Hypertension in pregnancy

Costing report
Implementing NICE guidance

August 2010

National costing report: Hypertension in pregnancy (August 2010) NICE clinical guideline 107

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This costing report accompanies the clinical guideline: Hypertension in pregnancy: the management of hypertensive disorders during pregnancy (available online at www.nice.org.uk/guidance/CG107). Issue date: August 2010

This guidance is written in the following context This report represents the view of the Institute, which was arrived at after careful consideration of the available data and through consulting healthcare professionals. It should be read in conjunction with the NICE guideline. The report and templates are implementation tools and focus on those areas that were considered to have significant impact on resource utilisation. The cost and activity assessments in the reports are estimates based on a number of assumptions. They provide an indication of the likely impact of the principal recommendations and are not absolute figures. Assumptions used in the report are based on assessment of the national average. Local practice may be different from this, and the template can be amended to reflect local practice to estimate local impact.

National Institute for Health and Clinical Excellence MidCity Place 71 High Holborn London WC1V 6NA www.nice.org.uk

National Institute for Health and Clinical Excellence, 2010. All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express written permission of the Institute.

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Contents
Executive summary .......................................................................................... 4 Supporting implementation ...................................................................... 4 Significant resource-impact recommendations ........................................ 4 Total cost impact ..................................................................................... 5 Benefits and savings ............................................................................... 5 Local costing template ............................................................................. 6 1 Introduction .............................................................................................. 7 1.1 1.2 1.3 1.4 2 Supporting implementation........................................................... 7 What is the aim of this report? ...................................................... 7 Epidemiology of hypertensive disorders during pregnancy .......... 8 Models of care .............................................................................. 8

Costing methodology ............................................................................... 9 2.1 2.2 2.3 2.4 Process ........................................................................................ 9 Scope of the cost-impact analysis ................................................ 9 General assumptions made........................................................ 13 Basis of unit costs ...................................................................... 13

Cost of significant resource-impact recommendations .......................... 14 3.1 3.2 Reducing the risk of hypertensive disorders in pregnancy ......... 14 Assessment of proteinuria in hypertensive disorders of pregnancy................................................................................... 17 3.3 Benefits and savings .................................................................. 21

Sensitivity analysis ................................................................................ 22 4.1 4.2 Methodology ............................................................................... 22 Impact of sensitivity analysis on costs ........................................ 22

5 6

Impact of guidance for commissioners .................................................. 23 Conclusion ............................................................................................. 23 6.1 6.2 Total national cost for England ................................................... 23 Next steps .................................................................................. 24

Appendix A. Approach to costing guidelines .................................................. 26 Appendix B. Results of sensitivity analysis .................................................... 27 Appendix C. References ................................................................................ 28

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Executive summary
This costing report looks at the resource impact of implementing the NICE guideline Hypertension in pregnancy: the management of hypertensive disorders during pregnancy in England. The costing method adopted is outlined in appendix A; it uses the most accurate data available, was produced in conjunction with key clinicians, and reviewed by clinical and financial professionals.

Supporting implementation
The NICE clinical guideline on hypertension in pregnancy is supported by a range of implementation tools available on our website www.nice.org.uk/guidance/CG107 and detailed in the main body of this report.

Significant resource-impact recommendations

Because of the breadth and complexity of the guideline, this report focuses on recommendations that are considered to have the greatest resource impact and therefore require the most additional resources to implement or can potentially generate savings. They are: Advising women at high risk of pre-eclampsia or with more than one moderate risk factor for pre-eclampsia to take 75 mg of aspirin daily from 12 weeks until the birth of the baby. Using an automated reagent-strip reading device or a spot urinary protein:creatinine ratio for estimating proteinuria in a secondary care setting.

In the guideline, drug names are marked with an asterisk if they do not have UK marketing authorisation for the indication in question at the time of publication (August 2010). Informed consent should be obtained and documented.

