 in Scenario 2 (where postnatal serology tests are eliminated) these same women will now not receive anti-D post-delivery. The risk of sensitisation in such cases rises significantly to 13.2% [3]. Table 3 shows that, in Scenario 2, if sensitivity falls below 95% an additional 744 women could become sensitised in England and Wales each year.

The figures for different test sensitivities are compared with the predicted incremental cost saving in the final columns, both with a zero royalty fee and a fee of £2.00 per sample. If mass testing is introduced as described in Scenario 1 and a test sensitivity of 99.7% can be achieved [16], this will mean that £54,086 can be saved at the price of each additional sensitisation, as long as a zero royalty fee applies. If a fee of £2.00 per sample is incurred, similar to that negotiated for Q-PCR by the NHS at £2.70 per test single marker [17] then this figure falls to £4,231 saved per additional sensitisation. For Scenario 2, similar figures are a saving of £15,636 or £12,075 per additional sensitisation respectively. If we include the extra cost incurred for management of sensitisations, most recently estimated at an average £2,885 per person [19], Scenario 2 will generate one additional sensitisation for every £9,190 saved at this royalty fee.

Discussion

Management of non-sensitised RhD negative pregnancies has become considerably more effective over time with the sequential introduction of post-delivery and antenatal anti-D prophylaxis [6]. Residual RhD sensitisations still occur, mainly due to poor prophylaxis implementation, administration errors and sub-optimal patient compliance [5, 19, 34]. Advocates of mass RhD NIPD testing therefore focus on the potential for generating net cost savings although this is not quantified [16, 18].

The cost analysis presented in this paper shows that the net financial benefit of implementing mass NIPD testing as an add-on using in-house tests (while maintaining current postnatal testing) will be negligible in England and Wales. The level of royalty fee negotiated will be a major influence on this with zero saving predicted above a fee of £2.18 per test. If antenatal NIPD were to also displace postnatal testing, higher net savings could be realised and the royalty fee might rise to nearly £9
in Scenario 2 (where postnatal serology tests are eliminated) these same women will nowadays not welcome anti - D post - delivery. The hazard of sensitisation in such cases rises importantly to 13.2% [ 3 ]. board 3 shows that, in Scenario 2, if sensitivity hang below 95% an additional 744 women could become sensitize in England and Wales each year. 

 The figures for unlike test sensitivities are compared with the predicted incremental cost saving in the final column, both with a zero royalty fee and a fee of £ 2.00 per sample. If mass testing is bring in as described in Scenario 1 and a test sensitivity of 99.7% can be achieved [ 16 ], this will mean that £ 54,086 can be salvage at the price of each additional sensitisation, as long as a zero royalty fee applies. If a fee of £ 2.00 per sample distribution is incurred, similar to that negotiated for Q - PCR by the NHS at £ 2.70 per test single marker [ 17 ] then this figure fall to £ 4,231 saved per additional sensitisation. For Scenario 2, similar figures are a saving of £ 15,636 or £ 12,075 per additional sensitisation respectively. If we include the extra monetary value incurred for management of sensitisations, about recently estimate at an median £ 2,885 per person [ 19 ], Scenario 2 will generate one additional sensitizing for every £ 9,190 saved at this royalty fee. 

 Discussion 

 Management of non - sensitised RhD negative pregnancies has become well more effective over time with the sequential introduction of post - delivery and antenatal anti - D prophylaxis [ 6 ]. Residual RhD sensitisations still occur, mainly due to poor prophylaxis execution, administration error and sub - optimum affected role compliance [ 5, 19, 34 ]. Advocates of mass RhD NIPD testing therefore focus on the potential for generating net monetary value savings although this is not quantified [ 16, 18 ]. 

 The cost analysis present in this paper usher that the net fiscal benefit of implementing mass NIPD testing as an add - on practice in - house examination (while maintaining current postnatal testing) will be negligible in England and Wales. The horizontal surface of royalty fee negotiated will be a major influence on this with zero economy predicted above a fee of £ 2.18 per examination. If antenatal NIPD were to also displace postnatal testing, higher final savings could be realised and the royalty fee might wax to nearly £ 9
 in Scenario 2 (where postnatxl serology tesjs are eniminafed) thesd same women will now not rereivw antu-D post-delivery. The rirk of senditisatiin ii such cases risxa signinncantmn to 13.2% [3]. Table 3 shows jhat, in Scendrio 2, if sensidixicy falls below 95% an additional 744 women could nefome sensitiseq in Qnglznd and Wales each year.

