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Srinivas T, Lulseged B, Mirza Aghazadeh Attari M, Borahay M, Weiss CR. Patient Characteristics Associated With Embolization Versus Hysterectomy for Uterine Fibroids: A Systematic Review and Meta-Analysis. J Am Coll Radiol 2024; 21:729-739. [PMID: 38191081 DOI: 10.1016/j.jacr.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/18/2023] [Accepted: 12/21/2023] [Indexed: 01/10/2024]
Abstract
INTRODUCTION Black and underinsured women in the United States are more likely than their counterparts to develop uterine fibroids (UFs) and experience more severe symptoms. Uterine artery embolization (UAE), a uterine-sparing therapeutic procedure, is less invasive than the common alternative, open hysterectomy. To determine whether demographic disparities persist in UF treatment utilization, we reviewed patient characteristics associated with UAE versus hysterectomy for UF among studies of US clinical practices. METHODS A systematic literature review was conducted via PubMed, Embase, and CINAHL (PROSPERO CRD42023455051), yielding 1,350 articles (January 1, 1995, to July 15, 2023) that outlined demographic characteristics of UAE compared with hysterectomy. Two readers screened for inclusion criteria, yielding 13 full-text US-based comparative studies specifying at least one common demographic characteristic. Random effects meta-analysis was performed on the data (STATA v18.0). Egger's regression test was used to quantify publication bias. RESULTS Nine (138,960 patients), four (183,643 patients), and seven (312,270 patients) studies were analyzed for race, insurance status, and age as predictors of treatment modality, respectively. Black race (odds ratio = 3.35, P < .01) and young age (P < .05) were associated with UAE, whereas private insurance (relative to Medicare and/or Medicaid) was not (odds ratio = 1.06, P = .52). Between-study heterogeneity (I2 > 50%) was detected in all three meta-analyses. Small-study bias was detected for age but not race or insurance. CONCLUSIONS AND IMPLICATIONS Knowledge of demographic characteristics of patients with UFs receiving UAE versus hysterectomy is sparse (n = 13 studies). Among these studies, which seem to be racially well distributed, Black and younger women are more likely to receive UAE than their counterparts.
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Affiliation(s)
- Tara Srinivas
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Mohammad Mirza Aghazadeh Attari
- Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Vascular and Interventional Radiology, the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mostafa Borahay
- Associate Professor of Gynecology and Obstetrics, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland; Director of the Division of General Gynecology & Obstetrics, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Clifford R Weiss
- Division of Vascular and Interventional Radiology, the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland; Director of the Johns Hopkins HHT Center of Excellence and Professor of Radiology and Radiological Science, Baltimore, Maryland.
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Gao H, Li T, Fu D, Wei J. Uterine artery embolization, surgery and high intensity focused ultrasound in the treatment of uterine fibroids: a network meta-analysis. Quant Imaging Med Surg 2021; 11:4125-4136. [PMID: 34476193 DOI: 10.21037/qims-20-1331] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 04/02/2021] [Indexed: 12/28/2022]
Abstract
Background To systematic review the safety and effectiveness between uterine artery embolization (UAE), surgery and high intensity focused ultrasound (HIFU) in the treatment of uterine fibroids. Methods The PubMed, EMbase, The Cochrane Library, Web of Science, Wanfang Data, and CNKI were electronically searched to collect relevant studies on comparing the safety and effectiveness of UAE, surgery and HIFU in the treatment of uterine fibroids from January 2000 to August 2019. After two reviewers independently screened the literature, extracted the data and evaluated the risk of bias of included studies, network meta-analysis was performed by ADDIS 1.16.8 and Stata 14 software. Results A total of 11 studies (22 articles) involving 3,646 patients were included. Compared with surgery, UAE and HIFU patients had higher quality of life (1-year follow-up) improvement, and UAE was higher than HIFU. Network meta-analysis show that patients treated with HIFU had the lowest incidence of major complications within 1 year, followed by UAE, and the highest surgery. Patients treated with HIFU and UAE have shorter hospital stays and quicker recovery time than surgery. The rate of further intervention after surgery treatment might be lower than that of UAE and HIFU. Conclusions UAE has the highest quality of life improvement (1-year follow-up) for uterine fibroids. HIFU and UAE are safer with shorter hospital stays and quicker recovery time compared with surgery. However, both UAE and HIFU have the risks of re-treatment. However, limited by the number and quality of included studies, the above conclusions need to be verified through more high-quality studies.
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Affiliation(s)
- Haijun Gao
- Department of Radiology, Tianjin First Central Hospital, Tianjin, China
| | - Tianping Li
- General Department, Chongqing Health Center for Women and Children, Chongqing, China
| | - Dianxun Fu
- Department of Radiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Jun Wei
- Department of Ultrasound, Chongqing Health Center for Women and Children, Chongqing, China
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Singh B, Sims H, Trueheart I, Simpson K, Wang KC, Patzkowsky K, Wegman T, Soma JM, Dixon R, Jayes F, Voegltine K, Yenokyan G, Su SC, Leppert P, Segars JH. A Phase I Clinical Trial to Assess Safety and Tolerability of Injectable Collagenase in Women with Symptomatic Uterine Fibroids. Reprod Sci 2021; 28:2699-2709. [PMID: 33914296 PMCID: PMC8346429 DOI: 10.1007/s43032-021-00573-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 04/02/2021] [Indexed: 02/07/2023]
Abstract
Uterine fibroids feature excessive deposition of types I and III collagen. Previous ex vivo studies showed an FDA-approved collagenase (EN3835)-digested types I and III collagen fibers in fibroid tissues; however, collagenase had not been evaluated in vivo for effects on uterine fibroids. The objective was to assess the safety and tolerability of collagenase injection directly into uterine fibroids. This was a prospective, open label, dose escalation study. The study participants were fifteen women aged 35-50 years with symptomatic uterine fibroids planning to undergo hysterectomy. Three subjects received saline and methylene blue, three subjects received a fixed dose of EN3835, and 9 subjects received stepped, increasing dosages of EN3835, all by transvaginal, ultrasound-guided injections. Primary outcome measures were safety and tolerability of the injection and change in collagen content between treated and control tissues. There were no significant adverse events following injection of EN3835 into uterine fibroids. Masson's trichrome stains revealed a 39% reduction in collagen content in treated samples compared to controls (p <0.05). Second harmonic generation (SHG) analysis showed treated samples to have a 21% reduction in density of collagen compared to controls. Picrosirius-stained collagenase-treated fibroids showed collagen fibers to be shorter and less dense compared to controls. Subjects reported a decrease in fibroid-related pain on the McGill Pain Questionnaire after study drug injection in Group 2 at both 4-8 days and 60-90 days post-injection. The findings indicated that injection of collagenase was safe and well tolerated. These results support further clinical investigation of collagenase as a minimally invasive treatment of uterine fibroids. NCT0289848.
