Universal cervical length screening with a cervicometer to prevent preterm birth <34 weeks: a decision and economic analysis

Estimates of avoided costs attributed to a short cervix screening program to prevent preterm birth from the perspective of the Unified Health System (SUS)

OBJECTIVE

To perform an economic cost analysis of the implementation of a short cervix screening program to reduce preterm birth in singleton pregnancies in a short-term time horizon.

METHODS

We performed a cost-benefit economic analysis using the P5 trial database, a randomized multicenter clinical trial for prevention of preterm birth. Data collection was conducted from July 2015 to March 2019 in 17 different Brazilian hospitals. We conducted a cost analysis for universal cervical screening in singleton pregnancies between 18 weeks and 22 weeks plus 6 days. In subjects with a cervical length ≤ 25 mm, the analysis incorporated the costs of administering 200 mg/day of vaginal progesterone prophylactically until 36 weeks gestation. These findings were subsequently compared with the economic implications of forgoing cervical screening. The time horizon comprised from birth to 10 weeks postpartum. The outcome was measured monetarily in Brazilian real (R$) from the perspective of the Unified Health System.

RESULTS

Among 7,844 women, 6.67% (523) had a cervix ≤ 25 mm. The cost of screening with transvaginal ultrasound and vaginal progesterone for prevention of births with < 34 weeks was estimated at R$ 383,711.36, while non-screening generated an estimated additional cost of R$ 446,501.69 (related to the 29 non-screened preterm deliveries). Thus, screening and prophylaxis would generate a final cost reduction of R$ 62,790.33, constituting a possible cost-benefit strategy.

CONCLUSION

Universal short cervix screening for preterm birth has lower costs compared to non-screening within a short-term time horizon, which suggests an interesting benefit-cost ratio. Future studies should consider the cost-effectiveness of prophylactic treatment using sensitivity analyses in different scenarios within the Brazilian health system, as well as analyses that consider the long-term costs associated with preterm births, to robustly justify the implementation of a short cervix screening program.

Ultrasound-Indicated Cervical Cerclage Efficacy Between 16 and 28 Weeks of Gestation in Twin Pregnancy: Retrospective Cohort Study

Objective

The aim of this study is to determine if cervical cerclage administration reduces the preterm birth (PTB) rate at a gestational age (GA) of 16–28 weeks in women with twin pregnancy.

Methods

This is a retrospective cohort study on asymptomatic twin pregnancy with an ultrasound-identified cervix length (CL) of ≦25 mm. The patients were divided into two groups: ultrasound-indicated cerclage (UIC) group and control (expectant management) group. The primary outcome was a PTB rate at <34 weeks. A logistic regression was also performed, and a subgroup analysis stratified by CL and GA at first short cervix diagnosis was planned.

Results

In all 320 women, there were no differences in the overall <34-week PTB rates and neonatal outcomes between the UIC group and control group. After performing a multivariate logistic regression analysis, the subgroup analyses were planned. In patients with a CL of ≦15 mm, the <34-week PTB rate was significantly decreased in the UIC subgroup compared with the control subgroup (60.78% vs 78.26%; odds ratio (OR) = 0.43, confidence interval (CI) = 95% [0.22–0.86]; and p = 0.020). In patients with a first short cervix diagnosis GA of ≦24 weeks, the <34-week PTB rate was significantly decreased in the UIC subgroup when compared with the control subgroup (61.54% vs 84.75%; OR = 0.29; CI = 95% [0.13–0.63]; and p = 0.001). Furthermore, compared with the control groups, the UIC groups had higher mean birth weight, lower perinatal mortality, and lower NICU admission, and the differences were statistically significant.

Conclusion

UIC could significantly reduce the <34-week PTB rate and improve perinatal outcomes in patients with a CL of ≦15mm or first short cervix diagnosis GA of ≦24 weeks with asymptomatic twin pregnancy during the second trimester.

Preference-Based Health-Related Quality of Life Outcomes Associated with Preterm Birth: A Systematic Review and Meta-analysis

OBJECTIVES

Assessments of health-related quality of life outcomes associated with preterm birth provide valuable complementary data to the objective biomedical assessments that have traditionally been reported. The objective of this study was to perform a systematic review and meta-analysis of health utility values associated with preterm birth generated using preference-based approaches to health-related quality of life measurement.

METHODS

Systematic searches of MEDLINE, Web of Science, EconLit, EMBASE, CINAHL, PsycINFO, the Cochrane Library and SCOPUS were performed, covering the literature from inception of the search engines to 26 June 2018. Studies reporting health utility values estimated using either direct or indirect utility elicitation methods and published in the English language were included. Central descriptive statistics and measures of variability surrounding health utility values for each study and control group, and differences between comparator groups, are reported for each included article. The effect of preterm birth on health utility values was estimated using a hierarchical linear model in a linear mixed-effects meta-regression.

RESULTS

Of 2139 unique articles retrieved, 20 articles met the inclusion criteria. All but one study used the Health Utilities Index (HUI) Mark 2 (HUI2) or Mark 3 (HUI3) measures as their primary health utility assessment method. All studies reporting health utility values for individuals born preterm or at low birthweight and a control group of individuals born at full term or normal birthweight reported lower utility values in the study groups, regardless of age at assessment, respondent type or valuation method. The meta-regression revealed that preterm birth was associated with a mean utility decrement of 0.066 (95% confidence interval [CI] 0.035-0.098; p < 0.001) after controlling for valuation method, respondent type, administration mode, year of publication, geographical region of study, study setting and age at assessment.

CONCLUSION

Evidence identified by this review can act as data inputs into future economic evaluations of preventive or treatment interventions for preterm birth. Future research should focus particularly on estimating health utility values during the various stages of adulthood, and incorporating the effects of preterm birth on the preference-based health-related quality of life outcomes of parents and other family members.