1
|
St Martin B, Markowitz MA, Myers ER, Lundsberg LS, Ringel N. Estimated National Cost of Pelvic Organ Prolapse Surgery in the United States. Obstet Gynecol 2024; 143:419-427. [PMID: 38128098 DOI: 10.1097/aog.0000000000005485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/16/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To estimate the national cost of pelvic organ prolapse (POP) surgery in the United States. METHODS In this cross-sectional, population-based study, we used the 2016-2018 Healthcare Cost and Utilization Project National Inpatient Samples and National Ambulatory Surgery Samples to identify patients undergoing POP surgery using International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes, ICD-10 procedural codes, and Current Procedural Terminology codes. Cost-to-charge ratios and weighted estimates were used to calculate nationwide costs. Descriptive analysis was used to identify the sociodemographic, clinical, and surgical characteristics of the population undergoing POP surgery. RESULTS Between 2016 and 2018, there were 140,762 POP surgical cases annually with an annual national cost estimated at $1.523 billion per year. The median cost per procedure increased slightly from $8,837 in 2016 to $8,958 in 2018. Overall, 82.5% of the total surgeries and 78% of the total national costs associated with POP surgery came from the ambulatory setting over this time period. Of these surgeries, 44.7% included an apical repair, and 42.3% included a concomitant hysterectomy. The average age of the population was 62 years, and 20% of the total population receiving prolapse surgery were younger than age 50 years. CONCLUSION The annual national cost associated with surgical correction of POP is substantial, and the majority of cases occur in an ambulatory setting. These findings will contribute to enhancing cost-effectiveness analyses and decision-making processes for both health care professionals and policymakers as the national population continues to age.
Collapse
Affiliation(s)
- Brad St Martin
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut; and the Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina
| | | | | | | | | |
Collapse
|
2
|
Petrick JL, Joslin CE, Johnson CE, Camacho TF, Peres LC, Bandera EV, Barnard ME, Beeghly A, Bethea TN, Dempsey LF, Guertin K, Harris HR, Moorman PG, Myers ER, Ochs-Balcom HM, Rosenow W, Setiawan VW, Wu AH, Schildkraut JM, Rosenberg L. Menopausal hormone therapy use and risk of ovarian cancer by race: the ovarian cancer in women of African ancestry consortium. Br J Cancer 2023; 129:1956-1967. [PMID: 37865688 PMCID: PMC10703895 DOI: 10.1038/s41416-023-02407-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 08/01/2023] [Accepted: 08/17/2023] [Indexed: 10/23/2023] Open
Abstract
BACKGROUND Most studies examining post-menopausal menopausal hormone therapy (MHT) use and ovarian cancer risk have focused on White women and few have included Black women. METHODS We evaluated MHT use and ovarian cancer risk in Black (n = 800 cases, 1783 controls) and White women (n = 2710 cases, 8556 controls), using data from the Ovarian Cancer in Women of African Ancestry consortium. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association of MHT use with ovarian cancer risk, examining histotype, MHT type and duration of use. RESULTS Long-term MHT use, ≥10 years, was associated with an increased ovarian cancer risk for White women (OR = 1.38, 95%CI: 1.22-1.57) and the association was consistent for Black women (OR = 1.20, 95%CI: 0.81-1.78, pinteraction = 0.4). For White women, the associations between long-term unopposed estrogen or estrogen plus progesterone use and ovarian cancer risk were similar; the increased risk associated with long-term MHT use was confined to high-grade serous and endometroid tumors. Based on smaller numbers for Black women, the increased ovarian cancer risk associated with long-term MHT use was apparent for unopposed estrogen use and was predominately confined to other epithelial histotypes. CONCLUSION The association between long-term MHT use and ovarian cancer risk was consistent for Black and White women.
Collapse
Affiliation(s)
| | - Charlotte E Joslin
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago School of Medicine, Chicago, IL, USA
- Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health, Chicago, IL, USA
| | - Courtney E Johnson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - T Fabian Camacho
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Lauren C Peres
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Elisa V Bandera
- Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | | | - Alicia Beeghly
- Department of Medicine, Division of Epidemiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Traci N Bethea
- Office of Minority Health and Health Disparities Research, Georgetown Lombardi Comprehensive Cancer Center, Georgetown University Medical Campus, Washington, DC, USA
| | - Lauren F Dempsey
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kristin Guertin
- Department of Public Health Sciences, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Holly R Harris
- Program in Epidemiology, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
| | - Patricia G Moorman
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Evan R Myers
- Department of Family Medicine and Community Health, Duke University Medical Center, Durham, NC, USA
| | - Heather M Ochs-Balcom
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Will Rosenow
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - V Wendy Setiawan
- University of Southern California Norris Comprehensive Cancer Center and Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA, USA
| | - Anna H Wu
- University of Southern California Norris Comprehensive Cancer Center and Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA, USA
| | - Joellen M Schildkraut
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lynn Rosenberg
- Slone Epidemiology Center at Boston University, Boston, MA, USA
| |
Collapse
|
3
|
Federspiel JJ, Wein LE, Duggal R, Myers ER, Boggess KA, James AH. Projected impact of guidelines on incidence of venous thromboembolism after cesarean delivery in the United States. J Thromb Haemost 2023; 21:3547-3556. [PMID: 37659859 PMCID: PMC10840688 DOI: 10.1016/j.jtha.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 07/27/2023] [Accepted: 08/07/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND There is large variation in recommended for postcesarean delivery venous thromboembolism (VTE) prophylaxis among commonly used guidelines. OBJECTIVES The aim of the study is to estimate implications of adoption of VTE prevention guidelines for rates of receipt of VTE prophylactic therapy and VTE following cesarean delivery (CD). METHODS We used administrative data from the 2015-2019 Nationalwide Readmissions Database to identify cesarean deliveries and rates of VTE stratified by risk factors, leading to different prophylactic strategies based on several national guidelines. We used input parameters from the literature to construct a hybrid decision tree/Markov model to project the implications of guideline adoption on VTE rates for the first 6 weeks following delivery. RESULTS Adoption of either the 2011 American College of Obstetricians and Gynecologists or the 2018 American Society for Hematology guidelines would avert a relatively small proportion (5%) of VTE cases, albeit with little low-molecular-weight heparin (LMWH) use (87-115 doses per 1000 CD patients). The 2012 American College of Chest Physicians guidelines were predicted to be more effective at averting VTE (21.2% reduction) with more LMWH usage (570 doses per 1000 deliveries). The 2015 Royal College of Obstetricians and Gynaecologists guidelines and universal use of 6 weeks of LMWH would avert an even larger proportion of cases (37.4% and 57.6%, respectively), at the cost of much higher rates of LMWH utilization (7233 doses per 1000 patients and 38 648 doses per 1000 patients). CONCLUSIONS Adoption of different guidelines would have notably varying implications for clinical practice and potential for alteration of the national rate of VTE following CD.
Collapse
Affiliation(s)
- Jerome J Federspiel
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA; Department of Gynecology and Obstetrics, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
| | - Lauren E Wein
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ryan Duggal
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Evan R Myers
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kimberly A Boggess
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Andra H James
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| |
Collapse
|
4
|
Sereda Y, Alarid-Escudero F, Bickell NA, Chang SH, Colditz GA, Hur C, Jalal H, Myers ER, Layne TM, Wang SY, Yeh JM, Trikalinos TA. Approaches to developing de novo cancer population models to examine questions about cancer and race in bladder, gastric, and endometrial cancer and multiple myeloma: the Cancer Intervention and Surveillance Modeling Network incubator program. J Natl Cancer Inst Monogr 2023; 2023:219-230. [PMID: 37947329 PMCID: PMC11009510 DOI: 10.1093/jncimonographs/lgad021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND We are developing 10 de novo population-level mathematical models in 4 malignancies (multiple myeloma and bladder, gastric, and uterine cancers). Each of these sites has documented disparities in outcome that are believed to be downstream effects of systemic racism. METHODS Ten models are being independently developed as part of the Cancer Intervention and Surveillance Modeling Network incubator program. These models simulate trends in cancer incidence, early diagnosis, treatment, and mortality for the general population and are stratified by racial subgroup. Model inputs are based on large population datasets, clinical trials, and observational studies. Some core parameters are shared, and other parameters are model specific. All models are microsimulation models that use self-reported race to stratify model inputs. They can simulate the distribution of relevant risk factors (eg, smoking, obesity) and insurance status (for multiple myeloma and uterine cancer) in US birth cohorts and population. DISCUSSION The models aim to refine approaches in prevention, detection, and management of 4 cancers given uncertainties and constraints. They will help explore whether the observed racial disparities are explainable by inequities, assess the effects of existing and potential cancer prevention and control policies on health equity and disparities, and identify policies that balance efficiency and fairness in decreasing cancer mortality.
Collapse
Affiliation(s)
- Yuliia Sereda
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, RI, USA
| | - Fernando Alarid-Escudero
- Department of Health Policy, School of Medicine, and Stanford Health Policy, Freeman-Spogli Institute for International Studies, Stanford University, Stanford, CA, USA
| | - Nina A Bickell
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, WA University School of Medicine, St Louis, MO, USA
| | - Graham A Colditz
- Division of Public Health Sciences, Department of Surgery, WA University School of Medicine, St Louis, MO, USA
| | - Chin Hur
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Hawre Jalal
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, USA
| | - Tracy M Layne
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Blavatnik Family Women’s Health Research Institute and Center for Scientific Diversity, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shi-Yi Wang
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, CT, USA
- Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale University School of Medicine, New Haven, CT, USA
| | - Jennifer M Yeh
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA, USA
| | - Thomas A Trikalinos
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, RI, USA
- Departments of Health Services, Policy, & Practice and of Biostatistics, Brown University School of Public Health, Providence, RI, USA
| |
Collapse
|
5
|
Albright BB, Heyward QD, Erkanli A, Loehrer AP, Myers ER, Havrilesky LJ, Moss HA. Geographic variation in the rate and route of hysterectomy for benign disease in the USA: A retrospective cross-sectional study. BJOG 2023; 130:1502-1510. [PMID: 37132056 PMCID: PMC10593101 DOI: 10.1111/1471-0528.17509] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 04/02/2023] [Accepted: 04/07/2023] [Indexed: 05/04/2023]
Abstract
OBJECTIVES To describe population rate of hysterectomy for benign disease in the USA, including geographic variation across states and Hospital Service Areas (HSAs; areas defined by common patient flows to healthcare facilities). DESIGN Cross-sectional study. SETTING Four US states including 322 HSAs. POPULATION A total of 316 052 cases of hysterectomy from 2012 to 2016. METHODS We compiled annual hysterectomy cases, merged female populations, and adjusted for reported rates of previous hysterectomy. We assessed small-area variation and created multi-level Poisson regression models. MAIN OUTCOME MEASURES Prior-hysterectomy-adjusted population rates of hysterectomy for benign disease. RESULTS The annual population rate of hysterectomy for benign disease was 49 per 10 000 hysterectomy-eligible residents, declining slightly over time, mostly among reproductive-age populations. Rates peaked among residents ages 40-49 years, and declined with increasing age, apart from an increase with universal coverage at age 65 years. We found large differences in age-standardised population rates of hysterectomy across states (range 42.2-69.0), and HSAs (range: overall 12.9-106.3; 25th-75th percentile 44.0-64.9). Among the non-elderly population, those with government-sponsored insurance had greater variation than those with private insurance (coefficient of variation 0.61 versus 0.32). Proportions of minimally invasive procedures were similar across states (71.0-74.8%) but varied greatly across HSAs (27-96%). In regression models, HSA population characteristics explained 31.8% of observed variation in annual rates. Higher local proportions of government-sponsored insurance and non-White race were associated with lower population rates. CONCLUSIONS We found substantial variation in rate and route of hysterectomy for benign disease in the USA. Local population characteristics explained less than one-third of observed variation.
Collapse
Affiliation(s)
- Benjamin B. Albright
- Department of Obstetrics and Gynecology, Duke University Medical Center, 20 Duke Medicine Circle, Durham, NC, USA
| | - Quetrell D. Heyward
- Department of Obstetrics and Gynecology, University of Pennsylvania Health System, 3400 Spruce Street, Philadelphia, PA, USA
| | - Alaattin Erkanli
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, 40 Duke Medicine Circle, Durham, NC, USA
| | - Andrew P. Loehrer
- Department of Surgery, Dartmouth Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH, USA
| | - Evan R. Myers
- Department of Obstetrics and Gynecology, Duke University Medical Center, 20 Duke Medicine Circle, Durham, NC, USA
| | - Laura J. Havrilesky
- Department of Obstetrics and Gynecology, Duke University Medical Center, 20 Duke Medicine Circle, Durham, NC, USA
| | - Haley A. Moss
- Department of Obstetrics and Gynecology, Duke University Medical Center, 20 Duke Medicine Circle, Durham, NC, USA
| |
Collapse
|
6
|
Cate JJM, Sundermann AC, Campbell AIK, Sugrue R, Dotters-Katz SK, James AH, Myers ER, Federspiel JJ. High rates of venous thromboembolism among deliveries complicated by cancer. J Thromb Haemost 2023; 21:2854-2862. [PMID: 37353083 PMCID: PMC10560586 DOI: 10.1016/j.jtha.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/01/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) risk is increased independently by both cancer and pregnancy. OBJECTIVES To estimate VTE risk in the postpartum period among patients delivering with a cancer diagnosis, stratified by cancer type and delivery route. METHODS We performed a retrospective cohort study utilizing the large, all-payer Nationwide Readmissions Database from October 2015 through December 2020. We identified delivery hospitalizations, cancer diagnoses, and VTE using patient demographics and diagnosis codes. The primary outcome was VTE incidence at 42 and 330 days from delivery admission date, comparing patients with and without cancer diagnoses. A secondary analysis included VTE risk stratified by cancer diagnosis and delivery route. Outcomes were compared using inverse probability-weighted survival curves. RESULTS The study population included 9 793 503 delivery hospitalizations (weighted estimate, 18 207 346), with a weighted estimate of 10 428 (0.06%) pregnant patients with cancer. Individuals with cancer were older, with higher rates of comorbid conditions, than those without cancer. VTE incidence in individuals with cancer at 42 and 330 days was 1.11% and 2.19%, respectively, vs 0.11% and 0.14%, respectively, in those without cancer. At 330 days, this finding was significant in both unadjusted (relative risk, 15.52; 95% CI, 11.54-19.51) and adjusted (relative risk, 9.68; 95% CI, 7.18-12.18) models. Stratification by cancer type and delivery route demonstrated elevated VTE risk across cancer types, with cesarean delivery conferring a greater risk. CONCLUSION Cancer in pregnancy confers excess thromboembolic risk extending beyond the immediate postpartum period. Further study is needed to identify optimal VTE prophylactic strategies for this population.
Collapse
Affiliation(s)
- Jennifer J M Cate
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA. https://twitter.com/healthyhappydoc
| | - Alexandra C Sundermann
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Ronan Sugrue
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sarah K Dotters-Katz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andra H James
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jerome J Federspiel
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| |
Collapse
|
7
|
Colman DE, Beltran TG, Weber JM, Erkanli A, Robinson WR, Myers ER, Gray BA. Patient and Surgery Characteristics of Inpatient Hysterectomies Among Transgender Individuals. LGBT Health 2023; 10:544-551. [PMID: 37252769 PMCID: PMC10574525 DOI: 10.1089/lgbt.2022.0388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
Purpose: The purpose of this study is to estimate population-based rates of inpatient hysterectomy and accompanying bilateral salpingo-oophorectomy by indication and evaluate surgical patient characteristics by indication, year, patient age, and hospital location. Methods: We used 2016 and 2017 cross-sectional data from the Nationwide Inpatient Sample to estimate the hysterectomy rate for individuals aged 18-54 years with a primary indication for gender-affirming care (GAC) compared to other indications. Outcome measures were population-based rates for inpatient hysterectomy and bilateral salpingo-oophorectomy by indication. Results: The population-based rate of inpatient hysterectomy for GAC per 100,000 was 0.05 (95% confidence interval [CI] = 0.02-0.09) in 2016 and 0.09 (95% CI = 0.03-0.15) in 2017. For comparison, the rates per 100,000 for fibroids were 85.76 in 2016 and 73.25 in 2017. Rates of bilateral salpingo-oophorectomy in the setting of hysterectomy were higher in the GAC group (86.4%) than in comparison groups (22.7%-44.1% for all other benign indications, 77.4% for cancer) across all age ranges. A higher rate of hysterectomies performed for GAC was done laparoscopically or robotically (63.6%) than other indications, and none was done vaginally, as opposed to comparison groups (0.7%-9.8%). Conclusion: The population-based rate for GAC was higher in 2017 compared to 2016 and low compared to other hysterectomy indications. Rates of concomitant bilateral salpingo-oophorectomy were more prevalent for GAC than for other indications at similar ages. The patients in the GAC group tended to be younger, insured, and most procedures occurred in the Northeast (45.5%) and West (36.4%).
