Extrapolating published survival curves to obtain evidence-based estimates of life expectancy in cerebral palsy

Estimates of congenital cytomegalovirus-attributable infant mortality in high-income countries: A review

As many as 5%-10% of infants with symptomatic congenital cytomegalovirus (cCMV) disease, or 0.4%-0.8% of all liveborn infants with cCMV infection, die in early infancy in high-income countries. However, estimates are uncertain due to several potential biases that can result from data limitations and study designs. First, infants with cCMV infections who die prior to diagnosis, which usually occurs at 1-4 weeks after birth, may be excluded from both the count of deaths and the denominator of cCMV births, resulting in left truncation and immortal time biases. These 'biases' are features of the data and do not reflect bias on the part of researchers, but understanding the potential existence of threats to validity can help with interpretation of findings. Left truncation of infant deaths occurring prior to diagnosis of cCMV can result in understatement of the burden of infant deaths due to cCMV. Conversely, overestimation of infant deaths associated with symptomatic cCMV may occur in clinical case series owing to greater representation of relatively severely affected infants owing to ascertainment and referral biases. In this review, we summarise the characteristics of 26 studies that reported estimates of cCMV-associated infant deaths, including potential biases or limitations to which those estimates may have been subject. We discuss study designs whose implementation might generate improved estimates of infant deaths attributable to cCMV. More complete estimates of the overall public health impact of cCMV could inform current and future screening, prevention, and vaccine research.

Preventing eviction during pregnancy: a cost-effectiveness analysis of a theoretical safety-net program

BACKGROUND

Eviction during pregnancy has been shown to be associated with adverse birth outcomes. A safety net program focused on covering the costs of rent during pregnancy may aid in preventing adverse complications.

OBJECTIVE

This study aimed to evaluate the cost-effectiveness of a program covering the cost of rent to prevent eviction during pregnancy.

STUDY DESIGN

A cost-effectiveness model using TreeAge software was designed to evaluate the cost, effectiveness, and incremental cost-effectiveness ratio associated with eviction compared to no eviction during pregnancy. The cost of eviction from a societal perspective was compared to the annual cost of housing in the no eviction group, which was estimated by the median contract rent in the United States from 2021 national census data. Birth outcomes included preterm birth, neonatal death, and major neurodevelopmental delay. Probabilities and costs were derived from the literature. The cost-effectiveness threshold was set at $100,000/QALY. We performed univariable and multivariable sensitivity analyses to assess the robustness of the results.

RESULTS

In our theoretical cohort of 30,000 pregnant individuals aged 15 to 44 years facing eviction annually, the no eviction during pregnancy strategy was associated with 1427 fewer preterm births, 47 fewer neonatal deaths, and 44 fewer cases of neurodevelopmental delay compared to eviction. At the median cost of rent in the United States, the no eviction strategy was associated with increased quality-adjusted life-years and decreased costs. Therefore, the no eviction strategy was the dominant strategy. In univariate sensitivity analysis varying the cost of housing, no eviction remained the cost-effective strategy and was cost-saving when rent was below $1016 per month.

CONCLUSION

The no eviction strategy is cost-effective and reduces cases of preterm birth, neonatal death, and neurodevelopmental delay. When rent is below the median of $1016 per month, no eviction is the cost-saving strategy. These findings suggest that policies supporting social programmatic implementation for rent coverage for pregnant people at risk of eviction have the potential to be highly beneficial in reducing costs and disparities in perinatal outcomes.

Life expectancy and its adjustment in cerebral palsy with severe impairment: Are we doing this right?

In children with very severe cerebral palsy, an adversarial legal process for medical negligence, when liability is admitted, requires an estimate of life expectancy. Medical experts using the same cohort data and the same clinical facts can produce quite different life expectancies, leading to arguments in legal conferences and courts. The issues that commonly arise include between-country comparisons, projected and therapy-induced advanced life expectancies, and the contribution of epilepsy, scoliosis, and especially cognition to life expectancy. In this review, these factors are discussed from an arithmetic, statistical, and medical viewpoint to initiate debate on the issue, including whether median survival should be advocated.

Prevention of perinatal depression with counseling in adolescents: a cost-effectiveness analysis

OBJECTIVE

The US Preventive Services Task Force recently recommended that clinicians refer all pregnant and postpartum individuals at increased risk of perinatal depression to a counseling intervention. Adolescents are considered a high-risk group for perinatal depression. Therefore, we examined whether it is cost effective for all pregnant adolescents to be referred for preventive counseling.

