Impact of eviction during pregnancy: a cost-effectiveness analysis

Abstract

Eviction in pregnancy has been associated with adverse birth outcomes. We aimed to evaluate the cost-effectiveness of eviction versus no eviction of individuals during pregnancy. A cost-effectiveness model using TreeAge software was designed to evaluate the cost, effectiveness, and incremental cost-effectiveness ratio (ICER) associated with eviction relative to no eviction in pregnancy. The estimated cost of eviction was compared to the annual median rent in the US to represent the cost of housing in the no eviction group. Birth outcomes included pre-term birth, neonatal death, and major neurodevelopmental delay. Probabilities and costs were derived from the literature. A cost-effectiveness threshold was set at $100,000/QALY, and sensitivity analyses were conducted to assess the robustness of the results. In our theoretical cohort of 50,000 pregnant individuals aged 18-44 facing eviction annually, no eviction during pregnancy was associated with 3,374 fewer pre-term births, 20 fewer neonatal deaths, and 30 fewer cases of neurodevelopmental delay compared to eviction. At the median cost of rent in the US, the eviction strategy was associated with lower QALYs but also lower costs (Table 1). Despite the lower cost of eviction, no eviction was the cost-effective strategy, with an ICER of $37,087. In univariate sensitivity analysis varying the cost of housing, no eviction remained the cost-effective strategy and became cost-saving when annual rent reached below $12,000 (Figure 1). The no eviction strategy is cost-effective and reduces cases of pre-term birth, neonatal death, and neurodevelopmental delay. When rent was lowered to $12,000, eviction became the cost-saving strategy. This rent price may be closer to the actual cost of rent for those facing eviction. These findings demonstrate that policy interventions to provide housing and prevent eviction of pregnant individuals are necessary and represent an actionable target to reduce costs and improve birth outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)