title: Cost-effectiveness of transvaginal ultrasound cervical length screening in singletons without a prior preterm birth: an update.
abstract: OBJECTIVE
  We sought to reevaluate the cost-effectiveness of universal transvaginal ultrasound (TVU) cervical length (CL) screening in singleton pregnancies without prior spontaneous preterm birth.
  
  
  METHODS
  We developed a decision model to assess costs and effects of universal TVU CL screening at 18-23 weeks' gestation compared to routine care for singleton pregnancies without prior preterm birth. Based on recent data, the model contains the following updates: (1) reduced incidence of CL ≤20 mm at initial screening ultrasound (0.83%), (2) vaginal progesterone supplementation for women with CL ≤20 mm, (3) additional ultrasound(s) for women with CL 21-24.9 mm, and (4) the assumption that vaginal progesterone reduces the rate of preterm birth <34 weeks' gestation by 39% if a short CL is diagnosed. The primary outcome was incremental cost-effectiveness ratio. We assumed a willingness to pay of $100,000 per quality-adjusted life year (QALY) gained. Additional outcomes included incidence of offspring with long-term neurological deficits and neonatal death. Sensitivity analyses were performed to assess the robustness of the results.
  
  
  RESULTS
  For every 100,000 women screened, universal TVU CL screening costs $9132 compared to routine care. Screening results in 215 QALYs gained and 10 fewer neonatal deaths or neonates with long-term neurologic deficits per 100,000 women screened. Based on the updated data, universal CL screening in low-risk women remains a cost-effective strategy (incremental cost-effectiveness ratio = $43/QALY), but is not cost saving as previously estimated. Sensitivity analyses reveal that when incidence of TVU CL ≤20 mm is <0.31%, universal TVU CL screening is no longer cost-effective. Additionally, when TVU CL costs >$314, progesterone reduces preterm delivery risk before 34 weeks <19%, or the incidence of a TVU CL 21-24.9 mm is >6.5%, CL screening is also no longer cost-effective.
  
  
  CONCLUSIONS
  Despite the reduced incidence and efficacy used in this model, universal TVU CL continues to be cost-effective when compared to routine care in singletons without prior preterm birth.
authors.affiliation: Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, RI. Electronic address: ewerner@wihri.org.
authors.forename: Erika F
authors.initials: EF
authors.lastname: Werner
authors.affiliation: Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, RI.
authors.forename: Maureen S
authors.initials: MS
authors.lastname: Hamel
authors.affiliation: Virginia Hospital Center Physician Group, Arlington, VA.
authors.forename: Kelly
authors.initials: K
authors.lastname: Orzechowski
authors.affiliation: Department of Obstetrics and Gynecology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Berghella
authors.affiliation: Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH.
authors.forename: Stephen F
authors.initials: SF
authors.lastname: Thung
mesh_terms: D000282:Administration, Intravaginal; D054791:Cervical Length Measurement / Q000191:economics*; D002584:Cervix Uteri / Q000000981:diagnostic imaging*; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D011247:Pregnancy; D011262:Pregnancy Trimester, Second; D047928:Premature Birth / Q000191:economics / Q000517:prevention & control*; D011374:Progesterone / Q000627:therapeutic use*; D011372:Progestins / Q000627:therapeutic use*; D019057:Quality-Adjusted Life Years; D018570:Risk Assessment
chemical_list: D011372:Progestins; D011374:Progesterone
keywords: cervical length; preterm birth; progesterone; transvaginal ultrasound