OBJECTIVE: To estimate the cost-effectiveness of a trial of labor after one previous cesarean (TOLAC) when incorporating long-term events and outcomes. METHODS: A Markov model comparing TOLAC with elective repeat cesarean delivery (ERCD) was developed for a hypothetical cohort with no contraindication to a TOLAC. Women were selected from a prospective study to derive probability estimates for potential events through three subsequent pregnancies. Probabilities for cerebral palsy and stress urinary incontinence, cost data, and quality-adjusted life-years (QALYs) were obtained from the literature. The primary outcome was cost-effectiveness measured as the marginal cost per QALY gained, with a $50,000 threshold per QALY used to define cost-effectiveness. RESULTS: The TOLAC strategy dominated the ERCD strategy at baseline, with $164.2 million saved and 500 QALYs gained per 100,000 women. The model was sensitive to six variables: the probability of uterine rupture and successful TOLAC among women with no prior vaginal delivery, the frequency of stress urinary incontinence, and the costs of failed TOLAC, successful TOLAC, and ERCD. When the probability of TOLAC success was at the base value, 67.2%, TOLAC was preferred if the probability of uterine rupture was 3.1% or less. When the probability of uterine rupture was at the base value, 0.8%, the TOLAC strategy was preferred as long as the probability of success was 47.2% or more. Probabilistic sensitivity analysis confirmed the base-case analysis. CONCLUSIONS: Under baseline circumstances, TOLAC is less expensive and more effective than an ERCD when considering long-term consequences when the likelihood of success is 47.2% or more.
OBJECTIVE: To estimate the cost-effectiveness of a trial of labor after one previous cesarean (TOLAC) when incorporating long-term events and outcomes. METHODS: A Markov model comparing TOLAC with elective repeat cesarean delivery (ERCD) was developed for a hypothetical cohort with no contraindication to a TOLAC. Women were selected from a prospective study to derive probability estimates for potential events through three subsequent pregnancies. Probabilities for cerebral palsy and stress urinary incontinence, cost data, and quality-adjusted life-years (QALYs) were obtained from the literature. The primary outcome was cost-effectiveness measured as the marginal cost per QALY gained, with a $50,000 threshold per QALY used to define cost-effectiveness. RESULTS: The TOLAC strategy dominated the ERCD strategy at baseline, with $164.2 million saved and 500 QALYs gained per 100,000 women. The model was sensitive to six variables: the probability of uterine rupture and successful TOLAC among women with no prior vaginal delivery, the frequency of stress urinary incontinence, and the costs of failed TOLAC, successful TOLAC, and ERCD. When the probability of TOLAC success was at the base value, 67.2%, TOLAC was preferred if the probability of uterine rupture was 3.1% or less. When the probability of uterine rupture was at the base value, 0.8%, the TOLAC strategy was preferred as long as the probability of success was 47.2% or more. Probabilistic sensitivity analysis confirmed the base-case analysis. CONCLUSIONS: Under baseline circumstances, TOLAC is less expensive and more effective than an ERCD when considering long-term consequences when the likelihood of success is 47.2% or more.
Authors: J M Guise; M S McDonagh; J Hashima; D F Kraemer; K B Eden; M Berlin; P Nygren; P Osterweil; K P Krages; M Helfand Journal: Evid Rep Technol Assess (Summ) Date: 2003-03
Authors: Nadia Badawi; Janine F Felix; Jennifer J Kurinczuk; Glenys Dixon; Linda Watson; John M Keogh; Jane Valentine; Fiona J Stanley Journal: Dev Med Child Neurol Date: 2005-05 Impact factor: 5.449
Authors: Catherine Y Spong; Mark B Landon; Sharon Gilbert; Dwight J Rouse; Kenneth J Leveno; Michael W Varner; Atef H Moawad; Hyagriv N Simhan; Margaret Harper; Ronald J Wapner; Yoram Sorokin; Menachem Miodovnik; Marshall Carpenter; Alan M Peaceman; Mary J O'Sullivan; Baha M Sibai; Oded Langer; John M Thorp; Susan M Ramin; Brian M Mercer Journal: Obstet Gynecol Date: 2007-10 Impact factor: 7.661
Authors: Anna Joy Rogers; Nathaniel G Rogers; Meredith L Kilgore; Akila Subramaniam; Lorie M Harper Journal: Value Health Date: 2016-11-11 Impact factor: 5.725
Authors: Charlotte Lindblad Wollmann; Kyle D Hart; Can Liu; Aaron B Caughey; Olof Stephansson; Jonathan M Snowden Journal: Acta Obstet Gynecol Scand Date: 2020-10-31 Impact factor: 3.636