Cost-effectiveness of external cephalic version for term breech presentation

Abstract

BackgroundExternal cephalic version (ECV) is recommended by the American College of Obstetricians and Gynecologists to convert a breech fetus to vertex position and reduce the need for cesarean delivery. The goal of this study was to determine the incremental cost-effectiveness ratio, from society's perspective, of ECV compared to scheduled cesarean for term breech presentation.MethodsA computer-based decision model (TreeAge Pro 2008, Tree Age Software, Inc.) was developed for a hypothetical base case parturient presenting with a term singleton breech fetus with no contraindications for vaginal delivery. The model incorporated actual hospital costs (e.g., $8,023 for cesarean and $5,581 for vaginal delivery), utilities to quantify health-related quality of life, and probabilities based on analysis of published literature of successful ECV trial, spontaneous reversion, mode of delivery, and need for unanticipated emergency cesarean delivery. The primary endpoint was the incremental cost-effectiveness ratio in dollars per quality-adjusted year of life gained. A threshold of $50,000 per quality-adjusted life-years (QALY) was used to determine cost-effectiveness.ResultsThe incremental cost-effectiveness of ECV, assuming a baseline 58% success rate, equaled $7,900/QALY. If the estimated probability of successful ECV is less than 32%, then ECV costs more to society and has poorer QALYs for the patient. However, as the probability of successful ECV was between 32% and 63%, ECV cost more than cesarean delivery but with greater associated QALY such that the cost-effectiveness ratio was less than $50,000/QALY. If the probability of successful ECV was greater than 63%, the computer modeling indicated that a trial of ECV is less costly and with better QALYs than a scheduled cesarean. The cost-effectiveness of a trial of ECV is most sensitive to its probability of success, and not to the probabilities of a cesarean after ECV, spontaneous reversion to breech, successful second ECV trial, or adverse outcome from emergency cesarean.ConclusionsFrom society's perspective, ECV trial is cost-effective when compared to a scheduled cesarean for breech presentation provided the probability of successful ECV is > 32%. Improved algorithms are needed to more precisely estimate the likelihood that a patient will have a successful ECV.

Planned vaginal breech delivery: current status and the need to reconsider

“…There is wide consensus that external cephalic version (ECV) is effective in reducing the incidence of breech presentation [34], and the American College of Obstetricians and Gynecologists [35] and many other medical policy makers suggest that ECV should be offered to all those parturients in whom there are no contraindications for this procedure. It should, however, also be born in mind that even in successful ECVs, there is an increased rate for emergency CS for fetal distress.…”

Zunanji obrat ploda na glavico v Porodnišnici Izola

“…Zato priporočilo izvajanja ZO že leta obstaja v smernicah uglednih porodniških združenj v svetu (2,35). Z zmanjšanjem števila carskih rezov je nižja obolevnost mater in nenazadnje manjši strošek za zdravstveni proračun (36). Zapleti so redki (21), še posebno pri manj agresivnem pristopu do posega.…”

A risk–benefit analysis of factor V Leiden testing to improve pregnancy outcomes: a case study of the capabilities of decision modeling in genomics

“…Of note, the estimates of utility of a successful pregnancy after multiple failed pregnancy attempts and the inability to conceive reported in previous studies are largely based on expert opinion, and studies apply the impact of such outcomes for varying durations. [23][24][25][26] In light of this, we selected utility estimates most widely used and accounted for this inaccuracy by conducting sensitivity analyses around these estimates.…”