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Rivero-Arias O, Png ME, White A, Yang M, Taylor-Phillips S, Hinton L, Boardman F, McNiven A, Fisher J, Thilaganathan B, Oddie S, Slowther AM, Ratushnyak S, Roberts N, Shilton Osborne J, Petrou S. Benefits and harms of antenatal and newborn screening programmes in health economic assessments: the VALENTIA systematic review and qualitative investigation. Health Technol Assess 2024; 28:1-180. [PMID: 38938110 PMCID: PMC11228689 DOI: 10.3310/pytk6591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024] Open
Abstract
Background Health economic assessments are used to determine whether the resources needed to generate net benefit from an antenatal or newborn screening programme, driven by multiple benefits and harms, are justifiable. It is not known what benefits and harms have been adopted by economic evaluations assessing these programmes and whether they omit benefits and harms considered important to relevant stakeholders. Objectives (1) To identify the benefits and harms adopted by health economic assessments in this area, and to assess how they have been measured and valued; (2) to identify attributes or relevance to stakeholders that ought to be considered in future economic assessments; and (3) to make recommendations about the benefits and harms that should be considered by these studies. Design Mixed methods combining systematic review and qualitative work. Systematic review methods We searched the published and grey literature from January 2000 to January 2021 using all major electronic databases. Economic evaluations of an antenatal or newborn screening programme in one or more Organisation for Economic Co-operation and Development countries were considered eligible. Reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist. We identified benefits and harms using an integrative descriptive analysis and constructed a thematic framework. Qualitative methods We conducted a meta-ethnography of the existing literature on newborn screening experiences, a secondary analysis of existing individual interviews related to antenatal or newborn screening or living with screened-for conditions, and a thematic analysis of primary data collected with stakeholders about their experiences with screening. Results The literature searches identified 52,244 articles and reports, and 336 unique studies were included. Thematic framework resulted in seven themes: (1) diagnosis of screened for condition, (2) life-years and health status adjustments, (3) treatment, (4) long-term costs, (5) overdiagnosis, (6) pregnancy loss and (7) spillover effects on family members. Diagnosis of screened-for condition (115, 47.5%), life-years and health status adjustments (90, 37.2%) and treatment (88, 36.4%) accounted for most of the benefits and harms evaluating antenatal screening. The same themes accounted for most of the benefits and harms included in studies assessing newborn screening. Long-term costs, overdiagnosis and spillover effects tended to be ignored. The wide-reaching family implications of screening were considered important to stakeholders. We observed good overlap between the thematic framework and the qualitative evidence. Limitations Dual data extraction within the systematic literature review was not feasible due to the large number of studies included. It was difficult to recruit healthcare professionals in the stakeholder's interviews. Conclusions There is no consistency in the selection of benefits and harms used in health economic assessments in this area, suggesting that additional methods guidance is needed. Our proposed thematic framework can be used to guide the development of future health economic assessments evaluating antenatal and newborn screening programmes. Study registration This study is registered as PROSPERO CRD42020165236. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127489) and is published in full in Health Technology Assessment; Vol. 28, No. 25. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Oliver Rivero-Arias
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - May Ee Png
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ashley White
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Miaoqing Yang
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Lisa Hinton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- THIS Institute, University of Cambridge, Cambridge, UK
| | | | - Abigail McNiven
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | - Sam Oddie
- Bradford Institute for Health Research, Bradford Children's Research, Bradford, UK
| | | | - Svetlana Ratushnyak
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Jenny Shilton Osborne
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Soukkhaphone B, Baradaran M, Nguyen BD, Nshimyumukiza L, Little J, Rousseau F, Audibert F, Langlois S, Reinharz D. Expansion of non-invasive prenatal screening to the screening of 10 types of chromosomal anomalies: a cost-effectiveness analysis. BMJ Open 2023; 13:e069485. [PMID: 37648381 PMCID: PMC10471875 DOI: 10.1136/bmjopen-2022-069485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 08/18/2023] [Indexed: 09/01/2023] Open
Abstract
OBJECTIVES To determine the cost-effectiveness of the addition of chromosomal anomalies detectable by non-invasive prenatal screening (NIPS), in a prenatal screening programme targeting common aneuploidies. DESIGN, SETTING AND PARTICIPANTS A simulation study was conducted to study the addition of chromosomal anomalies detectable by NIPS (sex chromosome aneuploidies, 22q11.2 deletion syndrome, large deletion/duplication >7 Mb and rare autosomal trisomies) to five basic strategies currently aiming the common trisomies: three strategies currently offered by the public healthcare systems in Canada, whose first-tier test is performed with biochemical markers, and two programmes whose first-tier test consists of NIPS-based methods. OUTCOME MEASURES The total number of cases of chromosomal anomalies detected and the costs related to the consumption of medical services. RESULTS The most effective and the most cost-effective option in almost all prenatal screening strategies is the option that includes all targeted additional conditions. In the strategies where NIPS is used as first-tier testing, the cost per additional case detected by adding all possible additional anomalies to a programme that currently targets only common trisomies is $C25 710 (95% CI $C25 489 to $C25 934) for massively parallel shotgun sequencing and $C57 711 (95% CI $C57 141 to $C58 292) for targeted massively parallel sequencing, respectively. The acceptability curves show that at a willingness-to-pay of $C50 000 per one additional case detected, the expansion of NIPS-based methods for the detection of all possible additional conditions has a 90% probability of being cost-effective. CONCLUSION From an economic perspective, in strategies that use NIPS as a first-tier screening test, expanding the programmes to detect any considered chromosomal anomalies other than the three common trisomies would be cost-effective. However, the potential expansion of prenatal screening programmes also requires consideration of societal issues, including ethical ones.
