Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
Lancet Glob Health. 2019 Sep;7(9):e1280-e1286. doi: 10.1016/S2214-109X(19)30336-5.
There is ongoing debate on the clinical benefits of antibiotic prophylaxis for reducing pelvic infection after miscarriage surgery. We aimed to study the cost-effectiveness of antibiotic prophylaxis in the surgical management of miscarriage in low-income countries.
We did an incremental cost-effectiveness analysis using data from 3412 women recruited to the AIMS trial, a randomised, double-blind, placebo-controlled trial designed to evaluate the effectiveness of antibiotic prophylaxis in the surgical management of miscarriage in Malawi, Pakistan, Tanzania, and Uganda. Economic evaluation was done from a health-care-provider perspective on the basis of the outcome of cost per pelvic infection avoided within 2 weeks of surgery. Pelvic infection was broadly defined by the presence of clinical features or the clinically identified need to administer antibiotics. We used non-parametric bootstrapping and multilevel random effects models to estimate incremental mean costs and outcomes. Decision uncertainty was shown via cost-effectiveness acceptability frontiers. The AIMS trial is registered with the ISRCTN registry, number ISRCTN97143849.
Between June 2, 2014, and April 26, 2017, 3412 women were assigned to receive either antibiotic prophylaxis (1705 [50%] of 3412) or placebo (1707 [50%] of 3412) in the AIMS trial. 158 (5%) of 3412 women developed pelvic infection within 2 weeks of surgery, of whom 68 (43%) were in the antibiotic prophylaxis group and 90 (57%) in the placebo group. There is 97-98% probability that antibiotic prophylaxis is a cost-effective intervention at expected thresholds of willingness-to-pay per additional pelvic infection avoided. In terms of post-surgery antibiotics, the antibiotic prophylaxis group was US$0·27 (95% CI -0·49 to -0·05) less expensive per woman than the placebo group. A secondary analysis, a sensitivity analysis, and all subgroup analyses supported these findings. Antibiotic prophylaxis, if implemented routinely before miscarriage surgery, could translate to an annual total cost saving of up to $1·4 million across the four participating countries and up to $8·5 million across the two regions of sub-Saharan Africa and south Asia.
Antibiotic prophylaxis is more effective and less expensive than no antibiotic prophylaxis. Policy makers in various settings should be confident that antibiotic prophylaxis in miscarriage surgery is cost-effective.
UK Medical Research Council, Wellcome Trust, and the UK Department for International Development.
关于抗生素预防用药在减少流产手术后盆腔感染方面的临床获益，目前仍存在争议。我们旨在研究在中低收入国家，抗生素预防用药在流产手术管理中的成本效益。
我们对 3412 名妇女的资料进行了增量成本效益分析，这些妇女参加了 AIMS 试验，这是一项随机、双盲、安慰剂对照试验，旨在评估抗生素预防用药在马拉维、巴基斯坦、坦桑尼亚和乌干达的流产手术管理中的效果。从卫生保健提供者的角度，基于手术后 2 周内避免每例盆腔感染的成本，进行经济性评价。盆腔感染的定义较为宽泛，包括临床特征或临床确定需要使用抗生素。我们采用非参数自举法和多级随机效应模型，来估计增量平均成本和结果。通过成本效益可接受性边界图来展示决策不确定性。AIMS 试验在 ISRCTN 注册中心注册，编号为 ISRCTN97143849。
2014 年 6 月 2 日至 2017 年 4 月 26 日期间，3412 名妇女被分配接受抗生素预防（3412 名中的 1705 名，占 50%）或安慰剂（3412 名中的 1707 名，占 50%）。3412 名妇女中，有 158 名（5%）在手术后 2 周内发生盆腔感染，其中 68 名（43%）在抗生素预防组，90 名（57%）在安慰剂组。在预期的每例避免的盆腔感染额外支付意愿的阈值下，抗生素预防很可能是一种具有成本效益的干预措施。在术后使用抗生素方面，与安慰剂组相比，抗生素预防组每名妇女的成本要低 0.27 美元（95%CI-0.49 至-0.05）。一项次要分析、敏感性分析和所有亚组分析都支持这些发现。如果在流产手术前常规使用抗生素预防，在这四个参与国家，每年可总共节省高达 140 万美元，在撒哈拉以南非洲和南亚这两个地区，每年可节省高达 850 万美元。
抗生素预防比不使用抗生素预防更有效且成本更低。在不同环境下的决策者应坚信，流产手术中使用抗生素预防具有成本效益。
英国医学研究理事会、惠康信托基金会和英国国际发展部。
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