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Lamsal R, Yeh EA, Pullenayegum E, Ungar WJ. A Systematic Review of Methods and Practice for Integrating Maternal, Fetal, and Child Health Outcomes, and Family Spillover Effects into Cost-Utility Analyses. PHARMACOECONOMICS 2024; 42:843-863. [PMID: 38819718 PMCID: PMC11249496 DOI: 10.1007/s40273-024-01397-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/12/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Maternal-perinatal interventions delivered during pregnancy or childbirth have unique characteristics that impact the health-related quality of life (HRQoL) of the mother, fetus, and newborn child. However, maternal-perinatal cost-utility analyses (CUAs) often only consider either maternal or child health outcomes. Challenges include, but are not limited to, measuring fetal, newborn, and infant health outcomes, and assessing their impact on maternal HRQoL. It is also important to recognize the impact of maternal-perinatal health on family members' HRQoL (i.e., family spillover effects) and to incorporate these effects in maternal-perinatal CUAs. OBJECTIVE The aim was to systematically review the methods used to include health outcomes of pregnant women, fetuses, and children and to incorporate family spillover effects in maternal-perinatal CUAs. METHODS A literature search was conducted in Medline, Embase, EconLit, Cochrane Collection, Cumulative Index to Nursing and Allied Health Literature (CINAHL), International Network of Agencies for Health Technology Assessment (INAHTA), and the Pediatric Economic Database Evaluation (PEDE) databases from inception to 2020 to identify maternal-perinatal CUAs that included health outcomes for pregnant women, fetuses, and/or children. The search was updated to December 2022 using PEDE. Data describing how the health outcomes of mothers, fetuses, and children were measured, incorporated, and reported along with the data on family spillover effects were extracted. RESULTS Out of 174 maternal-perinatal CUAs identified, 62 considered the health outcomes of pregnant women, and children. Among the 54 quality-adjusted life year (QALY)-based CUAs, 12 included fetal health outcomes, the impact of fetal loss on mothers' HRQoL, and the impact of neonatal demise on mothers' HRQoL. Four studies considered fetal health outcomes and the effects of fetal loss on mothers' HRQoL. One study included fetal health outcomes and the impact of neonatal demise on maternal HRQoL. Furthermore, six studies considered the impact of neonatal demise on maternal HRQoL, while four included fetal health outcomes. One study included the impact of fetal loss on maternal HRQoL. The remaining 26 only included the health outcomes of pregnant women and children. Among the eight disability-adjusted life year (DALY)-based CUAs, two measured fetal health outcomes. Out of 174 studies, only one study included family spillover effects. The most common measurement approach was to measure the health outcomes of pregnant women and children separately. Various approaches were used to assess fetal losses in terms of QALYs or DALYs and their impact on HRQoL of mothers. The most common integration approach was to sum the QALYs or DALYs for pregnant women and children. Most studies reported combined QALYs and incremental QALYs, or DALYs and incremental DALYs, at the family level for pregnant women and children. CONCLUSIONS Approximately one-third of maternal-perinatal CUAs included the health outcomes of pregnant women, fetuses, and/or children. Future CUAs of maternal-perinatal interventions, conducted from a societal perspective, should aim to incorporate health outcomes for mothers, fetuses, and children when appropriate. The various approaches used within these CUAs highlight the need for standardized measurement and integration methods, potentially leading to rigorous and standardized inclusion practices, providing higher-quality evidence to better inform decision-makers about the costs and benefits of maternal-perinatal interventions. Health Technology Assessment agencies may consider providing guidance for interventions affecting future lives in future updates.
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Affiliation(s)
- Ramesh Lamsal
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - E Ann Yeh
- Division of Neurology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, Canada
| | - Eleanor Pullenayegum
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Wendy J Ungar
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
- The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay Street, 11th Floor, Toronto, ON, M5G 0A4, Canada.
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Brinson AK, Jahnke HR, Rubin-Miller L, Henrich N, Peahl A, Shah N, Moss C. Digital health's influence on the association between birth preference and vaginal birth. Birth 2024. [PMID: 38804000 DOI: 10.1111/birt.12831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 11/27/2023] [Accepted: 05/02/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Women's preferred mode of birth during pregnancy is predictive of their actual mode of birth. Digital prenatal care services are a promising method for educating women on mode of birth to reduce elective cesareans. This study aimed to evaluate the influence of digital health on the association between birth preference and mode of birth. METHODS Data come from 5409 pregnant women enrolled in a digital platform for women's and family health. Multi-trajectory modeling identified trajectories of digital health usage throughout pregnancy. Adjusted logistic regression models tested associations between birth preferences and mode of birth. The modifying effect of digital health usage on the association between birth preference and mode of birth was assessed on the multiplicative scale. RESULTS Four distinct trajectories of digital service usage were identified and labeled as: (1) baseline users (52%): the reference group; (2) just-in timers (16%): high usage during the third trimester; (3) learners (26%): high educational resource usage (e.g., articles and classes) throughout pregnancy; and (4) super users (6%): high usage of both education and care resources throughout pregnancy. Overall, preferred mode of birth at enrollment was predictive of actual mode of birth; however, digital health usage moderated this association, whereby super users and learners who preferred a cesarean at enrollment were more likely to deliver vaginally, compared to baseline users who preferred a cesarean. CONCLUSION For the increasing proportion of women considering an elective cesarean, education through a prenatal digital health platform may help to encourage vaginal birth and reduce cesarean births.
