Economic analyses in obstetrics and gynecology: a methodologic evaluation of the literature

Challenges in economic evaluations in obstetric care: a scoping review and expert opinion

OBJECTIVE

The aim of this study is to identify items of economic evaluation guidelines that are frequently not complied within obstetric economic evaluations and to search for reasons for non-adherence.

DESIGN

Scoping review and qualitative study.

SETTING

Literature on economic evaluations in obstetric care and interviews with experts.

POPULATION OR SAMPLE

The sample included 229 scientific articles and five experts.

METHODS

A systematic literature search was performed. All types of literature about economic evaluations in obstetric care were included. The adherence to guidelines was assessed and articles were qualitatively analysed on additional information about reasons for non-adherence. Issues that arose from the scoping review were discussed with experts.

MAIN OUTCOME MEASURES

Adherence to guideline items of the included economic evaluations studies. Analytical themes describing reasons for non-adherence, resulting from qualitative analysis of articles and interviews with experts.

RESULTS

A total of 184 economic evaluations and 45 other type of articles were included. Guideline items frequently not complied with were time horizon, type of economic evaluation and effect measure. Reasons for non-adherence had to do with paucity of long-term health data and assessing and combining outcomes for mother and child resulting from obstetric interventions.

CONCLUSIONS

This study identified items of guidelines that are frequently not complied with and the reasons behind this. The results are a starting point for a broad consensus building on how to deal with these challenges that can result in special guidance for the conduct of economic evaluations in obstetric care.

TWEETABLE ABSTRACT

Non-adherence to guidelines in obstetric economic evaluation studies: the difficulties in detail.

Cost-Effectiveness of Old and New Technologies for Aneuploidy Screening

Cost-effectiveness analyses allow assessment of whether marginal gains from new technology are worth increased costs. Several studies have examined cost-effectiveness of Down syndrome (DS) screening and found it to be cost-effective. Noninvasive prenatal screening also appears to be cost-effective among high-risk women with respect to DS screening, but not for the general population. Chromosomal microarray (CMA) is a genetic sequencing method superior to but more expensive than karyotype. In light of CMAs greater ability to detect genetic abnormalities, it is cost-effective when used for prenatal diagnosis of an anomalous fetus. This article covers methodology and salient issues of cost-effectiveness.

Methodological reviews of economic evaluations in health care: what do they target?

INTRODUCTION AND OBJECTIVES

An increasing number of published studies of economic evaluations of health technologies have been reviewed and summarized with different purposes, among them to facilitate decision-making processes. These reviews have covered different aspects of economic evaluations, using a variety of methodological approaches. The aim of this study is to analyze the methodological characteristics of the reviews of economic evaluations in health care, published during the period 1990-2010, to identify their main features and the potential missing elements. This may help to develop a common procedure for elaborating these kinds of reviews.

METHODS

We performed systematic searches in electronic databases (Scopus, Medline and PubMed) of methodological reviews published in English, period 1990-2010. We selected the articles whose main purpose was to review and assess the methodology applied in the economic evaluation studies. We classified the data according to the study objectives, period of the review, number of reviewed studies, methodological and non-methodological items assessed, medical specialty, type of disease and technology, databases used for the review and their main conclusions. We performed a descriptive statistical analysis and checked how generalizability issues were considered in the reviews.

RESULTS

We identified 76 methodological reviews, 42 published in the period 1990-2001 and 34 during 2002-2010. The items assessed most frequently (by 70% of the reviews) were perspective, type of economic study, uncertainty and discounting. The reviews also described the type of intervention and disease, funding sources, country in which the evaluation took place, type of journal and author's characteristics. Regarding the intertemporal comparison, higher frequencies were found in the second period for two key methodological items: the source of effectiveness data and the models used in the studies. However, the generalizability issues that apparently are creating a growing interest in the economic evaluation literature did not receive as much attention in the reviews of the second period. The remaining items showed similar frequencies in both periods.

CONCLUSIONS

Increasingly more reviews of economic evaluation studies aim to analyze the application of methodological principles, and offer summaries of papers classified by either diseases or health technologies. These reviews are useful for finding literature trends, aims of studies and possible deficiencies in the implementation of methods of specific health interventions. As no significant methodological improvement was clearly detected in the two periods analyzed, it would be convenient to pay more attention to the methodological aspects of the reviews.