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Total cost impact

The annual changes in revenue costs arising from fully implementing the recommendations on offering women aspirin and the use of an automated reagent-strip reading device or a spot urinary protein:creatinine ratio for measuring proteinuria are summarised in the table below. Estimated recurrent costs and savings of implementation Recommendation Cost (000)
Advising women at high or moderate risk of pre-eclampsia to take aspirin increased use of aspirin Advising women at high or moderate risk of pre-eclampsia to take aspirin savings due to reduction in number of adverse events Using an automated reagent-strip reading device or a spot urinary protein:creatinine ratio for estimating proteinuria increased test costs Using an automated reagent-strip reading device or a spot urinary protein:creatinine ratio for estimating proteinuria savings due to reduction in adverse outcomes Net saving 337 1,409 289

6,948 7,731

The Guideline Development Group (GDG) considered, given the low cost of aspirin and relatively low cost of an automated reagent-strip reading device and a spot urinary protein:creatinine ratio for estimating proteinuria, that the above recommendations could be fully implemented in the first year after publication of the guideline.

Benefits and savings

In addition to the above, other recommendations in the guideline may lead to a change in resource use but could not be quantified because of uncertainty around current and future practice. These recommendations are described briefly here and are discussed more comprehensively in section 3.3. The GDG considered that: Recommendations 1.6.1.1, 1.6.2.1, 1.6.2.2, 1.6.3.2 and 1.6.3.5 on fetal monitoring should reinforce good practice and reduce variation in care. National costing report: Hypertension in pregnancy (August 2010) 5 of 28

 Recommendations 1.6.1.2, 1.6.2.3 and 1.6.4.2 relating to cardiotocographs for fetal monitoring will probably lead to a decrease in the number of cardiotocographs carried out nationally, potentially reducing associated costs. Recommendations relating to postnatal investigation, monitoring and treatment after pregnancy with chronic hypertension (1.2.6), pregnancy with gestational hypertension (1.4.3) and pregnancy with pre-eclampsia (1.5.3) may lead to a shift in resource use.

Local costing template

The costing template produced to support this guideline enables organisations in England, Wales and Northern Ireland to estimate the impact locally and replace variables with ones that depict the current local position. A sample calculation using this template showed that savings of around 15,300 could be made for a population of 100,000. This is equivalent to around 11,600 per 1000 pregnancies.

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1
1.1
1.1.1

Introduction
Supporting implementation
The NICE clinical guideline on hypertension in pregnancy is supported by the following implementation tools available on our website www.nice.org.uk/guidance/CG107: costing tools a national costing report (this document) a local costing template; a simple spreadsheet that can be used to estimate the local cost of implementation a slide set; key messages for local discussion audit support.

1.1.2

A practical guide to implementation, How to put NICE guidance into practice: a guide to implementation for organisations, is also available to download from the NICE website. It includes advice on establishing organisational level implementation processes as well as detailed steps for people working to implement different types of guidance on the ground.

1.2
1.2.1

What is the aim of this report?

This report provides estimates of the national cost impact arising from implementation of guidance on hypertension in pregnancy in England. These estimates are based on assumptions made about current practice and predictions of how current practice might change following implementation.

1.2.2

This report aims to help organisations plan for the financial implications of implementing NICE guidance.

1.2.3

This report does not reproduce the NICE guideline on hypertension in pregnancy and should be read in conjunction with it (see www.nice.org.uk/guidance/CG107).

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1.2.4

The costing template that accompanies this report is designed to help those assessing the resource impact at a local level in England, Wales or Northern Ireland. The costing template may help inform local action plans demonstrating how implementation of the guideline will be achieved.

1.3

Epidemiology of hypertensive disorders during pregnancy

1.3.1

Hypertension during pregnancy is defined as a diastolic blood pressure of 90 mmHg or greater on two occasions more than 4 hours apart or a single diastolic blood pressure above 110 mmHg. Hypertensive disorders during pregnancy occur in women with pre-existing primary or secondary chronic hypertension, and in women who develop new-onset hypertension in the second half of pregnancy. Both chronic hypertension and gestational hypertension can progress to pre-eclampsia.

