47 Universal screening for fecal incontinence in pregnant women with a history of obstetric anal sphincter injury: A cost-effectiveness analysis

Abstract

Fecal incontinence (FI), the involuntary passage of solid or liquid stool or mucus from the rectum, can have devastating effects on quality of life and presents a significant healthcare cost burden. Obstetric anal sphincter injuries (OASIS) are a known risk factor for the development of FI, but management of subsequent pregnancy after OASIS is controversial. The objective of this study is to determine if universal urogynecologic screening for FI for pregnant women with prior OASIS is cost-effective. We performed a cost-effectiveness analysis using a decision tree model. For pregnant women with history of OASIS in a previous delivery, we modeled the option of referral to urogynecology (FI screening) compared to no referral (usual care). From there, we modeled the option of proceeding with an elective cesarean delivery or trial of labor as well as the actual delivery method (vaginal, planned cesarean, or unplanned cesarean). A second sub-tree was constructed with branch points modeling the probabilities of various maternal peripartum complications. A third sub-tree modeled the treatment options for patients who developed FI. Probabilities used in the model were obtained from the published literature using PubMed to find relevant primary sources. Utilities used in the model were obtained from the Tufts Medical Center Cost-Effectiveness Analysis Registry if available. Otherwise, they were obtained from the published literature. We used the cost perspective of a third-party payer. Costs were gathered from the Medicare physician fee schedule reimbursement data or published literature and were converted to 2019 US dollars via consumer price index tables and year-specific currency conversion rates to account for inflation. Our primary outcome of cost-effectiveness was determined by using the incremental cost-effectiveness ratio (ICER). Model robustness was assessed using multiple 1-way sensitivity analyses. Our model demonstrated that universal FI screening and referral to urogynecology for pregnant patients with prior OASIS was cost-effective. Compared to the usual care strategy of no screening, the ICER for this strategy was $19,858.32/QALY, well below the WTP threshold of $50,000/QALY. Screening for FI reduced the ultimate rate of FI by 2.65% and reduced the ultimate rate of patients living with untreated FI by 15.87%. Screening increased the use of pelvic floor PT by 14.14% while rates of second and third-line surgical FI treatments (sacral neuromodulation or sphincteroplasty) increased by only 2.48% and 0.58%, respectively. The screening strategy reduced the rate of vaginal delivery by 24.84%, which in turn led to a 1.15% increase in the rate of peripartum maternal complications. Universal screening for fecal incontinence in women with a prior history of OASIS is a cost-effective strategy that decreases the overall incidence of FI, increases the utilization of treatment for FI, and only marginally increases the risk of maternal morbidity.