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Lamsal R, Yeh EA, Pullenayegum E, Ungar WJ. A Systematic Review of Methods and Practice for Integrating Maternal, Fetal, and Child Health Outcomes, and Family Spillover Effects into Cost-Utility Analyses. PHARMACOECONOMICS 2024:10.1007/s40273-024-01397-5. [PMID: 38819718 DOI: 10.1007/s40273-024-01397-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/12/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Maternal-perinatal interventions delivered during pregnancy or childbirth have unique characteristics that impact the health-related quality of life (HRQoL) of the mother, fetus, and newborn child. However, maternal-perinatal cost-utility analyses (CUAs) often only consider either maternal or child health outcomes. Challenges include, but are not limited to, measuring fetal, newborn, and infant health outcomes, and assessing their impact on maternal HRQoL. It is also important to recognize the impact of maternal-perinatal health on family members' HRQoL (i.e., family spillover effects) and to incorporate these effects in maternal-perinatal CUAs. OBJECTIVE The aim was to systematically review the methods used to include health outcomes of pregnant women, fetuses, and children and to incorporate family spillover effects in maternal-perinatal CUAs. METHODS A literature search was conducted in Medline, Embase, EconLit, Cochrane Collection, Cumulative Index to Nursing and Allied Health Literature (CINAHL), International Network of Agencies for Health Technology Assessment (INAHTA), and the Pediatric Economic Database Evaluation (PEDE) databases from inception to 2020 to identify maternal-perinatal CUAs that included health outcomes for pregnant women, fetuses, and/or children. The search was updated to December 2022 using PEDE. Data describing how the health outcomes of mothers, fetuses, and children were measured, incorporated, and reported along with the data on family spillover effects were extracted. RESULTS Out of 174 maternal-perinatal CUAs identified, 62 considered the health outcomes of pregnant women, and children. Among the 54 quality-adjusted life year (QALY)-based CUAs, 12 included fetal health outcomes, the impact of fetal loss on mothers' HRQoL, and the impact of neonatal demise on mothers' HRQoL. Four studies considered fetal health outcomes and the effects of fetal loss on mothers' HRQoL. One study included fetal health outcomes and the impact of neonatal demise on maternal HRQoL. Furthermore, six studies considered the impact of neonatal demise on maternal HRQoL, while four included fetal health outcomes. One study included the impact of fetal loss on maternal HRQoL. The remaining 26 only included the health outcomes of pregnant women and children. Among the eight disability-adjusted life year (DALY)-based CUAs, two measured fetal health outcomes. Out of 174 studies, only one study included family spillover effects. The most common measurement approach was to measure the health outcomes of pregnant women and children separately. Various approaches were used to assess fetal losses in terms of QALYs or DALYs and their impact on HRQoL of mothers. The most common integration approach was to sum the QALYs or DALYs for pregnant women and children. Most studies reported combined QALYs and incremental QALYs, or DALYs and incremental DALYs, at the family level for pregnant women and children. CONCLUSIONS Approximately one-third of maternal-perinatal CUAs included the health outcomes of pregnant women, fetuses, and/or children. Future CUAs of maternal-perinatal interventions, conducted from a societal perspective, should aim to incorporate health outcomes for mothers, fetuses, and children when appropriate. The various approaches used within these CUAs highlight the need for standardized measurement and integration methods, potentially leading to rigorous and standardized inclusion practices, providing higher-quality evidence to better inform decision-makers about the costs and benefits of maternal-perinatal interventions. Health Technology Assessment agencies may consider providing guidance for interventions affecting future lives in future updates.
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Affiliation(s)
- Ramesh Lamsal
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - E Ann Yeh
- Division of Neurology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, Canada
| | - Eleanor Pullenayegum
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Wendy J Ungar
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
- The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay Street, 11th Floor, Toronto, ON, M5G 0A4, Canada.
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Jackson H, Grzeskowiak L, Enticott J, Wise S, Callander E. How the structural determinants of health inequities impact access to prescription medication for pregnant women in Australia: a narrative review. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 42:100934. [PMID: 38357390 PMCID: PMC10865029 DOI: 10.1016/j.lanwpc.2023.100934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 09/06/2023] [Accepted: 09/21/2023] [Indexed: 02/16/2024]
Abstract
Structural factors that contribute to health disparities (e.g., population-level policies, cultural norms) impact the distribution of resources in society and can affect medication accessibility; even in high-income countries like Australia. Industry practices and regulatory approaches (e.g., a conservative approach to testing medicines in pregnant women) influence the availability of safety and efficacy data necessary for the licencing and funding of prescription medications used during pregnancy. Consequently, pregnant women may be prescribed medications outside of regulatory or funder-approved indications, posing risks for both prescribers and pregnant women and potentially compromising equitable access to medications. This review examines the regulatory and legislative structural factors that contribute to health disparities and perpetuate the deeply ingrained social norm that we should be protecting pregnant women from clinical research rather than safeguarding them through such research. Addressing these challenges requires a renewed commitment to integrated, woman-centred maternal healthcare and strengthened collaboration across all sectors. Funding Australian Government Research Training Program Stipend from the University of Technology Sydney, National Health and Medical Research Council (NHMRC) Fellowship, Channel 7 Children's Research Foundation Fellowship (CRF-210323).
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Affiliation(s)
- Hannah Jackson
- School of Public Health, Faculty of Health, University of Technology Sydney, New South Wales, Australia
| | - Luke Grzeskowiak
- College of Medicine and Public Health, Flinders University, South Australia, Australia
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, South Australia, Australia
| | - Joanne Enticott
- Monash Centre for Health Research and Implementation (MCHRI), Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Sarah Wise
- School of Public Health, Faculty of Health, University of Technology Sydney, New South Wales, Australia
| | - Emily Callander
- School of Public Health, Faculty of Health, University of Technology Sydney, New South Wales, Australia
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Van Muylder A, D'Hooghe T, Luyten J. Economic Evaluation of Medically Assisted Reproduction: A Methodological Systematic Review. Med Decis Making 2023; 43:973-991. [PMID: 37621143 DOI: 10.1177/0272989x231188129] [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] [Indexed: 08/26/2023]
Abstract
BACKGROUND Medically assisted reproduction (MAR) is a challenging application area for health economic evaluations, entailing a broad range of costs and outcomes, stretching out long-term and accruing to several parties. PURPOSE To systematically review which costs and outcomes are included in published economic evaluations of MAR and to compare these with health technology assessment (HTA) prescriptions about which cost and outcomes should be considered for different evaluation objectives. DATA SOURCES HTA guidelines and systematic searches of PubMed Central, Embase, WOS CC, CINAHL, Cochrane (CENTRAL), HTA, and NHS EED. STUDY SELECTION All economic evaluations of MAR published from 2010 to 2022. DATA EXTRACTION A predetermined data collection form summarized study characteristics. Essential costs and outcomes of MAR were listed based on HTA and treatment guidelines for different evaluation objectives. For each study, included costs and outcomes were reviewed. DATA SYNTHESIS The review identified 93 cost-effectiveness estimates, of which 57% were expressed as cost-per-(healthy)-live-birth, 19% as cost-per-pregnancy, and 47% adopted a clinic perspective. Few adopted societal perspectives and only 2% used quality-adjusted life-years (QALYs). Broader evaluations omitted various relevant costs and outcomes related to MAR. There are several cost and outcome categories for which available HTA guidelines do not provide conclusive directions regarding inclusion or exclusion. LIMITATIONS Studies published before 2010 and of interventions not clearly labeled as MAR were excluded. We focus on methods rather than which MAR treatments are cost-effective. CONCLUSIONS Economic evaluations of MAR typically calculate a short-term cost-per-live-birth from a clinic perspective. Broader analyses, using cost-per-QALY or BCRs from societal perspectives, considering the full scope of reproduction-related costs and outcomes, are scarce and often incomplete. We provide a summary of costs and outcomes for future research guidance and identify areas requiring HTA methodological development. HIGHLIGHTS The cost-effectiveness of MAR procedures can be exceptionally complex to estimate as there is a broad range of costs and outcomes involved, in principle stretching out over multiple generations and over many stakeholders.We list 21 key areas of costs and outcomes of MAR. Which of these needs to be accounted for alters for different evaluation objectives (determined by the type of economic evaluation, time horizon considered, and perspective).Published studies mostly investigate cost-effectiveness in the very short-term, from a clinic perspective, expressed as cost-per-live-birth. There is a lack of comprehensive economic evaluations that adopt a broader perspective with a longer time horizon. The broader the evaluation objective, the more relevant costs and outcomes were excluded.For several costs and outcomes, particularly those relevant for broader, societal evaluations of MAR, the inclusion or exclusion is theoretically ambiguous, and HTA guidelines do not offer sufficient guidance.
