Pinto N M, Nelson R, Puchalski M, Metz T D, Smith K J
Department of Pediatrics, University of Utah, Salt Lake City, UT, USA.
Ultrasound Obstet Gynecol. 2014 Jul;44(1):50-7. doi: 10.1002/uog.13287.
The economic implications of strategies to improve prenatal screening for congenital heart disease (CHD) in low-risk mothers have not been explored. The aim was to perform a cost-effectiveness analysis of different screening methods.
We constructed a decision analytic model of CHD prenatal screening strategies (four-chamber screen (4C), 4C + outflow, nuchal translucency (NT) or fetal echocardiography) populated with probabilities from the literature. The model included whether initial screens were interpreted by a maternal-fetal medicine (MFM) specialist and different referral strategies if they were read by a non-MFM specialist. The primary outcome was the incremental cost per defect detected. Costs were obtained from Medicare National Fee estimates. A probabilistic sensitivity analysis was undertaken on model variables commensurate with their degree of uncertainty.
In base-case analysis, 4C + outflow referred to an MFM specialist was the least costly strategy per defect detected. The 4C screen and the NT screen were dominated by other strategies (i.e. were more costly and less effective). Fetal echocardiography was the most effective, but most costly. On simulation of 10 000 low-risk pregnancies, 4C + outflow screen referred to an MFM specialist remained the least costly per defect detected. For an additional $580 per defect detected, referral to cardiology after a 4C + outflow was the most cost-effective for the majority of iterations, increasing CHD detection by 13 percentage points.
The addition of examination of the outflow tracts to second-trimester ultrasound increases detection of CHD in the most cost-effective manner. Strategies to improve outflow-tract imaging and to refer with the most efficiency may be the best way to improve detection at a population level.
尚未探讨改善低风险母亲先天性心脏病（CHD）产前筛查策略的经济影响。目的是对不同筛查方法进行成本效益分析。
我们构建了一个CHD产前筛查策略的决策分析模型（四腔心筛查（4C）、4C + 流出道、颈项透明层（NT）或胎儿超声心动图），模型中的概率来自文献。该模型包括初始筛查是否由母胎医学（MFM）专家解读，以及如果由非MFM专家解读时的不同转诊策略。主要结果是每检测到一个缺陷的增量成本。成本来自医疗保险国家费用估算。对与模型变量不确定性程度相称的变量进行了概率敏感性分析。
在基础病例分析中，转诊至MFM专家的4C + 流出道筛查是每检测到一个缺陷成本最低的策略。4C筛查和NT筛查被其他策略主导（即成本更高且效果更差）。胎儿超声心动图最有效，但成本最高。在模拟10000例低风险妊娠时，转诊至MFM专家的4C + 流出道筛查仍然是每检测到一个缺陷成本最低的。对于每检测到一个缺陷额外增加580美元，在4C + 流出道筛查后转诊至心脏病科在大多数迭代中是最具成本效益的，可将CHD检测率提高13个百分点。
在孕中期超声检查中增加流出道检查能以最具成本效益的方式提高CHD的检测率。改善流出道成像和以最高效率转诊的策略可能是在人群层面提高检测率的最佳方法。
