An Economic Perspective on Early Pregnancy Failure
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An Economic Perspective on Early Pregnancy Failure
February 18, 2010
Neel Shah, MD, MPP
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Case
ID: 37 yo G3P1011 @ 9 wk GA
HPI: + pregnancy test
PObHx: SVD x 1 (term), TAB x 1 (12wk)
PGynHx: irreg menses, nml PAP, no STI
PMH: unremarkable
PSH: none
Meds: PNV
All: NKDA
SH/FH: noncontributory
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Case
PEx: AVSS
abd soft/NT/ND
pelvic slightly enlarged freely mobile uterus, no mass
speculum os visualized and closed, no blood, physiologic discharge
Labs:
HCG 13863
HCT 42
PLT 241
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First Trimester SAB
SurgicalExpectant Medical
Septic
Hemorrhage
Threatened
Complete Inevitable
Missed
Incomplete
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First Trimester SAB
SurgicalExpectant Medical
Septic
Hemorrhage
Threatened
Complete Inevitable
Missed
Incomplete
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Historical Perspective
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Decision-Making Paradigm
Safety
Efficacy Cost
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Decision-Making Paradigm
Safety
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MIScarriage Treatment (MIST) Trial
Trinder J, et al. BMJ 2006;332:1235-1240
• Primary outcome: gynecological infection
• Secondary outcome:
• Complications (transfusion, readmission)
• Efficacy (unplanned surgical curettage)
• Psychological (depression, anxiety)
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Management Evidence: Safety
Trinder J, et al. BMJ 2006;332:1235-1240
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Management Evidence: Safety
Trinder J, et al. BMJ 2006;332:1235-1240
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Management Evidence: Safety
Smith LF, Ewings PD, Quinlan C. BMJ. 2009 Oct 8;339:b3827
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Decision-Making Paradigm
Safety
Efficacy
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Management Evidence: Efficacy
Study Type of SAB Treatment Arm Outcomes
Blohm et al (2005) “signs of miscarriage” (n = 126)
1. Placebo2. PGE 400 μg vag
54% complete at 7d81% complete at 7d
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Management Evidence: Efficacy
Study Type of SAB Treatment Arm Outcomes
Blohm et al (2005) “signs of miscarriage” (n = 126)
1. Placebo2. PGE 400 μg vag
54% complete at 7d81% complete at 7d
Zhang et al (2005) “pregnancy failure”(n = 652)
1. PGE 800 μg vag2. Vaccum asp
84% complete at 8d97% successful
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Management Evidence: Efficacy
Study Type of SAB Treatment Arm Outcomes
Blohm et al (2005) “signs of miscarriage” (n = 126)
1. Placebo2. PGE 400 μg vag
54% complete at 7d81% complete at 7d
Zhang et al (2005) “pregnancy failure”(n = 652)
1. PGE 800 μg vag2. Vaccum asp
84% complete at 8d97% successful
Trinder et al (2006)
Incomplete or missed(n = 1200)
1. Expectant2. PGE 800 μg vag3. Suction curettage
50% curettage38% curettage5% repeat
• Success depends on type of SAB
• Expectant: completion in at least 50% cases
• Medical: completion 85% within 7 days
• Curettage: completion 95%
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Decision-Making Paradigm
Safety
Efficacy Cost
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Cost-effectiveness: MIST trial
• Incremental Cost-Effectiveness Ratio (ICER)
Petrou S, Trinder J, Brocklehurst P, Smith L. BJOG. 2006 Aug;113(8):879-89
Cmedical - Csurgical
Emedical - Esurgical
C = hospital resources, cost to woman, lost productionE = gynecological infection avoided
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Cost-effectiveness: MIST Trial
Petrou S, Trinder J, Brocklehurst P, Smith L. BJOG. 2006 Aug;113(8):879-89
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Cost-effectiveness: MIST Trial
Petrou S, Trinder J, Brocklehurst P, Smith L. BJOG. 2006 Aug;113(8):879-89
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Cost-effectiveness: MIST Trial
Petrou S, Trinder J, Brocklehurst P, Smith L. BJOG. 2006 Aug;113(8):879-89
Cmedical - Csurgical
Emedical - Esurgical
C = hospital resources, cost to woman, lost productionE = gynecological infection avoided
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Cost-effectiveness: MIST Trial
Petrou S, Trinder J, Brocklehurst P, Smith L. BJOG. 2006 Aug;113(8):879-89
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Cost-effectiveness: MIST trial
• Incremental Cost-Effectiveness Ratio (ICER)
• Cost-Effectiveness Acceptability Curve (CEAC)
Petrou S, Trinder J, Brocklehurst P, Smith L. BJOG. 2006 Aug;113(8):879-89
Cmedical - Csurgical
Emedical - Esurgical
C = hospital resources, cost to woman, lost productionE = gynecological infection avoided
nonparametric bootstrap estimation (95% CI)
simultaneously summarizes uncertainty in costs and effects
uses alternative willingness to pay thresholds for preventing gyn infection
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Cost-effectiveness
Medical vs. Surgical
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Cost-effectiveness
Medical vs. Surgical
Expectant vs. Surgical Expectant vs. Medical
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Cost-effectiveness
expectant
medical
surgical
98%
2%
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Manual Vacuum Aspiration
Rocconi RP et al. J Reprod Med. 2005 Jul;50(7):486-90
X 500K women
= $779M savings
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Summary
• Decisions should be based on safety, efficacy and cost-effectiveness
• From a societal perspective, evidence strongly supports trial of expectant management for all patients
• Optimal strategy for society can be in tension with the optimal strategy for the patient in front of us
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www.CostsOfCare.org
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