Preeclampsia Prevention Using Routine Versus Screening Test–Indicated Aspirin in Low-Risk Women

Abstract

The objective was to evaluate whether routine aspirin 75 mg is more cost-effective than the Fetal Medicine Foundation screen-and-treat approach for preeclampsia prevention in low-risk nulliparous women. A health economic decision analytical model was devised to estimate the discounted net health and cost outcomes of routine aspirin versus Fetal Medicine Foundation screening test–indicated aspirin for a cohort of 100 000 low-risk nulliparous women. Both strategies were compared with no intervention. A subanalysis also compared disaggregated components of the algorithm. The analysis used data from hospital administration, literature, and a randomized controlled trial. Sensitivity analyses assessed the impact of aspirin adherence, test cost, and accuracy on study results. Presumed rates of preeclampsia were 3.75% with no intervention versus 0.45% with aspirin use. Results found that routine aspirin was the preferred strategy, in terms of greater health gains and larger cost savings. It provided 163 quality-adjusted life-years relative to no intervention, whereas the screen-and-treat policy achieved 108 quality-adjusted life-years. Routine aspirin would result in an estimated cost saving of €14.9 million annually relative to no intervention, whereas screen-and-treat approach would result in a smaller cost saving of €3.1 million. When the analysis was extended to consider alternative screen-and-treat strategies, routine aspirin remained the optimally cost-effective approach. In conclusion, routine aspirin use in low-risk nulliparous women has a greater health gain and cost saving compared with both the Fetal Medicine Foundation and other screen-and-treat approaches.

Pregestational diabetes in pregnancy: Complications, management, surveillance, and mechanisms of disease—A review

“…Evaluation in the non-diabetic population has suggested that given the additional costs of screening, and the low cost and low side effect profile of prevention with low dose aspirin, it would be pragmatic to offer aspirin as intervention to all women without screening, which would provide improved outcomes at less cost. 87 Among women with pre-existing diabetes in the ASPRE trial, the rate of early onset preeclampsia, before 34 weeks, was 1.3% in the screen negative group. 86 For these women, where the risk of early onset preeclampsia in the screen negative group is relatively high, the argument for universal aspirin in preference to screening is even more convincing.…”

Maternal adipose tissue to early preeclampsia risk detection: Is the time to maternal ultrasound beyond fetal evaluation?

“…Complementary laboratory assessments include the uterine artery pulsatility index by ultrasound and serum biomarkers. When both clinical and laboratory assessments are used, it is likely that all pregnant women at potential PE risk will be identified; however, such measurements come at a high cost 5, 27 …”

“…The unselected use of aspirin discouraged as a result. As such, an accurate predictive test that allows clinicians the ability of risk stratification for targeted aspirin dispensing 5 . The primary basis for a reliable predictive test is the combination of cost‐effectiveness from an acceptable false positive rate (FPR) and a high detection rate (DR) to receive both aspirin and differentiated obstetric care.…”

“…It is estimated that among low‐risk pregnant women, the associated predictive model cost of clinical data along with laboratory tests saves around € 3.1 million annually. In contrast, the use of aspirin saves € 14.9 million due to nondevelopment of PE maternal and fetal complications 5, 10 …”

Early and late onset pre-eclampsia and small for gestational age risk in subsequent pregnancies

“…[29] Whether such algorithms are cost effective in comparison to other screening mechanisms or even a policy of low dose aspirin in every pregnancy has been put into question. [30] Presence of some risk factors, such as previous pregnancies affected by pre-eclampsia or intrauterine growth restriction are now considered sufficient to prompt the intervention with low dose aspirin. Evidence supporting other risk factors such as nulliparity, obesity and family history of pre-eclampsia is weaker, and intervention requires the combined presence of two or more factors.…”