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Affiliation(s)
- Alison K Brinson
- Department of Anthropology, UNC Chapel Hill, Chapel Hill, North Carolina, USA
- Carolina Population Center, Chapel Hill, North Carolina, USA
- Maven Clinic, New York, New York, USA
| | | | | | | | - Alex Peahl
- Maven Clinic, New York, New York, USA
- University of Michigan-Obstetrics and Gynecology, Ann Arbor, Michigan, USA
| | - Neel Shah
- Maven Clinic, New York, New York, USA
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Pineles BL, Buskmiller CM, Qureshey EJ, Stephens AJ, Sibai BM. Recent trends in term trial of labor after cesarean by number of prior cesarean deliveries. AJOG GLOBAL REPORTS 2023; 3:100232. [PMID: 37342471 PMCID: PMC10277578 DOI: 10.1016/j.xagr.2023.100232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Cesarean delivery is a major source of maternal morbidity, and repeat cesarean delivery accounts for 40% of cesarean delivery, but recent data on the trial of labor after cesarean and vaginal birth after cesarean are limited. OBJECTIVE This study aimed to report the national rates of trial of labor after cesarean and vaginal birth after cesarean by number of previous cesarean deliveries and examine the effect of demographic and clinical characteristics on these rates. STUDY DESIGN This was a population-based cohort study using the US natality data files. The study sample was restricted to 4,135,247 nonanomalous singleton, cephalic deliveries between 37 and 42 weeks of gestation, with a history of previous cesarean delivery and delivered in a hospital between 2010 and 2019. Deliveries were grouped by number of previous cesarean deliveries (1, 2, or ≥3). The trial of labor after cesarean (deliveries with labor among deliveries with previous cesarean delivery) and vaginal birth after cesarean (vaginal deliveries among trial of labor after cesarean) rates were computed for each year. The rates were further subgrouped by history of previous vaginal delivery. Year of delivery, number of previous cesarean deliveries, history of previous cesarean delivery, age, race and ethnicity, maternal education, obesity, diabetes mellitus, hypertension, inadequate prenatal care, Medicaid payer, and gestational age were examined concerning the trial of labor after cesarean and vaginal birth after cesarean using multiple logistic regression. SAS software (version 9.4) was used for all analyses. RESULTS The trial of labor after cesarean rates increased from 14.4% in 2010 to 19.6% in 2019 (P<.001). This trend was seen in all categories of number of previous cesarean deliveries. Moreover, vaginal birth after cesarean rates increased from 68.5% in 2010 to 74.3% in 2019. The trial of labor after cesarean and vaginal birth after cesarean rates were the highest for deliveries with a history of both 1 previous cesarean delivery and a vaginal delivery (28.9% and 79.7%, respectively) and the lowest for those with a history of ≥3 previous cesarean deliveries and no history of vaginal delivery (4.5% and 46.9%, respectively). Factors associated with the trial of labor after cesarean and vaginal birth after cesarean rates are similar, but several factors have different directions of effect, such as non-White race and ethnicity, which is associated with a higher likelihood of trial of labor after cesarean but a lower likelihood of successful vaginal birth after cesarean. CONCLUSION More than 80% of patients with a history of previous cesarean delivery deliver by repeat scheduled cesarean delivery. With vaginal birth after cesarean rates increasing among those who attempt a trial of labor after cesarean, emphasis should be put on safely increasing the trial of labor after cesarean rates.
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Affiliation(s)
- Beth L. Pineles
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX (Drs Pineles, Buskmiller, Qureshey, Stephens, and Sibai)
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Pennsylvania Hospital, Philadelphia, PA (Dr Pineles)
| | - Cara M. Buskmiller
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX (Drs Pineles, Buskmiller, Qureshey, Stephens, and Sibai)
| | - Emma J. Qureshey
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX (Drs Pineles, Buskmiller, Qureshey, Stephens, and Sibai)
| | - Angela J. Stephens
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX (Drs Pineles, Buskmiller, Qureshey, Stephens, and Sibai)
| | - Baha M. Sibai
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX (Drs Pineles, Buskmiller, Qureshey, Stephens, and Sibai)
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Peahl A, Ojo A, Henrich N, Shah N, Jahnke H. Association Between Utilization of Digital Prenatal Services and Vaginal Birth After Cesarean. J Midwifery Womens Health 2023; 68:255-264. [PMID: 36655813 DOI: 10.1111/jmwh.13467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 12/05/2022] [Accepted: 12/15/2022] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Digital health services are a promising but understudied method for reducing common barriers to vaginal birth after cesarean (VBAC), including connection to facilities offering labor after cesarean and patient-centered counseling about mode of birth. This study assesses the relationship between use of digital prenatal services and VBAC. METHODS In this retrospective cohort study, we analyzed the use of digital prenatal services and mode of birth among users of an employer-sponsored digital women's and family digital health platform. All users had a prior cesarean birth. Users' self-reported data included demographics, medical history, and birth preferences. We used basic descriptive statistics and logistic regression models to assess the association between digital services utilization and VBAC, adjusting for key patient characteristics. RESULTS Of 271 included users, 44 (16.2%) had a VBAC and 227 (83.8%) had a cesarean birth. Users of both groups were similar in age, race, and ethnicity. Fewer users in the VBAC group (5/44, 11.4%) as compared with the cesarean birth group (62/227, 27.3%) had a prepregnancy body mass index greater than or equal to 30 (P = 0.02). Likewise, more users in the VBAC group preferred vaginal birth (34/44, 77.3% vs 55/227, 24.2%; P < 0.01). In adjusted models, the services associated with VBAC were care advocate appointments (adjusted odds ratio [aOR], 7.67; 95% CI, 1.99-54.4), health care provider appointments (aOR, 1.12; 95% CI, 1.02-1.25), and resource reads (aOR, 1.05, 95% CI, 1.00-1.09). VBAC rates were higher for users who reported the digital health platform influenced aspects of their pregnancy and birth. DISCUSSION Reducing cesarean birth rates is a national priority. Digital health services, particularly care coordination and education, are promising for accomplishing this goal through increasing rates of trial of labor after cesarean and subsequent VBAC rates.
