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Prenatal screening of congenital heart disease between ethics and cost‐effectiveness. Time for a change in current prenatal ultrasound screening policies?

The progressive reduction of the gross national product share allotted to financing health interventions during the last decades has increased the attention paid by governmental agencies and public health operators to the costs of the various preventive and therapeutic health interventions. The method of choice in evaluating the health outcomes and resource costs of health interventions is costeffectiveness analysis (CEA). This type of evaluation allows the definition of the cost to be sustained per unit of health outcome achieved, where health outcome units are usually years of life saved (YLS) or, if a qualitative assessment of the life gained is needed, quality-adjusted life-years (QUALY) 1 . This type of analysis has been widely applied to demonstrate the economic and medical advantages of some health interventions, such as, within the field of obstetrics and gynecology, screening for cervical and breast cancer 2,3 or the administration of hormone replacement therapy. However, in these cases, the health outcome could always be measured in YLS or QUALY. The problem with prenatal diagnosis is to find other units to replace YLS. In fact, to carry out such analysis for any of the various screening protocols currently used in pregnancy, such as serum biochemistry or nuchal translucency for Down’s syndrome or ultrasound screening for congenital anomalies, the following assumption is made: that the implementation of the screening procedure aims to detect an anomaly in order to prevent the affected fetus being born. Everybody can evaluate the inappropriateness of such an assessment. Nonetheless, in prenatal screening, we are bound to this type of decision-analysis approach if we want to perform a costeffectiveness analysis, irrespective of the personal discomfort associated with the possible ethical implications. It is not unlikely that it is this uneasiness that lies behind the severely reduced number of cost-effectiveness analyses published in the field of prenatal diagnosis when compared to other fields of medicine. In fact, we have run a Medline search for ‘cost-effectiveness’ and ‘fetus’ and compared the number of publications retrieved with the number of publications from a search for ‘cost-effectiveness’ and other medical conditions for the years 1998–99 (Table 1): the difference between the 342 references for ‘infections’ or the 97 for ‘breast cancer’ and the 18 references yielded for ‘fetus’ or the nine for ‘fetus and malformation’ needs no further comment. One of the most interesting and thorough evaluations of