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Affiliation(s)
- Astrid Van Muylder
- Department Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium (AVM, JL); Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium (TD); Department of Obstetrics, Gynecology and Reproductive Sciences Yale School of Medicine, New Haven, CT, USA (TD); Global Medical Affairs Fertility, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany (TD). The review was written at the Leuven Institute for Healthcare Policy. It was presented at the ESHRE 38th Annual Meeting (Milan 2022). The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Astrid Van Muylder and Jeroen Luyten have no conflicting interests to declare. The participation of Thomas D'Hooghe to this publication is part of his academic work; he does not see a conflict of interest as Merck KGaA was not involved in writing this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We acknowledge an internal funding from KU Leuven for this study. The funding agreement ensured the authors' independence in designing the study, interpreting the data, writing, and publishing the report. The following authors are employed by the sponsor: Astrid Van Muylder and Jeroen Luyten
| | - Thomas D'Hooghe
- Department Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium (AVM, JL); Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium (TD); Department of Obstetrics, Gynecology and Reproductive Sciences Yale School of Medicine, New Haven, CT, USA (TD); Global Medical Affairs Fertility, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany (TD). The review was written at the Leuven Institute for Healthcare Policy. It was presented at the ESHRE 38th Annual Meeting (Milan 2022). The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Astrid Van Muylder and Jeroen Luyten have no conflicting interests to declare. The participation of Thomas D'Hooghe to this publication is part of his academic work; he does not see a conflict of interest as Merck KGaA was not involved in writing this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We acknowledge an internal funding from KU Leuven for this study. The funding agreement ensured the authors' independence in designing the study, interpreting the data, writing, and publishing the report. The following authors are employed by the sponsor: Astrid Van Muylder and Jeroen Luyten
| | - Jeroen Luyten
- Department Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium (AVM, JL); Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium (TD); Department of Obstetrics, Gynecology and Reproductive Sciences Yale School of Medicine, New Haven, CT, USA (TD); Global Medical Affairs Fertility, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany (TD). The review was written at the Leuven Institute for Healthcare Policy. It was presented at the ESHRE 38th Annual Meeting (Milan 2022). The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Astrid Van Muylder and Jeroen Luyten have no conflicting interests to declare. The participation of Thomas D'Hooghe to this publication is part of his academic work; he does not see a conflict of interest as Merck KGaA was not involved in writing this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We acknowledge an internal funding from KU Leuven for this study. The funding agreement ensured the authors' independence in designing the study, interpreting the data, writing, and publishing the report. The following authors are employed by the sponsor: Astrid Van Muylder and Jeroen Luyten
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Lohan M, Gillespie K, Aventin Á, Gough A, Warren E, Lewis R, Buckley K, McShane T, Brennan-Wilson A, Lagdon S, Adara L, McDaid L, French R, Young H, McDowell C, Logan D, Toase S, Hunter RM, Gabrio A, Clarke M, O'Hare L, Bonell C, Bailey JV, White J. School-based relationship and sexuality education intervention engaging adolescent boys for the reductions of teenage pregnancy: the JACK cluster RCT. PUBLIC HEALTH RESEARCH 2023; 11:1-139. [PMID: 37795864 DOI: 10.3310/ywxq8757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023] Open
Abstract
Background The need to engage boys in gender-transformative relationships and sexuality education (RSE) to reduce adolescent pregnancy is endorsed by the World Health Organization and the United Nations Educational, Scientific and Cultural Organization. Objectives To evaluate the effects of If I Were Jack on the avoidance of unprotected sex and other sexual health outcomes. Design A cluster randomised trial, incorporating health economics and process evaluations. Setting Sixty-six schools across the four nations of the UK. Participants Students aged 13-14 years. Intervention A school-based, teacher-delivered, gender-transformative RSE intervention (If I Were Jack) versus standard RSE. Main outcome measures Self-reported avoidance of unprotected sex (sexual abstinence or reliable contraceptive use at last sex) after 12-14 months. Secondary outcomes included knowledge, attitudes, skills, intentions and sexual behaviours. Results The analysis population comprised 6556 students: 86.6% of students in the intervention group avoided unprotected sex, compared with 86.4% in the control group {adjusted odds ratio 0.85 [95% confidence interval (CI) 0.58 to 1.26], p = 0.42}. An exploratory post hoc analysis showed no difference for sexual abstinence [78.30% intervention group vs. 78.25% control group; adjusted odds ratio 0.85 (95% CI 0.58 to 1.24), p = 0.39], but more intervention group students than control group students used reliable contraception at last sex [39.62% vs. 26.36%; adjusted odds ratio 0.52 (95% CI 0.29 to 0.920), p = 0.025]. Students in schools allocated to receive the intervention had significantly higher scores on knowledge [adjusted mean difference 0.18 (95% CI 0.024 to 0.34), p = 0.02], gender-equitable attitudes and intentions to avoid unintended pregnancy [adjusted mean difference 0.61 (95% CI 0.16 to 1.07), p = 0.01] than students in schools allocated to receive the control. There were positive but non-significant differences in sexual self-efficacy and communication skills. The total mean incremental cost of the intervention compared with standard RSE was £2.83 (95% CI -£2.64 to £8.29) per student. Over a 20-year time horizon, the intervention is likely to be cost-effective owing to its impact on unprotected sex because it would result in 379 (95% CI 231 to 477) fewer unintended pregnancies, 680 (95% CI 189 to 1467) fewer sexually transmitted infections and a gain of 10 (95% CI 5 to 16) quality-adjusted life-years per 100,000 students for a cost saving of £9.89 (95% CI -£15.60 to -£3.83). Limitations The trial is underpowered to detect some effects because four schools withdrew and the intraclass correlation coefficient (0.12) was larger than that in sample size calculation (0.01). Conclusions We present, to our knowledge, the first evidence from a randomised trial that a school-based, male engagement gender-transformative RSE intervention, although not effective in increasing avoidance of unprotected sex (defined as sexual abstinence or use of reliable contraception at last sex) among all students, did increase the use of reliable contraception at last sex among students who were, or became, sexually active by 12-14 months after the intervention. The trial demonstrated that engaging all adolescents early through RSE is important so that, as they become sexually active, rates of unprotected sex are reduced, and that doing so is likely to be cost-effective. Future work Future studies should consider the longer-term effects of gender-transformative RSE as students become sexually active. Gender-transformative RSE could be adapted to address broader sexual health and other settings. Trial registration This trial is registered as ISRCTN10751359. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (PHR 15/181/01) and will be published in full in Public Health Research; Vol. 11, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Maria Lohan
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Kathryn Gillespie
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Áine Aventin
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Aisling Gough
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Emily Warren
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
| | - Ruth Lewis
- Medical Research Council/Chief Scientist Office Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Kelly Buckley
- Centre for Development, Evaluation, Complexity and Implementation in Public Health Improvement, Cardiff University, Cardiff, UK
| | - Theresa McShane
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | | | - Susan Lagdon
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Linda Adara
- Centre for Development, Evaluation, Complexity and Implementation in Public Health Improvement, Cardiff University, Cardiff, UK
| | - Lisa McDaid
- Medical Research Council/Chief Scientist Office Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Rebecca French
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
| | - Honor Young
- Centre for Development, Evaluation, Complexity and Implementation in Public Health Improvement, Cardiff University, Cardiff, UK
| | | | | | - Sorcha Toase
- Northern Ireland Clinical Trials Unit, Belfast, UK
| | - Rachael M Hunter
- Health Economics Analysis and Research Methods Team, University College London, London, UK
| | - Andrea Gabrio
- Care and Public Health Research Institute (CAPHRI) School for Public Health and Primary Care, Maastricht University, Maastricht, the Netherlands
| | - Mike Clarke
- Northern Ireland Clinical Trials Unit, Belfast, UK
| | - Liam O'Hare
- School of Social Sciences, Education and Social Work, Queen's University Belfast, Belfast, UK
| | - Chris Bonell
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
| | | | - James White
- Centre for Development, Evaluation, Complexity and Implementation in Public Health Improvement, Cardiff University, Cardiff, UK
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Skedgel C, Cubi-Molla P, Mott D, Gameiro S, Boivin J, Al-Janabi H, Brazier J, Markert M, Andersson FL, Jofre-Bonet M. Unmet Parenthood Goals, Health-Related Quality of Life and Apparent Irrationality: Understanding the Value of Treatments for Infertility. PHARMACOECONOMICS - OPEN 2023; 7:337-344. [PMID: 36920719 PMCID: PMC10016171 DOI: 10.1007/s41669-023-00402-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 05/11/2023]
Abstract
An increasing number of prospective parents are experiencing infertility along with associated negative impacts on mental health and life satisfaction that can extend across a network of individuals and family members. Assistive reproductive technologies (ART) can help prospective parents achieve their parenthood goals but, like any health technology, they must demonstrate acceptable 'value for money' to qualify for public funding. We argue that current approaches to understanding the value of ART, including quality-adjusted life-year (QALY) gains based on changes in health-related quality of life (HRQOL) and, more often, cost per live birth, are too narrow to capture the full impact of unmet parenthood goals and ART. We see a fundamental disconnect between measures of HRQOL and broader measures of wellbeing associated with met and unmet parenthood goals. We also suggest that simple concepts such as 'patient' and 'carer' are of limited applicability in the context of ART, where 'spillovers' extend across a wide network of individuals, and the person receiving treatment is often not the infertile individual. Consideration of individual and societal wellbeing beyond HRQOL is necessary to understand the full range of negative impacts associated with unmet parenthood goals and the corresponding positive impacts of successful ART. We suggest moving towards a wellbeing perspective on value to achieve a fuller understanding of value and promote cross-sector allocative efficiency.
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Affiliation(s)
- Chris Skedgel
- Office of Health Economics, Goldings House, 2nd Floor, Hay's Galleria, 2 Hay's Lane, London, SE1 2HB, UK.
| | - Patricia Cubi-Molla
- Office of Health Economics, Goldings House, 2nd Floor, Hay's Galleria, 2 Hay's Lane, London, SE1 2HB, UK
| | - David Mott
- Office of Health Economics, Goldings House, 2nd Floor, Hay's Galleria, 2 Hay's Lane, London, SE1 2HB, UK
| | - Sofia Gameiro
- School of Psychology, University of Cardiff, Cardiff, UK
| | - Jacky Boivin
- School of Psychology, University of Cardiff, Cardiff, UK
| | - Hareth Al-Janabi
- Health Economics Unit, Institute of Applied Health Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - John Brazier
- School of Health & Related Research, University of Sheffield, Sheffield, UK
| | | | | | - Mireia Jofre-Bonet
- Office of Health Economics, Goldings House, 2nd Floor, Hay's Galleria, 2 Hay's Lane, London, SE1 2HB, UK
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Adler A, Roth B, Lundy SD, Takeshima T, Yumura Y, Kuroda S. Sperm DNA fragmentation testing in clinical management of reproductive medicine. Reprod Med Biol 2023; 22:e12547. [PMID: 37915974 PMCID: PMC10616814 DOI: 10.1002/rmb2.12547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/26/2023] [Accepted: 10/12/2023] [Indexed: 11/03/2023] Open
Abstract
Background Approximately 8%-12% of couples worldwide face infertility, with infertility of individuals assigned male at birth (AMAB) contributing to at least 50% of cases. Conventional semen analysis commonly used to detect sperm abnormalities is insufficient, as 30% of AMAB patients experiencing infertility show normal results in this test. From a genetic perspective, the assessment of sperm DNA fragmentation (SDF) is important as a parameter of sperm quality. Methods In this narrative study, we review and discuss pathophysiological causes, DNA repair mechanisms, and management of high SDF. We then summarize literature exploring the association between SDF and reproductive outcomes. Main Findings Recent systematic reviews and meta-analyses have revealed a significant association between high SDF in AMAB individuals and adverse reproductive outcomes including embryo development, natural conception, intrauterine insemination, and in vitro fertilization. However, the association with live birth rates and pregnancy rates following intracytoplasmic injection remains inconclusive. The disparities among quantitative assays, inconsistent reference range values, absent high-quality prospective clinical trials, and clinical heterogeneity in AMAB patients with elevated SDF represent the main limitations affecting SDF testing. Conclusion The evaluation and management of SDF plays an important role in a subset of AMAB infertility, but widespread integration into clinical guidelines will require future high-quality clinical trials and assay standardization.
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Affiliation(s)
- Ava Adler
- Glickman Urological & Kidney InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Bradley Roth
- Glickman Urological & Kidney InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Scott D. Lundy
- Glickman Urological & Kidney InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Teppei Takeshima
- Department of Urology, Reproduction CenterYokohama City University Medical CenterYokohamaJapan
| | - Yasushi Yumura
- Department of Urology, Reproduction CenterYokohama City University Medical CenterYokohamaJapan
| | - Shinnosuke Kuroda
- Glickman Urological & Kidney InstituteCleveland Clinic FoundationClevelandOhioUSA
- Department of Urology, Reproduction CenterYokohama City University Medical CenterYokohamaJapan
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Keller E, Botha W, Chambers GM. Does in vitro fertilization (IVF) treatment provide good value for money? A cost-benefit analysis. Front Glob Womens Health 2023; 4:971553. [PMID: 36937042 PMCID: PMC10014591 DOI: 10.3389/fgwh.2023.971553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 01/30/2023] [Indexed: 03/05/2023] Open
Abstract
Background Using traditional health technology assessment (HTA) outcome metrics, such as quality-adjusted life-years, to assess fertility treatments raises considerable methodological challenges because the objective of fertility treatments is to create new life rather than extend, save, or improve health-related quality of life. Objective The aim of this study was to develop a novel cost-benefit framework to assess value for money of publicly funded IVF treatment; to determine the number of cost-beneficial treatment cycles for women of different ages; and to perform an incremental cost-benefit analysis from a taxpayer perspective. Methods We developed a Markov model to determine the net monetary benefit (NMB) of IVF treatment by female age and number of cycles performed. IVF treatment outcomes were monetized using taxpayers' willingness-to-pay values derived from a discrete choice experiment (DCE). Using the current funding environment as the comparator, we performed an incremental analysis of only funding cost-beneficial cycles. Similar outputs to cost-effectiveness analyses were generated, including net-benefit acceptability curves and cost-benefit planes. We created an interactive online app to provide a detailed and transparent presentation of the results. Results The results suggest that at least five publicly funded IVF cycles are cost-beneficial in women aged <42 years. Cost-benefit planes suggest a strong taxpayer preference for restricting funding to cost-beneficial cycles over current funding arrangements in Australia from an economic perspective. Conclusions The provision of fertility treatment is valued highly by taxpayers. This novel cost-benefit method overcomes several challenges of conventional cost-effectiveness methods and provides an exemplar for incorporating DCE results into HTA. The results offer new evidence to inform discussions about treatment funding arrangements.
