ECONOMIC PERSPECTIVE ON MISCARRIAGE

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Surgical management of early pregnancy failure became the standard of care during the pre-antibiotic era. Good medical decisions should be safe, effective, and economically responsible. The evidence supports a trial of expectant management for all women who present with miscarriage that do not clearly require intervention.

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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 Surgical Expectant Medical Septic Hemorrhage Threatened Complete Inevitable Missed Incomplete

Decision-Making Paradigm Safety Efficacy Cost

MIScarriage Treatment (MIST) Trial Trinder J, et al. BMJ 2006;332:1235-1240 ,[object Object],[object Object],[object Object],[object Object],[object Object]

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) ,[object Object],[object Object],54% complete at 7d 81% complete at 7d

Management Evidence: Efficacy ,[object Object],[object Object],[object Object],[object Object],Study Type of SAB Treatment Arm Outcomes Blohm et al (2005) “ signs of miscarriage” (n = 126) ,[object Object],[object Object],54% complete at 7d 81% complete at 7d Zhang et al (2005) “ pregnancy failure” (n = 652) ,[object Object],[object Object],84% complete at 8d 97% successful Trinder et al (2006) Incomplete or missed (n = 1200) ,[object Object],[object Object],[object Object],50% curettage 38% curettage 5% repeat

Cost-effectiveness: MIST trial ,[object Object],Petrou S, Trinder J, Brocklehurst P, Smith L. BJOG. 2006 Aug;113(8):879-89 C medical - C surgical E medical - E surgical C = hospital resources, cost to woman, lost production E = 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 C medical - C surgical E medical - E surgical C = hospital resources, cost to woman, lost production E = gynecological infection avoided

Cost-effectiveness: MIST trial ,[object Object],[object Object],Petrou S, Trinder J, Brocklehurst P, Smith L. BJOG. 2006 Aug;113(8):879-89 nonparametric bootstrap estimation (95% CI) simultaneously summarizes uncertainty in costs and effects uses alternative willingness to pay thresholds for preventing gyn infection C medical - C surgical E medical - E surgical C = hospital resources, cost to woman, lost production E = gynecological infection avoided

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 ,[object Object],[object Object],[object Object]

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ECONOMIC PERSPECTIVE ON MISCARRIAGE

1. An Economic Perspective on Early Pregnancy Failure February 18, 2010 Neel Shah, MD, MPP

2. 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

3. 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

4. First Trimester SAB Surgical Expectant Medical Septic Hemorrhage Threatened Complete Inevitable Missed Incomplete

5. First Trimester SAB Surgical Expectant Medical Septic Hemorrhage Threatened Complete Inevitable Missed Incomplete

6. Historical Perspective

7. Decision-Making Paradigm Safety Efficacy Cost

8. Decision-Making Paradigm Safety

10. Management Evidence: Safety Trinder J, et al. BMJ 2006;332:1235-1240

11. Management Evidence: Safety Trinder J, et al. BMJ 2006;332:1235-1240

12. Management Evidence: Safety Trinder J, et al. BMJ 2006;332:1235-1240

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

14. Decision-Making Paradigm Safety Efficacy

15.

16.

17.

18. Decision-Making Paradigm Safety Efficacy Cost

19.

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

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

22. Cost-effectiveness: MIST Trial Petrou S, Trinder J, Brocklehurst P, Smith L. BJOG. 2006 Aug;113(8):879-89 C medical - C surgical E medical - E surgical C = hospital resources, cost to woman, lost production E = gynecological infection avoided

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

24.

25. Cost-effectiveness Medical vs. Surgical

26. Cost-effectiveness Medical vs. Surgical Expectant vs. Surgical Expectant vs. Medical

27. Cost-effectiveness expectant medical surgical 98% 2%

28. Manual Vacuum Aspiration Rocconi RP et al. J Reprod Med. 2005 Jul;50(7):486-90 X 500K women = $779M savings

29.

30. www.CostsOfCare.org

31.

ECONOMIC PERSPECTIVE ON MISCARRIAGE

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