Cost-effectiveness analysis of carbetocin versus oxytocin for the prevention of postpartum hemorrhage following vaginal birth in the United Kingdom

Figures & data

Figure 1. Model diagram. *Mild/moderate PPH: blood loss of ≥500 ml and <1,000 ml. **Severe PPH: blood loss ≥1,000 ml.

Table 1. Clinical inputs.

	Oxytocin	Carbetocin	Source
Women experiencing a mild/moderate PPH event	9.20%	6.17%	Gallos^22
Women experiencing a severe PPH event	3.00%	2.61%
Women requiring additional uterotonic treatment	11.60%	5.20%
Women requiring blood transfusions	1.50%	1.20%
	No PPH	PPH
Maternal mortality due to PPH (per 100,000 maternities)	0	0.78	Knight^28

Table 2. Uterotonic treatment utilization inputs.

Administration of additional uterotonics (Su)^30:
Oxytocin 10 IU infusion (2 h)	0.82%
Oxytocin 10 IU infusion (4 h)	0.82%
Oxytocin 20 IU infusion (4 h)	0.82%
Oxytocin 30 IU infusion (4 h)	33.62%
Oxytocin 40 IU infusion (4 h)	45.92%
Misoprostol	6%
Ergometrine	6%
Ergometrine and Oxytocin	6%
Uterotonics for the treatment of PPH (Hollier-Hann)^18:
	Mild/moderate PPH	Severe PPH
Ergometrine and Oxytocin	30.00%	16.44%
Oxytocin	36.00%	23.29%
Carboprost	4.00%	23.29%
Ergometrine	20.00%	16.44%
Misoprostol	8.00%	20.55%
Carbetocin	2.00%	0.00%

Table 3. Resource utilization inputs.

	No PPH	Mild/moderate PPH	Severe PPH	Source
Length of stay (days)	1.30	1.91	3.55	Hollier-Hann^18
Women requiring a follow-up visit with a midwife	100%	100%	100%	van der Nelson^19
Women requiring a follow-up visit with a consultant	0.00%	2.90%	7.40%	van der Nelson^19
Additional staff required versus no PPH (no. of staff)				Richardson^20
Anesthetist	–	0.330	1.240
Obstetrician	–	0.142	0.714
Midwife	–	0.238	0.619
Junior doctor	–	0.762	1.140

Table 4. Cost inputs.

		Source
Drug acquisition costs (per unit)		MIMS^32
Oxytocin	£0.80
Carbetocin	£17.64
Misoprostol	£0.17
Ergometrine	£0.93
Ergometrine and Oxytocin	£1.38
Carboprost	£18.20
Saline	£1.06	van der Nelson^19
Staffing costs (per hour)		PSSRU^34
Nurse team manager	£56.00
Nurse team leader	£47.00
Day ward nurse	£38.00
24-h nurse	£38.00
Clinical support worker	£28.00
Midwife	£65.00
Foundation House Officer 1 (FY1)	£28.00
Foundation House Officer 2 (FY2)	£33.00
Specialty registrar	£47.00
Associate specialist	£108.00
Medical consultant	£109.00
Surgical consultant	£109.00
Additional costs
Fluid administration apparatus	£3.18	van der Nelson^19
Cost of operating theater	£1,060.61
High dependency unit (24 h stay)	£530.30
Unit of blood	£128.99	NHS^31
Hospital stay (per day)	£747.40	NHS^33, inflated to 2019
Post-natal midwife visit	£71.07	NHS^31
Post-natal obstetrician consultation	£142.82	NHS^31

Table 5. Utility inputs (Lee³⁵).

No PPH	0.790
Mild/moderate PPH	0.730
Severe PPH	0.540

Table 6. Distribution used for variables within each parameter category in the PSA.

Parameter category	Distribution
Women experiencing a mild/moderate PPH event	Dirichlet
Women experiencing a severe PPH event	Dirichlet
Women requiring additional uterotonic treatment	Beta
Women requiring blood transfusions	Beta
Maternal mortality due to PPH	Beta
Utilization of additional uterotonics*	Dirichlet
Utilization of uterotonics to treat PPH*	Dirichlet
Length of stay**	Normal
Women requiring a follow-up visit with a midwife**	Normal
Women requiring a follow-up visit with a consultant**	Beta
Additional staff required**	Normal
Drug acquisition costs	Not varied
Staffing costs	Normal
Additional costs	Normal
Utilities**	Beta

*Distribution did not vary by uterotonic administered.

**Distribution did not vary by whether a woman experienced a PPH event or PPH event severity.

Table 7. Base case cost, PPH events and QALY results following vaginal birth.

	Carbetocin	Oxytocin	Incremental
Per woman
Costs	£1,375	£1,430	−£55
Mild/Moderate PPH events	0.0617	0.0920	−0.0303
Severe PPH events	0.0261	0.0300	−0.0039
Total PPH events	0.0878	0.1220	−0.0342
QALYs	0.0646	0.0645	0.0001
Cost per cohort of 100 women
Mild/Moderate PPH	£2,709	£3,994	−£1,285
Severe PPH	£19,541	£22,479	−£2,938
Prophylactic treatment	£1,764	£160	£1,604
Retreatment	£257	£573	−£316
Recovery	£106,024	£108,567	−£2,543
Follow-up	£7,160	£7,177	−£17
Total costs	£137,455	£142,951	−£5,495

Figure 2. One-way sensitivity analysis tornado diagram.

Figure 3. Probabilistic sensitivity analysis scatter plot.

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