Costs and cost-effectiveness of periviable care

With increasing concerns regarding rapidly expanding healthcare costs, cost-effectiveness analysis allows assessment of whether marginal gains from new technology are worth the increased costs. Particular methodologic issues related to cost and cost-effectiveness analysis in the area of neonatal and periviable care include how costs are estimated, such as the use of charges and whether long-term costs are included; the challenges of measuring utilities; and whether to use a maternal, neonatal, or dual perspective in such analyses. A number of studies over the past three decades have examined the costs and the cost-effectiveness of neonatal and periviable care. Broadly, while neonatal care is costly, it is also cost effective as it produces both life-years and quality-adjusted life-years (QALYs). However, as the gestational age of the neonate decreases, the costs increase and the cost-effectiveness threshold is harder to achieve. In the periviable range of gestational age (22-24 weeks of gestation), whether the care is cost effective is questionable and is dependent on the perspective. Understanding the methodology and salient issues of cost-effectiveness analysis is critical for researchers, editors, and clinicians to accurately interpret results of the growing body of cost-effectiveness studies related to the care of periviable pregnancies and neonates.

Traumatic brain injury: methodological approaches to estimate health and economic outcomes

The effort to standardize the methodology and adherence to recommended principles for all economic evaluations has been emphasized in medical literature. The objective of this review is to examine whether economic evaluations in traumatic brain injury (TBI) research have been compliant with existing guidelines. Medline search was performed between January 1, 1995 and August 11, 2012. All original TBI-related full economic evaluations were included in the study. Two authors independently rated each study's methodology and data presentation to determine compliance to the 10 methodological principles recommended by Blackmore et al. Descriptive analysis was used to summarize the data. Inter-rater reliability was assessed with Kappa statistics. A total of 28 studies met the inclusion criteria. Eighteen of these studies described cost-effectiveness, seven cost-benefit, and three cost-utility analyses. The results showed a rapid growth in the number of published articles on the economic impact of TBI since 2000 and an improvement in their methodological quality. However, overall compliance with recommended methodological principles of TBI-related economic evaluation has been deficient. On average, about six of the 10 criteria were followed in these publications, and only two articles met all 10 criteria. These findings call for an increased awareness of the methodological standards that should be followed by investigators both in performance of economic evaluation and in reviews of evaluation reports prior to publication. The results also suggest that all economic evaluations should be made by following the guidelines within a conceptual framework, in order to facilitate evidence-based practices in the field of TBI.

Cost analysis of prenatal care using the activity-based costing model: a pilot study

The cost of prenatal care in a private nurse-midwifery practice was examined using the activity-based costing system. Findings suggest that the activities of the nurse-midwife (the health care provider) constitute the major cost driver of this practice and that the model of care and associated, time-related activities influence the cost. This pilot study information will be used in the development of a comparative study of prenatal care, client education, and self care.

Economic evaluations of single- versus double-embryo transfer in IVF

Multiple pregnancies lead to complications and induce high costs. The most successful way to decrease multiple pregnancies in IVF is to transfer only one embryo, which might reduce the efficacy of treatment. The objective of this review is to determine which embryo-transfer policy is most cost-effective: elective single-embryo transfer (eSET) or double-embryo transfer (DET). Several databases were searched for (cost* or econ*) and (single embryo* or double embryo* or one embryo* or two embryo* or elect* embryo or multip* embryo*). On the basis of five exclusion criteria, titles and abstracts were screened by two individual reviewers. The remaining papers were read for further selection, and data were extracted from the selected studies. A total of 496 titles were identified through the searches and resulted in the selection of one observational study and three randomized studies. Study characteristics, total costs and probability of live births were extracted. Besides this, cost-effectiveness and incremental cost-effectiveness were derived. It can be concluded that DET is the most expensive strategy. DET is also most effective if performed in one fresh cycle. eSET is only preferred from a cost-effectiveness point of view when performed in good prognosis patients and when frozen/thawed cycles are included. If frozen/thawed cycles are excluded, the choice between eSET and DET depends on how much society is willing to pay for one extra successful pregnancy.

Cost-Effectiveness Analysis of Prenatal Diagnosis: Methodological Issues and Concerns

With increasing concerns regarding rapidly expanding health care costs, cost-effectiveness analysis (CEA) provides a methodology to assess whether marginal gains from new technology are worth the increased costs. In the arena of prenatal diagnosis, particular methodological and ethical concerns include whether the effects of such testing on individuals other than the patient are included, how termination of pregnancy is included in the models, redundancy of screening and diagnostic methods, and how screening may reassure or cause anxiety in patients depending on their results. The existing literature has demonstrated cost-effectiveness of screening and diagnosis of neural tube defects, Down syndrome, and cystic fibrosis in the general population. Screening for genetic disorders which have a higher prevalence among particular groups has also been shown to be cost effective, including diseases such as hemoglobinopathies and Tay-Sachs disease. Understanding the methodology and salient issues of CEA is critical for researchers, editors and clinicians to accurately interpret results of the growing body of cost-effectiveness studies in prenatal diagnosis.

