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Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage: an economic evaluation based on the MifeMiso Trial

Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage: an economic evaluation based on the MifeMiso Trial
Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage: an economic evaluation based on the MifeMiso Trial

Objective: To assess the cost-effectiveness of mifepristone and misoprostol (MifeMiso) compared with misoprostol only for the medical management of a missed miscarriage. Design: Within-trial economic evaluation and model-based analysis to set the findings in the context of the wider economic evidence for a range of comparators. Incremental costs and outcomes were calculated using nonparametric bootstrapping and reported using cost-effectiveness acceptability curves. Analyses were performed from the perspective of the UK’s National Health Service (NHS). Setting: Twenty-eight UK NHS early pregnancy units. Sample: A cohort of 711 women aged 16–39 years with ultrasound evidence of a missed miscarriage. Methods: Treatment with mifepristone and misoprostol or with matched placebo and misoprostol tablets. Main outcome measures: Cost per additional successfully managed miscarriage and quality-adjusted life years (QALYs). Results: For the within-trial analysis, MifeMiso intervention resulted in an absolute effect difference of 6.6% (95% CI 0.7–12.5%) per successfully managed miscarriage and a QALYs difference of 0.04% (95% CI −0.01 to 0.1%). The average cost per successfully managed miscarriage was lower in the MifeMiso arm than in the placebo and misoprostol arm, with a cost saving of £182 (95% CI £26–£338). Hence, the MifeMiso intervention dominated the use of misoprostol alone. The model-based analysis showed that the MifeMiso intervention is preferable, compared with expectant management, and this is the current medical management strategy. However, the model-based evidence suggests that the intervention is a less effective but less costly strategy than surgical management. Conclusions: The within-trial analysis found that based on cost-effectiveness grounds, the MifeMiso intervention is likely to be recommended by decision makers for the medical management of women presenting with a missed miscarriage. Tweetable abstract: The combination of mifepristone and misoprostol is more effective and less costly than misoprostol alone for the management of missed miscarriages.

Cost-effectiveness, cost utility, economic evaluation, management, miscarriage, model
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Okeke Ogwulu, C.B.
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Williams, E.V.
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Hardy, P.
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Cheed, V.
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Yongzhong, S.
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Hamilton, Judith
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Deb, S.
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Bottomley, C
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Hardy, P.
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Cheed, V.
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Jeve, Y.
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Hamilton, Judith
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Bottomley, C
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Watkins, L
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Underwood, M.
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Cheong, Ying
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Quenby, S.
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Okeke Ogwulu, C.B., Williams, E.V., Chu, J.J., Devall, A.J., Beeson, L.E., Hardy, P., Cheed, V., Yongzhong, S., Jones, L.L., La Fontaine Papadopoulos, J.H., Bender-Atik, R., Brewin, J., Hinshaw, K., Choudhary, M., Ahmed, A., Naftalin, J., Nunes, N., Oliver, A., Izzat, F., Bhatia, K., Hassan, I., Jeve, Y., Hamilton, Judith, Deb, S., Bottomley, C, Ross, J., Watkins, L, Underwood, M., Cheong, Ying, Kumar, C.S., Gupta, P., Small, R., Pringles, S., Hodge, F.S., Shahid, A., Horne, A.W., Quenby, S., Gallos, I.D., Coomarasamy, A. and Roberts, T.E. (2021) Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage: an economic evaluation based on the MifeMiso Trial. BJOG: An International Journal of Obstetrics & Gynaecology, 128 (9), 1534-1545. (doi:10.1111/1471-0528.16737).

Record type: Article

Abstract

Objective: To assess the cost-effectiveness of mifepristone and misoprostol (MifeMiso) compared with misoprostol only for the medical management of a missed miscarriage. Design: Within-trial economic evaluation and model-based analysis to set the findings in the context of the wider economic evidence for a range of comparators. Incremental costs and outcomes were calculated using nonparametric bootstrapping and reported using cost-effectiveness acceptability curves. Analyses were performed from the perspective of the UK’s National Health Service (NHS). Setting: Twenty-eight UK NHS early pregnancy units. Sample: A cohort of 711 women aged 16–39 years with ultrasound evidence of a missed miscarriage. Methods: Treatment with mifepristone and misoprostol or with matched placebo and misoprostol tablets. Main outcome measures: Cost per additional successfully managed miscarriage and quality-adjusted life years (QALYs). Results: For the within-trial analysis, MifeMiso intervention resulted in an absolute effect difference of 6.6% (95% CI 0.7–12.5%) per successfully managed miscarriage and a QALYs difference of 0.04% (95% CI −0.01 to 0.1%). The average cost per successfully managed miscarriage was lower in the MifeMiso arm than in the placebo and misoprostol arm, with a cost saving of £182 (95% CI £26–£338). Hence, the MifeMiso intervention dominated the use of misoprostol alone. The model-based analysis showed that the MifeMiso intervention is preferable, compared with expectant management, and this is the current medical management strategy. However, the model-based evidence suggests that the intervention is a less effective but less costly strategy than surgical management. Conclusions: The within-trial analysis found that based on cost-effectiveness grounds, the MifeMiso intervention is likely to be recommended by decision makers for the medical management of women presenting with a missed miscarriage. Tweetable abstract: The combination of mifepristone and misoprostol is more effective and less costly than misoprostol alone for the management of missed miscarriages.

