Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency can cause virilization in affected females, potentially requiring post-natal surgical correction. Prenatal dexamethasone administration has been shown to reduce incidence and severity of virilization in newborn females. However, diagnostic information regarding fetal CAH status is not available until after critical embryological stages have passed, limiting the effectiveness of the intervention. We designed a model to examine the cost-effectiveness of empiric dexamethasone administration in pregnancies at high-risk for fetal CAH.METHODS:
A cost-effectiveness model was built using TreeAge Pro and incorporated probabilities, costs, and utilities from the literature. In pregnancies at-risk for CAH, we compared three strategies: empiric initiation of dexamethasone at 6 weeks gestation, conditional dexamethasone administration following a CVS at 10 weeks gestation, and no dexamethasone intervention. The cost-effectiveness threshold was set to $100,000 per quality-adjusted life year (QALY). The model's robustness was assessed with sensitivity analyses.RESULTS:
In a theoretical cohort of 1,000 women, empiric dexamethasone at 6 weeks gestation lead to 26 fewer affected female neonates requiring surgical intervention. This strategy lead to lower costs and higher QALYs when compared to dexamethasone administration at 10 weeks and no dexamethasone intervention. Because dexamethasone administration was associated with decreased severity and frequency of virilization, it was the cost-effective strategy across a broad range of sensitivity analyses.CONCLUSION:
In pregnancies at-risk for fetal virilization secondary to CAH, initiation of empiric dexamethasone before 6 weeks gestation was the cost-effective strategy resulting in fewer affected female infants, and fewer surgical corrections.