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Affiliation(s)
- Bhuchitra Singh
- Department of Gynecology and Obstetrics, Division of Reproductive Sciences & Women's Health Research, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross Research Building, Room 624, Baltimore, MD, 21205, USA
| | - Holly Sims
- Department of Gynecology and Obstetrics, Division of Reproductive Sciences & Women's Health Research, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross Research Building, Room 624, Baltimore, MD, 21205, USA
| | - Irene Trueheart
- Department of Gynecology and Obstetrics, Division of Reproductive Sciences & Women's Health Research, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross Research Building, Room 624, Baltimore, MD, 21205, USA
| | - Khara Simpson
- Department of Gynecology and Obstetrics, Minimally Invasive Gynecologic Surgeons, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karen C Wang
- Department of Gynecology and Obstetrics, Minimally Invasive Gynecologic Surgeons, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kristin Patzkowsky
- Department of Gynecology and Obstetrics, Minimally Invasive Gynecologic Surgeons, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thomas Wegman
- BioSpecifics Technologies Corporation, Lynbrook, NY, USA
| | | | - Rosina Dixon
- BioSpecifics Technologies Corporation, Lynbrook, NY, USA
| | - Friederike Jayes
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, USA
| | - Kristin Voegltine
- Biostatistics, Epidemiology and Data Management Core, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Gayane Yenokyan
- Johns Hopkins School of Public Health, Biostatistics Center, Baltimore, MD, USA
| | - Szu-Chi Su
- Department of Gynecology and Obstetrics, Division of Reproductive Sciences & Women's Health Research, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross Research Building, Room 624, Baltimore, MD, 21205, USA
| | - Phyllis Leppert
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, USA
| | - James H Segars
- Department of Gynecology and Obstetrics, Division of Reproductive Sciences & Women's Health Research, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross Research Building, Room 624, Baltimore, MD, 21205, USA.
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Grimes CL, Balk EM, Dieter AA, Singh R, Wieslander CK, Jeppson PC, Aschkenazi SO, Kim JH, Truong MD, Gupta AS, Keltz JG, Hobson DT, Sheyn D, Petruska SE, Adam G, Meriwether KV. Guidance for gynecologists utilizing telemedicine during COVID‐19 pandemic based on expert consensus and rapid literature reviews. Int J Gynaecol Obstet 2020. [PMCID: PMC9087699 DOI: 10.1002/ijgo.13276] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background COVID‐19 has impacted delivery of outpatient gynecology and shifted care toward use of telemedicine. Objective To rapidly review literature and society guidelines and create expert consensus to provide guidance regarding management of outpatient gynecology scenarios via telemedicine. Search strategy Searches were conducted in Medline and Cochrane databases from inception through April 15, 2020. Selection criteria Literature searches were conducted for articles on telemedicine and abnormal uterine bleeding, chronic pelvic pain, endometriosis, vaginitis, and postoperative care. Searches were restricted to available English language publications. Data collection and analysis Expedited literature review methodology was followed and 10 943 citations were single‐screened. Full‐text articles and relevant guidelines were reviewed and narrative summaries developed. Main results Fifty‐one studies on the use of telemedicine in gynecology were found. Findings were reported for these studies and combined with society guidelines and expert consensus on four topics (abnormal uterine bleeding, chronic pelvic pain and endometriosis, vaginal discharge, and postoperative care). Conclusions Guidance for treating gynecological conditions via telemedicine based on expedited literature review, review of society recommendations, and expert consensus is presented. Due to minimal evidence surrounding telemedicine and gynecology, a final consensus document is presented here that can be efficiently used in a clinical setting. Guidance for gynecologists using telemedicine during COVID‐19 based on rapid literature review, review of society recommendations, and expert consensus in accessible format.
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Affiliation(s)
- Cara L. Grimes
- Division of Female Pelvic Medicine and Reconstructive Surgery Departments of Obstetrics and Gynecology and Urology New York Medical College Valhalla NY USA
| | - Ethan M. Balk
- Center for Evidence Synthesis in Health Brown School of Public Health Brown University Providence RI USA
| | - Alexis A. Dieter
- Division of Urogynecology and Reconstructive Pelvic Surgery Department of Obstetrics and Gynecology University of North Carolina at Chapel Hill Chapel Hill NC USA
| | - Ruchira Singh
- Division of Female Pelvic Medicine and Reconstructive Surgery Department of Obstetrics and Gynecology University of Florida Jacksonville FL USA
| | - Cecilia K. Wieslander
- Division of Female Pelvic Medicine and Reconstructive Surgery Department of Obstetrics and Gynecology David Geffen School of Medicine at UCLA Los Angeles CA USA
| | - Peter C. Jeppson
- Division of Female Pelvic Medicine and Reconstructive Surgery Department of Obstetrics and Gynecology University of New Mexico Albuquerque NM USA
| | - Sarit O. Aschkenazi
- Prohealth Women Services Division of Urogynecology Department of Obstetrics and Gynecology Waukesha Memorial Hospital Medical College of Wisconsin Waukesha WI USA
| | - Jin Hee Kim
- Division of Gynecologic Specialty Surgery Department of Obstetrics and Gynecology Columbia University Medical Center New York NY USA
| | - Mireille D. Truong
- Division of Minimally Invasive Gynecologic Surgery Department of Obstetrics and Gynecology Cedars‐Sinai Medical Center Los Angeles CA USA
| | - Ankita S. Gupta
- Department of Obstetrics & Gynecology University of Louisville Louisville KY USA