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Martins R, Connolly MP. Valuing live births from assisted reproduction: A health economics viewpoint. Best Pract Res Clin Obstet Gynaecol 2022; 85:149-158. [PMID: 36443158 DOI: 10.1016/j.bpobgyn.2022.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 12/14/2022]
Abstract
Infertility is a medical condition that can be overcome, thanks to advances in medically assisted reproductive (MAR) therapies. Despite the ultimate measure of MAR efficacy being the birth of a new human being, there are ethical and methodological questions as to which outcome best translates the value of MAR in cost-effectiveness analyses. Many authors favour cost per life birth outcomes instead of more traditional cost per quality-adjusted life years (QALYs), which raises generalizability issues for decision-makers. Nonetheless, infertility and infertility treatments substantially differ from other health conditions and health treatments, particularly in the way they affect the quality of life of the infertile couple. Collecting quality of life measures in infertility and pregnancy is also surrounded by challenges not easily overcome. We reflect on cost-effectiveness methods applied to MAR technologies, on ethical considerations for valuing a MAR-generated life, and on its broader societal value for consideration by decision-makers.
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Affiliation(s)
- Rui Martins
- Global Market Access Solutions, Health Economics Unit, St-Prex, Switzerland; University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Mark P Connolly
- Global Market Access Solutions, Health Economics Unit, St-Prex, Switzerland; Unit of Pharmacoepidemiology & Pharmacoeconomics, Department of Pharmacy, University of Groningen, Groningen, the Netherlands.
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Jones M, Smith M, Lewis S, Parrott S, Coleman T. Investigating the cost-effectiveness of three cessation interventions on a national scale using the Economics of Smoking in Pregnancy (ESIP) decision analytical model. Addiction 2022; 117:2907-2917. [PMID: 35661312 PMCID: PMC9796630 DOI: 10.1111/add.15968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 05/20/2022] [Indexed: 01/01/2023]
Abstract
AIM To measure the cost-effectiveness of adding text message (TMB), exercise (EB) and abstinent-contingent financial incentive-based (CFIB) stop smoking interventions to standard smoking cessation support for pregnant women in England. DESIGN Modelling cost-effectiveness outcomes by separately adding three cessation interventions to standard cessation care offered to pregnant women in England. English National Health Service Stop Smoking Services (NHS SSS) statistics from 2019 to 2020 were used for estimating the base quit rate. Intervention effectiveness and cost data for interventions were taken from trial reports. Cost-effectiveness was derived using the economics of smoking in pregnancy (ESIP) model from a health service and personal social services perspective. Interventions were compared with each other as well as against standard cessation care. SETTING English NHS SSS. PARTICIPANTS/CASES A total of 13 799 pregnant women who accessed NHS SSS. Interventions and comparator; comparator: standard stop smoking support comprising behavioural intervention and an offer of nicotine replacement therapy (NRT). Three additive interventions were TMB, EB and CFIB. MEASUREMENTS Incremental cost-effectiveness ratios per quality-adjusted life-years gained for both mothers and offspring over their life-times; return on investment (ROI); and cost-effectiveness acceptability curves (CEACs). FINDINGS The addition of any of the interventions compared with standard care alone was preferred, but only significant for the addition of CFIB, with the CEAC suggesting an at least 90% chance of being favoured to standard care alone. When compared against each other CFIB appeared to yield the largest returns, but this was not significant. The estimated ROI for CFIB was £2 [95% confidence interval (CI) = £1-3] in health-care savings for every £1 spent by the NHS on the cessation intervention. CONCLUSIONS For a health system which currently provides behavioural support and an offer of nicotine replacement therapy as standard stop smoking support for pregnant women, the greatest economic gains would be provided by operating an abstinent-contingent financial incentives scheme alongside this.
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Affiliation(s)
- Matthew Jones
- NIHR School for Primary Care ResearchUniversity of NottinghamNottinghamUK
| | - Murray Smith
- Community and Health Research UnitUniversity of LincolnLincolnshireUK
| | - Sarah Lewis
- Division of Epidemiology and Public HealthUniversity of NottinghamNottinghamUK
| | - Steve Parrott
- Department of Health SciencesUniversity of YorkYorkUK
| | - Tim Coleman
- NIHR School for Primary Care ResearchUniversity of NottinghamNottinghamUK
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Johnston M, Fuscaldo G, Gwini SM, Catt S, Richings NM. Financing future fertility: Women's views on funding egg freezing. REPRODUCTIVE BIOMEDICINE & SOCIETY ONLINE 2022; 14:32-41. [PMID: 34693043 PMCID: PMC8517713 DOI: 10.1016/j.rbms.2021.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 05/19/2021] [Accepted: 07/19/2021] [Indexed: 06/13/2023]
Abstract
Like other assisted reproductive technology (ART) procedures, the cost of egg freezing (EF) is significant, presenting a potential barrier to access. Given recent technological advancements and rising demand for EF, it is timely to reassess how EF is funded. An online cross-sectional survey was conducted in Victoria, Australia and was completed by 656 female individuals. Participants were asked their views on funding for both medical and non-medical EF. The median age of participants was 28 years (interquartile range 23-37 years) and most participants were employed (44% full-time, 28% part-time, 33% students). There was very high support for public funding for medical EF (n = 574, 87%), with 302 (46%) participants indicating support for the complete funding of medical EF through the public system. Views about funding for non-medical EF were more divided; 43 (6%) participants supported full public funding, 235 (36%) supported partial public funding, 150 (23%) supported coverage through private health insurance, and 204 (31%) indicated that non-medical EF should be self-funded. If faced with the decision of what to do with surplus eggs, a high proportion of participants indicated that they would consider donation (71% to research, 59% to a known recipient, 52% to a donor programme), indicating that eggs surplus to requirements could be a potential source of donor eggs. This study provides insights that could inform policy review, and suggests revisiting whether the medical/non-medical distinction is a fair criterion to allocate funding to ART.
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Affiliation(s)
- Molly Johnston
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
- Monash Bioethics Centre, Monash University, Clayton, Australia
| | - Giuliana Fuscaldo
- University Hospital Geelong, Barwon Health, Geelong, Australia
- Eastern Health Clinical School, Monash University, Box Hill, Australia
| | - Stella May Gwini
- University Hospital Geelong, Barwon Health, Geelong, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Sally Catt
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
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11
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Gajic-Veljanoski O, Li C, Schaink AK, Guo J, Shehata N, Charames GS, de Vrijer B, Clarke G, Pechlivanoglou P, Okun N, Kandel R, Dooley J, Higgins C, Ng V, Sikich N. Cost-effectiveness of noninvasive fetal RhD blood group genotyping in nonalloimmunized and alloimmunized pregnancies. Transfusion 2022; 62:1089-1102. [PMID: 35170037 DOI: 10.1111/trf.16826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND We sought to determine the cost-effectiveness of noninvasive fetal RhD blood group genotyping in nonalloimmunized and alloimmunized pregnancies in Canada. STUDY DESIGN AND METHODS We developed two probabilistic state-transition (Markov) microsimulation models to compare fetal genotyping followed by targeted management versus usual care (i.e., universal Rh immunoglobulin [RhIG] prophylaxis in nonalloimmunized RhD-negative pregnancies, or universal intensive monitoring in alloimmunized pregnancies). The reference case considered a healthcare payer perspective and a 10-year time horizon. Sensitivity analysis examined assumptions related to test cost, paternal screening, subsequent pregnancies, other alloantibodies (e.g., K, Rh c/C/E), societal perspective, and lifetime horizon. RESULTS Fetal genotyping in nonalloimmunized pregnancies (at per-sample test cost of C$247/US$311) was associated with a slightly higher probability of maternal alloimmunization (22 vs. 21 per 10,000) and a reduced number of RhIG injections (1.427 vs. 1.795) than usual care. It was more expensive (C$154/US$194, 95% Credible Interval [CrI]: C$139/US$175-C$169/US$213) and had little impact on QALYs (0.0007, 95%CrI: -0.01-0.01). These results were sensitive to the test cost (threshold achieved at C$88/US$111), and inclusion of paternal screening. Fetal genotyping in alloimmunized pregnancies (at test cost of C$328/US$413) was less expensive (-C$6280/US$7903, 95% CrI: -C$6325/US$7959 to -C$6229/US$7838) and more effective (0.19 QALYs, 95% CrI 0.17-0.20) than usual care. These cost savings remained robust in sensitivity analyses. DISCUSSION Noninvasive fetal RhD genotyping saves resources and represents good value for the management of alloimmunized pregnancies. If the cost of genotyping is substantially decreased, the targeted intervention can become a viable option for nonalloimmunized pregnancies.
