Comparison of guidelines for evaluation of suspected PE in pregnancy: a cost-effectiveness analysis

  • Authors
  • Alex C. Spyropoulos
  • Benjamin Brenner
  • Chinara Feizullayeva
  • John A McCandlish
  • Pina C Sanelli
  • Thomas McGinn
  • Jason Naidich
  • Paul P. Cronin
  • Published
  • CHEST

Abstract

Background

Pulmonary embolism (PE) remains a leading cause of maternal mortality, yet diagnosis remains challenging. International diagnostic guidelines vary significantly in their recommendations, making it difficult to determine an optimal policy for evaluation.

Research question

Which societal-level diagnostic guideline for evaluation of suspected PE in pregnancy is an optimal policy in terms of its cost-effectiveness?

Study design and methods

We constructed a complex Markov decision model to evaluate the cost-effectiveness of each identified societal guideline for diagnosis of PE in pregnancy. Our model accounted for risk stratification, empiric treatment, diagnostic testing strategies, as well as short- and long-term effects from PE, treatment with low-molecular weight heparin, and radiation exposure from advanced imaging. We considered clinical and cost outcomes of each guideline from a U.S. health care system perspective with a lifetime horizon. Clinical effectiveness and costs were measured in time-discounted quality-adjusted life years (QALYs) and U.S. dollars respectively. Strategies were compared using the incremental cost-effectiveness ratio (ICER) with a willingness-to-pay threshold of $100,000 per QALY. One-way, multi-way, and probabilistic sensitivity analyses were performed.

Results

We identified six international societal-level guidelines. Base-case analysis showed the guideline proposed by the American Thoracic Society-Society of Thoracic Radiology (ATS-STR) yielded the highest health benefits (22.90 QALYs) and was cost-effective, with an ICER of $7,808 over the guideline proposed by the Australian Society of Thrombosis and Haemostasis and the Society of Obstetric Medicine of Australia and New Zealand (ASTH-SOMANZ). All remaining guidelines were dominated. The ATS-STR guideline-recommended strategy yielded an expected additional 2.7 QALYs per 100 patients evaluated over the ASTH-SOMANZ. Conclusions were robust to sensitivity analyses, with the ATS-STR guideline optimal in 86% of probabilistic sensitivity analysis scenarios.

Interpretation

The ATS-STR guideline for diagnosis of suspected PE in pregnancy is cost-effective and generates better expected health outcomes than guidelines proposed by other medical societies.

  • Keywords
  • Decision Science
  • Imaging
  • Venous thromboembolism in pregnancy