Cost-Effectiveness Analysis of Universal Screening for Subclinical Hypothyroidism in Pregnancy Based on the Czech Nation-Wide Pilot Screening Program in Light of Current Evidence

Objectives

In 2023, the Czech Guideline by Endocrinology society introduced universal screening of thyrotropin (TSH) in the first trimester of pregnancy. We modeled the incremental cost-effectiveness ratio (ICER), budget impact (BI), and new endocrinology referrals (ER) for universal screening of (1) TSH for subclinical hypothyroidism compared with the current testing and (2) extension to anti-thyroid peroxidase antibodies (anti-TPO).

Methods

A decision tree was built assuming that levothyroxine reduces the risks of gestational hypertension, miscarriage, and preterm birth and anti-TPO test improves diagnosis of postpartum thyroiditis. Models were parametrized using the best available evidence, probabilities, and utilities from the national pilot screening program. ICER was compared with a willingness-to-pay threshold of 47 430 EUR per quality-adjusted life year (QALY).

Results

Expecting 100 000 pregnancies yearly, introduction of universal TSH screening will result in 32.9 (−40 to 91.7) maternal QALYs gained, 65 (45-90) miscarriages and 52 (30-77) preterm deliveries prevented, with an ICER of 20 035 EUR/QALY (2315/3000 simulations cost-effective), the BI of 659 756 (439 993-895 993) EUR, and 2290 (1883-2728) ER (randomized-controlled-trial-level evidence). The extension of the TSH screening with anti-TPO will bring additional 111 (−398 to 604) QALY gained, ICER of 15 703 EUR per QALY (1945/3000 simulations cost-effective), the BI of 1 746 486 (1 241 391-2 350540) EUR, and 6927 (6121-7765) ER (low-level evidence).

Conclusions

Universal screening of TSH and extension with anti-TPO appear to be cost-effective. The population benefits of TSH screening are modest, but the BI is low. The model for anti-TPO is based on weak evidence and generates important BI.