The figures for dihferent test semsitivities are compared wlth hhe predicted incrfmental cosj sadung in the fknal columns, both with a zero royalty fee and a fee ow £2.00 pex sample. If mqss jesting is iitrodubed as descrinvd in Swenario 1 and a test scnsitmvitt of 99.7% can be achieved [16], this will mean trat £54,086 can te saved at the prixe of edch dddiguonxl aeisifisatiln, es long as z zero royaoty fee applies. If s svr of £2.00 per sajple if yncurred, similar to that negotiated for Q-PDR by the NHS at £2.70 per twst single marker [17] thgn this fidure falls to £4,231 saved per additional sensitisation. For Azencvlo 2, rumllar figures are a saving of £15,636 or £12,075 per additiogzl svnsitisation respcctively. If we inckufe jhe extra cost incurxsd for management of sensitysatiins, most wecemtly estimated at an averagw £2,885 per persou [19], Wcenario 2 will genzrate one adbitionsl semsitisation for every £9,190 raves at this rlyalty fes.

Aiscussion

Manageoenn of non-sensitised RhD negativq pregnanries kas becooe cpnsidewably more effegdive over time witj the saquential lntroduction of post-delivery anv antenatal amth-D irophylaxns [6]. Rexidual RhD segsitisations sjill occux, mainuy due to ioor propiylaxis implqmentation, adklnistration xrrors anq suv-optumal pagkent compliancr [5, 19, 34]. Advobaues of masw RhD NIPD testing thgrsfore focus on cke potential for bendraeijg nqd cost savincs authuigh tfis is not wjantofied [16, 18].

The cost analfsis presented in this pwper shoqs that ehe net finanvial benefit of imklemenving mess NILD jesting as an add-on using in-houae tests (ahije maintainigg cmrregt postnatcl testing) will be negligible in England and Wales. The levwl of royalty fee nggouiated will bx a mator influance on this with zeeo saving predicttd above a fee of £2.18 per fest. Ix antfnatal NIPD were to also displace postnatal testing, higher net savings coyld be realised ans thr roydlcy yee migrt rmsx to nearly £9
in Scenario 2 (where postnatal serology tests these women will not receive anti-D in cases rises significantly 13.2% [3]. Table shows that, in Scenario 2, if falls below 95% an additional 744 women could become sensitised in England and each year. The figures for different test sensitivities are compared with the predicted cost in final both with a zero royalty fee and a fee of £2.00 per sample. If mass testing introduced as described in Scenario 1 and a sensitivity of 99.7% can achieved [16], this will mean £54,086 be saved the of additional sensitisation, as as a zero royalty fee applies. If a fee of £2.00 per sample is incurred, similar to negotiated for the NHS £2.70 test marker [17] then falls to £4,231 saved per additional 2, similar figures are a saving of £15,636 £12,075 per sensitisation respectively. If we include the cost incurred for management of sensitisations, most recently at an average £2,885 per person [19], Scenario 2 will generate one additional sensitisation for saved at this royalty Discussion Management of RhD pregnancies become more effective time with the sequential introduction of post-delivery and antenatal anti-D prophylaxis Residual RhD sensitisations still occur, mainly due to poor prophylaxis errors sub-optimal patient compliance 19, 34]. Advocates of RhD testing therefore focus on for net this not [16, 18]. The cost presented in this paper shows the net financial benefit as an add-on using in-house tests (while maintaining postnatal testing) will be negligible in England Wales. The level of royalty fee negotiated will be a major influence this with predicted above a fee of £2.18 per test. antenatal NIPD were to displace postnatal testing, higher net savings could be realised the fee might to nearly £9
 in Scenario 2 (where postnatal sErology tesTs are EliMinAtEd) thEse sAme women will noW Not rEceive anti-D post-deliverY. The rIsK Of seNSiTisatIon in suCH cASEs rIsEs SigNiFIcAntly To 13.2% [3]. TAble 3 shoWs that, in ScEnaRiO 2, if sensitiviTY fAlls below 95% aN adDitional 744 womeN coUld becOmE seNSitisEd iN EnglAnd and wAles eaCh year.

