Prenatal screening for cystic fibrosis carriers: an economic evaluation

How are maternal and fetal outcomes incorporated when measuring benefits of interventions in pregnancy? Findings from a systematic review of cost-utility analyses

OBJECTIVE

Medical interventions used in pregnancy can affect the length and quality of life of both the pregnant person and fetus. The aim of this systematic review was to identify and describe the theoretical frameworks that underpin outcome measurement in cost-utility analyses of pregnancy interventions.

METHODS

Searches were conducted in the Paediatric Economic Database Evaluation (PEDE) database (up to 2017), as well as Medline, Embase and EconLit (2017-2019). We included all cost-utility analyses of any intervention given during pregnancy, published in English. We conducted a narrative synthesis of: study design; outcome construction (life expectancy, quality adjustment, discount rate); and whether the Incremental Cost-Effectiveness Ratio (ICER) was constructed using maternal or fetal outcomes. Where both outcomes were included, methods for combining them were extracted.

RESULTS

We identified 127 cost-utility analyses in pregnancy, of which 89 reported QALYs and 38 DALYs. Outcomes were considered solely for the fetus in 59 studies (47%), solely for the pregnant person in 13 studies (10%), and for both in 49 studies (39%). The choice to include or exclude one or both sets of outcomes was not consistent within particular clinical areas. Where outcomes for both mother and baby were included, methods for combining these outcomes varied. Twenty-nine studies summed QALYs/DALYs for maternal and fetal outcomes, with no adjustment. The remaining 20 took a variety of approaches designed to weigh maternal and fetal outcomes differently. These include (1) treating fetal outcomes as a component of maternal quality of life, rather than (or in addition to) an independent individual health outcome; (2) treating the maternal-fetal dyad as a single entity and applying a single utility value to each combination of outcomes; and (3) assigning a shorter time horizon to fetal outcomes to reduce the weight of lifetime fetal outcomes. Each approach made different assumptions about the relative value of maternal and fetal health outcomes, demonstrating a lack of consistency and the need for guidance.

CONCLUSION

Methods for capturing QALY/DALY outcomes in cost-utility analysis in pregnancy vary widely. This lack of consistency indicates a need for new methods to support the valuation of maternal and fetal health outcomes.

A Systematic Review of Methods and Practice for Integrating Maternal, Fetal, and Child Health Outcomes, and Family Spillover Effects into Cost-Utility Analyses

BACKGROUND

Maternal-perinatal interventions delivered during pregnancy or childbirth have unique characteristics that impact the health-related quality of life (HRQoL) of the mother, fetus, and newborn child. However, maternal-perinatal cost-utility analyses (CUAs) often only consider either maternal or child health outcomes. Challenges include, but are not limited to, measuring fetal, newborn, and infant health outcomes, and assessing their impact on maternal HRQoL. It is also important to recognize the impact of maternal-perinatal health on family members' HRQoL (i.e., family spillover effects) and to incorporate these effects in maternal-perinatal CUAs.

OBJECTIVE

The aim was to systematically review the methods used to include health outcomes of pregnant women, fetuses, and children and to incorporate family spillover effects in maternal-perinatal CUAs.

METHODS

A literature search was conducted in Medline, Embase, EconLit, Cochrane Collection, Cumulative Index to Nursing and Allied Health Literature (CINAHL), International Network of Agencies for Health Technology Assessment (INAHTA), and the Pediatric Economic Database Evaluation (PEDE) databases from inception to 2020 to identify maternal-perinatal CUAs that included health outcomes for pregnant women, fetuses, and/or children. The search was updated to December 2022 using PEDE. Data describing how the health outcomes of mothers, fetuses, and children were measured, incorporated, and reported along with the data on family spillover effects were extracted.

RESULTS

Out of 174 maternal-perinatal CUAs identified, 62 considered the health outcomes of pregnant women, and children. Among the 54 quality-adjusted life year (QALY)-based CUAs, 12 included fetal health outcomes, the impact of fetal loss on mothers' HRQoL, and the impact of neonatal demise on mothers' HRQoL. Four studies considered fetal health outcomes and the effects of fetal loss on mothers' HRQoL. One study included fetal health outcomes and the impact of neonatal demise on maternal HRQoL. Furthermore, six studies considered the impact of neonatal demise on maternal HRQoL, while four included fetal health outcomes. One study included the impact of fetal loss on maternal HRQoL. The remaining 26 only included the health outcomes of pregnant women and children. Among the eight disability-adjusted life year (DALY)-based CUAs, two measured fetal health outcomes. Out of 174 studies, only one study included family spillover effects. The most common measurement approach was to measure the health outcomes of pregnant women and children separately. Various approaches were used to assess fetal losses in terms of QALYs or DALYs and their impact on HRQoL of mothers. The most common integration approach was to sum the QALYs or DALYs for pregnant women and children. Most studies reported combined QALYs and incremental QALYs, or DALYs and incremental DALYs, at the family level for pregnant women and children.

CONCLUSIONS

Approximately one-third of maternal-perinatal CUAs included the health outcomes of pregnant women, fetuses, and/or children. Future CUAs of maternal-perinatal interventions, conducted from a societal perspective, should aim to incorporate health outcomes for mothers, fetuses, and children when appropriate. The various approaches used within these CUAs highlight the need for standardized measurement and integration methods, potentially leading to rigorous and standardized inclusion practices, providing higher-quality evidence to better inform decision-makers about the costs and benefits of maternal-perinatal interventions. Health Technology Assessment agencies may consider providing guidance for interventions affecting future lives in future updates.

A Systematic Review of Methods Used by Pediatric Cost-Utility Analyses to Include Family Spillover Effects

BACKGROUND

A child's health condition affects family members' health and well-being. However, pediatric cost-utility analysis (CUA) commonly ignores these family spillover effects leading to an incomplete understanding of the cost and benefits of a child's health intervention. Methodological challenges exist in assessing, valuing, and incorporating family spillover effects.

OBJECTIVE

This study systematically reviews and compare methods used to include family spillover effects in pediatric CUAs.

METHODS

A literature search was conducted in MEDLINE, Embase, EconLit, Cochrane collection, CINAHL, INAHTA, and the Pediatric Economic Database Evaluation (PEDE) database from inception to 2020 to identify pediatric CUAs that included family spillover effects. The search was updated to 2021 using PEDE. The data describing in which family members spillover effects were measured, and how family spillover effects were measured, incorporated, and reported, were extracted. Common approaches were grouped conceptually. Further, this review identified theories or theoretical frameworks used to justify approaches for integrating family spillover effects into CUA.

RESULTS

Of 878 pediatric CUAs identified, 35 included family spillover effects. Most pediatric CUAs considered family spillover effects on one family member. Pediatric CUAs reported eight different approaches to measure the family spillover effects. The most common method was measuring the quality-adjusted life years (QALY) loss of the caregiver(s) or parent(s) due to a child's illness or disability using an isolated approach whereby family spillover effects were quantified in individual family members separately from other health effects. Studies used four approaches to integrate family spillover effects into CUA. The most common method was to sum children's and parents/caregivers' QALYs. Only two studies used a theoretical framework for incorporation of family spillover effects.

CONCLUSIONS

Few pediatric CUAs included family spillover effects and the observed variation indicated no consensus among researchers on how family spillover effects should be measured and incorporated. This heterogeneity is mirrored by a lack of practical guidelines by Health Technology Assessment (HTA) agencies or a theoretical foundation for including family spillover effects in pediatric CUA. The results from this review may encourage researchers to develop a theoretical framework and HTA agencies to develop guidelines for including family spillover effects. Such guidance may lead to more rigorous and standardized methods for including family spillover effects and better-quality evidence to inform decision-makers on the cost-effectiveness of pediatric health interventions.

