BMJ 2001;323:423 ( 25 August )

Papers

Screening for Down's syndrome: effects, safety, and cost effectiveness of first and second trimester strategies

R E Gilbert, senior lecturer in clinical epidemiology, ^a C Augood, research fellow in systematic reviews, ^a R Gupta, research assistant in statistics, ^a A E Ades, reader in biostatistics, ^b S Logan, senior lecturer in epidemiology, ^a M Sculpher, senior research fellow, ^c J H P van der Meulen, senior lecturer in clinical epidemiology. ^d

^a Systematic Reviews Training Unit, Department of Paediatric Epidemiology and Biostatistics, Institute of Child Health, London WC1N 1EH, ^b Department of Paediatric Epidemiology and Biostatistics, Institute of Child Health, ^c Centre for Health Economics, University of York, Heslington, York YO1 5DD, ^d Health Services Research Unit, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT

Correspondence to: R E Gilbert r.gilbert{at}ich.ucl.ac.uk

Objective: To compare the effects, safety, and cost effectiveness of antenatal screening strategies for Down's syndrome.
Design: Analysis of incremental cost effectiveness.
Setting: United Kingdom.
Main outcome measures: Number of liveborn babies with Down's syndrome, miscarriages due to chorionic villus sampling or amniocentesis, healthcare costs of screening programme, and additional costs and additional miscarriages per additional affected live birth prevented by adopting a more effective strategy.
Results: Compared with no screening, the additional cost per additional liveborn baby with Down's syndrome prevented was £22 000 for measurement of nuchal translucency. The cost of the integrated test was £51 000 compared with measurement of nuchal translucency. All other strategies were more costly and less effective, or cost more per additional affected baby prevented. Depending on the cost of the screening test, the first trimester combined test and the quadruple test would also be cost effective options.
Conclusions: The choice of screening strategy should be between the integrated test, first trimester combined test, quadruple test, or nuchal translucency measurement depending on how much service providers are willing to pay, the total budget available, and values on safety. Screening based on maternal age, the second trimester double test, and the first trimester serum test was less effective, less safe, and more costly than these four options.

What is already known on this topic Screening strategies that combine nuchal translucency measurement with serum testing perform better than either of these tests used alone Serum testing in the second trimester using the triple test is cost effective compared with screening based on maternal age What this study adds The integrated test is the most effective, safest, and most expensive strategy The choice of screening strategy should be between the integrated test, first trimester combined test, quadruple test, or measurement of nuchal translucency Screening based on maternal age, the second trimester double test, and the first trimester serum test is less effective, less safe, and more costly than the above options

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