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

Study Objectives. To analyze the cost of diagnosis and treatment assoc iated with hydrosalpinges and pelvic adhesions using algorithmic pathw ays. Design. Analysis of six pathways: (1) Chlamydia Ige antibody tite r -> hysterosalpingogram -> diagnostic laparoscopy -> in vitro fertili zation (IVF); (2) Chlamydia Ige antibody titer -> diagnostic laparosco py -> therapeutic laparoscopy -> IVF; (3) hysterosalpingogram -> diagn ostic laparoscopy -> therapeutic laparoscopy -> IVF; (4) diagnostic la paroscopy -> 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 f rom laparoscopy, and hysterosalpingograms (HSGs). All patients identif ied with these three results available were included. Interventions. D etermination of results of laparoscopic treatment, IVF, and no therapy (observation only), based on the literature. Measurements and Main Re sults. The theoretical cost to achieve pregnancy for each pathway was calculated by mathematical modeling. The greatest number of pregnancie s for the least cost ($18,883/pregnancy) was from the diagnosis and tr eatment of adhesions at laparoscopy with no previous screening. The le ast costly approach to pregnancy for blocked tubes ($26,614/pregnancy) was to start with an HSG. All pathways for adhesions and any screenin g pathway using HSG for hydrosalpinges were more cost effective than I VF. Conclusions. These pathways are limited, as they require several a ssumptions and are based on a tertiary care population. Although HSG a nd laparoscopy appeared to be the most cost-effective approaches to pr egnancy, a primary care group may have a more cost-effective response to the use of Chlamydia trachomatis IgG antibody screening.