Collapse
Affiliation(s)
- Drew E. Colman
- Department of Combined Internal Medicine and Pediatrics, Los Angeles County+University of Southern California Medical Center, Los Angeles, California, USA
| | - Theo G. Beltran
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jeremy M. Weber
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Alaattin Erkanli
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Whitney R. Robinson
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Evan R. Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Beverly A. Gray
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| |
Collapse
|
8
|
Sundermann AC, Cate JM, Campbell AK, Dotters-Katz SK, Myers ER, Federspiel JJ. Maternal morbidity and mortality among patients with cancer at time of delivery. Am J Obstet Gynecol 2023; 229:324.e1-324.e7. [PMID: 37295633 PMCID: PMC10593119 DOI: 10.1016/j.ajog.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Individuals with cancer during pregnancy are a medically complex patient population that is anticipated to grow. A better understanding of this population and patterns of risk at time of delivery would offer an opportunity for providers to mitigate maternal morbidity. OBJECTIVE This study aimed to estimate the prevalence in the United States of concurrent cancer diagnoses at time of delivery by cancer type and associated maternal morbidity and mortality. STUDY DESIGN Using the National Inpatient Sample, we identified delivery-associated hospitalizations between 2007 and 2018. Concurrent cancer diagnoses were classified using the Clinical Classifications Software. Main outcomes included severe maternal morbidity, as defined by the Centers for Disease Control and Prevention indicators, and mortality during delivery hospitalization. We calculated adjusted rates for cancer diagnosis at time of delivery and adjusted odds ratios of severe maternal morbidity and maternal death during hospitalization using survey-weighted multivariable logistic regression models. RESULTS In this sample of 9,418,761 delivery-associated hospitalizations, 63 per 100,000 deliveries had a concurrent cancer diagnosis (95% confidence interval, 60-66; national weighted estimate, 46,654,042). The most common cancer types were breast cancer (8.4 per 100,000 deliveries), leukemia (8.4 per 100,000 deliveries), Hodgkin lymphoma (7.4 per 100,000 deliveries), non-Hodgkin lymphoma (5.4 per 100,000 deliveries), and thyroid cancer (4.0 per 100,000 deliveries). Patients with cancer were at significantly higher risk for any severe maternal morbidity (adjusted odds ratio, 5.25; 95% confidence interval, 4.73-5.83) and maternal death (adjusted odds ratio, 67.5; 95% confidence interval, 45.1-101.4). Risks of hysterectomy (adjusted odds ratio, 16.92; 95% confidence interval, 13.96-20.52), acute respiratory distress (adjusted odds ratio, 12.76; 95% confidence interval, 9.92-16.42), sepsis (adjusted odds ratio, 11.91; 95% confidence interval, 8.68-16.32), and embolism (adjusted odds ratio, 11.12; 95% confidence interval, 6.94-17.82) were particularly heightened among patients with cancer. Patients with leukemia, specifically, had the highest risk of adverse maternal outcomes (adjusted rate, 113 per 1000 deliveries; 95% confidence interval, 91-135 per 1000) when evaluating risk by cancer type. CONCLUSION Patients with cancer are at markedly increased risk of maternal morbidity and all-cause mortality during delivery-associated hospitalization. Risk is distributed unevenly within this population, with certain cancer types carrying unique risks for specific morbidity events.
Collapse
Affiliation(s)
| | - Jennifer M Cate
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Alexa K Campbell
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Sarah K Dotters-Katz
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Jerome J Federspiel
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| |
Collapse
|
9
|
Anchan RM, Spies JB, Zhang S, Wojdyla D, Bortoletto P, Terry K, Disler E, Milne A, Gargiulo A, Petrozza J, Brook O, Srouji S, Morton CC, Greenberg J, Wegienka G, Stewart EA, Nicholson WK, Thomas L, Venable S, Laughlin-Tommaso S, Diamond MP, Maxwell GL, Marsh EE, Myers ER, Vines AI, Wise LA, Wallace K, Jacoby VL. Long-term health-related quality of life and symptom severity following hysterectomy, myomectomy, or uterine artery embolization for the treatment of symptomatic uterine fibroids. Am J Obstet Gynecol 2023; 229:275.e1-275.e17. [PMID: 37244458 DOI: 10.1016/j.ajog.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 05/15/2023] [Accepted: 05/21/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Few studies have directly compared different surgical procedures for uterine fibroids with respect to long-term health-related quality of life outcomes and symptom improvement. OBJECTIVE We examined differences in change from baseline to 1-, 2-, and 3-year follow-up in health-related quality of life and symptom severity among patients who underwent abdominal myomectomy, laparoscopic or robotic myomectomy, abdominal hysterectomy, laparoscopic or robotic hysterectomy, or uterine artery embolization. STUDY DESIGN The COMPARE-UF registry is a multiinstitutional prospective observational cohort study of women undergoing treatment for uterine fibroids. A subset of 1384 women aged 31 to 45 years who underwent either abdominal myomectomy (n=237), laparoscopic myomectomy (n=272), abdominal hysterectomy (n=177), laparoscopic hysterectomy (n=522), or uterine artery embolization (n=176) were included in this analysis. We obtained demographics, fibroid history, and symptoms by questionnaires at enrollment and at 1, 2, and 3 years posttreatment. We used the UFS-QoL (Uterine Fibroid Symptom and Quality of Life) questionnaire to ascertain symptom severity and health-related quality of life scores among participants. To account for potential baseline differences across treatment groups, a propensity score model was used to derive overlap weights and compare total health-related quality of life and symptom severity scores after enrollment with a repeated measures model. For this health-related quality of life tool, a specific minimal clinically important difference has not been determined, but on the basis of previous research, a difference of 10 points was considered as a reasonable estimate. Use of this difference was agreed upon by the Steering Committee at the time when the analysis was planned. RESULTS At baseline, women undergoing hysterectomy and uterine artery embolization reported the lowest health-related quality of life scores and highest symptom severity scores compared with those undergoing abdominal myomectomy or laparoscopic myomectomy (P<.001). Those undergoing hysterectomy and uterine artery embolization reported the longest duration of fibroid symptoms with a mean of 6.3 years (standard deviation, 6.7; P<.001). The most common fibroid symptoms were menorrhagia (75.3%), bulk symptoms (74.2%), and bloating (73.2%). More than half (54.9%) of participants reported anemia, and 9.4% women reported a history of blood transfusion. Across all modalities, total health-related quality of life and symptom severity score markedly improved from baseline to 1-year with the largest improvement in the laparoscopic hysterectomy group (Uterine Fibroids Symptom and Quality of Life: delta= [+] 49.2; symptom severity: delta= [-] 51.3). Those undergoing abdominal myomectomy, laparoscopic myomectomy, and uterine artery embolization also demonstrated significant improvement in health-related quality of life (delta= [+]43.9, [+]32.9, [+]40.7, respectively) and symptom severity (delta= [-]41.4, [-] 31.5, [-] 38.5, respectively) at 1 year, and the improvement persisted from baseline for uterine-sparing procedures during second (Uterine Fibroids Symptom and Quality of Life: delta= [+]40.7, [+]37.4, [+]39.3 SS: delta= [-] 38.5, [-] 32.0, [-] 37.7 and third year (Uterine Fibroids Symptom and Quality of Life: delta= [+] 40.9, [+]39.9, [+]41.1 and SS: delta= [-] 33.9, [-]36.5, [-] 33.0, respectively), posttreatment intervals, however with a trend toward decline in degree of improvement from years 1 and 2. Differences from baseline were greatest for hysterectomy; however, this may reflect the relative importance of bleeding in the Uterine Fibroids Symptom and Quality of Life, rather than clinically meaningful symptom recurrence among women undergoing uterus-sparing treatments. CONCLUSION All treatment modalities were associated with significant improvements in health-related quality of life and symptom severity reduction 1-year posttreatment. However, abdominal myomectomy, laparoscopic myomectomy and uterine artery embolization indicated a gradual decline in symptom improvement and health-related quality of life by third year after the procedure.
Collapse
Affiliation(s)
- Raymond M Anchan
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Biostatistics, Yale School of Public Health, New Haven CT.
| | - James B Spies
- Department of Radiology, Georgetown University School of Medicine, Washington, DC
| | - Shuaiqi Zhang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Pietro Bortoletto
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, NY
| | - Kathryn Terry
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Emily Disler
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ankrish Milne
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Antonio Gargiulo
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - John Petrozza
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Olga Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Serene Srouji
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Cynthia C Morton
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Broad Institute of MIT and Harvard, Cambridge, MA; Manchester Centre for Audiology and Deafness, School of Health Sciences, University of Manchester, United Kingdom
| | - James Greenberg
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ganesa Wegienka
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI
| | - Elizabeth A Stewart
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN; Department of Surgery, Mayo Clinic, Rochester, MN
| | - Wanda K Nicholson
- Department of Obstetrics & Gynecology, Center for Women's Health Research, and Center for Health Promotion and Disease Prevention, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Laine Thomas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | | | - Shannon Laughlin-Tommaso
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN; Department of Surgery, Mayo Clinic, Rochester, MN
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, GA
| | - G Larry Maxwell
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, VA
| | - Erica E Marsh
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC
| | - Anissa I Vines
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lauren A Wise
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
| | - Kedra Wallace
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS
| | - Vanessa L Jacoby
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA; Department of Radiology, Georgetown University School of Medicine, Washington, DC
| |
Collapse
|
10
|
Robinson WR, Mathias JG, Wood ME, Anderson LG, Howard AG, Carey ET, Nicholson WK, Carey TS, Myers ER, Stürmer T, Doll KM. Ethnoracial Differences in Premenopausal Hysterectomy: The Role of Symptom Severity. Obstet Gynecol 2023; 142:350-359. [PMID: 37473411 PMCID: PMC10351903 DOI: 10.1097/aog.0000000000005225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/13/2023] [Accepted: 03/10/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE To evaluate whether greater symptom severity can explain higher hysterectomy rates among premenopausal non-Hispanic Black compared with White patients in the U.S. South rather than potential overtreatment of Black patients. METHODS Using electronic health record data from 1,703 patients who underwent hysterectomy in a large health care system in the U.S. South between 2014 and 2017, we assessed symptom severity to account for differences in hysterectomy rates for noncancerous conditions among premenopausal non-Hispanic Black, non-Hispanic White, and Hispanic patients. We used Poisson generalized linear mixed modeling to estimate symptom severity (greater than the 75th percentile on composite symptom severity scores of bleeding, bulk, or pelvic pain) as a function of race-ethnicity. We calculated prevalence ratios (PRs). We controlled for factors both contra-indicating and contributing to hysterectomy. RESULTS The overall median age of non-Hispanic White (n=1,050), non-Hispanic Black (n=565), and Hispanic (n=158) patients was 40 years. The White and Black patients were mostly insured (insured greater than 95%), whereas the Hispanic patients were often uninsured (insured 58.9%). White and Black patients were mostly treated outside academic medical centers (nonmedical center: 63.7% and 58.4%, respectively); the opposite was true for Hispanic patients (nonmedical center: 34.2%). Black patients had higher bleeding severity scores compared with Hispanic and White patients (median 8, 7, and 4 respectively) and higher bulk scores (median 3, 1, and 0, respectively), but pain scores differed (median 3, 5, and 4, respectively). Black and Hispanic patients were disproportionately likely to have severe symptoms documented on two or more symptoms (referent: not severe on any symptoms) (adjusted PR [Black vs White] 3.02, 95% CI 2.29-3.99; adjusted PR [Hispanic vs White] 2.61, 95% CI 1.78-3.83). Although Black and Hispanic patients were more likely to experience severe symptoms, we found no racial and ethnic differences in the number of alternative treatments attempted before hysterectomy. CONCLUSION We did not find evidence of overtreatment of Black patients. Our findings suggest potential undertreatment of Black and Hispanic patients with uterine-sparing alternatives earlier in their disease progression.
Collapse
Affiliation(s)
- Whitney R Robinson
- Division of Women's Community and Population Health, Department of Obstetrics and Gynecology, Duke University School of Medicine, the Margolis Center for Health Policy, Duke University, and the Duke-UNC Alzheimer's Disease Research Center, Durham, the Department of Epidemiology and the Department of Biostatistics, Gillings School of Global Public Health, the Carolina Population Center, and the Department of Obstetrics and Gynecology and the Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; the Department of Prevention and Community Health, George Washington Milken Institute of Public Health, Washington, DC; and the Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Borre ED, Johri M, Dubno JR, Myers ER, Emmett SD, Pavon JM, Francis HW, Ogbuoji O, Sanders Schmidler GD. Potential Clinical and Economic Outcomes of Over-the-Counter Hearing Aids in the US. JAMA Otolaryngol Head Neck Surg 2023; 149:607-614. [PMID: 37200042 PMCID: PMC10196927 DOI: 10.1001/jamaoto.2023.0949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/28/2023] [Indexed: 05/19/2023]
Abstract
Importance Over-the-counter (OTC) hearing aids are now available in the US; however, their clinical and economic outcomes are unknown. Objective To project the clinical and economic outcomes of traditional hearing aid provision compared with OTC hearing aid provision. Design, Setting, and Participants This cost-effectiveness analysis used a previously validated decision model of hearing loss (HL) to simulate US adults aged 40 years and older across their lifetime in US primary care offices who experienced yearly probabilities of acquiring HL (0.1%-10.4%), worsening of their HL, and traditional hearing aid uptake (0.5%-8.1%/y at a fixed uptake cost of $3690) and utility benefits (0.11 additional utils/y). For OTC hearing aid provision, persons with perceived mild to moderate HL experienced increased OTC hearing aid uptake (1%-16%/y) based on estimates of time to first HL diagnosis. In the base case, OTC hearing aid utility benefits ranged from 0.05 to 0.11 additional utils/y (45%-100% of traditional hearing aids), and costs were $200 to $1400 (5%-38% of traditional hearing aids). Distributions were assigned to parameters to conduct probabilistic uncertainty analysis. Intervention Provision of OTC hearing aids, at increased uptake rates, across a range of effectiveness and costs. Main Outcomes and Measures Lifetime undiscounted and discounted (3%/y) costs and quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs). Results Traditional hearing aid provision resulted in 18.162 QALYs, compared with 18.162 to 18.186 for OTC hearing aids varying with OTC hearing aid utility benefit (45%-100% that of traditional hearing aids). Provision of OTC hearing aids was associated with greater lifetime discounted costs by $70 to $200 along with OTC device cost ($200-$1000/pair; 5%-38% traditional hearing aid cost) due to increased hearing aid uptake. Provision of OTC hearing aids was considered cost-effective (ICER<$100 000/QALY) if the OTC utility benefit was 0.06 or greater (55% of the traditional hearing aid effectiveness). In probabilistic uncertainty analysis, OTC hearing aid provision was cost-effective in 53% of simulations. Conclusions and Relevance In this cost-effectiveness analysis, provision of OTC hearing aids was associated with greater uptake of hearing intervention and was cost-effective over a range of prices so long as OTC hearing aids were greater than 55% as beneficial to patient quality of life as traditional hearing aids.
