Cost-effectiveness of curettage versus expectant management in women with an incomplete evacuation after misoprostol treatment for first-trimester miscarriage: A randomized controlled trial and cohort study

Marike Lemmers* (Corresponding Author), Marianne A.C. Verschoor, Patrick M. Bossuyt, Judith A.F. Huirne, Teake Spinder, Theodoor E. Nieboer, Marlies Y. Bongers, Ineke A.H. Janssen, Marcel H.A. Van Hooff, Ben W.J. Mol, Willem M. Ankum, Judith E. Bosmans

*Corresponding author for this work

Research output: Contribution to journalComment/debatepeer-review

2 Citations (Scopus)

Abstract

Misoprostol was introduced over 10 years ago as a treatment option for women with first-trimester miscarriages alongside expectant management and curettage. It is an effective treatment for 50% to 85% of these women. Several studies have reported that misoprostol is cost-effective for miscarriage in comparison with curettage, although this result was not confirmed by other investigators. The MisoRESTstudy, a randomized controlled trial, compared curettage and expectant management in women with incomplete evacuation of the uterus after misoprostol treatment for first-trimester miscarriage. The results showed significantly more women with an empty uterus after curettage than after expectant management. Considering the high costs associated with curettage compared with expectant management, it is important to evaluate whether the additional costs of curettage in women with incomplete evacuation are justified by the additional clinical effects. The cost-effectiveness of curettage compared with expectant management is unknown in this population.

This randomized controlled trial and parallel cohort study compared curettage and expectant management in women who had an incomplete evacuation of the uterus after misoprostol treatment for first-trimester miscarriage. The study was conducted in the Netherlands from June 2012 and July 2014. The primary outcome, treatment success, was a sonographic finding of an empty uterus 6 weeks after study entry or an uneventful course. Analyses of cost-effectiveness and cost-utility were performed. Costs of health care utilization, informal care, and lost productivity were included. Bootstrapping was used to estimate cost-effectiveness planes and cost-effectiveness acceptability curves. Data were analyzed according to the intention-to-treat principle.

A total of 256 women from 27 hospitals were included; of these, 95 had curettage and 161 expectant management. Treatment was successful in 96% of the women treated with curettage and 83% of those treated with expectant management; the mean difference was 13%, with a 95% confidence interval (CI) of 5 to 20. Mean health care costs in the curettage group were significantly higher than in the expectant management group (mean difference, €1157; 95% CI, 955–1388). The incremental cost-effectiveness ratio for curettage compared with expectant management was €8586 for 1 extra successfully treated woman. The cost-effectiveness acceptability curve showed that the probability that curettage was cost-effective was 95% at a willingness-to-pay of €18 200/extra successfully treated woman.

The data indicate that curettage is not cost-effective compared with expectant management in women with an incomplete evacuation of the uterus after misoprostol treatment. Based on these results, the authors believe that curettage in this population should be restrained. Further studies are needed to determine whether there are factors that predict the probability of an empty uterus after expectant management. This could enable clinicians to offer tailored treatment to their patients.
Original languageEnglish
Pages (from-to)398-399
Number of pages2
JournalObstetrical and Gynecological Survey
Volume73
Issue number7
DOIs
Publication statusPublished - 1 Jul 2018

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