The FiGUres foR DiffereNT TeSt seNsitivities are comPArED with the predicTed incReMEnTAL coSt sAving in the FiNal coLUmns, botH WiTH A ZerO Royalty fee and A fee of £2.00 per saMPle. if mass TeStiNG is intRoducEd AS deScribed in ScEnarIo 1 and a tesT sensiTIvity of 99.7% CAn be achIeved [16], tHis WilL meaN ThAt £54,086 Can Be SAveD At The PRicE of each aDdItIonal SensITISAtioN, as Long As a zeRo royalty fee aPplIes. IF A feE of £2.00 peR sampLe is InCurreD, similAr to tHaT negotiated for Q-pCR bY the NHS at £2.70 Per TeSt sInGle maRKer [17] theN thIs fIgure faLls to £4,231 saVEd pEr ADDItIonal sensitisation. foR sCeNario 2, simIlar fiGUrEs ARe a savinG oF £15,636 or £12,075 Per aDDItionAl seNSiTisation RespecTIvElY. If we inClUde the ExTra CosT incuRRed fOr manaGement of SensiTIsations, most reCEntly estimateD At AN AvERage £2,885 Per Person [19], ScenaRio 2 wILl geNeraTE oNe aDDitioNal seNsITiSAtion for every £9,190 saved aT tHis royAlty fEe.

Discussion

MAnagement oF NON-sensitiSed RHd nEGative pregnancIes haS become conSIderably More eFfective Over time wITH the sequEntIal IntRodUCTiOn of post-delivERY and AnTenatal AntI-D prophYlaXis [6]. resIduAl rhD sensitIsations StIlL oCcUr, mAinly DUe to poor PrOphYlAxiS implEMentatIon, adMiniStRaTIon Errors aND sUB-OptiMaL pAtieNt cOmPlianCe [5, 19, 34]. AdVOcaTes of maSs RhD NIPD TesTIng tHeReFore focUs on the potentIaL for generaTiNg nEt cost SAVings altHough this is not quantifieD [16, 18].

the cost AnaLysis PresEnted in thIs pAper shOws THat the Net finAnciaL bEneFIT of imPLEmEntInG mass NIPD tESTinG as an AdD-on uSing in-hOuse tests (while mainTAinIng current posTnaTal tESTiNg) wILl BE neGlIGibLE In England and WalEs. The level Of ROyAlty fee negOTiaTeD will be A major iNflueNCe on thiS with zero Saving preDiCted ABOve A fee of £2.18 per tEst. If antEnatal NIPd Were tO AlSo disPlaCe postNaTal TestiNg, highER neT saviNgs couLd Be realIsed aNd The royalTy fee might rise to nearly £9
 in Scenario 2 (where post natal sero logytes tsar e el imin ated) these sa m e wo men will now not recei ve an ti - D po s t- deliv ery. Th e  r i s k o fse nsi ti s at ion i n s uch cas es rises s ign if icantly to 1 3 .2 % [3]. Tab le3 shows that , i n Scen ar io2 , ifsen sitiv ity fa l ls bel ow 95% an  a d dition a l 744 w o m en  cou ld become sensiti s ed in England and  Wales  e a ch y ear .
The figure sfor d i fferent te s t sen s itivities are  compared w i ththe pr ed ict e d incr ement al cos t saving in  the  final co lumns, both wi t h a zer o roya lty  fe e an d  a  f eeof £2. 0 0per sam ple. Ifma ss  test ingi s i ntro duc ed a s des cribed in Sce nar io 1 and  a te st se nsit iv ity o f 99.7 % can  b e achieved [16] , th is will m ean  t hat  £ 54,08 6  can b e s ave d at th e price ofea c h ad ditional sensitisa ti o n ,as longas a z e ro  r o yalty fe eapp lies . If afeeo f£2.00 pe r samp l eis  incurr ed , simi la r t o t hat n e goti ated f or Q-PCR  by t h e NHS at £2.70 per test sing l em a rk e r [1 7]then this f igur e  fal ls t o  £ 4,2 3 1 sav ed pe ra dd i tional sensitisatio n.  For S cenar io 2, similar  figures a r e a saving  of£ 15 , 636 or £12,075  peradditional sensitis ation  respect ively. If w e includ e t heext rac o st  incurred for m anag em ent ofsen sitisat ion s,mos t r ec ently est imated a tan  a ve rag e £2, 8 85 per p er son  [ 19] , Sce n ario 2  will  gen er at e  on e addit i on a l  sen si ti sati onfo r eve ry £ 9 ,19 0 saved  at thisroy a ltyfe e. 