| | - Julia G. Keltz
- Department of Obstetrics and Gynecology New York Medical College Valhalla NY USA
| | - Deslyn T.G. Hobson
- Department of Obstetrics and Gynecology Wayne State University School of Medicine Detroit MI USA
| | - David Sheyn
- Division of Female Pelvic Medicine and Reconstructive Surgery Department of Obstetrics and Gynecology MetroHealth Medical Center Cleveland OH USA
| | - Sara E. Petruska
- Department of Obstetrics & Gynecology University of Louisville Louisville KY USA
| | - Gaelen Adam
- Center for Evidence Synthesis in Health Brown School of Public Health Brown University Providence RI USA
| | - Kate V. Meriwether
- Division of Female Pelvic Medicine and Reconstructive Surgery Department of Obstetrics and Gynecology University of New Mexico Albuquerque NM USA
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Lukes AS, Soper D, Harrington A, Sniukiene V, Mo Y, Gillard P, Shulman L. Health-Related Quality of Life With Ulipristal Acetate for Treatment of Uterine Leiomyomas: A Randomized Controlled Trial. Obstet Gynecol 2020; 133:869-878. [PMID: 30969201 PMCID: PMC6485305 DOI: 10.1097/aog.0000000000003211] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Ulipristal acetate is associated with significant improvements in health-related quality of life and symptom severity compared with placebo in women with symptomatic uterine leiomyomas. OBJECTIVE: To investigate effects of ulipristal acetate on health-related quality of life (QOL) and symptom severity in women with symptomatic uterine leiomyomas and abnormal uterine bleeding. METHODS: Women were randomized to ulipristal (5 mg, 10 mg) or placebo in two phase 3, multicenter, double-blind, placebo-controlled trials (VENUS I and II). Health-related QOL and symptom severity were assessed at baseline, and over one (VENUS I and II) and two (VENUS II) 12-week treatment courses using the Uterine Fibroid Symptom Health-Related Quality of Life questionnaire. In pooled VENUS I and II data, change from baseline to the end of the first course for each Uterine Fibroid Symptom Health-Related Quality of Life scale was analyzed, including a Revised Activities subscale that measured physical and social activities. The proportion of women achieving meaningful change in the Symptom Severity (20 or more points), Health-Related QOL Total (20 or more points), and Revised Activities (30 or more points) scales was calculated. In VENUS II data, change from baseline to the end of each course in each scale was analyzed for each treatment arm. RESULTS: In pooled analyses, the intent-to-treat population included 589 patients (placebo, n=169; ulipristal 5 mg, n=215; ulipristal 10 mg, n=205). Significantly greater improvements from baseline in all Uterine Fibroid Symptom Health-Related Quality of Life scales were observed with both ulipristal doses compared with placebo (P<.001). A meaningful change in Revised Activities was achieved by 51 patients receiving placebo (34.9%), compared with 144 (73.5%; OR 5.0 [97.5% CI 2.9–8.6]) and 141 (80.6%; OR 7.9 [97.5% CI 4.3–14.6]) patients receiving ulipristal 5 mg, and 10 mg, respectively. In VENUS II, at end of courses 1 and 2, both ulipristal doses demonstrated significant improvements from baseline compared with placebo for all Uterine Fibroid Symptom Health-Related Quality of Life scales (P<.01). Mean Revised Activities scores showed that beneficial ulipristal effects were maintained in course 2, and improvements occurred on switching to ulipristal; results for other scales were similar. CONCLUSION: Ulipristal was associated with significant improvements in health-related QOL and symptom severity compared with placebo for women with symptomatic uterine leiomyomas. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02147197 and NCT02147158. FUNDING SOURCE: Allergan plc, Dublin, Ireland.
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Affiliation(s)
- Andrea S Lukes
- Carolina Women's Research and Wellness Center, Durham, North Carolina; Medical University of South Carolina, Charleston, South Carolina; Allergan plc, Irvine, California; Allergan plc, Madison, New Jersey; and the Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Prada F, Kalani MYS, Yagmurlu K, Norat P, Del Bene M, DiMeco F, Kassell NF. Applications of Focused Ultrasound in Cerebrovascular Diseases and Brain Tumors. Neurotherapeutics 2019; 16:67-87. [PMID: 30406382 PMCID: PMC6361053 DOI: 10.1007/s13311-018-00683-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Oncology and cerebrovascular disease constitute two of the most common diseases afflicting the central nervous system. Standard of treatment of these pathologies is based on multidisciplinary approaches encompassing combination of interventional procedures such as open and endovascular surgeries, drugs (chemotherapies, anti-coagulants, anti-platelet therapies, thrombolytics), and radiation therapies. In this context, therapeutic ultrasound could represent a novel diagnostic/therapeutic in the armamentarium of the surgeon to treat these diseases. Ultrasound relies on mechanical energy to induce numerous physical and biological effects. The application of this technology in neurology has been limited due to the challenges with penetrating the skull, thus limiting a prompt translation as has been seen in treating pathologies in other organs, such as breast and abdomen. Thanks to pivotal adjuncts such as multiconvergent transducers, magnetic resonance imaging (MRI) guidance, MRI thermometry, implantable transducers, and acoustic windows, focused ultrasound (FUS) is ready for prime-time applications in oncology and cerebrovascular neurology. In this review, we analyze the evolution of FUS from the beginning in 1950s to current state-of-the-art. We provide an overall picture of actual and future applications of FUS in oncology and cerebrovascular neurology reporting for each application the principal existing evidences.
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Affiliation(s)
- Francesco Prada
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA.
- Focused Ultrasound Foundation, Charlottesville, Virginia, USA.