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Grants
- PEGASUS 2 project, which funded by Genome Canada, the Canadian Institutes for Health Research, Genome Québec, Genome BC, Genome Alberta, the Québec Ministère de l'enseignement supérieur, de la recherche, de la science et de la technologie, the Fonds de recherche Québec - Santé, la Fondation de l’Université Laval and the Centre de recherche du CHU de Québec
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Affiliation(s)
| | | | | | - Leon Nshimyumukiza
- Laval University, Quebec City, Quebec, Canada
- Institut National d'Excellence en Santé et Services Sociaux, Quebec City, Quebec, Canada
| | | | - Francois Rousseau
- Laval University, Quebec City, Quebec, Canada
- CHU de Québec-Université Laval Research Center, Quebec City, Quebec, Canada
| | - Francois Audibert
- CHU Sainte-Justine, Quebec City, Quebec, Canada
- University of Montreal, Montreal, Quebec, Canada
| | - Sylvie Langlois
- The University of British Columbia, Vancouver, British Columbia, Canada
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Hui L, Ellis K, Mayen D, Pertile MD, Reimers R, Sun L, Vermeesch J, Vora NL, Chitty LS. Position statement from the International Society for Prenatal Diagnosis on the use of non-invasive prenatal testing for the detection of fetal chromosomal conditions in singleton pregnancies. Prenat Diagn 2023; 43:814-828. [PMID: 37076973 DOI: 10.1002/pd.6357] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 04/15/2023] [Indexed: 04/21/2023]
Abstract
Key points
What is already known about this topic?
In 2015, the International Society for Prenatal Diagnosis (ISPD) published its first position statement on the use of non‐invasive prenatal testing (NIPT) to screen for aneuploidy. Widespread uptake across the globe and subsequent published research has shed new light on test performance and implementation issues.
What does this study add?
This new position statement replaces the 2015 statement with updated information on the current technologies, clinical experience, and implementation practices.
As an international organization, ISPD recognizes that there are important population‐specific considerations in the organization of prenatal screening and diagnosis. These opinions are designed to apply to high income settings where prenatal screening for aneuploidy is an established part of antenatal care.
This position statement is not a clinical practice guideline but represents the consensus opinion of the current ISPD Board based on the current state of knowledge and clinical practice.
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Affiliation(s)
- Lisa Hui
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia
- Reproductive Epidemiology Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Perinatal Medicine, Mercy Hospital for Women, Heidelberg, Victoria, Australia
- Department of Obstetrics and Gynaecology, Northern Health, Epping, Victoria, Australia
| | - Katie Ellis
- Illumina ANZ, Sydney, New South Wales, Australia
| | - Dora Mayen
- Genetics Clinic, Hospital Angeles Lomas, Estado de Mexico, Mexico
| | - Mark D Pertile
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Rebecca Reimers
- San Diego Perinatal Center, Rady Children's Hospital, San Diego, California, USA
- Scripps Research Institute, La Jolla, California, USA
| | - Luming Sun
- Department of Fetal Medicine & Prenatal Diagnosis Center, Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | | | - Neeta L Vora
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Division of Maternal Fetal Medicine, Chapel Hill, North Carolina, USA
| | - Lyn S Chitty
- Great Ormond Street NHS Foundation Trust, London, UK
- UCL Great Ormond Street Institute of Child Health, London, UK
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Shayan-Moghadam R, Sharafi M, Violas P, Nabian MH, Mehrpour SR. Grisel's syndrome and Down syndrome: a case report. INTERNATIONAL JOURNAL OF BURNS AND TRAUMA 2023; 13:94-98. [PMID: 37215515 PMCID: PMC10195222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 02/02/2023] [Indexed: 05/24/2023]
Abstract
Grisel's syndrome is a non-traumatic subluxation of the atlantoaxial joint following an inflammatory process in the upper respiratory tract. Patients with Down syndrome have higher risks of developing atlantoaxial instability. This issue is mainly due to low muscle tone, loose ligaments, and alterations to the bone in patients with Down syndrome. Accompaniment of Grisel's syndrome and Down syndrome was not perused in recent investigations. To our knowledge, only one case of Grisel's syndrome in an adult patient with Down syndrome has been reported. In this study, we present a case of Grisel syndrome in a 7-year-old boy with Down syndrome following lymphadenitis. A 7-year-old boy with Down syndrome was admitted to the orthopedic ward of Shariati hospital with a possible diagnosis of Grisel's syndrome and treated with mento-occipital traction for ten days. In this case report, we represent a child with Down syndrome with Grisel's syndrome for the first time. We also imitated a simple and applicable non-surgical treatment for Grisel's syndrome.