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Affiliation(s)
- Olga Gajic-Veljanoski
- Ontario Health (Clinical Institutes and Quality Programs/Health Technology Assessment), Toronto, Ontario, Canada
| | - Chunmei Li
- Ontario Health (Clinical Institutes and Quality Programs/Health Technology Assessment), Toronto, Ontario, Canada
| | - Alexis K Schaink
- Ontario Health (Clinical Institutes and Quality Programs/Health Technology Assessment), Toronto, Ontario, Canada
| | - Jennifer Guo
- Ontario Health (Clinical Institutes and Quality Programs/Health Technology Assessment), Toronto, Ontario, Canada
| | - Nadine Shehata
- Mount Sinai Hospital (Division of Hematology), and Department of Medicine, Department of Laboratory Management and Evaluation, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - George S Charames
- Mount Sinai Hospital (Department of Pathology and Laboratory Medicine), and Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Barbra de Vrijer
- Western University, Schulich School of Medicine and Dentistry/Department of Obstetrics and Gynaecology, and London Health Sciences Centre, London, Ontario, Canada
| | - Gwen Clarke
- Laboratory Services, Canadian Blood Services, Edmonton, Alberta, Canada
| | - Petros Pechlivanoglou
- Child Health Evaluative Sciences, The Hospital for Sick Children, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Nanette Okun
- Sunnybrook Health Sciences Centre (Maternal-Fetal Medicine Division), and Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
| | - Rita Kandel
- Mount Sinai Hospital (Department of Pathology and Laboratory Medicine), and Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Joseph Dooley
- Department of Family Medicine, The Northern Ontario School of Medicine and Sioux Lookout Menoyawin Health Centre, Sioux Lookout, Ontario, Canada
| | - Caroline Higgins
- Ontario Health (Clinical Institutes and Quality Programs/Health Technology Assessment), Toronto, Ontario, Canada
| | - Vivian Ng
- Ontario Health (Clinical Institutes and Quality Programs/Health Technology Assessment), Toronto, Ontario, Canada
| | - Nancy Sikich
- Ontario Health (Clinical Institutes and Quality Programs/Health Technology Assessment), Toronto, Ontario, Canada
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12
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van Hoogenhuijze NE, van Eekelen R, Mol F, Schipper I, Groenewoud ER, Traas MAF, Janssen CAH, Teklenburg G, de Bruin JP, van Oppenraaij RHF, Maas JWM, Moll E, Fleischer K, van Hooff MHA, de Koning CH, Cantineau AEP, Lambalk CB, Verberg M, van Heusden AM, Manger AP, van Rumste MME, van der Voet LF, Pieterse QD, Visser J, Brinkhuis EA, den Hartog JE, Glas MW, Klijn NF, van der Zanden M, Bandell ML, Boxmeer JC, van Disseldorp J, Smeenk J, van Wely M, Eijkemans MJC, Torrance HL, Broekmans FJM. Economic evaluation of endometrial scratching before the second IVF/ICSI treatment: a cost-effectiveness analysis of a randomized controlled trial (SCRaTCH trial). Hum Reprod 2022; 37:254-263. [PMID: 34864993 PMCID: PMC8804332 DOI: 10.1093/humrep/deab261] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 10/12/2021] [Indexed: 11/22/2022] Open
Abstract
STUDY QUESTION Is a single endometrial scratch prior to the second fresh IVF/ICSI treatment cost-effective compared to no scratch, when evaluated over a 12-month follow-up period? SUMMARY ANSWER The incremental cost-effectiveness ratio (ICER) for an endometrial scratch was €6524 per additional live birth, but due to uncertainty regarding the increase in live birth rate this has to be interpreted with caution. WHAT IS KNOWN ALREADY Endometrial scratching is thought to improve the chances of success in couples with previously failed embryo implantation in IVF/ICSI treatment. It has been widely implemented in daily practice, despite the lack of conclusive evidence of its effectiveness and without investigating whether scratching allows for a cost-effective method to reduce the number of IVF/ICSI cycles needed to achieve a live birth. STUDY DESIGN, SIZE, DURATION This economic evaluation is based on a multicentre randomized controlled trial carried out in the Netherlands (SCRaTCH trial) that compared a single scratch prior to the second IVF/ICSI treatment with no scratch in couples with a failed full first IVF/ICSI cycle. Follow-up was 12 months after randomization.Economic evaluation was performed from a healthcare and societal perspective by taking both direct medical costs and lost productivity costs into account. It was performed for the primary outcome of biochemical pregnancy leading to live birth after 12 months of follow-up as well as the secondary outcome of live birth after the second fresh IVF/ICSI treatment (i.e. the first after randomization). To allow for worldwide interpretation of the data, cost level scenario analysis and sensitivity analysis was performed. PARTICIPANTS/MATERIALS, SETTING, METHODS From January 2016 until July 2018, 933 women with a failed first IVF/ICSI cycle were included in the trial. Data on treatment and pregnancy were recorded up until 12 months after randomization, and the resulting live birth outcomes (even if after 12 months) were also recorded.Total costs were calculated for the second fresh IVF/ICSI treatment and for the full 12 month period for each participant. We included costs of all treatments, medication, complications and lost productivity costs. Cost-effectiveness analysis was carried out by calculating ICERs for scratch compared to control. Bootstrap resampling was used to estimate the uncertainty around cost and effect differences and ICERs. In the sensitivity and scenario analyses, various unit costs for a single scratch were introduced, amongst them, unit costs as they apply for the United Kingdom (UK). MAIN RESULTS AND THE ROLE OF CHANCE More live births occurred in the scratch group, but this also came with increased costs over a 12-month period. The estimated chance of a live birth after 12 months of follow-up was 44.1% in the scratch group compared to 39.3% in the control group (risk difference 4.8%, 95% CI -1.6% to +11.2%). The mean costs were on average €283 (95% CI: -€299 to €810) higher in the scratch group so that the point average ICER was €5846 per additional live birth. The ICER estimate was surrounded with a high level of uncertainty, as indicated by the fact that the cost-effectiveness acceptability curve (CEAC) showed that there is an 80% chance that endometrial scratching is cost-effective if society is willing to pay ∼€17 500 for each additional live birth. LIMITATIONS, REASONS FOR CAUTION There was a high uncertainty surrounding the effects, mainly in the clinical effect, i.e. the difference in the chance of live birth, which meant that a single straightforward conclusion could not be ascertained as for now. WIDER IMPLICATIONS OF THE FINDINGS This is the first formal cost-effectiveness analysis of endometrial scratching in women undergoing IVF/ICSI treatment. The results presented in this manuscript cannot provide a clear-cut expenditure for one additional birth, but they do allow for estimating costs per additional live birth in different scenarios once the clinical effectiveness of scratching is known. As the SCRaTCH trial was the only trial with a follow-up of 12 months, it allows for the most complete estimation of costs to date. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by ZonMW, the Dutch organization for funding healthcare research. A.E.P.C., F.J.M.B., E.R.G. and C.B. L. reported having received fees or grants during, but outside of, this trial. TRIAL REGISTRATION NUMBER Netherlands Trial Register (NL5193/NTR 5342).
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Affiliation(s)
- N E van Hoogenhuijze
- Department of Gynaecology and Reproductive Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - R van Eekelen
- Dutch Consortium for Healthcare Evaluation and Research in Obstetrics and Gynaecology—NVOG Consortium 2.0, Amsterdam, The Netherlands
| | - F Mol
- Amsterdam UMC, University of Amsterdam, Center for Reproductive Medicine, Reproduction and Development, Amsterdam, The Netherlands
| | - I Schipper
- Division of Reproductive Endocrinology and Infertility, Department Obstetrics and Gynaecology, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - E R Groenewoud
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Noordwest Ziekenhuisgroep, Den Helder, The Netherlands
| | - M A F Traas
- Department of Gynaecology, Gelre Hospital, Apeldoorn, The Netherlands
| | - C A H Janssen
- Department of Gynaecology, Groene Hart Hospital, Gouda, The Netherlands
| | - G Teklenburg
- Isala Fertility Clinic, Isala Hospital, Zwolle, The Netherlands
| | - J P de Bruin
- Department of Gynaecology and Obstetrics, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | | | - J W M Maas
- Department of Gynaecology, Maxima Medical Centre, Veldhoven, The Netherlands
| | - E Moll
- Department of Gynaecology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - K Fleischer
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - M H A van Hooff
- Department of Gynaecology, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - C H de Koning
- Department of Gynaecology, Tergooi Hospital, Hilversum, The Netherlands
| | - A E P Cantineau
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - C B Lambalk
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M Verberg
- Fertility Clinic, Fertility Clinic Twente, Hengelo, The Netherlands
| | - A M van Heusden
- Fertility Clinic, Medisch Centrum Kinderwens, Leiderdorp, The Netherlands
| | - A P Manger
- Department of Gynaecology, Diakonessenhuis, Utrecht, The Netherlands
| | - M M E van Rumste
- Department of Gynaecology, Catharina Hospital, Eindhoven, The Netherlands
| | - L F van der Voet
- Department of Gynaecology, Deventer Hospital, Deventer, The Netherlands
| | - Q D Pieterse
- Fertility Center, Haga Hospital, The Hague, The Netherlands
| | - J Visser
- Department of Gynaecology and Obstetrics, Amphia Hospital, Breda, The Netherlands
| | - E A Brinkhuis
- Department of Gynaecology and Obstetrics, Meander Hospital, Amersfoort, The Netherlands
| | - J E den Hartog
- Department of Obstetrics and Gynaecology, Maastricht UMC+, Maastricht, The Netherlands
| | - M W Glas
- Fertility Clinic, Wilhelmina Hospital Assen, Assen, The Netherlands
| | - N F Klijn
- Department of Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - M van der Zanden
- Department of Gynaecology, Haaglanden Medical Centre, The Hague, The Netherlands
| | - M L Bandell
- Department of Gynaecology, Albert Schweitzer Hospital, Sliedrecht, The Netherlands
| | - J C Boxmeer
- Department of Gynaecology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - J van Disseldorp
- Department of Gynaecology and Obstetrics, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J Smeenk
- Department of Reproductive Medicine, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - M van Wely
- Dutch Consortium for Healthcare Evaluation and Research in Obstetrics and Gynaecology—NVOG Consortium 2.0, Amsterdam, The Netherlands
| | - M J C Eijkemans
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - H L Torrance
- Department of Gynaecology and Reproductive Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - F J M Broekmans
- Department of Gynaecology and Reproductive Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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Abel L, Quaife M. A Pregnant Pause: Rethinking Economic Evaluation in Contraception and Pregnancy. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:32-35. [PMID: 35031097 DOI: 10.1016/j.jval.2021.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/03/2021] [Indexed: 06/14/2023]
Abstract
Pregnancy presents a unique challenge to economic evaluation, requiring methods that can account for both maternal and fetal outcomes. The ethical challenges to healthcare presented by pregnancy are well understood, but these have not yet been incorporated into cost-effectiveness approaches. Economic evaluations of pregnancy currently take an ad hoc approach to outcome valuation, opening the door to biased estimates and inconsistent resource allocation. We summarize the limitations of current economic evaluation methods and outline key areas for future work.
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Affiliation(s)
- Lucy Abel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, England, UK.
| | - Matthew Quaife
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, England, UK
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14
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Luyten J, Verbeke E, Schokkaert E. To be or not to be: Future lives in economic evaluation. HEALTH ECONOMICS 2022; 31:258-265. [PMID: 34743370 DOI: 10.1002/hec.4454] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 10/22/2021] [Accepted: 10/24/2021] [Indexed: 06/13/2023]
Abstract
Sometimes healthcare will affect the health of people living in the future, or their chance of coming into existence. Should such outcomes be valued in health-economic evaluation? Guidelines implicitly recommend their inclusion but this rule has counterintuitive implications and is not consistently applied in practice. We suggest making a distinction between "necessary" and "potential" future lives in Health Technology Assessment. Necessary lives will exist independent of our healthcare choices and should be included. Potential lives are choice-dependent and should be excluded. This rule offers intuitive solutions within the HTA framework, and it changes the cost-effectiveness of several interventions where necessary future lives are affected.
