Cost-effectiveness Analysis of Intraoperative Cell Salvage for Obstetric Hemorrhage

Abstract

Background: Cost-effectiveness analyses on cell salvage for cesarean delivery to inform national and societal guidelines on obstetric blood management are lacking. This study examined the cost-effectiveness of cell salvage strategies in obstetric hemorrhage from a societal perspective.

Methods: Markov decision analysis modeling compared the cost-effectiveness of three strategies: use of cell salvage for every cesarean delivery, cell salvage use for high-risk cases, and no cell salvage. A societal perspective and lifetime horizon was assumed for the base case of a 26-yr-old primiparous woman presenting for cesarean delivery. Each strategy integrated probabilities of hemorrhage, hysterectomy, transfusion reactions, emergency procedures, and cell salvage utilization; utilities for quality of life; and costs at the societal level. One-way and Monte Carlo probabilistic sensitivity analyses were performed. A threshold of $100,000 per quality-adjusted life-year gained was used as a cost-effectiveness criterion.

Results: Cell salvage use for cases at high risk for hemorrhage was cost-effective (incremental cost-effectiveness ratio, $34,881 per quality-adjusted life-year gained). Routine cell salvage use for all cesarean deliveries was not cost-effective, costing $415,488 per quality-adjusted life-year gained. Results were not sensitive to individual variation of other model parameters. The probabilistic sensitivity analysis showed that at the $100,000 per quality-adjusted life-year gained threshold, there is more than 85% likelihood that cell salvage use for cases at high risk for hemorrhage is favorable.

Conclusions: The use of cell salvage for cases at high risk for obstetric hemorrhage is economically reasonable; routine cell salvage use for all cesarean deliveries is not. These findings can inform the development of public policies such as guidelines on management of obstetric hemorrhage.

Figure 1

Markov State Transition Diagram. Each circle represents a health state and arrows in between circle demonstrate potential directions of transition that each patient can make with each cycle of the model. Circular arrows pointing back toward the same health state indicates a return to the same health state in the next cycle (cycle length = 1 year). Post-transfusion related illness was modeled as a health state associated only with the receipt of IOCS and allogeneic transfusion. All women in the cohort eventually transition to a “die” health state, not pictured. *Model start point IOCS, intraoperative cell salvage

Figure 2

ICER Tornado diagram for one-way sensitivity analysis for the strategies IOCS High Risk Only vs. No IOCS. The vertical line denotes the base-case expected value ($34,881). Variation around the variables listed induces a ≥10% variation from the base case ICER. The utility of the well state after transfusion is the most sensitive parameter. The probability of using cell salvage and the disutility of hysterectomy are least influential to the results of the model (not shown). ICER, incremental cost effectiveness ratio IOCS, intraoperative cell salvage

Figure 3

Monte Carlo Probabilistic Sensitivity Analysis. At the $100,000 per quality-adjusted life year gained threshold, there is > 85% likelihood that cell salvage for cesarean deliveries at high risk for hemorrhage is a favorable strategy. At willingness-to-pay thresholds below $35,000 per quality-adjusted life year gained, a strategy of no cell salvage for any cesarean delivery is favored. Below a willingness to pay threshold of $200,000 per quality-adjusted life year gained, using cell salvage for all cesarean deliveries is not a favorable strategy.