Carrier Screening Programs for Cystic Fibrosis, Fragile X Syndrome, Hemoglobinopathies and Thalassemia, and Spinal Muscular Atrophy: A Health Technology Assessment

Background

We conducted a health technology assessment to evaluate the safety, effectiveness, and cost-effectiveness of carrier screening programs for cystic fibrosis (CF), fragile X syndrome (FXS), hemoglobinopathies and thalassemia, and spinal muscular atrophy (SMA) in people who are considering a pregnancy or who are pregnant. We also evaluated the budget impact of publicly funding carrier screening programs, and patient preferences and values.

Methods

We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included study using the Cochrane Risk of Bias tool and the Risk of Bias Assessment tool for Non-randomized Studies (RoBANS), and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted cost-effectiveness analyses comparing preconception or prenatal carrier screening programs to no screening. We considered four carrier screening strategies: 1) universal screening with standard panels; 2) universal screening with a hypothetical expanded panel; 3) risk-based screening with standard panels; and 4) risk-based screening with a hypothetical expanded panel. We also estimated the 5-year budget impact of publicly funding preconception or prenatal carrier screening programs for the given conditions in Ontario. To contextualize the potential value of carrier screening, we spoke with 22 people who had sought out carrier screening.

Results

We included 107 studies in the clinical evidence review. Carrier screening for CF, hemoglobinopathies and thalassemia, FXS, and SMA likely results in the identification of couples with an increased chance of having an affected pregnancy (GRADE: Moderate). Screening likely impacts reproductive decision-making (GRADE: Moderate) and may result in lower anxiety among pregnant people, although the evidence is uncertain (GRADE: Very low).We included 21 studies in the economic evidence review, but none of the study findings were directly applicable to the Ontario context. Our cost-effectiveness analyses showed that in the short term, preconception or prenatal carrier screening programs identified more at-risk pregnancies (i.e., couples that tested positive) and provided more reproductive choice options compared with no screening, but were associated with higher costs. While all screening strategies had similar values for health outcomes, when comparing all strategies together, universal screening with standard panels was the most cost-effective strategy for both preconception and prenatal periods. The incremental cost-effectiveness ratios (ICERs) of universal screening with standard panels compared with no screening in the preconception period were $29,106 per additional at-risk pregnancy detected and $367,731 per affected birth averted; the corresponding ICERs in the prenatal period were about $29,759 per additional at-risk pregnancy detected and $431,807 per affected birth averted.We estimated that publicly funding a universal carrier screening program in the preconception period over the next 5 years would require between $208 million and $491 million. Publicly funding a risk-based screening program in the preconception period over the next 5 years would require between $1.3 million and $2.7 million. Publicly funding a universal carrier screening program in the prenatal period over the next 5 years would require between $128 million and $305 million. Publicly funding a risk-based screening program in the prenatal period over the next 5 years would require between $0.8 million and $1.7 million. Accounting for treatment costs of the screened health conditions resulted in a decrease in the budget impact of universally provided carrier screening programs or cost savings for risk-based programs.Participants value the perceived potential positive impact of carrier screening programs such as medical benefits from early detection and treatment, information for reproductive decision-making, and the social benefit of awareness and preparation. There was a strong preference expressed for thorough, timely, unbiased information to allow for informed reproductive decision-making.

Conclusions

Carrier screening for CF, FXS, hemoglobinopathies and thalassemia, and SMA is effective at identifying at-risk couples, and test results may impact preconception and reproductive decision-making.The cost-effectiveness and budget impact of carrier screening programs are uncertain for Ontario. Over the short term, carrier screening programs are associated with higher costs, and also higher chances of detecting at-risk pregnancies compared with no screening. The 5-year budget impact of publicly funding universal carrier screening programs is larger than that of risk-based programs. However, accounting for treatment costs of the screened health conditions results in a decrease in the total additional costs for universal carrier screening programs or in cost savings for risk-based programs.The people we spoke with who had sought out carrier screening valued the potential medical benefits of early detection and treatment, particularly the support and preparation for having a child with a potential genetic condition.

Economic evaluation of reproductive carrier screening for recessive genetic conditions: a systematic review

INTRODUCTION

Autosomal recessive (AR) and x-linked (XL) conditions are rare but collectively common which impact millions of people globally on morbidity, mortality and costs. Advanced medical technologies allow prospective parents to make informed reproductive decisions to avoid having affected children. Economic evaluations targeting on reproductive carrier screening (RCS) for AR and/or XL conditions have been conducted, but there has not been a systematic review in this area.

AREAS COVERED

A systematic search of economic evaluations for RCS was undertaken using the following databases - EMBASE, MEDLINE and SCOPUS. The search strategy was designed to capture full economic evaluations related to RCS since 1990. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) strategy. The included 23 studies adopted various types of methodologies to conduct economic evaluations. The majority of studies examined a single condition. The various clinical strategies and screened conditions caused the different cost-effectiveness conclusions in the published studies.

EXPERT OPINION

Establishing a validated and practical clinical strategy of RCS and investigating the cost-effectiveness of multiple conditions in one economic evaluation are critical for implementing RCS in the future. Further economic evaluations are essential to provide evidence-based practice for decision-makers.

The cost-effectiveness of genotyping versus sequencing for prenatal cystic fibrosis carrier screening

OBJECTIVE

We investigated the cost-effectiveness of three sequential prenatal cystic fibrosis (CF) carrier screening strategies: genotyping both partners, genotyping one partner then sequencing the second, and sequencing both partners.

METHOD

A decision-analytic model compared the strategies in a theoretical cohort of four million pregnant couples in the US population and five racial/ethnic sub-populations. Inputs were obtained from literature and varied in sensitivity analysis. Outcomes included cost per quality-adjusted life year (QALY), missed carrier couples, affected newborns, missed prenatal diagnoses, terminations, and procedure-related losses. The cost-effectiveness threshold was $100,000/QALY.

RESULTS

Sequencing both partners identified 1099 carrier couples that were missed by genotyping both partners, leading to 273 fewer missed prenatal diagnoses, 152 more terminations, and 152 fewer affected newborns. A similar trend was observed in the genotyping followed by sequencing strategy. The incremental cost-effectiveness ratio of genotyping followed by sequencing compared to genotyping both partners was $180,004/QALY and the incremental cost-effectiveness ratio of sequencing both partners compared to genotyping followed by sequencing was $17.6 million/QALY. Sequencing both partners was cost-effective below $339 per test, genotyping/sequencing between $340 and $1837, and genotyping both partners above $1838. Sequencing was not cost-effective among five racial/ethnic sub-populations.

CONCLUSION

Despite improved outcomes, sequencing for prenatal CF carrier screening was not cost-effective compared to genotyping. The clinical significance of the incremental cost-effectiveness of CF carrier screening is a matter of deliberation for public policy debate.

Cost-effectiveness of the CFTR gene-sequencing test for asymptomatic carriers in the Colombian population

Introducción.

La fibrosis quística es una enfermedad genética de carácter autosómico recesivo clasificada como enfermedad huérfana de alto costo.

Objetivo.

Determinar la razón de costo-efectividad de la prueba diagnóstica de secuenciación del gen CFTR para los portadores asintomáticos familiares en primer, segundo y tercer grados de consanguinidad.

Materiales y métodos.

Se hizo una búsqueda sistemática sobre la evaluación de las características operativas de la prueba diagnóstica y los modelos de árbol de decisiones en estudios de costo-efectividad. Se elaboró un modelo de árbol de decisiones tomando como unidad de análisis la prevención de futuras concepciones. Los costos de la enfermedad se obtuvieron del reporte de alto costo del Ministerio de Salud de Colombia. Los costos de la prueba se obtuvieron de laboratorios nacionales. Se hizo un análisis de sensibilidad, determinístico y probabilístico, con la perspectiva del tercer pagador y horizonte a un año.

Resultados.

