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

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.

Cancer, employment, and American Indians: A participatory action research pilot study

American Indian cancer survivors are an underserved and understudied group. In this pilot study we attempted to address, through participatory action research, missing information about those factors that serve to either facilitate employment or hinder it for adult cancer survivors. One task of the study was to develop and/or modify instrumentation that could be used in a subsequent, in-depth census study. The pilot sample consisted of 10 cancer survivors, all members of a Northern Minnesota American Indian tribe, and 10 family members. All survivors reported having health problems such as fatigue since their cancer treatments. Rehabilitation counselors can assist survivors and their family members by advising them in regard to employment discrimination and accommodations such as flexible work schedules.

Vocal intensity characteristics in normal and elderly speakers

The relationship of lung pressure, fundamental frequency, peak airflow, open quotient, and maximal flow declination rate to vocal intensity for a normal speaking, young male control group and an elderly male group was investigated. The control group consisted of 17 healthy male subjects with a mean age of 30 years and the elderly group consisted of 11 healthy male subjects with a mean age of 77 years. Data were collected at three levels of vocal intensity: soft, comfortable, and loud, corresponding to 25%, 50%, and 75% of dynamic range, respectively. Phonational threshold pressure and lung pressure were obtained using the intraoral technique. The oral airflow waveform was inverse filtered to provide an approximation to the glottal airflow waveform from which measures of fundamental frequency, peak airflow, open quotient, and maximal flow declination rate were determined. Excess lung pressure was calculated as lung pressure minus estimated phonational threshold pressure. The results show for both groups an increase in sound pressure level across the conditions, with corresponding increases in lung pressure, excess lung pressure, fundamental frequency, peak airflow, and maximal flow declination rate. Open quotient decreased with increasing vocal intensity. Lung pressure, sound pressure level, and peak airflow were all found to be significantly greater for the control group than for the elderly group at each condition. Open quotient was found to be significantly lower in the control group than in the elderly group at each condition. No significant difference was observed for excess lung pressure, phonational threshold pressure, fundamental frequency, or maximal flow declination rate between the two groups. These results show that a difference in vocal intensity does exist between young and elderly voices and that this difference is the result of differences in lung pressure, peak airflow, and open quotient.

Recruitment of American Indians and Alaska Natives into clinical trials

Challenges in recruiting American Indians and Alaska Natives into cancer clinical trials are addressed in this article. Researchers, health care providers, and American Indian and Alaska Native patients face significant communication barriers when prevention or treatment trials are designed or implemented. For researchers, the challenges lie in understanding the cultural distinctiveness of individual tribes, coping with the family orientation of Indian subjects, dealing with the lack of standardized research measures, and defining the subject's pathway in seeking and obtaining healing and health care services. For providers, the challenges center on patient-provider communication, illness beliefs, transportation, and sociocultural barriers. This article explores these complex issues and offers recommendations for researchers and health care providers on conducting research in American Indian and Alaska Native populations.

Characteristics of American Indian women cigarette smokers: prevalence and cessation status

A high rate of cigarette smoking is documented among the American Indian population in California, but data on Indian women smokers have not been widely studied. This paper reports on a survey conducted in a smoking cessation project implemented and evaluated as part of a National Cancer Institute (NCI) cooperative agreement. Characteristics of Indian women smokers are presented and cessation status is examined. The overall goal of the project was to increase long-term smoking cessation among American Indian populations through a reproducible clinic-based smoking cessation program. To ascertain smoking prevalence and tobacco use patterns, a self-administered survey was completed by 1,369 adult male and female American Indian health clinic users in Northern California. Study results reported several important characteristics of Indian women smokers. Single and divorced participants had a higher smoking rate (40.4% and 42%) than married participants (34.4%); 54.5% of unemployed women smoked; and level of education was strongly associated with smoking status (p = .011). Almost 80% (79.9%) of women former smokers quit using the "cold turkey" method. Fewer than 50% of Indian women smokers reported willingness to quit at the following smoking cessation stages: "immediately" or "ready" (12.4%), "in one month" (10.5%), and "in six months" (25.2%). This points to a need for effective tobacco cessation interventions for American Indians, which will take into consideration Indian women smokers' demographic characteristics, lenient attitudes toward smoking, and smoking behaviors.

