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
Open accessAbstract
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.
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Direct health service costs for medical management ranged from £298 in a US study to £1421 in a UK study.
“Direct health service costs for medical management ranged from £298 in a study from the United States 120 through to £1421 in a UK study. 113”
From Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss (2021) · cites this paper as [113]
Citation 113 is attached to the £1421 UK-study figure, not the £298 US-study figure. The Material and methods section says costs were estimated using Dutch guidelines and reported in 2014 euros; the Discussion also describes Dutch healthcare practice. This paper therefore does not report the attributed cost from a UK study. (LLM, conf=0.87)
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Experimental — accuracy not yet measuredIn the MIST trial economic evaluation, the mean value of work absences due to miscarriage was £431, with no significant difference between expectant, medical, and surgical management.
“The mean value of work absences was estimated at £431 with no significant difference in values observed between the three management methods evaluated (expectant, management, surgical).”
From Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss (2021) · cites this paper as [113]
The Results (page unavailable) report no statistically significant difference in lost-productivity costs between curettage and expectant management. But this is an evaluation alongside the MisoREST trial, not the MIST trial; it compares two groups, reports costs in euros, and does not give a mean work-absence value of £431 or a three-way comparison with medical management. (LLM, conf=0.84)
Experimental — accuracy not yet measuredAssuming economic consequences of miscarriage are felt only over the short term, combining national prevalence data for England with estimates of hospital and community health and social services costs, costs to patients, and broader societal costs associated with lost productivity generates an annual national estimate of economic burden of £471 million.
“For example, assuming that the economic consequences of miscarriage are felt only over the short term and combining national prevalence data for England with estimates of costs of hospital and community health and social services, 113 costs to patients 127 and broader societal costs associated with lost productivity 113 generates an annual national estimate of economic burden of £471 million.”
From Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss (2021) · cites this paper as [113]
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Experimental — accuracy not yet measuredMost published studies aimed to provide information about options less costly than current practice or to probe the value of adjuncts to current practice.
“Most published studies have aimed to provide information about options that are less costly than current practice, 111-118 or to probe the value of adjuncts to current practice. 119”
From Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss (2021) · cites this paper as [113]
Unit cost estimates in published studies have been derived from primary research methods and administrative tariffs.
“Unit costs estimates have been derived from a number of sources, including primary research methods 113,115,116 and administrative tariffs. 120,121”
From Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss (2021) · cites this paper as [113]
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- Authors
- Lemmers, M., Verschoor, M. A. C., Bossuyt, P. M., Huirne, J. A. F., Spinder, T., Nieboer, T. E., Bongers, M. Y., Janssen, I. A. H., Van Hooff, M. H. A., Mol, B. W. J., Ankum, W. M., Bosmans, J. E., & on behalf of the MisoREST study group
- Affiliations
- Amsterdam UMC Location University of Amsterdam (NL)
- Amsterdam UMC Location Vrije Universiteit Amsterdam (NL)
- Medisch Centrum Leeuwarden (NL)
- Radboud University Medical Center (NL)
- Maastricht University (NL)
- Groene Hart Ziekenhuis (NL)
- Department of Obstetrics and Gynecology Sint Franciscus Gasthuis Rotterdam the Netherlands
- South Australian Health and Medical Research Institute (AU)
- Amsterdam Public Health (NL)
- Corresponding author
- Lemmers, Marike
- ORCID
- Venue
- Acta Obstetricia et Gynecologica Scandinavica
- Publisher
- Wiley
- Published
- 2018-01-19
- Volume
- 97
- Issue
- 3
- Pages
- 294-300
- ISSN
- 0001-6349 (ISSN-L)
- 1600-0412
- OpenAlex
- W2780780487
- Cited by
- 23
- References
- 28
- Citations by year
- 2026: 3 · 2025: 3 · 2024: 1 · 2023: 2 · 2022: 5 · 2021: 5 · 2019: 4
- FWCI
- 1.03
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Acta Obstetricia Et Gynecologica Scandinavica (publishedVersion)
- PubMed (publishedVersion)
- Research Publications (Maastricht University) (publishedVersion, other-oa)
- Amsterdam UMC (VU Amsterdam) - Institutional Repository (publishedVersion)
- VU Research Portal (publishedVersion, other-oa)
- Pure Amsterdam UMC (submittedVersion, other-oa)
- Radboud Repository (Radboud University) (submittedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Research Publications (Maastricht University) (submittedVersion)
- Funders
- ZonMw (80‐82310‐97‐12066)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Reproductive Health and Contraception
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Health Systems, Economic Evaluations, Quality of Life
- Life Sciences › Immunology and Microbiology › Immunology › Reproductive System and Pregnancy
- Keywords
- curettage, expectant management, incomplete evacuation, first-trimester miscarriage, misoprostol, cost-effectiveness, cost-utility analysis, cost-effectiveness acceptability curves, incremental cost-effectiveness ratio, health care costs, productivity loss
- MeSH terms
- Abortifacient Agents, Nonsteroidal, Abortion, Incomplete, Adult, Combined Modality Therapy, Cost-Benefit Analysis, Curettage, Female, Follow-Up Studies, Humans, Netherlands, Pregnancy, Pregnancy Trimester, First, Prospective Studies, Misoprostol, Treatment Outcome, Health Care Costs, Watchful Waiting
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