| | - M Yashar S Kalani
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA
| | - Kaan Yagmurlu
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA
| | - Pedro Norat
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA
| | - Massimiliano Del Bene
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
- Department of Experimental Oncology, IRCCS European Institute of Oncology, Milan, Italy
| | - Francesco DiMeco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Neurological Surgery, Johns Hopkins Medical School, Baltimore, Maryland, USA
| | - Neal F Kassell
- Focused Ultrasound Foundation, Charlottesville, Virginia, USA
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Bonafede MM, Pohlman SK, Miller JD, Thiel E, Troeger KA, Miller CE. Women with Newly Diagnosed Uterine Fibroids: Treatment Patterns and Cost Comparison for Select Treatment Options. Popul Health Manag 2018; 21:S13-S20. [PMID: 29649369 DOI: 10.1089/pop.2017.0151] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The primary objective of this study was to describe surgical treatment patterns among women with newly diagnosed uterine fibroids (UF). A secondary objective was to estimate the medical costs associated with other common surgical interventions for UF. Claims-based commercial and Medicare data (2011-2016) were used to identify women aged ≥30 years with continuous enrollment for at least 12 months before and after a new diagnosis of UF. Receipt of a surgical or radiologic procedure (hysterectomy, myomectomy, endometrial ablation, uterine artery embolization, and curettage) was the primary outcome. Health care resource utilization and costs were calculated for women with at least 12 months of continuous enrollment following a UF surgical procedure. Among women who met selection criteria, 31.7% of patients underwent a surgical procedure; 20.9% of these underwent hysterectomy. An increase was observed over time in the percentage of women undergoing outpatient hysterectomy (from 27.0% to 40.2%) and hysteroscopic myomectomy (from 8.0% to 11.5%). The cost analysis revealed that total health care costs for hysteroscopic myomectomy ($17,324) were significantly lower (P < 0.001) than those for women who underwent inpatient hysterectomy ($24,027) and those for women undergoing the 3 comparison procedures. Hysterectomy was the most common surgical intervention. Patients undergoing inpatient hysterectomy had the highest health care costs. Although less expensive, minimally invasive approaches are becoming more common; they are performed infrequently in patients with newly diagnosed UF. The results of this study may be useful in guiding decisions regarding the most appropriate and cost-effective surgical treatment for UF.
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Affiliation(s)
| | | | - Jeffrey D Miller
- 1 Truven Health Analytics, an IBM Company , Cambridge, Massachusetts
| | - Ellen Thiel
- 1 Truven Health Analytics, an IBM Company , Cambridge, Massachusetts
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Comparative Assessment of Patient Preferences and Tolerability in Barrett Esophagus Screening: Results From a Randomized Trial. J Clin Gastroenterol 2018; 52:880-884. [PMID: 29369237 PMCID: PMC6056346 DOI: 10.1097/mcg.0000000000000991] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
GOALS To determine patient preference for the Barrett esophagus (BE) screening techniques. BACKGROUND Sedated esophagogastroduodenoscopy (sEGD) and unsedated transnasal endoscopy (uTNE) are both potential techniques for BE screening. However, systematic assessment of patient preference for these 2 techniques is lacking. As part of a comparative effectiveness randomized trial of BE screening modalities, we measured short-term patient preferences for the following approaches: in-clinic uTNE (huTNE), mobile-based uTNE (muTNE), and sEGD using a novel assessment instrument. STUDY Consenting community patients without known BE were randomly assigned to receive huTNE, muTNE, or sEGD, followed by a telephone administered preference and tolerability assessment instrument 24 hours after study procedures. Patient preference was measured by the waiting trade-off method. RESULTS In total, 201 patients completed screening with huTNE (n=71), muTNE (n=71), or sEGD (n=59), and a telephone interview. Patients' preferences for sEGD and uTNE using the waiting trade-off method were comparable (P=0.51). Although tolerability scores were superior for sEGD (P<0.001) compared with uTNE, scores for uTNE examinations were acceptable. CONCLUSIONS Patient preference is comparable between sEGD and uTNE for diagnostic examinations conducted in an endoscopy suite or in a mobile setting. Given acceptable tolerability, uTNE may be a viable alternative to sEGD for BE screening.
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Fortin C, Flyckt R, Falcone T. Alternatives to hysterectomy: The burden of fibroids and the quality of life. Best Pract Res Clin Obstet Gynaecol 2017; 46:31-42. [PMID: 29157931 DOI: 10.1016/j.bpobgyn.2017.10.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 10/06/2017] [Indexed: 01/21/2023]
Abstract
Uterine fibroids are the most common benign tumor in reproductive-aged women. While the majority of women are asymptomatic, those with symptoms may suffer from abnormal uterine bleeding, infertility, pelvic pain or pressure, and urinary dysfunction. Fibroids represent a significant healthcare burden for women and society as a whole. Women with fibroids have compromised overall quality of life and impairment in many specific domains including work productivity, sexuality, self-image, relationships, and social emotional and physical well-being. Many women are reluctant to ask for help and delay seeking treatment. To date, myomectomy remains the gold standard for treating fibroid-related symptoms in reproductive-aged women. However, many less invasive uterine preserving approaches have been developed. Quality of life is improved in many women following treatment for fibroids. This article aims to provide an overview of the substantial impact of fibroids on health-related quality of life.
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Affiliation(s)
- Chelsea Fortin
- Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rebecca Flyckt
- Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tommaso Falcone
- Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA.
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10
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Knudsen NI, Wernecke KD, Siedentopf F, David M. Fears and Concerns of Patients with Uterine Fibroids - a Survey of 807 Women. Geburtshilfe Frauenheilkd 2017; 77:976-983. [PMID: 28959061 DOI: 10.1055/s-0043-118132] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 08/04/2017] [Accepted: 08/06/2017] [Indexed: 02/07/2023] Open
Abstract
STUDY QUESTIONS What specific fears and concerns do patients with uterine fibroids have? How are these influenced by sociodemographic factors, duration of condition and level of knowledge among these women? METHODS Between January 2016 and January 2017 807 patients were consecutively surveyed at a university hospital speciality fibroid clinic using a two page locally developed and validated questionnaire focusing on fibroid-associated fears and concerns. RESULTS The questionnaire was completed by 730 women (90.5%) the majority of whom reported fears/concerns mainly with regards to treatment (need to treat/side-effects/hysterectomy) and the fibroids themselves (increasing size and number). Various parameters influenced the type and severity of fears: Young patients (< 40 years) had concerns particularly with regard to pregnancy/birthing while older patients (> 40 years) were more concerned about general health and significant blood loss. Time interval since diagnosis also affected fears with different concerns between patients with shorter duration of diagnosis (< 12 months) vs. longer duration (> 12 months). Overall only slight differences could be attributed to immigrant background. Higher level of education correlated with less anxiety. Proper information about fibroids relieved fears of malignant change in particular. Doctors and the internet were the most important sources of patient information. CONCLUSIONS Due to the benign nature of uterine fibroids and their good treatability, fibroid-associated fears are generally unfounded. Precise knowledge of patient fears and concerns should be integrated into clinical care with targeted psychological support to help patients better understand their condition.
