Preferences for fertility in women with pelvic inflammatory disease

Valuing the health states associated with Chlamydia trachomatis infections and their sequelae: a systematic review of economic evaluations and primary studies

OBJECTIVES

Economic evaluations of interventions to prevent and control sexually transmitted infections such as Chlamydia trachomatis are increasingly required to present their outcomes in terms of quality-adjusted life-years using preference-based measurements of relevant health states. The objectives of this study were to critically evaluate how published cost-effectiveness studies have conceptualized and valued health states associated with chlamydia and to examine the primary evidence available to inform health state utility values (HSUVs).

METHODS

A systematic review was conducted, with searches of six electronic databases up to December 2012. Data on study characteristics, methods, and main results were extracted by using a standard template.

RESULTS

Nineteen economic evaluations of relevant interventions were included. Individual studies considered different health states and assigned different values and durations. Eleven studies cited the same source for HSUVs. Only five primary studies valued relevant health states. The methods and viewpoints adopted varied, and different values for health states were generated.

CONCLUSIONS

Limitations in the information available about HSUVs associated with chlamydia and its complications have implications for the robustness of economic evaluations in this area. None of the primary studies could be used without reservation to inform cost-effectiveness analyses in the United Kingdom. Future debate should consider appropriate methods for valuing health states for infectious diseases, because recommended approaches may not be suitable. Unless we adequately tackle the challenges associated with measuring and valuing health-related quality of life for patients with chlamydia and other infectious diseases, evaluating the cost-effectiveness of interventions in this area will remain problematic.

Medical decision analysis for the management of unifocal, flat, low-grade dysplasia in ulcerative colitis

BACKGROUND

Management of unifocal, flat, low-grade dysplasia (LGD) in ulcerative colitis (UC) remains controversial.

OBJECTIVE

To compare the relative costs and effectiveness of immediate colectomy and enhanced colonoscopic surveillance for the management of LGD.

DESIGN AND SETTING

Medical decision analysis by using state-transition Markov models. Transition probabilities and health utilities were derived from the literature, and costs were derived from national hospital data sets and Medicare and/or Medicaid reimbursement schedules.

PATIENTS

Two simulated cohorts of 10,000 patients with longstanding UC who were newly diagnosed with unifocal, flat LGD on initial surveillance colonoscopy.

INTERVENTIONS

Immediate colectomy or enhanced surveillance (repeated colonoscopy at 3, 6, and 12 months, and then annually).

MAIN OUTCOME MEASUREMENTS

Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.

RESULTS

Immediate colectomy dominated over enhanced surveillance and yielded higher QALYs (20.1 vs 19.9 years) and lower costs ($75,900 vs $83,900). These findings were robust to variations in model parameters, with immediate colectomy remaining dominant in 90% of simulations in sensitivity analysis. Varying postcolectomy health utility outside the range in the probabilistic sensitivity analysis rendered enhanced surveillance cost effective. When the health utility was below 0.77, the incremental cost-effectiveness ratio was $50,000 per QALY.

LIMITATIONS

Data based on observational studies and analyses rely on model assumptions.

CONCLUSIONS

Our analysis showed that immediate colectomy was preferable to enhanced surveillance. Health preference toward the postcolectomy state is, however, an influential factor. This decision analysis model provides a conceptual framework for physicians and patients to understand the relative benefits and costs of both interventions.

Quality of life utilities for pelvic inflammatory disease health states

PURPOSE

Quality of life utilities for health states associated with pelvic inflammatory disease (PID) have been estimated but not directly measured. Utilities for PID could have important implications on the cost-effectiveness of interventions to prevent and manage this disease.

METHODS

We obtained, in women with versus without a history of PID, visual analogue scale (VAS) and time-tradeoff (TTO) valuations for 5 PID-associated health states: ambulatory PID treatment, hospital PID treatment, ectopic pregnancy, chronic pelvic pain, and infertility. Subjects read brief scenarios describing the medical, functional, and social activity effects typically associated with each state, then gave valuations in the order above.

RESULTS

Health state valuations were obtained from 56 women with and 150 women without a PID history. Subjects with a PID history had significantly lower mean valuations (P <0.05) on the VAS for ectopic pregnancy (0.55 vs. 0.63), pelvic pain (0.45 vs. 0.53), and infertility (0.53 vs. 0.66) but not on the TTO; VAS differences remained significant when controlling for demographic and childbearing characteristics. VAS and TTO valuations were similar in women with versus without a history of PID for the ambulatory and hospital PID treatment health states.

CONCLUSION

PID has substantial impact on utility. In addition, some PID-related health states are valued less by women who have experienced PID, which could affect cost-effectiveness analyses of PID treatments when examined from the societal versus patient perspective.

Time from sexually transmitted infection acquisition to pelvic inflammatory disease development: influence on the cost-effectiveness of different screening intervals

OBJECTIVES

To prevent pelvic inflammatory disease (PID), some experts recommend screening for sexually transmitted infection (STI) every 12 months, with more frequent screening suggested in higher-risk women. Nevertheless, the time from STI acquisition to PID development, possibly an important factor to consider in screening interval choice, is unknown and its influence on the effectiveness and cost-effectiveness of screening is unclear.

METHODS

Using a Markov model, we estimated PID cases averted and the incremental cost-effectiveness resulting from 6- or 12-month screening strategies for high-risk young women (6%/year infection risk, 2.8%/year PID risk with 12-month screening) while varying PID development time from 1 to 12 months after initial infection. Lower-risk women and alternative parameter values were examined in sensitivity analyses.

RESULTS

Relative to 12-month screening, 6-month screening decreases PID cases from 6.0% (1 month development time)to 19.4% (12 months); the incremental cost per quality-adjusted life-year (QALY) gained compared with the other strategies varies from $16,600 (12 months development time) to $31,800 (1 month) for high-risk women. In lower-risk women, every 6-month screening is more economically unfavorable, with greater costs per QALY gained at shorter PID development time.

CONCLUSION

From a cost-effectiveness standpoint, uncertainty about PID development time is not a significant factor in choosing a screening interval in high-risk women, but could be important in lower-risk groups. Significant increases in PID cases averted occur with more frequent screening when PID development time is lengthened, which may allow estimation of this interval through the use of more sophisticated modeling techniques.

Modifiable risk factors for impaired fertility in women: What nurse practitioners need to know

PURPOSE

To provide an overview of impaired fertility in childbearing-aged women, to review the current research on modifiable lifestyle risk factors implicated in its development, and to suggest strategies for nurse practitioners (NPs) to assist women in behavioral changes that will allow them to protect their fertility.

DATA SOURCES

Original research articles and comprehensive review articles identified through Medline, CINAHL, and OVID databases.

CONCLUSIONS

Research has shown that advancing age, a history of a sexually transmitted infection and/or pelvic inflammatory disease, extremes of body weight, and tobacco and caffeine use are potentially modifiable risk factors in the development of impaired fertility.

IMPLICATIONS FOR PRACTICE

NPs must be aware of the link between these behaviors and the development of impaired fertility in order to assist women in preserving their fertility. Individual counseling, education, and community-wide education strategies are discussed.