Se obtuvo una razón incremental de costo-efectividad (RICE) de USD$ 5.051,10 por obtener 10,89 % más de probabilidades de evitar el nacimiento de un niño enfermo con fibrosis quística por pareja. Para los familiares de segundo y tercer grados, se encontró una RICE de USD$ 19.380,94 y USD$ 55.913,53, respectivamente, al aplicar el PIB per cápita. Esta tecnología fue costo-efectiva en 39 %, 61,18 % y 74,36 % para 1, 2 y 3 PIB per cápita en familiares de primer grado de consanguinidad.

Conclusiones.

La prueba genética de detección de portadores del gen CFTR resultó costo-efectiva dependiendo del umbral de la disponibilidad de pagar, y de los supuestos y limitaciones establecidas en el modelo.

Non-invasive prenatal sequencing for multiple Mendelian monogenic disorders using circulating cell-free fetal DNA

Current non-invasive prenatal screening is targeted toward the detection of chromosomal abnormalities in the fetus^1,2. However, screening for many dominant monogenic disorders associated with de novo mutations is not available, despite their relatively high incidence³. Here we report on the development and validation of, and early clinical experience with, a new approach for non-invasive prenatal sequencing for a panel of causative genes for frequent dominant monogenic diseases. Cell-free DNA (cfDNA) extracted from maternal plasma was barcoded, enriched, and then analyzed by next-generation sequencing (NGS) for targeted regions. Low-level fetal variants were identified by a statistical analysis adjusted for NGS read count and fetal fraction. Pathogenic or likely pathogenic variants were confirmed by a secondary amplicon-based test on cfDNA. Clinical tests were performed on 422 pregnancies with or without abnormal ultrasound findings or family history. Follow-up studies on cases with available outcome results confirmed 20 true-positive, 127 true-negative, zero false-positive, and zero-false negative results. The initial clinical study demonstrated that this non-invasive test can provide valuable molecular information for the detection of a wide spectrum of dominant monogenic diseases, complementing current screening for aneuploidies or carrier screening for recessive disorders.

2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum

BACKGROUND

Thyroid disease in pregnancy is a common clinical problem. Since the guidelines for the management of these disorders by the American Thyroid Association (ATA) were first published in 2011, significant clinical and scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid disease in women during pregnancy, preconception, and the postpartum period.

METHODS

The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles were eligible for inclusion. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations. The guideline task force had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed, and communicated to the ATA and task force members.

RESULTS

The revised guidelines for the management of thyroid disease in pregnancy include recommendations regarding the interpretation of thyroid function tests in pregnancy, iodine nutrition, thyroid autoantibodies and pregnancy complications, thyroid considerations in infertile women, hypothyroidism in pregnancy, thyrotoxicosis in pregnancy, thyroid nodules and cancer in pregnant women, fetal and neonatal considerations, thyroid disease and lactation, screening for thyroid dysfunction in pregnancy, and directions for future research.

CONCLUSIONS

We have developed evidence-based recommendations to inform clinical decision-making in the management of thyroid disease in pregnant and postpartum women. While all care must be individualized, such recommendations provide, in our opinion, optimal care paradigms for patients with these disorders.

Economic burden of ambulatory and home-based care for adults with cystic fibrosis

OBJECTIVE

The purpose of this study was to measure costs associated with care for adults with cystic fibrosis, from a societal perspective.

METHODS

Over a 4-week period, 110 participants completed the Ambulatory and Home Care Record, a self-administered data collection instrument that measures costs to the health system, costs to employers, care recipients' direct out-of-pocket expenditures, and time costs borne by care recipients and their family caregivers. Health system costs were based on the costs incurred through expenditures on physicians, hospital clinics, pharmaceuticals, and home care agencies. Out-of-pocket costs were obtained using self-reports by care recipients, and time losses were valued using the human capital approach.

RESULTS

The annual mean societal costs of ambulatory care for cystic fibrosis was $Can29 885 per care recipient (year 2002 value). Time losses incurred by care recipients and their family caregivers accounted for the majority (72%) of these costs, and system costs accounted for the second highest percentage of costs (21%). Although almost all participants (109) recorded out-of-pocket expenditures, these costs accounted for only a small proportion (3%) of total costs.

CONCLUSION

Measuring societal costs is necessary for practitioners, managers, and policy decision-makers, to ensure that care recipients and their families receive the necessary resources to provide care.

Impact of pulmonary exacerbations and lung function on generic health-related quality of life in patients with cystic fibrosis

BACKGROUND

The analysis aimed to examine the impact of pulmonary exacerbations (PEs) and lung function on generic measures of HRQL in patients with cystic fibrosis (CF) using trial-based data.

METHODS

In a 48-week randomized, placebo-controlled study of ivacaftor in patients ≥12 years with CF and a G551D-CFTR mutation the relationship between PEs, PE-related hospitalizations and percent predicted forced expiratory volume in one second (ppFEV1) with EQ-5D measures (index and visual analog scale [VAS]) was examined in post-hoc analyses. Multivariate mixed-effects models were employed to describe the association of PEs, PE-related hospitalizations, and ppFEV1 on EQ-5D measures.

RESULTS

One hundred sixty one patients (age: mean 25.5 [SD 9.5] years; baseline ppFEV1: 63.6 [16.4]) contributed 1,214 observations (ppFEV1: no lung dysfunction [n = 157], mild [n = 419], moderate [n = 572], severe [n = 66]). Problems were most frequently reported on pain/discomfort, anxiety/depression, and usual activities EQ-5D items. The mean (SE) EQ-5D index nominally decreased (worsened) with worsening severity of lung dysfunction (P = 0.070): 0.931 (0.023); mild: 0.923 (0.021); moderate: 0.904 (0.018); severe: 0.870 (0.020). 146 PEs were experienced by 72 patients, including 52 PEs (35.6 %) that required hospitalization. Mean EQ-5D index and VAS scores were lowest (worst) within 1 week (before or after PE start) for PEs requiring hospitalization. Pulmonary exacerbations, PE-related hospitalizations, and ppFEV1 were significant predictors of EQ-5D index and VAS.

CONCLUSIONS

In a clinical study of patients with CF (≥12 years of age and a G551D-CFTR mutation), PEs, primarily those requiring hospitalization, were associated with low EQ-5D index and VAS scores. The impact of ppFEV1 was relatively smaller. Reducing PEs, in particular those requiring hospitalization, would likely improve HRQL among these patients.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT00909532 ; URL: clinicaltrials.gov, May 26, 2009.

Carrier screening by next-generation sequencing: health benefits and cost effectiveness

BACKGROUND

Compared with conventional genotyping, which typically tests for a limited number of mutations, next-generation DNA sequencing (NGS) provides increased accuracy for carrier screening. The objective of this study was to evaluate the cost effectiveness of carrier screening using NGS versus genotyping for 14 of the recessive disorders for which medical society guidelines recommend screening.

METHODS

Data from published literature, population surveys, and expert opinion were used to develop a decision tree model capturing decisions and outcomes related to carrier screening and reproductive health.

RESULTS

Modeling a population of 1,000,000 couples that was representative of the United States population and that contained 83,421 carriers of pathogenic mutations, carrier screening using NGS averted 21 additional affected births as compared with genotyping, and reduced costs by approximately $13 million. As compared with no screening, NGS carrier screening averted 223 additional affected births. The results are sensitive to assumptions regarding mutation detection rates and carrier frequencies in multiethnic populations.

CONCLUSION

This study demonstrated that NGS-based carrier screening offers the greater benefit in clinical outcomes and lower total healthcare cost as compared with genotyping.

Evaluating Cost-effectiveness of Interventions That Affect Fertility and Childbearing: How Health Effects Are Measured Matters

BACKGROUND

Current guidelines for economic evaluations of health interventions define relevant outcomes as those accruing to individuals receiving interventions. Little consensus exists on counting health impacts on current and future fertility and childbearing. Our objective was to characterize current practices for counting such health outcomes.