1.3.2 1.3.3

In 2008 there were 665,800 pregnancies in England1. Pregnancy-induced hypertension and pre-eclampsia are common complications of pregnancy. It is estimated that gestational hypertension complicates 1215% of pregnancies (around 89,900 pregnancies per year) and that between 15% and 30% of cases of gestational hypertension subsequently develop pre-eclampsia, characterised by the development of proteinuria2.

1.4
1.4.1

Models of care
The clinical guideline contains recommendations for the diagnosis and management of hypertensive disorders during pregnancy in the antenatal, intrapartum and postnatal periods. This spans both primary and secondary care and may include more than one midwifery team. It includes recommendations for women with chronic hypertension who wish to conceive and recommendations

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for advice to women after a pregnancy complicated by hypertension.

2
2.1
2.1.1

Costing methodology
Process
We use a structured approach for costing clinical guidelines (see appendix A).

2.1.2

Information has been collected about the number of pregnancies that are complicated by hypertensive disorders. However, less information is available about the detailed management of these pregnancies, which led to problems in building a comprehensive bottom-up model for costing (a costing methodology in which the unit cost of individual elements and number of units are estimated and added together to provide a total cost). To overcome this limitation, we had to make assumptions in the costing model. We developed these assumptions and tested them for reasonableness with members of the GDG and key clinical practitioners in the NHS.

2.2
2.2.1

Scope of the cost-impact analysis

The guideline offers best practice advice on the care of women who are suspected of having, or are diagnosed with, hypertensive disorders in pregnancy.

2.2.2

The guideline does not cover the management of women with hypertension and diabetes or the infants of women who have had hypertensive disorders during pregnancy. Therefore, these issues are outside the scope of the costing work.

2.2.3

Due to the breadth and complexity of the guideline, we worked with the GDG and other professionals to identify the recommendations that would have the most significant resource-impact (see table 1). Costing work has focused on these recommendations.

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Table 1 Recommendations with a significant resource impact High-cost recommendations Key priority? Recommendation number Advise women at high risk of preeclampsia to take 75 mg of aspirin

1.1.2.1

daily from 12 weeks until the birth of the baby. Women at high risk are those with any of the following: hypertensive disease during a previous pregnancy chronic kidney disease autoimmune disease such as systemic lupus erythematosis or antiphospholipid syndrome type 1 or type 2 diabetes chronic hypertension. Advise women with more than one moderate risk factor for preeclampsia to take 75 mg of aspirin* daily from 12 weeks until the birth of the baby. Factors indicating moderate risk are: first pregnancy age 40 years or older pregnancy interval of more than 10 years

1.1.2.2

In this guideline, drug names are marked with an asterisk if they do not have UK marketing authorisation for the indication in question at the time of publication (August 2010). Informed consent should be obtained and documented.

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 body mass index (BMI) of 35 kg/m2 or more at first visit family history of preeclampsia multiple pregnancy. Use an automated reagent-strip reading device or a spot urinary protein:creatinine ratio for estimating proteinuria in a secondary care setting.
1.3.1.1

2.2.4

Nine of the recommendations in the guideline have been identified as key priorities for implementation, and two of these are also among the three recommendations considered to have significant resource impact.

2.2.5

Providing specific information for women who take angiotensinconverting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs [recommendation 1.2.1.1]) can be carried out as part of their existing management programme and is therefore unlikely to have a significant effect on resources.

2.2.6

In pregnant women with uncomplicated chronic hypertension the aim of treatment should be to keep blood pressure lower than 150/100 mmHg (recommendation 1.2.3.1). This change in practice is not considered to be large and is therefore unlikely to have a significant impact on NHS resources.

2.2.7

Two recommendations relating to pregnancy with gestational hypertension (1.4.1.3) or with pre-eclampsia (1.5.1.2) mention offering women with these conditions an integrated package of care covering admission to hospital, treatment, measurement of blood

