Letters

Study might be better described as a cost description of screening

BMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7035.909b (Published 06 April 1996) Cite this as: BMJ 1996;312:909
  1. Sarah Walters
  1. Senior lecturer in public health and epidemiology University of Birmingham, Birmingham B15 2TT

    EDITOR,—H S Cuckle and colleagues' paper on the cost effectiveness of antenatal screening for cystic fibrosis raises several important questions.1 Firstly, their choice of cost effectiveness analysis rather than cost-benefit analysis makes an implicit assumption that the goal of a screening programme is to reduce births of affected infants and thus reduce health expenditure. This can be achieved only by introducing screening into a situation where there is high uptake (that is, antenatal clinics) and maximisation of the rate of subsequent termination of affected pregnancies. This is not the only model of screening. Indeed, it is one that explicitly limits reproductive choice in those women and couples who would not consider termination but might consider preimplantation diagnosis or artificial insemination by donor.

    We know that a proportion of women in Britain would not consider termination of an affected pregnancy.2 In their cost effectiveness analysis Lieu et al found that the proportion of women accepting termination of an affected pregnancy had a large effect on costs, particularly when it fell below 50%.3 In Cuckle and colleagues' example the cost per affected birth avoided would increase to £92000 if therapeutic abortion was accepted in only half of the cases.

    Lieu et al also showed that increasing costs of lifetime medical care for a patient with cystic fibrosis had a large effect on the cost effectiveness of a screening programme. Unfortunately, Cuckle and colleagues quote a single annual figure for medical care derived from a single unit treating adult patients. This does not account for the fact that care may be cheaper for children, who tend to be in better health than adults with cystic fibrosis, nor does it use discounting over the current median life expectancy of 28 years.4 Indeed, their study might be better described as a cost description of screening for cystic fibrosis, since effectiveness is not considered in great depth and factors known to affect cost effectiveness have been omitted from the sensitivity analysis.

    This study makes other important assumptions, not the least of which is that a disease for which the life expectancy for the current birth cohort is probably at least 40 years should be prevented. The study shows what a programme that maximises termination of affected pregnancies might cost the NHS, but not that it is cost effective. It does not address the moral and ethical issues that such screening would raise, or the costs of providing a service for women who would not consider termination of pregnancy. We may be able to screen, and might potentially be able to do it cost effectively, but should we do it and, if so, how?

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