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

Duby Okeke Ogwulu; Eleanor Williams; Justin Chu; Adam Devall; Leanne Beeson; Pollyanna Hardy; Versha Cheed; Yongzhong Sun; Laura Jones; Jenny La Fontaine; Ruth Bender Atik; Jane Brewin; Kim Hinshaw; Meenakshi Choudhary; Amna Ahmed; Joel Naflalin; Natalie  Nunes; Abigail  Oliver; Feras Izzat; Kalsang  Bhatia; Ismail Hassan; Yadava Jeve; Jude Hamilton; Debs Shilpa; Cecilia Bottomley; Jackie Ross; Linda Watkins; Martyn  Underwood; Ying Cheong; Chitra S  Kumar; Pratima Gupta; Rachel Small; Stewart  Pringle; Frances  Hodge; Anupama Shahid; Andrew W. Horne; Siobhan Quenby; Ioannis Gallos; Arri Coomarasamy; Tracy Roberts

doi:10.1111/1471-0528.16737

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

Duby Okeke Ogwulu, Eleanor Williams, Justin Chu, Adam Devall, Leanne Beeson, Pollyanna Hardy, Versha Cheed, Yongzhong Sun, Laura Jones, Jenny La Fontaine, Ruth Bender Atik, Jane Brewin, Kim Hinshaw, Meenakshi Choudhary, Amna Ahmed, Joel Naflalin , Natalie Nunes, Abigail Oliver, Feras Izzat, Kalsang BhatiaIsmail Hassan, Yadava Jeve, Jude Hamilton, Debs Shilpa, Cecilia Bottomley, Jackie Ross, Linda Watkins, Martyn Underwood, Ying Cheong, Chitra S Kumar, Pratima Gupta, Rachel Small, Stewart Pringle, Frances Hodge, Anupama Shahid, Andrew W. Horne, Siobhan Quenby, Ioannis Gallos, Arri Coomarasamy, Tracy Roberts

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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.

Original language	English
Pages (from-to)	1534-1545
Journal	BJOG: An International Journal of Obstetrics & Gynaecology
Volume	128
Issue number	9
Early online date	10 May 2021
DOIs	https://doi.org/10.1111/1471-0528.16737
Publication status	E-pub ahead of print - 10 May 2021

Bibliographical note

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.

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

ASJC Scopus subject areas

Obstetrics and Gynaecology

Access to Document

10.1111/1471-0528.16737Licence: Creative Commons: Attribution (CC BY)

1471-0528.16737Final published version, 1.95 MBLicence: Creative Commons: Attribution (CC BY)

A randomised trial of mifepristone and misoprostol alone in the medical management of missed miscarriage: The MIFEMISO Trial
Devall, A. (Co-Investigator), Middleton, L. (Co-Investigator), Coomarasamy, A. (Principal Investigator), Roberts, T. (Co-Investigator), Jones, L. (Co-Investigator) & Gough, R. (Co-Investigator)
NIHR EVALUATION, TRIALS AND STUDIES COORDINATING CENTRE
1/02/17 → 31/03/24
Project: Other Government Departments

Cite this

Okeke Ogwulu, D., Williams, E., Chu, J., Devall, A., Beeson, L., Hardy, P., Cheed, V., Sun, Y., Jones, L., La Fontaine, J., Bender Atik, R., Brewin, J., Hinshaw, K., Choudhary, M., Ahmed, A., Naflalin , J., Nunes, N., Oliver, A., Izzat, F., ... Roberts, T. (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. Advance online publication. https://doi.org/10.1111/1471-0528.16737

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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{\textquoteright}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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Okeke Ogwulu, D , Williams, E, Chu, J, Devall, A, Beeson, L, Hardy, P , Cheed, V , Sun, Y , Jones, L, La Fontaine, J, Bender Atik, R, Brewin, J, Hinshaw, K, Choudhary, M, Ahmed, A, Naflalin , J, Nunes, N, Oliver, A, Izzat, F, Bhatia, K, Hassan, I, Jeve, Y, Hamilton, J, Shilpa, D, Bottomley, C, Ross, J, Watkins, L, Underwood, M, Cheong, Y, Kumar, CS, Gupta, P, Small, R, Pringle, S, Hodge, F, Shahid, A, Horne, AW, Quenby, S, Gallos, I , Coomarasamy, A & Roberts, T 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, vol. 128, no. 9, pp. 1534-1545. https://doi.org/10.1111/1471-0528.16737

Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage: an economic evaluation based on the MifeMiso Trial. / Okeke Ogwulu, Duby ; Williams, Eleanor; Chu, Justin et al.
In: BJOG: An International Journal of Obstetrics & Gynaecology, Vol. 128, No. 9, 10.05.2021, p. 1534-1545.

Research output: Contribution to journal › Article › peer-review

TY - JOUR

T1 - Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage

T2 - an economic evaluation based on the MifeMiso Trial

AU - Okeke Ogwulu, Duby

AU - Williams, Eleanor

AU - Chu, Justin

AU - Devall, Adam

AU - Beeson, Leanne

AU - Hardy, Pollyanna

AU - Cheed, Versha

AU - Sun, Yongzhong

AU - Jones, Laura

AU - La Fontaine, Jenny

AU - Bender Atik, Ruth

AU - Brewin, Jane

AU - Hinshaw, Kim

AU - Choudhary, Meenakshi

AU - Ahmed, Amna

AU - Naflalin , Joel

AU - Nunes, Natalie

AU - Oliver, Abigail

AU - Izzat, Feras

AU - Bhatia, Kalsang

AU - Hassan, Ismail

AU - Jeve, Yadava

AU - Hamilton, Jude

AU - Shilpa, Debs

AU - Bottomley, Cecilia

AU - Ross, Jackie

AU - Watkins, Linda

AU - Underwood, Martyn

AU - Cheong, Ying

AU - Kumar, Chitra S

AU - Gupta, Pratima

AU - Small, Rachel

AU - Pringle, Stewart

AU - Hodge, Frances

AU - Shahid, Anupama

AU - Horne, Andrew W.

AU - Quenby, Siobhan

AU - Gallos, Ioannis

AU - Coomarasamy, Arri

AU - Roberts, Tracy

N1 - 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. Publisher Copyright: © 2021 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.

PY - 2021/5/10

Y1 - 2021/5/10

N2 - 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.

AB - 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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KW - cost utility

KW - economic evaluation

KW - management

KW - miscarriage

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JO - BJOG: An International Journal of Obstetrics & Gynaecology

JF - BJOG: An International Journal of Obstetrics & Gynaecology

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Okeke Ogwulu D , Williams E, Chu J, Devall A, Beeson L, Hardy P et al. 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. 2021 May 10;128(9):1534-1545. Epub 2021 May 10. doi: 10.1111/1471-0528.16737

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

Abstract

Bibliographical note

Keywords

ASJC Scopus subject areas

Access to Document

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A randomised trial of mifepristone and misoprostol alone in the medical management of missed miscarriage: The MIFEMISO Trial

Cite this