Abstract
Hypothyroidism in pregnancy can lead to adverse maternal and fetal outcomes. Although screening of high-risk women is advocated, universal screening remains controversial. The objective of the study was to compare the cost-effectiveness of universal screening of pregnant women for autoimmune thyroid disease (AITD) with screening only high-risk women and with no screening. A decision-analytic model compared the incremental cost per quality-adjusted life-year (QALY) gained among the following: 1) universal screening, 2) high-risk screening, and 3) no screening. Screening consisted of a first-trimester thyroid-stimulating hormone level and antithyroid peroxidase antibodies. Women with abnormal results underwent further testing and, when indicated, levothyroxine therapy. Randomized controlled trials provided probabilities for adverse obstetrical outcomes. The model accounted for the development of postpartum thyroiditis and overt hypothyroidism. Additional scenarios in which therapy prevented cases of decreased child intelligence quotient were explored. Medical consequences of AITD in pregnancy, QALY, and costs were measured. Risk-based screening and universal screening were both cost-effective relative to no screening, with incremental cost-effectiveness ratios (ICERs) of $6,753/QALY and $7,138/QALY, respectively. Universal screening was cost-effective compared with risk-based screening, with an ICER of $7,258/QALY. Screening remained cost-effective in various clinical scenarios, including when only overt hypothyroidism was assumed to have adverse obstetrical outcomes. Universal screening was cost-saving in the scenario of untreated maternal hypothyroidism resulting in decreased child intelligence, with levothyroxine therapy being preventive. Universal screening of pregnant women in the first trimester for AITD is cost-effective, not only compared with no screening but also compared with screening of high-risk women.
Highlights
Universal screening was cost-effective compared with risk-based screening, with an incremental costeffectiveness ratio (ICER) of $7,258/quality-adjusted life-year (QALY)
Universal screening of pregnant women in the first trimester for autoimmune thyroid disease (AITD) is cost-effective, compared with no screening and compared with screening of high-risk women. (J Clin Endocrinol Metab 97: 1536 –1546, 2012)
Two prior analyses have demonstrated the cost-effectiveness of universal screening of pregnant women for thyroid disease compared with no screening [25, 26], but these studies were limited by the absence of randomized controlled trial (RCT) data showing levothyroxine benefit
Summary
Suite (Williamstown, MA) to investigate the difference in costs and health benefits among three alternatives of screening pregnant women for AITD. The three screening strategies include the following: 1) universal screening, 2) risk-based screening, and 3) no screening (Fig. 1A). Universal screening of all pregnant women is contrasted with risk-based screening of only those pregnant women at high risk for AITD, as defined in The Endocrine Society’s clinical practice guidelines on management of thyroid disease in pregnancy [19]. Women with no known history of thyroid disease were included in the model. Lifetime medical costs and utilities related to the treatment of AITD and sequelae were included but not other medical costs or nonmedical costs
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