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INFORMED choice rather than cost-effectiveness or moral judgements should be the driving force behind women’s options for the management of missed miscarriages, says a leading consumer advocate.
Carol Bennett, chief executive officer of Consumers Health Forum of Australia, told MJA InSight that the decision by some Australian hospitals not to offer both medical management, via the administration of misoprostol, and surgical management, via dilatation and curettage (D&C), was “a concern”.
She was commenting on research in the latest MJA that found medical management of missed miscarriage between 6 and 13 weeks gestation was “clinically effective, safe and acceptable”, with 73% of women who had received misoprostol saying they would recommend medical management to other women, while 18.2% indicated they would undergo surgery next time. (1)
The descriptive study involved 264 women who requested medical management of a missed miscarriage at Mater Mothers’ Hospital, Brisbane over a 3-year period.
Of the women involved in the study, 107 (40.5%) required a repeat dose of misoprostol the day after the initial dose and 79 (29.9%) made unscheduled visits for care. Among the 241 women who had a follow-up ultrasound, failure of medical management (presence of a gestational sac) was found in 32 (13.3%). Complete miscarriage was induced without surgery in 206 (78%).
“Despite clinical trials showing that medical management is an acceptable alternative to surgical management, it has not been widely implemented into clinical practice in Australia”, the authors wrote.
Although a longer duration of bleeding and more severe short-term pain were common with medical management, the authors wrote that “convalescence, transfusion requirement, and risk of infection and future fertility complications are not increased” in comparison with surgical management.
Associate Professor Steven Robson, vice-president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, said he was aware that some hospitals, particularly in NSW — including at least one major Sydney public hospital — did not offer medical management for miscarriages.
“The college supports women being given all the options available so they can choose which one best suits them”, Professor Robson told MJA InSight.
“It’s hard to believe that cost-effectiveness is one of the reasons not to offer medical management as misoprostol is very cheap — less that 50c a tablet. Perhaps it is anxiety about it being off licence.”
Misoprostol is not PBS listed for medical management of miscarriage but is now listed with mifepristone for the termination of pregnancies up 49 days’ gestation. (2)
A leading health economist said the cost-effectiveness of medical versus surgical management of miscarriage in Australia has not been closely examined.
Associate Professor Lisa Gold, from Deakin Health Economics at Deakin University, Melbourne, told MJA InSight that the largest cost analysis — the UK Miscarriage Treatment Trial (MIST) — showed that the cost differences were less than might be expected. (3)
“MIST showed that medical management has lower initial hospital costs than surgery but that medical management also has a higher proportion that ‘fail’ and end up needing surgery”, Professor Gold said.
“The total hospital costs are much more similar than a simple comparison of cost of drugs versus cost of surgery suggests.
“The MIST values study shows that the most important thing for women is for whatever treatment they have to reduce the pain. The next most important factor is a quicker return to normal activities”, she said.
“Overall, women valued surgery higher than medical and both higher than expectant care — but values data are always very variable.”
“Women have different values and so some women will prefer surgery and others will prefer medical management — so we should give them a choice.”
Ms Bennett said it was important that women had choice about what was a very important life decision. “People who are given a choice make the decision that is best for them — give them the information about all the choices available and let them make that decision.
“If that choice is determined by drivers in the health system — whether that’s cost-effectiveness or some moral judgement — then I would be concerned about that”, she said. “The health system is here to service the needs of patients, not the providers, and the patients’ interests should be the driver for all decision making.”
1. MJA 2013; 199: 341-346
2. RANZCOG 2012: The use of misoprostol in obstetrics
3. BMJ 2006; 332: 1235-1240
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I have no comment on the management of miscarriage, it is well outside my area of expertise. My concern is the prominence the MJA is increasingly giving to consumer lobbyists with skewed priorities. Nothing could better encapsulate the muddle-headedness of consumer advocacy than Ms Bennett saying that cost effectiveness should not drive choices offered to patients.
Until consumers actually pay the true cost of services out of their own pockets, it is unethical for we service providers to not consider cost in the choices offered to patients. Autonomy and choice is one important component of ethical practice. Just use of finite resources is another.
This is nothing new. The first studies comparing expectant vs medical vs surgical management appeared 20 years ago. Results from a British NHS study would be different to say, private sector patients in Australia. Trying to provide all the available evidence would be like turning a short hearing into a two month court case. Most women want the safest most practical method for them, in their individual circumstances and/or mindset. I am amazed that the reflex “needs a D&C” still appears on referrals. “D&C” as a description belongs in the museum of abandoned procedures. It’s either a “suction evacuation of retained products” for miscarriage, or hysteroscopy with directed endometrial biopsy for menstrual disorder in this day and age.
The patient acceptability data may be skewed because the only women studied (according to the article) were women who “requested” medical mangement. In groups who want a particular type of treatment at the onset, they are frequently much more likely to put up with side effects (like needing frequent blood tests, scans, vaginal bleeding and hospital visits) than women who aren’t already committed to a treatment modality.
The average woman might just want a simple surgical procedure that sorts the problem out with a minimum of ests and visits, even with the attendant known risks of minor surgery. I don’t know what the answer is but I am wary of the patient acceptability data presented in this trial. I believe the best option is to allow women to choose between medical and surgical options based on being given complete data on risks/benefits for both modalities of treatment.