title: Lifetime cost-effectiveness of trial of labor after cesarean in the United States.
abstract: OBJECTIVE
  To estimate the cost-effectiveness of a trial of labor after one previous cesarean (TOLAC) when incorporating long-term events and outcomes.
  
  
  METHODS
  A Markov model comparing TOLAC with elective repeat cesarean delivery (ERCD) was developed for a hypothetical cohort with no contraindication to a TOLAC. Women were selected from a prospective study to derive probability estimates for potential events through three subsequent pregnancies. Probabilities for cerebral palsy and stress urinary incontinence, cost data, and quality-adjusted life-years (QALYs) were obtained from the literature. The primary outcome was cost-effectiveness measured as the marginal cost per QALY gained, with a $50,000 threshold per QALY used to define cost-effectiveness.
  
  
  RESULTS
  The TOLAC strategy dominated the ERCD strategy at baseline, with $164.2 million saved and 500 QALYs gained per 100,000 women. The model was sensitive to six variables: the probability of uterine rupture and successful TOLAC among women with no prior vaginal delivery, the frequency of stress urinary incontinence, and the costs of failed TOLAC, successful TOLAC, and ERCD. When the probability of TOLAC success was at the base value, 67.2%, TOLAC was preferred if the probability of uterine rupture was 3.1% or less. When the probability of uterine rupture was at the base value, 0.8%, the TOLAC strategy was preferred as long as the probability of success was 47.2% or more. Probabilistic sensitivity analysis confirmed the base-case analysis.
  
  
  CONCLUSIONS
  Under baseline circumstances, TOLAC is less expensive and more effective than an ERCD when considering long-term consequences when the likelihood of success is 47.2% or more.
authors.affiliation: The George Washington University Biostatistics Center, Washington, DC, USA. Electronic address: sgilbert@bsc.gwu.edu.
authors.forename: Sharon A
authors.initials: SA
authors.lastname: Gilbert
authors.forename: William A
authors.initials: WA
authors.lastname: Grobman
authors.forename: Mark B
authors.initials: MB
authors.lastname: Landon
authors.forename: Michael W
authors.initials: MW
authors.lastname: Varner
authors.forename: Ronald J
authors.initials: RJ
authors.lastname: Wapner
authors.forename: Yoram
authors.initials: Y
authors.lastname: Sorokin
authors.forename: Baha M
authors.initials: BM
authors.lastname: Sibai
authors.forename: John M
authors.initials: JM
authors.lastname: Thorp
authors.forename: Susan M
authors.initials: SM
authors.lastname: Ramin
authors.forename: Brian M
authors.initials: BM
authors.lastname: Mercer
mesh_terms: D000328:Adult; D000368:Aged; D002755:Choice Behavior; D003362:Cost-Benefit Analysis; D017558:Elective Surgical Procedures; D005260:Female; D006801:Humans; D008390:Markov Chains; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011247:Pregnancy; D011248:Pregnancy Complications / Q000191:economics* / Q000453:epidemiology; D011336:Probability; D019057:Quality-Adjusted Life Years; D014219:Trial of Labor; D014481:United States / Q000453:epidemiology; D016064:Vaginal Birth after Cesarean / Q000191:economics*
keywords: accreta; cost-effectiveness; elective repeat; trial of labor
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