American Indian women's talking circle. A cervical cancer screening and prevention project

BACKGROUND

Cervical cancer is important to American Indian women due to high mortality and low survival rates compared with other ethnic groups. This article describes the development and implementation of a culturally acceptable cervical cancer screening program in urban and rural American Indian health clinics in California.

METHODS

A team of researchers used social learning theory, research data, and focus groups to design a cervical cancer screening program. The major component of the program was the adaptation of a culturally acceptable mode of communication called Talking Circles. The American Indian Talking Circle project used the Talking Circle format, coupled with traditional Indian stories, as a vehicle to provide cancer education and to improve adherence to cancer screening. Eight American Indian clinics were randomly assigned into intervention and control sites (n = 400 women). The intervention was administered to 200 Indian women 18 years and older in four American Indian clinics; four additional American Indian clinics (n = 200 women) served as control sites.

RESULTS

Preliminary results from the research show that American Indian women responded favorably to a culturally framed education project. Initial reports indicate that health-related information is accepted and acted on when it is coupled with cultural information that is presented in a sensitive manner. Final evaluation of the project is forthcoming.

CONCLUSIONS

Utilizing a culturally acceptable intervention has the potential to improve the health status of American Indian Women.

Patient and smoking patterns in northern California American Indian Clinics. Urban and rural contrasts

BACKGROUND

This article elaborates on an earlier article about a smoking cessation program conducted in Northern California Indian clinics. Whereas the previous article discussed Indian smoking rates in general, this article compares the smoking patterns of Indians who live in urban and rural settings. The differences between the two populations are described, and the implications of these differences for planning, policy, and education are discussed.

METHODS

A self-report questionnaire was administered to 1369 adult Indians seeking health services at 18 American Indian health care clinics in Northern California. Data were collected on demographic characteristics; smoking behaviors; readiness to quit smoking; knowledge, behavior, and attitude; and a social support and "hassles" measures.

RESULTS

Urban Indians were more mobile and reported higher smoking rates, a higher level of education, less social support, and more hassles than rural Indians.

CONCLUSIONS

Indians living in urban areas continue to experience a high degree of stress. Long-term isolation from reservations and traditional homelands may have contributed to the breakdown of social support systems among urban Indians. These and several other factors should be considered when designing tobacco control programs.

Prevalence of smoking among adult American Indian clinic users in northern California

BACKGROUND

The American Indian Cancer Control Project is a 5-year program funded by the National Cancer Institute designed to promote smoking cessation among adult Indians living in Northern California. This article describes the result of our smoking prevalence survey. Our Indian-specific program combines the physician's anti-smoking message with the efforts of Indian Community Health Representatives, who have access to the Indian patients' families and communities. The study sites consist of 4 urban and 14 rural American Indian clinics in Northern California. This article reports on the results of the smoking prevalence study conducted in the first phase of the project.

METHODS

A total of 1,369 adult Northern California Indian patients at 18 Indian health clinics completed a questionnaire designed to assess smoking rates and patterns as well as health problems. Participants were adult American Indians attending 1 of 18 Indian health care clinics in Northern California during 1991. The participants included patients waiting for appointments with the clinic physician, dentist, and nurses.

RESULTS

Forty percent (37.35, 42.64; 95% confidence interval) of the adult population in the sample smoke cigarettes; they hold lenient attitudes toward smoking and began smoking at an early age. These patients rate obesity as the No. 1 health problem, followed by high blood pressure, arthritis/rheumatism, and problems with alcohol. The survey also found that the highest smoking rate was among the Sioux (62%), a non-California tribe. This was followed by high rates among native California tribes: Maidu (46%), Pit River (39%), Pomo (38%), Hupa (37%), and Yurok (32%).