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Affiliation(s)
- Jeroen Luyten
- Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
| | - Evelyn Verbeke
- Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
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15
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Noninvasive Fetal RhD Blood Group Genotyping: A Health Technology Assessment. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2020; 20:1-160. [PMID: 33240456 PMCID: PMC7670296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND RhD blood group incompatibility during pregnancy can cause serious health problems for the fetus. Noninvasive fetal RhD blood group genotyping is a test for fetal RhD status that may help prevent unnecessary preventive treatment (Rh immunoglobulin [RhIG] injections) and intensive pregnancy monitoring. We conducted a health technology assessment of noninvasive fetal RhD blood group genotyping for RhD-negative (RhD-) pregnancies. Our assessment evaluated the test's diagnostic accuracy, clinical utility, and cost-effectiveness, the budget impact of publicly funding this test, and patients' and providers' preferences and values. METHODS We performed a systematic literature search of the clinical and economic evidence to conduct an overview of reviews for test accuracy, a systematic review for clinical utility, and a review of the test's cost-effectiveness compared with usual care. We assessed the risk of bias of each included systematic review and study using the ROBIS and RoBANs tools, respectively. We assessed the quality of the body of clinical evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We developed probabilistic Markov microsimulation models to determine the cost-effectiveness and cost-utility of noninvasive fetal RhD genotyping compared with usual care from the Ontario Ministry of Health perspective. We also estimated the 5-year budget impact of publicly funding this test in Ontario. To examine patient and provider preferences related to noninvasive fetal RhD genotyping, we conducted a literature survey of quantitative studies on preference; the Canadian Agency for Drugs and Technologies in Health (CADTH) performed a review of qualitative literature about patient preferences; and we conducted interviews and an online survey with Ontario patients. RESULTS We included six systematic reviews in the overview of reviews on diagnostic test accuracy and 11 studies in the clinical utility review. Across systematic reviews, test accuracy was high for noninvasive fetal RhD genotyping. The evidence suggests that implementation of noninvasive fetal RhD genotyping may lead to avoidance of unnecessary RhIG prophylaxis (GRADE: Low), good compliance with targeted RhIG prophylaxis (GRADE: Very low), and high uptake of genotyping (GRADE: Low). Alloimmunization may not increase when using noninvasive fetal RhD genotyping to target prenatal RhIG prophylaxis (GRADE: Very low), and may allow unnecessary monitoring and invasive procedures to be avoided in alloimmunized pregnancies (GRADE: Very low).We included eight published economic studies that reported inconsistent results regarding the cost-effectiveness of noninvasive fetal RhD genotyping. In nonalloimmunized RhD- pregnancies, compared with usual care, the intervention identified more maternal alloimmunization cases (probability: 0.0022 vs. 0.0020) and was associated with a reduced number of RhIG injections per pregnancy (1.79 vs 1.43). It was more expensive ($154, 95% credible interval [CrI] $139 to $169) but had little impact on the QALYs of newborns followed over a 10-year time horizon (0.0007, 95% CrI -0.01 to 0.01). The cost of noninvasive fetal RhD genotyping and inclusion of paternal RhD typing were drivers of the cost-effectiveness results in this population. In alloimmunized RhD- pregnancies, noninvasive fetal RhD genotyping was associated with lower resource use during the pregnancy. Compared with usual care, it was less costly (-$6,280, 95% CrI -$6,325 to -$6,229) and more effective (0.19 QALYs, 95% CrI 0.17 to 0.20).The annual budget impact of publicly funding noninvasive fetal RhD genotyping in nonalloimmunized RhD- pregnancies in Ontario ranges from $2.6 million in year 1 (uptake of 80%) to $3.4 million in year 5 (uptake of 100%), with a 5-year total of about $14.8 million. In alloimmunized pregnancies, we estimate cost savings, from about $9 million in year 1 to about $12 million in year 5, with 5-year total savings of about $51.5 million.We included two studies in the survey of quantitative preferences literature. In the quantitative literature, RhD- pregnant people support routine offering of noninvasive fetal RhD genotyping as part of pregnancy care, with a preference to be adequately informed about the test process, attributes, timing, and risks in advance of the test, ideally in a dialogue with their health care provider. More than half of obstetric health care providers were supportive of offering the test. The qualitative review by CADTH and our own engagement with Ontario patients yielded similar results. Participants consistently expressed a desire for more information about the test and assurance about its safety. They also consistently mentioned the prevention of unnecessary monitoring and treatment as potential benefits. CONCLUSIONS Noninvasive fetal RhD blood group genotyping is an accurate test to determine RhD incompatibility and guide management of RhD- pregnancies. Compared with usual care, noninvasive fetal RhD genotyping is less costly and more effective for the management of alloimmunized pregnancies. For nonalloimmunized pregnancies, noninvasive fetal RhD genotyping would generally not be considered cost-effective, compared with usual care, unless the cost of testing is much lower than what is proposed now. Publicly funding noninvasive fetal RhD genotyping for guiding the management of RhD- pregnancies in Ontario over next 5 years is associated with a total budget impact of about $15 million in nonalloimmunized pregnancies and total cost savings of about $51 million in alloimmunized pregnancies. Patients and providers indicated support for the routine use of noninvasive fetal RhD genotyping in RhD- pregnancies.
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Agarwal A, Majzoub A, Baskaran S, Panner Selvam MK, Cho CL, Henkel R, Finelli R, Leisegang K, Sengupta P, Barbarosie C, Parekh N, Alves MG, Ko E, Arafa M, Tadros N, Ramasamy R, Kavoussi P, Ambar R, Kuchakulla M, Robert KA, Iovine C, Durairajanayagam D, Jindal S, Shah R. Sperm DNA Fragmentation: A New Guideline for Clinicians. World J Mens Health 2020; 38:412-471. [PMID: 32777871 PMCID: PMC7502318 DOI: 10.5534/wjmh.200128] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 07/13/2020] [Accepted: 07/13/2020] [Indexed: 12/13/2022] Open
Abstract
Sperm DNA integrity is crucial for fertilization and development of healthy offspring. The spermatozoon undergoes extensive molecular remodeling of its nucleus during later phases of spermatogenesis, which imparts compaction and protects the genetic content. Testicular (defective maturation and abortive apoptosis) and post-testicular (oxidative stress) mechanisms are implicated in the etiology of sperm DNA fragmentation (SDF), which affects both natural and assisted reproduction. Several clinical and environmental factors are known to negatively impact sperm DNA integrity. An increasing number of reports emphasizes the direct relationship between sperm DNA damage and male infertility. Currently, several assays are available to assess sperm DNA damage, however, routine assessment of SDF in clinical practice is not recommended by professional organizations. This article provides an overview of SDF types, origin and comparative analysis of various SDF assays while primarily focusing on the clinical indications of SDF testing. Importantly, we report four clinical cases where SDF testing had played a significant role in improving fertility outcome. In light of these clinical case reports and recent scientific evidence, this review provides expert recommendations on SDF testing and examines the advantages and drawbacks of the clinical utility of SDF testing using Strength-Weaknesses-Opportunities-Threats (SWOT) analysis.
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Affiliation(s)
- Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA.
| | - Ahmad Majzoub
- Department of Urology, Hamad Medical Corporation, Doha, Qatar
- Department of Urology, Weill Cornell Medicine - Qatar, Doha, Qatar
| | - Saradha Baskaran
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | | | - Chak Lam Cho
- Department of Surgery, Union Hospital, Hong Kong
- S. H. Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong
| | - Ralf Henkel
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Medical Bioscience, University of the Western Cape, Bellville, South Africa
| | - Renata Finelli
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Kristian Leisegang
- School of Natural Medicine, Faculty of Community and Health Sciences, University of the Western Cape, Bellville, South Africa
| | - Pallav Sengupta
- Department of Physiology, Faculty of Medicine, Bioscience and Nursing, MAHSA University, Jenjarom, Malaysia
| | - Catalina Barbarosie
- Department of Genetics, Faculty of Biology, University of Bucharest, Bucharest, Romania
| | - Neel Parekh
- Department of Urology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Marco G Alves
- Department of Microscopy, Laboratory of Cell Biology & Unit for Multidisciplinary Research in Biomedicine (UMIB), Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Porto, Portugal
| | - Edmund Ko
- Department of Urology, Loma Linda University, Loma Linda, CA, USA
| | - Mohamed Arafa
- Department of Urology, Hamad Medical Corporation, Doha, Qatar
- Andrology Department, Cairo University, Giza, Egypt
| | - Nicholas Tadros
- Division of Urology, Southern Illinois University School of Medicine, Springfield, IL, USA
| | | | - Parviz Kavoussi
- Austin Fertility & Reproductive Medicine/Westlake IVF, Austin, TX, USA
| | - Rafael Ambar
- Urology Department of Centro Universitario em Saude do ABC, Santo André, Brazil
| | | | - Kathy Amy Robert
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Concetta Iovine
- Department of Environmental, Biological and Pharmaceutical Sciences and Technologies, University of Campania "Luigi Vanvitelli", Caserta, Italy
| | | | - Sunil Jindal
- Department of Andrology and Reproductive Medicine, Jindal Hospital, Meerut, India
| | - Rupin Shah
- Department of Urology, Lilavati Hospital and Research Centre, Mumbai, India
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Kotirum S, Kiatpongsan S, Kapol N. Systematic review of economic evaluation studies on preconception care interventions. Health Care Women Int 2020; 42:503-517. [PMID: 32940580 DOI: 10.1080/07399332.2020.1817025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Implementation of preconception care interventions have been encouraged for improving maternal and child health outcomes; therefore, evidence on their cost-effectiveness is needed. We conducted the systematic review to examine the efficiency of those interventions by collecting evidence from published economic evaluation studies. Out of 14 included studies, almost all (12/14) were in high-income countries. All studies were not cost-utility analysis with genetic disease screening and diabetes management were the common interventions for evaluating their efficiency during preconception period. Preconception care interventions are likely to be cost-effective, especially in low-income countries which incremental benefits had a greater return than developed nations.
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Affiliation(s)
- Surachai Kotirum
- Department of Community Pharmacy, Faculty of Pharmacy, Silpakorn University, Muang, Nakhon Pathom, Thailand
| | | | - Nattiya Kapol
- Department of Community Pharmacy, Faculty of Pharmacy, Silpakorn University, Muang, Nakhon Pathom, Thailand
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Hulst SM, Brouwer W, Mol BW, van den Akker-van Marle ME. Challenges in economic evaluations in obstetric care: a scoping review and expert opinion. BJOG 2020; 127:1399-1407. [PMID: 32277547 PMCID: PMC7539957 DOI: 10.1111/1471-0528.16243] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The aim of this study is to identify items of economic evaluation guidelines that are frequently not complied within obstetric economic evaluations and to search for reasons for non-adherence. DESIGN Scoping review and qualitative study. SETTING Literature on economic evaluations in obstetric care and interviews with experts. POPULATION OR SAMPLE The sample included 229 scientific articles and five experts. METHODS A systematic literature search was performed. All types of literature about economic evaluations in obstetric care were included. The adherence to guidelines was assessed and articles were qualitatively analysed on additional information about reasons for non-adherence. Issues that arose from the scoping review were discussed with experts. MAIN OUTCOME MEASURES Adherence to guideline items of the included economic evaluations studies. Analytical themes describing reasons for non-adherence, resulting from qualitative analysis of articles and interviews with experts. RESULTS A total of 184 economic evaluations and 45 other type of articles were included. Guideline items frequently not complied with were time horizon, type of economic evaluation and effect measure. Reasons for non-adherence had to do with paucity of long-term health data and assessing and combining outcomes for mother and child resulting from obstetric interventions. CONCLUSIONS This study identified items of guidelines that are frequently not complied with and the reasons behind this. The results are a starting point for a broad consensus building on how to deal with these challenges that can result in special guidance for the conduct of economic evaluations in obstetric care. TWEETABLE ABSTRACT Non-adherence to guidelines in obstetric economic evaluation studies: the difficulties in detail.
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Affiliation(s)
- S M Hulst
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands
| | - Wbf Brouwer
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - B W Mol
- Monash Medical Centre, Monash University, Clayton, Vic., Australia
| | - M E van den Akker-van Marle
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands
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Gumbie M, Parkinson B, Cutler H, Gauld N, Mumford V. Is Reclassification of the Oral Contraceptive Pill from Prescription to Pharmacist-Only Cost Effective? Application of an Economic Evaluation Approach to Regulatory Decisions. PHARMACOECONOMICS 2019; 37:1049-1064. [PMID: 31069781 DOI: 10.1007/s40273-019-00804-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND AND OBJECTIVE Unplanned pregnancies can lead to poorer maternal and child health outcomes. The Australian Therapeutic Goods Administration committee rejected reclassifying a range of oral contraceptive pills (OCPs) from prescription to pharmacist-only medicines in 2015, mainly based on safety concerns. Improving access to OCPs may encourage some women to use contraceptives or switch from other contraceptive methods. However, some adverse events may increase and some women may stop using condoms, increasing their risk of sexually transmitted infections. This study aimed to estimate the cost effectiveness of reclassifying OCPs from prescription to pharmacist-only. PERSPECTIVE Healthcare system. SETTING Australian primary care. METHODS A Markov model was used to synthesise data from a variety of sources. The model included all Australian women aged 15-49 years (N = 5,644,701). The time horizon was 35 years. Contraceptive use before reclassification was estimated using data from the Household, Income and Labour Dynamics in Australia (HILDA) survey, while survey data informed use after reclassification. Health outcomes included pregnancies, pregnancy outcomes (live birth, miscarriage, stillbirth, ectopic pregnancy and abortion), sexually transmitted infections, adverse events (venous thromboembolism, depression, myocardial infarction and stroke), ovarian cancer cases and quality-adjusted life-years. Costs included those related to general practitioner and specialist consultations, contraceptives and other medicines, pharmacist time, hospitalisations and adverse events. All costs were reported in 2016 Australian Dollars. A 5% discount rate was applied to health outcomes and costs. RESULTS Reclassifying OCPs resulted in 85.70 million quality-adjusted life-years experienced and costs of $46,910.14 million over 35 years, vs. 85.68 million quality-adjusted life-years experienced and costs of $50,274.95 million with OCPs remaining prescription-only. Thus, reclassifying OCPs was more effective and cost saving. However, a sensitivity analysis found that more research on the probability of pregnancy in women not using contraception and not trying to conceive is needed. CONCLUSION Reclassifying OCPs is likely to be considered cost effective by Australian decision makers.
