Lifetime Cost-Effectiveness of Trial of Labor After Cesarean in the United States

Abstract

Objective To estimate the cost-effectiveness of a trial of labor after one previous cesarean (TOLAC) when incorporating long-term events and outcomes. Methods A Markov model comparing TOLAC with elective repeat cesarean delivery (ERCD) was developed for a hypothetical cohort with no contraindication to a TOLAC. Women were selected from a prospective study to derive probability estimates for potential events through three subsequent pregnancies. Probabilities for cerebral palsy and stress urinary incontinence, cost data, and quality adjusted life years (QALYs) were obtained from the literature. The primary outcome was cost-effectiveness measured as the marginal cost per QALY gained, with a $50,000 threshold per QALY used to define cost-effectiveness. Results The TOLAC strategy dominated the ERCD strategy at baseline, with $164.2 million saved and 500 QALYs gained per 100,000 women. The model was sensitive to six variables: the probability of uterine rupture and successful TOLAC among women with no prior vaginal delivery, the frequency of stress urinary incontinence, and the costs of failed TOLAC, successful TOLAC, and ERCD. When the probability of TOLAC success was at the base value, 67.2%, TOLAC was preferred if the probability of uterine rupture was 3.1% or less. When the probability of uterine rupture was at the base value, 0.8%, the TOLAC strategy was preferred as long as the probability of success was 47.2% or more. Probabilistic sensitivity analysis confirmed the base-case analysis. Conclusions Under baseline circumstances, TOLAC is less expensive and more effective than an ERCD when considering long-term consequences when the likelihood of success is 47.2% or more.

Economic Evaluations Comparing a Trial of Labor with an Elective Repeat Cesarean Delivery: A Systematic Review

“…The remaining studies used long-term analytic horizons and reported discount rates for both costs and utilities, thus evaluating future costs and consequences in terms of their present value. Two studies (34, 37) allowed for the decision made in the index pregnancy to impact the outcomes and costs of future pregnancies by utilizing a Markov model.…”

“…In these studies, cost components generally included short-term hospitalization costs (direct and indirect), professional fees, and long-term costs. Among the three studies (32, 34, 35) with a societal perspective – which considers the costs borne by the patient and is thus recommended by the Panel on Cost-effectiveness in Health and Medicine – patient out-of-pocket costs and loss of employment productivity were added into calculations (24). Chuang et al did not report the perspective taken, but it appears to be that of the hospital.…”

“…Wymer et al compared successive delivery outcomes and determined that the benefits of a TOLAC accrue over multiple cesareans, with a decreasing incremental cost and increasing probability of cost-effectiveness. Grobman et al and Gilbert et al (34) did not compare successive models but rather built the events over a woman’s reproductive life into their base case model and concluded qualitatively that the risks and costs associated with routine ERCD are potentially greater than societal willingness to pay.…”

“…Although the heterogeneity in study methods make it impossible to summarize the cutoff value at which these parameters changed the outcome conclusion, TOLAC was found to be cost-effective in univariate sensitivity analyses if probability of TOLAC success was greater than 42% (35), 46% (34), 74% (32), or 95% (31), depending on the study. In the study reporting a 95% TOLAC success threshold, Chuang et al had assumed at baseline that a TOLAC was more expensive than an ERCD, making it an outlier among the studies.…”

Impact of Obstetrician/Gynecologist Hospitalists on Quality of Obstetric Care (Cesarean Delivery Rates, Trial of Labor After Cesarean/Vaginal Birth After Cesarean Rates, and Neonatal Adverse Events)

“…Models examining cost and quality of life have shown TOLAC to save $164.2 million and gain 500 quality-adjusted life years per 100,000 women. 28 Within this same study, cost-effectiveness was found for a strategy of TOLAC over ERCD when the success rate of TOLAC was as low as 47.2%. Other studies have shown TOLAC to be more cost-effective relative to ERCD with increasing efficiency with each subsequent delivery.…”