METHODS

We developed a framework characterizing health interventions with direct and/or indirect effects on fertility and childbearing and how such outcomes are reported. We identified interventions spanning the framework and performed a targeted literature review for economic evaluations of these interventions. For each article, we characterized how the potential health outcomes from each intervention were considered, focusing on quality-adjusted life-years (QALYs) associated with fertility and childbearing.

RESULTS

We reviewed 108 studies, identifying 7 themes: 1) Studies were heterogeneous in reporting outcomes. 2) Studies often selected outcomes for inclusion that tend to bias toward finding the intervention to be cost-effective. 3) Studies often avoided the challenges of assigning QALYs for pregnancy and fertility by instead considering cost per intermediate outcome. 4) Even for the same intervention, studies took heterogeneous approaches to outcome evaluation. 5) Studies used multiple, competing rationales for whether and how to include fertility-related QALYs and whose QALYs to include. 6) Studies examining interventions with indirect effects on fertility typically ignored such QALYs. 7) Even recent studies had these shortcomings. Limitations include that the review was targeted rather than systematic.

CONCLUSIONS

Economic evaluations inconsistently consider QALYs from current and future fertility and childbearing in ways that frequently appear biased toward the interventions considered. As the Panel on Cost-Effectiveness in Health and Medicine updates its guidelines, making the practice of cost-effectiveness analysis more consistent is a priority. Our study contributes to harmonizing methods in this respect.

Human Genetics Society of Australasia position statement: population-based carrier screening for cystic fibrosis

Since the discovery in 1989 that mutations in cystic fibrosis transmembrane conductance regulator (CFTR) underlie cystic fibrosis (CF), the most common life shortening genetic disorder in Caucasians, it has been possible to identify heterozygous mutation carriers at risk of having affected children. The Human Genetics Society of Australasia has produced a position statement with recommendations in relation to population-based screening for CF. These include: (1) that screening should be offered to all relatives of people with or carriers of CF (cascade testing) as well as to all couples planning to have children or who are pregnant; (2) the minimum CFTR mutation panel to be tested consists of 17 mutations which are those mutations that are associated with typical CF and occur with a frequency of 0.1% or higher among individuals diagnosed with CF in Australasia; (3) that genetic counselling is offered to all couples where both members are known to have one or two CFTR mutations and that such couples are given the opportunity to meet with a physician with expertise in the management of CF as well as a family/individual affected by the condition.

Socio-economic burden of rare diseases: A systematic review of cost of illness evidence

Cost-of-illness studies, the systematic quantification of the economic burden of diseases on the individual and on society, help illustrate direct budgetary consequences of diseases in the health system and indirect costs associated with patient or carer productivity losses. In the context of the BURQOL-RD project ("Social Economic Burden and Health-Related Quality of Life in patients with Rare Diseases in Europe") we studied the evidence on direct and indirect costs for 10 rare diseases (Cystic Fibrosis [CF], Duchenne Muscular Dystrophy [DMD], Fragile X Syndrome [FXS], Haemophilia, Juvenile Idiopathic Arthritis [JIA], Mucopolysaccharidosis [MPS], Scleroderma [SCL], Prader-Willi Syndrome [PWS], Histiocytosis [HIS] and Epidermolysis Bullosa [EB]). A systematic literature review of cost of illness studies was conducted using a keyword strategy in combination with the names of the 10 selected rare diseases. Available disease prevalence in Europe was found to range between 1 and 2 per 100,000 population (PWS, a sub-type of Histiocytosis, and EB) up to 42 per 100,000 population (Scleroderma). Overall, cost evidence on rare diseases appears to be very scarce (a total of 77 studies were identified across all diseases), with CF (n=29) and Haemophilia (n=22) being relatively well studied, compared to the other conditions, where very limited cost of illness information was available. In terms of data availability, total lifetime cost figures were found only across four diseases, and total annual costs (including indirect costs) across five diseases. Overall, data availability was found to correlate with the existence of a pharmaceutical treatment and indirect costs tended to account for a significant proportion of total costs. Although methodological variations prevent any detailed comparison between conditions and based on the evidence available, most of the rare diseases examined are associated with significant economic burden, both direct and indirect.

Ethical considerations in choosing a model for population-based cystic fibrosis carrier screening

Cystic fibrosis (CF) carrier testing can be used to inform reproductive decision making, allowing carriers to avoid having a child with CF. A government-funded, population-based CF carrier screening program would allow greater equity of access to this test. The setting in which CF carrier screening is offered significantly affects the extent to which participants make well informed, voluntary decisions to accept or decline testing. Screening offered before pregnancy and in non-clinical environments better promotes participant autonomy than screening offered in the prenatal consultation.

Impact of gene patents and licensing practices on access to genetic testing for cystic fibrosis

Cystic fibrosis is one of the most commonly tested autosomal recessive disorders in the United States. Clinical cystic fibrosis is associated with mutations in the CFTR gene, of which the most common mutation among Caucasians, DeltaF508, was identified in 1989. The University of Michigan, Johns Hopkins University, and the Hospital for Sick Children, where much of the initial research occurred, hold key patents on cystic fibrosis genetic sequences, mutations, and methods for detecting them. Several patents, including the one that covers detection of the DeltaF508 mutation, are jointly held by the University of Michigan and the Hospital for Sick Children in Toronto, with Michigan administering patent licensing in the United States. The University of Michigan broadly licenses the DeltaF508 patent for genetic testing with >60 providers of genetic testing to date. Genetic testing is now used in newborn screening, diagnosis, and for carrier screening. Interviews with key researchers and intellectual property managers, a survey of laboratories' prices for cystic fibrosis genetic testing, a review of literature on cystic fibrosis tests' cost-effectiveness, and a review of the developing market for cystic fibrosis testing provide no evidence that patents have significantly hindered access to genetic tests for cystic fibrosis or prevented financially cost-effective screening. Current licensing practices for cystic fibrosis genetic testing seem to facilitate both academic research and commercial testing. More than 1000 different CFTR mutations have been identified, and research continues to determine their clinical significance. Patents have been nonexclusively licensed for diagnostic use and have been variably licensed for gene transfer and other therapeutic applications. The Cystic Fibrosis Foundation has been engaged in licensing decisions, making cystic fibrosis a model of collaborative and cooperative patenting and licensing practice.

PGD for all cystic fibrosis carrier couples: novel strategy for preventive medicine and cost analysis

Over 1000 children affected with cystic fibrosis (CF) are born annually in the USA. Since IVF with preimplantation genetic diagnosis (PGD) is an alternative to raising a sick child or to aborting an affected fetus, a cost-benefit analysis was performed for a national IVF-PGD program for preventing CF. The amount spent to deliver healthy children for all CF carrier-couples by IVF-PGD was compared with the average annual and lifetime direct medical costs per CF patient avoided. Treating annually about 4000 CF carrier-couples with IVF-PGD would result in 3715 deliveries of non-affected children at a cost of $57,467 per baby. Because the average annual direct medical cost per CF patient was $63,127 and life expectancy is 37 years, savings would be $2.3 million per patient and $2.2 billion for all new CF patients annually in lifetime treatment costs. Cumulated net saving of an IVF-PGD program for all carrier-couples for 37 years would be $33.3 billion. A total of 618,714 cumulative years of patients suffering because of CF and thousands of abortions could be prevented. A national IVF-PGD program is a highly cost-effective novel modality of preventive medicine and would avoid most births of individuals affected with debilitating genetic disease.

The cost-effectiveness of prenatal screening for spinal muscular atrophy

OBJECTIVE

We sought to investigate the cost-effectiveness of prenatal screening for spinal muscular atrophy (SMA).

STUDY DESIGN

A decision analytic model was created to compare a policy of universal SMA screening to that of no screening. The primary outcome was incremental cost per maternal quality-adjusted life year. Probabilities, costs, and outcomes were estimated through literature review. Univariate and multivariate sensitivity analyses were performed to test the robustness of our model to changes in baseline assumptions.

