Mifepristone Combination Therapy Compared With Misoprostol Monotherapy for the Management of Miscarriage: A Cost-Effectiveness Analysis.

OBJECTIVE: To assess whether mifepristone pretreatment adversely affects the cost of medical management of miscarriage. METHODS: Decision tree analyses were constructed, and Monte Carlo simulations were run comparing costs of combination therapy (mifepristone and misoprostol) with monotherapy (misoprostol alone) for medical management of miscarriage in multiple scenarios weighing clinical practice, patient income, and surgical evacuation modalities for failed medical management. Rates of completed medical evacuation for each were obtained from a recent randomized controlled trial. RESULTS: In every scenario, combination therapy offered a significant cost advantage over monotherapy. Using a Monte Carlo analysis, cost differences favoring combination therapy ranged from 6.3% to 19.5% in patients making federal minimum wage. The cost savings associated with combination therapy were greatest in scenarios using a staged approach to misoprostol administration and in scenarios using in-operating room dilation and curettage as the only modality for uterine evacuation, a savings of $190.20 (99% CI 189.35-191.07) and $217.85 (99% CI 217.19-218.50) per patient in a low-income wage group, respectively. A smaller difference was seen in scenarios using in-office manual vacuum aspiration to complete medical management failures. As patients' wages increased, the difference in cost between combination therapy and monotherapy increased. CONCLUSION: Mifepristone combined with misoprostol is, overall, more cost effective than monotherapy, and therefore cost should not be a deterrent to its adoption in the management of miscarriage.

The Unit and Scale-Up Cost of Postabortion Care in Tanzania.

INTRODUCTION: Based on research conducted in 2017, we estimated the cost to the Tanzanian health care system of providing postabortion care (PAC). PAC is an integrated service package that addresses the curative and preventive needs of women experiencing complications from abortion. PAC services include treating complications of miscarriage and incomplete abortion, providing voluntary family planning counseling and services, and engaging the community to reduce future unintended pregnancies and repeat abortions. METHODS: Thirty-one public and private health facilities, representing 3 levels of health care, were selected for data collection from key care providers and administrators in 3 regions. We gathered data on the direct costs of PAC startup (i.e., training and capital costs), as well as the recurrent costs of medicines, supplies, hospitalization, and personnel, and the indirect costs of PAC provision. We also gathered data to estimate PAC clients' out-of-pocket expenses. Estimates of the average cost per client (i.e., unit cost) were calculated for treatment of routine and severe abortion complications, treatment at different levels of health care, postabortion contraception, and various available treatment methods. RESULTS: We found that the unit cost of PAC training per provider was US$163.43. The total unit cost was $72.91. The unit recurrent cost of treating routine complications, which included 81% of the cases in our sample, was $36.23. The cost of treating incomplete abortion through manual vacuum aspiration was $22.63, while the cost of treatment with misoprostol was $18.74. The average cost of providing voluntary postabortion family planning was $11.56. We estimated an average client out-of-pocket expenditure on PAC of $22.96. CONCLUSION: We applied our unit cost estimates to those on PAC utilization and provision and unmet need for PAC that were derived from research conducted in Tanzania in 2013-2016, and we estimated an annual national cost of PAC of $4,170,476. We estimated the cost of providing PAC for all women who have abortion complications, including those who do not access PAC, at $10,426,299. Investing more resources in voluntary family planning and PAC treatment of routine complications at the primary level would likely reduce health system costs.

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

INTRODUCTION: Curettage is more effective than expectant management in women with suspected incomplete evacuation after misoprostol treatment for first-trimester miscarriage. The cost-effectiveness of curettage vs. expectant management in this group is unknown. MATERIAL AND METHODS: From June 2012 until July 2014 we conducted a randomized controlled trial and parallel cohort study in the Netherlands, comparing curettage with expectant management in women with an incomplete evacuation of the uterus after misoprostol treatment for first-trimester miscarriage. Successful treatment was defined as a sonographic finding of an empty uterus 6 weeks after study entry, or an uneventful course. Cost-effectiveness and cost-utility analyses were performed. We included costs of healthcare utilization, informal care and lost productivity. Cost-effectiveness planes and cost-effectiveness acceptability curves were estimated using bootstrapping. RESULTS: We included 256 women from 27 hospitals; 95 curettage and 161 expectant management. Treatment was successful in 96% of the women treated with curettage vs. 83% of the women after expectant management (mean difference 13%, 95% confidence interval 5-20). Mean costs were significantly higher in the curettage group (mean difference €1157; 95% C confidence interval €955-1388). The incremental cost-effectiveness ratio for curettage vs. expectant management was €8586 per successfully treated woman. The cost-effectiveness acceptability curve showed that at a willingness-to-pay of €18 200/extra successfully treated women, the probability that curettage is cost-effective is 95%. CONCLUSIONS: Curettage is not cost-effective compared with expectant management in women with an incomplete evacuation of the uterus after misoprostol treatment. This indicates that curettage in this group should be restrained.

