Klinik ve Ülke Verilerimiz Işığında Rhesus D Genotiplemesi ile Desteklenmiş Rhesus D Negatif Gebe İzlem Programı Uygulamanın Prosedür Spesifik Maliyet-Etkinlik Analizi

Öz

Amaç: Ülkemiz şartlarında fetal RhD genotiplemesi ile hedeflenmiş antenatal anti-D profilaksi programı uygulamanın maliyet etkinlik ve uygulanabilirlik analizini yapmaktır.

Materyal -Metot: RhD genotiplemesi yolu ile hedeflenmiş antenatal anti-D profilaksi programı ile evrensel anti-D profilaksisi programlarını karşılaştırmak amacı ile ulusal perinatal istatistikler, yayınlanmış literatür, hastanemiz hasta kayıtları ve ulusal maliyet kaynakları gözden geçirilerek bir analiz modeli oluşturuldu.

Bulgular: RhD negatif gebelik oranı %10.1 ve bu gebeliklerdeki RhD negatif fetüs oranı %21.4'idi. Antenatal ve postnatal profilaksi programına katılım oranı sırası ile %26.3 ve %66.7'idi. Hastalarımızın %7'sinde sensitizasyon riskli olaylar nedeni ile ikiden fazla anti-D profilaksisi yapılmıştı. Anti-D Immunglobulin (300µgr) birim maliyeti 295.2TL'idi. Evrensel antenatal profilaksi programına ait 'Gebelik başına ortalama maliyet' 564,8TL'idi. Bu maliyetin aşılmamasını sağlayacak RhD geneotipleme birim maliyeti 52.4TL olarak belirlendi. Bu program yürütüldüğünde her yıl 551 (%0.38) hastanın yanlış negatiflik nedeniyle sensitizasyon riski yaratacak şekilde profilaksi programı dışında kalacağı ve 6328 (%4.37) hastanın ise yanlış pozitiflik nedeni ile gereksiz antenatal anti-D profilaksisi almaları gerekeceği belirlendi.

Sonuç: Antenatal RhD genotiplemesi, postpartum profilaksi programı ile birlikte uygulandığı tüm klinik seneryolar için ek maliyet oluşturmaktadır. Hem maliyeti azaltacak hasta sayısı ve oranının ülkemizde Avrupa ülkelerinden daha az olması hem de mevcut hasta populasyonun daha çok postpartum profilaksi programına uygun hastane başvurularında bulunması nedeni ile ülkemizde profilaksi programına RhD geneotiplemesinin eklenmesinin maliyet etkin bir yaklaşım olmayacağını görüşündeyiz. Yine de bireysel hasta görüşmeleri esnasında RhD genotiplesi yolu ile gereksiz anti-D profilaksisinden ve bu sayede işlemin getirebileceği çok düşük ihtimalli olası yan etkilerden kaçınılabileceği hususunda bilgilendirmede bulunmak da etik bir yaklaşım olabilir.

Anahtar Kelimeler

• Anti-D,Maliyet etkinliği,Ekstraselüler serbest fetal DNA,Genotipleme,RhD immünoglobulin

Procedure Specific Cost-Effectiveness Analysis of Implementing a Rhesus D Genotyping Targeted Rhesus D Negative Pregnancy Monitoring Program in Turkey

Öz

Aim: To analyze the feasibility of fetal Rhesus D (RhD) genotyping targeted antenatal anti-D prophylaxis program under the specific conditions of Turkey.

Material and Method: An analyzing method was built to compare the two prophylaxis programs by utilizing national perinatal statistics, published literature, hospital patient records and national cost resources.

Results: The incidence of RhD negative pregnancy and RhD negative fetus in those pregnancies, were 10.1% and 21.4%, respectively. The attendance rate of antenatal and postnatal prophylaxis programs were 26.3% and 66.7%, respectively and 7% of those patients required additional doses. The average cost of anti-D immunoglobulin was 77.7 US$. The average per pregnancy cost of universal antenatal prophylaxis program was 148.6 US$. The individual cost of RhD gene genotyping shouldn’t be exceeding 13.7 US$ not to increase expenditure. In the case of program implementation; 551 (0.38%) patients would be falsely excluded and additional 6328 (4.37%) patients had to receive unnecessary prophylaxis each year.

Conclusion: Antenatal RhD genotyping is bearing additional cost in all clinical scenarios when followed by postpartum prophylaxis. The implementation of RhD genotyping targeted anti-D prophylaxis program in Turkey would not be a cost-effective approach, due to the facts that the number and proportion of patients who cause cost reduction were found to be far more lower than European countries and that the existing patient population is mostly applying to hospitals appropriate for postpartum prophylaxis. However, it would be an ethical approach to inform patients at the individual level about the potential benefits of antenatal RhD genotyping.

Anahtar Kelimeler

• Anti-D,Cost-effectiveness,Extracellular free fetal DNA,Genotyping,RhD immunoglobulin

Kaynakça

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