An economic evaluation of single dose systemic methotrexate and laparoscopic surgery for the treatment of unruptured ectopic pregnancy

Abstract

Objective To compare the direct and indirect costs of single dose systemic methotrexate with laparoscopic surgery for the treatment of unruptured ectopic pregnancy.Design A cost minimisation study undertaken alongside a randomised trial. Setting Departments of Obstetrics and Gynaecology in three hospitals in Auckland, New Zealand.Participants Sixty-two women with an ectopic pregnancy randomised to treatment with either a single dose of methotrexate (50mg/m 2 ) or laparoscopic surgery.Main outcome measures Direct and indirect costs based on the results of the randomised trial.Results Direct costs per case were signi®cantly lower in the methotrexate group (mean $NZ 1470) than in the laparoscopy group (mean $NZ 3083) with a mean difference of $NZ 1613 (95% CI $NZ 1166 -$NZ 2061). These signi®cant differences existed under a wide range of alternative assumptions about unit costs. The difference in direct costs in favour of methotrexate was greatest for women presenting with low pretreatment serum b-hCG concentrations. Mean indirect costs were also signi®cantly lower in the methotrexate group (mean $NZ 1141) than in the laparoscopy group (mean $NZ 1899) with a mean difference of $NZ 758 (95% CI $NZ 277 -$NZ 1240). For women presenting with pretreatment serum b-hCG concentrations of over 1500 IU/ L this difference in indirect costs is lost due to the prolonged follow up required and a higher rate of surgical intervention in women receiving methotrexate.Conclusion This economic evaluation shows that treating suitable women with an ectopic pregnancy using systemic methotrexate therapy results in a signi®cant reduction in direct costs. The indirect costs borne by the woman and her carers are only likely to be reduced in women with pretreatment serum b-hCG concentrations under 1500 IU/L.

A randomised trial comparing single dose systemic methotrexate and laparoscopic surgery for the treatment of unruptured tubal pregnancy

“…The ®ndings in our study are important because despite the reduction in time lost from work associated with medical therapy 17 we have been unable to demonstrate any bene®t in terms of psychological outcomes to support its use. It is possible that the instruments we have used were too insensitive to detect such differences or that the psychological morbidity associated with early pregnancy loss and fear over lost future fertility make any effects related to the type of treatment given unimportant.…”

“…In order to assess whether the less invasive nature of methotrexate therapy might make it an acceptable treatment even if less effective than laparoscopy healthrelated quality of life and psychological outcomes as well as treatment side effects have been evaluated. A cost effectiveness study undertaken alongside this trial has been reported separately 17 .…”

The non‐surgical management of ectopic pregnancy

“…A study in the Netherlands has shown that systemic methotrexate therapy could reduce costs if administered to patients with low initial serum hCG levels without confirmatory laparoscopy69. In New Zealand it has been shown that single‐dose methotrexate resulted in a 52% reduction in direct costs and a 40% reduction in indirect costs compared to laparoscopic surgery70. Women with hCG levels > 1500 IU/L had higher indirect costs owing to an increased likelihood of surgical intervention and the need for prolonged follow‐up.…”

Clinical utility of serum reproductive hormones for the early diagnosis of ectopic pregnancy in the first trimester

“…For example, when the b-hCG level is >1500 IU/L, the cost-effective benefits may lessen due to the need for prolonged follow-up and surgical intervention. 19 The success rate of single-dose methotrexate was reported to be 97% at a b-hCG level below 2000 IU/L, but dropped to 74% for b-hCG levels >2000 IU/L. [20][21][22] It is obvious that a combination of estradiol and daily b-hCG variation is helpful in the early diagnosis of an EP, which is valuable, not only for improving the treatment effect, but also in reducing the associated medical costs.…”