Persistent pregnancies of unknown location are defined by abnormally trending serum human chorionic gonadotropin with nondiagnostic ultrasound. There is no consensus on optimal management. This study aimed to assess the cost-effectiveness of 3 primary management strategies for persistent pregnancies of unknown location: (1) expectant management, (2) empirical 2-dose methotrexate, and (3) uterine evacuation followed by methotrexate, if indicated. This was a prospective economic evaluation performed concurrently with the Expectant versus Active Management for Treatment of Persistent Pregnancies of Unknown Location multicenter randomized trial that was conducted from July 2014 to June 2019. Participants were randomized 1:1:1 to expectant management, 2-dose methotrexate, or uterine evacuation. The analysis was from the healthcare sector perspective with a 6-week time horizon after randomization. Costs were expressed in 2018 US dollars. Effectiveness was measured in quality-adjusted life years and the rate of salpingectomy. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves were generated. Sensitivity analyses were performed to assess the robustness of the analysis. Methotrexate had the lowest mean cost ($875), followed by expectant management ($1085) and uterine evacuation ($1902) (=.001). Expectant management had the highest mean quality-adjusted life years (0.1043), followed by methotrexate (0.1031) and uterine evacuation (0.0992) (=.0001). The salpingectomy rate was higher for expectant management than for methotrexate (9.4% vs 1.2%, respectively; =.02) and for expectant management than for uterine evacuation (9.4% vs 8.1%, respectively; =.04). Uterine evacuation, with the highest costs and the lowest quality-adjusted life years, was dominated by both expectant management and methotrexate. In the base case analysis, expectant management was not cost-effective compared with methotrexate at a willingness to pay of $150,000 per quality-adjusted life year given an incremental cost-effectiveness ratio of $175,083 per quality-adjusted life year gained (95% confidence interval, −$1,666,825 to $2,676,375). Threshold analysis demonstrated that methotrexate administration would have to cost $214 (an increase of $16 or 8%) to favor expectant management. Moreover, expectant management would be favorable in lower-risk patient populations with rates of laparoscopic surgical management for ectopic pregnancy not exceeding 4% of pregnancies of unknown location. Based on the cost-effectiveness acceptability curves, the probability of expectant management being cost-effective compared with methotrexate at a willingness to pay of $150,000 per quality-adjusted life year gained was 50%. The results were dependent on the cost of surgical intervention and the expected rate of methotrexate failure. The management of pregnancies of unknown location with a 2-dose methotrexate protocol may be cost-effective compared with expectant management and uterine evacuation. Although uterine evacuation was dominated, expectant management vs methotrexate results were sensitive to modest changes in treatment costs of both methotrexate and surgical management.

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期待与积极管理治疗不明地点持续妊娠的成本效益分析

位置不明的持续妊娠是通过非诊断性超声检测血清人绒毛膜促性腺激素的异常趋势来定义的。对于最佳管理尚未达成共识。本研究旨在评估针对不明部位持续妊娠的 3 种主要管理策略的成本效益：(1) 期待管理，(2) 经验性 2 剂甲氨蝶呤，以及 (3) 清宫，然后在需要时使用甲氨蝶呤。这是一项前瞻性经济评估，与 2014 年 7 月至 2019 年 6 月进行的治疗未知地点持续妊娠的期待治疗与积极治疗多中心随机试验同时进行。参与者按 1:1:1 随机分配至期待治疗，2 剂甲氨蝶呤，或子宫清宫术。该分析是从医疗保健行业的角度进行的，随机分组后的时间范围为 6 周。成本以 2018 年美元表示。有效性以质量调整生命年和输卵管切除率来衡量。生成增量成本效益比和成本效益可接受曲线。进行敏感性分析以评估分析的稳健性。甲氨蝶呤的平均成本最低（875 美元），其次是期待治疗（1085 美元）和清宫术（1902 美元）(=.001)。期待治疗的平均质量调整生命年最高 (0.1043)，其次是甲氨蝶呤 (0.1031) 和清宫术 (0.0992) (=.0001)。期待治疗的输卵管切除率高于甲氨蝶呤（分别为 9.4% vs 1.2%；=.02），期待治疗的输卵管切除率高于清宫术（分别为 9.4% vs 8.1%；=.04）。子宫清宫术的成本最高，质量调整生命年最低，主要以期待治疗和甲氨蝶呤为主。在基本案例分析中，考虑到每个质量调整生命年的增量成本效益比为 175,083 美元（95% 置信区间），与愿意为每个质量调整生命年支付 150,000 美元的甲氨蝶呤相比，预期治疗并不具有成本效益。 ，−1,666,825 美元至 2,676,375 美元）。阈值分析表明，甲氨蝶呤给药费用必须为 214 美元（增加 16 美元或 8%）才能支持期待治疗。此外，期待治疗对于低风险患者人群是有利的，腹腔镜手术治疗异位妊娠的比率不超过未知地点妊娠的 4%。根据成本效益可接受性曲线，如果愿意为每个质量调整生命年支付 150,000 美元，则与甲氨蝶呤相比，预期治疗具有成本效益的概率为 50%。结果取决于手术干预的费用和甲氨蝶呤的预期失败率。与期待治疗和清宫相比，使用 2 剂甲氨蝶呤方案治疗不明部位妊娠可能具有成本效益。尽管清宫术占主导地位，但预期治疗与甲氨蝶呤的结果对甲氨蝶呤和手术治疗的治疗成本的适度变化敏感。