title: Economic Evaluations of Thrombophilia Screening Prior to Prescribing Combined Oral Contraceptives: A Systematic and Critical Review.
abstract: BACKGROUND
  Combined oral contraceptives (COCs) increase the risk of venous thromboembolism (VTE), particularly among women with inherited clotting disorders. The World Health Organization classifies combined hormonal contraception as an "unacceptable health risk" for women with thrombogenic mutations but advises against universal thrombophilia screening before prescribing COCs given the low prevalence of thrombophilia and high screening costs.
  
  
  OBJECTIVE
  Through the lens of lifetime costs and benefits, this paper systematically and critically reviews all published economic evaluations of thrombophilia screening prior to prescribing COCs.
  
  
  METHODS
  We searched relevant databases for economic evaluations of thrombophilia screening before prescribing COCs. After extracting the key study characteristics and economic variables, we evaluated each article using the Quality of Health Economic Studies (QHES) and the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) instruments.
  
  
  RESULTS
  Seven economic evaluations of thrombophilia screening before prescribing COCs met our inclusion criteria. Only the two economic evaluations focusing exclusively on selective screening exceeded the 75-point threshold for high-quality economic studies based on the QHES instrument, whereas only one of these exceeded the 85% CHEERS threshold. Only three of the seven economic evaluations performed sensitivity analysis on key parameters. Most studies underestimated the benefits of thrombophilia screening by comparing one-time costs of genetic screening against benefits per person-year, thus implicitly assuming a 1-year duration of COC use, neglecting the long-term implications of VTE and/or neglecting the lifetime benefits of awareness of inherited thrombophilia.
  
  
  CONCLUSIONS
  Our review highlights the lack of methodologically rigorous economic evaluations of universal thrombophilia screening before prescribing COCs.
authors.affiliation: Department of Economics, Seattle University, 901 12th Avenue, Seattle, WA, 98122, USA.
authors.forename: Erin
authors.initials: E
authors.lastname: Vernon
authors.affiliation: Department of Economics, Seattle University, 901 12th Avenue, Seattle, WA, 98122, USA. bgh@seattleu.edu.
authors.forename: Bridget
authors.identifier: http://orcid.org/0000-0002-4655-3829
authors.initials: B
authors.lastname: Hiedemann
authors.affiliation: College of Nursing, Seattle University, 901 12th Avenue, Seattle, WA, 98122, USA.
authors.forename: Bonnie H
authors.initials: BH
authors.lastname: Bowie
mesh_terms: D000328:Adult; D003267:Contraception / Q000191:economics* / Q000379:methods*; D003277:Contraceptives, Oral, Combined / Q000191:economics*; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D008403:Mass Screening / Q000191:economics*; D018570:Risk Assessment; D012307:Risk Factors; D019851:Thrombophilia / Q000191:economics* / Q000517:prevention & control*; D055815:Young Adult
chemical_list: D003277:Contraceptives, Oral, Combined
keywords: Combine Oral Contraceptive; Economic Evaluation; Factor Versus Leiden; Selective Screening; Thrombophilia