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Strategies for Prescribing Aspirin to Prevent Preeclampsia: A Cost-Effectiveness Analysis.

In the September 2019 issue, Mallampati et al1 conclude that a policy of universal aspirin administration starting in early pregnancy is more cost effective in preterm preeclampsia prevention than a policy of restricting aspirin to those at high risk after serum and ultrasound screening or riskfactor assessment. However, this claim is dependent on the unrealistic assumption that aspirin compliance would be unrelated to policy, whereas compliance is more likely to be higher in high-risk pregnancies. I have carried out a cost-benefit analysis with varying compliance to demonstrate this dependence (Table 1). This new analysis uses efficacy and adverse outcomes of aspirin and unit costs specified by Mallampati et al; detection and false-positive rates for screening or risk assessment were not specified, so these, together with incidence, were taken from a large U.K. study.2 Among 8,775 singleton pregnancies, including 0.67% with preterm preeclampsia, the detection and falsepositive rates were 80% and 10% for screening and 90% and 64% for risk assessment using the American College of Obstetricians and Gynecologists’ recommendations. The table shows that, assuming 100% compliance, universal aspirin is the most effective and cost-saving policy. However, in the two tabulated examples with lower and differential compliance rates, the situation is reversed; selective is shown to be more effective than universal aspirin administration, and less costly.