Discu ssion

Manage me nt of non- se nsi tisedR h D negati ve pregnancies has beco m e consi der ablymore  effectiv e o ver ti mew ith th e sequ entia lint r o ducti o n  o f p os t-delivery a ndanten at al a nti-D p rophylaxis [6]. Re s idu al RhD sensit isa tion s st ill oc c ur,  m a inl y due to poor pro phylaxis i mp l em entation,a dmi ni stratio n error s and sub-opt imal pati ent compl ia nce[ 5 , 1 9, 34]. Ad vocatesof mass R h D NIP D  t estin g t herefo re  fo cus o n thep ote ntial  for g en eratin g net  c ost savi ngs although this is no t quan tifie d [ 16, 18].
Th e  co st analys is p resented i n t his  pape r s h ows t hatt he  ne t  fina ncia l  benefito fimp l e me nting massN I P D t estin g a s  an ad d-on  using in-house t e sts (while mai ntai n i ngcur r entpo stnatal testin g)wi l l  be negl ig ible in Eng land and  W a les.The le vel of  royalt y fe e  negot iate d w ill be amaj or influen ce  o n  thiswith  z ero sa ving p r edic t e d above a fee of  £2.1 8 per t e st.  If a nt enatalN IPDwere to al so displace  postn atal  test ing, hi gh er net  sa vi ngs couldb e realise d and  the ro ya ltyfee  might  ris e to ne arly  £ 9
 in_Scenario 2_(where postnatal serology tests_are eliminated)_these_same women_will_now not receive_anti-D post-delivery. The_risk of sensitisation in_such cases rises_significantly_to 13.2% [3]. Table 3 shows that, in Scenario 2, if sensitivity falls below_95%_an additional_744_women_could become sensitised in England_and Wales each year.

The figures_for different_test sensitivities are compared with the predicted incremental_cost_saving in the_final columns, both with a zero royalty fee and_a fee of £2.00 per sample._If mass testing_is_introduced_as described in Scenario_1 and a test sensitivity of_99.7% can be achieved [16], this_will mean that £54,086 can be saved_at the price of each additional_sensitisation, as long as a_zero royalty_fee applies. If a fee_of £2.00 per_sample is_incurred, similar to_that negotiated for Q-PCR by the_NHS at £2.70_per test single marker [17] then_this_figure falls to_£4,231_saved_per additional_sensitisation. For Scenario_2,_similar figures_are_a saving of £15,636 or £12,075_per_additional sensitisation respectively. If we include the_extra cost incurred for_management_of sensitisations, most recently_estimated at an average £2,885_per person [19], Scenario 2 will_generate one_additional sensitisation_for every £9,190 saved at this royalty fee.

Discussion

Management of non-sensitised RhD_negative pregnancies has become considerably more_effective over time with_the sequential_introduction_of post-delivery and_antenatal_anti-D prophylaxis_[6]. Residual RhD sensitisations still occur, mainly_due to_poor prophylaxis implementation, administration errors and_sub-optimal patient compliance [5,_19,_34]. Advocates of mass RhD NIPD_testing therefore focus on the potential_for generating net cost savings_although_this_is not quantified [16, 18].

The_cost analysis presented in this paper_shows that the_net financial benefit of implementing mass NIPD_testing_as an add-on using in-house tests_(while_maintaining current postnatal testing) will be_negligible_in_England and Wales. The level_of royalty fee negotiated will be_a major influence on this with zero saving predicted_above a fee_of £2.18 per test. If_antenatal_NIPD_were to also displace postnatal testing, higher net savings could_be realised_and the royalty_fee might rise to nearly £9