Cost-effectiveness analysis of implementing screening on preterm pre-eclampsia at first trimester of pregnancy in Germany and Switzerland

Implementation of the new S2e guideline "first-trimester diagnostics and therapy @ 11-13 + 6 weeks of pregnancy": a survey in outpatient practices

PURPOSE

The objective of this study was to ascertain the awareness of the guideline since its publication, its impact on outpatient approaches, implementation, and any alterations to daily practices.

METHODS

A questionnaire containing 36 items pertaining to first-trimester diagnostics and therapy was distributed to certificated gynecologists specializing in screening in Lower Saxony and East Westphalia. The questionnaire contained both multiple choice and open questions. The questions addressed information about the structure of the study population, the presentation of mandatory and optionally recommended settings for early structured fetal malformation diagnostics and echocardiography, the basic treatment regimens for first-trimester screening, and the utilization and management of non-invasive fetal test systems.

RESULTS

92.1% of the 38 respondents were familiar with the guideline at the time of the survey. The mandatory recommended structures are consistently displayed by 92.1-100% of participants, the remaining optional settings are displayed ranging from 7.9 to 55.3%. The majority of participants consider the combination of biochemistry and ultrasound markers as an indication for invasive diagnostics. 71.1% offer a non-invasive prenatal test in parallel with the first-trimester screening, while 65.8% of participants offer screening for preeclampsia. It was indicated by the participants that the publication of the guideline tended to have an impact on the outpatient approach to first-trimester screening. On average, the participants have modified their practice in first-trimester screening since the guideline was published.

CONCLUSION

The recommendations outlined in the guideline have achieved a high level of awareness among most outpatient specialists, thereby exerting a notable influence on the formulation of treatment algorithms. In the contemporary context of patient-centered medicine and rapidly evolving healthcare, guidelines have emerged as a pivotal instrument for the effective aggregation of information.

Neonatal cost savings in hypertensive disorders of pregnancy: Economic evaluation of the sFlt-1/PlGF test with real world implementation of biomarkers

BACKGROUND

Preeclampsia is a key cause of prematurity in the U.S. and incurs significant healthcare costs. An imbalance between soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) predicts severe preeclampsia and aids in its management.

OBJECTIVE

This study aimed to assess the cost-effectiveness of the sFlt-1/PlGF test as an addition to standard care for patients at risk of developing preeclampsia.

STUDY DESIGN

A decision tree analysis was conducted to assess the cost effectiveness of the ratio test in the United States, using data from Preeclampsia Risk Assessment: Evaluation of Cut-offs to Improve Stratification [PRAECIS] and from a real-world evidence study conducted after the implementation of sFlt-1/PlGF testing into routine clinical practice (Biomarker Examination and Analysis for Clinical Obstetrical Navigation Study [BEACON]). The model compared standard of care alone versus a biomarker-based approach utilizing the sFlt-1/PlGF test for managing patients at risk of preeclampsia with severe features. Published data was used to estimate theoretical cost values of infants for their first six months of life.

RESULTS

The analysis indicated potential total neonatal cost savings of nearly $10,595,332 (95% CI: $6,555,439 to $14,730,536) per 1,000 patients using the sFlt-1/PlGF ratio test, translating to about $10,595 saved per patient. The incremental cost-effectiveness ratio (ICER) analysis showed a mean cost savings of $62,572 for each pregnancy prolonged by two weeks.

CONCLUSION

The sFlt-1/PlGF test, when used alongside standard care, enhances risk stratification for severe preeclampsia and may lead to significant neonatal cost savings by reducing preterm deliveries and neonatal intensive care admissions.

Early first-trimester transvaginal ultrasound screening for cesarean scar pregnancy in patients with previous cesarean delivery: analysis of the evidence

Obstetric hemorrhage is a leading cause of maternal morbidity and mortality. An important etiology of obstetric hemorrhage is placenta accreta spectrum. In the last 2 decades, there has been increased clinical experience of the devastating effect of undiagnosed, as well as late diagnosed, cases of cesarean scar pregnancy. There is a growing body of evidence suggesting that cesarean scar pregnancy is an early precursor of second- and third-trimester placenta accreta spectrum. As such, cesarean scar pregnancy should be diagnosed in the early first trimester. This early diagnosis could be achieved by introducing regimented sonographic screening in pregnancies of patients with previous cesarean delivery. This opinion article evaluates the scientific and clinical basis of whether cesarean scar pregnancy, with special focus on its early first-trimester discovery, complies with the accepted requirements of a screening test. Each of the 10 classical screening criteria of Wilson and Jungner were systematically applied to evaluate if the criteria were met by cesarean scar pregnancy, to analyze if it is possible and realistic to carry out screening in a population-wide fashion.

Externally validated prediction models for pre-eclampsia: systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the performance of existing externally validated prediction models for pre-eclampsia (PE) (specifically, any-onset, early-onset, late-onset and preterm PE).

METHODS

A systematic search was conducted in five databases (MEDLINE, EMBASE, Emcare, CINAHL and Maternity & Infant Care Database) and using Google Scholar/reference search to identify studies based on the Population, Index prediction model, Comparator, Outcome, Timing and Setting (PICOTS) approach until 20 May 2023. We extracted data using the CHARMS checklist and appraised the risk of bias using the PROBAST tool. A meta-analysis of discrimination and calibration performance was conducted when appropriate.