An analysis of the cost of incomplete abortion to the public health sector in South Africa--1994.

OBJECTIVE: To analyse the medical costs incurred in treating women for incomplete abortion. This study was performed in conjunction with a nationwide survey of women who presented to public hospitals with incomplete abortion in 1994. DESIGN: Cost analysis with two modified Delphi panels used to develop models of resource use reflecting three severity categories of symptoms and three hospital treatment settings. SETTING: Public hospitals in South Africa. PARTICIPANTS: A panel of 15 senior level obstetrician/ gynaecologists and a second panel of 11 patient care managers representing district, regional and tertiary level hospitals in 7 provinces. MAIN RESULTS: A conservative estimate of the total cost of treating women is R18.7 million +/- R3.5 million for 1994. An estimated R9.74 million +/- R1.3 million of this was spent treating women with 'unsafe' incomplete abortions. CONCLUSIONS: The management of incomplete abortion requires significant public sector expenditure. The long-term indirect costs to women, their families and communities are discussed and treatment costs estimated so that unmet needs for medical care resulting from unsafe abortions can be addressed.

[Use of manual vacuum aspiration in reducing cost and duration of hospitalization due to incomplete abortion in an urban area of northeastern Brazil]. / Uso da aspiração manual a vácuo na redução do custo e duração de internamentos por aborto incompleto em fortaleza, CE, Brasil.

INTRODUCTION: In most developed countries vacuum aspiration has been shown to be safer and less costly than sharp curettage (SC) for uterine evacuation. In many of the developing countries, including Brazil, sharp curettage (SC) is the most commonly used technique for treating cases of incomplete abortion admitted to hospital. The procedure often involves light to heavy sedation for pain control and an overnight hospital stay for patient recuperation and monitoring. Two hypotheses are examined: the first, that the use of manual vacuum aspiration (MVA)--a variation of the vacuum aspiration, would be less costly than SC for the treatment of cases of incomplete abortion admitted to hospital; and the second, that the treatment of incomplete abortion with MVA would substantially reduce the length of hospital stay. METHODOLOGY: Thirty women with diagnosis of first trimester incomplete abortion were randomly allocated to the SC or MVA group. Rapid-assessment data collection techniques were used to identify factors that contributed to cost reduction and hospital stay. RESULTS AND CONCLUSION: The results of the study show that, overall, patients treated for incomplete abortion with MVA spent 77% less time in the hospital and consumed 41% fewer resources than similarly diagnosed patients treated with SC. Recommendations are made as to the need of certain changes in patient management. Particularly necessary is information regarding cultural perception and concepts of abortion treatment.

Biosocial profile of women with incomplete abortions in Ga-Rankuwa Hospital, Medunsa, RSA.

OBJECTIVES: 1. To obtain information on the nature and extent of the problems of incomplete abortion in Ga-Rankuwa Hospital. 2. To gain a better understanding of women's attitudes regarding abortions in the Ga-Rankuwa community. 3. To identify the predominant biosocial factors that might influence outcome, morbidity, mortality, management and cost among those who induce abortion. DESIGN: Cross sectional descriptive observational study. SETTING: Ga-Rankuwa Hospital which is a tertiary hospital approximately 40 km from Pretoria. SUBJECTS: 355 women of various ages and gestational ages were studied. MAIN OUTCOME MEASURES: It was noted from this study that women in the younger age group, of less parity, single and unemployed were found more likely to interfere with their pregnancies and thus induce abortion. RESULTS: There was no statistical difference between those who induced abortion and those who had spontaneous abortion, in terms of gestational age at which the abortion occurred. More of those who had interfered with their pregnancies were admitted for septic incomplete abortion, whereas those with no evidence of intervention were admitted to inevitable and spontaneous abortion (p < 0.001). Of those who had induced abortion 98.5pc stated that they did not want their pregnancies, compared with 39.3pc of those who did not interfere with their pregnancies (p < 0.001). CONCLUSION: The study highlights the importance and relevance of the abortion issue particularly in RSA where abortion is about to be legalized. Whether the legalization will decrease morbidity and mortality associated with criminally induced abortions remains to be established. The study also shows that those who induce abortion are worse off in terms of morbidity and other sequelae as well as cost to the health care system. Strategies for reducing the rate of abortion have been discussed.

