693 Transabdominal cerclage vs. vaginal cerclage: a cost-effectiveness analysis

Abstract

Patients with recurrent pregnancy loss due to cervical insufficiency often receive a vaginal cerclage (VC). The MAVRIC trial demonstrated the superior efficacy of transabdominal cerclage (TAC) compared with VC for those with a history of a prior failed VC. However, the TAC is costly and may have other complications. In this study, we evaluated the cost-effectiveness of performing TAC versus VC for patients with a history of VC failure. We used TreeAge to construct a decision-analytic model to compare patient outcomes between those who received a TAC to those who received VC. Our theoretical cohort contained 20,000 patients, the approximate number of pregnancies with prior VC failure per year in the US. We assumed that all patients with TAC undergo cesarean delivery. Outcomes were wound infection in TAC, cesarean delivery, previable delivery, stillbirth, neonatal death, maternal mortality, and cerebral palsy. We derived all values from literature including MAVRIC for cerclage outcomes and discounted QALYs at a rate of 3%. To further assess our model, we performed univariate sensitivity analyses. In our theoretical cohort, TAC was associated with a decrease in 3,363 previable deliveries, 261 neonatal deaths, and 236 cases of cerebral palsy. However, TAC was associated with an additional 11,656 cesarean deliveries, 1 maternal mortality, and 870 wound infections (Table 1). TAC was a cost-effective strategy as it resulted in increased QALYs (despite increased costs) and an incremental cost-effectiveness ratio (ICER) of $3,007/QALY. Sensitivity analyses demonstrated that TAC was cost-effective over a wide range of the probabilities for cesarean delivery, neonatal death, and previable delivery. In this study, TAC was a cost-effective strategy to prevent previable deliveries and improve neonatal outcomes, but required additional cesarean deliveries and increased costs. We found that TAC is a cost-effective strategy and may be considered for patients with a history of VC failure.