Medical management of early pregnancy loss cost-effective compared with office uterine aspiration

Early pregnancy loss (EPL), or miscarriage, is common. With
an increased availability of highly sensitive pregnancy tests and early
ultrasounds, many patients are diagnosed with an EPL before the onset of
symptoms. Once diagnosed, pregnant individuals have 3 treatment routes
available to them: expectant management (watching and waiting), surgical
intervention (uterine aspiration in the office or operating room), or medical
management (using medications to induce uterine contractions and expel tissue).
These 3 options differ in effectiveness, patient experience, and cost.

With improved medication management effectiveness, patient
and clinician interests in expanding access to medication management have
increased and the COVID-19 pandemic has highlighted the importance of treatment
options that minimize in-person clinic visits.

The comparative cost-effectiveness of medication management
and in-office management has significant implications for clinical care and reproductive
health policy. If medication management is preferred by many patients,
decreases the need to access in-person clinical care during a pandemic, and is
found to be cost-effective, clinicians and policy makers should increase
efforts to improve mifepristone availability and reduce access burdens.

Given the clinical efficacy of medical management of EPL
using mifepristone pretreatment, and its proven cost-effectiveness compared
with misoprostol-alone treatment for EPL, authors Nagendra D, Gutman SM,
Koelper NC, et al developed a decision analytical model combining the Pregnancy
Failure Regimens (PreFaiR) trial data and data from the published literature to
assess the cost-effectiveness of medical management with mifepristone
pretreatment followed by misoprostol (“medical management”) compared with an
office based uterine aspiration arm (“uterine aspiration”) for the treatment of
EPL.

The analysis was from the healthcare sector perspective with
a 30-day time horizon. Costs were in 2018 US dollars. Effectiveness was
measured in quality-adjust life-years gained and the rate of complete
gestational sac expulsion with no additional interventions. The primary outcome
was the incremental cost per quality-adjust life-year gained. Sensitivity
analysis was performed to identify the key uncertainties.

Mean per-person costs were higher for uterine aspiration
than for medical management ($828 vs $661; P<.004).

Uterine aspiration more frequently led to complete
gestational sac expulsion than medical management (97.3% vs 83.8%; P<.0001);
however, estimated quality-adjust life-years were higher for medical management
than for uterine aspiration (0.082 vs 0.079; P<.0001).

Medical management dominated uterine aspiration, with lower
costs and higher confidence interval. The probability that medical management
is cost-effective relative to uterine aspiration is 97.5% for all
willingness-to-pay values of $5600/quality-adjust life-year.

Sensitivity analysis did not identify any thresholds that
would substantially change outcomes.

This study demonstrated that from the healthcare
perspective, medical management with mifepristone pretreatment followed by
misoprostol was cost-effective compared with office uterine aspiration for EPL
treatment, with higher effectiveness (QALYs) and lower costs.

Medical management of EPL with mifepristone pretreatment and
misoprostol has been found to be costeffective compared with office uterine
aspiration, with similar QALYs and lower costs, making it a high-value care
alternative. Increasing access to mifepristone and eliminating unnecessary
restrictions will improve early pregnancy care.

Source: Nagendra D, Gutman SM, Koelper NC, et al. Medical
management of early pregnancy loss is cost-effective compared to office uterine
aspiration. Am J Obstet Gynecol 2022;227:737.e1-11.

https://doi.org/10.1016/j.ajog.2022.06.054

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