Cost-effectiveness of low-dose aspirin for the prevention of preterm birth: a prospective study of the Global Network for Women's and Children's Health Research

Health economic evaluations of programs reducing preterm birth: A scoping review

Background

Preterm birth has lifelong implications, placing a burden on individuals, families, communities and the health system. While several interventions to reduce preterm birth have been economically evaluated, no scoping review has been undertaken.

Objective

To conduct a scoping review of economic evaluations of interventions that have reduced preterm birth, identify gaps in the literature and inform future health care providers and researchers on the economic value of preterm birth reduction interventions.

Methods

Databases such as PubMed, Cumulative Index to Nursing and Allied Health Literature, EBSCO, Medline (OVID), EMBASE, NHS Health Technology Assessment, the Cost-Effectiveness Analysis Registry, and the NHS Economic Evaluation Database and grey literature were comprehensively searched for economic evaluations of interventions that reduced preterm birth conducted since 2000. Items included: preterm birth reduction, intervention, method of economic evaluation, time-horizon of analysis, study population, perspective of evaluation, effectiveness, and costs. Review processes were undertaken by two reviewers, and disagreements were resolved by the larger team.

Results

Fifteen publications met the inclusion criteria, including pharmacological interventions (5), telemedicine (1), diagnostic procedures (2), public and community health (2), prenatal care and nutrition (2), father's involvement (1), doula care (1) and a comprehensive maternity service redesign (1). Variations were observed in study design, time-horizon, study population and method of evaluation. Most studies (n = 13) adopted either a healthcare payer, provider, or system perspective. Shorter timehorizons for analysis were adopted in all studies, except one that conducted a lifetime economic evaluation. All included interventions, except one, were found to be costeffective, cost-beneficial or led to cost-savings.

Conclusion

Despite preterm birth placing a high economic burden on health systems and society, we found a dearth of long-term economic evaluations of prevention and reduction initiatives. Future research on preterm birth reduction initiatives should include economic evaluations.

The effects of low-dose aspirin on preterm birth: a systematic review and meta-analysis of randomized controlled trials

AIM

To conduct a systematic review and meta-analysis of all randomized controlled trials (RCTs) that evaluated the efficacy of low-dose aspirin (LDA, ≤ 160 mg/day) on preventing preterm birth (PB).

METHODS

Five databases were screened from inception until June 25, 2023. The RCTs were assessed for quality according to Cochrane's risk of bias tool. The endpoints were summarized as risk ratio (RR) with 95% confidence interval (CI).

RESULTS

Overall, 40 RCTs were analyzed. LDA significantly decreased the risk of PB < 37 weeks (RR: 0.91, 95% CI 0.87, 0.96, p < 0.001, moderate certainty of evidence) with low between-study heterogeneity (I2 = 23.2%, p = 0.11), and PB < 34 weeks (RR: 0.78, 95% CI 0.61, 0.99, p = 0.04, low certainty of evidence) with high between-study heterogeneity (I2 = 58.3%, p = 0.01). There were no significant differences between both groups regarding the risk of spontaneous (RR: 0.94, 95% CI 0.83, 1.07, p = 0.37) and medically indicated (RR: 1.28, 95% CI 0.87, 1.88, p = 0.21) BP < 37 weeks. Sensitivity analysis revealed robustness for all outcomes, except for the risk of PB < 34 weeks. For PB < 37 weeks and PB < 34 weeks, publication bias was detected based on visual inspection of funnel plots for asymmetry and statistical significance for Egger's test (p = 0.009 and p = 0.0012, respectively).

CONCLUSION

LDA can significantly reduce the risk of PB < 37 and < 34 weeks. Nevertheless, further high-quality RCTs conducted in diverse populations, while accounting for potential confounding factors, are imperative to elucidate the optimal aspirin dosage, timing of initiation, and treatment duration for preventing preterm birth and to arrive at definitive conclusions.

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.