P-733 Implementing preconception expanded carrier screening in a universal healthcare system: insights from a cost-effectiveness analysis
Authors: Busnelli A , Ciani O , Tarricone R , Chiani V , Cortellessa F , Caroselli S , Levi-Setti P.E , Capalbo A 
Published: June 2022

Abstract

Study question
Would reimbursement of expanded carrier screening (ECS) panels of different gene content be cost-effective in a universal healthcare system?

Summary answer
Both tested ECS panels would be cost-effective if reimbursed by the Italian national healthcare system for a population without personal/familiar or racial/ethnic preconception genetic risks.

What is known already
Collectively, Mendelian diseases are a significant cause of infant mortality and hospitalization. Current preconception screening strategies test a limited number of individuals based on self-reported personal/familiar or racial/ethnic background. Consequently, the majority of at risk couples (ARCs) remain hidden in the general population. If adopted at a population level, multiplex platforms can thus improve screening effectiveness by allowing rapid ECS for a large number of conditions. Available economic evaluations assume the perspective of private/commercial payers. However, the decision to reimburse ECS in a tax-based national healthcare system would benefit from a cost-effectiveness analysis from the perspective of the public payer.

Study design, size, duration
This cost-effectiveness decision model compared lifetime costs and effects of two preconception ECS panels (i.e., “Strategy A1” (testing Cystic Fibrosis, Spinal-Muscular-Atrophy, Beta Thalassemia, Phenylketonuria and Fragile-X-Syndrome) and “Strategy A2” (testing “Strategy A1” + 16 common severe highly-penetrant childhood conditions in the Mediterranean population)) with no screening (“Strategy B”). We embraced the perspective of the Italian National Healthcare System. The time horizon for each condition equals an affected child’s life expectancy.

Participants/materials, setting, methods
We included couples seeking pregnancy without personal/familiar or racial/ethnic genetic risk. The cost-effectiveness analysis was based on a decision tree model where: i) the ECS panels sensitivity was 100%; ii) the probability for at risk couples (ARCs) to be risk-adverse was 77% based on data available from the literature; iii) all the forms of intervention that risk-adverse couples opted for lowered to zero the risk to conceive an affected child for the considered conditions.

Main results and the role of chance
Unitary cost of €240 for Strategy A1 and of €270 for Strategy A2 for each couple were estimated through a market analysis simulating a public ECS provision. For risk-adverse couples, the cost of intervention was estimated as equal to €8,376. This resulted from the weighted mean of the cost of the different options available (i.e., in vitro fertilization (IVF) with preimplantation testing for monogenic disorders (PGT-M) or, in case of natural conception, prenatal diagnosis and, eventually, termination of pregnancy). Strategy A1 was dominant versus no screening: Strategy A1 entailed savings equal to €1,395 and an incremental benefit of 0.0154 life years gained. Strategy A2 was dominant versus no screening: Strategy A2 entailed savings of €2,273 and an incremental benefit of 0.0238 life years gained. Strategy A2, when compared with Strategy A1, entailed an incremental cost of €649 and higher health benefits (0.7688 life years gained) (incremental cost-effectiveness ratio (ICER): €844).

Limitations, reasons for caution
This decision analytic model relies on input parameters on costs and life expectancy associated to each Mendelian disease derived from the literature. However, the feasibility to generate experimental evidence to inform this type of studies is very limited. The cost-effectiveness profiles established are valid under the assumptions listed.

Wider implications of the findings
Cost-effectiveness analyses like the one performed are useful policy tools to inform decisions regarding preconception screening programs for detectable severe recessive highly penetrant early-onset genetic conditions.

Trial registration number
not applicable