STUDY DESIGN

We developed a decision-analytic model using TreeAge Pro software to compare outcomes in pregnant adolescents who received versus did not receive counseling interventions. We used a theoretical cohort of 180,000 individuals, which is the estimated annual number of births to persons ≤ 19 years in the US. Outcomes included perinatal depression, chronic depression, maternal suicide attributed to depression, preterm delivery, neonatal death, cerebral palsy, and sudden infant death syndrome (SIDS), in addition to cost and quality-adjusted life years (QALYs). The willingness-to-pay (WTP) threshold was set to $100,000/QALY. We derived model inputs from the literature, and sensitivity analyses were used to assess robustness of the model.

RESULTS

A strategy of referral to counseling interventions was cost effective in our theoretical cohort, with 8935 fewer cases of perinatal depression, 1606 fewer cases of chronic depression, 166 fewer preterm deliveries, 4 fewer neonatal deaths, 1 fewer case of cerebral palsy, 20 fewer cases of SIDS. In total, there were 21,976 additional QALYs and cost savings of $223,549,872, making it the dominant strategy (better outcomes with lower costs). We found that counseling interventions remained cost saving until the annual direct and indirect cost of chronic, severe depression was set below $30,000, at which point it became cost effective (baseline input: $182,309).

CONCLUSION

We found it was cost effective to refer all pregnant adolescents for preventive counseling interventions. Clinicians should develop approaches to identify and refer pregnant adolescents for behavioral counseling to prevent perinatal depression.

Comparative cost-utility analysis of postoperative discharge pathways following posterior spinal fusion for scoliosis in non-ambulatory cerebral palsy patients

PURPOSE

Accelerated postoperative discharge (AD) pathways have demonstrated numerous benefits for patients with adolescent idiopathic scoliosis undergoing PSF. Although early evidence supports the application of AD pathways over more traditional discharge (TD) approaches for patients with neuromuscular scoliosis, the economic impact of these pathways has not been investigated.

METHODS

A decision-analysis model was constructed using a hypothetical 15-year-old male with non-ambulatory CP with a 65-degree thoracolumbar scoliosis and pelvic obliquity undergoing operative treatment with PSF from T2-pelvis with pedicle screw fixation. The literature was reviewed to estimate costs, probabilities, and quality-adjusted life years (QALYs)) for identified complication profiles for discharge pathways. QALYs were constructed using age-matched values for US population average, applying a CP diagnosis corrective value. A probabilistic sensitivity analysis was performed using a second-order Monte Carlo simulations. Incremental cost-utility ratio and incremental net monetary benefit (NMB) were calculated. One-way sensitivity analyses were performed by selective variable variation.

RESULTS

AD pathway resulted in an average cost and effectiveness of $67,069 and 15.4 QALYs compared with $81,312 and 15.4 QALYs for TD. AD resulted in a 2.1% greater NMB with a cost-effectiveness ratio of $4361/QALY compared with $5290/QALY in the TD. The cost-effectiveness of TD was inversely sensitive to implant cost variation while the AD maintained effectiveness despite cost variations.

CONCLUSION

This cost-utility analysis demonstrated that the implementation of an AD pathway following PSF for non-ambulatory CP scoliosis is economically more effective, providing a 17.5% cost reduction with enhanced value of care evidenced by a 2.1% greater NMB over a TD pathway. The cost-effectiveness of the AD was maintained despite implant cost variations.

Behavioral Smoking Cessation Counseling During Pregnancy: A Cost-Effectiveness Analysis

OBJECTIVE

To examine the cost effectiveness of using behavioral smoking cessation counseling during pregnancy.

METHODS

We designed a decision-analytic model using TreeAge Pro 2020 software to compare the cost effectiveness and outcomes among women who received behavioral smoking cessation counseling compared with women who received usual care during pregnancy. We used a theoretical cohort of 285,000 women, the approximate number of pregnant women who smoke each year in the United States. Outcomes included maternal abstinence from smoking, fetal growth restriction, stillbirth, preterm delivery, neonatal death, and cerebral palsy, in addition to cost and quality-adjusted life-years (QALYs) for both the woman and the neonate. All model inputs were derived from the literature, and a willingness-to-pay threshold was set at $100,000 per QALY. Sensitivity analyses were performed to determine the robustness of baseline assumptions.

