An outcomes analysis of five prenatal screening strategies for trisomy 21 in women younger than 35 years.
OBJECTIVE
This study was undertaken to examine the cost-effectiveness and procedural-related losses associated with 5 prenatal screening strategies for fetal aneuploidy in women under 35 years old.


METHODS
Five prenatal screening strategies were compared in a decision analysis model: triple screen: maternal age and midtrimester serum alpha-fetoprotein, human chorionic gonadotropin (hCG), and unconjugated estriol; quad screen: triple screen plus serum dimeric inhibin A; first-trimester screen: maternal age, serum pregnancy-associated plasma protein A and free beta-hCG and fetal nuchal translucency at 10 to 14 weeks' gestation; integrated screen: first-trimester screen plus quad screen, but first-trimester results are withheld until the quad screen is completed when a composite result is provided; sequential screen: first-trimester screen plus quad screen, but the first-trimester screen results are provided immediately and prenatal diagnosis offered if positive; later prenatal diagnosis is available if the quad screen is positive. Model estimates were literature derived, and cost estimates also included local sources. The 5 strategies were compared for cost, the numbers of Down syndrome fetuses detected and live births averted, and the number of procedure-related euploid losses. Sensitivity analyses were performed for parameters with imprecise point estimates.


RESULTS
In the baseline analysis, sequential screening was the least expensive strategy ($455 million). It detected the most Down syndrome fetuses (n=1213), averted the most Down syndrome live births (n=678), but led to the highest number of procedure-related euploid losses (n=859). The integrated screen had the fewest euploid losses (n=62) and averted the second most Down syndrome live births (n=520). If fewer than 70% of women diagnosed with fetal Down syndrome elect to abort, the quad screen became the least expensive strategy.


CONCLUSIONS
Although sequential screening was the most cost-effective prenatal screening strategy for fetal trisomy 21, it had the highest procedure-related euploid loss rate. The patient's perspective on detection versus fetal safety may help define the optimal screening strategy.
Biggio
Joseph R
JR
Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Reproductive Genetics, University of Alabama at Birmingham, Ala, USA.
Morris
T Christopher
TC
Owen
John
J
Stringer
Jeffery S A
JS
D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D004314:Down Syndrome / Q000175:diagnosis*; D005260:Female; D005313:Fetal Death / Q000209:etiology; D006801:Humans; D008423:Maternal Age; D008962:Models, Theoretical; D011247:Pregnancy; D018566:Pregnancy, High-Risk; D011296:Prenatal Diagnosis / Q000009:adverse effects / Q000191:economics / Q000379:methods*; D012680:Sensitivity and Specificity