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An Economic Evaluation based on the MifeMiso Trial - Main Document
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MifeMiso BJOG Submission Figure 2
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MifeMiso BJOG Submission Tables
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MifeMiso BJOG Submission Figure 4 Model analysis_Revised
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MifeMiso BJOG Submission Figure 3 CEAC for the primary outcome_Revised
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MifeMiso Figure Model Pathway_Revised
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Accepted/In Press date: 12 April 2021
Published date: August 2021
Additional Information: Funding Information: The National Institute for Health Research (NIHR) Health Technology Assessment programme (15/160/02) funded this project. A final report of data collected in this study will be published in the NIHR Journals Library. The views expressed in this article are those of the authors and not necessarily those of the UK National Health Service, the NIHR or the UK Department of Health and Social Care. The charity Tommy’s, whose funding supports the UK National Miscarriage Research Network, also supported the project. Funding Information: The National Institute for Health Research (NIHR) Health Technology Assessment programme (15/160/02) funded this project. A final report of data collected in this study will be published in the NIHR Journals Library. The views expressed in this article are those of the authors and not necessarily those of the UK National Health Service, the NIHR or the UK Department of Health and Social Care. The charity Tommy?s, whose funding supports the UK National Miscarriage Research Network, also supported the project. We thank all of the women who participated in this study and the following investigators for supervising recruitment and randomisation at the study centres: Sangeetha Devarajan, Frances Hodge, Jane Mears, Faizah Mukri, Kalpana Rao, Penny Robshaw and Nirmala Vaithilingham. We thank Janet Scollen for her outstanding contribution to recruitment and randomisation and all the other MifeMiso research nurses and midwives who assisted in the collection of data. We also thank Mary Nulty and Hannah Noordali for their support in administering the trial, Lee Middleton for his statistical support in the design of the trial, Rajendra Rai for chairing the trial steering committee, Maya Al-Memar and Ruth Bender-Atik for participating in the trial steering committee, Abha Maheshwari for chairing the data monitoring committee, Neelam Potdar and Mike Bradburn for participating in the data monitoring committee and all those not otherwise mentioned above who have contributed to the MifeMiso trial. Publisher Copyright: © 2021 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.
Keywords: Cost-effectiveness, cost utility, economic evaluation, management, miscarriage, model

Identifiers

Local EPrints ID: 451758
URI: http://eprints.soton.ac.uk/id/eprint/451758
ISSN: 1470-0328
PURE UUID: 975eaa25-8756-4cbc-abf7-0c7d43ee44bb
ORCID for Ying Cheong: ORCID iD orcid.org/0000-0001-7687-4597

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Date deposited: 26 Oct 2021 16:30
Last modified: 17 Mar 2024 03:13

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Contributors

Author: C.B. Okeke Ogwulu
Author: E.V. Williams
Author: J.J. Chu
Author: A.J. Devall
Author: L.E. Beeson
Author: P. Hardy
Author: V. Cheed
Author: S. Yongzhong
Author: L.L. Jones
Author: J.H. La Fontaine Papadopoulos
Author: R. Bender-Atik
Author: J. Brewin
Author: K. Hinshaw
Author: M. Choudhary
Author: A. Ahmed
Author: J. Naftalin
Author: N. Nunes
Author: A. Oliver
Author: F. Izzat
Author: K. Bhatia
Author: I. Hassan
Author: Y. Jeve
Author: Judith Hamilton
Author: S. Deb
Author: C Bottomley
Author: J. Ross
Author: L Watkins
Author: M. Underwood
Author: Ying Cheong ORCID iD
Author: C.S. Kumar
Author: P. Gupta
Author: R. Small
Author: S. Pringles
Author: F.S. Hodge
Author: A. Shahid
Author: A.W. Horne
Author: S. Quenby
Author: I.D. Gallos
Author: A. Coomarasamy
Author: T.E. Roberts

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