Intended conservative management versus cesarean hysterectomy for known
or suspected placenta accreta spectrum: a cost-effectiveness analysis
Abstract
Objective: We examined the cost-effectiveness of conservative
management (CM) compared to planned cesarean hysterectomy (CH) for
placenta accreta spectrum (PAS). Design: A cost-effectiveness analysis
in a theoretical cohort of patients. Setting : A decision analytic
model. Population : A theoretical cohort of 1000 pregnant patients
with PAS greater than 20 weeks gestation. Methods : In base case
analysis, we assumed that between 20-40% of individuals would be
eligible for CM. Model inputs were derived from the literature. Analysis
was conducted from a healthcare system perspective with a one year
analytic horizon. Outcomes included hysterectomy, surgical site
infection (SSI), length of hospitalization, intensive care unit (ICU)
admission, and death. An incremental cost-effectiveness ratio (ICER) of
$50,000 per quality-adjusted life year (QALY) defined
cost-effectiveness. Sensitivity analyses were performed. Main outcome
measures: The cost gained per life year and per QALY. Results: For
base-case estimates, CM was the cost-saving strategy with an ICER of
$9330.51 USD. Compared to CH, CM resulted in 905 fewer hysterectomies,
80 fewer instances of SSI, and 5 fewer deaths. CM resulted in 149 more
admissions with length of stay >5 days and 25 more ICU
admissions . In probabilistic sensitivity analysis, CM was the
cost-effective strategy in 71% of runs and the dominant strategy in
42% of runs. Conclusion: CM was the cost-effective strategy for
management of PAS in greater than 70% of iterations of our model.
Modeling demonstrated significant uncertainty in the comparative
effectiveness of the two strategies, highlighting the need for
prospective research evaluating the effectiveness of CM.