Cost-effectiveness of history-indicated cerclage vs cervical length assessment for prevention of preterm birth
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Published on: September 13, 2022
Lea Nehme1, Jim C Huang2, Alfred Abuhamad1
1Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA.
Insights
Transvaginal ultrasound cervical length assessment is more cost-effective than history-indicated cerclage for preventing recurrent preterm birth. The ultrasound strategy offers better maternal and neonatal outcomes at a lower lifetime cost.
Area of Science:
- Maternal-fetal medicine
- Health economics
- Neonatal care
Background:
- Preterm birth is a leading cause of neonatal morbidity and mortality.
- A history of preterm birth is a significant risk factor for recurrence.
- Preterm delivery imposes a substantial burden on healthcare systems.
Purpose of the Study:
- To compare the cost-effectiveness of two strategies for preventing recurrent preterm birth: history-indicated cerclage versus transvaginal ultrasound cervical length assessment.
- To evaluate the net monetary benefit from both maternal and neonatal perspectives.
Main Methods:
- A decision analysis model was developed to compare the two strategies.
- Lifetime costs, including cerclage, ultrasounds, maternal and neonatal care, and disability, were analyzed.
- Quality-adjusted life years (QALYs) were used to measure effectiveness.
- Sensitivity analyses and Monte Carlo simulations were performed to assess robustness.
Main Results:
- The history-indicated cerclage strategy was more costly ($85,038 vs $70,155) and less effective (maternal: 26.74 QALYs vs 26.78 QALYs; neonatal: 28.91 QALYs vs 29.06 QALYs).
- The ultrasound strategy yielded a higher net monetary benefit.
- Transvaginal ultrasound cervical length assessment was the preferred strategy in 84% (maternal) and 88% (neonatal) of simulation trials.
Conclusions:
- Transvaginal ultrasound cervical length assessment is a more cost-effective strategy than history-indicated cerclage for individuals with a history of preterm birth.
- The ultrasound approach offers superior maternal and neonatal outcomes with lower overall costs.
- This finding supports the adoption of ultrasound-based cervical length assessment for managing recurrent preterm birth risk.
Background:
Preterm birth is one of the major causes of neonatal morbidity and mortality. Preterm delivery is a large burden to our health care system, and a history of preterm birth is one of the most common risk factors for subsequent preterm birth.
Objective:
We sought to examine the cost-effectiveness of the history-indicated cerclage strategy compared with the transvaginal ultrasound cervical length assessment strategy in individuals with a history of preterm birth.
Study Design:
We developed a decision analysis model to compare history-indicated cerclage and cervical length assessment. The primary outcome was the net monetary benefit from a maternal and neonatal perspective of both strategies, defined as the value of an intervention with a known willingness to pay threshold for a unit of benefit. The time horizon was set to be a lifetime. Costs (in 2022 USD) included those for the cerclage, serial transvaginal ultrasounds, maternal care for admission, neonatal care, and severe disability. Probabilities, utilities, and costs were derived from the literature. A cost-effectiveness threshold was set at $100,000 per QALY (quality-adjusted life year). We first conducted 1-way sensitivity analyses with associated variables as sensitivity analyses. We then performed a probabilistic sensitivity analysis using Monte Carlo simulation with 1000 trials to test the robustness of the results in the setting of simultaneous changes in probabilities, costs, and utilities.
Results:
In our base-case analysis, the history-indicated cerclage strategy compared to transvaginal ultrasound cervical length assessment was associated with more cost ($85,038 vs $70,155), with slightly less effectiveness from the maternal perspective (26.74 QALY vs 26.78 QALY) and from the neonatal perspective (28.91 QALY vs 29.06 QALY), and with less maternal and neonatal net monetary benefit. Therefore, the history-indicated cerclage strategy was dominated. With the 1000 trials of Monte Carlo simulation, transvaginal ultrasound cervical length assessment was the preferred strategy 84% and 88% of the time from the maternal and neonatal perspectives, respectively.
Conclusion:
The history-indicated cerclage strategy was more expensive and slightly less effective than the transvaginal ultrasound cervical length assessment strategy with a lower net monetary benefit.
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