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pressure, testing for proteinuria and blood tests. Although these recommendations may lead to a shift in existing practice and potentially savings (for example, through a reduction in the number of blood tests carried out), accurately assessing the current baseline across different degrees of hypertension and management methods is not possible. Any cost impact will depend on local protocols and should therefore be assessed locally. 2.2.8 Consultant obstetric staff can document in the womans notes the maternal (biochemical, haematological and clinical) and fetal thresholds for elective birth before 34 weeks in women with preeclampsia (1.5.2.2) at the same time as other information and should not therefore lead to a significant shift in use of NHS resources. 2.2.9 Recommendation 1.5.3.10 to offer all women who have had preeclampsia a medical review at the postnatal review (68 weeks after the birth), formalises what is probably already current practice, and so should not lead to a significant shift in the use of NHS resources. 2.2.10 Providing specific information for women who have had preeclampsia about future risks (recommendation 1.10.4.2) can be carried out as part of their existing management programme and is therefore unlikely to have a significant effect on resources. 2.2.11 We limited the consideration of costs and savings to direct costs to the NHS that will arise from implementation. We have not included consequences for the individual, the private sector or the not-forprofit sector. If applicable, any realisable cost savings arising from a change in practice have been offset against the cost of implementing the change.

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2.3
2.3.1

General assumptions made

The model is based on the number of annual pregnancies in England and the number of these pregnancies that are likely to be complicated by hypertensive disorders.

2.3.2

Pregnancies complicated by hypertensive disorders have several possible outcomes including normal birth, pre-eclampsia, neonatal admission and neonatal death. The cost associated with all outcomes was estimated to help to assess the national cost impact of implementing the recommendations within the guideline.

2.4
2.4.1

Basis of unit costs

The way the NHS is funded has undergone reform with the introduction of Payment by results, based on a national tariff. The national tariff will be applied to all activity for which Healthcare Resource Groups (HRGs) or other appropriate case-mix measures are available. Where a national tariff price or indicative price exists for an activity this has been used as the unit cost; this has then been inflated by the national average market forces factor.

2.4.2

Using these prices ensures that the costs in the report are the cost to the primary care trust (PCT) of commissioning predicted changes in activity at the tariff price, but may not represent the actual cost to individual trusts of delivering the activity.

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Cost of significant resource-impact recommendations

3.1

Reducing the risk of hypertensive disorders in pregnancy

Recommendations 3.1.1 Advise women at high risk of pre-eclampsia to take 75 mg of aspirin daily from 12 weeks until the birth of the baby. Women at high risk are those with any of the following: hypertensive disease during a previous pregnancy, chronic kidney disease, autoimmune disease such as systemic lupus erythematosis or antiphospholipid syndrome, type 1 or type 2 diabetes, or chronic hypertension (1.1.2.1). 3.1.2 Advise women with more than one moderate risk factor for preeclampsia to take 75 mg of aspirin* daily from 12 weeks until the birth of the baby. Factors indicating moderate risk are: first pregnancy, age 40 years or older, pregnancy interval of more than 10 years, body mass index (BMI) of 35 kg/m2 or more at first visit, family history of pre-eclampsia, or multiple pregnancy (1.1.2.2). Background 3.1.3 Advising women at risk of pre-eclampsia to take aspirin can reduce the likelihood of adverse events associated with these risk factors such as the progression to pre-eclampsia itself, deliveries at less than 34 weeks, number of babies born small for their gestational age, neonatal admissions and neonatal deaths. Assumptions made 3.1.4 Gestational hypertension is estimated to complicate 1215% of pregnancies. Using a midpoint of 13.5% indicates that around

In this guideline, drug names are marked with an asterisk if they do not have UK marketing authorisation for the indication in question at the time of publication (August 2010). Informed consent should be obtained and documented.

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89,900 pregnancies per year are complicated by gestational hypertension. For the purposes of this costing report all of these women are assumed to be at risk of developing pre-eclampsia. 3.1.5 The probabilities3 and assumed costs of the different outcomes associated with pregnancies at risk of pre-eclampsia are provided in table 2. Table 2 Probabilities and assumed costs of the different outcomes associated with pregnancies at risk of pre-eclampsia Outcome Probability of Probability of Cost of outcome no outcome with outcome () aspirin (%) aspirin (%)
Pre-eclampsia Delivery before 34 weeks Small for gestational age Neonatal admission Neonatal death Normal birth 11.30 12.40 0.50 59.90 11.10 12.00 0.49 61.41 1,881 749 634 1,174 8.70 7.20 7.90 7.10 4,300 2,630