RESULTS

Universal screening for SMA is not cost-effective at $4.9 million per quality-adjusted life year. In all, 12,500 women need to be screened to prevent 1 case of SMA, at a cost of $5.0 million per case averted. Our results were most sensitive to the baseline prevalence of disease.

CONCLUSION

Universal prenatal screening for SMA is not cost-effective. For populations at high risk, such as those with a family history, SMA testing may be a cost-effective strategy.

Healthcare expenditures for privately insured people with cystic fibrosis

With improved survival and new therapies for people with cystic fibrosis (CF), updated information on medical care expenditures for those individuals is needed. We estimated medical care expenditures, including both insurance reimbursements and patient out-of-pocket expenses, for privately insured people with CF and investigated how those expenditures varied with certain complications of CF. From a private insurance claims database of people covered by health plans associated with large corporate employers, we identified people with CF who were currently receiving medical care for the disorder and characterized their medical expenditures during the period 2004-2006. We selected a matching group of people who did not have CF based on age, sex, and geographic area, and calculated incremental expenditures associated with CF. We also examined the effect of age and certain complications of CF on these expenditures. The annual medical care expenditure for a person with actively managed CF averaged $48,098 in 2006 dollars, which was 22 times higher than for a person without CF. This ratio is high relative to other chronic disorders. Outpatient prescription medications made up the largest component of total expenditures for people with CF (39%). Those who were recorded in claims data as having a liver or lung transplant, malnutrition, diabetes, or a chronic Pseudomonas aeruginosa pulmonary infection incurred much higher expenditures than people without these conditions. People with CF will incur high medical expenditures throughout their lifespan. These findings will assist in the development of economic evaluations of future CF screening and management initiatives.

A cost-benefit analysis of preimplantation genetic diagnosis for carrier couples of cystic fibrosis

OBJECTIVE

To perform a cost-benefit analysis of preimplantation genetic diagnosis (PGD) for carrier couples of cystic fibrosis (CF) compared with the alternative of natural conception (NC) followed by prenatal testing and termination of affected pregnancies.

DESIGN

Cost-benefit analysis using a decision analytic model.

SETTING

Outpatient reproductive health practices.

PATIENT(S)

A simulated cohort of 1,000 female patients.

INTERVENTION(S)

We calculated the net benefit of giving birth to a child as the present value of lifetime earnings minus lifetime medical costs.

MAIN OUTCOME MEASURE(S)

Net benefits in dollars.

RESULT(S)

When used for women younger than 35 years of age, the net benefit of PGD over NC was $182,000 ($715,000 vs. $532,000, respectively). For women aged 35-40 years, the net benefit of PGD over NC was $114,000 ($634,000 vs. $520,000, respectively). For women older than 40 years, however, the net benefit of PGD over NC was -$148,000 ($302,000 vs. $450,000, respectively).

CONCLUSION(S)

Preimplantation genetic diagnosis provides net economic benefits when used by carrier couples of CF. Although there is an upper limit of maternal age at which economic benefit can be demonstrated, carrier couples of CF should be offered PGD for prevention of an affected child.

Population screening for reproductive risk for single gene disorders in Australia: now and the future

Abstract As the results of the Human Genome Project are realized, it has become technically possible to identify carriers of numerous autosomal and X-linked recessive disorders. Couples at risk of having a child with one of these conditions have a number of reproductive options to avoid having a child with the condition should they wish. In Australia the haemoglobinopathies are the only group of conditions for which population screening is widely offered and which is government funded. In some Australian states there are also population screening programs for cystic fibrosis and autosomal recessive conditions more common in Ashkenazi Jewish individuals which are generally offered on a user pays basis. It is predicted that as consumer demand increases and testing becomes cheaper, that many people planning or in the early stages of pregnancy will have carrier screening for multiple genetic conditions. This will have significant implications for genetic counseling, laboratory and prenatal testing resources. In addition such screening raises a number of ethical issues including the value of lives of those born with genetic conditions for which screening is available.

Measuring the value of public health systems: the disconnect between health economists and public health practitioners

We investigated ways of defining and measuring the value of services provided by governmental public health systems. Our data sources included literature syntheses and qualitative interviews of public health professionals. Our examination of the health economic literature revealed growing attempts to measure value of public health services explicitly, but few studies have addressed systems or infrastructure. Interview responses demonstrated no consensus on metrics and no connection to the academic literature. Key challenges for practitioners include developing rigorous, data-driven methods and skilled staff; being politically willing to base allocation decisions on economic evaluation; and developing metrics to capture "intangibles" (e.g., social justice and reassurance value). Academic researchers evaluating the economics of public health investments should increase focus on the working needs of public health professionals.

Quality-adjusted life year weights among elderly patients with heart failure

BACKGROUND

When assessing health-related quality of life (HRQoL) in elderly patients with heart failure (HF), the process of obtaining quality-adjusted life year (QALY) weights is generally complicated and time-consuming.

AIM

To evaluate whether information regarding HRQoL and QALY weights can be derived directly from the established and widely used New York Heart Association (NYHA) functional classification system.

METHODS

NYHA functional status was assessed independently both by the individual patients and by the examining cardiologist in 323 elderly patients with symptoms of HF recruited from primary care. HRQoL was evaluated using the SF-36 questionnaire and a time trade-off (TTO) scenario. The TTO technique generates direct QALY weights.

RESULTS

Both the TTO technique and SF-36 values demonstrated a statistically significant correlation with NYHA functional status. The TTO values also correlated with all SF-36 dimensions. Increasing impairment was associated with statistically significant drops in both SF-36 values and TTO-based QALY weights. For patients in NYHA classes I-IV the QALY weights were 0.77, 0.68, 0.61, and 0.50, respectively. Thus in elderly patients, symptoms of HF have a major impact on perceived quality of life.

CONCLUSION

The results of the present study show that QALY weights, an important instrument in the health economic evaluation of treatment strategies, can be derived directly from NYHA classification in elderly HF patients.

Cost-effectiveness of a school-based Tay-Sachs and cystic fibrosis genetic carrier screening program

PURPOSE

To explore the cost-effectiveness of school-based multi-disease genetic carrier screening.

METHOD

Decision analysis of the cost-effectiveness of a school-based Tay-Sachs disease and cystic fibrosis genetic carrier screening program, relative to no screening. Data relating to ethnicity profile, test-accepting behavior, and screening program cost were sourced from an existing program in Sydney, Australia.

RESULTS

Compared to no screening, the incremental cost-effectiveness of the screening program is A dollar 5,834 per additional carrier detected. This cost-effectiveness ratio is most sensitive to changes in genetic test accuracy, and the cost of laboratory assays. The results imply a cost per affected birth avoided of approximately A dollar 530,000 (approximately US dollar 371,000).

CONCLUSIONS

This preconceptional genetic carrier screening program offers comparable cost-effectiveness to prenatal screening programs for cystic fibrosis.

Economic evaluation of cystic fibrosis screening: A review of the literature

OBJECTIVES

To critically examine the economic evidence regarding cystic fibrosis (CF) carrier screening and to understand issues relating to the transferability of international findings to any national context for policy decisions.

METHODS

A systematic literature search identified 14 studies (out of 29 economic studies on CF) focusing on preconception or prenatal screening between 1990 and 2006. These studies were then assessed against international benchmarks on conducting and reporting of economic evaluations, costing methodology used and focusing on the transferability of the evidence to national contexts.

RESULTS

The primary outcome measures varied considerably between studies and there was considerable ambiguity and variation on how costs were estimated. The Incremental Cost Effectiveness Ratio (ICER) and net savings, for preconception and prenatal screening were inconsistent and varied significantly, even after adjusting for timing and exchange rates. Differences in screening participation rates, reproductive choices, test sensitivity, cost of test and lifetime cost of care make up a large part of the ICER variations.