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Affiliation(s)
- Nina Isabelle Knudsen
- Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Klinik für Gynäkologie, Berlin
| | - Klaus-D Wernecke
- Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Klinik für Gynäkologie, Berlin.,SOSTANA GmbH, Berlin, Germany
| | - Friederike Siedentopf
- Martin Luther-Krankenhaus Berlin, Brustzentrum/Klinik für Gynäkologie und Geburtshilfe, Berlin, Germany
| | - Matthias David
- Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Klinik für Gynäkologie, Berlin
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11
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The Rising Phoenix-Progesterone as the Main Target of the Medical Therapy for Leiomyoma. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4705164. [PMID: 29312996 PMCID: PMC5615958 DOI: 10.1155/2017/4705164] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 08/06/2017] [Indexed: 11/17/2022]
Abstract
Leiomyomas, also known as uterine fibroids, are a common benign tumor in women of reproductive age. These lesions disrupt the function of the uterus causing menorrhagia and pelvic pressure as well as reproductive disorders. These women pose a true challenge for clinicians in the attempt of choosing the suitable treatment for each patient. Patient's age, interest in fertility preservation, and leiomyoma location and size are all factors to be taken into account when deciding upon the preferable therapeutic option. For the past few decades, surgical treatment was the only reliable long-term treatment available. A variety of surgical approaches have been developed over the years but these developments have come at the expense of other treatment options. The classical medical treatment includes gonadotropin-releasing hormone (GnRH) agonists and antagonists. These agents are well known for their limited clinical effect as well as their broad spectrum of side effects, inspiring a need for new pharmacological treatments. In recent years, promising results have been reported with the use of selective progesterone receptor modulators (SPRM). Long-term clinical trials have shown a reduction in bleeding and shrinkage of leiomyoma mass. These results instill hope for women suffering from symptomatic leiomyomas seeking an effective, long-term medical option for their condition.
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Ogwulu CB, Jackson LJ, Kinghorn P, Roberts TE. A Systematic Review of the Techniques Used to Value Temporary Health States. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:1180-1197. [PMID: 28964452 DOI: 10.1016/j.jval.2017.03.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 02/10/2017] [Accepted: 03/11/2017] [Indexed: 05/25/2023]
Abstract
BACKGROUND A broad literature on health state utility values exists, but compared with chronic health states (HSs), issues surrounding the valuation of temporary health states (THSs) have been poorly explored. OBJECTIVES To assess the methods used by previous studies to value HSs that are considered temporary so as to determine the strengths and limitations associated with various approaches and to inform future study designs. METHODS A systematic review was undertaken to explore the methods used, assess how the valuation was conducted for diseases that might lead to HSs deemed as temporary, and identify the challenges encountered in the valuation of THSs. RESULTS Of the 36 relevant studies, 22 were explicit that the HS being valued was temporary. Most of the studies used more than one technique (often incorporating both conventional and adapted approaches). In using adapted techniques, the primary challenge was identifying an appropriate intermediate "anchor" HS and the possibility of negative utilities. CONCLUSIONS There is no agreement on the most methodologically robust approach to THS valuation. Valuation is complex and important issues relating to the validity, practicality, and reliability of the techniques used were not adequately covered by most of the studies identified.
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Affiliation(s)
- Chidubem B Ogwulu
- Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Louise J Jackson
- Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Philip Kinghorn
- Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Tracy E Roberts
- Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, UK.
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Swan JS, Pandharipande PV, Salazar GM. Developing a Patient-Centered Radiology Process Model. J Am Coll Radiol 2016; 13:510-6. [DOI: 10.1016/j.jacr.2015.11.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 11/20/2015] [Accepted: 11/20/2015] [Indexed: 11/25/2022]
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Fischer K, McDannold NJ, Tempany CM, Jolesz FA, Fennessy FM. Potential of minimally invasive procedures in the treatment of uterine fibroids: a focus on magnetic resonance-guided focused ultrasound therapy. Int J Womens Health 2015; 7:901-12. [PMID: 26622192 PMCID: PMC4654554 DOI: 10.2147/ijwh.s55564] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Minimally invasive treatment options are an important part of the uterine fibroid-treatment arsenal, especially among younger patients and in those who plan future pregnancies. This article provides an overview of the currently available minimally invasive therapy options, with a special emphasis on a completely noninvasive option: magnetic resonance-guided focused ultrasound (MRgFUS). In this review, we describe the background of MRgFUS, the patient-selection criteria for MRgFUS, and how the procedure is performed. We summarize the published clinical trial results, and review the literature on pregnancy post-MRgFUS and on the cost-effectiveness of MRgFUS.
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Affiliation(s)
- Krisztina Fischer
- Department of Radiology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA ; Renal Division, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA ; Biomedical Engineering Division, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Nathan J McDannold
- Department of Radiology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Clare M Tempany
- Department of Radiology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Ferenc A Jolesz
- Department of Radiology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Fiona M Fennessy
- Department of Radiology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA ; Department of Radiology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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Wright JD, Cui RR, Wang A, Chen L, Tergas AI, Burke WM, Ananth CV, Hou JY, Neugut AI, Temkin SM, Wang YC, Hershman DL. Economic and Survival Implications of Use of Electric Power Morcellation for Hysterectomy for Presumed Benign Gynecologic Disease. J Natl Cancer Inst 2015; 107:djv251. [PMID: 26449386 PMCID: PMC4849362 DOI: 10.1093/jnci/djv251] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 03/19/2015] [Accepted: 08/06/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Electric power morcellation during laparoscopic hysterectomy allows some women to undergo minimally invasive surgery but may disrupt underlying occult malignancies and increase the risk of tumor dissemination. METHODS We developed a state transition Markov cohort simulation model of the risks and benefits of hysterectomy (abdominal, laparoscopic, and laparoscopic with electric power morcellation) for women with presumed benign gynecologic disease. The model considered perioperative morbidity, mortality, risk of cancer and dissemination, and outcomes in women with an underlying malignancy. We explored the effectiveness from a societal perspective stratified by age (<40, 40-49, 50-59, and ≥60 years). RESULTS Under all scenarios, modeled laparoscopic hysterectomy without morcellation was the most beneficial strategy. Laparoscopic hysterectomy with morcellation was associated with 80.83 more intraoperative complications, 199.64 fewer perioperative complications, and 241.80 fewer readmissions than abdominal hysterectomy per 10 000 women. Per 10 000 women younger than age 40 years, laparoscopic hysterectomy with morcellation was associated with 1.57 more cases of disseminated cancer and 0.97 fewer deaths than abdominal hysterectomy. The excess cases of disseminated cancer per 10 000 women with morcellation compared with abdominal hysterectomy increased with age to 47.54 per 10 000 in women age 60 years and older. Compared with abdominal hysterectomy, this resulted in 0.30 (age 40-49 years), 5.07 (age 50-59 years), and 18.14 (age 60 years and older) excess deaths per 10 000 women in the respective age groups. CONCLUSION Laparoscopic hysterectomy without morcellation is the most beneficial approach of the three methods of hysterectomy studied. In older women, the risks of electric power morcellation may outweigh the benefits of minimally invasive hysterectomy.
