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An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
An Economic Perspective on Early Pregnancy Failure
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An Economic Perspective on Early Pregnancy Failure

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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 …

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.

Published in: Health & Medicine
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  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
  9. MIScarriage Treatment (MIST) Trial Trinder J, et al. BMJ 2006;332:1235-1240 <ul><li>Primary outcome: gynecological infection </li></ul><ul><li>Secondary outcome: </li></ul><ul><ul><li>Complications (transfusion, readmission) </li></ul></ul><ul><ul><li>Efficacy (unplanned surgical curettage) </li></ul></ul><ul><ul><li>Psychological (depression, anxiety) </li></ul></ul>
  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. Management Evidence: Efficacy Study Type of SAB Treatment Arm Outcomes Blohm et al (2005) “ signs of miscarriage” (n = 126) <ul><li>Placebo </li></ul><ul><li>PGE 400 μg vag </li></ul>54% complete at 7d 81% complete at 7d
  16. Management Evidence: Efficacy Study Type of SAB Treatment Arm Outcomes Blohm et al (2005) “ signs of miscarriage” (n = 126) <ul><li>Placebo </li></ul><ul><li>PGE 400 μg vag </li></ul>54% complete at 7d 81% complete at 7d Zhang et al (2005) “ pregnancy failure” (n = 652) <ul><li>PGE 800 μg vag </li></ul><ul><li>Vaccum asp </li></ul>84% complete at 8d 97% successful
  17. Management Evidence: Efficacy <ul><li>Success depends on type of SAB </li></ul><ul><li>Expectant: completion in at least 50% cases </li></ul><ul><li>Medical: completion 85% within 7 days </li></ul><ul><li>Curettage: completion 95% </li></ul>Study Type of SAB Treatment Arm Outcomes Blohm et al (2005) “ signs of miscarriage” (n = 126) <ul><li>Placebo </li></ul><ul><li>PGE 400 μg vag </li></ul>54% complete at 7d 81% complete at 7d Zhang et al (2005) “ pregnancy failure” (n = 652) <ul><li>PGE 800 μg vag </li></ul><ul><li>Vaccum asp </li></ul>84% complete at 8d 97% successful Trinder et al (2006) Incomplete or missed (n = 1200) <ul><li>Expectant </li></ul><ul><li>PGE 800 μg vag </li></ul><ul><li>Suction curettage </li></ul>50% curettage 38% curettage 5% repeat
  18. Decision-Making Paradigm Safety Efficacy Cost
  19. Cost-effectiveness: MIST trial <ul><li>Incremental Cost-Effectiveness Ratio (ICER) </li></ul>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
  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. Cost-effectiveness: MIST trial <ul><li>Incremental Cost-Effectiveness Ratio (ICER) </li></ul><ul><li>Cost-Effectiveness Acceptability Curve (CEAC) </li></ul>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
  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. Summary <ul><li>Decisions should be based on safety, efficacy and cost-effectiveness </li></ul><ul><li>From a societal perspective, evidence strongly supports trial of expectant management for all patients </li></ul><ul><li>Optimal strategy for society can be in tension with the optimal strategy for the patient in front of us </li></ul>
  30. www.CostsOfCare.org
  31.  

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