title: Cost-effectiveness of prenatal screening strategies for congenital heart disease.
abstract: OBJECTIVE
  The economic implications of strategies to improve prenatal screening for congenital heart disease (CHD) in low-risk mothers have not been explored. The aim was to perform a cost-effectiveness analysis of different screening methods.
  
  
  METHODS
  We constructed a decision analytic model of CHD prenatal screening strategies (four-chamber screen (4C), 4C + outflow, nuchal translucency (NT) or fetal echocardiography) populated with probabilities from the literature. The model included whether initial screens were interpreted by a maternal-fetal medicine (MFM) specialist and different referral strategies if they were read by a non-MFM specialist. The primary outcome was the incremental cost per defect detected. Costs were obtained from Medicare National Fee estimates. A probabilistic sensitivity analysis was undertaken on model variables commensurate with their degree of uncertainty.
  
  
  RESULTS
  In base-case analysis, 4C + outflow referred to an MFM specialist was the least costly strategy per defect detected. The 4C screen and the NT screen were dominated by other strategies (i.e. were more costly and less effective). Fetal echocardiography was the most effective, but most costly. On simulation of 10 000 low-risk pregnancies, 4C + outflow screen referred to an MFM specialist remained the least costly per defect detected. For an additional $580 per defect detected, referral to cardiology after a 4C + outflow was the most cost-effective for the majority of iterations, increasing CHD detection by 13 percentage points.
  
  
  CONCLUSIONS
  The addition of examination of the outflow tracts to second-trimester ultrasound increases detection of CHD in the most cost-effective manner. Strategies to improve outflow-tract imaging and to refer with the most efficiency may be the best way to improve detection at a population level.
authors.affiliation: Department of Pediatrics, University of Utah, Salt Lake City, UT, USA.
authors.forename: N M
authors.initials: NM
authors.lastname: Pinto
authors.forename: R
authors.initials: R
authors.lastname: Nelson
authors.forename: M
authors.initials: M
authors.lastname: Puchalski
authors.forename: T D
authors.initials: TD
authors.lastname: Metz
authors.forename: K J
authors.initials: KJ
authors.lastname: Smith
mesh_terms: D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D004452:Echocardiography / Q000191:economics; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006330:Heart Defects, Congenital / Q000000981:diagnostic imaging* / Q000191:economics; D006801:Humans; D009010:Monte Carlo Method; D048208:Nuchal Translucency Measurement / Q000191:economics; D011247:Pregnancy; D011262:Pregnancy Trimester, Second; D012680:Sensitivity and Specificity; D018608:Ultrasonography, Doppler / Q000191:economics; D016216:Ultrasonography, Prenatal / Q000191:economics* / Q000379:methods; D014481:United States
keywords: congenital heart disease; cost; cost analysis; nuchal translucency measurement; prenatal diagnosis; prenatal ultrasound