3.1.6

The cost of managing pre-eclampsia and the cost of neonatal deaths are taken from the health economic modelling in the full guideline (see www.nice.org.uk/guidance/CG107). The cost of delivery before 34 weeks is assumed to be the national tariff for HRG code NZ01A (normal delivery 19 years and over with complications) plus the cost of a neonatal intensive care unit level 2 admission (code CC11) taken from 2007/08 reference costs. The cost for a small-for-gestational-age birth is assumed to be the national tariff for HRG NZ01A, the cost of a normal birth is assumed to be the national tariff for HRG NZ01B (normal delivery without complications) and the cost for a neonatal admission is the

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cost of a neonatal intensive care unit level 2 admission (code CC11) taken from 2007/08 reference costs. 3.1.7 The unit costs of aspirin is taken from the health economic modelling in the full guideline (see www.nice.org.uk/guidance/CG107) which uses drug costs from the British National Formulary (BNF) and assumes that aspirin is prescribed for a period of 26 weeks. 3.1.8 The GDG estimated that around 40% of the women who would be advised to take aspirin following implementation of the guideline were currently being offered and using aspirin. The GDG considered that the recommendations in question (1.1.2.1 and 1.1.2.2) could be fully implemented in the first year following publication of the guideline, that is, use could increase to around 100% of the target population. Cost summary 3.1.9 The estimated saving associated with advising women at high or moderate risk of pre-eclampsia to taken aspirin is 1.1 million. The details are summarised in table 3.

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Table 3 Estimated costs and savings associated with advising women at high or moderate risk of pre-eclampsia to take aspirin
Current cost (000s) Advising women at high or moderate risk of pre-eclampsia to take aspirin increased use of aspirin Advising women at high or moderate risk of pre-eclampsia to take aspirin costs and savings due to reduction in number of adverse events Pre-eclampsia Delivery before 34 weeks Small for gestational age Neonatal admissions Neonatal death Normal birth Total Predicted Change in cost cost (000s) (000s) 224 561 337

32,388 16,926 18,970 8,240 283 63,845 140,876

30,533 16,784 18,767 8,079 279 64,801 139,804

1,855 142 203 162 3 956 1,072

3.2

Assessment of proteinuria in hypertensive disorders of pregnancy

Background 3.2.1 Use an automated reagent-strip reading device or a spot urinary protein:creatinine ratio for estimating proteinuria in a secondary care setting (1.3.1.1). 3.2.2 Reliably detecting significant proteinuria is most important in women with new-onset hypertension during pregnancy because it distinguishes between pregnancies with pre-eclampsia and those with gestational hypertension. This sets the standard for future monitoring and management.

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3.2.3

The GDG considered that using a visual urinary dipstick to estimate proteinuria was a poor test for the diagnosis of pre-eclampsia and that using an automated reagent-strip reading device or a spot urinary protein:creatinine ratio was associated with an increase in the number of true positives, and a significant reduction in the number of false negatives. The cost of false negatives is significantly higher than other outcomes 4.

Assumptions made 3.2.4 It is estimated that gestational hypertension complicates 1215% of pregnancies. Using a midpoint of 13.5% indicates that around 89,900 pregnancies per year are complicated by gestational hypertension. For the purposes of this costing report all of these women are assumed to be assessed for proteinuria in secondary care. 3.2.5 The probabilities4 and assumed costs of the different diagnostic outcomes associated with estimates of proteinuria to diagnose preeclampsia are shown in table 4. Table 4 Probabilities and assumed costs of the different diagnostic outcomes associated with estimates of proteinuria to diagnose pre-eclampsia
Diagnostic outcome Probability of outcome visual urinalysis (%) 9.9 13.1 8.1 68.9 Probability of outcome automated urinalysis (%) 14.8 15.6 3.2 66.4 Probability of Cost of outcome spot outcome () urine protein:creatinine ratio (%) 17.6 4,300 0.7 0.4 81.3 2,949 5,700 2,774