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Affiliation(s)
- Ramin Shayan-Moghadam
- Department of Orthopaedic Surgery, Center for Orthopedic Trans-disciplinary Applied Research, Shariati Hospital, Tehran University of Medical SciencesTehran, Iran
| | - Mohammadhasan Sharafi
- Department of Orthopaedic and Trauma Surgery, Shariati Hoapital and School of Medicine, Tehran University of Medical SciencesTehran, Iran
| | - Philippe Violas
- Pediatric Orthopedic Service, Central Hospital University of Rennes35000 Rennes, France
| | - Mohammad Hossein Nabian
- Department of Orthopaedic Surgery, Center for Orthopedic Trans-disciplinary Applied Research, Shariati Hospital, Tehran University of Medical SciencesTehran, Iran
| | - Saeed Reza Mehrpour
- Department of Orthopedics and Trauma Surgery, Shariati Hospital, TUMSTehran, Iran
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Ghiasi M, Armour C, Walker M, Shaver N, Bennett A, Little J. Issues associated with possible implementation of Non-Invasive Prenatal Testing (NIPT) in first-tier screening: A rapid scoping review. Prenat Diagn 2023; 43:62-71. [PMID: 36461628 DOI: 10.1002/pd.6278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 10/24/2022] [Accepted: 11/27/2022] [Indexed: 12/04/2022]
Abstract
In recent years, as the implementation and use of Non-Invasive Prenatal Testing (NIPT) have increased, the cost of the test has been decreasing. The cost of NIPT is expected to fall further in the upcoming years. As a result of the decreasing cost of NIPT, many jurisdictions may change their prenatal screening policies toward abandoning serum-based screening and instead, implement and support NIPT as the first-tier screening for all women. There are several concerns in replacing first-trimester screening with NIPT. In this scoping review, we aimed to map the existing knowledge about possible issues in the systematic implementation of NIPT as the primary method of first-tier screening and to assess if any jurisdiction has altered its policy and discontinued serum-based prenatal screening in exchange for NIPT. The Medline database (Ovid) and Google Scholar was searched and all the studies discussing, investigating, or reporting on the systematic implementation of NIPT as the primary method of first-tier screening were included. All the studies went through a two-stage screening process and included full-text articles were reviewed. We did not find any articles indicating a country or region that replaced traditional prenatal screening by NIPT. The included articles were charted, and the data about the possible issues in the systematic implementation of NIPT as the primary method of first-tier screening are summarized narratively and presented in tables in four categories. The findings of this scoping review may be informative for stakeholders and policymakers regarding recent changes in NIPT implementation policies around the world and may aid with developing policy for NIPT implementation with a broader perspective.
