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

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 ><.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