Should all pregnant diabetic women undergo a fetal echocardiography? A cost-effectiveness analysis comparing four screening strategies

Objective To determine if a policy of universal fetal echocardiography for all pregnant diabetic women is cost-effective as a screening tool for congenital heart defects. Study Design Using a decision-analysis model, we compared the cost-effectiveness of four screening strategies: (1) none—no ultrasound is performed; (2) selective fetal echocardiography after abnormal detailed anatomic survey; (3) fetal echocardiography for only high hemoglobin A1C, and (4) universal fetal echocardiography for all diabetics. The sensitivity and specificity for each strategy were derived by literature search. The analysis was from a societal perspective using a willingness-to-pay threshold ($50 000) and a theoretic cohort of 40 000 pregnant diabetics. Costs included costs of tests and the costs of complications and of raising a child with a cardiac defect. Outcomes were reported as cost per quality-adjusted life years (QALY) gained for each congenital heart defect prevented by each strategy and the number of congenital heart defects detected. One-way, multiway and probabilistic sensitivity analyses were performed. Results Compared with the other strategies, selective fetal echocardiography after abnormal detailed anatomic survey costs less per QALY gained for cardiac defect screening. Although universal fetal echocardiography was associated with a higher detection rate for cardiac defects, it was more costly. The sensitivity analyses revealed a robust model over a wide range of values. Conclusion Under the baseline assumptions, selective fetal echocardiography after an abnormal detailed anatomic survey is more cost-effective compared with universal fetal echocardiography as a screening strategy for cardiac defects in pregnant diabetics. Copyright © 2006 John Wiley & Sons, Ltd.