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Affiliation(s)
- Maryam Ghiasi
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Christine Armour
- Department of Medical Genetics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Prenatal Screening Ontario (PSO), Better Outcomes Registry & Network (BORN) Ontario, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Mark Walker
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Nicole Shaver
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Alexandria Bennett
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Julian Little
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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Dai P, Yang Y, Zhao G, Gu Z, Ren H, Hu S, Liu N, Jiao W, Li J, Kong X. A dPCR-NIPT assay for detections of trisomies 21, 18 and 13 in a single-tube reaction-could it replace serum biochemical tests as a primary maternal plasma screening tool? J Transl Med 2022; 20:269. [PMID: 35706031 PMCID: PMC9198625 DOI: 10.1186/s12967-022-03455-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 05/24/2022] [Indexed: 11/25/2022] Open
Abstract
Background The next generation sequencing (NGS) based non-invasive prenatal test (NIPT) has outplayed the traditional serum biochemical tests (SBT) in screen of fetal aneuploidies with a high sensitivity and specificity. However, it has not been widely used as a primary screen tool due to its high cost and the cheaper SBT is still the choice for primary screen even with well-known shortages in sensitivity and specificity. Here, we report a multiplex droplet digital PCR NIPT (dPCR-NIPT) assay that can detect trisomies 21, 18 and 13 (T21, T18 and T13) in a single tube reaction with a better sensitivity and specificity than the SBT and a much cheaper price than the NGS-NIPT. Methods In this study, the dPCR-NIPT assay’s non-clinical characteristics were evaluated to verify the cell free fetal DNA (cffDNA) fraction enrichment efficiencies, the target cell free DNA (cfDNA) concentration enrichment, the analytical sensitivity, and the sample quality control on the minimum concentration of cfDNA required for the assay. We validated the clinical performance for this assay by blindly testing 283 clinical maternal plasma samples, including 36 trisomic positive samples, from high risk pregnancies to access its sensitivity and specificity. The cost effectiveness of using the dPCR-NIPT assay as the primary screen tool was also analyzed and compared to that of the existing contingent strategy (CS) using the SBT as the primary screen tool and the strategy of NGS-NIPT as the first-tier screen tool in a simulating situation. Results For the non-clinical characteristics, the sample processing reagents could enrich the cffDNA fraction by around 2 folds, and the analytical sensitivity showed that the assay was able to detect trisomies at a cffDNA fraction as low as 5% and the extracted cfDNA concentration as low as 0.2 ng/μL. By testing the 283 clinical samples, the dPCR-NIPT assay demonstrated a detection sensitivity of 100% and a specificity of 95.12%. Compared to the existing CS and the NGS-NIPT as the first-tier screen strategy, dPCR-NIPT assay used as a primary screen tool followed by the NGS-NIPT rescreen is the most economical approach to screen pregnant women for fetal aneuploidies without sacrificing the positive detection rate. Conclusion This is the first report on a dPCR-NIPT assay, consisting of all the necessary reagents from sample processing to multiplex dPCR amplification, can detect T21, T18 and T13 in a single tube reaction. The study results reveal that this assay has a sensitivity and specificity superior to the SBT and a cost much lower than the NGS-NIPT. Thus, from both the test performance and the economic benefit points of views, using the dPCR-NIPT assay to replace the SBT as a primary screen tool followed by the NGS-NIPT rescreen would be a better approach than the existing CS for detection of fetal aneuploidies in maternal plasma. Supplementary Information The online version contains supplementary material available at 10.1186/s12967-022-03455-y.
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Affiliation(s)
- Peng Dai
- The Genetics and Prenatal Diagnosis Center, The Department of Obstetrics and Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
| | - Yanfeng Yang
- Shanghai Tage Biotechnology Co., Ltd, Shanghai, 201201, China
| | - Ganye Zhao
- The Genetics and Prenatal Diagnosis Center, The Department of Obstetrics and Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
| | - Zhiqiang Gu
- Shanghai Tage Biotechnology Co., Ltd, Shanghai, 201201, China
| | - Huanan Ren
- The Genetics and Prenatal Diagnosis Center, The Department of Obstetrics and Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
| | - Shuang Hu
- The Genetics and Prenatal Diagnosis Center, The Department of Obstetrics and Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
| | - Ning Liu
- The Genetics and Prenatal Diagnosis Center, The Department of Obstetrics and Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
| | - Weimeng Jiao
- Shanghai Tage Biotechnology Co., Ltd, Shanghai, 201201, China
| | - Jinfang Li
- Henan Newbern Medical Technology Co. Ltd, Zhengzhou, 450053, Henan, China
| | - Xiangdong Kong
- The Genetics and Prenatal Diagnosis Center, The Department of Obstetrics and Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China.
