Recent studies have compared maternal and neonatal outcomes associated with fetoscopic surgical approach for repair of myelomeningocele as compared to an open approach.
In this study, we compared the cost-effectiveness of these techniques in the setting of a woman seeking future pregnancies.
A decision-analytic model using TreeAge software was designed to compare the costs, and outcomes of fetoscopic versus open repair in patients with prenatally diagnosed myelomeningocele. We assumed a theoretical cohort of 500 women with a pregnancy affected by myelomeningocele planning to have a future pregnancy. Our model accounted for costs and quality adjusted life years of the woman, the neonate with myelomeningocele, and the neonate in a subsequent pregnancy. Neonatal outcomes from the incident pregnancy included motor function more than two levels better than anatomic level, motor function less than two levels better than anatomic level and same motor function as anatomic level, preterm birth in the index pregnancy, neonatal death in the index pregnancy, major neurodevelopmental disability as a result of preterm birth in the index pregnancy. Neonatal outcomes in the subsequent pregnancy included stillbirth, preterm birth, neonatal and major neurodevelopmental disability as a result of preterm birth. Probabilities were derived from the literature, and we used a willingness-to-pay threshold of $100,000 per QALY.
In the index pregnancy, fetoscopic surgical technique resulted in 140 fewer cases of preterm birth, and fewer cases of neurodevelopmental disability and neonatal death. Fetoscopic technique resulted in 130 more cases of functional level >2 levels better than anatomic level, 35 fewer cases of functional level >2 levels worse than anatomic level, and 107 fewer cases of function same as anatomic level. In the subsequent pregnancy, fetoscopic surgery led to 22 fewer cases of delivery complications (uterine dehiscence, uterine rupture and excessive bleeding), 24 fewer cases of stillbirth, and 22 fewer cases of preterm birth. While the fetoscopic approach was more costly, it was cost effective with an ICER of $1,029/QALY in our theoretical cohort of 500 patients. Monte Carlo probabilistic sensitivity analysis showed that fetoscopic technique is cost effective 100% of the time.
In our theoretical cohort, the fetoscopic approach was more costly, but resulted in improved outcomes when a subsequent pregnancy was considered.