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Affiliation(s)
- Mutsa Gumbie
- Centre for the Health Economy, Macquarie University, Sydney, NSW, 2109, Australia
| | - Bonny Parkinson
- Centre for the Health Economy, Macquarie University, Sydney, NSW, 2109, Australia.
| | - Henry Cutler
- Centre for the Health Economy, Macquarie University, Sydney, NSW, 2109, Australia
| | - Natalie Gauld
- School of Pharmacy, University of Auckland, Auckland, 1023, New Zealand
| | - Virginia Mumford
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
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Abstract
Many countries tightly ration access to publicly funded fertility treatments such as in vitro fertilisation (IVF). One basis for excluding people from access to IVF is their body mass index. In this paper, I consider a number of potential justifications for such a policy, based on claims about effectiveness and cost-efficiency, and reject these as unsupported by available evidence. I consider an alternative justification: that those whose subfertility results from avoidable behaviours for which they are responsible are less deserving of treatment. I ultimately stop short of endorsing or rejecting such a justification, though highlight some reasons for thinking it is unlikely to be practicable.
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Affiliation(s)
- Rebecca C H Brown
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Suite 8 Littlegate House, 16-17 St Ebbes Street, OX1 1PT, Oxford, UK.
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Dugdale CM, Ciaranello AL, Bekker LG, Stern ME, Myer L, Wood R, Sax PE, Abrams EJ, Freedberg KA, Walensky RP. Risks and Benefits of Dolutegravir- and Efavirenz-Based Strategies for South African Women With HIV of Child-Bearing Potential: A Modeling Study. Ann Intern Med 2019; 170:614-625. [PMID: 30934067 PMCID: PMC6736740 DOI: 10.7326/m18-3358] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Dolutegravir is superior to efavirenz for HIV antiretroviral therapy (ART) but may be associated with an increased risk for neural tube defects (NTDs) in newborns if used by women at conception. OBJECTIVE To project clinical outcomes of ART policies for women of child-bearing potential in South Africa. DESIGN Model of 3 strategies: efavirenz for all women of child-bearing potential (EFV), dolutegravir for all women of child-bearing potential (DTG), or World Health Organization (WHO)-recommended efavirenz without contraception or dolutegravir with contraception (WHO approach). DATA SOURCES Published data on NTD risks (efavirenz, 0.05%; dolutegravir, 0.67% [Tsepamo study]), 48-week ART efficacy with initiation (efavirenz, 60% to 91%; dolutegravir, 96%), and age-stratified fertility rates (2 to 139 per 1000 women). TARGET POPULATION 3.1 million South African women with HIV (aged 15 to 49 years) starting or continuing first-line ART, and their children. TIME HORIZON 5 years. PERSPECTIVE Societal. INTERVENTION EFV, DTG, and WHO approach. OUTCOME MEASURES Deaths among women and children, sexual and pediatric HIV transmissions, and NTDs. RESULTS OF BASE-CASE ANALYSIS Compared with EFV, DTG averted 13 700 women's deaths (0.44% decrease) and 57 700 sexual HIV transmissions, but increased total pediatric deaths by 4400 because of more NTDs. The WHO approach offered some benefits compared with EFV, averting 4900 women's deaths and 20 500 sexual transmissions while adding 300 pediatric deaths. Overall, combined deaths among women and children were lowest with DTG (358 000 deaths) compared with the WHO approach (362 800 deaths) or EFV (367 300 deaths). RESULTS OF SENSITIVITY ANALYSIS Women's deaths averted with DTG exceeded pediatric deaths added with EFV unless dolutegravir-associated NTD risk was 1.5% or greater. LIMITATION Uncertainty in NTD risks and dolutegravir efficacy in resource-limited settings, each examined in sensitivity analyses. CONCLUSION Although NTD risks may be higher with dolutegravir than efavirenz, dolutegravir will lead to many fewer deaths among women, as well as fewer overall HIV transmissions. These results argue against a uniform policy of avoiding dolutegravir in women of child-bearing potential. PRIMARY FUNDING SOURCE National Institutes of Health, National Institute of Allergy and Infectious Diseases and Eunice Kennedy Shriver National Institute of Child Health and Human Development; Massachusetts General Hospital; and Harvard University Center for AIDS Research.
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Affiliation(s)
- Caitlin M Dugdale
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (C.M.D., A.L.C., K.A.F.)
| | - Andrea L Ciaranello
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (C.M.D., A.L.C., K.A.F.)
| | | | | | - Landon Myer
- University of Cape Town, Cape Town, South Africa (L.B., L.M., R.W.)
| | - Robin Wood
- University of Cape Town, Cape Town, South Africa (L.B., L.M., R.W.)
| | - Paul E Sax
- Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts (P.E.S.)
| | | | - Kenneth A Freedberg
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (C.M.D., A.L.C., K.A.F.)
| | - Rochelle P Walensky
- Massachusetts General Hospital, Harvard Medical School, and Brigham and Women's Hospital, Boston, Massachusetts (R.P.W.)
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Nomura K, Karita K, Araki A, Nishioka E, Muto G, Iwai-Shimada M, Nishikitani M, Inoue M, Tsurugano S, Kitano N, Tsuji M, Iijima S, Ueda K, Kamijima M, Yamagata Z, Sakata K, Iki M, Yanagisawa H, Kato M, Inadera H, Kokubo Y, Yokoyama K, Koizumi A, Otsuki T. For making a declaration of countermeasures against the falling birth rate from the Japanese Society for Hygiene: summary of discussion in the working group on academic research strategy against an aging society with low birth rate. Environ Health Prev Med 2019; 24:14. [PMID: 30836940 PMCID: PMC6402135 DOI: 10.1186/s12199-019-0768-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 02/14/2019] [Indexed: 12/15/2022] Open
Abstract
In 1952, the Japanese Society for Hygiene had once passed a resolution at its 22nd symposium on population control, recommending the suppression of population growth based on the idea of cultivating a healthier population in the area of eugenics. Over half a century has now passed since this recommendation; Japan is witnessing an aging of the population (it is estimated that over 65-year-olds made up 27.7% of the population in 2017) and a decline in the birth rate (total fertility rate 1.43 births per woman in 2017) at a rate that is unparalleled in the world; Japan is faced with a "super-aging" society with low birth rate. In 2017, the Society passed a resolution to encourage all scientists to engage in academic researches to address the issue of the declining birth rate that Japan is currently facing. In this commentary, the Society hereby declares that the entire text of the 1952 proposal is revoked and the ideas relating to eugenics is rejected. Since the Society has set up a working group on the issue in 2016, there have been three symposiums, and working group committee members began publishing a series of articles in the Society's Japanese language journal. This commentary primarily provides an overview of the findings from the published articles, which will form the scientific basis for the Society's declaration. The areas we covered here included the following: (1) improving the social and work environment to balance between the personal and professional life; (2) proactive education on reproductive health; (3) children's health begins with nutritional management in women of reproductive age; (4) workplace environment and occupational health; (5) workplace measures to counter the declining birth rate; (6) research into the effect of environmental chemicals on sexual maturity, reproductive function, and the children of next generation; and (7) comprehensive research into the relationship among contemporary society, parental stress, and healthy child-rearing. Based on the seven topics, we will set out a declaration to address Japan's aging society with low birth rate.
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Affiliation(s)
- Kyoko Nomura
- Department of Public Health, Akita University Graduate School of Medicine, Akita, Japan
| | - Kanae Karita
- Department of Public Health, Kyorin University Gender Equality Promotion Office, Kyorin University School of Medicine, Tokyo, Japan
| | - Atsuko Araki
- Hokkaido University Center for Environmental and Health Sciences, Sapporo, Japan
| | - Emiko Nishioka
- Department of Maternal Nursing, Division of Nursing, National Defense Medical College, Saitama, Japan
| | - Go Muto
- Department of Hygiene, Kitasato University School of Medicine, Kanagawa, Japan
| | - Miyuki Iwai-Shimada
- Center for Health and Environmental Risk Research, National Institute for Environmental Studies, Ibaragi, Japan
| | - Mariko Nishikitani
- Institute of Decision Science for a Sustainable Society, Kyushu University, Fukuoka, Japan
| | - Mariko Inoue
- Graduate School of Public Health, Teikyo University, Tokyo, Japan
| | - Shinobu Tsurugano
- Health Care Center, The University of Electro-Communications, Tokyo, Japan
| | - Naomi Kitano
- Research Center for Community Medicine and Department of Public Health, Wakayama Medical University School of Medicine, Wakayama, Japan
| | - Mayumi Tsuji
- Department of Environmental Health, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Sachiko Iijima
- Graduate School of Health Care and Nursing, Juntendo University, Chiba, Japan
| | - Kayo Ueda
- Graduate School of Global Environmental Studies, Kyoto University, Kyoto, Japan
| | - Michihiro Kamijima
- Department of Occupational and Environmental Health, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Zentaro Yamagata
- Department of Health Sciences, School of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Kiyomi Sakata
- Department of Hygiene and Preventive Medicine, Iwate medical University, Iwate, Japan
| | - Masayuki Iki
- Department of Public Health, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Hiroyuki Yanagisawa
- Department of Public Health and Environmental Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Masashi Kato
- Department of Occupational and Environmental Health, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidekuni Inadera
- Department of Public Health, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Yoshihiro Kokubo
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazuhito Yokoyama
- Department of Epidemiology and Environmental Health, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | | | - Takemi Otsuki
- Department of Hygiene, Kawasaki Medical School, Okayama, Japan
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23
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Jones M, Smith M, Lewis S, Parrott S, Coleman T. A dynamic, modifiable model for estimating cost-effectiveness of smoking cessation interventions in pregnancy: application to an RCT of self-help delivered by text message. Addiction 2019; 114:353-365. [PMID: 30347119 PMCID: PMC6519118 DOI: 10.1111/add.14476] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 08/10/2018] [Accepted: 10/16/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIMS Previous evaluations of smoking cessation interventions in pregnancy have several limitations. Our solution to these limitations is the Economics of Smoking in Pregnancy (ESIP) model, which estimates the life-time cost-effectiveness of smoking cessation interventions in pregnancy from a National Health Service (NHS) and personal social services perspective. We aim to (1) describe how ESIP has been constructed and (2) illustrate its use with trial data. METHODS ESIP links mothers' and offspring pregnancy outcomes to estimate the burdens of smoking-related disease they experience with different rates of smoking in pregnancy, both in pregnancy and throughout their life-times. Smoking rates are inputted by model users. ESIP then estimates the costs of treating disease burdens and also mothers' and offspring life-years and quality-adjusted life years (QALYs). By comparing costs incurred and healthy life following different smoking rates, ESIP estimates incremental cost-effectiveness and benefit-cost ratios for mothers or offspring or both combined. We illustrate ESIP use using data from a pragmatic randomized controlled trial that tested a smoking cessation intervention in pregnancy. RESULTS Throughout women's and offspring life-times, the intervention proved cheaper than usual care, having a negative incremental cost of £38.37 (interquartile range = £21.46-56.96) and it improved health, demonstrating a 0.04 increase in incremental QALYs for mothers and offspring, implying that it is 'dominant' over usual care. Benefit-cost ratios suggested that every £1 spent would generate a median of £14 (interquartile range = £8-20) in health-care savings. CONCLUSIONS Economics of Smoking in Pregnancy is the first economic model to link mothers' and infants' costs and benefits while reporting cost-effectiveness in readily-comparable units. Using ESIP with data from a trial which reported only short-term economic analysis showed that the intervention was very likely to be cost-effective in the longer term and to generate health-care savings.