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Fisher SA, Miller ES, Yee LM, Grobman WA, Premkumar A. Universal First-Trimester Cytomegalovirus Screening and Valaciclovir Prophylaxis in Pregnant Persons: A Cost-Effectiveness Analysis. Am J Obstet Gynecol MFM 2022; 4:100676. [PMID: 35714861 DOI: 10.1016/j.ajogmf.2022.100676] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 06/10/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Recent studies suggest a possible benefit of valaciclovir prophylaxis to prevent vertical transmission after a positive serologic screen for primary maternal cytomegalovirus infection during pregnancy, although its cost-effectiveness remains uncertain. OBJECTIVE We sought to determine the circumstances under which universal first-trimester maternal serologic screening for maternal cytomegalovirus infection, with valaciclovir prophylaxis to prevent congenital cytomegalovirus, is cost-effective. STUDY DESIGN We performed a decision analysis from the perspective of the pregnant person to assess whether universal maternal screening in the first trimester, with subsequent valaciclovir prophylaxis (8g/day from time of positive serologic screen for primary maternal cytomegalovirus infection through 21 weeks' gestation) for those who are acutely infected, is cost-effective compared to usual care (i.e., no routine serologic screening, but amniocentesis if mid-trimester sonographic findings suggest cytomegalovirus). For baseline estimates, we assumed a 35% risk of congenital cytomegalovirus after primary maternal infection and a 71% risk reduction with valaciclovir. We varied valaciclovir's efficacy to identify whether and at what threshold universal screening would be estimated to be cost-effective, compared to usual care. Monte Carlo analyses were performed. A willingness-to-pay threshold of $100,000/quality-adjusted life year was used to define cost-effectiveness. RESULTS Under base-case estimates, first-trimester universal screening and valaciclovir prophylaxis for seropositive pregnant persons with acute cytomegalovirus infection is not cost-effective, with a cost of $137,854 per maternal QALY, but results in 14 fewer cytomegalovirus-affected children per 100,000 pregnancies compared to usual care. In one-way sensitivity analysis, universal screening and treatment is estimated to be the cost-effective strategy if the incidence of primary maternal cytomegalovirus infection exceeds 2.6%, baseline risk of vertical transmission of cytomegalovirus without prophylaxis is greater than 36.8%, and the risk reduction of vertical transmission of cytomegalovirus with valaciclovir prophylaxis exceeds 75.9%. In Monte Carlo analyses, first-trimester universal serologic screening with valaciclovir prophylaxis is estimated to be the cost-effective strategy in 46.8% of runs. CONCLUSION Universal first-trimester serologic screening with valaciclovir prophylaxis is not the cost-effective strategy for antenatal management of cytomegalovirus under the base-case estimates. Although universal screening is cost-effective in certain circumstances when the efficacy of valaciclovir exceeds the base case, that result is not robust to variation of estimates across their reasonable ranges. These data can inform future studies to evaluate screening and treatment to prevent congenital CMV.
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Affiliation(s)
- Stephanie A Fisher
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Emily S Miller
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Lynn M Yee
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - William A Grobman
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The Ohio State University College of Medicine, Cleveland, Ohio.
| | - Ashish Premkumar
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Obstetrics and Gynecology, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois.
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Xiao G, Zhao Y, Huang W, Hu L, Wang G, Luo H. Health economic evaluation of noninvasive prenatal testing and serum screening for down syndrome. PLoS One 2022; 17:e0266718. [PMID: 35421148 PMCID: PMC9009700 DOI: 10.1371/journal.pone.0266718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 03/25/2022] [Indexed: 11/24/2022] Open
Abstract
Background Down syndrome (DS), also known as trisomy 21 (T21), is the most common genetic disorder associated with intellectual disability. There are two methods commonly used for prenatal testing of DS: serum screening (SS) for biomarkers in maternal serum and noninvasive prenatal testing (NIPT) for aneuploidy by cell-free DNA (cfDNA) in maternal plasma. However, cost-effectiveness analyses of these two methods are mostly based on data derived from simulations with various models, with theoretical values calculated. In this study, we statistically analyzed clinical DS screening data and pregnancy outcomes during the follow-up of pregnant women in Zhuhai City, China. The economics of the two mainstream prenatal DS screening methods was evaluated from a public health perspective. Methods A retrospective analysis was performed on the data of 17,363 pregnant women who received SS and NIPT during gestation in Zhuhai from 2018 to 2019, and a cost-effectiveness analysis was performed with four screening strategies. In strategy I, all pregnant women received SS, and those with T21 risk ≥1/270 had invasive prenatal diagnosis (IPD). In strategy II, all pregnant women received SS, those with T21 risk ≥ 1/270 had IPD, and those with 1/270 > T21 risk ≥ 1/1,000 had NIPT; then, women at high risk based on NIPT also had IPD. In strategy III, all pregnant women received SS, and those with T21 risk ≥1,000 had NIPT; then, women at high risk based on NIPT results had IPD. In strategy IV, all pregnant women received NIPT and those at high risk based on NIPT results had IPD. Finally, to assess the cost and effectiveness of DS screening, the total costs were calculated as the sum of screening and diagnosis as well as the direct and indirect economic burden during the average life cycle of DS patients. Results A total of 22 of the 17,363 (1/789) pregnant women had DS, of which only one woman was over 35 years of age. SS detected 1,024 cases at high risk of T21 (≥1/270), 8 cases were true positive, with a positive predictive value of 0.78% and a detection rate of 36.4%. NIPT detected 27 cases at high risk of T21 (Z ≥ 3) and 22 cases of DS, with a positive predictive value of 81.5% and a detection rate of 100%. Strategy I had the largest total cost of 65.54 million CNY, strategy II and III had similar total costs of 40 million CNY, and strategy IV had the lowest total cost of 14.91 million CNY. By comparison, the screening strategy with NIPT alone had the highest health economic value for DS. Conclusions SS was greatly affected by nuchal translucency and the accuracy of gestational age measured by ultrasonography. Unstandardized ultrasonography was an important reason for the low DS detection rate with SS. The influence of interfering factors on NIPT was much lower than in SS. NIPT can be used as an alternative to SS and as a primary screening strategy of prenatal DS screening for secondary prevention and control of birth defects. NIPT greatly decreased the frequency of IPD and the miscarriages associated with IPD, saved the limited medical and health resources, and greatly increased DS detection rate. Therefore, NIPT has great social and economic benefits.
