An Economic Perspective on Early Pregnancy Failure

February 18, 2010

Neel Shah, MD, MPP

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

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

First Trimester SAB

SurgicalExpectant Medical

Septic

Hemorrhage

Threatened

Complete Inevitable

Missed

Incomplete

First Trimester SAB

SurgicalExpectant Medical

Septic

Hemorrhage

Threatened

Complete Inevitable

Missed

Incomplete

Historical Perspective

Decision-Making Paradigm

Safety

Efficacy Cost

Decision-Making Paradigm

Safety

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)

Management Evidence: Safety

Trinder J, et al. BMJ 2006;332:1235-1240

Management Evidence: Safety

Trinder J, et al. BMJ 2006;332:1235-1240

Management Evidence: Safety

Smith LF, Ewings PD, Quinlan C. BMJ. 2009 Oct 8;339:b3827

Decision-Making Paradigm

Safety

Efficacy

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

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

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%

Decision-Making Paradigm

Safety

Efficacy Cost

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

Cost-effectiveness: MIST Trial

Petrou S, Trinder J, Brocklehurst P, Smith L. BJOG. 2006 Aug;113(8):879-89

Cost-effectiveness: MIST Trial

Petrou S, Trinder J, Brocklehurst P, Smith L. BJOG. 2006 Aug;113(8):879-89

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

Cost-effectiveness: MIST Trial

Petrou S, Trinder J, Brocklehurst P, Smith L. BJOG. 2006 Aug;113(8):879-89

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

Cost-effectiveness

Medical vs. Surgical

Cost-effectiveness

Medical vs. Surgical

Expectant vs. Surgical Expectant vs. Medical

Cost-effectiveness

expectant

medical

surgical

98%

2%

Manual Vacuum Aspiration

Rocconi RP et al. J Reprod Med. 2005 Jul;50(7):486-90

X 500K women

= $779M savings

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

www.CostsOfCare.org