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Affiliation(s)
- Matthew Jones
- Division of Primary CareUniversity of NottinghamNottinghamUK
| | - Murray Smith
- Community and Health Research UnitUniversity of LincolnLincolnshireUK
| | - Sarah Lewis
- Division of Epidemiology and Public HealthUniversity of NottinghamNottinghamUK
| | - Steve Parrott
- Department of Health SciencesUniversity of YorkYorkUK
| | - Tim Coleman
- Division of Primary CareUniversity of NottinghamNottinghamUK
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24
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Nomura K, Karita K, Araki A, Nishioka E, Muto G, Iwai-Shimada M, Nishikitani M, Inoue M, Tsurugano S, Kitano N, Tsuji M, Iijima S, Ueda K, Kamijima M, Yamagata Z, Sakata K, Iki M, Yanagisawa H, Kato M, Yokoyama K, Koizumi A, Otsuki T. [Toward a Declaration to Address Japan's Aging Society with Low Birth Rate: Summary of the Japanese Society for Hygiene's Working Group on Academic Research Strategy against an Aging Society with Low Birth Rate]. Nihon Eiseigaku Zasshi 2019; 74. [PMID: 30647203 DOI: 10.1265/jjh.18034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kyoko Nomura
- Department of Public Health, Akita University Graduate School of Medicine
| | - Kanae Karita
- Department of Public Health, Kyorin University, School of Medicine/Kyorin University Gender Equality Promotion Office
| | - Atsuko Araki
- Hokkaido University Center for Environmental and Health Sciences
| | - Emiko Nishioka
- National Defense Medical College Division of Nursing Maternal Nursing
| | - Go Muto
- Department of Epidemiology and Environmental Health, Juntendo University Graduate School of Medicine
| | - Miyuki Iwai-Shimada
- Centre for Health and Environmental Risk Research, National Institute for Environmental Studies
| | - Mariko Nishikitani
- Institute of Decision Science for a Sustainable Society, Kyushu University
| | - Mariko Inoue
- Graduate School of Public Health, Teikyo University
| | | | - Naomi Kitano
- Research Center for Community Medicine and Department of Public Health, Wakayama Medical University School of Medicine
| | - Mayumi Tsuji
- Department of Industrial Hygiene, University of Occupational and Environmental Health, Japan
| | - Sachiko Iijima
- Graduate School of Health Care and Nursing, Juntendo University Graduate School of Medicine
| | - Kayo Ueda
- Graduate School of Global Environmental Studies, Kyoto University
| | - Michihiro Kamijima
- Department of Occupational and Environmental Health, Nagoya City University Graduate School of Medical Sciences
| | - Zentaro Yamagata
- Department of Health Sciences, School of Medicine, University of Yamanashi
| | - Kiyomi Sakata
- Department of Hygiene and Preventive Medicine, Iwate Medical University
| | - Masayuki Iki
- Department of Public Health, Kinki University Faculty of Medicine
| | - Hiroyuki Yanagisawa
- Department of Public Health & Environmental Medicine, The Jikei University School of Medicine
| | - Masashi Kato
- Department of Occupational and Environmental Health, Nagoya University Graduate School of Medicine
| | - Kazuhito Yokoyama
- Department of Epidemiology and Environmental Health, Juntendo University Graduate School of Medicine
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25
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Iijima S, Yokoyama K. [Socioeconomic Factors and Policies Regarding Declining Birth Rates in Japan]. Nihon Eiseigaku Zasshi 2018; 73:305-312. [PMID: 30270298 DOI: 10.1265/jjh.73.305] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The factors contributing to the declining birthrate in Japan include the declining marriage rate, an increase in the average age of those getting married, economic burden, childcare burden, later child-bearing, and infertility. There is a gender difference in role division, with 70% of unmarried people live with their parents and continue to work while leaving the household chores to their mothers. The loss of these housekeeping services and the increase in the number of irregular workers are factors contributing to the declining marriage rate and the increase in the average age of those getting married. The expansion of the family support policy in Japan from the male breadwinner model to the earner-career model may have been delayed, but it is expected to provide economic benefits as well as actual childcare service benefits in order to reduce the economic and physical burden of childcare for married couples. It is also necessary to provide education in reproductive health to both men and women in schools and workplaces regarding late child-bearing and infertility. Furthermore, it is necessary to evaluate the cost-effectiveness analysis of improvements in fertility and disclose the relevant information in addition to sharing information on medical technology related to pregnancy/childbirth and treatment of diseases. It is urgent to prepare society for natural and healthy pregnancies/childbirths during optimal child-bearing years.
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Affiliation(s)
- Sachiko Iijima
- Graduate School of Health Care and Nursing, Juntendo University
| | - Kazuhito Yokoyama
- Department of Epidemiology and Environmental Health, School of Medicine, Juntendo University
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26
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Bailey SL, Bono RS, Nash D, Kimmel AD. Implementing parallel spreadsheet models for health policy decisions: The impact of unintentional errors on model projections. PLoS One 2018; 13:e0194916. [PMID: 29570737 PMCID: PMC5865740 DOI: 10.1371/journal.pone.0194916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 03/13/2018] [Indexed: 11/22/2022] Open
Abstract
Background Spreadsheet software is increasingly used to implement systems science models informing health policy decisions, both in academia and in practice where technical capacity may be limited. However, spreadsheet models are prone to unintentional errors that may not always be identified using standard error-checking techniques. Our objective was to illustrate, through a methodologic case study analysis, the impact of unintentional errors on model projections by implementing parallel model versions. Methods We leveraged a real-world need to revise an existing spreadsheet model designed to inform HIV policy. We developed three parallel versions of a previously validated spreadsheet-based model; versions differed by the spreadsheet cell-referencing approach (named single cells; column/row references; named matrices). For each version, we implemented three model revisions (re-entry into care; guideline-concordant treatment initiation; immediate treatment initiation). After standard error-checking, we identified unintentional errors by comparing model output across the three versions. Concordant model output across all versions was considered error-free. We calculated the impact of unintentional errors as the percentage difference in model projections between model versions with and without unintentional errors, using +/-5% difference to define a material error. Results We identified 58 original and 4,331 propagated unintentional errors across all model versions and revisions. Over 40% (24/58) of original unintentional errors occurred in the column/row reference model version; most (23/24) were due to incorrect cell references. Overall, >20% of model spreadsheet cells had material unintentional errors. When examining error impact along the HIV care continuum, the percentage difference between versions with and without unintentional errors ranged from +3% to +16% (named single cells), +26% to +76% (column/row reference), and 0% (named matrices). Conclusions Standard error-checking techniques may not identify all errors in spreadsheet-based models. Comparing parallel model versions can aid in identifying unintentional errors and promoting reliable model projections, particularly when resources are limited.
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Affiliation(s)
- Stephanie L. Bailey
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, United States of America
- Physics Department, University of California–Santa Cruz, Santa Cruz, California, United States of America
| | - Rose S. Bono
- Physics Department, University of California–Santa Cruz, Santa Cruz, California, United States of America
| | - Denis Nash
- Department of Epidemiology and Biostatistics, City University of New York, New York, United States of America
| | - April D. Kimmel
- Physics Department, University of California–Santa Cruz, Santa Cruz, California, United States of America
- * E-mail:
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Botha W, Donnolley N, Shanahan M, Chambers GM. Assessment of the societal and individual preferences for fertility treatment in Australia: study protocol for stated preference discrete choice experiments. BMJ Open 2018; 8:e020509. [PMID: 29444788 PMCID: PMC5829889 DOI: 10.1136/bmjopen-2017-020509] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION In Australia, societal and individual preferences for funding fertility treatment remain largely unknown. This has resulted in a lack of evidence about willingness to pay (WTP) for fertility treatment by either the general population (the funders) or infertile individuals (who directly benefit). Using a stated preference discrete choice experiment (SPDCE) approach has been suggested as a more appropriate method to inform economic evaluations of fertility treatment. We outline the protocol for an ongoing study which aims to assess fertility treatment preferences of both the general population and infertile individuals, and indirectly estimate their WTP for fertility treatment. METHODS AND ANALYSIS Two separate but related SPDCEs will be conducted for two population samples-the general population and infertile individuals-to elicit preferences for fertility treatment to indirectly estimate WTP. We describe the qualitative work to be undertaken to design the SPDCEs. We will use D-efficient fractional experimental designs informed by prior coefficients from the pilot surveys. The mode of administration for the SPDCE is also discussed. The final results will be analysed using mixed logit or latent class model. ETHICS AND DISSEMINATION This study is being funded by the Australian National Health and Medical Research Council (NHMRC) project grant AP1104543 and has been approved by the University of New South Wales Human Research Ethics Committee (HEC 17255) and a fertility clinic's ethics committee. Findings of the study will be disseminated in peer-reviewed journals and presented at various conferences. A lay summary of the results will be made publicly available on the University of New South Wales National Perinatal Epidemiology and Statistics Unit website. Our results will contribute to the development of an evidence-based policy framework for the provision of cost-effective and patient-centred fertility treatment in Australia.
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Affiliation(s)
- Willings Botha
- The National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health, University of New South Wales-Randwick Campus, Sydney, New South Wales, Australia
| | - Natasha Donnolley
- The National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health, University of New South Wales-Randwick Campus, Sydney, New South Wales, Australia
| | - Marian Shanahan
- National Drug and Alcohol Research Centre, University of New South Wales-Randwick Campus, Sydney, New South Wales, Australia
| | - Georgina M Chambers
- The National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health, University of New South Wales-Randwick Campus, Sydney, New South Wales, Australia
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28
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Nshimyumukiza L, Menon S, Hina H, Rousseau F, Reinharz D. Cell-free DNA noninvasive prenatal screening for aneuploidy versus conventional screening: A systematic review of economic evaluations. Clin Genet 2018; 94:3-21. [PMID: 29030960 DOI: 10.1111/cge.13155] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 04/24/2017] [Accepted: 04/26/2017] [Indexed: 12/28/2022]
Abstract
Although noninvasive prenatal testing (NIPT) for aneuploidies using cell-free fetal DNA in maternal blood has been reported to have a high accuracy, only little evidence about its cost-effectiveness is available. We systematically reviewed and assessed quality of economic evaluation studies published between January 1, 2009 and January 1, 2016 where NIPT was compared to the current screening practices consisting of biochemical markers with or without nuchal translucency (NT) and/or maternal age. We included 16 studies and we found that, at current level of NIPT prices, contingent NIPT provide the best value for money, especially for publicly funded screening programs. NIPT as first-line test was found not cost-effective in the majority of studies. The NIPT unit cost, the risk cut-offs for current screening practice, the screening uptake rates (first- and second-line screening) as well as the costs and uptake rates of invasive diagnostic screening were the most common uncertain variables. The overall quality of included studies was fair. Considering a possible drop in prices and an ongoing NIPT expansion to include other chromosomes abnormalities other than T21, T18, T13 and sex chromosomes aneuploidies, future research are needed to examine the potential cost-effectiveness of implementing NIPT as first-line test.