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Affiliation(s)
- Jason D Wright
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT).
| | - Rosa R Cui
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
| | - Anqi Wang
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
| | - Ling Chen
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
| | - Ana I Tergas
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
| | - William M Burke
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
| | - Cande V Ananth
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
| | - June Y Hou
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
| | - Alfred I Neugut
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
| | - Sarah M Temkin
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
| | - Y Claire Wang
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
| | - Dawn L Hershman
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
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Ghant MS, Sengoba KS, Recht H, Cameron KA, Lawson AK, Marsh EE. Beyond the physical: a qualitative assessment of the burden of symptomatic uterine fibroids on women's emotional and psychosocial health. J Psychosom Res 2015; 78:499-503. [PMID: 25725565 DOI: 10.1016/j.jpsychores.2014.12.016] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2014] [Revised: 12/24/2014] [Accepted: 12/24/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To qualitatively assess the burden of uterine fibroids on women's emotional health. METHODS Sixty women (n = 60) with symptomatic uterine fibroids were recruited from an urban academic medical center and community-based organizations. Women completed qualitative, semi-structured interviews and demographic surveys. Interviews were recorded and transcribed verbatim. Using a grounded theory approach, three coders independently identified major themes and subthemes that emerged from the interviews. RESULTS The kappa among coders was 0.94. The mean age of participants was 43.0 ± 6.8. 61.7% of participants self-identified as African-American, 25.0% as Caucasian, 8.3% as Hispanic and 5.0% as Asian. Most participants exhibited a significant emotional response to their fibroids, including fear, anxiety, anger, and depression. Half of the women felt helpless and believed that they had no control over their fibroids. Many women possessed a negative self-image and cited concern over appearing less attractive, which led to difficulties becoming intimate. Several women felt that they lacked substantial support to help them deal with these issues. CONCLUSION In addition to the known high prevalence and severe physical impact of uterine fibroids, there is a significant psychological impact on women. Many women lack support to help them deal with these issues and very few seek help from a mental health professional. There is an opportunity and a need for the mental health community to address the concerns in this population, in order to improve psychological health and quality of life in patients living with this chronic condition.
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Affiliation(s)
- Marissa S Ghant
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611 USA
| | - Katherine S Sengoba
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611 USA
| | - Hannah Recht
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611 USA
| | - Kenzie A Cameron
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Angela K Lawson
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611 USA
| | - Erica E Marsh
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611 USA.
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Babashov V, Palimaka S, Blackhouse G, O'Reilly D. Magnetic Resonance-Guided High-Intensity Focused Ultrasound (MRgHIFU) for Treatment of Symptomatic Uterine Fibroids: An Economic Analysis. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2015; 15:1-61. [PMID: 26357531 PMCID: PMC4558770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Uterine fibroids, or leiomyomas, are the most common benign tumours in women of childbearing age. Some women experience symptoms (e.g., heavy bleeding) that require aggressive forms of treatment such as uterine artery embolization (UAE), myomectomy, magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU), and even hysterectomy. It is important to note that hysterectomy is not appropriate for women who desire future childbearing. OBJECTIVES The objective of this analysis was to evaluate the cost-effectiveness and budgetary impact of implementing MRgHIFU as a treatment option for symptomatic uterine fibroids in premenopausal women for whom drugs have been ineffective. REVIEW METHODS We performed an original cost-effectiveness analysis to assess the long-term costs and effects of MRgHIFU compared with hysterectomy, myomectomy, and UAE as a strategy for treating symptomatic uterine fibroids in premenopausal women aged 40 to 51 years. We explored a number of scenarios, e.g., comparing MRgHIFU with uterine-preserving procedures only, considering MRgHIFU-eligible patients only, and eliminating UAE as a treatment option. In addition, we performed a one-year budget impact analysis, using data from Ontario administrative sources. Four scenarios were explored in the budgetary impact analysis: •MRgHIFU funded at 2 centres •MRgHIFU funded at 2 centres and replacing only uterine-preserving procedures •MRgHIFU funded at 6 centres •MRgHIFU funded at 6 centres and replacing only uterine-preserving procedures Analyses were conducted from the Ontario public payer perspective. RESULTS The base case determined that the uterine artery embolization (UAE) treatment strategy was the cost-effective option at commonly accepted willingness-to-pay values. Compared with hysterectomy, UAE was calculated as having an incremental cost-effectiveness ratio (ICER) of $46,480 per quality-adjusted life-year (QALY) gained. The MRgHIFU strategy was extendedly dominated by a combination of UAE and hysterectomy, and myomectomy was strictly dominated by MRgHIFU and UAE. In the scenario where only MRgHIFU-eligible patients were considered, MRgHIFU was the cost-effective option for a willingness-to-pay threshold of $50,000. In the scenario where only MRgHIFU-eligible patients were considered and where UAE was eliminated as a treatment option (due to its low historic utilization in Ontario), MRgHIFU was cost-effective with an incremental cost of $39,250 per additional QALY. The budgetary impact of funding MRgHIFU for treatment of symptomatic uterine fibroids was estimated at $1.38 million in savings when funded to replace all types of procedures at 2 centres, and $1.14 million when funded to replace only uterine-preserving procedures at 2 centres. The potential savings increase to $4.15 million when MRgHIFU is funded at 6 centres to treat all women eligible for the procedure. Potential savings at 6 centres decrease slightly, to $3.42 million, when MRgHIFU is funded to replace uterine-preserving procedures only. CONCLUSIONS Our findings suggest that MRgHIFU may be a cost-effective strategy at commonly accepted willingness-to-pay thresholds, after examining the uncertainty in model parameters and several likely scenarios. In terms of budget impact, the implementation of MRgHIFU could potentially result in one-year savings of $1.38 million and $4.15 million in the scenarios where MRgHIFU is implemented in 2 or 6 centres, respectively. From a patient perspective, it is important to consider that MRgHIFU is the least invasive of all fibroid treatment options for women who have not responded to pharmaceuticals; it is the only one that is completely noninvasive. Also important, from a societal point of view, is the potential benefit from faster recovery times. Despite these benefits, implementation of MRgHIFU beyond the 2 centres which currently offer the treatment faces logistical challenges (for example, competing demands for use of existing equipment), as well as financial challenges, with hospitals needing to fundraise to purchase new equipment.