RESULTS

In our theoretical cohort, behavioral smoking cessation counseling compared with usual care was associated with 9,019 additional women stopping smoking during pregnancy (34,604 vs 25,585). Smoking cessation counseling also resulted in 911 fewer cases of fetal growth restriction, 20 fewer stillbirths, 250 fewer preterm deliveries, 11 fewer neonatal deaths, and one less case of cerebral palsy. Using behavioral smoking cessation counseling interventions during pregnancy led to better outcomes despite higher costs, with an incremental cost-effectiveness ratio of $71,658 per QALY, which was below our willingness-to-pay threshold of $100,000 per QALY, making the intervention cost effective. Sensitivity analyses demonstrated that the counseling intervention was cost effective at probabilities of smoking cessation greater than 11.6% (baseline input: 12.1%) or the cost of the behavioral intervention was less than $475.21 (baseline input: $368.78).

CONCLUSION

Behavioral smoking cessation counseling during pregnancy was associated with fewer adverse neonatal outcomes and was cost effective. Increasing utilization of such interventions and increasing insurance coverage of this care are important initiatives to improve outcomes in this at-risk population.

Effectiveness of powered exoskeleton use on gait in individuals with cerebral palsy: A systematic review

Background

Cerebral palsy (CP) is a leading cause of childhood disability. The motor impairments of individuals with CP significantly affect the kinematics of an efficient gait pattern. Robotic therapies have become increasingly popular as an intervention to address this. Powered lower limb exoskeletons (PoLLE) are a novel form of robotic therapy that allow the individual to perform over-ground gait training and yet its effectiveness for CP is unknown.

Purpose

To determine the effectiveness of PoLLE use on gait in individuals with CP.

Method

A systematic search of eight electronic databases was conducted in March 2020. Studies included children (0–18 years) and or adults (18+ years) diagnosed with CP who used a PoLLE for gait training. This review was conducted and reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement, with the methodology registered with PROSPERO (CRD42020177160). A modified version of the McMaster critical review form for quantitative studies was used to assess the methodological quality. Due to the heterogeneity of the included studies, a descriptive synthesis using the National Health & Medical Research Council (NHMRC) FORM framework was undertaken.

Results

Of the 2089 studies screened, ten case series and three case studies met the inclusion criteria highlighting the current evidence base is emerging and low level. A range of PoLLEs were investigated with effectiveness measured by using a number of outcome measures. Collectively, the body of evidence indicates there is some consistent positive evidence on the effectiveness of PoLLE in improving gait in individuals with CP, with minimal adverse effects. While this is a positive and encouraging finding for an emerging technology, methodological concerns also need to be acknowledged.

Conclusion

With rapidly evolving technology, PoLLEs could play a transformative role in the lives of people impacted by CP. Ongoing research is required to further strengthen the evidence base and address current methodological concerns.

Excessive premature mortality among children with cerebral palsy in rural Uganda: A longitudinal, population-based study

Background

Studies from high-income countries reported reduced life expectancy in children with cerebral palsy (CP), while no population-based study has evaluated mortality of children with CP in sub-Saharan Africa. This study aimed to estimate the mortality rate (MR) of children with CP in a rural region of Uganda and identify risk factors and causes of death (CODs).

Methods and findings

This population-based, longitudinal cohort study was based on data from Iganga-Mayuge Health and Demographic Surveillance System in eastern Uganda. We identified 97 children (aged 2–17 years) with CP in 2015, whom we followed to 2019. They were compared with an age-matched cohort from the general population (n = 41 319). MRs, MR ratios (MRRs), hazard ratios (HRs), and immediate CODs were determined.

MR was 3952 per 100 000 person years (95% CI 2212–6519) in children with CP and 137 per 100 000 person years (95% CI 117–159) in the general population. Standardized MRR was 25·3 in the CP cohort, compared with the general population. In children with CP, risk of death was higher in those with severe gross motor impairments than in those with milder impairments (HR 6·8; p = 0·007) and in those with severe malnutrition than in those less malnourished (HR = 3·7; p = 0·052). MR was higher in females in the CP cohort, with a higher MRR in females (53·0; 95% CI 26·4–106·3) than in males (16·3; 95% CI 7·2–37·2). Age had no significant effect on MR in the CP cohort, but MRR was higher at 10–18 years (39·6; 95% CI 14·2–110·0) than at 2–6 years (21·0; 95% CI 10·2–43·2). Anaemia, malaria, and other infections were the most common CODs in the CP cohort.

Conclusions

Risk of premature death was excessively high in children with CP in rural sub-Saharan Africa, especially in those with severe motor impairments or malnutrition. While global childhood mortality has significantly decreased during recent decades, this observed excessive mortality is a hidden humanitarian crisis that needs to be addressed.

