(765) Intended conservative management versus cesarean hysterectomy for known/suspected placenta accreta spectrum: a cost-effectiveness analysis

Although the standard of treatment for placenta accreta spectrum (PAS) is planned cesarean hysterectomy (CH), an alternative approach in which the placenta and uterus are left in situ, conservative management (CM), is gaining acceptance. CM reduces immediate PAS morbidity, but delayed morbidity may lead to greater costs over time. We examined the cost-effectiveness of offering CM compared to CH as standard treatment for PAS.

Study Design: A decision analysis (DA) compared CH with CM for 1000 persons with known or suspected PAS > 20 weeks gestation. In the base case analysis, we assumed 20-40% of patients with PAS would be eligible for CM and 50% would accept the intervention. Using probabilities derived from the literature, 78% would achieve successful CM at delivery and 82% would meet their intended delivery date. The DA was conducted from a healthcare system perspective with the analytic horizon the first postpartum year. Incremental cost-effectiveness ratios (ICER) for each strategy were calculated and compared. Utilities and costs were derived from the literature and Healthcare Cost and Utilization Project and adjusted to 2023 US dollars. An ICER of $50,000 per QALY defined cost-effectiveness. Standard sensitivity analyses were performed.

Results: For base-case estimates, CM was the dominant strategy. Compared to CH, CM resulted in 905 fewer hysterectomies, 80 fewer instances of surgical site infection, and 5 fewer deaths. CM resulted in 149 more admissions with length of stay >5 days and 25 more ICU admissions. CM was the cost-effective strategy in 72% of runs and the dominant strategy in 41% of runs. In our threshold analysis, 23% of patients would need to accept and undergo successful CM for it to be cost-effective, while it would remain cost-effective if no more than 51% were admitted to the ICU.

Conclusion: CM was the cost-effective or cost-saving management strategy compared to CH for PAS. However, modeling demonstrated significant uncertainty in the comparative effectiveness of the two strategies, highlighting the need for prospective research evaluating the effectiveness of CM.