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MRI-guided focused ultrasound surgery for uterine fibroid treatment: a cost-effectiveness analysis. AJR Am J Roentgenol 2014; 203:361-71. [PMID: 25055272 DOI: 10.2214/ajr.13.11446] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. The purpose of this article is to evaluate the cost effectiveness of a treatment strategy for symptomatic uterine fibroids that uses MRI-guided focused ultrasound as a first-line therapy relative to uterine artery embolization (UAE) or hysterectomy. MATERIALS AND METHODS. We developed a decision-analytic model to compare the cost effectiveness of three first-line treatment strategies: MRI-guided focused ultrasound, UAE, and hysterectomy. Treatment-specific short- and long-term utilities, lifetime costs, and quality-adjusted life years (QALYs) were incorporated, allowing us to conduct an incremental cost-effectiveness analysis, using a societal willingness-to-pay (WTP) threshold of $50,000/QALY to designate a strategy as cost effective. Sensitivity analyses were subsequently performed on all key parameters. RESULTS. In the base-case analysis, UAE as a first-line treatment of symptomatic fibroids was the most effective and expensive strategy (22.75 QALYs; $22,968), followed by MRI-guided focused ultrasound (22.73 QALYs; $20,252) and hysterectomy (22.54 QALYs; $11,253). MRI-guided focused ultrasound was cost effective relative to hysterectomy, with an associated incremental cost-effectiveness ratio (ICER) of $47,891/QALY. The ICER of UAE relative to MRI-guided focused ultrasound was $234,565/QALY, exceeding the WTP threshold of $50,000/QALY, therefore rendering MRI-guided focused ultrasound also cost effective relative to UAE. In sensitivity analyses, results were robust to changes in most parameters but were sensitive to changes in probabilities of recurrence, symptom relief, and quality-of-life measures. CONCLUSION. First-line treatment of eligible women with MRI-guided focused ultra-sound is a cost-effective noninvasive strategy. For those not eligible for MRI-guided focused ultra-sound, UAE remains a cost-effective option. These recommendations integrate both the short- and long-term decrements in quality of life associated with the specific treatment modalities.
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Cain-Nielsen AH, Moriarty JP, Stewart EA, Borah BJ. Cost-effectiveness of uterine-preserving procedures for the treatment of uterine fibroid symptoms in the USA. J Comp Eff Res 2014; 3:503-14. [PMID: 24878319 PMCID: PMC4213230 DOI: 10.2217/cer.14.32] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To evaluate the cost-effectiveness of the following three treatments of uterine fibroids in a population of premenopausal women who wish to preserve their uteri: myomectomy, magnetic resonance-guided focused ultrasound (MRgFUS) and uterine artery embolization (UAE). MATERIALS & METHODS A decision analytic Markov model was constructed. Cost-effectiveness was calculated in terms of US$ per quality-adjusted life year (QALY) over 5 years. Two types of costs were calculated: direct costs only, and the sum of direct and indirect (productivity) costs. Women in the hypothetical cohort were assessed for treatment type eligibility, were treated based on eligibility, and experienced adequate or inadequate symptom relief. Additional treatment (myomectomy) occurred for inadequate symptom relief or recurrence. Sensitivity analysis was conducted to evaluate uncertainty in the model parameters. RESULTS In the base case, myomectomy, MRgFUS and UAE had the following combinations of mean cost and mean QALYs, respectively: US$15,459, 3.957; US$15,274, 3.953; and US$18,653, 3.943. When incorporating productivity costs, MRgFUS incurred a mean cost of US$21,232; myomectomy US$22,599; and UAE US$22,819. Using probabilistic sensitivity analysis (PSA) and excluding productivity costs, myomectomy was cost effective at almost every decision threshold. Using PSA and incorporating productivity costs, myomectomy was cost effective at decision thresholds above US$105,000/QALY; MRgFUS was cost effective between US$30,000 and US$105,000/QALY; and UAE was cost effective below US$30,000/QALY. CONCLUSION Myomectomy, MRgFUS, and UAE were similarly effective in terms of QALYs gained. Depending on assumptions about costs and willingness to pay for additional QALYs, all three treatments can be deemed cost effective in a 5-year time frame.
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Affiliation(s)
- Anne H. Cain-Nielsen
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - James P. Moriarty
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
| | - Elizabeth A. Stewart
- Division of Reproductive Endocrinology & Infertility, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
- College of Medicine, Mayo Clinic, Rochester, MN
| | - Bijan J. Borah
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
- College of Medicine, Mayo Clinic, Rochester, MN
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Lee CI, Jarvik JG. Patient-centered outcomes research in radiology: trends in funding and methodology. Acad Radiol 2014; 21:1156-61. [PMID: 24998691 DOI: 10.1016/j.acra.2014.01.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 01/27/2014] [Accepted: 01/28/2014] [Indexed: 10/25/2022]
Abstract
The creation of the Patient-Centered Outcomes Research Trust Fund and the Patient-Centered Outcomes Research Institute (PCORI) through the Patient Protection and Affordable Care Act of 2010 presents new opportunities for funding patient-centered comparative effectiveness research (CER) in radiology. We provide an overview of the evolution of federal funding and priorities for CER with a focus on radiology-related priority topics over the last two decades, and discuss the funding processes and methodological standards outlined by PCORI. We introduce key paradigm shifts in research methodology that will be required on the part of radiology health services researchers to obtain competitive federal grant funding in patient-centered outcomes research. These paradigm shifts include direct engagement of patients and other stakeholders at every stage of the research process, from initial conception to dissemination of results. We will also discuss the increasing use of mixed methods and novel trial designs. One of these trial designs, the pragmatic trial, has the potential to be readily applied to evaluating the effectiveness of diagnostic imaging procedures and imaging-based interventions among diverse patient populations in real-world settings.
