Clinical and financial analyses of ectopic pregnancy management at a large health plan.

STUDY OBJECTIVE To compare three treatment options for ectopic pregnancy-laparotomy, laparoscopy, and methotrexate-including clinical aspects, costs, and reproductive outcomes. DESIGN Retrospective review of outpatient and inpatient records of all patients with a diagnosis of ectopic pregnancy insured by Fallon Community Health from 1990 to 1995. SETTING Multispecialty group practice and a university-affiliated private hospital. PATIENTS One hundred seven women treated for ectopic pregnancy. INTERVENTIONS Thirty-six women were treated by laparotomy, 58 by laparoscopy, and 13 by single-dose intramuscular methotrexate. Data from the chart review were analyzed to define differences among the three groups with respect to several predetermined outcome variables: initial symptoms, risk factors, human chorionic gonadotropin levels, size of ectopic gestation, procedure types, rupture rates, surgical outcomes and morbidity, failure rates, length of convalescence, reproductive outcomes, and costs. MEASUREMENTS AND MAIN RESULTS The incidence of ectopic pregnancy was 8.6/1000 reported pregnancies. Initially, 38% of surgical patients had laparoscopic treatment, but by 1995 the figure reached 100%. From 1994 to 1995, 13 (29%) of 45 pregnancies were treated with single-dose methotrexate. Compared with laparoscopy, length of stay was significantly longer for laparotomy (3.1 vs 1.3 days), as was recuperation time (2.4 vs 4.6 wks). Laparotomy had similar rates of total complications as laparoscopy (13.9% vs 10.3%). The rate of treatment failures (persistent trophoblastic activity) were 2.7% and 3.4%, respectively. The rate of persistence for laparoscopic salpingostomy was 6.1%. Methotrexate therapy resulted in no tubal ruptures or treatment failures. Two of 13 women required a second injection. The only complication of methotrexate therapy was mild leukocytopenia in one patient. Total charges were similar for laparotomy and laparoscopy ($6720 vs $6840). Outpatient methotrexate therapy cost significantly less than the two surgical procedures (average $818/case, p < 0.001). Laparotomy resulted in similar intrauterine pregnancy rates as laparoscopy (66% vs 77%), and similar repeat tubal pregnancy rates (17% vs 7%). CONCLUSION The results of this study support laparoscopy and methotrexate as efficacious, safe, and cost effective for the treatment of ectopic pregnancy compared with laparotomy. Reproductive outcomes were similar among the three groups.