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Affiliation(s)
- Alex Peahl
- Maven Clinic, New York, New York.,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Ayotomiwa Ojo
- Maven Clinic, New York, New York.,Harvard Medical School, Boston, Massachusetts
| | | | - Neel Shah
- Maven Clinic, New York, New York.,Harvard Medical School, Boston, Massachusetts.,Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Making the financial case for immediate postpartum intrauterine device: a budget impact analysis. Am J Obstet Gynecol 2022; 226:702.e1-702.e10. [PMID: 34801445 DOI: 10.1016/j.ajog.2021.11.1348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 10/24/2021] [Accepted: 11/14/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Clinical guidelines support inpatient postpartum intrauterine device insertion. However, inpatient placement remains infrequent, in part because of inconsistent private insurance reimbursement. OBJECTIVE The purpose of this study was to explore how the payer's costs and number of unintended pregnancies associated with a postpartum intrauterine device differed on the basis of placement timing. STUDY DESIGN Using a decision tree model and following a hypothetical cohort of people who intend to use an intrauterine device after their delivery, we conducted a cost analysis comparing the planned approach of inpatient vs outpatient postpartum insertion. Using a 2-year time horizon, the probability and cost estimates were derived from literature review. Our primary outcome was the total accrued costs to the payer. Secondarily, we examined the rates of early repeat pregnancy and sensitivity to estimates of key inputs, including the expulsion rates and the intrauterine device cost. RESULTS Although an inpatient intrauterine device placement's upfront costs were higher, the total cost of this approach was lower. Including the costs of managing expulsions and complications, our model suggests that for every 1000 people desiring a postpartum intrauterine device, the intended inpatient intrauterine device placement resulted in total cost savings of $211,100 and the prevention of 37 additional pregnancies compared with outpatient placement. The inpatient cost savings were superior to the outpatient savings, largely because of a known high proportion not returning for outpatient placement and the resulting higher number of unintended pregnancies among the patients desiring outpatient placement. In sensitivity analyses, we found that the total cost to the payer was sensitive to the probability of expulsion after immediate postpartum intrauterine device placement. CONCLUSION For beneficiaries desiring postpartum intrauterine device, payers are likely to save money by fully reimbursing inpatient intrauterine device placement rather than incentivizing placement at the frequently missed postpartum visit. These results support the financial case for private insurers to fully and separately reimburse (ie, "unbundle" from the single payment for delivery) inpatient postpartum intrauterine device placement.
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Roa L, Caddell L, Choksi N, Devi S, Pyda J, Boatin AA, Shrime M. Optimizing availability of obstetric surgical care in India: A cost-effectiveness analysis examining rates and access to Cesarean sections. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0001369. [PMID: 36962905 PMCID: PMC10021835 DOI: 10.1371/journal.pgph.0001369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 11/14/2022] [Indexed: 12/15/2022]
Abstract
The objective of this study is to assess the cost-effectiveness of three different strategies with different availabilities of cesarean sections (CS). The setting was rural and urban areas of India with varying rates of CS and access to comprehensive emergency obstetric care (CEmOC) for women of reproductive age in India. Three strategies with different access to CEmOC and CS rates were evaluated: (A) India's national average (50.2% access, 17.2% CS rate), (B) rural areas (47.2% access, 12.8% CS rate) and(C) urban areas (55.7% access, 28.2% CS rate). We performed a first-order Monte Carlo simulation using a 1-year cycle time and 34-year time horizon. All inputs were derived from literature. A societal perspective was utilized with a willingness-to-pay threshold of $1,940. The outcome measures were costs and quality-adjusted life years were used to calculate the incremental cost-effectiveness ratio (ICER). Maternal and neonatal outcomes were calculated. Strategy C with the highest access to CEmOC despite the highest CS rate was cost-effective, with an ICER of 354.90. Two-way sensitivity analysis demonstrated this was driven by increased access to CEmOC. The highest CS rate strategy had the highest number of previa, accreta and ICU admissions. The strategy with the lowest access to CEmOC had the highest number of fistulae, uterine rupture, and stillbirths. In conclusion, morbidity and mortality result from lack of access to CEmOC and overuse of CS. While interventions are needed to address both, increasing access to surgical obstetric care drives cost-effectiveness and is paramount to optimize outcomes.
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Affiliation(s)
- Lina Roa
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, AB, Canada
| | - Luke Caddell
- Department of General Surgery, Stanford University, Stanford, CA, United States of America
| | - Namit Choksi
- Smt. Kashibai Navale Medical College and General Hospital, Pune, Maharashtra, India
- School of Healthcare, Rishihood University, Sonepat, Haryana, India
| | - Shylaja Devi
- Gudalur Adivasi Hospital, Gudalur, Nilgiris, Tamil Nadu, India
| | - Jordan Pyda
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Adeline A Boatin
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Mark Shrime
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
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Zhang HL, Zheng LH, Cheng LC, Liu ZD, Yu L, Han Q, Miao GY, Yan JY. Prediction of vaginal birth after cesarean delivery in Southeast China: a retrospective cohort study. BMC Pregnancy Childbirth 2020; 20:538. [PMID: 32933509 PMCID: PMC7493317 DOI: 10.1186/s12884-020-03233-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 09/03/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND We aimed to develop and validate a nomogram for effective prediction of vaginal birth after cesarean (VBAC) and guide future clinical application. METHODS We retrospectively analyzed data from hospitalized pregnant women who underwent trial of labor after cesarean (TOLAC), at the Fujian Provincial Maternity and Children's Hospital, between October 2015 and October 2017. Briefly, we included singleton pregnant women, at a gestational age above 37 weeks who underwent a primary cesarean section, in the study. We then extracted their sociodemographic data and clinical characteristics, and randomly divided the samples into training and validation sets. We employed the least absolute shrinkage and selection operator (LASSO) regression to select variables and construct VBAC success rate in the training set. Thereafter, we validated the nomogram using the concordance index (C-index), decision curve analysis (DCA), and calibration curves. Finally, we adopted the Grobman's model to perform comparisons with published VBAC prediction models. RESULTS Among the 708 pregnant women included according to inclusion criteria, 586 (82.77%) patients were successfully for VBAC. Multivariate logistic regression models revealed that maternal height (OR, 1.11; 95% CI, 1.04 to 1.19), maternal BMI at delivery (OR, 0.89; 95% CI, 0.79 to 1.00), fundal height (OR, 0.71; 95% CI, 0.58 to 0.88), cervix Bishop score (OR, 3.27; 95% CI, 2.49 to 4.45), maternal age at delivery (OR, 0.90; 95% CI, 0.82 to 0.98), gestational age (OR, 0.33; 95% CI, 0.17 to 0.62) and history of vaginal delivery (OR, 2.92; 95% CI, 1.42 to 6.48) were independently associated with successful VBAC. The constructed predictive model showed better discrimination than that from the Grobman's model in the validation series (c-index 0.906 VS 0.694, respectively). On the other hand, decision curve analysis revealed that the new model had better clinical net benefits than the Grobman's model. CONCLUSIONS VBAC will aid in reducing the rate of cesarean sections in China. In clinical practice, the TOLAC prediction model will help improve VBAC's success rate, owing to its contribution to reducing secondary cesarean section.