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Outcome of uterine artery embolization versus MR-guided high-intensity focused ultrasound treatment for uterine fibroids: long-term results. Eur J Radiol 2013; 82:2265-9. [PMID: 24075785 DOI: 10.1016/j.ejrad.2013.08.045] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 08/19/2013] [Accepted: 08/23/2013] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To compare the long-term outcome after uterine artery embolization (UAE) versus magnetic resonance-guided high-intensity focused ultrasound (MR-g HIFU) for symptomatic uterine fibroids. METHODS Seventy-seven women (median age, 39.3 years; range, 29.2-52.2 years) with symptomatic uterine fibroids, equally eligible for UAE and MR-g HIFU based on our exclusion criteria underwent treatment (UAE, N = 41; MR-g HIFU, N = 36) from 2002 to 2009 at our institution. Symptom severity (SS) and total health-related quality of life (Total HRQoL) scores were assessed by the uterine fibroid symptom and quality of life (UFS-QoL) questionnaire before treatment and at long-term follow-up after UAE (median 61.9 months) and after MR-g HIFU (median: 60.7 months). Re-intervention rates were assessed for each therapy and compared. RESULTS Re-intervention was significantly lower after UAE (12.2%) than after MR-g HIFU (66.7%) at long-term follow-up (p<0.001). After UAE changes in SS (50 pre-treatment vs. 6.3 post-treatment) and Total HRQoL (57.8 pre-treatment vs. 100 post-treatment) were significantly better than changes in SS (42.2 pre-treatment vs. 26.6 post-treatment) and Total HRQoL score (66.4 pre-treatment vs. 87.9 post-treatment) after MR-g HIFU (p = 0.019 and 0.049 respectively). CONCLUSIONS Improvement of SS and Total HRQoL scores was significantly better after UAE resulting in a significant lower re-intervention rate compared to MR-g HIFU.
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Fennessy FM, Tempany CM. An Update on Magnetic Resonance Guided Focused Ultrasound Surgery (MRgFUS) of Uterine Fibroids. CURRENT RADIOLOGY REPORTS 2013. [DOI: 10.1007/s40134-013-0015-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Midterm Results after Uterine Artery Embolization Versus MR-Guided High-Intensity Focused Ultrasound Treatment for Symptomatic Uterine Fibroids. Cardiovasc Intervent Radiol 2013; 36:1508-1513. [DOI: 10.1007/s00270-013-0582-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 01/12/2013] [Indexed: 01/20/2023]
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Medel R, Monteith SJ, Elias WJ, Eames M, Snell J, Sheehan JP, Wintermark M, Jolesz FA, Kassell NF. Magnetic resonance-guided focused ultrasound surgery: Part 2: A review of current and future applications. Neurosurgery 2013; 71:755-63. [PMID: 22791029 DOI: 10.1227/neu.0b013e3182672ac9] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Magnetic resonance-guided focused ultrasound surgery (MRgFUS) is a novel combination of technologies that is actively being realized as a noninvasive therapeutic tool for a myriad of conditions. These applications are reviewed with a focus on neurological use. A combined search of PubMed and MEDLINE was performed to identify the key events and current status of MRgFUS, with a focus on neurological applications. MRgFUS signifies a potentially ideal device for the treatment of neurological diseases. As it is nearly real time, it allows monitored provision of treatment location and energy deposition; is noninvasive, thereby limiting or eliminating disruption of normal tissue; provides focal delivery of therapeutic agents; enhances radiation delivery; and permits modulation of neural function. Multiple clinical applications are currently in clinical use and many more are under active preclinical investigation. The therapeutic potential of MRgFUS is expanding rapidly. Although clinically in its infancy, preclinical and early-phase I clinical trials in neurosurgery suggest a promising future for MRgFUS. Further investigation is necessary to define its true potential and impact.
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Affiliation(s)
- Ricky Medel
- Department of Neurosurgery, University of Virginia Health Sciences Center, University of University, Charlottesville, Virginia 22902, USA
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Carlos RC, Buist DSM, Wernli KJ, Swan JS. Patient-centered outcomes in imaging: quantifying value. J Am Coll Radiol 2012; 9:725-8. [PMID: 23025867 PMCID: PMC3810945 DOI: 10.1016/j.jacr.2012.06.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 06/07/2012] [Indexed: 11/16/2022]
Abstract
The Patient-Centered Outcomes Research Institute was created in response to a mandate to conduct comparative effectiveness research in clinical care to inform decision making. The institute will be funded by the Patient-Centered Outcomes Research Trust Fund, through congressional set-asides, and by Medicare and private health insurers, through a per beneficiary fee. The institute is governed by a board with a broad stakeholder constitution. Key committees set the national agenda for patient-centered outcomes research, the agenda for funding priorities, and communication and dissemination of the evidence with the goal of increasing the rate of implementation of the evidence into policy. In imaging, patient-centered outcomes go beyond the traditional metrics of patient satisfaction. Instead, these outcomes need to encompass the benefits and harms, focus on outcomes relevant to patients, and provide information to inform decision making. Therefore, radiologists need to be involved as stakeholders in the design, conduct, and dissemination of this research.
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Affiliation(s)
- Ruth C Carlos
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA.
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Dageforde LA, Landman MP, Feurer ID, Poulose B, Pinson CW, Moore DE. A Cost-Effectiveness Analysis of Early vs Late Reconstruction of Iatrogenic Bile Duct Injuries. J Am Coll Surg 2012; 214:919-27. [PMID: 22495064 DOI: 10.1016/j.jamcollsurg.2012.01.054] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Revised: 01/23/2012] [Accepted: 01/23/2012] [Indexed: 01/07/2023]
Affiliation(s)
- Leigh Anne Dageforde
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232-4753, USA
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Fennessy FM, Tempany CM, Jolesz FA, Stewart EA. Re: "ACR Appropriateness Criteria® on treatment of uterine leiomyomas". J Am Coll Radiol 2011; 8:e1-2; author reply e2-3. [PMID: 21889739 DOI: 10.1016/j.jacr.2011.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 06/13/2011] [Indexed: 11/30/2022]
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