C-sections, and it is more convenient for them. Patients may elect a C-section, but they are swayed by their doctors. My impression is that we 'sell C-section' to our patients. I am a salaried physician, so this doesn't enter into my practice. If I were in private practice, I would have the choice between getting more reimbursement [for a C-section] or getting paid less and letting patients labor for hours."

Dr. Broder reports receiving support from Ethicon. Dr. Archer reports financial ties with Ferring, Bayer, Pfizer, Agile, Watson, HRA Pharma, and Chemo. Dr. Kauffman has disclosed no relevant financial relationships.

American Congress of Obstetricians and Gynecologists (ACOG) 59th Annual Clinical Meeting: Abstract 65. May 3, 2011.

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