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Affiliation(s)
- Hua-Le Zhang
- Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, No.18, Daoshan Rd., Gulou Dist, Fuzhou City, Fujian province, China
| | - Liang-Hui Zheng
- Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, No.18, Daoshan Rd., Gulou Dist, Fuzhou City, Fujian province, China
| | - Li-Chun Cheng
- Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, No.18, Daoshan Rd., Gulou Dist, Fuzhou City, Fujian province, China
| | - Zhao-Dong Liu
- Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, No.18, Daoshan Rd., Gulou Dist, Fuzhou City, Fujian province, China
| | - Lu Yu
- Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, No.18, Daoshan Rd., Gulou Dist, Fuzhou City, Fujian province, China
- Fujian Medical University, Fuzhou, China
| | - Qin Han
- Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, No.18, Daoshan Rd., Gulou Dist, Fuzhou City, Fujian province, China
| | | | - Jian-Ying Yan
- Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, No.18, Daoshan Rd., Gulou Dist, Fuzhou City, Fujian province, China.
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Lipschuetz M, Guedalia J, Rottenstreich A, Novoselsky Persky M, Cohen SM, Kabiri D, Levin G, Yagel S, Unger R, Sompolinsky Y. Prediction of vaginal birth after cesarean deliveries using machine learning. Am J Obstet Gynecol 2020; 222:613.e1-613.e12. [PMID: 32007491 DOI: 10.1016/j.ajog.2019.12.267] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 12/30/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Efforts to reduce cesarean delivery rates to 12-15% have been undertaken worldwide. Special focus has been directed towards parturients who undergo a trial of labor after cesarean delivery to reduce the burden of repeated cesarean deliveries. Complication rates are lowest when a vaginal birth is achieved and highest when an unplanned cesarean delivery is performed, which emphasizes the need to assess, in advance, the likelihood of a successful vaginal birth after cesarean delivery. Vaginal birth after cesarean delivery calculators have been developed in different populations; however, some limitations to their implementation into clinical practice have been described. Machine-learning methods enable investigation of large-scale datasets with input combinations that traditional statistical analysis tools have difficulty processing. OBJECTIVE The aim of this study was to evaluate the feasibility of using machine-learning methods to predict a successful vaginal birth after cesarean delivery. STUDY DESIGN The electronic medical records of singleton, term labors during a 12-year period in a tertiary referral center were analyzed. With the use of gradient boosting, models that incorporated multiple maternal and fetal features were created to predict successful vaginal birth in parturients who undergo a trial of labor after cesarean delivery. One model was created to provide a personalized risk score for vaginal birth after cesarean delivery with the use of features that are available as early as the first antenatal visit; a second model was created that reassesses this score after features are added that are available only in proximity to delivery. RESULTS A cohort of 9888 parturients with 1 previous cesarean delivery was identified, of which 75.6% of parturients (n=7473) attempted a trial of labor, with a success rate of 88%. A machine-learning-based model to predict when vaginal delivery would be successful was developed. When features that are available at the first antenatal visit are used, the model showed a receiver operating characteristic curve with area under the curve of 0.745 (95% confidence interval, 0.728-0.762) that increased to 0.793 (95% confidence interval, 0.778-0.808) when features that are available in proximity to the delivery process were added. Additionally, for the later model, a risk stratification tool was built to allocate parturients into low-, medium-, and high-risk groups for failed trial of labor after cesarean delivery. The low- and medium-risk groups (42.4% and 25.6% of parturients, respectively) showed a success rate of 97.3% and 90.9%, respectively. The high-risk group (32.1%) had a vaginal delivery success rate of 73.3%. Application of the model to a cohort of parturients who elected a repeat cesarean delivery (n=2145) demonstrated that 31% of these parturients would have been allocated to the low- and medium-risk groups had a trial of labor been attempted. CONCLUSION Trial of labor after cesarean delivery is safe for most parturients. Success rates are high, even in a population with high rates of trial of labor after cesarean delivery. Application of a machine-learning algorithm to assign a personalized risk score for a successful vaginal birth after cesarean delivery may help in decision-making and contribute to a reduction in cesarean delivery rates. Parturient allocation to risk groups may help delivery process management.
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Affiliation(s)
- Michal Lipschuetz
- The Mina and Everard Goodman Faculty of Life Sciences, Bar-Ilan University, Ramat-Gan, Israel; Obstetrics & Gynecology Division, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Joshua Guedalia
- The Mina and Everard Goodman Faculty of Life Sciences, Bar-Ilan University, Ramat-Gan, Israel
| | - Amihai Rottenstreich
- Obstetrics & Gynecology Division, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Sarah M Cohen
- Obstetrics & Gynecology Division, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Doron Kabiri
- Obstetrics & Gynecology Division, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Gabriel Levin
- Obstetrics & Gynecology Division, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Simcha Yagel
- Obstetrics & Gynecology Division, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - Ron Unger
- The Mina and Everard Goodman Faculty of Life Sciences, Bar-Ilan University, Ramat-Gan, Israel
| | - Yishai Sompolinsky
- Obstetrics & Gynecology Division, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Vanderlaan J, Edwards JA, Dunlop A. Geospatial variation in caesarean delivery. Nurs Open 2020; 7:627-633. [PMID: 32089861 PMCID: PMC7024620 DOI: 10.1002/nop2.433] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 10/24/2019] [Accepted: 11/25/2019] [Indexed: 11/15/2022] Open
Abstract
Aim The purpose of this study was to evaluate the variation in caesarean delivery rates across counties in Georgia and to determine whether county-level characteristics were associated with clusters. Design This was a retrospective, observational study. Methods Rates of primary and repeat caesarean by maternal county of residence were calculated for 2008 through 2012. Global Moran's I (Spatial Autocorrelation) was used to identify geographic clustering. Characteristics of high and low-rate counties were compared using student's t test and chi-squared test. Results Spatial analysis of both primary and repeat caesarean rate identified the presence of clusters (Moran's I = 0.375; p < .001). Counties in high-rate clusters had significantly lower access to midwives, more deliveries paid by Medicaid, higher proportion of births for women belonging to racial/ethnic minority groups and were more likely to be rural.