CONCLUSION

The heterogeneity in study design, model inputs and reporting of economic evaluations of CF carrier screening makes comparability and transferability across countries and even within countries difficult. This reinforces the need to assess any technology within the relevant context, and to not simply generalize from reported studies. In turn, this adds to the complex task of making efficient resource allocation decisions in the area of CF carrier screening. Our evaluation adds weight to the calls for revisiting the way economic studies are conducted and reported.

Pharmacogenomic testing to prevent aminoglycoside-induced hearing loss in cystic fibrosis patients: potential impact on clinical, patient, and economic outcomes

BACKGROUND

Aminoglycosides are commonly used in cystic fibrosis patients to treat Pseudomonas aeruginosa respiratory infections. Aminoglycoside-induced hearing loss may occur in 1%-15% of patients with cystic fibrosis, ranging from mild to severe. Recently, a genetic test to identify patients with a mitochondrial mutation (A1555G) that may predispose patients to this adverse event has become available. Although the A1555G variant is very rare, it seems to confer a high risk of severe hearing loss in patients exposed to aminoglycosides.

OBJECTIVE

The objective was to evaluate the potential clinical, patient, and economic outcomes associated with the use of A1555G testing in a cystic fibrosis population, and explore data gaps and uncertainty in its clinical implementation.

METHODS

We developed a decision-analytic model to evaluate a hypothetical cohort of patients with cystic fibrosis from a societal perspective. Clinical and economic data were derived primarily from a critical literature review. The incidence of aminoglycoside-induced severe hearing loss, quality-adjusted life-years, and total health care costs were evaluated. Sensitivity analyses were conducted to evaluate uncertainty in our results.

RESULTS

In the base-case analysis, A1555G testing decreased the risk of severe aminoglycoside-induced hearing loss by 0.12% in the cystic fibrosis population. The discounted incremental cost per quality-adjusted life-years gained was $79,300, but varied widely from $33,000 to testing being dominated by the no testing strategy (higher costs and lower quality-adjusted life-years with testing) in sensitivity analyses. If avoidance of aminoglycosides in patients testing positive leads to an absolute increase in the lifetime risk of death from Pseudomonas infection of 0.8% or greater, A1555G testing would lead to a decrease in quality-adjusted life-years.

CONCLUSIONS

The results of our analysis suggest that there are significant data gaps and uncertainty in the outcomes with A1555G testing, but it is not likely cost-effective, and could lead to worse patient outcomes due to avoidance of first-line therapy in the >95% of patients who are false-positives. Additional research is needed before pharmacogenetic testing for the A1555G mitochondrial mutation can be recommended, even in a population with a high likelihood of exposure to aminoglycosides.

Genetic screening for cystic fibrosis: An overview of the science and the economics

The aim of this paper is to provide an overview of the current scientific and economic thinking on the use of genetic technologies for cystic fibrosis (CF) screening. The paper takes a public health genetics viewpoint and gives an overview of the genetics behind CF, then describes current practices in screening for the disease. We then discuss the current literature on the economic evaluations of screening for CF. As the "wet" science improves, there are direct implications for health service. Therefore, it is important to keep examining both clinical practice and economics behind the technologies.

Is cystic fibrosis carrier screening cost effective?

Between 2001 and 2005, 6,166 females underwent cystic fibrosis (CF) carrier screening at our institution. Only 36% were Caucasian. We identified 143 carrier females and subsequently tested 85 of their partners. The observed carrier frequency was not significantly different than expected for any racial or ethnic group tested. We identified 6 positive couples (5 Caucasian, 1 Arab American) and 1 affected fetus. In just under 4 years, our institution spent approximately $334,000 on CF population screening. Comparing this to the lifetime medical cost for a CF patient, CF population-based carrier screening is cost effective at our institution, despite the high number of non-Caucasians being screened.

Measuring health preferences for use in cost-utility and cost-benefit analyses of interventions in children: theoretical and methodological considerations

Valuing the health of children for cost-utility or cost-benefit analysis poses a number of additional challenges when compared with valuing adult health. Some of these challenges relate to the inability of young children to value changes in health directly and the potential biases associated with using proxy respondents. Other challenges arise from children not being able to perform as independent economic actors, but dependent on others for care and decision making. In addition, illness in children may affect parent/caregiver quality of life, further complicating the measurement of value associated with a change in a child's health status. We review the most common approaches (QALYs and willingness-to-pay values) for valuing health in economic evaluations and consider the methodological and practical issues associated with measuring child health using each framework. Recommendations for advancing the field of valuing child health for economic evaluations will vary by age; a 'one size fits all' approach does not readily fit. Although limitations exist for all of the methods considered for valuing child health, the currently recommended approach for infants and preschoolers is direct valuation by a proxy respondent. For school-age children and adolescents, existing multi-attribute instruments can be applied in some situations but direct valuation may be required for others. Future research should focus on minimising bias from proxy respondents, consideration of a family- or household-based approach to valuing health effects, and development of generic instruments with domains that are appropriate to children and that vary with age.

Economic analyses of human genetics services: a systematic review

PURPOSE

The study's purpose was to conduct a structured review of economic analyses of genetic services. These will be increasingly valuable tools for assessing the clinical and economic outcomes of new medical technologies.

METHODS

We searched for economic studies published between January 1990 and August 2004 from a variety of publicly available databases. Articles were first reviewed to determine whether they were original studies, and second to determine whether they were formal cost-effectiveness analyses by established criteria. Articles meeting these criteria were graded using a validated rating scale.

RESULTS

Of 149 articles, 63 met established criteria for cost-effectiveness analyses. The majority (87%) were published since 1996. The majority of studies considered adult (31) or prenatal (25) conditions with the remainder considering preconception or pediatric conditions. More than half used life years gained or an ad hoc measure of outcome (e.g., cases detected). Twenty-five percent measured outcome as quality-adjusted life years. The disease areas most considered were cancer (21%) and aneuploidies (18%). The average quality ranking was 87 of 100 possible (range 48-100). Common shortcomings included lack of statement of perspective, lack of discussion of potential bias, and lack of disclosure of funding sources.

CONCLUSIONS

Relatively few economic evaluations are available for genetic services, and most are clustered in specific disease areas. Overall quality was high, but varied widely. Most shortcomings that would improve study quality are easy to address. To improve the relevance of these studies, researchers need to incorporate measures of outcome that are familiar to decision makers, including quality-adjusted life years.

Genetic characterisation of circulating fetal cells allows non-invasive prenatal diagnosis of cystic fibrosis

OBJECTIVES

Cystic fibrosis (CF) is an autosomal recessive disease due to mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. The purpose of this study was to develop a molecular method to characterise both paternal and maternal CFTR alleles in DNA from circulating fetal cells (CFCs) isolated by ISET (isolation by size of epithelial tumour/trophoblastic cells).

METHODS

The molecular protocol was defined by developing the F508del mutation analysis and addressing it both to single trophoblastic cells, isolated by ISET and identified by short tandem repeats (STR) genotyping, and to pooled trophoblastic genomes, thus avoiding the risk of allele drop out (ADO). This protocol was validated in 100 leucocytes from F508del carriers and subsequently blindly applied to the blood (5 mL) of 12 pregnant women, at 11 to 13 weeks of gestation, whose offspring had a 1/4 risk of CF. Ten couples were carriers of F508del mutation, while two were carriers of unknown CFTR mutations.

RESULTS

Results showed that one fetus was affected, seven were heterozygous carriers of a CFTR mutation, and four were healthy homozygotes. These findings were consistent with those obtained by chorionic villus sampling (CVS).

CONCLUSION

Our data show that the ISET-CF approach affords reliable prenatal diagnosis (PND) of cystic fibrosis and is potentially applicable to pregnant women at risk of having an affected child, thus avoiding the risk of iatrogenic miscarriage.

