title: Revisiting the cost-effectiveness of universal cervical length screening: importance of progesterone efficacy.
abstract: Preterm birth (PTB) is a significant cause of neonatal morbidity and mortality. Studies have shown that vaginal progesterone therapy for women diagnosed with shortened cervical length can reduce the risk of PTB. However, published cost-effectiveness analyses of vaginal progesterone for short cervix have not considered an appropriate range of clinically important parameters.
  
  
  
  To evaluate the cost-effectiveness of universal cervical length screening in women without a history of spontaneous PTB, assuming that all women with shortened cervical length receive progesterone to reduce the likelihood of PTB.
  
  
  
  A decision analysis model was developed to compare universal screening and no-screening strategies. The primary outcome was the cost-effectiveness ratio of both the strategies, defined as the estimated patient cost per quality-adjusted life-year (QALY) realized by the children. One-way sensitivity analyses were performed by varying progesterone efficacy to prevent PTB. A probabilistic sensitivity analysis was performed to address uncertainties in model parameter estimates.
  
  
  
  In our base-case analysis, assuming that progesterone reduces the likelihood of PTB by 11%, the incremental cost-effectiveness ratio for screening was $158,000/QALY. Sensitivity analyses show that these results are highly sensitive to the presumed efficacy of progesterone to prevent PTB. In a 1-way sensitivity analysis, screening results in cost-saving if progesterone can reduce PTB by 36%. Additionally, for screening to be cost-effective at WTP=$60,000 in three clinical scenarios, progesterone therapy has to reduce PTB by 60%, 34% and 93%. Screening is never cost-saving in the worst-case scenario or when serial ultrasounds are employed, but could be cost-saving with a two-day hospitalization only if progesterone were 64% effective.
  
  
  
  Cervical length screening and treatment with progesterone is a not a dominant, cost-effective strategy unless progesterone is more effective than has been suggested by available data for US women. Until future trials demonstrate greater progesterone efficacy, and effectiveness studies confirm a benefit from screening and treatment, the cost-effectiveness of universal cervical length screening in the United States remains questionable.
authors.affiliation: Department of Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, Alabama. Electronic address: sjain@uab.edu.
authors.forename: Siddharth
authors.initials: S
authors.lastname: Jain
authors.affiliation: Department of Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: Meredith
authors.initials: M
authors.lastname: Kilgore
authors.affiliation: Center for Women's Reproductive Health, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: Rodney K
authors.initials: RK
authors.lastname: Edwards
authors.affiliation: Center for Women's Reproductive Health, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: John
authors.initials: J
authors.lastname: Owen
mesh_terms: D000282:Administration, Intravaginal; D054791:Cervical Length Measurement / Q000187:drug effects* / Q000191:economics; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D008403:Mass Screening / Q000191:economics* / Q000379:methods; D011247:Pregnancy; D047928:Premature Birth / Q000209:etiology / Q000517:prevention & control*; D011374:Progesterone / Q000008:administration & dosage* / Q000191:economics / Q000494:pharmacology; D019057:Quality-Adjusted Life Years; D012102:Reproductive Control Agents / Q000008:administration & dosage* / Q000191:economics / Q000494:pharmacology; D016896:Treatment Outcome; D002577:Uterine Cervical Diseases / Q000188:drug therapy*
chemical_list: D012102:Reproductive Control Agents; D011374:Progesterone
keywords: cervical length screening; cost-effectiveness analysis; preterm birth; progesterone