Collapse
Affiliation(s)
- Ethan D. Borre
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Mohini Johri
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Judy R. Dubno
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Evan R. Myers
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Division of Women’s Community and Population Health, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, North Carolina
| | - Susan D. Emmett
- Department of Otolaryngology–Head and Neck Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock
| | - Juliessa M. Pavon
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, Durham, North Carolina
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Howard W. Francis
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Osondu Ogbuoji
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Center for Policy Impact in Global Health, Duke Global Health Institute, Durham, North Carolina
| | - Gillian D. Sanders Schmidler
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
12
|
Neighbors CE, Myers ER, Weerasinghe NP, Wijayaratne GB, Bodinayake CK, Nagahawatte A, Tillekeratne LG, Woods CW. Influenza Vaccination Implementation in Sri Lanka: A Cost-Effectiveness Analysis. Vaccines (Basel) 2023; 11:vaccines11050932. [PMID: 37243036 DOI: 10.3390/vaccines11050932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/27/2023] [Accepted: 04/29/2023] [Indexed: 05/28/2023] Open
Abstract
Influenza causes an estimated 3 to 5 million cases of severe illness annually, along with substantial morbidity and mortality, particularly in low- and middle-income countries (LMICs). Currently, Sri Lanka has no influenza vaccination policies and does not offer vaccination within the public healthcare sector. Therefore, we performed a cost-effectiveness analysis of influenza vaccine implementation for the Sri Lankan population. We designed a static Markov model that followed a population cohort of Sri Lankans in three age groups, 0-4, 5-64, and 65+ years, through two potential scenarios: trivalent inactivated vaccination (TIV) and no TIV across twelve-monthly cycles using a governmental perspective at the national level. We also performed probabilistic and one-way sensitivity analyses to identify influential variables and account for uncertainty. The vaccination model arm reduced influenza outcomes by 20,710 cases, 438 hospitalizations, and 20 deaths compared to no vaccination in one year. Universal vaccination became cost-effective at approximately 98.01% of Sri Lanka's 2022 GDP per capita (incremental cost-effectiveness ratio = 874,890.55 Rs/DALY averted; 3624.84 USD/DALY averted). Results were most sensitive to the vaccine coverage in the 5-64-year-old age group, the cost of the influenza vaccine dose in the 5-64-years-old age group, vaccine effectiveness in the under-5-years-old age group, and the vaccine coverage in the under-5-years-old age group. No value for a variable within our estimated ranges resulted in ICERs above Rs. 1,300,000 (USD 5386.15) per DALY adverted. Providing influenza vaccines was considered highly cost-effective compared to no vaccines. However, large-scale national studies with improved data are needed to better inform estimates and determine the impact of vaccination implementation.
Collapse
Affiliation(s)
- Coralei E Neighbors
- Hubert-Yeargan Center for Global Health, Duke University, Durham, NC 27710, USA
| | - Evan R Myers
- Division of Women's Community and Population Health, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, NC 27710, USA
| | - Nayani P Weerasinghe
- Department of Microbiology, Faculty of Medicine, University of Ruhuna, Galle 80000, Sri Lanka
| | - Gaya B Wijayaratne
- Department of Microbiology, Faculty of Medicine, University of Ruhuna, Galle 80000, Sri Lanka
| | - Champica K Bodinayake
- Department of Microbiology, Faculty of Medicine, University of Ruhuna, Galle 80000, Sri Lanka
- Department of Medicine, Faculty of Medicine, University of Ruhuna, Galle 80000, Sri Lanka
- Duke Global Health Institute, Duke University, Durham, NC 27710, USA
| | - Ajith Nagahawatte
- Department of Microbiology, Faculty of Medicine, University of Ruhuna, Galle 80000, Sri Lanka
- Duke Global Health Institute, Duke University, Durham, NC 27710, USA
| | - L Gayani Tillekeratne
- Department of Medicine, Faculty of Medicine, University of Ruhuna, Galle 80000, Sri Lanka
- Duke Global Health Institute, Duke University, Durham, NC 27710, USA
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC 27710, USA
| | - Christopher W Woods
- Hubert-Yeargan Center for Global Health, Duke University, Durham, NC 27710, USA
- Duke Global Health Institute, Duke University, Durham, NC 27710, USA
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC 27710, USA
| |
Collapse
|
13
|
Anchan RM, Wojdyla D, Bortoletto P, Terry K, Disler E, Milne A, Gargiulo A, Petrozza J, Brook O, Srouji S, Morton CC, Greenberg J, Wegienka G, Stewart EA, Nicholson WK, Thomas L, Venable S, Laughlin-Tommaso S, Diamond MP, Maxwell GL, Marsh EE, Myers ER, Vines AI, Wise LA, Wallace K, Jacoby VL, Spies JB. A Comparative Analysis of Health-Related Quality of Life 1 Year Following Myomectomy or Uterine Artery Embolization: Findings from the COMPARE-UF Registry. J Womens Health (Larchmt) 2023; 32:423-433. [PMID: 36637808 PMCID: PMC10079244 DOI: 10.1089/jwh.2022.0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Objective: To compare 12-month post-treatment health-related quality of life (HR-QoL) and symptom severity (SS) changes among patients with symptomatic uterine fibroids (SUF) not seeking fertility and undergo a hysterectomy, abdominal myomectomy (AM), or uterine artery embolization (UAE). Materials and Methods: The Comparing Options for Management: Patient-Centered Results for Uterine Fibroids (COMPARE-UF) Registry is a multi-institutional prospective observational cohort study of patients treated for SUF. A subset of 1465 women 31-45 years of age, who underwent either hysterectomy (n = 741), AM (n = 446), or UAE (n = 155) were included in this analysis. Demographics, fibroid history, and symptoms were obtained by baseline questionnaires and at 1 year post-treatment. Results were stratified by all treatments and propensity score weighting to adjust for differences in baseline characteristics. Results: Women undergoing UAE reported the lowest baseline HR-QoL and highest SS scores (mean = 40.6 [standard deviation (SD) = 23.8]; 62.3 [SD = 24.2]) followed by hysterectomy (44.3 [24.3]; 59.8 [SD = 24.1]). At 12 months, women who underwent a hysterectomy experienced the largest change in both HR-QoL (48.7 [26.2]) and SS (51.9 [25.6]) followed by other uterine-sparing treatments. Propensity score weighting revealed all treatments produced substantial improvement, with hysterectomy patients reporting the highest HR-QoL score (92.0 [17.8]) compared with myomectomy (86.7 [17.2]) and UAE (82.6 [21.5]) (p < 0.0001). Similarly, hysterectomy patients reported the lowest SS scores (8.2 [15.1]) compared with myomectomy (16.5 [15.1]) and UAE (19.6 [17.5]) (p < 0.0001). Conclusion: All procedures showed improvement in HR-QoL and reduction in SS score at 12 months, hysterectomy showing maximum improvement. Of importance, at 12 months, patients who underwent either a myomectomy or UAE reported comparable symptom relief and HR-QoL. Clinicaltrials.Gov Identifier: NCT02260752.
Collapse
Affiliation(s)
- Raymond M. Anchan
- Department of Obstetrics, Gynecology, and Reproductive Biology, Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Pietro Bortoletto
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Kathryn Terry
- Department of Obstetrics, Gynecology, and Reproductive Biology, Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Emily Disler
- Department of Obstetrics, Gynecology, and Reproductive Biology, Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ankrish Milne
- Department of Obstetrics, Gynecology, and Reproductive Biology, Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Antonio Gargiulo
- Department of Obstetrics, Gynecology, and Reproductive Biology, Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John Petrozza
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Olga Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Serene Srouji
- Department of Obstetrics, Gynecology, and Reproductive Biology, Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Cynthia C. Morton
- Department of Obstetrics, Gynecology, and Reproductive Biology, Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Manchester Centre for Audiology and Deafness, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - James Greenberg
- Department of Obstetrics, Gynecology, and Reproductive Biology, Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ganesa Wegienka
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA
| | | | - Wanda K. Nicholson
- Department of Obstetrics and Gynecology, Center for Women's Health Research, and Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Laine Thomas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Shannon Laughlin-Tommaso
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael P. Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia, USA
| | - G. Larry Maxwell
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Erica E. Marsh
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Evan R. Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anissa I. Vines
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Lauren A. Wise
- Slone Epidemiology Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Kedra Wallace
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Vanessa L. Jacoby
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, California, USA
| | - James B. Spies
- Department of Radiology, Georgetown University School of Medicine, Washington, District of Columbia, USA
| |
Collapse
|
14
|
Borre ED, Dubno JR, Myers ER, Emmett SD, Pavon JM, Francis HW, Ogbuoji O, Sanders Schmidler GD. Model-Projected Cost-Effectiveness of Adult Hearing Screening in the USA. J Gen Intern Med 2023; 38:978-985. [PMID: 35931909 PMCID: PMC10039166 DOI: 10.1007/s11606-022-07735-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/28/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND While 60% of older adults have hearing loss (HL), the majority have never had their hearing tested. OBJECTIVE We sought to estimate long-term clinical and economic effects of alternative adult hearing screening schedules in the USA. DESIGN Model-based cost-effectiveness analysis simulating Current Detection (CD) and linkage of persons with HL to hearing healthcare, compared to alternative screening schedules varying by age at first screen (45 to 75 years) and screening frequency (every 1 or 5 years). Simulated persons experience yearly age- and sex-specific probabilities of acquiring HL, and subsequent hearing aid uptake (0.5-8%/year) and discontinuation (13-4%). Quality-adjusted life-years (QALYs) were estimated according to hearing level and treatment status. Costs from a health system perspective include screening ($30-120; 2020 USD), HL diagnosis ($300), and hearing aid devices ($3690 year 1, $910/subsequent year). Data sources were published estimates from NHANES and clinical trials of adult hearing screening. PARTICIPANTS Forty-year-old persons in US primary care across their lifetime. INTERVENTION Alternative screening schedules that increase baseline probabilities of hearing aid uptake (base-case 1.62-fold; range 1.05-2.25-fold). MAIN MEASURES Lifetime undiscounted and discounted (3%/year) costs and QALYs and incremental cost-effectiveness ratios (ICERs). KEY RESULTS CD resulted in 1.20 average person-years of hearing aid use compared to 1.27-1.68 with the screening schedules. Lifetime total per-person undiscounted costs were $3300 for CD and ranged from $3630 for 5-yearly screening beginning at age 75 to $6490 for yearly screening beginning at age 45. In cost-effectiveness analysis, yearly screening beginning at ages 75, 65, and 55 years had ICERs of $39,100/QALY, $48,900/QALY, and $96,900/QALY, respectively. Results were most sensitive to variations in hearing aid utility benefit and screening effectiveness. LIMITATION Input uncertainty around screening effectiveness. CONCLUSIONS We project that yearly hearing screening beginning at age 55+ is cost-effective by US standards.
Collapse
Affiliation(s)
- Ethan D Borre
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Judy R Dubno
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Evan R Myers
- Division of Women's Community and Population Health, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, NC, USA
| | - Susan D Emmett
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Juliessa M Pavon
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, Durham, NC, USA
| | - Howard W Francis
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Osondu Ogbuoji
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC, USA
- Center for Policy Impact in Global Health, Duke Global Health Institute, Durham, NC, USA
| | - Gillian D Sanders Schmidler
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA.
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
| |
Collapse
|
15
|
Borre ED, Myers ER, Dubno JR, Emmett SD, Pavon JM, Francis HW, Ogbuoji O, Sanders Schmidler GD. Estimated Monetary Value of Future Research Clarifying Uncertainties Around the Optimal Adult Hearing Screening Schedule. JAMA Health Forum 2022; 3:e224065. [PMID: 36367737 PMCID: PMC9652748 DOI: 10.1001/jamahealthforum.2022.4065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 09/14/2022] [Indexed: 11/13/2022] Open
Abstract
Importance Adult hearing screening is not routinely performed, and most individuals with hearing loss (HL) have never had their hearing tested as adults. Objective To project the monetary value of future research clarifying uncertainties around the optimal adult hearing screening schedule. Design, Setting, and Participants In this economic evaluation, a validated decision model of HL (DeciBHAL-US: Decision model of the Burden of Hearing loss Across the Lifespan) was used to simulate current detection and treatment of HL vs hearing screening schedules. Key model inputs included HL incidence (0.06%-10.42%/y), hearing aid uptake (0.54%-8.14%/y), screening effectiveness (1.62 × hearing aid uptake), utility benefits of hearing aids (+0.11), and hearing aid device costs ($3690). Distributions to model parameters for probabilistic uncertainty analysis were assigned. The expected value of perfect information (EVPI) and expected value of partial perfect information (EVPPI) using a willingness to pay of $100 000 per quality-adjusted life-year (QALY) was estimated. The EVPI and EVPPI estimate the upper bound of the dollar value of future research. This study was based on 40-year-old persons over their remaining lifetimes in a US primary care setting. Exposures Screening schedules beginning at ages 45, 55, 65, and 75 years, and frequencies of every 1 or 5 years. Main Outcomes and Measures The main outcomes were QALYs and costs (2020 US dollars) from a health system perspective. Results The average incremental cost-effectiveness ratio for yearly screening beginning at ages 55 to 75 years ranged from $39 200 to $80 200/QALY. Yearly screening beginning at age 55 years was the optimal screening schedule in 38% of probabilistic uncertainty analysis simulations. The population EVPI, or value of reducing all uncertainty, was $8.2 to $12.6 billion varying with willingness to pay and the EVPPI, or value of reducing all screening effectiveness uncertainty, was $2.4 billion. Conclusions and Relevance In this economic evaluation of US adult hearing screening, large uncertainty around the optimal adult hearing screening schedule was identified. Future research on hearing screening has a high potential value so is likely justified.
Collapse
Affiliation(s)
- Ethan D. Borre
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Evan R. Myers
- Division of Women’s Community and Population Health, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, North Carolina
| | - Judy R. Dubno
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Susan D. Emmett
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Juliessa M. Pavon
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Howard W. Francis
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Osondu Ogbuoji
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Center for Policy Impact in Global Health, Duke Global Health Institute, Durham, North Carolina
| | - Gillian D. Sanders Schmidler
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
16
|
Nash R, Johnson CE, Harris HR, Peres LC, Joslin CE, Bethea TN, Bandera EV, Ochs-Balcom HM, Myers ER, Guertin KA, Camacho F, Beeghly-Fadiel A, Moorman PG, Setiawan VW, Rosenberg L, Schildkraut JM, Wu AH. Race Differences in the Associations between Menstrual Cycle Characteristics and Epithelial Ovarian Cancer. Cancer Epidemiol Biomarkers Prev 2022; 31:1610-1620. [PMID: 35654411 PMCID: PMC9711941 DOI: 10.1158/1055-9965.epi-22-0115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/04/2022] [Accepted: 05/31/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Menstrual cycle characteristics-including age at menarche and cycle length- have been associated with ovarian cancer risk in White women. However, the associations between menstrual cycle characteristics and ovarian cancer risk among Black women have been sparsely studied. METHODS Using the Ovarian Cancer in Women of African Ancestry (OCWAA) Consortium that includes 1,024 Black and 2,910 White women diagnosed with epithelial ovarian cancer (EOC) and 2,325 Black and 7,549 White matched controls, we investigated associations between menstrual cycle characteristics (age at menarche, age at menstrual regularity, cycle length, and ever missing three periods) and EOC risk by race and menopausal status. Multivariable logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI). RESULTS Black women were more likely to be <11 years at menarche than White women (controls: 9.9% vs. 6.0%). Compared with ≥15 years at menarche, <11 years was associated with increased EOC risk for White (OR = 1.25; 95% CI, 0.99-1.57) but not Black women (OR = 1.10; 95% CI, 0.80-1.55). Among White women only, the association was greater for premenopausal (OR = 2.20; 95% CI, 1.31-3.68) than postmenopausal women (OR = 1.06; 95% CI, 0.82-1.38). Irregular cycle length was inversely associated with risk for White (OR = 0.78; 95% CI, 0.62-0.99) but not Black women (OR = 1.06; 95% CI, 0.68-1.66). CONCLUSIONS Earlier age at menarche and cycle irregularity are associated with increased EOC risk for White but not Black women. IMPACT Associations between menstrual cycle characteristics and EOC risk were not uniform by race.