Obstetric management for stillbirth complicated by a prior cesarean delivery: a cost-effectiveness analysis

BACKGROUND

The primary concern for a trial of labor after cesarean (TOLAC) is a uterine rupture leading to neonatal injury or mortality and maternal mortality. In individuals who have a term stillbirth, the neonatal concern is absent, yet repeat cesarean delivery remains common in this setting. Given the increased maternal risks from cesarean, it is important to evaluate obstetric management options in the population of women who have a term stillbirth and prior cesarean delivery (CD).

OBJECTIVES

To examine the outcomes and costs of a TOLAC via induction of labor verses a repeat CD for cases of stillbirth occurring near term.

STUDY DESIGN

A decision-analytic model incorporating the current and a subsequent delivery using TreeAge software was designed to compare outcomes in women induced for a TOLAC to those undergoing repeat CD in the setting of stillbirth at 34-41 weeks' gestation. We used a theoretical cohort of 6000 women, the estimated annual number of women a prior cesarean who experience a stillbirth in the United States. Outcomes included quality-adjusted life years (QALY) for both modes of delivery with consideration of future pregnancy risks. Future pregnancy risks included uterine rupture, hysterectomy, placenta accreta, maternal death, neonatal death, and neonatal neurological deficits. Probabilities were derived from the literature, and a cost-effectiveness threshold was set at $100,000/QALY.

RESULTS

In our theoretical cohort of 6000 women with a prior CD and current stillbirth, induction of labor resulted in 4836 fewer cesarean deliveries during stillbirth management, 1040 fewer cesarean deliveries in the subsequent pregnancy, and 14 fewer cases of placenta accreta in the subsequent pregnancy, despite 29 additional uterine ruptures across both pregnancies. Induction of labor was found to be the dominant strategy, resulting in decreased costs and increased QALYs. Univariate sensitivity analyses demonstrated that induction of labor was cost effective until the risk of uterine rupture in the first delivery exceeded 0.83% (baseline estimate: 0.38%). Additional univariate sensitivity analyses found that induction of labor was cost effective until the risk of IOL failure in the first delivery exceeded 64% (baseline estimate: 19%).

CONCLUSION

In our theoretical cohort, induction of labor for TOLAC in the setting of a stillbirth with a history of prior CD is cost effective compared to a repeat CD. The results of this analysis demonstrate the benefit of induction of labor among women in this scenario who desire a future pregnancy.

Antenatal Corticosteroids for Pregnant Women at High Risk of Preterm Delivery with COVID-19 Infection: A Decision Analysis

OBJECTIVE

Antenatal corticosteroids given prior to preterm deliveries reduce the risk of adverse neonatal outcomes. However, steroid administration in the setting of a viral respiratory infection can worsen maternal outcomes. Therefore, the decision to administer corticosteroids must balance the neonatal benefits with the potential harm to the mother if she is infected with the novel coronavirus disease 2019 (COVID-19). This study aimed to determine the gestational ages for which administering antenatal corticosteroids to women at high risk of preterm labor with concurrent COVID-19 infection results in improved combined maternal and infant outcomes.

STUDY DESIGN

A decision-analytic model using TreeAge (2020) software was constructed for a theoretical cohort of hospitalized women with COVID-19 in the United States. All model inputs were derived from the literature. Outcomes included maternal intensive care unit (ICU) admission and death, along with infant outcomes of death, respiratory distress syndrome, intraventricular hemorrhage, and neurodevelopmental delay. Quality-adjusted life years (QALYs) were assessed from the maternal and infant perspectives. Sensitivity analyses were performed to determine if the results were robust over a range of assumptions.

RESULTS

In our theoretical cohort of 10,000 women delivering between 24 and 33 weeks of gestation with COVID-19, corticosteroid administration resulted in 2,200 women admitted to the ICU and 110 maternal deaths. No antenatal corticosteroid use resulted in 1,500 ICU admissions and 75 maternal deaths. Overall, we found that corticosteroid administration resulted in higher combined QALYs up to 31 weeks of gestation in all hospitalized patients, and up to 29 weeks of gestation in ICU patients.

CONCLUSION

Administration of antenatal corticosteroids at less than 32 weeks of gestation for hospitalized patients and less than 30 weeks of gestation for patients admitted to the ICU resulted in higher combined maternal and infant outcomes compared with expectant management for women at high risk of preterm birth with COVID-19 infection. These results can guide clinicians in their counseling and management of these pregnant women.

