Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK; The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK; Parexel Access Consulting, Parexel International, Stockholm, Sweden.
Value Health. 2021 Apr;24(4):513-521. doi: 10.1016/j.jval.2020.11.005. Epub 2021 Jan 21.
Fetal growth restriction is a major risk factor for stillbirth. A routine late-pregnancy ultrasound scan could help detect this, allowing intervention to reduce the risk of stillbirth. Such a scan could also detect fetal presentation and predict macrosomia. A trial powered to detect stillbirth differences would be extremely large and expensive.
It is therefore critical to know whether this would be a good investment of public research funds. The aim of this study is to estimate the cost-effectiveness of various late-pregnancy screening and management strategies based on current information and predict the return on investment from further research.
Synthesis of current evidence structured into a decision model reporting expected costs, quality-adjusted life-years, and net benefit over 20 years and value-of-information analysis reporting predicted return on investment from future clinical trials.
Given a willingness to pay of £20 000 per quality-adjusted life-year gained, the most cost-effective strategy is a routine presentation-only scan for all women. Universal ultrasound screening for fetal size is unlikely to be cost-effective. Research exploring the cost implications of induction of labor has the greatest predicted return on investment. A randomized, controlled trial with an endpoint of stillbirth is extremely unlikely to be a value for money investment.
Given current value-for-money thresholds in the United Kingdom, the most cost-effective strategy is to offer all pregnant women a presentation-only scan in late pregnancy. A randomized, controlled trial of screening and intervention to reduce the risk of stillbirth following universal ultrasound to detect macrosomia or fetal growth restriction is unlikely to represent a value for money investment.
胎儿生长受限是导致死胎的主要危险因素。晚期妊娠常规超声检查有助于发现这一问题，从而采取干预措施降低死胎风险。该检查还可检测胎儿先露部位，并预测巨大儿。要想检测出死胎差异，试验所需的样本量会非常大，且费用高昂。
因此，明确这是否是公共研究资金的良好投资至关重要。本研究旨在根据现有信息评估各种晚期妊娠筛查和管理策略的成本效益，并预测进一步研究的投资回报。
对现有证据进行综合，构建决策模型，报告 20 年内的预期成本、质量调整生命年和净收益，并进行价值信息分析，报告未来临床试验的投资回报预测。
若每获得一个质量调整生命年愿意支付 20000 英镑，最具成本效益的策略是对所有女性进行常规的仅先露位超声检查。对所有孕妇进行胎儿大小的常规超声筛查不太可能具有成本效益。探索引产成本影响的研究具有最大的预测投资回报。以死胎为结局的随机对照试验极不可能是一项物有所值的投资。
根据英国目前的物有所值标准，最具成本效益的策略是为所有孕妇在妊娠晚期提供仅先露位超声检查。对所有孕妇进行常规超声筛查，以检测巨大儿或胎儿生长受限，并采取干预措施降低其风险，从而开展降低死胎风险的随机对照试验，不太可能是一项物有所值的投资。