Collapse
Affiliation(s)
- Rebecca Nash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta GA
| | - Courtney E Johnson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta GA
| | - Holly R. Harris
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Lauren C. Peres
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Charlotte E Joslin
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago School of Medicine and Division of Epidemiology and Biostatistics, School of Public Health, Chicago, IL
| | - Traci N. Bethea
- Office of Minority Health and Health Disparities Research, Georgetown Lombardi Comprehensive Cancer Center, Georgetown University Medical Campus, Washington, DC
| | - Elisa V. Bandera
- Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Heather M. Ochs-Balcom
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, The State University of New York, Buffalo, NY
| | - Evan R. Myers
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Kristin A Guertin
- Department of Population Health and Prevention Sciences, University of Virginia School of Medicine, Charlottesville, VA
| | - Fabian Camacho
- Department of Population Health and Prevention Sciences, University of Virginia School of Medicine, Charlottesville, VA
| | - Alicia Beeghly-Fadiel
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Patricia G. Moorman
- Department of Family Medicine and Community Health, Duke University Medical Center, Durham, NC
| | - Veronica Wendy Setiawan
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Lynn Rosenberg
- Slone Epidemiology Center at Boston University, Boston, MA
| | - Joellen M. Schildkraut
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta GA
| | - Anna H. Wu
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA
| |
Collapse
|
17
|
Wheeler SM, Myers SO, Swamy GK, Myers ER. Estimated Prevalence of Risk Factors for Preeclampsia Among Individuals Giving Birth in the US in 2019. Obstet Gynecol Surv 2022. [DOI: 10.1097/ogx.0000000000001059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
18
|
Mosher CL, Nanna MG, Jawitz OK, Raman V, Farrow NE, Aleem S, Casaburi R, MacIntyre NR, Palmer SM, Myers ER. Cost-effectiveness of Pulmonary Rehabilitation Among US Adults With Chronic Obstructive Pulmonary Disease. JAMA Netw Open 2022; 5:e2218189. [PMID: 35731514 PMCID: PMC9218844 DOI: 10.1001/jamanetworkopen.2022.18189] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
IMPORTANCE Pulmonary rehabilitation (PR) after exacerbation of chronic obstructive pulmonary disease (COPD) is effective in reducing COPD hospitalizations and mortality while improving health-related quality of life, yet use of PR remains low. Estimates of the cost-effectiveness of PR in this setting could inform policies to improve uptake. OBJECTIVE To estimate the cost-effectiveness of participation in PR after hospitalization for COPD. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation estimated the cost-effectiveness of participation in PR compared with no PR after COPD hospitalization in the US using a societal perspective analysis. A Markov microsimulation model was developed to estimate the cost-effectiveness in the US health care system with a lifetime horizon, 1-year cycle length, and a discounted rate of 3% per year for both costs and outcomes. Data sources included published literature from October 1, 2001, to April 1, 2021, with the primary source being an analysis of Medicare beneficiaries living with COPD between January 1, 2014, and December 31, 2015. The analysis was designed and conducted from October 1, 2019, to December 15, 2021. A base case microsimulation, univariate analyses, and a probabilistic sensitivity analysis were performed. INTERVENTIONS Pulmonary rehabilitation compared with no PR after COPD hospitalization. MAIN OUTCOMES AND MEASURES Net cost in US dollars, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio. RESULTS Among the hypothetical cohort with a mean age of 76.9 (age range, 60-92) years and 58.6% women, the base case microsimulation from a societal perspective demonstrated that PR resulted in net cost savings per patient of $5721 (95% prediction interval, $3307-$8388) and improved quality-adjusted life expectancy (QALE) (gain of 0.53 [95% prediction interval, 0.43-0.63] years). The findings of net cost savings and improved QALE with PR did not change in univariate analyses of patient age, the Global Initiative for Obstructive Lung Disease stage, or number of PR sessions. In a probabilistic sensitivity analysis, PR resulted in net cost savings and improved QALE in every one of 1000 samples and was the dominant strategy in 100% of simulations at any willingness-to-pay threshold. In a 1-way sensitivity analysis of total cost, assuming completion of 36 sessions, a single PR session would remain cost saving to $171 per session and had an incremental cost-effectiveness ratio of $884 per session for $50 000/QALY and $1597 per session for $100 000/QALY. CONCLUSIONS AND RELEVANCE In this economic evaluation, PR after COPD hospitalization appeared to result in net cost savings along with improvement in QALE. These findings suggest that stakeholders should identify policies to increase access and adherence to PR for patients with COPD.
Collapse
Affiliation(s)
- Christopher L. Mosher
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Michael G. Nanna
- Duke Clinical Research Institute, Durham, North Carolina
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Oliver K. Jawitz
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Vignesh Raman
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Norma E. Farrow
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Samia Aleem
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Richard Casaburi
- Rehabilitation Clinical Trials Center, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California
| | - Neil R. MacIntyre
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Scott M. Palmer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Evan R. Myers
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Women’s Community and Population Health, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| |
Collapse
|
19
|
Myers ER. Core feature sets: not just for outcomes, not just for research. Am J Obstet Gynecol 2022; 226:605-606. [PMID: 35500999 DOI: 10.1016/j.ajog.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 03/01/2022] [Indexed: 11/26/2022]
|
20
|
Wallace K, Stewart EA, Wise LA, Nicholson WK, Parry JP, Zhang S, Laughlin-Tommaso S, Jacoby V, Anchan RM, Diamond MP, Venable S, Shiflett A, Wegienka GR, Maxwell GL, Wojdyla D, Myers ER, Marsh E. Anxiety, Depression, and Quality of Life After Procedural Intervention for Uterine Fibroids. J Womens Health (Larchmt) 2022; 31:415-424. [PMID: 34101502 PMCID: PMC8972021 DOI: 10.1089/jwh.2020.8915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Background: Quality of life (QOL) and psychological health has been reported to be decreased among women with gynecological conditions such as uterine fibroids (UFs). Materials and Methods: Women enrolled in the Comparing Options for Management: PAtient-centered REsults for Uterine Fibroids (COMPARE-UF) registry, receiving procedural therapy for symptomatic UFs, were eligible for this analysis if they completed a series of health-related QOL surveys administered at three time points (baseline, 6-12 weeks postprocedure, and 1 year postprocedure; n = 1486). Ethical approval for this study was obtained at each recruiting site and the coordinating center (NCT02260752, clinicaltrials.gov). Results: More than 26% (n = 393) of women reported moderate anxiety/depression on the baseline anxiety/depression domain of the Euro-QOL 5-dimension instrument. At both the 6-12 weeks and 1-year postprocedural follow-up, there was significant improvement in the UF QOL symptom severity score (p < 0.001, p < 0.001), the total UF symptom QOL score (p < 0.001, p < 0.001), and the Euro-QOL 5-dimension visual analog scale (p < 0.001, p = 0.004) compared with the preprocedural baseline scores. The reporting of anxiety/depression decreased by 66.4% among women who were at baseline, whereas 5.6% of women previously reporting no anxiety/depression reported anxiety/depression at the 1-year follow-up. Conclusion: UF symptoms were more severe among women reporting anxiety/depression at baseline. At the 1-year follow-up, health-related QOL scores improved among all women and the prevalence of anxiety/depression decreased in most, but not all women, whereas severity of anxiety/depression worsened in a small percentage of women (5.6%). Overall, these results suggest that UF treatment improves symptoms of anxiety/depression associated with symptomatic UFs.
Collapse
Affiliation(s)
- Kedra Wallace
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi, USA.,Address correspondence to: Kedra Wallace, PhD, Department of Obstetrics and Gynecology, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216, USA
| | | | - Lauren A. Wise
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Wanda Kay Nicholson
- Center for Women's Health Research, Department of Obstetrics and Gynecology, UNC School of Medicine, Chapel Hill, North Carolina, USA
| | - John Preston Parry
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Shuaiqi Zhang
- Duke Clinical Research Institute, Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | | | - Vanessa Jacoby
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California at San Francisco, San Francisco, California, USA
| | - Raymond M. Anchan
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael P. Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia, USA
| | | | - Amber Shiflett
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Ganesa R. Wegienka
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA
| | - George Larry Maxwell
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Evan R. Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Erica Marsh
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| |
Collapse
|
21
|
Wise LA, Thomas L, Anderson S, Baird DD, Anchan RM, Terry KL, Marsh EE, Wegienka G, Nicholson WK, Wallace K, Bigelow R, Spies J, Maxwell GL, Jacoby V, Myers ER, Stewart EA. Route of myomectomy and fertility: a prospective cohort study. Fertil Steril 2022; 117:1083-1093. [PMID: 35216832 PMCID: PMC9081130 DOI: 10.1016/j.fertnstert.2022.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To assess prospectively the association between the myomectomy route and fertility. DESIGN Prospective cohort study. SETTING The Comparing Treatments Options for Uterine Fibroids (COMPARE-UF) Study is a multisite national registry of eight clinic centers across the United States. PATIENT(S) Reproductive-aged women undergoing surgery for symptomatic uterine fibroids. INTERVENTION(S) Not applicable. MAIN OUTCOME MEASURE(S) We used life-table methods to estimate cumulative probabilities and 95% confidence intervals (CI) of pregnancy and live birth by the myomectomy route during 12, 24, and 36 months of follow-up (2015-2019). We also conducted 12-month interval-based analyses that used logistic regression to estimate odds ratios and 95% CIs for associations of interest. In all analyses, we used propensity score weighting to adjust for differences across surgical routes. RESULT(S) Among 1,095 women who underwent myomectomy (abdominal = 388, hysteroscopic = 273, and laparoscopic = 434), 202 reported pregnancy and 91 reported live birth during 36 months of follow-up. There was little difference in the 12-month probability of pregnancy or live birth by route of myomectomy overall or among women intending pregnancy. In interval-based analyses, adjusted ORs for pregnancy were 1.28 (95% CI, 0.76-2.14) for hysteroscopic myomectomy and 1.19 (95% CI, 0.76-1.85) for laparoscopic myomectomy compared with abdominal myomectomy. Among women intending pregnancy, adjusted ORs were 1.27 (95% CI, 0.72-2.23) for hysteroscopic myomectomy and 1.26 (95% CI, 0.77-2.04) for laparoscopic myomectomy compared with abdominal myomectomy. Associations were slightly stronger but less precise for live birth. CONCLUSION(S) The probability of conception or live birth did not differ appreciably by the myomectomy route among women observed for 36 months postoperatively. CLINICAL TRIALS REGISTRATION NUMBER: (NCT02260752, clinicaltrials.gov).
Collapse
Affiliation(s)
- Lauren A Wise
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts.
| | - Laine Thomas
- Department of Biostatistics, Duke University, Durham, North Carolina
| | - Sophia Anderson
- Department of Biostatistics, Duke University, Durham, North Carolina
| | - Donna D Baird
- Epidemiology Branch, National Institute of Environmental Health Sciences, Durham, North Carolina
| | - Raymond M Anchan
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kathryn L Terry
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Erica E Marsh
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Ganesa Wegienka
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
| | - Wanda Kay Nicholson
- Center for Women's Health Research, Department of Obstetrics and Gynecology, UNC School of Medicine, Chapel Hill, North Carolina
| | - Kedra Wallace
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Robert Bigelow
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - James Spies
- Department of Radiology, MedStar Georgetown University Hospital, Washington, D.C
| | - George L Maxwell
- Department of Obstetrics and Gynecology and the Women's Health Integrated Research Center, Inova Fairfax Hospital, Falls Church, Virginia
| | - Vanessa Jacoby
- School of Medicine, University of California San Francisco, San Francisco California
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina
| | | |
Collapse
|
22
|
Borre ED, Myers ER, Dubno JR, O'Donoghue GM, Diab MM, Emmett SD, Saunders JE, Der C, McMahon CM, Younis D, Francis HW, Tucci DL, Wilson BS, Ogbuoji O, Schmidler GDS. Development and validation of DeciBHAL-US: A novel microsimulation model of hearing loss across the lifespan in the United States. EClinicalMedicine 2022; 44:101268. [PMID: 35072020 PMCID: PMC8762067 DOI: 10.1016/j.eclinm.2021.101268] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/29/2021] [Accepted: 12/21/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Hearing loss affects over 50% of people in the US across their lifespan and there is a lack of decision modeling frameworks to inform optimal hearing healthcare delivery. Our objective was to develop and validate a microsimulation model of hearing loss across the lifespan in the US. METHODS We collaborated with the Lancet Commission on Hearing Loss to outline model structure, identify input data sources, and calibrate/validate DeciBHAL-US (Decision model of the Burden of Hearing loss Across the Lifespan). We populated the model with literature-based estimates and validated the conceptual model with key informants. We validated key model endpoints to the published literature, including: 1) natural history of sensorineural hearing loss (SNHL), 2) natural history of conductive hearing loss (CHL), and 3) the hearing loss cascade of care. We reported the coefficient of variance root mean square error (CV-RMSE), considering values ≤15% to indicate adequate fit. FINDINGS For SNHL prevalence, the CV-RMSE for model projected male and female age-specific prevalence compared to sex-adjusted National Health and Nutrition Examination Survey (NHANES) data was 4.9 and 5.7%, respectively. Incorporating literature-based age-related decline in SNHL, we validated mean four-frequency average hearing loss in the better ear (dB) among all persons to longitudinal data (CV-RMSE=11.3%). We validated the age-stratified prevalence of CHL to adjusted NHANES data (CV-RMSE=10.9%). We incorporated age- and severity-stratified time to first hearing aid (HA) use data and HA discontinuation data (adjusted for time-period of use) and validated to NHANES estimates on the prevalence of adult HA use (CV-RMSE=10.3%). INTERPRETATION Our results indicate adequate model fit to internal and external validation data. Future incorporation of cost and severity-stratified utility data will allow for cost-effectiveness analysis of US hearing healthcare interventions across the lifespan. Further research might expand the modeling framework to international settings. FUNDING This study was funded by the National Institute on Deafness and Other Communication Disorders and the National Institute on Aging (3UL1-TR002553-03S3 and F30 DC019846).
Collapse
Affiliation(s)
- Ethan D. Borre
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, United States of America
| | - Evan R. Myers
- Division of Women's Community and Population Health, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, NC, United States of America
| | - Judy R. Dubno
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, United States of America
| | - Gerard M. O'Donoghue
- Department of Otolaryngology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Mohamed M. Diab
- Duke Global Health Institute, Duke University, Durham, NC, United States of America
| | - Susan D. Emmett
- Duke Global Health Institute, Duke University, Durham, NC, United States of America
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC, United States of America
| | - James E. Saunders
- Department of Surgery, Geisel School of Medicine, Dartmouth University, Lebanon, NH, United States of America
| | - Carolina Der
- Facultad de Medicina Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile
| | | | - Danah Younis
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, United States of America
| | - Howard W. Francis
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC, United States of America
| | - Debara L. Tucci
- National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, MD, United States of America
| | - Blake S. Wilson
- Duke Global Health Institute, Duke University, Durham, NC, United States of America
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC, United States of America
- Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC, United States of America
- Department of Electrical & Computer Engineering, Pratt School of Engineering, Duke University, Durham, NC, United States of America
| | - Osondu Ogbuoji
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, United States of America
- Duke Global Health Institute, Duke University, Durham, NC, United States of America
- Center for Policy Impact in Global Health, Duke Global Health Institute, Durham, NC, United States of America
| | - Gillian D. Sanders Schmidler
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, United States of America
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States of America
| |
Collapse
|
23
|
Abstract
IMPORTANCE Low-dose aspirin (LDA) is one of the few evidence-based interventions for preventing preeclampsia, which is a leading cause of maternal or fetal morbidity and mortality. Current guidelines recommend LDA based on the presence of risk factors for preeclampsia, but the population-based prevalence of these factors is unknown. OBJECTIVE To estimate population-level prevalence of preeclampsia risk factors used in prophylactic LDA guidelines for pregnant patients and the association of these risk factors with reported rates of pregnancy-related hypertension. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted using National Center for Health Statistics birth certificate data to describe the frequency of pregnant individuals with moderate to high-risk factors for preeclampsia and pregnancy-related hypertension rates. The study used all birth records in the United States for the 2019 calendar year. EXPOSURES Documentation of preeclampsia risk factors: multifetal gestation, pregestational diabetes, chronic hypertension (high-risk factors) and nulliparity, a body mass index greater than 30, African American race, a maternal age 35 years or older, an interval of more than 10-years since last birth, and having low socioeconomic status (moderate risk factors). MAIN OUTCOMES AND MEASURES Prevalence of each risk factor alone and in combinations leading to a recommendation for LDA; incidence of pregnancy-related hypertension by risk factor and combinations of risk factors. RESULTS There were 3 695 019 pregnancies in 2019, including 528 778 with no risk factors, 169 540 with 1 or more high-risk factors, and 2 996 701 with 1 or more moderate-risk factors. The mean (SD) of the cohort was 29.1 (5.8) years. Multifetal gestation was the most common high-risk factor and found in 123 995 pregnancies (3.4%), and low socioeconomic status was the most common moderate-risk factor and present in 1 732 729 pregnancies (46.9%). Based on 2021 criteria (a single high- or moderate-risk factors for preeclampsia), 3 166 241 pregnant patients (85.7%) were eligible for LDA. The incidence of pregnancy-related hypertension increased with the number of moderate-risk factors. The 2021 guidelines suggest considering or recommend LDA in 92.3% of pregnancies diagnosed with pregnancy-related hypertension. CONCLUSIONS AND RELEVANCE These data support the recently published guidelines and suggest further simplified guidelines recommending LDA to patients with any single moderate-risk factors.