Manejo ambulatorio del aborto como estrategia para aumentar la cobertura y reducir los costos / Hospital ambulatory abortion management: Strategy to increase coverage and reduce costs

Se presenta este trabajo con el propósito de precisar si una forma diferente de atender el aborto tiene o no ventajas sobre la metodología convencional. Desde el 1°de junio de 1989 se inició en el Departamento de Ginecoobstetricia del Hospital Nacional María Auxiliadora de Lima-Perú una investigación operacional acerca de la atención ambulatoria del aborto incompleto no complicado. Para ello se evaluó la atención del aborto incompleto en el año inmediatamente anterior, periodo en el cual todos los casos fueron manejados a través de hospitalización, con una permanencia promedio de dos dias. Los casos seleccionados como "Aborto Incompleto no Complicado", luego de preparación en la sala de urgencia, fueron derivados a la sala de legrados uterinos que para tal fin se instaló al ingreso del centro obstétrico. Realizado el procedimiento con analgesia o anestesia local, las pacientes eran ubicadas en un ambiente contiguo para observación, y al cabo de dos horas fueron enviadas a sus casas con la indicación de regresar a control en un mes. Durante el año de evaluación previa, se encontró una tasa de aborto de 193,3 por mil nacidos vivos, todos manejados mediante hospitalización. Al 31 de mayo de 1990, en que terminó la investigación, se habia atendido 1078 abortos (tasa 260 por mil nacidos vivos), de los cuales 641 (60 por ciento) fueron de manejo ambulatorio. En los casos atendidos ambulatoriamente, no se registro complicaciones en el acto operatorio ni en las dos horas subsiguientes. De otro lado, es notoria la ventaja que significó el uso de este procedimiento al abaratar los costos para el hospital y para el paciente. Por cada procedimiento el hospital dejó de gastar 106 dólares americanos y, a la paciente le significó reducir el costo a la mitad. De otro lado el procedimiento contribuye a descongestionar los servicios de hospitalización y dedicar las cama a otro tipo de atenciones, por lo que se aumentó el rendimiento.

Starting June 1, 1989, an operational investigation on ambulatory management of noncomplicated incomplete abortion was performed at Maria Auxiliadora's Hospital, Lima-Peru, to establish advantages or disadvantages. Previously, management of incomplete abortion the year before was evaluated, period when all cases were hospitalized during two days. Cases selected as "noncomplicated incomplete abortion" were prepared in the emergency room and sent for dilatation and curettage in a special room in the Obstetrical Center. The procedure was done with analgesia or local anesthesia and then the patient was sent for two hours observation in a contiguous room and finally dismissed home with indications to return for control in one month. The year before the study, abortion rate was 193,3 per thousand live newborns, 1990, 1078 abortions bad been attended (rate 26-0 x 1000 l.n.), including 641 (60%) ambulatory. No complications were present during surgery and within two hours of recovery in the ambulatory group. Ambulatory management reduced hospital costs in 106 U.S. dollars for each procedure and the patient saved one half her expenses. The procedure also frees hospital beds as they can be used for other type of medical attentions. As such, productivity increases. We suggest implementation of ambulatory management of uncomplicated incomplete abortion in all institutions.

A time and cost analysis of the management of incomplete abortion with manual vacuum aspiration.

OBJECTIVES: Traditionally, management of incomplete abortion involves use of D&C or suction curettage in the operating room. Such management is costly and time-consuming. In order to potentially save time and money, we studied the use of manual vacuum aspiration curettage (MVAC) for the management of this problem. METHODS: Data on hospital charges and times (e.g. waiting time, procedure time) were obtained for all cases of incomplete abortion presenting to hospital between January 1990 and July 1992. Between January 1990 and July 1991, all cases were managed traditionally. After July 1991, all cases were managed using MVAC in either the emergency room or the labor ward. RESULTS: Compared to the use of electrical suction equipment in the operating theatre, MVAC procedures resulted in significant savings in terms of both waiting times and costs. Waiting time was reduced by 52% and procedure time was reduced from a mean of 33 min to 19 min (P < 0.01). Total hospital costs were reduced by 41% (P < 0.01). CONCLUSIONS: Use of manual vacuum aspiration curettage in the management of incomplete abortion can reduce hospital costs and save time for both patients and clinicians.

Costs and resource utilization for the treatment of incomplete abortion in Kenya and Mexico.

In much of the developing world, sharp curettage (SC) is the most commonly used technique for treating incomplete abortion. The procedure is usually performed in a hospital setting where physicians and operating theatres are available; it often involves light to heavy sedation for pain control and an overnight hospital stay for patient recuperation and monitoring. This study examined the hypothesis that use of manual vacuum aspiration (MVA)--a variation of vacuum aspiration (VA)--would be less costly than SC and thus be advantageous to healthcare systems with limited resources. The purpose of the study was to identify and, where possible, to explain the factors that contributed to cost differences between MVA and SC for treatment of incomplete abortion. To achieve this objective, researchers observed patient management and documented resource use at hospital sites in Kenya and Mexico. The results of the study support the researchers' hypothesis that, in most cases, treatment with MVA required a shorter patient stay and fewer hospital resources than SC, as the two techniques were practiced at the various study sites. The policy decision to adopt MVA, supported by procurement of instruments and incorporation of training in its use, is the basic prerequisite to achieving reduced levels of resource use. The study results also suggest that the full advantages of MVA can be realized only if it is introduced in conjunction with certain changes in patient management, such as offering outpatient treatment for incomplete abortion.