True positive False positive False negative True negative

3.2.6

The costs of the outcomes are taken from the health economic modelling in the full guideline (see

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www.nice.org.uk/guidance/CG107). The cost of managing preeclampsia (true positives) assumes that it is managed in line with the guideline recommendations on new-onset hypertension with proteinuria. True negative pre-eclampsia is assumed to be managed in line with the guideline recommendations on new-onset hypertension without proteinuria. Women with false positive outcomes are assumed to be admitted to hospital for 1 day and their hypertension subsequently managed in line with the guideline recommendations on new-onset hypertension without proteinuria. False negative outcomes are assumed to eventually be managed as true positive outcomes, but with additional costs as a result of the delay in diagnosing pre-eclampsia. 3.2.7 The cost of an automated test (3.13) is taken from the health economic modelling in the full guideline (see www.nice.org.uk/guidance/CG107). This figure assumes that the cost of an automated machine is 740, that it will last for 5 years, and that 100 women will use it each year (a total of 500 women over the lifetime of the machine). An annual discount rate of 3.5% is assumed. It is also assumed that the cost to collect the sample is the same as for visual urinalysis so that 3.13 is the incremental cost of the automated test. 3.2.8 The cost of a spot urinary protein:creatinine ratio test (4.91) is taken from the health economic modelling in the full guideline (see www.nice.org.uk/guidance/CG107). It is also assumed that the cost to collect the sample is the same as for visual urinalysis so that 4.91 is the incremental cost of the protein:creatinine ratio test. 3.2.9 Use of automated urinalysis and spot urinary protein:creatinine ratio varies in the NHS. The GDG estimated that current use was around 20%. It has been assumed for the purposes of this costing report that this is split equally between automated urinalysis and spot urinary protein:creatinine ratio (that is, 10% each). The remaining 80% is assumed to be visual urinalysis. National costing report: Hypertension in pregnancy (August 2010) 19 of 28

3.2.10

The GDG considered that, because of the relatively low cost of an automated reagent-strip reading device and spot urinary protein:creatinine ratio for estimating proteinuria, recommendation 1.3.1.1 could be fully implemented in the first year after publication of the guideline, that is, use of automated urinalysis/protein:creatinine ratio could be increased to around 100%. It is assumed that use will be split equally between the two tests (50% each).

Cost summary 3.2.11 The estimated saving associated with using an automated reagentstrip reading device or a spot urinary protein:creatinine ratio for estimating proteinuria in a secondary care setting is 6.6 million. The details are summarised in table 5. Table 5 Estimated costs and savings associated with using an automated dipstick for estimating proteinuria to diagnose pre-eclampsia in secondary care
Current cost (000s) Using an automated reagent-strip device or a spot urinary protein:creatinine ratio for estimating proteinuria in secondary care increased test costs Using an automated reagent-strip device or a spot urinary protein:creatinine ratio for estimating proteinuria in secondary care savings due to reduction in adverse outcomes True positive False positive False negative True negative Total 72 Predicted cost (000s) Change in cost (000s) 361 289

43,119 32,147 35,062 174,216 284,616

62,542 21,627 9,316 184,111 277,957

19,423 -10,520 25,746 9,895 6,659

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3.3

Benefits and savings

In addition to the recommendations discussed in sections 3.1 and 3.2, other recommendations in the guideline may lead to a change in resource use but could not be quantified because of uncertainty around current and future practice. Recommendations 1.6.1.1, 1.6.2.1, 1.6.2.2, 1.6.3.2 and 1.6.3.5 on fetal monitoring are likely to reinforce good practice and reduce variation in care. The opinion of the GDG was that in some cases the number of assessments currently provided will be higher than recommended in the guideline. However, the GDG was also of the opinion that in other cases the frequency of assessments, particularly umbilical artery doppler velocimetry, is currently lower than what is recommended in the guideline. In both these circumstances, existing practice will change on implementation of the guidance with a potential cost impact. A national baseline across these recommendations was difficult to assess and organisations should assess the impact of these recommendations locally. The GDG thought that recommendations 1.6.1.2, 1.6.2.3 and 1.6.4.2 relating to cardiotocographs for fetal monitoring will probably lead to a decrease in the number of cardiotocographs carried out nationally, with potential savings for the NHS. Assessing an accurate baseline for the number of cardiotocographs carried out is problematic, and changing this common practice is also likely to be challenging. Therefore we have not made a national estimate of savings that could result from these recommendations, but organisations are encouraged to assess the impact of these recommendations locally. The unit cost for a cardiotograph is around 365. The GDG considered that the recommendations relating to postnatal investigation, monitoring and treatment for the management of pregnancy with chronic hypertension (1.2.6), the management of pregnancy with gestational hypertension (1.4.3) and the management of pregnancy with pre-eclampsia (1.5.3) may lead to a shift in resource use. Although these recommendations may lead to more intensive use of midwives time, this increase in resource use should be balanced by a reduction in the number National costing report: Hypertension in pregnancy (August 2010) 21 of 28