Collapse
Affiliation(s)
- Sarahn M. Wheeler
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina
| | | | - Geeta K. Swamy
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina
| | - Evan R. Myers
- Division of Women’s Community and Population Health, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
24
|
Albright BB, Myers ER, Moss HA, Ko EM, Sonalkar S, Havrilesky LJ. Surveillance for gestational trophoblastic neoplasia following molar pregnancy: a cost-effectiveness analysis. Am J Obstet Gynecol 2021; 225:513.e1-513.e19. [PMID: 34058170 PMCID: PMC9941751 DOI: 10.1016/j.ajog.2021.05.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/24/2021] [Accepted: 05/24/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Historically, published guidelines for care after molar pregnancy recommended monitoring human chorionic gonadotropin levels for the development of gestational trophoblastic neoplasia until normal and then for 6 months after the first normal human chorionic gonadotropin. However, there are little data underlying such recommendations, and recent evidence has demonstrated that gestational trophoblastic neoplasia diagnosis after human chorionic gonadotropin normalization is rare. OBJECTIVE We sought to estimate the cost-effectiveness of alternative strategies for surveillance for gestational trophoblastic neoplasia after human chorionic gonadotropin normalization after complete and partial molar pregnancy. STUDY DESIGN A Markov-based cost-effectiveness model, using monthly cycles and terminating after 36 months/cycles, was constructed to compare alternative strategies for asymptomatic human chorionic gonadotropin surveillance after the first normal (none; monthly testing for 1, 3, 6, and 12 months; or every 3-month testing for 3, 6, and 12 months) for both complete and partial molar pregnancy. The risk of reduced surveillance was modeled by increasing the probability of high-risk disease at diagnosis. Probabilities, costs, and utilities were estimated from peer-reviewed literature, with all cost data applicable to the United States and adjusted to 2020 US dollars. The primary outcome was cost per quality-adjusted life year ($/quality-adjusted life year) with a $100,000/quality-adjusted life year willingness-to-pay threshold. RESULTS Under base-case assumptions, we found no further surveillance after the first normal human chorionic gonadotropin to be the dominant strategy from both the healthcare system and societal perspectives, for both complete and partial molar pregnancy. After complete mole, this strategy had the lowest average cost (healthcare system, $144 vs maximum $283; societal, $152 vs maximum $443) and highest effectiveness (2.711 vs minimum 2.682 quality-adjusted life years). This strategy led to a slightly higher rate of death from gestational trophoblastic neoplasia (0.013% vs minimum 0.009%), although with high costs per gestational trophoblastic neoplasia death avoided (range, $214,000 to >$4 million). Societal perspective costs of lost wages had a greater impact on frequent surveillance costs than rare gestational trophoblastic neoplasia treatment costs, and no further surveillance was more favorable from this perspective in otherwise identical analyses. No further surveillance remained dominant or preferred with incremental cost-effectiveness ratio of <$100,000 in all analyses for partial mole, and most sensitivity analyses for complete mole. Under the assumption of no disutility from surveillance, surveillance strategies were more effective (by quality-adjusted life year) than no further surveillance, and a single human chorionic gonadotropin test at 3 months was found to be cost-effective after complete mole with incremental cost-effectiveness ratio of $53,261 from the healthcare perspective, but not from the societal perspective (incremental cost-effectiveness ratio, $288,783). CONCLUSION Largely owing to the rare incidence of gestational trophoblastic neoplasia after human chorionic gonadotropin normalization after molar pregnancy, prolonged surveillance is not cost-effective under most assumptions. It would be reasonable to reduce, and potentially eliminate, current recommendations for surveillance after human chorionic gonadotropin normalization after molar pregnancy, particularly among partial moles. With any reduction in surveillance, patients should be counseled on symptoms of gestational trophoblastic neoplasia and established in routine gynecologic care.
Collapse
Affiliation(s)
- Benjamin B Albright
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC.
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Haley A Moss
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Emily M Ko
- Department of Obstetrics and Gynecology, University of Pennsylvania Health System, Philadelphia, PA
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, University of Pennsylvania Health System, Philadelphia, PA
| | - Laura J Havrilesky
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| |
Collapse
|
25
|
Wilson C, Phillips AK, Iobst SE, Myers ER, Trego L, Allard RJ, Landoll R. A Scoping Review of Unintended Pregnancy in Active Duty United States Military Women. Womens Health Issues 2021; 31 Suppl 1:S66-S80. [PMID: 34454705 DOI: 10.1016/j.whi.2020.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/14/2020] [Accepted: 11/12/2020] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The purpose of this scoping review was to apply the Social Ecological Model for Military Women's Health to literature on unintended pregnancy (UIP) to answer the question: In United States active duty military women (population) with the potential for UIP (context), what is known about risk factors, prevention, and pregnancy outcomes (concepts)? METHODS We conducted this review based on a PRISMA-ScR protocol registered a priori in Open Science Framework. Following a literature search of six databases and the grey literature, we used DistillerSR to manage data screening and data charting. The Social Ecological Model for Military Women's Health served as the theoretical framework to chart findings regarding UIP at the individual, microsystem, mesosystem, exosystem, and macrosystem levels. RESULTS A total of 74 research, review, and grey literature articles met the inclusion criteria. Risk factors included specific demographics, military service, and recent deployment. Prevention included contraceptive practices, access, and education that should take place early in servicewomen's careers and before deployment. Outcomes included early return from deployment, personal career challenges, and seeking alternative health services outside the military health system. CONCLUSIONS Research and policy initiatives should focus on decreasing risk factors in the military working environment, with particular attention to the deployed environment. These initiatives should include input from military leaders, health care providers, servicewomen, and servicemen with the goal of decreasing the incidence of unintended pregnancies. Pregnancy intentionality among military women should be considered as a concept to shape intervention research to reduce unintended pregnancies.
Collapse
Affiliation(s)
- Candy Wilson
- Uniformed Services University of the Health Sciences, Daniel K. Inouye Graduate School of Nursing, Bethesda, Maryland.
| | | | | | - Evan R Myers
- Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, North Carolina
| | - Lori Trego
- University of Colorado Anschutz Medical Campus, College of Nursing, Aurora, Colorado
| | - Rhonda J Allard
- Uniformed Services University of the Health Sciences, James A. Zimble Learning Resource Center, Bethesda, Maryland
| | - Ryan Landoll
- Uniformed Services University of the Health Sciences, F. Edward Hebert School of Medicine, Bethesda, Maryland
| |
Collapse
|
26
|
Davis CP, Bandera EV, Bethea TN, Camacho F, Joslin CE, Wu AH, Beeghly-Fadiel A, Moorman PG, Myers ER, Ochs-Balcom HM, Peres LC, Rosenow WT, Setiawan VW, Rosenberg L, Schildkraut JM, Harris HR. Genital Powder Use and Risk of Epithelial Ovarian Cancer in the Ovarian Cancer in Women of African Ancestry Consortium. Cancer Epidemiol Biomarkers Prev 2021; 30:1660-1668. [PMID: 34155063 DOI: 10.1158/1055-9965.epi-21-0162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/01/2021] [Accepted: 06/01/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Genital powder use is more common among African-American women; however, studies of genital powder use and ovarian cancer risk have been conducted predominantly in White populations, and histotype-specific analyses among African-American populations are limited. METHODS We used data from five studies in the Ovarian Cancer in Women of African Ancestry consortium. Participants included 620 African-American cases, 1,146 African-American controls, 2,800 White cases, and 6,735 White controls who answered questions on genital powder use prior to 2014. The association between genital powder use and ovarian cancer risk by race was estimated using logistic regression. RESULTS The prevalence of ever genital powder use for cases was 35.8% among African-American women and 29.5% among White women. Ever use of genital powder was associated with higher odds of ovarian cancer among African-American women [OR = 1.22; 95% confidence interval (CI) = 0.97-1.53] and White women (OR = 1.36; 95% CI = 1.19-1.57). In African-American women, the positive association with risk was more pronounced among high-grade serous tumors (OR = 1.31; 95% CI = 1.01-1.71) than with all other histotypes (OR = 1.05; 95% CI = 0.75-1.47). In White women, a significant association was observed irrespective of histotype (OR = 1.33; 95% CI = 1.12-1.56 and OR = 1.38; 95% CI = 1.15-1.66, respectively). CONCLUSIONS While genital powder use was more prevalent among African-American women, the associations between genital powder use and ovarian cancer risk were similar across race and did not materially vary by histotype. IMPACT This is one of the largest studies to date to compare the associations between genital powder use and ovarian cancer risk, overall and by histotype, between African-American and White women.
Collapse
Affiliation(s)
- Colette P Davis
- Program in Epidemiology, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Elisa V Bandera
- Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Traci N Bethea
- Office of Minority Health and Health Disparities Research, Georgetown Lombardi Comprehensive Cancer Center, Georgetown University Medical Campus, Washington, District of Columbia
| | - Fabian Camacho
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Charlotte E Joslin
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago School of Medicine and Division of Epidemiology and Biostatistics, School of Public Health, Chicago, Illinois
| | - Anna H Wu
- University of Southern California Norris Comprehensive Cancer Center and Department of Preventive Medicine, Keck School of Medicine, Los Angeles, California
| | - Alicia Beeghly-Fadiel
- Department of Medicine, Division of Epidemiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Patricia G Moorman
- Department of Family Medicine and Community Health, Duke University Medical Center, Durham, North Carolina
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Heather M Ochs-Balcom
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, The State University of New York, Buffalo, New York
| | - Lauren C Peres
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Will T Rosenow
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Veronica W Setiawan
- University of Southern California Norris Comprehensive Cancer Center and Department of Preventive Medicine, Keck School of Medicine, Los Angeles, California
| | - Lynn Rosenberg
- Slone Epidemiology Center at Boston University, Boston, Massachusetts
| | - Joellen M Schildkraut
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Holly R Harris
- Program in Epidemiology, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington. .,Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington
| |
Collapse
|
27
|
White-Traut R, Brandon D, Kavanaugh K, Gralton K, Pan W, Myers ER, Andrews B, Msall M, Norr KF. Protocol for implementation of an evidence based parentally administered intervention for preterm infants. BMC Pediatr 2021; 21:142. [PMID: 33761902 PMCID: PMC7988259 DOI: 10.1186/s12887-021-02596-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/07/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Multi-sensory behavioral interventions for preterm infants have the potential to accelerate feeding, growth, and optimize developmental trajectories and increase parents' interactive engagement with their infants. However, few neonatal intensive care units (NICUs) provide evidence-based standardized early behavioral interventions as routine care. Lack of implementation is a major gap between research and clinical practice. H-HOPE, is a standardized behavioral intervention with an infant- directed component (Massage+) and a parent-directed component (four participatory guidance sessions that focus on preterm infants' behaviors and appropriate responses). H-HOPE has well documented efficacy. The purpose of this implementation study is to establish H-HOPE as the standard of care in 5 NICUs. METHODS The study employs a Type 3 Hybrid design to simultaneously examine the implementation process and effectiveness in five NICUs. To stagger implementation across the clinical sites, we use an incomplete stepped wedge design. The five participating NICUs were purposively selected to represent different acuity levels, number of beds, locations and populations served. Our implementation strategy integrates our experience conducting H-HOPE and a well-established implementation model, the Consolidated Framework for Implementation Research (CFIR). The CFIR identifies influences (facilitators and barriers) that affect successful implementation within five domains: intervention characteristics, outer setting (the hospital and external events and stakeholders), inner setting (NICU), implementers' individual characteristics, and the implementation process. NICUs will use the CFIR process, which includes three phases: Planning and Engaging, Executing, and Reflecting and Evaluating. Because sustaining is a critical goal of implementation, we modify the CFIR implementation process by adding a final phase of Sustaining. DISCUSSION This study builds on the CFIR, adding Sustaining H-HOPE to observe what happens when sites begin to maintain implementation without outside support, and extends its use to the NICU acute care setting. Our mixed methods analysis systematically identifies key facilitators and barriers of implementation success and effectiveness across the five domains of the CFIR. Long term benefits have not yet been studied but may include substantial health and developmental outcomes for infants, more optimal parent-child relationships, reduced stress and costs for families, and substantial indirect societal benefits including reduced health care and special education costs. TRIAL REGISTRATION ClinicalTrials.gov registration number NCT04555590 , Registered on 8/19/2020.
Collapse
Affiliation(s)
- Rosemary White-Traut
- Department of Nursing Research and Evidence-Based Practice, Children's Wisconsin, Milwaukee, WI, USA.
- Women, Children and Family Health Science, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA.
| | - Debra Brandon
- School of Nursing, Duke University, Durham, North Carolina, USA
| | - Karen Kavanaugh
- Department of Nursing Research and Evidence-Based Practice, Children's Wisconsin, Milwaukee, WI, USA
- Women, Children and Family Health Science, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA
| | - Karen Gralton
- Department of Nursing Research and Evidence-Based Practice, Children's Wisconsin, Milwaukee, WI, USA
| | - Wei Pan
- School of Nursing and Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Evan R Myers
- Division of Women's Community and Population Health, Department of Obstetrics & Gynecology, Duke University School of Medicine, Duke University, Durham, North Carolina, USA
| | - Bree Andrews
- College of Medicine, Department of Pediatrics, University of Chicago, Chicago, IL, USA
| | - Michael Msall
- College of Medicine, Department of Pediatrics, University of Chicago, Chicago, IL, USA
| | - Kathleen F Norr
- Department of Nursing Research and Evidence-Based Practice, Children's Wisconsin, Milwaukee, WI, USA
- Women, Children and Family Health Science, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA
| |
Collapse
|
28
|
Federspiel JJ, Wein LE, Addae-Konadu KL, Darwin KC, Talamo LE, Myers ER, James AH. Venous thromboembolism incidence among patients recommended for pharmacologic thromboembolism prophylaxis after cesarean delivery in selected guidelines. J Thromb Haemost 2021; 19:830-838. [PMID: 33345404 PMCID: PMC7925427 DOI: 10.1111/jth.15218] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 12/01/2020] [Accepted: 12/14/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Multiple guidelines regarding risk stratification for venous thromboembolism (VTE) incidence following cesarean delivery have been promulgated. OBJECTIVE To estimate the percentage of cesarean delivery patients for which pharmacologic VTE would be recommended and subsequent incidence of VTE, based on several guidelines. PATIENTS/METHODS This retrospective cohort study used data from the Nationwide Readmissions Database from October 2015 through December 2017. Diagnosis and procedure codes were used to identify patients undergoing cesarean delivery, incidence of VTE, and risk factors used to stratify risk in the existing guidelines. Time-to-event analysis was used to analyze data, stratified by risk categorization in 2011 American College of Obstetricians and Gynecologists (ACOG), 2012 American College of Chest Physicians (ACCP), 2015 Royal College of Obstetricians and Gynaecologists (RCOG), and 2018 American Society of Hematology (ASH) guidelines. RESULTS/CONCLUSIONS In a cohort of 1 235 149 cesarean deliveries, VTE incidence was 2.1 per 1000 deliveries at 330 days following delivery (95% confidence interval: 2.0-2.2). Proportions of patients that would be recommended for pharmacologic prophylaxis ranged from 0.2% in 2018 ASH guidelines to 73.4% in 2015 RCOG criteria. Among groups considered at elevated risk for VTE for which pharmacologic prophylaxis would be recommended, VTE incidence varied from 35.2 per 1000 deliveries based on 2018 ASH criteria to 2.5 per 1000 in 2015 RCOG criteria. In a large cohort of cesarean deliveries in the United States, application of different risk stratification guidelines identified widely different proportions at risk of VTE following delivery, with implications for being categorized as having elevated risk.