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Affiliation(s)
- Gefei Xiao
- Department of Clinic Laboratory (Institute of medical genetics), Zhuhai Center for Maternal and Child Healthcare, Zhuhai, Guangdong province, China
- * E-mail:
| | - Yanling Zhao
- Department of Clinic Laboratory (Institute of medical genetics), Zhuhai Center for Maternal and Child Healthcare, Zhuhai, Guangdong province, China
| | - Wuyan Huang
- Department of Clinic Laboratory (Institute of medical genetics), Zhuhai Center for Maternal and Child Healthcare, Zhuhai, Guangdong province, China
| | - Liqing Hu
- Department of Clinic Laboratory (Institute of medical genetics), Zhuhai Center for Maternal and Child Healthcare, Zhuhai, Guangdong province, China
| | - Guoqing Wang
- Department of Clinic Laboratory (Institute of medical genetics), Zhuhai Center for Maternal and Child Healthcare, Zhuhai, Guangdong province, China
| | - Huayu Luo
- Department of Clinic Laboratory (Institute of medical genetics), Zhuhai Center for Maternal and Child Healthcare, Zhuhai, Guangdong province, China
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Cuckle H, Heinonen S, Anttonen AK, Stefanovic V. Cost of providing cell-free DNA screening for Down syndrome in Finland using different strategies. J Perinat Med 2022; 50:233-243. [PMID: 34860478 DOI: 10.1515/jpm-2021-0467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 11/11/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVES A financial analysis is carried out to assess costs and benefits of providing cell-free DNA screening in Finland, using different strategies. METHODS Three cell-free DNA screening strategies are considered: Primary, all women; Secondary, those with positive Combined test; and Contingent, the 10-30% with the highest Combined test risks. Three costs are estimated: additional cost for 10,000 pregnancies compared with the Combined test; 'marginal' cost of avoiding a Down syndrome birth which occurs in a pregnancy that would have been false-negative using the Combined test; and marginal cost of preventing the iatrogenic loss of a non-Down syndrome birth which occurs in a pregnancy that would have been false-positive. RESULTS Primary cell-free DNA will require additional funds of €250,000. The marginal cost per Down syndrome birth avoided is considerably less than the lifetime medical and indirect cost; the marginal cost per unaffected iatrogenic fetal loss prevented is higher than one benefit measure but lower than another. If the ultrasound component of the Combined test is retained, as would be in Finland, the additional funds required rise to €992,000. Secondary cell-free DNA is cost-saving as is a Contingent strategy with 10% selected but whilst when 20-30% costs rise they are much less than for the Primary strategy and are cost-beneficial. CONCLUSIONS When considering the place of cell-free DNA screening it is important to make explicit the additional and marginal costs of different screening strategies and the associated benefits. Under most assumptions the balance is favorable for Contingent screening.