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Affiliation(s)
| | - Johnathan A. Edwards
- Department of Biomedical InformaticsEmory University School of MedicineAtlantaGA
| | - Anne Dunlop
- Nell Hodgson Woodruff School of NursingEmory UniversityAtlantaGA
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10
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Sudhof LS, Shainker SA, Einerson BD. Tranexamic acid in the routine treatment of postpartum hemorrhage in the United States: a cost-effectiveness analysis. Am J Obstet Gynecol 2019; 221:275.e1-275.e12. [PMID: 31226298 DOI: 10.1016/j.ajog.2019.06.030] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 06/10/2019] [Accepted: 06/12/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND The World Maternal Antifibrinolytic trial demonstrated that tranexamic acid administered during postpartum hemorrhage reduces hemorrhage-related mortality and laparotomies. The World Health Organization has thus recommended early use of tranexamic acid in the treatment of postpartum hemorrhage. This recommendation has not been universally adopted in the United States, in part because of concerns about cost-effectiveness. OBJECTIVE We aim to demonstrate the cost-effectiveness of routine tranexamic acid administration in the treatment of postpartum hemorrhage in the United States, where the rate of hemorrhage-related mortality is lower than that described in the World Maternal Antifibrinolytic trial. STUDY DESIGN We constructed a decision tree comparing 3 strategies in women with a clinical diagnosis of postpartum hemorrhage: no tranexamic acid, tranexamic acid given at any time, and ideal use of tranexamic acid given within 3 hours of delivery. The study was performed from a health care institution perspective with a time horizon of delivery until 6 weeks postpartum. We included interventions that differed by arm in the World Maternal Antifibrinolytic trial (hemorrhage-related mortality, laparotomies, and brace or compression sutures) and incorporated probabilities and costs based on available data for a population of women with postpartum hemorrhage in the United States. In our base case, the rate of postpartum hemorrhage-related mortality was 0.0388%, and the cost of tranexamic acid was $37.80. We assumed that the relative risk reduction in death and laparotomy with tranexamic acid would be similar to the World Maternal Antifibrinolytic trial (19% and 36%, respectively). The primary outcome was incremental cost per hemorrhage-related death averted, and a main secondary outcome was incremental cost per laparotomy avoided under each strategy. Another planned secondary outcome was cost per quality-adjusted life-year. We anticipated that the risk reduction (benefit) because of tranexamic acid in the United States may be less than in the World Maternal Antifibrinolytic trial; thus, we performed 1-way and 2-way sensitivity analyses to explore the parameter uncertainty across a wide range of data-supported estimates. Probabilistic sensitivity analyses with Monte Carlo simulation were performed. RESULTS Tranexamic acid strategies were dominant (more effective and cost saving) compared with no tranexamic acid for patients with postpartum hemorrhage in the United States. One-way analyses showed that tranexamic acid is cost saving as long as the relative risk reduction of death with tranexamic acid is greater than 4.7%; the model was not sensitive to any other variables. Threshold analyses outside the bounds defined in the model showed that tranexamic acid is cost saving as long as the relative risk reduction of laparotomy with tranexamic acid is greater than 7% or the cost of tranexamic acid is less than $194. A 2-way sensitivity analysis of the risk reduction of death because of tranexamic acid and the baseline risk of postpartum hemorrhage-related death confirmed that tranexamic acid is cost saving across a wide range of plausible estimates. Furthermore, probabilistic sensitivity analysis demonstrated that the tranexamic acid strategies are cost saving in >99.9% of 10,000 Monte Carlo simulations. Despite the initial cost of administration, the annual net cost savings expected from routine use of tranexamic acid for the treatment of postpartum hemorrhage in the United States is $11.3 million, and we estimate that 9 maternal deaths would be averted in 1 year with this strategy. Giving tranexamic acid within 3 hours would almost triple the cost savings and improve maternal outcomes much further. CONCLUSION A policy of routine tranexamic acid early in the treatment of postpartum hemorrhage is likely to be cost saving in the United States. This conclusion holds true even when the relative risk reduction with tranexamic acid is significantly less than reported in the World Maternal Antifibrinolytic trial and when tranexamic acid is significantly more expensive than currently reported.
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DeJoy SA, Bohl MG, Mahoney K, Blake C. Estimating the Financial Impact of Reducing Primary Cesareans. J Midwifery Womens Health 2019; 65:56-63. [PMID: 31353803 DOI: 10.1111/jmwh.13010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 04/20/2019] [Accepted: 04/26/2019] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Preventing a primary cesarean birth in nulliparous women with term, singleton, vertex pregnancies (NTSV) is recognized as an important strategy to reduce maternal morbidities and risks to the newborn. Multiple professional organizations are supporting approaches to safely reduce NTSV cesarean rates, including the American College of Obstetricians and Gynecologists; the Society for Maternal-Fetal Medicine; and the Association of Women's Health, Obstetric and Neonatal Nurses. The American College of Nurse-Midwives (ACNM) is leading one such effort as part of its Healthy Birth Initiative: the Reducing Primary Cesareans (RPC) Learning Collaborative. The objective of this study is to estimate the cost savings of a decrease in NTSV cesareans at one hospital participating in the RPC Learning Collaborative. METHODS All women giving birth at Baystate Medical Center from October 1, 2016, to March 31, 2017, and their newborns were identified by Medicare Severity Diagnosis Related Group (N = 1747). Total hospital costs were calculated using a resource consumption profile for each of 6 groups: women who had vaginal birth, primary cesarean, and repeat cesarean and their linked newborns. A model was developed to estimate cost differences for the first and second births and overall cost savings. RESULTS For the NTSV birth, total costs for primary cesarean and newborn care were $5989 higher compared with vaginal birth and newborn care. For the subsequent birth, repeat cesareans and newborn care were $4250 higher compared with vaginal birth. In 2016, 69 primary cesareans were prevented, for an actual cost savings of $413,241. Projecting the prevention of 66 subsequent repeat cesareans would result in additional savings of $280,500, for a total savings of $693,741. Apgar score at 5 minutes and length of stay remained unchanged. DISCUSSION Participation in ACNM's RPC Learning Collaborative led to significant savings in hospital costs during the first year without affecting quality metrics. This cost comparison model could be replicated by other hospitals involved in cesarean reduction endeavors.