Collapse
Affiliation(s)
- Jerome J Federspiel
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Gynecology and Obstetrics, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Lauren E Wein
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kateena L Addae-Konadu
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kristin C Darwin
- Department of Gynecology and Obstetrics, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Laura E Talamo
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Evan R Myers
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andra H James
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| |
Collapse
|
29
|
Tran AP, Al Naber J, Myers ER. Authors' response to letter to the editor: the role of core outcomes in shared decision-making for uterine fibroid treatment. Am J Obstet Gynecol 2021; 224:331. [PMID: 33212040 DOI: 10.1016/j.ajog.2020.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 11/10/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Annie P Tran
- Center for Medical Technology Policy, 401 East Pratt St., Ste. 631, Baltimore, MD 21202.
| | - Jennifer Al Naber
- Center for Medical Technology Policy, 401 East Pratt St., Ste. 631, Baltimore, MD 21202
| | | |
Collapse
|
30
|
Wegienka G, Stewart EA, Nicholson WK, Zhang S, Li F, Thomas L, Spies JB, Venable S, Laughlin-Tommaso S, Diamond MP, Anchan RM, Maxwell GL, Marsh EE, Myers ER, Vines AI, Wise LA, Wallace K, Jacoby VL. Black Women Are More Likely Than White Women to Schedule a Uterine-Sparing Treatment for Leiomyomas. J Womens Health (Larchmt) 2021; 30:355-366. [PMID: 33524308 DOI: 10.1089/jwh.2020.8634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: To evaluate differences in the proportion of uterine fibroid (UF) treatments that are uterine-sparing between Black women and White women and identify factors that could explain disparities. Methods: Women at age 18-54 years who were enrolled from 10 clinical sites in the United States into the Comparing Options for Management: Patient-Centered Results for UFs (COMPARE-UF) treatment registry completed questionnaires before their UF procedure. UF symptoms and quality of life were assessed by questionnaires. Details on UF imaging and treatment (hysterectomy, myomectomy, or uterine artery embolization [UAE]) were collected from each patient's medical record. Random-effects logistic regression was used to assess the association between race and the odds of having a uterine-sparing procedure versus hysterectomy. Subgroup analyses compared each uterine-sparing procedure with hysterectomy. Results: In this cohort of 1141 White women and 1196 Black women, Black women tended to be younger (median 41.0 vs. 42.0 years) and report worse symptoms, pain, and function on every scale compared with White women. Black women were more likely to have had a prior UF treatment compared with White women (22.8% vs. 14.6%). White women had more hysterectomies (43.6% vs. 32.2%) and myomectomies (50.9% vs. 50.2%) versus Black women. Black women had more UAEs (15.1% vs. 4.7%) than White women. After adjusting for clinical site and other variables, Black women had greater odds than White women of having a myomectomy (odds ratio [OR] = 2.41, 95% confidence interval [CI] = 1.63-3.56) or a UAE versus hysterectomy (OR = 4.24, 95% CI = 2.41-7.46). Conclusion: In these participants, Black women were more likely to schedule a uterine-sparing UF treatment and a nonsurgical UF treatment than their White counterparts; this may not be true for all women. Longer comparative effectiveness studies are needed to inform women about the durability of UF treatments. Greater understanding of factors influencing treatment selection is needed as are studies that include women without access to tertiary care centers. Clinical Trial Registration: Clinicaltrials.gov, NCT02260752 (enrollment start: November 2015).
Collapse
Affiliation(s)
- Ganesa Wegienka
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA
| | - Elizabeth A Stewart
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Wanda K Nicholson
- Department of Obstetrics and Gynecology, Center for Women's Health Research, and Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Shuaiqi Zhang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Fan Li
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Laine Thomas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - James B Spies
- Department of Radiology, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | | | - Shannon Laughlin-Tommaso
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia, USA
| | - Raymond M Anchan
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - George Larry Maxwell
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Erica E Marsh
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anissa I Vines
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Lauren A Wise
- Slone Epidemiology Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Kedra Wallace
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Vanessa L Jacoby
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, California, USA
| |
Collapse
|
31
|
Gonzalez R, Havrilesky LJ, Myers ER, Secord AA, Dottino JA, Berchuck A, Moss HA. Cost-effectiveness analysis comparing "PARP inhibitors-for-all" to the biomarker-directed use of PARP inhibitor maintenance therapy for newly diagnosed advanced stage ovarian cancer. Gynecol Oncol 2020; 159:483-490. [PMID: 32863036 DOI: 10.1016/j.ygyno.2020.08.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 08/04/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Clinical trials evaluating universal PARP inhibitor (PARPi) frontline maintenance therapy for advanced stage ovarian cancer have reported progression-free survival (PFS) benefit. It is unclear whether PARPi maintenance therapy will universally enhance value (clinical benefits relative to cost of delivery). We compared a "PARPi-for-all" to a biomarker-directed frontline maintenance therapy approach as a value-based care strategy. METHODS The cost of two frontline PARPi maintenance strategies, PARPi-for-all and biomarker-directed maintenance, was compared using modified Markov decision models simulating the study designs of the PRIMA, VELIA, and, PAOLA-1 trials. Outcomes of interest included overall costs and incremental cost-effectiveness ratios (ICERs) reported in US dollars per quality adjusted progression-free life-year (QA-PFY) gained. RESULTS PARPi-for-all was more costly and provided greater PFS benefit than a biomarker-directed strategy for each trial. The mean cost per patient for the PARPi-for-all strategy was $166,269, $286,715, and $366,506 for the PRIMA, VELIA, and PAOLA-1 models, respectively. For the biomarker-directed strategy, the mean cost per patient was $98,188, $167,334, and $260,671 for the PRIMA, VELIA, and PAOLA-1 models. ICERs of PARPi-for-all compared to biomarker-directed maintenance were: $593,250/QA-PFY (PRIMA), $1,512,495/QA-PFY (VELIA), and $3,347,915/QA-PFY (PAOLA-1). At current drug pricing, there is no PFS improvement in a biomarker negative cohort that would make PARPi-for-all cost-effective compared to biomarker-directed maintenance. CONCLUSIONS This study highlights the high costs of universal PARPi maintenance treatment, compared with a biomarker-directed PARPi strategy. Maintenance therapy in the front-line setting should be reserved for those with germline or somatic HRD mutations until the cost of therapy is significantly reduced.
Collapse
Affiliation(s)
- Rafael Gonzalez
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, United States of America; Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, United States of America.
| | - Laura J Havrilesky
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, United States of America; Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, United States of America
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, United States of America
| | - Angeles Alvarez Secord
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, United States of America; Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, United States of America
| | - Joseph A Dottino
- Division of Surgery, Department of Gynecologic Oncology and Reproductive Medicine, MD Anderson Cancer Center, Houston, TX, United States of America
| | - Andrew Berchuck
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, United States of America; Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, United States of America
| | - Haley A Moss
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, United States of America; Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, United States of America
| |
Collapse
|
32
|
Stewart EA, Diamond MP, Williams ARW, Carr BR, Myers ER, Feldman RA, Elger W, Mattia-Goldberg C, Schwefel BM, Chwalisz K. Safety and efficacy of the selective progesterone receptor modulator asoprisnil for heavy menstrual bleeding with uterine fibroids: pooled analysis of two 12-month, placebo-controlled, randomized trials. Hum Reprod 2020; 34:623-634. [PMID: 30865281 DOI: 10.1093/humrep/dez007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 09/28/2018] [Indexed: 12/12/2022] Open
Abstract
STUDY QUESTION Can asoprisnil, a selective progesterone receptor modulator, provide clinically meaningful improvements in heavy menstrual bleeding (HMB) associated with uterine fibroids with an acceptable safety profile? SUMMARY ANSWER Uninterrupted treatment with asoprisnil for 12 months effectively controlled HMB and reduced fibroid and uterine volume with few adverse events. WHAT IS KNOWN ALREADY In a 3-month study, asoprisnil (5, 10 and 25 mg) suppressed uterine bleeding, reduced fibroid and uterine volume, and improved hematological parameters in a dose-dependent manner. STUDY DESIGN, SIZE, DURATION In two Phase 3, double-blind, randomized, placebo-controlled, multicentre studies, women received oral asoprisnil 10 mg, asoprisnil 25 mg or placebo (2:2:1) once daily for up to 12 months. PARTICIPANTS/MATERIALS, SETTING, METHODS Premenopausal women ≥18 years of age in North America with HMB associated with uterine fibroids were included (N = 907). The primary efficacy endpoint was the percentage of women who met all three predefined criteria at 12 months or the final month for patients who prematurely discontinued: (1) ≥50% reduction in monthly blood loss (MBL) by menstrual pictogram, (2) hemoglobin concentration ≥11 g/dL or an increase of ≥1 g/dL, and (3) no interventional therapy for uterine fibroids. Secondary efficacy endpoints included changes in other menstrual bleeding parameters, volume of the largest fibroids, uterine volume and health-related quality of life (HRQL). MAIN RESULTS AND THE ROLE OF CHANCE In all, 90% and 93% of women in the asoprisnil 10-mg and 25-mg groups, respectively, and 35% of women in the placebo group met the primary endpoint (P < 0.001). Similar results were observed at month 6 (P < 0.001). The percentage of women who achieved amenorrhea in any specified month ranged from 66-78% in the asoprisnil 10-mg group and 83-93% in the asoprisnil 25-mg group, significantly higher than with placebo (3-12%, P < 0.001). Hemoglobin increased rapidly (by month 2) with asoprisnil treatment and was significantly higher versus placebo throughout treatment. The primary fibroid and uterine volumes were significantly reduced from baseline through month 12 with asoprisnil 10 mg (median changes up to -48% and -28%, respectively) and 25 mg (median changes up to -63% and -39%, respectively) versus placebo (median changes up to +16% and +13%, respectively; all P < 0.001). Dose-dependent, significant improvements in HRQL (Uterine Fibroid Symptom and Quality of Life instrument) were observed with asoprisnil treatment. Asoprisnil was generally well tolerated. Endometrial biopsies indicated dose- and time-dependent decreases in proliferative patterns and increases in quiescent or minimally stimulated endometrium at month 12 of treatment. Although not statistically significantly different at month 6, mean endometrial thickness at month 12 increased by ~2 mm in both asoprisnil groups compared with placebo (P < 0.01). This effect was associated with cystic changes in the endometrium on MRI and ultrasonography, which led to invasive diagnostic and therapeutic procedures in some asoprisnil-treated women. LIMITATIONS, REASONS FOR CAUTION Most study participants were black; few Asian and Hispanic women participated. The study duration may have been insufficient to fully characterize the endometrial effects. WIDER IMPLICATIONS OF THE FINDINGS Daily uninterrupted treatment with asoprisnil was highly effective in controlling menstrual bleeding, improving anemia, reducing fibroid and uterine volume, and increasing HRQL in women with HMB associated with uterine fibroids. However, this treatment led to an increase in endometrial thickness and invasive diagnostic and therapeutic procedures, with potential unknown consequences. STUDY FUNDING/COMPETING INTEREST(S) This trial was funded by AbbVie Inc. (prior sponsors: TAP Pharmaceutical Products Inc., Abbott Laboratories). E.A. Stewart was a site investigator in the Phase 2 study of asoprisnil and consulted for TAP during the design and conduct of these studies while at Harvard Medical School and Brigham and Women's Hospital. She received support from National Institutes of Health grants HD063312, HS023418 and HD074711 and research funding, paid to Mayo Clinic for patient care costs related to an NIH-funded trial from InSightec Ltd. She consulted for AbbVie, Allergan, Bayer HealthCare AG, Gynesonics, and Welltwigs. She received royalties from UpToDate and the Med Learning Group. M.P. Diamond received research funding for the conduct of the studies paid to the institution and consulted for AbbVie. He is a stockholder and board and director member of Advanced Reproductive Care. He has also received funding for study conduct paid to the institution from Bayer and ObsEva. A.R.W. Williams consulted for TAP and Repros Therapeutics Inc. He has current consultancies with PregLem SA, Gedeon Richter, HRA Pharma and Bayer. B.R. Carr consulted for and received research funding from AbbVie. E.R. Myers consulted for AbbVie, Allergan and Bayer. R.A. Feldman received compensation for serving as a principal investigator and participating in the conduct of the trial. W. Elger was co-inventor of several patents related to asoprisnil. C. Mattia-Goldberg is a former employee of AbbVie and may own AbbVie stock or stock options. B.M. Schwefel and K. Chwalisz are employees of AbbVie and may own AbbVie stock or stock options. TRIAL REGISTRATION NUMBER NCT00152269, NCT00160381 (clinicaltrials.gov). TRIAL REGISTRATION DATE 7 September 2005; 8 September 2005. DATE OF FIRST PATIENT’S ENROLMENT 12 September 2002; 6 September 2002.
Collapse
Affiliation(s)
- E A Stewart
- Departments of Obstetrics & Gynecology and Surgery, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - M P Diamond
- Department of Obstetrics & Gynecology, Augusta University, Augusta, GA, USA
| | - A R W Williams
- Department of Pathology, University of Edinburgh, Edinburgh, UK
| | - B R Carr
- Department of Obstetrics & Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - E R Myers
- Department of Obstetrics & Gynecology, Duke University Medical Center, Durham, NC, USA
| | | | - W Elger
- Evestra GmbH, Berlin-Dahlem, Germany
| | | | | | | |
Collapse
|
33
|
Tran AP, Al Naber J, Tambor ES, Myers ER. Addressing heterogenous outcomes in uterine fibroid research: a call to action. Am J Obstet Gynecol 2020; 223:75.e1-75.e5. [PMID: 32199924 DOI: 10.1016/j.ajog.2020.03.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/27/2020] [Accepted: 03/12/2020] [Indexed: 01/20/2023]
Abstract
Uterine fibroid tumors are the most common benign pelvic tumors in women, with complications that include heavy menstrual bleeding, pelvic pain, reproductive complications, and bulk-related symptoms. Although the majority of uterine fibroid tumors are asymptomatic, those women who experience symptoms can experience substantial burdens on quality of life and daily functioning. Comparative effectiveness reviews of available medical, surgical, and radiologic treatments have found that a lack of high-quality data to inform treatment decisions is, in part, due to the use of heterogeneous outcomes and instruments in clinical studies. With multiple new interventions emerging, this call-to-action encourages the development and use of a core outcome set that will capture the most relevant, patient-important outcomes in late-phase and after-marketing therapeutic trials for uterine fibroid tumors. The core outcome set should be developed by a diverse, multistakeholder group comprised of key healthcare decision-makers. Development and uptake of a core outcome set ensures that a consistent, collaboratively vetted set of outcomes will be accessible across different studies and promotes transparency for innovators who seek to anticipate the evidence needs of patients, providers, payers, regulators, and other stakeholders.