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Affiliation(s)
- Howard Cuckle
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Seppo Heinonen
- Department of Obstetrics and Gynecology, Fetomaternal Medical Centre, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anna-Kaisa Anttonen
- HUSLAB Laboratory of Genetics and Department of Clinical Genetics, HUS Diagnostic Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Vedran Stefanovic
- Department of Obstetrics and Gynecology, Fetomaternal Medical Centre, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Cubo AM, Huélamo M, Martín-Seisdedos MC, Hernández-Hernández E, Lapresa-Alcalde MV, Rodríguez-Martín MDLO, Doyague MJ, Sayagués JM. Population contingent cfDNA screening implementation: increasing diagnostic accuracy and reducing invasive testing. 6 years results in a single center. Fetal Diagn Ther 2022; 49:103-113. [PMID: 35259749 DOI: 10.1159/000523848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/23/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES In 2018, a contingent screening program was implemented in the community of Castilla y Leon (Spain). This study aimed to compare the results achieved in the University Hospital of Salamanca during the three years of contingent screening (2018-2020) with those of the previous three years (2015-2017) to assess the modification in the rate of trisomies detection and the number of invasive tests. METHODS A total of 9903 singleton pregnancies without malformations nor nuchal translucency >p99 were included. 5165 patients underwent combined screening and 4738 had contingent screening based on the combined test risk. In the combined test group, women were offered an invasive test if the risk was ≥1:270 whilst risks under 1:270 were considered low risks, and no further testing was offered. In the contingent screening group, invasive testing was offered if the risk was ≥1:100 (≥1:50 from 2020 onwards) whilst cfDNA was offered if the combined test risk was between 1:100 to 1:1000 (1:50-1:1000 from 2020 onwards). When risk was <1:1000, no further testing was offered. RESULTS There were 30 cases of trisomy 21 throughout the 6 years of study. 4 cases had risks <1:270 and were diagnosed by cfDNA. Risk >1:1000 threshold for contingent test detected 100% T21. There were no false-negative results. "No-call" cfDNA results were minimized by repeating blood collection two weeks later, as fetal fraction was doubled. Invasive testing had a drop rate of 84% after contingent screening implementation. DISCUSSION The implementation of population-based contingent screening significantly reduces the number of invasive tests without lowering diagnostic accuracy. To achieve the maximum efficiency of the program, it is important to know the best cut-offs according to the population where the program is to be implemented. The number of uninformative results due to low fetal fraction (FF) can be reduced by repeating the test 2 weeks after the initial extraction: this increases the FF to twice the initial one, achieving informative results and avoiding unnecessary invasive tests.
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Affiliation(s)
- Ana María Cubo
- Department of Obstetrics and Gynecology, Salamanca University Hospital, Salamanca, Spain
- Department of Diagnostic and Biolomedical Sciences, Faculty of Medicine, Salamanca University, Salamanca, Spain
- IBSAL - Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
| | - Marta Huélamo
- Department of Obstetrics and Gynecology, Salamanca University Hospital, Salamanca, Spain
- Department of Diagnostic and Biolomedical Sciences, Faculty of Medicine, Salamanca University, Salamanca, Spain
- IBSAL - Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
| | | | - Estrella Hernández-Hernández
- Department of Obstetrics and Gynecology, Salamanca University Hospital, Salamanca, Spain
- IBSAL - Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
| | - Maria Victoria Lapresa-Alcalde
- Department of Obstetrics and Gynecology, Salamanca University Hospital, Salamanca, Spain
- Department of Diagnostic and Biolomedical Sciences, Faculty of Medicine, Salamanca University, Salamanca, Spain
- IBSAL - Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
| | - María de la O Rodríguez-Martín
- Department of Obstetrics and Gynecology, Salamanca University Hospital, Salamanca, Spain
- Department of Diagnostic and Biolomedical Sciences, Faculty of Medicine, Salamanca University, Salamanca, Spain
- IBSAL - Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
| | - María José Doyague
- Department of Obstetrics and Gynecology, Salamanca University Hospital, Salamanca, Spain
- Department of Diagnostic and Biolomedical Sciences, Faculty of Medicine, Salamanca University, Salamanca, Spain
- IBSAL - Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
| | - José María Sayagués
- Department of Diagnostic and Biolomedical Sciences, Faculty of Medicine, Salamanca University, Salamanca, Spain
- IBSAL - Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
- Department of Pathology, Salamanca University Hospital, Salamanca, Spain
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11
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Di Giacomo M, Piacenza M, Siciliani L, Turati G. The effect of co-payments on the take-up of prenatal tests. JOURNAL OF HEALTH ECONOMICS 2022; 81:102553. [PMID: 34808492 DOI: 10.1016/j.jhealeco.2021.102553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 10/29/2021] [Accepted: 11/01/2021] [Indexed: 06/13/2023]
Abstract
Noninvasive prenatal screening tests help identify genetic disorders in a fetus, but their take-up remains low in several countries. Using a regression discontinuity design, we test the causal effect of a policy that eliminated co-payments for noninvasive screening tests in Italy. We identify the treatment effects by a discontinuity in women's eligibility for a free test based on their conception date. We find that the policy increases the probability of women's undergoing noninvasive screening tests by 5.5 percentage points, and the effect varies by socioeconomic status. We do not find evidence of substitution effects with more expensive and riskier invasive diagnostic tests. In addition, the increase in take-up does not affect pregnancy termination or newborn health. We find some evidence of positive effects on mothers' health behaviors during pregnancy as measured by reductions in mothers' weight gain and hospital admissions during pregnancy, but these are statistically significant only at the 10 percent level.