Design, execution, interpretation, and reporting of economic evaluation studies in obstetrics

OBJECTIVE

The purpose of this article was to propose guidelines for the design, execution, interpretation, and reporting of economic evaluation studies in obstetrics. Study design We performed a PubMed search of economic evaluation articles to identify those articles that deal with the quality of published economic evaluation studies, the development of guidelines, and the development of checklists/guidelines for the reporting of economic evaluation studies. All other articles were excluded from the review.

RESULTS

We identified 160 articles. We included 8 articles in our review that reported on the quality of published economic analyses, 12 articles that reported on guidelines, and 3 articles that reported on checklists/guidelines that are used by journals. There were 2 articles that dealt with the quality of published economic evaluations in obstetrics and gynecology, both of which showed less than optimal quality. There were only 4 articles that provided some general guidelines for the reporting of economic evaluations in obstetrics and gynecology. We found no articles on any checklist/guidelines for the reporting of economic evaluation studies in obstetrics and gynecology.

CONCLUSION

There is a need to improve the design, execution, interpretation, and reporting of economic evaluation studies in obstetrics.

Cost-effectiveness analyses in gynecologic oncology: methodological quality and trends

OBJECTIVES

To evaluate methodological quality and trends of cost-effectiveness analyses (CEA) published in gynecologic oncology.

METHODS

A medical literature search of articles from 1966 through 2002 was performed to identify original, English-language articles that included economic analyses in gynecologic oncology. We included articles that were cost-effectiveness or cost-benefit analyses or performed these analyses as part of their study. Ten methodological principles that should be incorporated in CEAs were assessed for each study. Each article was given a score of 0, 1, or 2 for each of the 10 methodological principles (max score = 20). Data were analyzed using the Student t test, ANOVA, and linear regression.

RESULTS

We screened 693 articles to identify 68 that met our inclusion criteria. The articles focused on cervical cancer (n = 53; 78%), ovarian cancer (n = 11; 16%), uterine cancer (n = 2; 3%), and general perioperative care (n = 2; 3%). The mean (+/-SD) methodological principle score was 16.1 (+/-4.1) and we observed a significant improvement in the total score over time (P = 0.01). Primary CEA's (CEA identified as the objective of the study) were of higher quality than secondary CEA's (primary objective of the study was not CEA but CEA was included in the study; total scores 18.2 vs. 11.6, respectively; P<0.0001). Studies with at least one investigator in public health or healthcare economies also had higher quality (mean total score 17.7 vs. 15.2; P=0.006). The most common limitations of published CEAs were in methodology or presentation of incremental analyses, sensitivity analyses, and discounting.

CONCLUSIONS

Cost-effectiveness analyses in gynecologic oncology showed significant improvement in quality over the last two decades. Despite this progress, methodological improvement is still needed in the areas of incremental comparisons and sensitivity analysis. Understanding the methodology of cost-effectiveness analysis is critical for researchers, editors, and readers to accurately interpret results of the growing body of CEA articles.

Economic evaluation in obstetrics and gynaecology: principles and practice

Greater attention in health care over the last 2 decades has been placed on determining how best to spend the resources available. Economic evaluation is a commonly used tool to compare health-care services and treatments on the basis of costs and benefits. However, the principles on which economic evaluations are based are not well understood, and guidelines for conducting such evaluations in practice are often not followed. This paper describes the overarching principle of opportunity cost, and highlights the implication that decision-making in health care should necessarily be based on both costs and benefits. Two notions of efficiency, technical and allocative, are also presented, and the important point is made that the specific type of economic evaluation chosen must be based not on the unit of benefit in the given study, as is commonly done, but rather on the type of efficiency being addressed. The 3 primary types of economic evaluation are outlined, and a common pitfall in economic evaluation, the incremental cost-effectiveness ratio, is critiqued. Finally, a number of methodological considerations when conducting economic evaluations in practice are presented.

Paying for prevention standardizing the measurement of the value of health care interventions

It is not clear if spending more on tests that enhance the accuracy of Pap smears would lead to a greater reduction in cancer incidence than if the money were spent to include a greater proportion of women in primary screening. The cost effectiveness of tests beyond the Pap smear has not been clearly demonstrated. There is the question of whether cervical cancer incidence can be decreased more by improving the tests for patients who are already screened or by improving access to the unscreened population. Cervical cancer screening represents only one of many public health issues competing for resources. Given that there are choices to be made, the optimal yardstick against which all resource-competing programs are measured should be marginal benefit versus marginal cost.