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Affiliation(s)
- Susan A DeJoy
- Division of Midwifery and Community Health, Department of Obstetrics and Gynecology, Baystate Medical Center, Springfield, Massachusetts
| | - Matthew G Bohl
- Clinical Financial Planning and Decision Support, Baystate Health, Springfield, Massachusetts
| | - Kathleen Mahoney
- Healthcare Quality, Baystate Medical Center, Springfield, Massachusetts
| | - Constance Blake
- Department of Nursing, Baystate Medical Center, Springfield, Massachusetts
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12
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Sargent JA, Savitsky LM, Dissanayake MV, Lo JO, Cheng YW, Caughey AB. Gestational Weight Gain during Pregnancy as an Important Factor Influencing a Successful Trial of Labor following Two Previous Cesareans. Am J Perinatol 2019; 36:588-593. [PMID: 30231273 PMCID: PMC7138436 DOI: 10.1055/s-0038-1670679] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE We sought to identify factors associated with a successful trial of labor (TOL) following two cesarean deliveries (CDs) in a contemporary North American cohort. STUDY DESIGN This is a retrospective cohort study of term, nonanomalous, singleton, vertex pregnancies attempting a vaginal birth after cesarean (VBAC) following a history of two previous CDs in the United States from 2012 to 2014. Maternal and intrapartum factors were analyzed using chi-square tests and multivariable logistic regression. RESULTS A total of 22,762 women met the inclusion criteria and underwent TOL. Of these, 12,192 (53.6%) had a VBAC. Using multivariate logistic regression, previous vaginal delivery and delivery at 40 to 41 weeks' gestation were associated with VBAC; maternal age, education, Medicaid insurance, non-Caucasian race/ethnicity, weight (overweight or obese), and gestational weight gain above the Institute of Medicine guidelines (adjusted odds ratio: 0.88; 95% confidence interval: 0.81-0.95) were associated with CD. Induction of labor did not affect the VBAC rate. CONCLUSION For those desiring a TOL after two previous CDs, prospective studies are needed to assess interventions that limit gestational weight gain as well as the safety and optimal timing of an induction of labor. The decision to attempt a TOL should be guided by counseling regarding the risks, benefits, and chances of a successful TOL.
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Affiliation(s)
- James A. Sargent
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Leah M. Savitsky
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington
| | - Mekhala V. Dissanayake
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Jamie O. Lo
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Yvonne W. Cheng
- Department of Obstetrics and Gynecology, California Pacific Medical Center, San Francisco, California
| | - Aaron B. Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
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13
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Fobelets M, Beeckman K, Healy P, Grylka-Baeschlin S, Nicoletti J, Devane D, Gross MM, Morano S, Daly D, Begley C, Putman K. Health economic analysis of a cluster-randomised trial (OptiBIRTH) designed to increase rates of vaginal birth after caesarean section. BJOG 2019; 126:1043-1051. [PMID: 30957402 DOI: 10.1111/1471-0528.15673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To perform a health economic analysis of an intervention designed to increase rates of vaginal birth after caesarean, compared with usual care. DESIGN Economic analysis alongside the cluster-randomised OptiBIRTH trial (Optimising childbirth by increasing vaginal birth after caesarean section (VBAC) through enhanced women-centred care). SETTING Fifteen maternity units in three European countries - Germany (five), Ireland (five), and Italy (five) - with relatively low VBAC rates. POPULATION Pregnant women with a history of one previous lower-segment caesarean section; sites were randomised (3:2) to intervention or control. METHODS A cost-utility analysis from both societal and health-services perspectives, using a decision tree. MAIN OUTCOME MEASURES Costs and resource use per woman and infant were compared between the control and intervention group by country, from pregnancy recognition until 3 months postpartum. Based on the caesarean section rates, and maternal and neonatal morbidities and mortality, the incremental cost-utility ratios were calculated per country. RESULTS The mean difference in costs per quality-adjusted life years (QALYs) gained from a societal perspective between the intervention and the control group, using a probabilistic sensitivity analysis, was: €263 (95% CI €258-268) and 0.008 QALYs (95% CI 0.008-0.009 QALYs) for Germany, €456 (95% CI €448-464) and 0.052 QALYs (95% CI 0.051-0.053 QALYs) for Ireland, and €1174 (95% CI €1170-1178) and 0.006 QALYs (95% CI 0.005-0.007 QALYs) for Italy. The incremental cost-utility ratios were €33,741/QALY for Germany, €8785/QALY for Ireland, and €214,318/QALY for Italy, with a 51% probability of being cost-effective for Germany, 92% for Ireland, and 15% for Italy. CONCLUSION The OptiBIRTH intervention was likely to be cost-effective in Ireland and Germany. TWEETABLE ABSTRACT The OptiBIRTH intervention (to increase VBAC rates) is likely to be cost-effective in Germany and Ireland.
