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 guidelines for evaluation of suspected PE in pregnancy are 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 guidelines 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 US health care system perspective with a lifetime horizon. Clinical effectiveness and costs were measured in time-discounted quality-adjusted life years (QALYs) and US dollars, respectively. Strategies were compared using the incremental cost-effectiveness ratio (ICER) with a willingness-to-pay threshold of $100,000/QALY. One-way, multiway, 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 and 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 guidelines 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/100 patients evaluated over the ASTH-SOMANZ. Conclusions were robust to sensitivity analyses, with the ATS-STR guidelines optimal in 86% of probabilistic sensitivity analysis scenarios.

Interpretation

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

中文翻译：

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妊娠期疑似肺栓塞评估指南的比较

背景

肺栓塞 (PE) 仍然是孕产妇死亡的主要原因，但诊断仍然具有挑战性。国际诊断指南的建议差异很大，因此很难确定最佳的评估政策。

研究问题

就其成本效益而言，哪些用于评估疑似 PE 的社会级诊断指南是最佳政策？

研究设计和方法

我们构建了一个复杂的马尔可夫决策模型，以评估每个已确定的妊娠期 PE 诊断社会指南的成本效益。我们的模型考虑了风险分层、经验性治疗、诊断测试策略，以及 PE 的短期和长期影响、低分子量肝素治疗和高级成像的辐射暴露。我们从美国医疗保健系统的角度考虑了每项指南的临床和成本结果，并具有终生的视野。临床有效性和成本分别以时间贴现的质量调整生命年（QALYs）和美元来衡量。使用增量成本效益比 (ICER) 比较策略，支付意愿阈值为 100,000 美元/QALY。进行了单向、多向和概率敏感性分析。

结果

我们确定了六项国际社会层面的指南。基础案例分析表明，美国胸科协会和胸科放射学会 (ATS-STR) 提出的指南产生了最高的健康益处（22.90 QALYs）并且具有成本效益，ICER 比澳大利亚提出的指南高出 7,808 美元血栓形成和止血协会以及澳大利亚和新西兰产科医学协会 (ASTH-SOMANZ)。所有剩余的指导方针都占主导地位。与 ASTH-SOMANZ 相比，ATS-STR 指南推荐的策略产生了预期的额外 2.7 QALY/100 名患者。结论对敏感性分析是稳健的，ATS-STR 指南在 86% 的概率敏感性分析场景中是最佳的。

解释

用于诊断妊娠期疑似 PE 的 ATS-STR 指南具有成本效益，并且比其他医学协会提出的指南产生更好的预期健康结果。