Cuker, Adam

Abstract Maternal iron deficiency (ID) affects nearly 85% of all pregnancies worldwide by the third trimester and is strongly linked with maternal morbidity, poor birth outcomes, and cognitive and behavioral developmental deficits in children. Despite its burden on maternofetal health, no guidelines exist for routine screening of ID in pregnant individuals in the United States. The World Health Organization uses a diagnostic (ie, nonscreening) ferritin threshold of 15 μg/L for ID in the first trimester of pregnancy, with no guidance for the second and third trimesters. Routine screening for ID in pregnancy could identify a large proportion of mothers who remain undiagnosed and untreated under the current clinical status quo. Accordingly, we conducted, to our knowledge, the first cost-effectiveness analysis of ferritin-based ID screening in pregnant women in the United States, comparing thresholds of (1) 30 μg/L vs (2) 15 μg/L vs (3) no screening from a modified US societal perspective accounting for wages lost to infusion time, infusion administration costs, and the cost of annual hematology follow-up. We found that screening at 30 μg/L was the preferred strategy across extensive base-case, threshold, and sensitivity analyses and across all examined willingness-to-pay thresholds, with an incremental cost-effectiveness ratio of $34 000/quality-adjusted life year (QALY; 95% credible interval, $32 000-$36 200/QALY) compared with no screening. No parameter variation changed this outcome, and screening at 30 μg/L was favored in 100% of 10 000 Monte Carlo iterations. Population-level regular second- and third-trimester screening for ID using physiologically informed ferritin ranges should be considered for all pregnant women in the United States.

Abstract Iron-deficiency anemia (IDA) affects nearly one-third of women globally, with heavy menstrual bleeding (HMB) being a significant risk factor among those of reproductive age. Despite the substantial burden of HMB-related IDA, patients often face delays in receiving effective treatment. Oral iron is typically used as first-line therapy, despite frequent gastrointestinal side effects and challenges in treatment adherence. This study evaluated the reproductive life span cost-effectiveness of first-line intravenous (IV) vs oral iron therapy for women with HMB and IDA. We developed a Markov model simulating a cohort of women aged 18 to 51 years, comparing first-line treatment with IV iron dextran, IV ferumoxytol, IV iron sucrose, or oral ferrous sulfate. Costs and quality-adjusted life years (QALYs) were estimated from the societal perspective. IV iron dextran was the cost-effective treatment, yielding 19.26 QALYs at a cost of $157 500, compared with 19.10 QALYs at $152 900 for oral ferrous sulfate. The incremental cost-effectiveness ratio for IV iron dextran was $28 600 per QALY. Treatment with IV ferumoxytol and iron sucrose cost $158 300 and $163 500, respectively, and did not provide additional QALY benefit compared with IV iron dextran, which remained the cost-effective treatment across a range of scenarios and sensitivity analyses. Our findings indicate that first-line treatment with IV iron dextran is the cost-effective strategy for managing IDA in women with HMB at commonly accepted willingness-to-pay thresholds. These results support expanding access to IV iron as a first-line option, and highlight the need to reduce treatment delays and insurance-related barriers.