Collapse
Affiliation(s)
- Annie P Tran
- Center for Medical Technology Policy, Baltimore, MD
| | | | | | | |
Collapse
|
34
|
Laughlin-Tommaso SK, Lu D, Thomas L, Diamond MP, Wallace K, Wegienka G, Vines AI, Anchan RM, Wang T, Maxwell GL, Jacoby V, Marsh EE, Spies JB, Nicholson WK, Stewart EA, Myers ER. Short-term quality of life after myomectomy for uterine fibroids from the COMPARE-UF Fibroid Registry. Am J Obstet Gynecol 2020; 222:345.e1-345.e22. [PMID: 31678093 DOI: 10.1016/j.ajog.2019.09.052] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/12/2019] [Accepted: 09/30/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Uterine fibroids may decrease quality of life in a significant proportion of affected women. Myomectomy offers a uterine-sparing treatment option for patients with uterine fibroids that can be performed abdominally, laparoscopically (with or without robotic assistance), and hysteroscopically. Quality of life information using validated measures for different myomectomy routes, especially hysteroscopic myomectomy, is limited. OBJECTIVE To compare women's perception of their short-term health-related quality of life measures and reported time to return to usual activities and return to work for different routes of myomectomy. MATERIALS AND METHODS Comparing Options for Management: Patient-centered Results for Uterine Fibroids (COMPARE-UF) is a prospective nationwide fibroid registry that enrolled premenopausal women seeking treatment for uterine fibroids at 8 clinical sites. For this analysis, we included women undergoing hysteroscopic, abdominal, or laparoscopic myomectomy who completed the postprocedure questionnaire scheduled between 6 and 12 weeks after surgery. Health-related quality of life outcomes, such as pain, anxiety, and return to usual activitie, were assessed for each route. The hysteroscopic myomectomy group had large differences in demographics, fibroid number, and uterine size compared to the other groups; thus, a direct comparison of quality of life measures was performed only for abdominal and laparoscopic approaches after propensity weighting. Propensity weighting was done using 24 variables that included demographics, quality of life baseline measures, and fibroid and uterine measurements. RESULTS A total of 1206 women from 8 COMPARE-UF sites underwent myomectomy (338 hysteroscopic, 519 laparoscopic, and 349 abdominal). All women had substantial improvement in short-term health-related quality of life and symptom severity scores, which was not different among groups. Average symptom severity scores decreased about 30 points in each group. Return to usual activities averaged 0 days (interquartile range, 0-14 days) for hysteroscopic myomectomy, 21 days (interquartile range, 14-28 days) for laparoscopic myomectomy, and 28 days (interquartile range, 14-35 days) for abdominal myomectomy. After propensity adjustment, quality of life outcomes in the laparoscopic and abdominal myomectomy groups were similar except for more anxiety in the laparoscopic myomectomy group and slightly more pain in the abdominal myomectomy group. After propensity weighting, return to usual activities favored laparoscopic compared to abdominal procedures; median time was the same at 21 days, but the highest quartile of women in the abdominal group needed an additional week of recovery (interquartile range,14.0-28.0 for laparoscopic versus 14.0-35.0 for abdominal, P < .01). Time to return to work was also longer in the abdominal arm (median, 22 days; interquartile range, 14-40 days, versus median, 42; interquartile range, 27-56). CONCLUSION Women who underwent myomectomy had substantial improvement in health-related quality of life, regardless of route of myomectomy. After propensity weighting, abdominal myomectomy was associated with a nearly 2-week longer time to return to work than laparoscopic myomectomy.
Collapse
|
35
|
Wallace K, Zhang S, Thomas L, Stewart EA, Nicholson WK, Wegienka GR, Wise LA, Laughlin-Tommaso SK, Diamond MP, Marsh EE, Jacoby VL, Anchan RM, Venable S, Larry GM, Lytle B, Wang T, Myers ER. Comparative effectiveness of hysterectomy versus myomectomy on one-year health-related quality of life in women with uterine fibroids. Fertil Steril 2020; 113:618-626. [DOI: 10.1016/j.fertnstert.2019.10.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 10/08/2019] [Accepted: 10/13/2019] [Indexed: 10/24/2022]
|
36
|
Diamond MP, Stewart EA, Williams ARW, Carr BR, Myers ER, Feldman RA, Elger W, Mattia-Goldberg C, Schwefel BM, Chwalisz K. A 12-month extension study to evaluate the safety and efficacy of asoprisnil in women with heavy menstrual bleeding and uterine fibroids. Hum Reprod Open 2019; 2019:hoz027. [PMID: 31777761 PMCID: PMC6870550 DOI: 10.1093/hropen/hoz027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 08/01/2019] [Accepted: 08/12/2019] [Indexed: 12/11/2022] Open
Abstract
STUDY QUESTION What is the safety and efficacy profile during long-term (12–24 months) uninterrupted treatment with the selective progesterone receptor modulator asoprisnil, 10 and 25 mg in women with heavy menstrual bleeding (HMB) associated with uterine fibroids? SUMMARY ANSWER Uninterrupted treatment with asoprisnil should be avoided due to endometrial safety concerns and unknown potential long-term consequences. WHAT IS KNOWN ALREADY Asoprisnil was well tolerated in shorter-term studies and effectively suppressed HMB and reduced fibroid volume. STUDY DESIGN, SIZE, DURATION Women with uterine fibroids who had previously received placebo (n = 87) or asoprisnil 10 mg (n = 221) or 25 mg (n = 215) for 12 months in two double-blind studies entered this randomized uncontrolled extension study and received up to 12 additional months of treatment followed by 6 months of post-treatment follow-up. Women who previously received placebo were re-randomized to either asoprisnil 10 or 25 mg for the extension study. This report focuses on the 436 women who received asoprisnil in the double-blind studies and this extension study. Results for women who previously received placebo in the double-blind studies are not described. PARTICIPANTS/MATERIALS, SETTING, METHODS Women ≥18 years of age who completed a 12-month, double-blind, placebo-controlled study, had estradiol levels indicating that they were not menopausal and had no endometrial hyperplasia or other significant endometrial pathology were eligible. The safety endpoints were focused on endometrial assessments. The composite primary efficacy endpoint was the proportion of women who demonstrated a response to treatment by meeting all three of the following criteria at the final month for participants who prematurely discontinued or at month 12 for those who completed the study: a reduction from initial baseline to final visit of ≥50% in the menstrual pictogram score, hemoglobin concentration ≥11 g/dl or an increase of ≥1 g/dl from initial baseline at the final visit, and no surgical or invasive intervention for uterine fibroids. Other efficacy endpoints included rates for amenorrhea and suppression of bleeding, changes in fibroid and uterine volume and changes in hematologic parameters. No statistical tests were planned or performed for this uncontrolled study. MAIN RESULTS AND ROLE OF CHANCE Imaging studies revealed a progressive increase in endometrial thickness and cystic changes that frequently prompted invasive diagnostic procedures. Endometrial biopsy results were consistent with antiproliferative effects of asoprisnil. Two cases of endometrial cancer were diagnosed. At the final month of this extension study (total duration of uninterrupted treatment up to 24 months), the primary efficacy endpoint was achieved in 86 and 92% of women in the asoprisnil 10- and 25-mg groups, respectively. During each month of treatment, amenorrhea was observed in the majority of women (up to 77 and 94% at 10 and 25 mg, respectively). There was a progressive, dose-dependent decrease in the volume of the primary fibroid with asoprisnil 10 and 25 mg (−55.7 and −75.2% median decrease, respectively, from baseline [i.e. the beginning of the placebo-controlled study] to month 12 [cumulative months 12–24] of this extension study). These effects were associated with improvements in quality of life measures. LIMITATIONS, REASONS FOR CAUTION This study was uncontrolled, which limits the interpretation of safety and efficacy findings. The study also had multiple protocol amendments with the addition of diagnostic procedures and, because no active comparator was included, the potential place of asoprisnil in comparison to therapies such as GnRH agonists and surgery cannot be determined. WIDER IMPLICATIONS OF THE FINDINGS Long-term, uninterrupted treatment with asoprisnil leads to prominent cystic endometrial changes that are consistent with the ‘late progesterone receptor modulator’ effects, which prompted invasive diagnostic procedures, although treatment efficacy is maintained. Although endometrial cancers were uncommon during both treatment and follow-up, these findings raise concerns regarding endometrial safety during uninterrupted long-term treatment with asoprisnil. This study shows that uninterrupted treatment with asoprisnil should be avoided due to safety concerns and unknown potential long-term consequences. STUDY FUNDING/COMPETING INTEREST(S) AbbVie Inc. (prior sponsor, TAP Pharmaceutical Products Inc.) sponsored the study and contributed to the design and conduct of the study, data management, data analysis, interpretation of the data and the preparation and approval of the manuscript. Financial support for medical writing and editorial assistance was provided by AbbVie Inc. M. P. Diamond received research funding for the conduct of the study paid to the institution and is a consultant to AbbVie. He is a stockholder and board and director member of Advanced Reproductive Care. He has also received funding for study conduct paid to the institution for Bayer and ObsEva. E. A. Stewart participated as a site investigator in the phase 2 study of asoprisnil and served as a consultant to TAP Pharmaceuticals during the time of design and conduct of the studies while on the faculty of Harvard Medical School and Brigham and Women’s Hospital, Boston, MA. In the last 3 years, she has received support from National Institutes of Health grants HD063312, HS023418 and HD074711. She has served as a consultant for AbbVie Inc., Allergan, Bayer HealthCare AG and Myovant for consulting related to uterine leiomyoma and to Welltwigs for consulting related to infertility. She has received royalties from UpToDate and the Med Learning Group. A.R.W. Williams has acted as a consultant for TAP Pharmaceutical Products Inc. and Repros Therapeutics Inc. He has current consultancies with PregLem SA, Gedeon Richter, HRA Pharma and Bayer. B.R. Carr has served as consultant and received research funding from AbbVie Inc. and Synteract (Medicines360). E.R. Myers has served as consultant for AbbVie Inc., Allergan and Bayer. R.A. Feldman received compensation for serving as a principal investigator and participating in the conduct of the trial. W. Elger was a co-inventor of several patents related to asoprisnil. C. Mattia-Goldberg is a former employee of AbbVie Inc. and owns AbbVie stock or stock options. B.M. Schwefel and K. Chwalisz are employees of AbbVie Inc. and own AbbVie stock or stock options. TRIAL REGISTRATION NUMBER NCT00156195 at clinicaltrials.gov.
Collapse
Affiliation(s)
- M P Diamond
- Department of Obstetrics & Gynecology, Augusta University, Augusta, GA 30912, USA
| | - E A Stewart
- Departments of Obstetrics & Gynecology and Surgery, Mayo Clinic and Mayo Medical School, Rochester, MN 55905, USA
| | - A R W Williams
- Department of Pathology, University of Edinburgh, Edinburgh, UK
| | - B R Carr
- Department of Obstetrics & Gynecology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - E R Myers
- Department of Obstetrics & Gynecology, Duke University Medical Center, Durham, NC 27710, USA
| | - R A Feldman
- Miami Research Associates, Miami, FL 33143, USA
| | - W Elger
- Evestra GmbH, Berlin-Dahlem, Germany
| | | | | | - K Chwalisz
- AbbVie Inc., North Chicago, IL 60064, USA
| |
Collapse
|
37
|
Moss HA, Berchuck A, Neely ML, Myers ER, Havrilesky LJ. Estimating Cost-effectiveness of a Multimodal Ovarian Cancer Screening Program in the United States: Secondary Analysis of the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS). JAMA Oncol 2019; 4:190-195. [PMID: 29222541 DOI: 10.1001/jamaoncol.2017.4211] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Importance The United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) is the largest randomized clinical trial to evaluate screening's impact on ovarian cancer mortality, assigning women to multimodal screening (MMS) with serum cancer antigen 125 (CA-125) interpreted using a risk algorithm. If the MMS screening method is eventually shown to reduce mortality and be cost-effective, then it may be accepted by the medical community as a feasible screening tool. Objective To estimate the cost-effectiveness of an MMS screening program in the United States. Design, Setting, and Participants A Markov simulation model was constructed using data from UKCTOCS to compare MMS with no screening in the United States. Screening would begin at the age of 50 years for women in the general population. Published estimates of the long-term effect of MMS screening on ovarian cancer mortality and the trial's published hazard ratios were used to simulate mortality estimates up to 40 years from start of screening. Base-case costs included CA-125, ultrasound, and false-positive work-up results, in addition to a risk algorithm cost estimate of $100. The utility and costs of ovarian cancer treatment were incorporated into the model. Interventions Screening strategies varied by costs of the algorithm and treatment for advanced ovarian cancer, rates of screening compliance, ovarian cancer incidence, and extrapolation of ovarian cancer mortality. Main Outcomes and Measures Costs, quality-adjusted life-years (QALYs), and mortality reduction of ovarian cancer screening. Results Multimodal screening is both more expensive and more effective in reducing ovarian cancer mortality over a lifetime than no screening. After accounting for uncertainty in the underlying parameters, screening women starting at age 50 years with MMS is cost-effective 70% of the time, when decision makers are willing to pay $150 000 per QALY. Screening reduced mortality by 15%, with an incremental cost-effectiveness ratio (ICER) ranging from $106 187 (95% CI, $97 496-$127 793) to $155 256 (95% CI, $150 369-$198 567). Conclusions and Relevance Ovarian cancer screening is potentially cost-effective in the United States depending on final significance of mortality reduction and cost of the CA-125 risk algorithm. These results are limited by uncertainty around the effect of screening on ovarian cancer mortality beyond the 11 years of UKCTOCS.
Collapse
Affiliation(s)
- Haley A Moss
- Duke University Medical Center, Durham, North Carolina
| | | | - Megan L Neely
- Duke Clinical Research Institute, Durham, North Carolina
| | - Evan R Myers
- Duke University Medical Center, Durham, North Carolina
| | | |
Collapse
|
38
|
Greenup RA, Rushing C, Fish L, Campbell BM, Tolnitch L, Hyslop T, Peppercorn J, Wheeler SB, Zafar SY, Myers ER, Hwang ES. Financial Costs and Burden Related to Decisions for Breast Cancer Surgery. J Oncol Pract 2019; 15:e666-e676. [PMID: 31356147 DOI: 10.1200/jop.18.00796] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Financial toxicity is a well-recognized adverse effect of cancer care, yet little is known about how women consider treatment costs when facing preference-sensitive decisions for breast cancer surgery or how surgical treatment choice affects financial harm. We sought to determine how financial costs and burden relate to decisions for breast cancer surgery. METHODS Women (≥ 18 years old) with a history of breast cancer were recruited from the Army of Women and Sisters Network to complete an 88-item electronic survey. Descriptive statistics and regression analysis were used to evaluate the impact of costs on surgical decisions and financial harm after breast cancer surgery. RESULTS A total of 607 women with stage 0 to III breast cancer were included. Most were white (90%), were insured privately (70%) or by Medicare (25%), were college educated (78%), and reported household incomes of more than $74,000 (56%). Forty-three percent underwent breast-conserving surgery, 25% underwent mastectomy, 32% underwent bilateral mastectomy, and 36% underwent breast reconstruction. Twenty-eight percent reported that costs of treatment influenced their surgical decisions, and at incomes of $45,000 per year, costs were prioritized over breast preservation or appearance. Overall, 35% reported financial burden as a result of their cancer treatment, and 78% never discussed costs with their cancer team. When compared with breast-conserving surgery, bilateral mastectomy with or without reconstruction was significantly associated with higher incurred debt, significant to catastrophic financial burden, treatment-related financial hardship, and altered employment. Among the highest incomes, 65% of women were fiscally unprepared, reporting higher-than-expected (26%) treatment costs. CONCLUSION Cancer treatment costs influenced decisions for breast cancer surgery, and comparably effective surgical treatments differed significantly in their risk of patient-reported financial burden, debt, and impact on employment. Cost transparency may inform preference-sensitive surgical decisions and improve patient-centered care.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - S Yousuf Zafar
- 1Duke University, Durham, NC.,3University of North Carolina, Chapel Hill, NC
| | | | | |
Collapse
|
39
|
Greenup RA, Rushing CN, Fish LJ, Lane WO, Peppercorn JM, Bellavance E, Tolnitch L, Hyslop T, Myers ER, Zafar SY, Hwang ES. Perspectives on the Costs of Cancer Care: A Survey of the American Society of Breast Surgeons. Ann Surg Oncol 2019; 26:3141-3151. [PMID: 31342390 DOI: 10.1245/s10434-019-07594-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cancer treatment costs are not routinely addressed in shared decisions for breast cancer surgery. Thus, we sought to characterize cost awareness and communication among surgeons treating breast cancer. METHODS We conducted a self-administered, confidential electronic survey among members of the American Society of Breast Surgeons from 1 July to 15 September 2018. Questions were based on previously published or validated survey items, and assessed surgeon demographics, cost sensitivity, and communication. Descriptive summaries and cross-tabulations with Chi-square statistics were used, with exact tests where warranted, to assess findings. RESULTS Of those surveyed (N = 2293), 598 (25%) responded. Surgeons reported that 'risk of recurrence' (70%), 'appearance of the breast' (50%), and 'risks of surgery' (47%) were the most influential on patients' decisions for breast cancer surgery; 6% cited out-of-pocket costs as significant. Over half (53%) of the surgeons agreed that doctors should consider patient costs when choosing cancer treatment, yet the majority of surgeons (58%) reported 'infrequently' (43%) or 'never' (15%) considering patient costs in medical recommendations. The overwhelming majority (87%) of surgeons believed that patients should have access to the costs of their treatment before making medical decisions. Surgeons treating a higher percentage of Medicaid or uninsured patients were more likely to consistently consider costs (p < 0.001). Participants reported that insufficient knowledge or resources (61%), a perceived inability to help with costs (24%), and inadequate time (22%) impeded cost discussions. Notably, 20% of participants believed that discussing costs might impact the quality of care patients receive. CONCLUSIONS Cost transparency remains rare, however in shared decisions for breast cancer surgery, improved cost awareness by surgeons has the potential to reduce financial hardship.