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Affiliation(s)
- L Nshimyumukiza
- Département de Médecine Sociale et Préventive, Faculté de Médecine, Université Laval, Quebec, Canada
| | - S Menon
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium
| | - H Hina
- Faculté des Sciences Infirmières, Université Laval, Quebec, Canada
| | - F Rousseau
- Centre de Recherche du Centre Hospitalier Universitaire de Québec, Quebec, Canada.,Département de Biologie Moléculaire, Biochimie Médicale et Pathologie, Faculté de Médecine, Université Laval, Quebec, Canada
| | - D Reinharz
- Département de Médecine Sociale et Préventive, Faculté de Médecine, Université Laval, Quebec, Canada
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D'Souza R, Shah PS, Sander B. Clinical decision analysis in perinatology. Acta Obstet Gynecol Scand 2017; 97:491-499. [PMID: 29164601 DOI: 10.1111/aogs.13264] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 11/15/2017] [Indexed: 11/27/2022]
Abstract
Clinical decision-making in perinatology involves trade-offs between two intricately related individuals - mother and fetus. Decision-making in perinatology is challenging due to competing interests of the mother and the fetus. Although decision analytic methods are increasingly used to develop processes for clinical and cost-effectiveness analyses in perinatology, there are no guidelines on the conduct and reporting of decision analysis studies that takes into account the complexities of the mother-fetus dyad. This article describes the basics of decision analysis and highlights areas that require special consideration in the perinatal context. It emphasizes the importance of obtaining patient preferences related to combined maternal-fetal health states, stresses the relevance of both maternal and offspring health outcomes over appropriate time horizons, and explains challenges around the use of quality-adjusted life years as an outcome measure in perinatology. It also provides insight into the complexities of dyad status in clinical and cost-effectiveness analyses in perinatology.
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Affiliation(s)
- Rohan D'Souza
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Prakesh S Shah
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Division of Neonatology, Department of Pediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Beate Sander
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Toronto Health Economics and Technology Assessment Collaborative, Toronto, Canada
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30
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Kibel M, Vanstone M. Reconciling ethical and economic conceptions of value in health policy using the capabilities approach: A qualitative investigation of Non-Invasive Prenatal Testing. Soc Sci Med 2017; 195:97-104. [PMID: 29169104 DOI: 10.1016/j.socscimed.2017.11.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 11/13/2017] [Accepted: 11/15/2017] [Indexed: 01/22/2023]
Abstract
When evaluating new morally complex health technologies, policy decision-makers consider a broad range of different evaluations, which may include the technology's clinical effectiveness, cost effectiveness, and social or ethical implications. This type of holistic assessment is challenging, because each of these evaluations may be grounded in different and potentially contradictory assumptions about the technology's value. One such technology where evaluations conflict is Non-Invasive Prenatal Testing (NIPT). Cost-effectiveness evaluations of NIPT often assess NIPT's ability to deliver on goals (i.e preventing the birth of children with disabilities) that social and ethical analyses suggest it should not have. Thus, cost effectiveness analyses frequently contradict social and ethical assessments of NIPT's value. We use the case of NIPT to explore how economic evaluations using a capabilities approach may be able to capture a broader, more ethical view of the value of NIPT. The capabilities approach is an evaluative framework which bases wellbeing assessments on a person's abilities, rather than their expressed preferences. It is linked to extra-welfarist approaches in health economic assessment. Beginning with Nussbaum's capability framework, we conducted a directed qualitative content analysis of interview data collected in 2014 from 27 Canadian women with personal experience of NIPT. We found that eight of Nussbaum's ten capabilities related to options, states, or choices that women valued in the context of NIPT, and identified one new capability. Our findings suggest that women value NIPT for its ability to provide more and different choices in the prenatal care pathway, and that a capabilities approach can indeed capture the value of NIPT in a way that goes beyond measuring health outcomes of ambiguous social and ethical value. More broadly, the capabilities approach may serve to resolve contradictions between ethical and economic evaluations of health technologies, and contribute to extra-welfarist approaches in the assessment of morally complex health technologies.
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Affiliation(s)
- Mia Kibel
- Arts and Science Program, McMaster University, Commons Building Room 105, 1280 Main Street West, Hamilton, Ontario, L8S 4K1, Canada.
| | - Meredith Vanstone
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre, 100 Main Street West, 5th Floor, Hamilton, Ontario, L8P 1H6, Canada; Centre for Health Economics and Policy Analysis, McMaster University, Canada; McMaster program for Education Research, Innovation & Theory, McMaster University, Canada.
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31
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Majzoub A, Agarwal A, Esteves SC. Sperm DNA fragmentation: a rationale for its clinical utility. Transl Androl Urol 2017; 6:S455-S456. [PMID: 29082933 PMCID: PMC5643606 DOI: 10.21037/tau.2017.03.63] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Ahmad Majzoub
- Department of Urology, Hamad Medical Corporation, Doha, Qatar
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, Campinas, SP, Brazil
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Esteves SC, Agarwal A, Cho CL, Majzoub A. A Strengths-Weaknesses-Opportunities-Threats (SWOT) analysis on the clinical utility of sperm DNA fragmentation testing in specific male infertility scenarios. Transl Androl Urol 2017; 6:S734-S760. [PMID: 29082207 PMCID: PMC5643602 DOI: 10.21037/tau.2017.08.20] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Sperm DNA fragmentation (SDF) is recognized as a leading cause of male infertility because it can impair the paternal genome through distinct pathophysiological mechanisms. Current evidence supports SDF as a major factor in the pathophysiology of several conditions, including varicocele, unexplained infertility, assisted reproductive technology failure, and environmental lifestyle factors, although the mechanisms involved have not been fully described yet. Measurement of the levels of DNA fragmentation in semen provides valuable information on the integrity of paternal chromatin and may guide therapeutic strategies. A recently published clinical practice guideline (CPG) highlighted how to use the information provided by SDF testing in daily practice, which triggered a series of commentaries by leading infertility experts. These commentaries contained an abundance of information and conflicting views about the clinical utility of SDF testing, which underline the complex nature of SDF. Methods A search of papers published in response to the CPG entitled “Clinical utility of sperm DNA fragmentation testing: practice recommendations based on clinical scenarios” was performed within the Translational Andrology and Urology (TAU) website (http://tau.amegroups.com/). The start and end dates for the search were May 2017 and August 2017, respectively. Each commentary meeting our inclusion criteria was rated as “supportive without reservation”, “supportive with reservation”, “not supportive” or “neutral”. We recorded whether articles discussed either SDF characteristics as a laboratory test method or clinical scenarios, or both. Subsequently, we extracted the particulars from each commentary and utilized the ‘Strengths-Weaknesses-Opportunities-Threats’ (SWOT) analysis to understand the perceived advantages and drawbacks of SDF as a specialized sperm function method in clinical practice. Results Fifty-eight fertility experts from six continents and twenty-two countries contributed commentaries. Overall, participants (87.9%; n=51) were supportive of the recommendations provided by the CPG on the utility of SDF testing based on clinical scenarios. The majority of participants made explicit remarks about both the clinical scenarios and SDF assays’ characteristics. Among ‘not supportive’ and ‘supportive with reservation’ participants, 75% (n=30/40) and 77.5% (n=31/40) expressed concerns related to technical limitations of SDF testing methods and clinical utility of the test in one or more clinical scenarios discussed in the CPG, respectively. The SWOT analysis revealed that the CPG provides a reasonable evidence-based proposal for integration of SDF testing in the routine daily practice. It also uncovered gaps of knowledge and threats limiting the widespread application of SDF in everyday practice, thus allowing the identification of opportunities to further refine SDF testing and its clinical utility. Conclusions The understanding of the role of SDF in male infertility requires an in-depth analysis of the multifactorial pathophysiological processes and the theories involved. The SWOT analysis allowed an objective evaluation of CPG on the clinical utility of SDF testing based on clinical scenarios and its accompanying commentaries written by global experts in all possible angles. Implementation of SDF testing in the clinic may not only increase the outcome of ART but more importantly improve the health of both fathers to be and resulting offspring.
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Affiliation(s)
- Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, Campinas, SP, Brazil.,Division of Urology, Department of Surgery, Universtity of Campinas (UNICAMP), SP, Brazil.,Faculty of Health, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Ashok Agarwal
- American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Chak-Lam Cho
- Division of Urology, Department of Surgery, Kwong Wah Hospital, Hong Kong, China
| | - Ahmad Majzoub
- Department of Urology, Hamad Medical Corporation, Doha, Qatar
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Gariepy A, Lundsberg LS, Vilardo N, Stanwood N, Yonkers K, Schwarz EB. Pregnancy context and women's health-related quality of life. Contraception 2017; 95:491-499. [PMID: 28188745 PMCID: PMC5466832 DOI: 10.1016/j.contraception.2017.02.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 01/31/2017] [Accepted: 02/01/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective was to quantify the association of pregnancy context and health-related quality of life (HRQoL). STUDY DESIGN English- or Spanish-speaking women, aged 16-44, with pregnancies <24 weeks' gestation were enrolled in this cross-sectional study between June 2014 and June 2015. Participants completed self-assessments of pregnancy "context," including timing, intention, wantedness, desirability, happiness, and planning (measured with the London Measure of Unplanned Pregnancy). HRQoL was measured using the Patient Reported Outcomes Measurement Information System Global Short Form. Associations between measures of pregnancy context and HRQoL scores in the lowest tertile were examined using multivariable logistic regression to adjust for potential confounding variables. RESULTS We enrolled 161 participants (mean age=27.2±6.6 years). Only 14% self-identified as White, non-Hispanic; 42% Hispanic; 37% Black, non-Hispanic; and 7% multiracial. Most (79%) participants were unmarried, and 75% were parenting. Mean gestational age was 9±4.6 weeks. In unadjusted models, women reporting mixed feelings about wanting to have a baby, an undesired pregnancy or feeling unhappy about learning of their pregnancy more frequently had low mental and physical HRQoL compared to women reporting wanted, desired, happy pregnancies. Women with an unplanned pregnancy or pregnancy occurring at the wrong time also had lower physical HRQoL than women reporting pregnancies that were planned or happened at the right time. However, after multivariate adjustment, including history of depression, pregnancy contexts were not associated with low mental or physical HRQoL. CONCLUSIONS After adjusting for multiple confounders, pregnancy context is not significantly associated with HRQoL. IMPLICATIONS The focus on pregnancy intention in public health programs may not sufficiently assess multidimensional aspects of pregnancy context and may not align with patient-centered outcomes such as HRQoL.
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Affiliation(s)
- Aileen Gariepy
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT.
| | - Lisbet S Lundsberg
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Nicole Vilardo
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Nancy Stanwood
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Kimberly Yonkers
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT; Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - Eleanor B Schwarz
- Department of Internal Medicine, University of California, Davis, CA
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34
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Murdoch B, Ravitsky V, Ogbogu U, Ali-Khan S, Bertier G, Birko S, Bubela T, De Beer J, Dupras C, Ellis M, Granados Moreno P, Joly Y, Kamenova K, Master Z, Marcon A, Paulden M, Rousseau F, Caulfield T. Non-invasive Prenatal Testing and the Unveiling of an Impaired Translation Process. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:10-17. [DOI: 10.1016/j.jogc.2016.09.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 08/29/2016] [Indexed: 12/15/2022]
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35
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Myers ER. How Should We Estimate the Cost-effectiveness of Interventions That Affect Reproduction? Med Decis Making 2015; 35:812-4. [PMID: 26296618 DOI: 10.1177/0272989x15602227] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 07/31/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Evan R Myers
- Department of Obstetrics and Gynecology and Duke Evidence-based Practice Center, Duke University Medical Center, Durham, NC (ERM)
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