Selective fetoscopic laser photocoagulation or expectant management for stage I twin-twin transfusion: a cost-effectiveness analysis

Background: Selective fetoscopic laser photocoagulation (SFLP) is the preferred intervention for stage II-IV twin-twin transfusion syndrome (TTTS), however there is no consensus on whether SFLP or expectant management (EM) is the preferred strategy to manage Quintero stage I TTTS.Objective: To estimate whether SFLP or EM is the cost-effective strategy for management of Quintero stage I TTTS.Study Design: A decision-analysis (DA) model compared SFLP to EM for 1,000 pregnant people with monochorionic-diamniotic twins affected by stage I TTTS. All subjects were assumed to be appropriate candidates for either SFLP or EM. Probabilities, costs, and utilities were derived from the literature. The DA was conducted from a health care payor perspective and the analytic horizon was over the course of an offspring's lifetime, with primary outcomes of survivorship (i.e., no intrauterine fetal demise or neonatal death) and long-term neurodevelopmental impairment (NDI). The model incorporated Markov processes with 4-week cycles throughout pregnancy. Incremental cost-effectiveness ratios (ICER) for each strategy were calculated and compared to estimate marginal cost effectiveness. An ICER of $100,000 per quality-adjusted life year (QALY) was used to define the cost-effectiveness threshold. One-way sensitivity and Monte Carlo analyses (MCA), as well as microsimulations, were performed. Results: For base-case estimates, SFLP was found to be cost effective compared to EM in the management of stage I TTTS. In one-way sensitivity analysis, varying each variable along pre-specified ranges did not result in changes in the conclusion. MCA projects SFLP as the cost-effective strategy in 100% of runs. Conclusions: With base-case estimates, SFLP is estimated to be the cost-effective strategy for the treatment of Quintero stage I TTTS when compared with EM. This remained true across a wide range of inputs.