Grand Rounds

Universal Ultrasound Screening for Fetal Macrosomia: Is It Cost-Effective?

BACKGROUND AND PURPOSE:

Wastlund et al. (BJOG, 2019) sought to determine the most cost-effective strategy for fetal macrosomia detection in the third trimester

Health economic simulation model
Participants
- Nulliparous | Third Trimester | Based on treatment within the UK NHS system
Study design
- Two detection strategies for fetal macrosomia detection
  - Universal ultrasound scanning at approximately 36 weeks
  - Selective ultrasound scanning
- Three management strategies
  - Planned caesarean section
  - Induction of labor
  - Expectant management
- Probabilities, costs and health outcomes based on the literature
- Potential litigation costs not included
Primary outcomes
- Expected costs to the NHS and quality-adjusted life-years (QALYs) gained from each strategy
- Calculation of net benefit and most cost-effective strategy

Compared with selective ultrasound, universal ultrasound (planned cesarean)
- Increased QALYs (over 20 years) by 0.0038 (95% CI, 0.0012 to 0.0076)
- Increased costs by £123.50 (95% CI, 99.6 to 149.9)
The most cost-effective policy was selective ultrasound coupled with induction of labor where macrosomia was suspected

The most cost-effective strategy for detecting and managing suspected fetal macrosomia is selective ultrasound and induction of labor
The health gain to universal screening is so small is because risk of severe neonatal outcomes resulting from undiagnosed macrosomia is low vs the risk of interventions
If the cost of the ultrasound dropped substantially in price, universal scanning could become cost-effective (a reduction of approximately 75%)
- Combining the scan to assess breech presentation could also potentially tip the balance regarding cost-effectiveness

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