Evaluating Cost-effectiveness of Interventions That Affect Fertility and Childbearing

Abstract

Background Current guidelines for economic evaluations of health interventions define relevant outcomes as those accruing to individuals receiving interventions. Little consensus exists on counting health impacts on current and future fertility and childbearing. Objective To characterize current practices for counting such health outcomes. Design We developed a framework characterizing health interventions with direct and/or indirect effects on fertility and childbearing and how such outcomes are reported. We identified interventions spanning the framework and performed a targeted literature review for economic evaluations of these interventions. For each article, we characterized how the potential health outcomes from each intervention were considered, focusing on QALYs associated with fertility and childbearing. Results We reviewed 108 studies, identifying seven themes: 1) Studies were heterogeneous in reporting outcomes. 2) Studies often selected outcomes for inclusion that tend to bias toward finding the intervention to be cost-effective. 3) Studies often avoided the challenges of assigning QALYs for pregnancy and fertility by instead considering cost per intermediate outcome. 4) Even for the same intervention, studies took heterogeneous approaches to outcome evaluation. 5) Studies employed multiple, competing rationales for whether and how to include fertility-related QALYs and whose QALYs to include. 6) Studies examining interventions with indirect effects on fertility typically ignored such QALYs. 7) Even recent studies had these shortcomings. Limitations The review was targeted rather than systematic. Conclusions Economic evaluations inconsistently consider QALYs from current and future fertility and childbearing in ways that frequently appear biased towards the interventions considered. As the Panel on Cost-Effectiveness in Health and Medicine updates its guidelines, making the practice of cost-effectiveness analysis more consistent is a priority. Our study contributes to harmonizing methods in this respect.

Cell‐free DNA noninvasive prenatal screening for aneuploidy versus conventional screening: A systematic review of economic evaluations

“…Methodological challenges especially related to the choice and valuation of outcomes can make cost-effectiveness results biased and those should be interpreted with caution. 13,35 Those challenges are mostly related on the choices of time horizon and health outcomes. Ideally, if we strictly follow guidelines of economic evaluation, 36 a wellconducted economic evaluation should consider a time horizon enough to capture all relevant health outcomes and costs.…”

“…Therefore, economic evaluation of a prenatal intervention such as screening and diagnosis has also to capture all relevant costs and outcomes within a pregnancy, but also over a long time horizon enough to capture future health outcomes and the economic impact of an intervention. 13,35 Even if most women opt for pregnancy termination after confirmation of aneuploidy diagnosis, it is important to consider also long-term horizon in order to measure consequences related to treatment and management of cases born alive (ie, those not detected by prenatal screening and those whose mothers declined the termination of pregnancy) which include the costs outside the health care system that are difficult to assess. Regarding the health outcomes measures in economic evaluation of screening for aneuploidy, our review found that there were a variety of outcomes used, mostly, the number of DS/aneuploidy detected.…”

“…However, studies performed poorly for other items. We noted that, according to the framework developed by Goldhaber-Fiebert and Brandeau, 13 no study (0%) has included all major short-and long-term maternal, fetal as well as negative outcomes and costs (item 10). Indeed, some studies considered only within-pregnancy outcomes and costs 17,[19][20][21][22]24,[26][27][28][29] ; others 18,23,[30][31][32] considered costs within pregnancy and over a lifetime basis whereas outcomes were considered over a pregnancy duration basis only; 1 study (6%) 25 included shortand long-term health outcomes but omitted to include lifetime costs.…”

Pregnancy context and women’s health-related quality of life

“…While the concept of HRQoL is applicable to all patient populations and health states, the transient nature of pregnancy may require a different conceptual model [32,33] than that used for chronic diseases like cancer and diabetes that have extensive research literature regarding assessment of HRQoL. Further testing with domain specific PROMIS measures (e.g.…”

Clinical decision analysis in perinatology

“…Thus, short‐term outcomes may be based on primary data, whereas long‐term effects are often extrapolated. Time horizons considered by CDA studies in perinatology include “pregnancy and delivery”, “pregnancy and the postpartum period” (variably, 6 weeks to 1 year), “the mother's reproductive life” and maternal lifetime for maternal outcomes and anything between a few months after birth to the entire lifetime for offspring outcomes . Caution must be exercised while considering short time horizons such as pregnancy and delivery alone, as the implications of some interventions and outcomes extend beyond that time horizon.…”