To determine the cost-effectiveness of inpatient, continuous fetal monitoring versus outpatient management of monochorionic-monoamniotic (MCMA) twin gestations.METHODS:
A decision-analytic model was created comparing continuous fetal monitoring versus outpatient daily nonstress test (NST) in a theoretical cohort of 250 MCMA pregnancies. The two arms were broken down based on gestational age beginning at 26 weeks gestation. All probabilities, utilities, and costs were derived from the literature. The primary outcome was the incremental cost per quality-adjusted life year (QALY). Rates of intrauterine fetal demise (IUFD), neonatal death, and cerebral palsy were also investigated. The cost-effectiveness threshold was set at $100,000 per QALY. Univariate and multivariate analyses were used to investigate model robustness.RESULTS:
Inpatient continuous fetal monitoring results in improved neonatal outcomes and decreased cost. Compared to outpatient management, inpatient management would lead to 43 fewer cases of single IUFD, 7 fewer cases of double IUFD, 34 fewer neonatal deaths and 5 fewer neonates with cerebral palsy. Inpatient management improved effectiveness by 4.500 QALYs and saved $6.6 million (primary strategy improved outcomes). Inpatient management remained the dominant strategy as our estimated cost of per week was doubled to $8,325/week, and remained cost-effective up to five-times our estimated cost.CONCLUSION:
Inpatient management is a cost-effective strategy for antenatal management of MCMA twin gestations that can reduce perinatal morbidity and mortality. Hospitalization of 5 patients would prevent an IUFD and 8 patients would prevent one neonatal death.