Uterine aspiration: From OR to office

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2 Office-based procedures are less expensive

There has been a trend in recent decades to obtain cost savings by moving appropriately selected gynecologic procedures from the operative suite to the outpatient setting. Because of MVA’s minimal up-front and ongoing costs, office-based suction aspiration is one of the most cost-effective procedures performed in the outpatient setting.

Dalton and colleagues, for example, demonstrated that in women diagnosed with early pregnancy failure, suction curettage is 50% less expensive when performed in the office as compared to in the operating suite.6 Likewise, in a cohort of patients who presented to the emergency department with an incomplete abortion, Blumenthal and colleagues showed a 41% procedural cost reduction by offering D&C in the outpatient setting instead of the OR.7 Waiting times and mean procedure times also were reduced by nearly half.

Recent studies have broadened cost analyses beyond the comparison of inpatient versus outpatient procedures. A multicenter trial of women with first-trimester pregnancy failure compared the costs of medication management with those of surgical procedures; as expected, the cost of D&C in the OR was significantly more expensive than medication management.8 However, MVA in the office was less expensive than medication management, due largely to the increased cost of managing medication failures.

In addition, a recent, well-designed decision model study demonstrated that offering women with early pregnancy failure a greater array of management options decreases costs.9 The study compared the costs when women were offered the most common options, expectant management or uterine evacuation in the OR, versus the costs when additional options were also offered. When options were expanded to include medication management and MVA in the office, costs decreased by nearly 20% overall.9

3 Office-based procedures are more patient centered

The benefits of surgical management of an early pregnancy failure include very high success rates (98%) and convenient timing. Among women who elect surgical management, a desire to expedite the process in a predictable fashion is a common factor in their decision.10,11 It is unsurprising then that 68% of patients will select an office-based procedure if they do not perceive that the clinician has a setting preference.6

When surgical management is performed in the OR, scheduling delays are common. Such delays can be clinically important: Women progressing to a miscarriage while awaiting surgical treatment may be at risk for urgent, unplanned interval procedures for incomplete abortion, and they may be dissatisfied with the inability to access the desired management. While women are highly satisfied after treatment for early pregnancy failure in general,6 OR treatment can cause dissatisfaction because patients miss more work days or need assistance at home.12 In a cross-sectional study, patients who elected office-based aspiration reported less delay to treatment (less than 2 hours) compared with women who elected OR procedures (more than 12 hours), and shorter time to procedure initiation was a satisfier.13

Women also note fear of the hospital setting and general anesthesia, and they tend to see hospital-based services as more invasive.11 Clinicians can offer anesthesia in the outpatient setting with nonsteroidal anti-inflammatory medications and a paracervical block, oral sedation with an anxiolytic, or in some cases intravenous (IV) sedation with conscious sedation.

Continue to: Our process for office-based uterine aspiration

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