In the field of pre-eclampsia, very few cost-effectiveness studies have been performed. |
Because of substantial variations in the aims and results of these studies, no unequivocal conclusions can be drawn as to what constitutes cost-effective care in pre-eclampsia. |
Limited data exist to support the cost effectiveness of biomarkers for pre-eclampsia. |
1 Introduction
2 Methods
2.1 Search Strategy
2.2 Study Selection and Data Extraction
2.3 Quality of Reporting
3 Results
3.1 Systematic Search
Study | Study design | Analysis | ||||||
---|---|---|---|---|---|---|---|---|
Method and perspective | Perspective | Alternatives compared | Time horizon | Discount rates (%) | Sensitivity analysis | Parameters in the sensitivity analysis | ||
Costs | Effects | |||||||
Screening and diagnosis | ||||||||
Shmueli [27] | Decision tree | Payer | No screening versus screening for placental protein-13, placental growth factor and uterine artery Doppler pulsatility index | 30 years | 3 | 3 | Best- and worst-case scenarios | False positive rate, test cost, pre-eclampsia prevalence, test’s detection rate, effectiveness of preventive measures (measured as the proportion of women whose pre-eclampsia was not prevented by the preventive procedures) |
Meads [26] | Decision tree | Health care decision maker | No intervention versus intervention (in a wide range of different testing and treatment options) | NR | NR | NR | Probabilistic sensitivity analysis | Sensitivity and specificity of the test, prevalence rates, cost of pre-eclampsia |
Hadker [25] | Decision tree | UK health care payer | Standard pre-eclampsia diagnostic practice versus standard practice + novel pre-eclampsia test using biomarkers | NR | NA | NA | Univariate | Pre-eclampsia incidence rate, sensitivity of current tests, specificity of current tests, proportion of patients stratified as being at high risk of pre-eclampsia, cost of the novel pre-eclampsia test |
Treatment | ||||||||
Vijgen [29] | Trial-based CEA | Societal | Labour induction compared with expectant monitoring in women with pre-eclampsia at term | 1 year | NA | NA | Univariate | Labour and operating theatre costs, delivery costs, antepartum admission costs, neonatal ward admission costs, no separation in admission phase, values of admissions using lower/higher unit costs |
Simon [28] | Trial-based CEA | Treatment provider (hospital) | Magnesium sulphate for pre-eclampsia in 3 categories of countries grouped by GNI | <1 year | NA | NA | Univariate | Severity of pre-eclampsia, relative risk of pre-eclampsia, cost of magnesium sulphate |
Blackwell [30] | Decision tree | NR | Seizure prophylaxis with magnesium sulphate versus control group with no prophylaxis | 30 years | 3 | 0 | Univariate | Incidence of pre-eclampsia, incidence of severe pre-eclampsia, seizure rate with severe pre-eclampsia, seizure rate with mild pre-eclampsia, non-preventable seizure rate, mortality from eclampsia, efficacy of magnesium sulphate |
Study | Categories of included costs | Currency, price year |
---|---|---|
Screening and diagnosis | ||
Shmueli [27] | Screening test cost, supplement and medication cost, cost of visit frequency, cost of prenatal care, pre-delivery hospitalization, maternal and neonatal costs, offspring’s lifetime costs considering 30-year follow-up | Price year not mentioned |
Meads [26] | Test costs (body mass index measurements, maternal serum α-fetoprotein, cellular fibronectin, total fibronectin, fetal DNA, maternal serum human chorionic gonadotropin, serum unconjugated oestriol, serum uric acid, urinary calcium excretion, urinary calcium creatinine ratio, total proteinuria, albuminuria, microalbuminuria, albumin/creatinine ratio, Doppler examinations), treatment costs (antioxidants, calcium, garlic, magnesium, fish oils, medications [antihypertensive, antiplatelet, diuretic, nitric oxide, progesterone]), intervention costs, pre-eclampsia costs (including all hospital costs for mother and baby, without costs of normal delivery) | GBP, 2005–2006 |
Hadker [25] | Pre-eclampsia assessment costs, drug costs, pre-eclampsia management costs (physician office visits, physical exams, regular blood pressure checks, blood and urine tests and cardiotocography, as well as hospital stays for day assessments, intensive care, inpatient monitoring and delivery or termination of pregnancy), cost of the novel test, and cost of all testing | Price year not mentioned |
Treatment | ||
Vijgen [29] | Direct medical costs: hospital stay (mother and child), specialist care, outpatient visit, psychologist, midwife, general practitioner, paramedical, home care, day care, induction methods, medications (antihypertensive medication and antibiotics, analgesics during labour), neonatal monitoring, operation room, labour room. Direct non-medical costs: modes of travelling to hospital and use of informal care given by partner or family. Indirect medical costs: sick leave from work | EUR, 2007 |