of readmissions to secondary care if people are managed more closely in primary care.

4
4.1
4.1.1

Sensitivity analysis
Methodology
There are a number of assumptions in the model for which no empirical evidence exists. Because of the limited data, the model developed is based mainly on discussions of typical values and predictions of how things might change as a result of implementing the guidance and is therefore subject to a degree of uncertainty.

4.1.2

As part of discussions with practitioners, we discussed possible minimum and maximum values of variables, and calculated their impact on costs across this range.

4.1.3

Wherever possible we have used the national tariff plus market forces factor to determine cost. We used the variation of costs for the 25th and 75th percentiles from reference costs compared with the reference cost national average as a guide to inform the maximum and minimum range of costs.

4.1.4

It is not possible to arrive at an overall range for total cost because the minimum or maximum of individual lines would not occur simultaneously. We undertook one-way simple sensitivity analysis, altering each variable independently to identify those that have greatest impact on the calculated total cost.

4.1.5

Appendix B contains a table detailing all variables modified and the key conclusions drawn are discussed below.

4.2

Impact of sensitivity analysis on costs

Prevalence of gestational hypertension 4.2.1 Varying the prevalence of gestational hypertension between 12% and 15% results in a difference in the savings generated of 1.7 National costing report: Hypertension in pregnancy (August 2010) 22 of 28

million, from 6.9 million at the minimum to 8.6 million at the maximum. Current and future use of visual urinalysis 4.2.2 Varying the assumptions about current and future use of visual urinalysis (and therefore also the use of automated urinalysis and spot urinary protein:creatinine ratio tests) has a significant impact on the savings that may be generated by implementing this guidance. Varying current use between 60% and 100% results in an increase in savings generated of 3.3 million. At 60%, projected savings are 6.1 million, with savings of 9.4 million projected at 100%. Varying future use between 0% and 40% results in a decrease in the savings generated of 3.3 million, from 7.7 million to 4.4 million.

5
5.1.1

Impact of guidance for commissioners

The guideline is likely to have an impact for commissioners. Implementing the recommendations in the guideline may lead to a reduction in the number of adverse events associated with hypertension in pregnancy such as pre-eclampsia and delivery before 34 weeks. Admissions associated with these adverse events may therefore fall.

5.1.2

The costs for managing hypertensive disorders in pregnancy fall under programme budgeting category 218X (maternity and reproductive health).

6
6.1
6.1.1

Conclusion
Total national cost for England
Using the significant resource-impact recommendations shown in table 1 and assumptions specified in section 3 we have estimated the annual savings generated by fully implementing the guideline in

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England to be 7,731,000. Table 6 shows the breakdown of cost of each significant resource-impact recommendation. Table 6 Estimated recurrent costs and savings of implementation Recommendation Cost (000)
Advising women at high or moderate risk of pre-eclampsia to take aspirin increased use of aspirin Advising women at high or moderate risk of pre-eclampsia to take aspirin savings due to reduction in number of adverse events Using an automated reagent-strip reading device or a spot urinary protein:creatinine ratio for estimating proteinuria increased test costs Using an automated reagent-strip reading device or a spot urinary protein:creatinine ratio for estimating proteinuria savings due to reduction in adverse outcomes Net saving 337 1,409 289

6,948 7,731

6.1.2

We applied reality tests against existing data wherever possible, but this was limited by the availability of detailed data. We consider this assessment to be reasonable, given the limited detailed data regarding diagnosis and treatment paths and the time available. However, the costs presented are estimates and should not be taken as the full cost of implementing the guideline.

