Cost-effectiveness analysis of induction of labour at 41 weeks and expectant management until 42 weeks in low risk women (INDEX trial). (March 2023)

• Record Type: Journal Article
• Authors: Bruinsma, Aafke; Keulen, Judit KJ; van Eekelen, Rik; van Wely, Madelon; Kortekaas, Joep C; van Dillen, Jeroen; van de Post, Joris AM; Mol, Ben W; de Miranda, Esteriek
• Is Part Of: European journal of obstetrics and gynecology and reproductive biology X. Volume 17(2023)
• Publication Date: 2023-03
• Subjects: Late-term pregnancy -- Cost-effectiveness -- Induction of labour -- Expectant management -- Perinatal outcomes
• DOI: 10.1016/j.eurox.2023.100178
• Languages: English
• ISSNs: 2590-1613

Abstract

Abstract: Objective: To assess the cost-effectiveness of elective induction of labour (IOL) at 41 weeks and expectant management (EM) until 42 weeks. Design: Cost-effectiveness analysis from a healthcare perspective alongside a randomised controlled trial (INDEX). Setting: 123 primary care midwifery practices and 45 obstetric departments of hospitals in the Netherlands. Population: We studied 1801 low-risk women with late-term pregnancy, randomised to IOL at 41 weeks (N = 900) or EM until 42 weeks (N = 901). Methods: The incremental cost-effectiveness ratio (ICER) was expressed as the ratio of the difference in costs and the difference in main perinatal outcomes. A Cost-Effectiveness Acceptability Curve (CEAC) was constructed to assess whether induction is cost-effective for a range of monetary values as thresholds. We performed subgroup analysis for parity. Main outcome measures: Direct medical costs, composite adverse perinatal outcome (CAPO) (perinatal mortality, NICU admission, Apgar 5 min < 7, plexus brachialis injury and/or meconium aspiration syndrome) and composite severe adverse perinatal outcome (SAPO) (including Apgar 5 min < 4 instead of < 7). Results: The average costs were €3858 in the induction group and €3723 in the expectant group (mean difference €135; 95 % CI −235 to 493). The ICERs of IOL compared to EM to prevent one additional CAPO and SAPO was €9436 and €14, 994, respectively. The CEAC showed a 80 % chance of IOL being cost-effective with a willingness-to-pay of €22, 000 for prevention of one CAPO and €50, 000 for one SAPO. Subgroup analysis showed a willingness-to-pay to prevent one CAPO for nulliparous of €47, 000 and for multiparous €190, 000. To prevent one SAPO the willingness-to-pay is €62, 000 for nulliparous and €970, 000 for multiparous women. Conclusions: Induction at 41 weeks has an 80 % chance of being cost-effective at a willingness-to-pay of €22, 000 for prevention of one CAPO and €50, 000 for prevention of one SAPO. Subgroup analysis suggests that induction could be cost-effective for nulliparous women while it is unlikely cost-effective for multiparous women. Cost-effectiveness in other settings will depend on baseline characteristics of the population and health system organisation and funding.