Simon [28] | Total cost was calculated as the sum of treatment and other costs. Treatment cost included magnesium sulphate and its administration (staffing, equipment, consumables). Other costs covered all other aspects of hospital care in the trial, such as treating pre-eclampsia, eclampsia, and side effects of magnesium sulphate treatment; and costs of antenatal and postnatal ward stay, high dependency and/or intensive care, artificial ventilation, delivery and medication for the mother and the costs of the hospital stay, neonatal intensive care and artificial ventilation for the baby | USD, 2001 |
Blackwell [30] | Drug cost, pharmacy personnel time charges | Price year not mentioned |
Study | Main findings |
---|---|
Screening and diagnosis approaches | |
Shmueli [27] | From a payer perspective, screening for pre-eclampsia is cost effective under various scenarios The incremental cost per pre-eclampsia case averted is $68,973 (prevalence 1.7 %) Early screening: $19,491 per QALY gained (prevalence 1.7 %) With a test cost of $115, the total cost until discharge with/without screening is equal; at a prevalence of 3%, screening is cheaper |
Meads [26] | From a decision maker viewpoint, giving calcium supplementation to all pregnant women (‘no test/calcium all)’ without any initial testing is the most effective ‘test/treatment’ combination |
Hadker [25] | The model estimated that the costs of a typical pregnancy are $2919 per patient when the new test is used, as compared with $4468 without the test (standard practice); this represents savings of $1549 per pregnant woman; the savings are attributed to the new test’s improved accuracy |
Treatment approaches | |
Vijgen [29] | From a societal point of view, induction of delivery is cost effective compared with expectant monitoring in term pre-eclampsia; induction does not result in a higher rate of caesarean section, while fewer patients progress to severe disease |
Simon [28] | From a hospital perspective, use of magnesium sulphate prevents more cases of eclampsia in low-GNI countries than in high-GNI countries High-GNI countries: $28,335 per case of eclampsia prevented Middle-GNI countries: $3,305 per case of eclampsia prevented Low-GNI countries: $609 per case of eclampsia prevented Also, treating only severe cases of pre-eclampsia substantially lowers the ICER, i.e. has a more favourable cost-to-effect ratio |
Blackwell [30] | Universal prophylaxis using magnesium sulphate for all women with pre-eclampsia is cost effective compared with the strategy of treating only those with severe disease; ICER for universal compared with selected strategy: $13,356 per seizure prevented and $626,782 per death averted, which is considered cost effective assuming 1 death averted saves on average 30 life-years and given a threshold of $50,000 per life-year gained |
3.2 Summary of Included Studies
3.2.1 Studies on Screening and Diagnosis
3.2.2 Studies on Treatment
3.3 Assessment of Quality of Reporting
CHEERS section/item | Item no. | References | Recommendation for BIA reporting format | Reference | ||||
---|---|---|---|---|---|---|---|---|
Shmueli [27] | Meads [26] | Vijgen [29] | Simon [28] | Blackwell [30] | Hadker [25] | |||
Title and abstract | ||||||||
Title | 1 | Y | Y | Y | Y | Y | Title | Y |
Abstract | 2 | Y | Y | Y | Y | P | Abstract | Y |
Introduction | ||||||||
Background and objectives | 3 | Y | Y | Y | Y | Y | Epidemiology and treatment | Y |
Clinical impact | Y | |||||||
Economic impact | Y | |||||||
Technology details | Y | |||||||
Choice of comparator | Y | |||||||
Methods | ||||||||
Target population and subgroups | 4 | Y | Y | Y | Y | Y | Patient population | Y |
Setting and location | 5 | Y | Y | Y | Y | Y | Technology mix | Y |
Study perspective | 6 | Y | Y | Y | Y | N | Time horizon | N |
Comparators | 7 | Y | Y | Y | Y | Y | Perspective and target audience | Y |
Time horizon | 8 | Y | N | Y | Y | Y | Model description | Y |
Discount rate | 9 | Y | N | NA | NA | P | Input data: | |
Choice of health outcomes | 10 | Y | Y | Y | Y | Y | Data sources | P |
Measurement of effectiveness | 11a | NA | NA | P | P | NA | Data collection | P |
11b | P | Y | NA | NA | P | Analysis | Y | |
Measurement and valuation of preference based outcomes | 12 | P | P | P | P | P | ||
Estimating resources and costs | 13a | NA | NA | Y | P | NA | ||
13b | P | Y | NA | NA | P | |||
Currency, price date and conversion | 14 | P | Y | Y | Y | P | ||
Choice of model | 15 | P | P | NA | NA | P | ||
Assumptions | 16 | Y | Y | NA | NA | Y | ||
Analytical methods | 17 | P | P | P | P | P | ||
Results | ||||||||
Study parameters | 18 | Y | Y | Y | P | Y | Incremental budget impact | Y |
Incremental costs and outcomes | 19 | Y | Y | P | Y | Y | Sensitivity analysis | Y |
Characterizing uncertainty | 20a | NA | NA | Y | P | NA | Inclusion of graphics: | |
20b | Y | Y | NA | NA | Y | Figure of the model | Y | |
Characterizing heterogeneity | 21 | Y | Y | NA | NA | Y | Table of assumptions | Y |
Tables of inputs and outputs | Y | |||||||
Schematic representation of sensitivity analysis | P | |||||||
Discussion | ||||||||
Study findings, limitations, generalizability and current knowledge | 22 | Y | Y | P | P | Y | ||
Other | ||||||||
Source of funding | 23 | Y | Y | Y | Y | N | ||
Conflict of interest | 24 | N | Y | Y | N | N |