RESULTS

Twenty-three studies reported 52 externally validated prediction models for PE (one preterm, 20 any-onset, 17 early-onset and 14 late-onset PE models). No model had the same set of predictors. Fifteen any-onset PE models were validated externally once, two were validated twice and three were validated three times, while the Fetal Medicine Foundation (FMF) competing-risks model for preterm PE prediction was validated widely in 16 different settings. The most common predictors were maternal characteristics (prepregnancy body mass index, prior PE, family history of PE, chronic medical conditions and ethnicity) and biomarkers (uterine artery pulsatility index and pregnancy-associated plasma protein-A). The FMF model for preterm PE (triple test plus maternal factors) had the best performance, with a pooled area under the receiver-operating-characteristics curve (AUC) of 0.90 (95% prediction interval (PI), 0.76-0.96), and was well calibrated. The other models generally had poor-to-good discrimination performance (median AUC, 0.66 (range, 0.53-0.77)) and were overfitted on external validation. Apart from the FMF model, only two models that were validated multiple times for any-onset PE prediction, which were based on maternal characteristics only, produced reasonable pooled AUCs of 0.71 (95% PI, 0.66-0.76) and 0.73 (95% PI, 0.55-0.86).

CONCLUSIONS

Existing externally validated prediction models for any-, early- and late-onset PE have limited discrimination and calibration performance, and include inconsistent input variables. The triple-test FMF model had outstanding discrimination performance in predicting preterm PE in numerous settings, but the inclusion of specialized biomarkers may limit feasibility and implementation outside of high-resource settings. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

First trimester screening for pre-eclampsia and targeted aspirin prophylaxis: a cost-effectiveness cohort study

OBJECTIVE

Investigate cost-effectiveness of first trimester pre-eclampsia screening using the Fetal Medicine Foundation (FMF) algorithm and targeted aspirin prophylaxis in comparison with standard care.

DESIGN

Retrospective observational study.

SETTING

London tertiary hospital.

POPULATION

5957 pregnancies screened for pre-eclampsia using the National Institute for Health and Care Excellence (NICE) method.

METHODS

Differences in pregnancy outcomes between those who developed pre-eclampsia, term pre-eclampsia and preterm pre-eclampsia were compared by the Kruskal-Wallis and Chi-square tests. The FMF algorithm was applied retrospectively to the cohort. A decision analytic model was used to estimate costs and outcomes for pregnancies screened using NICE and those screened using the FMF algorithm. The decision point probabilities were calculated using the included cohort.

MAIN OUTCOME MEASURES

Incremental healthcare costs and QALY gained per pregnancy screened.

RESULTS

Of 5957 pregnancies, 12.8% and 15.9% were screen-positive for development of pre-eclampsia using the NICE and FMF methods, respectively. Of those who were screen-positive by NICE recommendations, aspirin was not prescribed in 25%. Across the three groups, namely, pregnancies without pre-eclampsia, term pre-eclampsia and preterm pre-eclampsia there was a statistically significant trend in rates of emergency caesarean (respectively 21%, 43% and 71.4%; P < 0.001), admission to neonatal intensive care unit (NICU) (5.9%, 9.4%, 41%; P < 0.001) and length of stay in NICU. The FMF algorithm was associated with seven fewer cases of preterm pre-eclampsia, cost saving of £9.06 and QALY gain of 0.00006/pregnancy screened.

CONCLUSIONS

Using a conservative approach, application of the FMF algorithm achieved clinical benefit and an economic cost saving.

Which first-trimester risk assessment method for preeclampsia is most suitable? A model-based impact study

BACKGROUND

Low-dose aspirin treatment reduces the risk of preeclampsia among high-risk pregnant women. Internationally, several first-trimester risk-calculation methods are applied.

OBJECTIVE

This study aimed to assess the costs and benefits of different first-trimester preeclampsia risk estimation algorithms: EXPECT (an algorithmic prediction model based on maternal characteristics), National Institute for Health and Care Excellence (a checklist of risk factors), and the Fetal Medicine Foundation (a prediction model using additional uterine artery Doppler measurement and laboratory testing) models, coupled with low-dose aspirin treatment, in comparison with no risk assessment.

STUDY DESIGN

We constructed a decision analytical model estimating the number of cases of preeclampsia with each strategy and the costs of risk assessment for preeclampsia and early aspirin treatment, expressed in euros (€) in a hypothetical population of 100,000 women. We performed 1-way sensitivity analyses to assess the impact of adherence rates on model outcomes.

RESULTS

Application of the EXPECT, National Institute for Health and Care Excellence, and Fetal Medicine Foundation models results in respectively 1.98%, 2.55%, and 1.90% of the women developing preeclampsia, as opposed to 3.00% of women in the case of no risk assessment. Overall, the net financial benefits of the EXPECT, National Institute for Health and Care Excellence, and Fetal Medicine Foundation models relative to no risk assessment are €144, €43, and €38 per patient, respectively. The respective percentages of women receiving aspirin treatment are 18.6%, 10.2%, and 6.0% for the 3 risk assessment methods.

CONCLUSION

The EXPECT and Fetal Medicine Foundation model are comparable with regard to numbers of prevented preeclampsia cases, and both are superior to the National Institute for Health and Care Excellence model and to no risk assessment. EXPECT is less resource-demanding and results in the highest cost savings, but also requires the highest number of women to be treated with aspirin. When deciding which strategy is preferable, cost savings and easier use have to be weighed against the degree of overtreatment, although low-dose aspirin has no clear disadvantages during pregnancy.