6.1.3

Implementing other recommendations in the guideline relating to fetal monitoring and postnatal investigation, monitoring and treatment after pregnancy may lead to a change in resource use but could not be quantified because of uncertainty around current and future practice.

6.2
6.2.1

Next steps
The local costing template produced to support this guideline enables organisations such as PCTs or health boards in Wales and Northern Ireland to estimate the impact locally and replace variables with ones that depict the current local position. A sample calculation using this template showed that a population of 100,000 could expect to save 15,300. This is equivalent to around 11,600

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per 1000 pregnancies. Use this template to calculate the cost of implementing this guidance in your area.

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Appendix A. Approach to costing guidelines Guideline at first consultation stage

Identify significant recommendations and population cohorts affected through analysing the clinical pathway

Identify key cost drivers gather information required and research cost behaviour Develop costing model incorporating sensitivity analysis Draft national cost -impact report Determine links between national cost and local implementation

Internal peer review by qualified accountant within NICE

Develop local cost template

Circulate report and template to cost -impact panel and GDG for comments Update based on feedback and any changes following consultations Cost-impact review meeting

Final sign off by NICE

Prepare for publication in conjunction with guideline

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Sensitivity analysis

Assessment of sensitivity costs to a range of variables

Appendix B. Results of sensitivity analysis

National costing report: Hypertension in pregnancy (August 2010)

Baseline Minimum Maximum Baseline Minimum Maximum Change costs costs costs value value value (000s) (000s) (000s) (000s) 665,800 640,000 690,000 -7,731 -7,432 -8,012 -580 13.5% 12.0% 15.0% -7,731 -6,872 -8,590 -1,718 40% 20% 60% -7,731 -8,089 -7,374 715 80% 60% 100% -7,731 -6,066 -9,396 -3,330 10% 20% 0% -7,731 -6,066 -9,396 -3,330 0% 0% 40% -7,731 -7,731 -4,402 3,329 50% 50% 30% -7,731 -7,731 -4,402 3,329

Parameter varied Annual number of pregnancies Prevalence of gestational hypertension Current use of aspirin Current use of visual urinalysis Current use of automated urinalysis/PCR Future use of visual urinalysis Future use of automated urinalysis/PCR

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Appendix C. References
1

Office for National Statistics (2010) Birth statistics review of the National Statistician on births and patterns of family building in England and Wales 2008. London: Office for National Statistics. Available from www.statistics.gov.uk Anumba D.O.C., Lincoln K., Robson S.C. (2010) Predictive value of clinical and laboratory indices at first assessment in women referred with suspected gestational hypertension. Hypertension in Pregnancy 29: 16379 National Collaborating Centre for Womens and Childrens Health (2010) Hypertension in pregnancy: the management of hypertensive disorders during pregnancy (full guideline). Appendix H: Cost effectiveness of aspirin compared with no aspirin in preventing pre-eclampsia in women at risk of developing pre-eclampsia. London: Royal College of Obstetricians and Gynaecologists. Available from www.nice.org.uk/guidance/CG107 National Collaborating Centre for Womens and Childrens Health (2010). Hypertension in pregnancy: the management of hypertensive disorders during pregnancy (full guideline). Appendix L: Cost-effectiveness of automated urinalysis compared to visual urinalysis in the detection and quantification of proteinuria in women with gestational hypertension. Appendix M: Cost effectiveness of quantifying proteinuria in women with gestational hypertension. London: Royal College of Obstetricians and Gynaecologists. Available from www.nice.org.uk/guidance/CG107
5 4 3 2

Department of Health (2010) NHS reference costs 20082009. National average unit cost for currency code DA13 Electrocardiogram. London: Department of Health. Available from www.dh.gov.uk

National costing report: Hypertension in pregnancy (August 2010)

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