Timing of elective delivery in gastroschisis: a decision and cost-effectiveness analysis.
OBJECTIVE
To determine the most cost-effective timing of delivery in pregnancies complicated by gastroschisis, using a decision-analytic model.


METHODS
We created a decision-analytic model to compare planned delivery at 35, 36, 37, 38 and 39 weeks' gestation. Outcomes considered were stillbirth, death within 1 year of birth and respiratory distress syndrome (RDS). Probability estimates of events (stillbirth, complex gastroschisis and RDS for each gestational age at delivery and risk of death with simple and complex gastroschisis), utilities and costs assigned to the outcomes were obtained from the published literature. Cost analysis was assessed from a societal perspective, using a willingness-to-pay threshold of $100,000 per surviving infant. Outcomes and costs were considered throughout 1 year of postnatal life. Multiway sensitivity analysis was performed to address uncertainties in baseline assumptions.


RESULTS
In the base-case analysis, delivery at 38 weeks' gestation was the most cost-effective strategy. Planned delivery at 35 weeks was associated with the fewest stillbirths and deaths within 1 year of delivery, owing largely to a lower ongoing risk of stillbirth. In Monte Carlo simulation when every variable was varied over its entire range, delivery at 38 weeks was cost-effective compared to delivery at 39 weeks in 76% of trials and delivery at 37 weeks was cost-effective in 69% of trials. Delivery at 38 weeks resulted in three additional cases of RDS for every 100 stillbirths or deaths within 1 year that were prevented.


CONCLUSIONS
For pregnancies complicated by gastroschisis, the most cost-effective timing of delivery is at 38 weeks. Few additional cases of RDS are caused for every one stillbirth or death within 1 year that was prevented with delivery at 37-38 weeks compared with at 39 weeks.
The Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL, USA.
L M
LM
Harper
The Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, MO, USA.
K R
KR
Goetzinger
The Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL, USA.
J R
JR
Biggio
The Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, MO, USA.
G A
GA
Macones
D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D036861:Delivery, Obstetric / Q000379:methods* / Q000592:standards; D017558:Elective Surgical Procedures / Q000379:methods*; D005260:Female; D020139:Gastroschisis / Q000000981:diagnostic imaging / Q000473:pathology / Q000503:physiopathology*; D006801:Humans; D007231:Infant, Newborn; D011247:Pregnancy; D011248:Pregnancy Complications / Q000000981:diagnostic imaging / Q000473:pathology / Q000503:physiopathology*; D011256:Pregnancy Outcome; D016032:Randomized Controlled Trials as Topic; D016019:Survival Analysis; D014463:Ultrasonography
cost effectiveness; decision analysis; early term birth; gastroschisis; respiratory distress