Accuracy of terminology and methodology in economic analyses in otolaryngology

OBJECTIVE

Economic studies increasingly guide health care resource allocation decisions. Because rigorous adherence to accepted definitions and research techniques is critical to ensure accuracy, we evaluated the terminology and methods of otolaryngology economic analyses.

STUDY DESIGN

A total of 71 articles published from 1990 to 1999 in 6 peer-reviewed otolaryngology journals with terms such as "cost-effective" in their title or representing economic analyses were reviewed for terminology and use of established methodology guidelines.

RESULTS

Over half (35 of 66) of terms such as "cost-effective" were used incorrectly, and 60% of articles (39 of 64) confused "charge" and "cost" data. Eleven percent (7 of 64) of papers specified the perspective of their analysis. About half (17 of 30) reported a summary measure such as a cost-effectiveness ratio. Only one third (23 of 63) performed sensitivity analyses.

CONCLUSION

Adherence to accepted definitions and research methods is inconsistent, although we did note moderate improvements in making the distinction between costs and charges, defining of study perspective, and performing sensitivity analysis.

SIGNIFICANCE

Greater attention to both terminology and methodology can enhance the quality of economic analyses and ultimately improve certain resource allocation decisions.

Measuring cost-effectiveness of surgical procedures

Our review of CEA of surgical procedures suggests that much of the existing cost analysis literature does not adhere to basic recommended analytic guidelines. However, those authors who specifically planned to perform a CEA analysis met all or nearly all of the methodologic principles (Table 1). Investigators who conduct CEA are strongly encouraged to use the many outstanding methodologic reviews for CEA. An example of threshold analysis was presented by Gray et al in their CEA of laparoscopy versus laparotomy for the treatment of ectopic pregnancy. They calculated that cost per successful treatment would be equal between the two strategies at an initial failure rate of 32% for laparoscopy (compared with their baseline value of 19%). This type of analysis is helpful, in addition to sensitivity analyses, to identify the value of a variable that results in an equal outcome. In the only cost-utility analysis performed on gynecologic surgery, Sculpher studied the trade-offs between a less invasive, less costly procedure (transcervical resection of the endometrium) with a more invasive, more costly, and more effective procedure (abdominal hysterectomy) to treat menorrhagia. Hysterectomy resulted in an incremental cost of 1,500 British pounds per QALY during 2 years of follow-up. This is much less than the range of $30,000 to $100,000 that represents a currently acceptable C/E ratio. Grover et al evaluated the cost-effectiveness of performing a concurrent hysterectomy in women undergoing bilateral salpingo-oophorectomy. They observed that in 45-year-old women, the additional concurrent procedure dominated the alternative strategy of bilateral salpingo-oophorectomy, being both less expensive and increasing average life expectancy. The concurrent hysterectomy strategy also dominated for women aged 55, but both with less cost-savings and gains in life expectancy compared with 45-year-old women. Selecting an appropriate time frame for the analysis is difficult and may dramatically affect the results of the analysis. The time frame should be long enough to measure all clinically relevant costs and benefits. For example, Kung et al compared the cost per cure of stress urinary incontinence of laparoscopic and open Burch procedures. The probability of cure after each procedure was estimated from a retrospective cohort of 62 women with a mean follow-up of 1.2 years for the laparoscopic Burch strategy and 2.7 years in the open Burch strategy. The authors found that the laparoscopic Burch dominated, with lower costs and a higher cure rate. However, the analysis would be more informative with much longer follow-up, because most women who undergo an incontinence procedure have a life expectancy far greater than 1 to 2 years. Ramsey et al performed an economic analysis to assess the long-term costs of behavioral therapy, pharmacotherapy, and surgical therapy used for stress urinary incontinence. They found that in the short-term, behavioral and pharmacotherapy were less costly. However, if life expectancy was equal to or greater than 3.5 years, surgical therapy was least costly. In many articles that evaluate the cost of managing ectopic pregnancy, only short-term costs of the procedures and follow-up visits are considered. Mol et al considered a longer time frame and also included the costs of infertility management based on the future probability of conception correlated with the different management strategies. Selection of an effectiveness measure after surgical intervention is often difficult and controversial. For benign disease, life years or QALYs will be minimally affected by a reasonably safe intervention. In the short-term, utility may be negatively affected by surgery and recovery. In longer-term analyses, these effects will be diluted by time and be negligible. Intermediate measures such as days of hospitalization averted or lives saved are often more appropriate for gynecologic interventions than are longer-term outcomes such as lif