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Affiliation(s)
- Marina Di Giacomo
- University of Torino, Department of Economics, Social Sciences, Applied Mathematics and Statistics (ESOMAS).
| | - Massimiliano Piacenza
- University of Piemonte Orientale, Department of Economics and Business (DISEI), Novara, Italy.
| | - Luigi Siciliani
- University of York, Department of Economics and Related Studies, York, United Kingdom.
| | - Gilberto Turati
- Università Cattolica del Sacro Cuore, Department of Economics and Finance, Rome, Italy.
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12
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Fujimoto AB, Ayer T, Caughey AB, Keskinocak P. A comparison of first trimester prenatal screening strategies for Down Syndrome with maternal age and preferences considerations. Prenat Diagn 2020; 40:1553-1562. [PMID: 32794316 DOI: 10.1002/pd.5811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/07/2020] [Accepted: 08/08/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Screening for Down Syndrome (DS) includes traditional ultrasound and serum-based and cell-free DNA (cfDNA) testing. While cfDNA testing usually has superior performance, it is significantly more costly. As an alternative, a hybrid strategy combining contingent cfDNA with traditional testing is recommended when universal cfDNA screening is not feasible. This study compares the efficacy of traditional, contingent cfDNA, and universal cfDNA screening strategies at various cut-offs based on maternal age and parents' preferences, which may improve testing outcomes and patients' satisfaction. METHOD Decision trees were used to analyze a cohort of 3 855 500 pregnancies from 12 to 50 years old. The performance of the strategies was compared using the number of adverse outcomes (undetected DS live births and euploid procedure-related losses). RESULTS Universal cfDNA results in the fewest number of adverse outcomes in every scenario. Contingent cfDNA performs better than traditional screening when the cut-offs used to identify high-risk cases for cfDNA testing are relatively low. These cut-offs change depending on the maternal age and parents' preference. CONCLUSION Maternal age and parents' preferences should be considered when choosing cut-offs for contingent cfDNA to remain as an effective strategy compared to traditional screening and to improve patient satisfaction.
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Affiliation(s)
- Akane B Fujimoto
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Turgay Ayer
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Pinar Keskinocak
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
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Thorolfsdottir E, Lunde Å, Stefansdottir V, Hjartardottir H, Rut Haraldsdottir K. Comparing prenatal screening experiences of Icelandic women who received false-positive and true-negative first-trimester combined screening results in Iceland in 2012-2016. J Genet Couns 2020; 29:644-657. [PMID: 32198907 DOI: 10.1002/jgc4.1269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/24/2020] [Accepted: 02/25/2020] [Indexed: 01/04/2023]
Abstract
First-trimester combined screening (FTS) has been offered to all pregnant women in Iceland since 2003. Individuals with high-risk FTS results are offered an invasive test option with a ≤1% risk of fetal loss. This study gives insight into the prenatal screening and diagnosis experiences and preferences of 101 women who underwent FTS in Iceland in the years 2012-2016, comparing the experience of those who received false-positive FTS results to those who received true-negative results. Retrospective patient-reported anxiety levels at the time of receiving FTS results were significantly higher in those who received false-positive results compared to those who received true-negative results. For a subset of these participants, the anxiety lasted through pregnancy, and for a smaller subset, it lasted even longer. Non-invasive prenatal testing (NIPT) is currently not offered in Iceland, aside from the rare exceptional case. Given the extremely low false-positive rates of NIPT, we believe NIPT is worth considering as Iceland's standard first-tier screening method for trisomy 13, 18, and 21. We believe the findings of this study are beneficial not only for Iceland but also for other countries where FTS is the first-tier prenatal screening method or the only offered test. Additionally, only 21% of participants in our study reported that they had heard of NIPT, which emphasizes the need for comprehensive NIPT pretest information to be available prior to its uptake to ensure informed and autonomous decision-making.
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Affiliation(s)
- Eirny Thorolfsdottir
- Department of Genetics and Molecular Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - Åshild Lunde
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Vigdis Stefansdottir
- Department of Genetics and Molecular Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - Hulda Hjartardottir
- Prenatal Diagnostic Unit, Women's and Children's Services, Landspitali University Hospital, Reykjavik, Iceland
| | - Kristin Rut Haraldsdottir
- Prenatal Diagnostic Unit, Women's and Children's Services, Landspitali University Hospital, Reykjavik, Iceland
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