Genetic health technology and economic evaluation: a critical review

The aim of the review is to establish whether, on the basis of previous published evidence, current accepted guidance for health economic evaluation needs to be adapted to evaluate healthcare based on use of genetic information. Online literature search strategies were designed (using PubMed and the NHS Economic Evaluation Database [NHS EED], among others) to gather papers carrying out or discussing economic evaluation and genetics. Papers meeting the inclusion criteria were obtained and reviewed. The papers purporting to be economic analyses were classified using the criteria of the NHS EED and the British Medical Journal (BMJ) working party on peer review of health economic literature. Of 120 English-language papers that met the criteria for review, only 37 were economic evaluations according to the criteria set out by the NHS EED and BMJ working party on economic evaluations. Of these 37, only 33 papers discussed economic evaluation methodologies in the genetics context. The economic evaluation papers did not seem to tackle any of the problems discussed in the methodological papers. Economic evaluation methods offer a structured approach for evaluation of changes but may need to change in order to assess the new technologies. We have found that such studies have not been widely reported, and that those that have been reported do not depart from current economic methods. We have identified a need for better skills and guidance in health economics within this growing area of research.

Cost-Effectiveness Analysis of Prenatal Diagnosis: Methodological Issues and Concerns

With increasing concerns regarding rapidly expanding health care costs, cost-effectiveness analysis (CEA) provides a methodology to assess whether marginal gains from new technology are worth the increased costs. In the arena of prenatal diagnosis, particular methodological and ethical concerns include whether the effects of such testing on individuals other than the patient are included, how termination of pregnancy is included in the models, redundancy of screening and diagnostic methods, and how screening may reassure or cause anxiety in patients depending on their results. The existing literature has demonstrated cost-effectiveness of screening and diagnosis of neural tube defects, Down syndrome, and cystic fibrosis in the general population. Screening for genetic disorders which have a higher prevalence among particular groups has also been shown to be cost effective, including diseases such as hemoglobinopathies and Tay-Sachs disease. Understanding the methodology and salient issues of CEA is critical for researchers, editors and clinicians to accurately interpret results of the growing body of cost-effectiveness studies in prenatal diagnosis.

Screening for Single Gene Genetic Disease

The screening and directed testing for genetic disease caused by single gene mutations is an expanding part of the overall scheme of prenatal care. In addition to reproductive choice, carrier screening and fetal diagnostic testing afford the important opportunity for preparation of the family and the delivery site for the birth of a fetus with a known genetic disorder. Increasingly the primary care provider in pregnancy bears the burden of engaging patients in discussions regarding available genetic tests appropriate to their family or personal history, their ethnic group, and with every patient for a limited but growing number of diseases. Ethnic-based risk identification and testing has expanded recently with, for example, the addition of familial dysautonomia for patients of Askhenazi ancestry. Widespread, or nearly universal, screening has emerged for cystic fibrosis and new initiatives are gaining momentum for prenatal maternal carrier screening for fragile X syndrome. The fruits of the human genome project will undoubtedly lead to the identification of more genes that underlie human disease. This will expand the menu of possible prenatal testing options and will raise the level of complexity in both counseling, testing logisitics and health care resource allocation.

Quality-adjusted life-years lack quality in pediatric care: a critical review of published cost-utility studies in child health

OBJECTIVES

Cost-utility analysis in which health benefits are quantified in terms of quality-adjusted life-years (QALYs) has now become the standard type of cost-effectiveness analysis. These studies are potentially influential in determining the extent of funding for particular pediatric interventions, and so their methodologic quality is extremely important. The objective of this study was twofold: first, to critically appraise published cost-utility analyses of interventions in child and adolescent health care in terms of the methods used to derive QALYs and, second, to discuss unresolved methodologic issues that are pertinent to the measurement of QALYs in pediatric populations.

METHODS

A comprehensive search using computerized databases (including Medline, Embase, Econlit, and databases specific to economic evaluation), Web searches, and citation tracking was undertaken to identify cost-utility studies of interventions that were aimed at those who were younger than 16 years and published before April 2004. The methods of individual studies were compared with the recognized published guidelines of the US Panel on Cost-Effectiveness in Health and Medicine and the National Institute for Clinical Excellence in England and Wales, which recommend the use of a generic health state classification system (eg, Health Utility Index, EuroQol-5D), a choice-based valuation method (eg, standard gamble or time trade-off) and preferences of the general public in estimating QALYs. Studies therefore were categorized and evaluated according to the methods used to describe the health state, the valuation technique, and source of preferences.

RESULTS

Fifty-four studies were reviewed, 34 (63%) of which were published in the past 5 years. A generic health status classification instrument was used in 22 (35%) cases; the remainder developed study-specific health state descriptions or elicited preferences directly from patients or proxies. In 3 (5%) cases, sources were unclear. Preference weights were elicited using choice-based techniques in 28 (42%) cases, either as tariffs for health status classification instruments (17 cases) or by directly valuing health state descriptions or patient health (11 cases). Preferences of the general public were used in only 23 (37%) cases. Four studies aggregated QALYs for mother/child or parents/child pairs without giving any theoretical justification. Although there was an increasing tendency for studies to use generic health status classification instruments, choice-based methods, and preferences of the general public, the majority of studies still did not adhere to these standard recommendations even in the period between January 2000 and March 2004. Despite increasing standardization in the methods advocated for economic evaluation over the past 10 years, there remains extensive variation in the actual methods used by researchers to calculate QALYs for children and adolescents. It is unclear whether these results suggest poor practice or a set of positive (or reactive) choices made by analysts in a methodologically uncertain area in which specific guidance is lacking regarding how to address the complexities of pediatric outcomes within the QALY framework. Many aspects of QALY measurement in children are not yet fully developed. In particular, there is (1) a lack of appropriate health state classification instruments that take account of the dynamics of child development, (2) a lack of health state classification instruments for use in children and infants who are younger than 5 years, and (3) the need to understand fully the role of proxies for measuring and valuing child health. Additional research efforts are also required to develop methods that account for the health benefits of parents or caregivers of the child and to consider the implications of combining different forms of utility measurement in childhood and adulthood.

CONCLUSIONS

Although variations from standard recommendations may be attributable to poor practice among researchers who are either unaware of these recommendations or choose not to follow them, they could equally be the result of attempts to make research more rigorous and more defensible than it might be if the standard recommendations were followed. There are 4 potential approaches to conducting cost-utility analysis in pediatric populations: (1) the explicit development of a generic instrument designed to be applicable across both child and adult populations (likely to be difficult in practice), (2) insistence on use of a generic instrument developed for adults, (3) the use of generic instruments specifically developed for children without being concerned about comparability with interventions aimed at adults, and (4) abandoning attempts to use single outcome measures that combine mortality with quality weights. In the absence of a clear way forward, it is suggested that an expert panel be convened to debate and further consider these potential solutions and recommendations for best practice and future research. In the interim, comparisons of the relative cost-effectiveness reported as cost per QALY gained across interventions for different diseases and populations should be treated with extreme caution.

Implementing prenatal screening for cystic fibrosis in routine obstetric practice

OBJECTIVE

The purpose of this study was to assess the outcome of the type of prescreening counseling on choices for prenatal cystic fibrosis screening.

STUDY DESIGN

From October 2001 to November 2002, regardless of ethnicity, all prenatal patients (n = 855) at the Air Force Medical Genetics Center, Biloxi, Miss, received education on prenatal screening for cystic fibrosis by group genetic counseling either by a presentation by a genetics professional (430 patients) or by a similar audiovisual presentation only (425 patients). A combination pretest/posttest document was used to evaluate learning and served as the consent. Partner testing was recommended for mutation-positive patients.

RESULTS

Fifty-eight percent patients requested screening, of whom 68% were white. Regardless of the type of counseling, patients showed an improvement in knowledge based on pre- and posttest scores. There was no significant difference in choices to undergo screening on the basis of counseling method. Fifteen mutation carriers were identified. Only 6 partners of mutation-positive patients were available and consented to be tested. To date, no infants have been born with cystic fibrosis.