KEY POINTS

· Antenatal steroids reduce adverse neonatal outcomes.. · Steroids worsen maternal outcomes in COVID-19.. · Steroids given < 32 weeks result in improved outcomes..

FitSkills: protocol for a stepped wedge cluster randomised trial of a community-based exercise programme to increase participation among young people with disability

INTRODUCTION

There is a need to develop relevant, acceptable initiatives that facilitate physical activity participation in young people with disability. FitSkills was developed to support young people with disability to exercise. The primary aims are to investigate if FitSkills can be scaled up from a small, university-led programme to run as a larger community-university partnership programme, and to determine its effectiveness in improving physical activity participation and health-related quality of life for young people with disability. The secondary aims are to evaluate cost-effectiveness, changes in attitudes towards disability and other health-related outcomes for young people with disability.

METHODS AND ANALYSIS

A stepped wedge cluster randomised trial using a cohort design and embedded health economic evaluation will compare the effect of FitSkills with a control phase. FitSkills matches a young person with disability with a student mentor and the pair exercise together at their local gymnasium for 1 hour, two times per week for 12 weeks (24 sessions in total). One hundred and sixty young people with disability aged 13 to 30 years will be recruited. Eight community gymnasia will be recruited and randomised into four cluster units to have FitSkills introduced at 3-month intervals. Primary (feasibility, participation and health-related quality of life) and secondary outcomes will be collected longitudinally every 3 months from trial commencement, with eight data collection time points in total. The Practical Robust Implementation and Sustainability Model will be used to support knowledge translation and implementation of project findings into policy and practice.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the La Trobe University Human Ethics Committee (HEC17-012), Australian Catholic University (2017-63R), Deakin University (2017-206) and the Victorian Department of Education and Training (2018_003616). Results will be disseminated through published manuscripts, conference presentations, public seminars and practical resources for stakeholder groups.

TRIAL REGISTRATION NUMBER

ACTRN12617000766314.

TRIAL SPONSOR

La Trobe University.

Beyond stereotypes of cerebral palsy: Exploring the lived experiences of young Canadians

BACKGROUND

Health for people with cerebral palsy (CP) must extend beyond physical impairments to include social, environmental, and psychological factors that are rarely captured by quantitative research alone. This qualitative study sought to explore the lived experience of young people with CP with their physical, mental, and emotional health in the context of a larger longitudinal Canadian study focusing on brain function, physical and mental health, and well-being.

METHODS

An integrated research team (including people with CP or other impairments, clinicians, and researchers) was formed to study participant-identified research needs. A purposive sample of 16 people with CP (seven female), aged 17-29, Gross Motor Function Classification System (GMFCS) levels I-V, participated in three focus groups that were conceptualized and analysed using interpretive description methodology.

RESULTS

This study reports the experiences of people with CP across GMFCS levels and identifies some consequences of growing up with the condition: physical and mental health issues, importance of meaningful participation, impact of the environment, and identity formation. Participants shared challenges related to accessibility, healthcare, social/environmental supports, relationships, and sustainable employment.

DISCUSSION

Body structure and function challenges impact participation in activities of daily living, threatening participants' ability to form positive identities and live meaningful lives. People with CP desire to work but may require additional training, accommodation, and support to do so. Environmental conditions, including relationships, supportive people, and accessibility, shape participants' health, well-being, and social/civic engagement. This study confirms the need for improved care for adults with CP, including multidisciplinary adult health team(s) and community services.

Standard Period Life Table Used to Compute the Life Expectancy of Diseased Subpopulations: More Confusing Than Helpful

Life expectancy (LE) based on a period life table (PLT) traditionally serves as a general population summary metric. It is, however, becoming more frequently reported for chronically afflicted subpopulations. In general populations, there is always an obvious real cohort sharing the hypothetical PLT cohort characteristics, and the LE estimate is intuitively understood as that real cohort mean survival time, assuming constancy of death risks. In diseased subpopulations, the correspondence between the hypothetical cohort and a real cohort is not straightforward. Furthermore, the excess mortality of chronic diseases usually changes according to age at onset and time since onset. The standard PLT method does not allow for proper control of these issues, so the LE estimate can only be deemed valid under specific assumptions. Without clear statements about the real cohort to whom the estimate is intended and the assumptions allowing disregard of the effect of age at onset and time since onset, LEs of afflicted subpopulations computed with the PLT are only abstract numbers summarizing mortality rates. If called "life expectancy," they can be seriously misleading. The same applies to health-adjusted LE.