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Affiliation(s)
- M Fobelets
- Department of Public Health I-CHER (Interuniversity Centre for Health Economics Research), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium.,Department Health Care, Knowledge Centre Brussels Integrated Care, Erasmus University College Brussels, Brussels, Belgium
| | - K Beeckman
- Department of Public Health I-CHER (Interuniversity Centre for Health Economics Research), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium.,Department of Nursing and Midwifery, Nursing and Midwifery Research Group, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - P Healy
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - S Grylka-Baeschlin
- Midwifery Research and Education Unit, Hannover Medical School, Hannover, Germany
| | - J Nicoletti
- School of Medicine and Midwifery, Department of Neurology, Ophthalmology, Maternal and Childhood Sciences, Genoa University, Genoa, Italy
| | - D Devane
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland.,HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland
| | - M M Gross
- Midwifery Research and Education Unit, Hannover Medical School, Hannover, Germany
| | - S Morano
- School of Medicine and Midwifery, Department of Neurology, Ophthalmology, Maternal and Childhood Sciences, Genoa University, Genoa, Italy
| | - D Daly
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - C Begley
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland.,Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - K Putman
- Department of Public Health I-CHER (Interuniversity Centre for Health Economics Research), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
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Cost-effectiveness of opportunistic salpingectomy vs tubal ligation at the time of cesarean delivery. Am J Obstet Gynecol 2019; 220:106.e1-106.e10. [PMID: 30170036 DOI: 10.1016/j.ajog.2018.08.032] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 08/06/2018] [Accepted: 08/20/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Removal of the fallopian tubes at the time of hysterectomy or interval sterilization has become routine practice to prevent ovarian cancer. While emerging as a strategy, uptake of this procedure at the time of cesarean delivery for pregnant women seeking permanent sterilization has not been widely adopted due to perceptions of increased morbidity and operative difficulty with a lack of available data in this setting. OBJECTIVE We sought to conduct a cost-effectiveness analysis comparing strategies for long-term sterilization and ovarian cancer risk reduction at the time of cesarean delivery, including bilateral tubal ligation, opportunistic salpingectomy, and long-acting reversible contraception. STUDY DESIGN A decision-analytic and cost-effectiveness model was constructed for pregnant women undergoing cesarean delivery who desired permanent sterilization in the US population, comparing 3 strategies: (1) bilateral tubal ligation, (2) bilateral opportunistic salpingectomy, and (3) postpartum long-acting reversible contraception. This theoretic cohort consisted of 110,000 pregnant women desiring permanent sterilization at the time of cesarean delivery and ovarian cancer prevention at an average of 35 years who were monitored for an additional 40 years based on an average US female life expectancy of 75 years. The primary outcome measure was the incremental cost-effectiveness ratio. Effectiveness was measured as quality-adjusted life years. Secondary outcomes included: the number of ovarian cancer cases and deaths, procedure-related complications, and unintended and ectopic pregnancies. The 1-, 2-, and 3-way and Monte Carlo probabilistic sensitivity analyses were performed. The willingness-to-pay threshold was set at $100,000. RESULTS Both bilateral tubal ligation and bilateral opportunistic salpingectomy with cesarean delivery have favorable cost-effectiveness ratios. In the base case analysis, salpingectomy was more cost-effective with an incremental cost-effectiveness ratio of $23,189 per quality-adjusted life year compared to tubal ligation. Long-acting reversible contraception after cesarean was not cost-effective (ie, dominated). Although salpingectomy and tubal ligation were both cost-effective over a wide range of cost and risk estimates, the incremental cost-effectiveness ratio analysis was highly sensitive to the uncertainty around the estimates of salpingectomy cancer risk reduction, risk of perioperative complications, and cost. Monte Carlo probabilistic sensitivity analysis estimated that tubal ligation had a 49% chance of being the preferred strategy over salpingectomy. If the true salpingectomy risk of perioperative complications is >2% higher than tubal ligation or if the cancer risk reduction of salpingectomy is <52%, then tubal ligation is the preferred, more cost-effective strategy. CONCLUSION Bilateral tubal ligation and bilateral opportunistic salpingectomy with cesarean delivery are both cost-effective strategies for permanent sterilization and ovarian cancer risk reduction. Although salpingectomy and tubal ligation are both reasonable strategies for cesarean patients seeking permanent sterilization and cancer risk reduction, threshold analyses indicate that the risks and benefits of salpingectomy with cesarean delivery need to be better defined before a preferred strategy can be determined.
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15
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Fobelets M, Beeckman K, Faron G, Daly D, Begley C, Putman K. Vaginal birth after caesarean versus elective repeat caesarean delivery after one previous caesarean section: a cost-effectiveness analysis in four European countries. BMC Pregnancy Childbirth 2018; 18:92. [PMID: 29642858 PMCID: PMC5896042 DOI: 10.1186/s12884-018-1720-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 03/28/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The OptiBIRTH study incorporates a multicentre cluster randomised trial in 15 hospital sites across three European countries. The trial was designed to test a complex intervention aimed at improving vaginal birth after caesarean section (VBAC) rates through increasing women's involvement in their care. Prior to developing a robust standardised model to conduct the health economic analysis, an analysis of a hypothetical cohort was performed to estimate the costs and health effects of VBAC compared to elective repeat caesarean delivery (ERCD) for low-risk women in four European countries. METHODS A decision-analytic model was developed to estimate the costs and the health effects, measured using Quality Adjusted Life Years (QALYs), of VBAC compared with ERCD. A cost-effectiveness analysis for the period from confirmation of pregnancy to 6 weeks postpartum was performed for short-term consequences and during lifetime for long-term consequences, based on a hypothetical cohort of 100,000 pregnant women in each of four different countries; Belgium, Germany, Ireland and Italy. A societal perspective was adopted. Where possible, transition probabilities, costs and health effects were adapted from national data obtained from the respective countries. Country-specific thresholds were used to determine the cost-effectiveness of VBAC compared to ERCD. Deterministic and probabilistic sensitivity analyses were conducted to examine the uncertainty of model assumptions. RESULTS Within a 6-week time horizon, VBAC resulted in a reduction in costs, ranging from €3,334,052 (Germany) to €66,162,379 (Ireland), and gains in QALYs ranging from 6399 (Italy) to 7561 (Germany) per 100,000 women birthing in each country. Compared to ERCD, VBAC is the dominant strategy in all four countries. Applying a lifetime horizon, VBAC is dominant compared to ERCD in all countries except for Germany (probabilistic analysis, ICER: €8609/QALY). In conclusion, compared to ERCD, VBAC remains cost-effective when using a lifetime time. CONCLUSIONS In all four countries, VBAC was cost-effective compared to ERCD for low-risk women. This is important for health service managers, economists and policy makers concerned with maximising health benefits within limited and constrained resources.