CONCLUSION

Audio-visual counseling is an effective means to educate patients about genetic screening and does not require a trained genetics professional to administer. Partner testing in mobile populations may prove problematic.

Pediatric cystic fibrosis: evaluating costs and genetic testing

The purpose of this article is to present a systematic, critical review of literature and data sources pertaining to pediatric cystic fibrosis, emphasizing and evaluating factors of costs and genetic testing. Cystic fibrosis is the most common fatal genetic disease in the United States. Therefore, its cause, prevalence, cost, and prevention make it important for review. Furthermore, the recent National Institutes of Health Consensus Statement on Genetic Testing for Cystic Fibrosis, the laboratory standards and guidelines published by the American College of Medical Genetics, the American College of Obstetricians and Gynecologists, and the National Human Genome Research Institute, and the increasing interest in genetic testing make it timely to discuss this major pediatric health topic. A broad educational effort, particularly among health care professionals, and genetic screening are advocated.

Preference-based approaches to measuring the benefits of perinatal care

Studies that measure benefits of health care interventions in natural or physical units cannot incorporate the several health changes that might occur within a single measure, and they overlook individuals' preferences for those health changes. This paper discusses and critically appraises the application of preference-based approaches to the measurement of the benefits of perinatal care that have developed out of economic theory. These include quality adjusted life year (QALY)-based approaches, monetary-based approaches, and discrete choice experiments. QALY-based approaches use scaling techniques, such as the rating scale, standard gamble approach, and time trade-off approach, or multi-attribute utility measures, to measure the health-related quality of life weights of health states. Monetary-based approaches include the revealed preference approach, which involves observing decisions that individuals actually make concerning health risks, and the willingness-to-pay approach, which provides a framework for investigating individuals' willingness to pay for benefits of health care interventions. Discrete choice experiments describe health care interventions in terms of their attributes, and elicit preferences for scenarios that combine different levels of those attributes. Empirical examples are used to illustrate each preference-based approach to benefit measurement, and several methodological issues raised by the application of these approaches to the perinatal context are discussed. Particular attention is given to identifying the relevant attributes to incorporate into the measurement instrument, appropriate respondents for the measurement exercise, potential sources of bias in description and valuation processes, and the practicality, reliability, and validity of alternative measurement approaches. The paper's conclusion is that researchers should be explicit and rigorous in their application of preference-based approaches to benefit measurement in the context of perinatal care.

Possibilities and barriers in the implementation of a preconceptional screening programme for cystic fibrosis carriers: a focus group study

OBJECTIVE

This qualitative study aimed to explore possibilities and barriers in the implementation of a nationwide preconceptional cystic fibrosis (CF) carrier screening programme.

METHODS

Sessions were held with two focus groups of CF patients and CF relatives, one focus group of people from the target population (couples planning a pregnancy), and two focus groups of potential providers (general practitioners (GPs) and municipal health service workers).

RESULTS

Important barriers in the implementation of a preconceptional CF carrier screening programme included the problem of reaching the target population, the heavy workload of GPs, the limited public knowledge about CF in general, and the absence of a preconceptional consultation setting. In general, there was a positive attitude among the participants towards CF carrier screening.

CONCLUSION

This study revealed some important barriers in the implementation of CF carrier screening programmes. More research is needed to specify and quantify the importance of the various barriers. Eventually, different intervention strategies should be included in an implementation plan to overcome the most important barriers in the organization and execution of screening.

Economic Considerations for Health Insurance Coverage of Emerging Genetic Tests

Public and private health insurance plans face the question of whether to cover emerging genetic tests for cancer and other diseases. This paper outlines issues in the economic evaluation of new genetic tests, illustrating key methodological issues and policy implications with findings from a comprehensive and systematic review of the 14 full economic evaluations published over the past 5 years that have addressed both the costs and consequences of molecular genetic tests. Key questions for framing an evaluation include: whose viewpoint matters, which costs and consequences are relevant, and to which clinical alternatives should new genetic tests be compared? While economic evaluation research can inform coverage decisions about genetic tests, the coverage decision-making process must also inform economic researchers about the aims, context, and value systems within which genetic tests will be covered and practised.

Prenatal screening for cystic fibrosis: an economic analysis

Cystic fibrosis (CF) is the most common life-shortening genetically transmitted disease in Denmark with a birth prevalence of 1 in 4700, resulting in 12-15 new cases of cystic fibroses annually. The aim of this study is to disclose the societal resource implications of introducing a population wide prenatal screening programme for cystic fibrosis in Denmark. The present analysis is limited to the monetary consequences of introducing a screening programme, where costs of screening are compared to the potential benefits measured in cost savings involved if births of CF patients are avoided. Screening costs in a Danish setting were estimated at DKK 2 771 262 ( pound sterlings 231 438) per aborted affected fetus in the first screening round, stabilising at DKK 1 864 594 ( pound sterlings 155 383) per aborted affected fetus at subsequent screening rounds. Comparing this figure with the estimated benefits of avoiding a CF case (DKK 2.1-4.4 million; pound sterlings 175 000-366 667) suggests that introducing a screening programme for cystic fibrosis will be net cost saving irrespective of the perspective of the analysis, assumptions on replacement children and method of estimating long-term production gains/losses.

Methodological limitations of economic evaluations of antenatal screening

A review of recent economic studies of antenatal screening reveals widespread violation of accepted economic evaluation methodology. In particular, the costs and benefits of antenatal screening are often misclassified and conflated, and the non-resource effects of averted costs are often excluded from the evaluation process. The result is a widespread violation of the explicit and systematic approaches taken by economic analysts more generally, and conclusions that may be described as misleading. This letter calls for economic analysts to be consistent in their application of economic evaluation methodology to antenatal screening programmes.

Accessing genetic variation: genotyping single nucleotide polymorphisms

Understanding the relationship between genetic variation and biological function on a genomic scale is expected to provide fundamental new insights into the biology, evolution and pathophysiology of humans and other species. The hope that single nucleotide polymorphisms (SNPs) will allow genes that underlie complex disease to be identified, together with progress in identifying large sets of SNPs, are the driving forces behind intense efforts to establish the technology for large-scale analysis of SNPs. New genotyping methods that are high throughput, accurate and cheap are urgently needed for gaining full access to the abundant genetic variation of organisms.

Patients' fear of genetic discrimination by health insurers: the impact of legal protections

PURPOSE

The impact of laws restricting health insurers' use of genetic information has been assessed from two main vantage points: (1) whether they reduce the extent of genetic discrimination and (2) whether they reduce the fear of discrimination and the resulting deterrence to undergo genetic testing. A previous report from this study concluded that there are almost no well-documented cases of health insurers either asking for or using presymptomatic genetic test results in their underwriting decisions, either before or after these laws, or in states with or without these laws. This report evaluates the perceptions and the resulting behavior by patients and clinicians.

METHODS

A comparative case study analysis was performed in seven states with different laws respecting health insurers' use of genetic information (no law, new prohibition, mature prohibition). Semistructured interviews were conducted in person with five patient advocates and with 30 experienced genetic counselors or medical geneticists, most of whom deal with adult-onset disorders. Also, multiple informed consent forms and patient information brochures were collected and analyzed using qualitative methods.

RESULTS

Patients' and clinicians' fear of genetic discrimination greatly exceeds reality, at least for health insurance. It is uncertain how much this fear actually deters genetic testing. The greatest deterrence is to those who do not want to submit the costs of testing for reimbursement and who cannot afford to pay for testing. There appears to be little deterrence for tests that are more easily affordable or when the need for the information is much greater. Fear of discrimination plays virtually no role in testing decisions in pediatric or prenatal situations, but is significant for adult-onset genetic conditions.

CONCLUSION

Existing laws have not greatly reduced the fear of discrimination. This may be due, in part, to clinicians' lack of confidence that these laws can prevent discrimination until there are test cases of actual enforcement. Ironically, there may be so little actual discrimination that it may not be possible to initiate good test cases.