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Affiliation(s)
- Maaike Fobelets
- I-CHER (Interuniversity Centre for Health Economics Research), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussels, Laarbeeklaan 103, 1090 Brussels, Belgium
- Department of Public Health, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Katrien Beeckman
- Department of Public Health, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
- Department of Nursing and Midwifery, Nursing and Midwifery research group, Universitair Ziekenhuis Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Gilles Faron
- Department of Obstetrics, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Déirdre Daly
- School of Nursing and Midwifery, Trinity College Dublin, 24 D’Olier Street, Dublin, D02 T283 Ireland
| | - Cecily Begley
- School of Nursing and Midwifery, Trinity College Dublin, 24 D’Olier Street, Dublin, D02 T283 Ireland
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Koen Putman
- I-CHER (Interuniversity Centre for Health Economics Research), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussels, Laarbeeklaan 103, 1090 Brussels, Belgium
- Department of Public Health, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
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16
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Rogers AJ, Rogers NG, Kilgore ML, Subramaniam A, Harper LM. Economic Evaluations Comparing a Trial of Labor with an Elective Repeat Cesarean Delivery: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:163-173. [PMID: 28212958 PMCID: PMC5319694 DOI: 10.1016/j.jval.2016.08.738] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 08/01/2016] [Accepted: 08/19/2016] [Indexed: 05/16/2023]
Abstract
BACKGROUND For women who have had a previous low transverse cesarean delivery, the decision to undergo a trial of labor after cesarean (TOLAC) or an elective repeat cesarean delivery (ERCD) has important clinical and economic ramifications. OBJECTIVES To evaluate the cost-effectiveness of the alternative choices of a TOLAC and an ERCD for women with low-risk, singleton gestation pregnancies. METHODS We searched EMBASE, MEDLINE, CINAHL, Cochrane Library, EconLit, and the Cost-Effectiveness Analysis Registry with no language, publication, or date restrictions up until October 2015. Studies were included if they were primary research, compared a TOLAC with an ERCD, and provided information on the relative cost of the alternatives. Abstracts and partial economic evaluations were excluded. RESULTS Of 310 studies initially reviewed, 7 studies were included in the systematic review. In the base-case analyses, 4 studies concluded that TOLAC was dominant over ERCD, 1 study found ERCD to be dominant, and 2 studies found that although TOLAC was more costly, it offered more benefits and was thus cost-effective from a population perspective when considering societal willingness to pay for better outcomes. In sensitivity analyses, cost-effectiveness was found to be dependent on a high likelihood of TOLAC success, low risk of uterine rupture, and low relative cost of TOLAC compared with ERCD. CONCLUSIONS For women who are likely to have a successful vaginal delivery, routine ERCD may result in excess morbidity and cost from a population perspective.
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Affiliation(s)
- Anna Joy Rogers
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Nathaniel G Rogers
- Departments of Medicine and Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Meredith L Kilgore
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Akila Subramaniam
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lorie M Harper
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Abstract
Placenta accreta can lead to hemorrhage, resulting in hysterectomy, blood transfusion, multiple organ failure, and death. Accreta has been increasing steadily in incidence owing to an increase in the cesarean delivery rate. Major risk factors are placenta previa in women with prior cesarean deliveries. Obstetric ultrasonography can be used to diagnose placenta accreta antenatally, which allows for scheduled delivery in a multidisciplinary center of excellence for accreta. Controversies exist regarding optimal management, including optimal timing of delivery, surgical approach, use of adjunctive measures, and conservative (uterine-sparing) therapy. We review the definition, risk factors, diagnosis, management, and controversies regarding placenta accreta.
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Affiliation(s)
- Robert M Silver
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of Utah Health Sciences Center, 30 North 1900 East 2B200 SOM, Salt Lake City, UT 84132, USA
| | - Kelli D Barbour
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of Utah Health Sciences Center, 30 North 1900 East 2B200 SOM, Salt Lake City, UT 84132, USA.
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Impact of Obstetrician/Gynecologist Hospitalists on Quality of Obstetric Care (Cesarean Delivery Rates, Trial of Labor After Cesarean/Vaginal Birth After Cesarean Rates, and Neonatal Adverse Events). Obstet Gynecol Clin North Am 2015; 42:477-85. [PMID: 26333637 DOI: 10.1016/j.ogc.2015.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Care via obstetric hospitalists continues to expand, quickly becoming an integral part of labor and delivery management in urban and suburban areas. Overall lower cesarean delivery rates have been found with obstetric hospitalist care. Continuous 24-hour coverage of labor units has displayed lower rates of neonatal adverse events and likely reduces time in decision to delivery. Further study is needed on maternal and neonatal outcomes to corroborate earlier observations, and to closely examine the type of obstetric hospitalist model being observed to aid in planning the ideal deployment of providers in this workforce of the future.
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Friedman AM, Ananth CV, Chen L, D'Alton ME, Wright JD. An economic analysis of trial of labor after cesarean delivery. J Matern Fetal Neonatal Med 2015; 29:1030-5. [PMID: 25865742 DOI: 10.3109/14767058.2015.1035250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Given that cesarean delivery is one of the most commonly performed surgical procedures in the United States and an important contributor to obstetric care costs, this analysis sought to examine maternal hospital costs associated with trial of labor after cesarean delivery (TOLAC) versus repeat cesarean delivery (RCD). METHODS A national sample was used to identify women with singleton pregnancy who underwent either TOLAC or RCD from 2006 to 2012. Women with diagnoses that could confound cost via extended hospital length of stay prior to delivery were excluded. Other medical and obstetric covariates that could influence cost were included in an adjusted model. RESULTS A total of 485,247 women were identified, including 365,596 (75.3%) cesarean deliveries without labor, 41,988 (8.6%) successful and 77,663 (16.0%) unsuccessful TOLAC deliveries. The inflation-adjusted median costs in this cohort were $5512 for cesarean without labor, $4175 for successful TOLAC, $5166 for all TOLAC attempts, and $5759 for failed TOLAC. In a multivariable model, hospital region was a major predictor of median cost as were demographic variables and medical comorbidities. CONCLUSION TOLAC is associated with modest reductions of cost for maternal hospitalizations. However, other medical, demographic and hospital factors appear to be more important factors.
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Affiliation(s)
- Alexander M Friedman
- a Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology , Columbia University College of Physicians and Surgeons , New York , NY , USA and
| | - Cande V Ananth
- a Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology , Columbia University College of Physicians and Surgeons , New York , NY , USA and.,b Department of Epidemiology , Joseph L. Mailman School of Public Health, Columbia University , New York , NY , USA
| | - Ling Chen
- a Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology , Columbia University College of Physicians and Surgeons , New York , NY , USA and
| | - Mary E D'Alton
- a Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology , Columbia University College of Physicians and Surgeons , New York , NY , USA and
| | - Jason D Wright
- a Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology , Columbia University College of Physicians and Surgeons , New York , NY , USA and
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