Collapse
Affiliation(s)
- Rachel A Greenup
- Department of Surgery, Duke University, Durham, NC, USA. .,Department of Population Health Sciences, Duke University, Durham, NC, USA. .,Duke Cancer Institute, Duke University, Durham, NC, USA. .,Duke Cancer Control and Population Sciences, Duke University, Durham, NC, USA.
| | - Christel N Rushing
- Duke Cancer Institute, Duke University, Durham, NC, USA.,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Laura J Fish
- Duke Cancer Institute, Duke University, Durham, NC, USA.,Duke Cancer Control and Population Sciences, Duke University, Durham, NC, USA.,Duke School of Medicine, Duke University, Durham, NC, USA
| | | | | | | | - Lisa Tolnitch
- Department of Surgery, Duke University, Durham, NC, USA
| | - Terry Hyslop
- Duke Cancer Institute, Duke University, Durham, NC, USA.,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Evan R Myers
- Department of Medicine, Duke University, Durham, NC, USA.,Department of Obstetrics and Gynecology, Duke University, Durham, NC, USA
| | - S Yousuf Zafar
- Department of Population Health Sciences, Duke University, Durham, NC, USA.,Duke Cancer Institute, Duke University, Durham, NC, USA.,Duke Cancer Control and Population Sciences, Duke University, Durham, NC, USA.,Department of Medicine, Duke University, Durham, NC, USA
| | - E Shelley Hwang
- Department of Surgery, Duke University, Durham, NC, USA.,Duke Cancer Institute, Duke University, Durham, NC, USA
| |
Collapse
|
40
|
Kamal AH, Wolf SP, Troy J, Leff V, Dahlin C, Rotella JD, Handzo G, Rodgers PE, Myers ER. Policy Changes Key To Promoting Sustainability And Growth Of The Specialty Palliative Care Workforce. Health Aff (Millwood) 2019; 38:910-918. [DOI: 10.1377/hlthaff.2019.00018] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Arif H. Kamal
- Arif H. Kamal is an associate professor of medicine at Duke Cancer Institute, in Durham, North Carolina
| | - Steven P. Wolf
- Steven P. Wolf is a biostatistician at the Duke University School of Medicine, in Durham
| | - Jesse Troy
- Jesse Troy is an assistant professor in the Department of Pediatrics, Duke University School of Medicine
| | - Victoria Leff
- Victoria Leff is a palliative care social worker in the Section of Palliative Care at Duke University Hospital, in Durham
| | - Constance Dahlin
- Constance Dahlin is director of professional practice at the Hospice and Palliative Nurses Association, in Boston, Massachusetts
| | - Joseph D. Rotella
- Joseph D. Rotella is chief medical officer at the American Academy of Hospice and Palliative Medicine, in Chicago, Illinois
| | - George Handzo
- George Handzo is director of health services research and quality at the Healthcare Chaplaincy Network, in New York City
| | - Phillip E. Rodgers
- Phillip E. Rodgers is an associate professor of family medicine at the University of Michigan Medical School, in Ann Arbor
| | - Evan R. Myers
- Evan R. Myers is a professor of obstetrics and gynecology at the Duke University School of Medicine
| |
Collapse
|
41
|
Kamal AH, Wolf SP, Troy J, Leff V, Dahlin C, Rotella JD, Handzo G, Rodgers PE, Myers ER. Policy Changes Key To Promoting Sustainability And Growth Of The Specialty Palliative Care Workforce. Health Aff (Millwood) 2019. [DOI: 10.10.1377/hlthaff.2019.00018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Arif H. Kamal
- Arif H. Kamal is an associate professor of medicine at Duke Cancer Institute, in Durham, North Carolina
| | - Steven P. Wolf
- Steven P. Wolf is a biostatistician at the Duke University School of Medicine, in Durham
| | - Jesse Troy
- Jesse Troy is an assistant professor in the Department of Pediatrics, Duke University School of Medicine
| | - Victoria Leff
- Victoria Leff is a palliative care social worker in the Section of Palliative Care at Duke University Hospital, in Durham
| | - Constance Dahlin
- Constance Dahlin is director of professional practice at the Hospice and Palliative Nurses Association, in Boston, Massachusetts
| | - Joseph D. Rotella
- Joseph D. Rotella is chief medical officer at the American Academy of Hospice and Palliative Medicine, in Chicago, Illinois
| | - George Handzo
- George Handzo is director of health services research and quality at the Healthcare Chaplaincy Network, in New York City
| | - Phillip E. Rodgers
- Phillip E. Rodgers is an associate professor of family medicine at the University of Michigan Medical School, in Ann Arbor
| | - Evan R. Myers
- Evan R. Myers is a professor of obstetrics and gynecology at the Duke University School of Medicine
| |
Collapse
|
42
|
Hopkins MK, Grotegut CA, Swamy GK, Myers ER, Havrilesky LJ. Induction of Labor versus Scheduled Cesarean in Morbidly Obese Women: A Cost-Effectiveness Analysis. Am J Perinatol 2019; 36:399-405. [PMID: 30130822 DOI: 10.1055/s-0038-1668591] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To assess the costs, complication rates, and harm-benefit tradeoffs of induction of labor (IOL) compared to scheduled cesarean delivery (CD) in women with class III obesity. STUDY DESIGN We conducted a cost analysis of IOL versus scheduled CD in nulliparous morbidly obese women. Primary outcomes were surgical site infection (SSI), chorioamnionitis, venous thromboembolism, blood transfusion, and readmission. Model outcomes were mean cost of each strategy, cost per complication avoided, and complication tradeoffs. We assessed the costs, complication rates, and harm-benefit tradeoffs of IOL compared with scheduled CD in women with class III obesity. RESULTS A total of 110 patients underwent scheduled CD and 114 underwent IOL, of whom 61 (54%) delivered via cesarean. The group delivering vaginally experienced fewer complications. SSI occurred in 0% in the vaginal delivery group, 13% following scheduled cesarean, and 16% following induction then cesarean. In the decision model, the mean cost of induction was $13,349 compared with $14,575 for scheduled CD. Scheduled CD costs $9,699 per case of chorioamnionitis avoided, resulted in 18 cases of chorioamnionitis avoided per additional SSI and 3 cases of chorioamnionitis avoided per additional hospital readmission. In sensitivity analysis, IOL is cost saving compared with scheduled CD unless the cesarean rate following induction exceeds 70%. CONCLUSION In morbidly obese women, induction of labor remains cost-saving until the rate of cesarean following induction exceeds 70%.
Collapse
Affiliation(s)
- Maeve K Hopkins
- Division of Maternal and Fetal Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chad A Grotegut
- Division of Maternal and Fetal Medicine, Duke University Medical Center, Durham, North Carolina
| | - Geeta K Swamy
- Division of Maternal and Fetal Medicine, Duke University Medical Center, Durham, North Carolina
| | - Evan R Myers
- Division of Clinical and Epidemiologic Research, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Laura J Havrilesky
- Division of Gynecologic Oncology, Duke University Medical Center, Durham, North Carolina
| |
Collapse
|
43
|
Mendelsohn AB, Brinkley E, Franke KM, Lang K, Myers ER, Velentgas P. Comparative effectiveness of uterine fibroids procedures using linked medical record and claims data. J Comp Eff Res 2018; 7:1209-1218. [PMID: 30451534 DOI: 10.2217/cer-2018-0049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIMS To compare durability of uterus-conserving procedures for symptomatic fibroids in terms of incidence and time to subsequent procedures. PATIENTS & METHODS We conducted a retrospective database study of 2648 patients having a uterus-conserving procedure for uterine fibroids from 2005 to 2011 with a minimum of 2 years follow-up. RESULTS Patients with myomectomy or uterine artery embolization as their index procedure had lower risk of a subsequent procedure during the study compared with patients who underwent endometrial ablation. CONCLUSION While subject to known limitations of using electronic medical record and administrative claims data, this research provides additional evidence regarding expectations for time to subsequent procedures that may be helpful for women and their healthcare providers to consider when making treatment choices.
Collapse
Affiliation(s)
| | - Emma Brinkley
- Real-World Insights, QuintilesIMS, Cambridge, MA 02139, USA
| | | | - Kathy Lang
- Real-World Insights, QuintilesIMS, Cambridge, MA 02139, USA
| | - Evan R Myers
- Department of Obstetrics & Gynecology, Duke University Medical Center, Durham, NC 27710, USA
| | | |
Collapse
|
44
|
Morse JE, Calvert SB, Jurkowski C, Tassinari M, Sewell CA, Myers ER. Evidence-based pregnancy testing in clinical trials: Recommendations from a multi-stakeholder development process. PLoS One 2018; 13:e0202474. [PMID: 30208049 PMCID: PMC6135366 DOI: 10.1371/journal.pone.0202474] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 08/03/2018] [Indexed: 12/27/2022] Open
Abstract
Most clinical trials exclude pregnant women in order to avoid the possibility of adverse embryonic and/or fetal effects. Currently, there are no evidence-based guidelines regarding appropriate methods for identifying early pregnancy among research subjects. This lack of guidance results in wide variation in pregnancy testing plans, leading to the potential for inadequate protection against embryonic or fetal exposure in some cases and unnecessary burdens on research participants in others, as well as inefficiencies caused by disagreements among sponsors, investigators, and regulators. To address this issue, the Clinical Trials Transformation Initiative convened content experts and stakeholders to develop recommendations for pregnancy testing in clinical research based on currently available evidence. Recommendations included: 1) the study protocol should clearly state the rationale for pregnancy testing and the plan for handling positive and indeterminate tests; 2) protocols should include an assessment of the pregnancy testing plan advantages (reduced risk of embryo/fetal exposure) versus the burdens (participant burden, study team workload, costs); 3) protocols should assess the participant burdens regarding the likelihood of false negative and false positive results; 4) participant administered home pregnancy testing should be avoided in clinical trials; and 5) the consent process should describe the extent of knowledge about the study intervention's potential risk to the embryo/fetus and the limitations and consequences of pregnancy testing. CTTI has also developed an online tool to help implement these recommendations.
Collapse
Affiliation(s)
- Jessica E. Morse
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
| | - Sara B. Calvert
- Clinical Trials Transformation Initiative, Duke University Medical Center, Durham, North Carolina, United States of America
- * E-mail:
| | - Claire Jurkowski
- Global Pharmacovigilance and Epidemiology, Bristol-Myers Squibb, Hopewell, New Jersey, United States of America
| | - Melissa Tassinari
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, United States of America
| | - Catherine A. Sewell
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, United States of America
| | - Evan R. Myers
- Department of Obstetrics & Gynecology and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, United States of America
| |
Collapse
|
45
|
Hicklin KT, Ivy JS, Wilson JR, Cobb Payton F, Viswanathan M, Myers ER. Simulation model of the relationship between cesarean section rates and labor duration. Health Care Manag Sci 2018; 22:635-657. [PMID: 29995263 DOI: 10.1007/s10729-018-9449-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 06/13/2018] [Indexed: 11/25/2022]
Abstract
Cesarean delivery is the most common major abdominal surgery in many parts of the world, and it accounts for nearly one-third of births in the United States. For a patient who requires a C-section, allowing prolonged labor is not recommended because of the increased risk of infection. However, for a patient who is capable of a successful vaginal delivery, performing an unnecessary C-section can have a substantial adverse impact on the patient's future health. We develop two stochastic simulation models of the delivery process for women in labor; and our objectives are (i) to represent the natural progression of labor and thereby gain insights concerning the duration of labor as it depends on the dilation state for induced, augmented, and spontaneous labors; and (ii) to evaluate the Friedman curve and other labor-progression rules, including their impact on the C-section rate and on the rates of maternal and fetal complications. To use a shifted lognormal distribution for modeling the duration of labor in each dilation state and for each type of labor, we formulate a percentile-matching procedure that requires three estimated quantiles of each distribution as reported in the literature. Based on results generated by both simulation models, we concluded that for singleton births by nulliparous women with no prior complications, labor duration longer than two hours (i.e., the time limit for labor arrest based on the Friedman curve) should be allowed in each dilation state; furthermore, the allowed labor duration should be a function of dilation state.
Collapse
Affiliation(s)
- Karen T Hicklin
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.
| | - Julie S Ivy
- Edward P. Fitts Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, NC, 27695, USA
| | - James R Wilson
- Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, NC, 27695, USA
| | - Fay Cobb Payton
- College of Management, North Carolina State University, Raleigh, NC, 27695, USA
| | | | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, 27710, USA
| |
Collapse
|
46
|
Chou R, Baker WL, Bañez LL, Iyer S, Myers ER, Newberry S, Pincock L, Robinson KA, Sardenga L, Sathe N, Springs S, Wilt TJ. Agency for Healthcare Research and Quality Evidence-based Practice Center methods provide guidance on prioritization and selection of harms in systematic reviews. J Clin Epidemiol 2018; 98:98-104. [DOI: 10.1016/j.jclinepi.2018.01.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 01/11/2018] [Accepted: 01/18/2018] [Indexed: 12/12/2022]
|
47
|
Moss HA, Samimi G, Havrilesky LJ, Sherman ME, Myers ER. Estimating the number of potential family members eligible for BRCA1 and BRCA2 mutation testing in a "Traceback" approach. Genet Epidemiol 2017; 42:117-122. [PMID: 29193313 DOI: 10.1002/gepi.22095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 09/28/2017] [Accepted: 10/10/2017] [Indexed: 11/11/2022]
Abstract
U.S. guidelines recommend BRCA1/2 mutation testing for women diagnosed with high-grade ovarian cancer (HGOC) to increase recognition of carriers, but most remain unidentified and at risk. Accordingly, an approach termed "Traceback" has been proposed in which probands are retrospectively identified by testing archived pathology specimens, and family members are traced to provide genetic counseling and testing. We used population-based data to estimate the number of family members who might be contacted through such a program. We used incidence data from the Surveillance, Epidemiology, and End Results (SEER) Program to estimate the number of women diagnosed with HGOC from 2005 to 2016, and census data to estimate the number of spouses, offspring, and siblings (both sexes). Using overall survival for HGOC from SEER and all-cause mortality rates from the Centers for Diseases Control and Prevention, we estimated the number of patients, spouses, offspring, and siblings of HGOC cases living in 2017. Due to the high mortality rate of HGOC, consent from living probands may be possible in only 42% of the cases; consent to test pathology specimens would need to be sought from next of kin for the remainder. In 2017, an estimated 406,919 living next of kin (spouses, siblings, offspring) would be available for potential consent. Testing archived ovarian cancer pathology specimens may enable the identification of BRCA1/2 mutation carriers, but consent from next of kin would be required in in 58% of cases. Although Traceback offers the possibility of identifying unaffected BRCA1/2 mutation carriers, pilot feasibility studies that include assessment of methods to secure consent are needed.
Collapse
Affiliation(s)
| | - Goli Samimi
- Division of Cancer Prevention, National Cancer Institute, Rockville, MD, USA
| | | | | | | |
Collapse
|
48
|
Dorth JA, Lee WR, Chino J, Abouassaly R, Ellis RJ, Myers ER. Cost-Effectiveness of Primary Radiation Therapy Versus Radical Prostatectomy for Intermediate- to High-Risk Prostate Cancer. Int J Radiat Oncol Biol Phys 2017; 100:383-390. [PMID: 29353655 DOI: 10.1016/j.ijrobp.2017.10.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 10/05/2017] [Accepted: 10/12/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE To compare, using a cost-effectiveness analysis, the quality-adjusted life expectancy (QALE) and cost between the 2 treatment options for intermediate- to high-risk prostate cancer: (1) radiation (RT) with androgen deprivation therapy (ADT) or (2) radical prostatectomy (RP) followed by adjuvant RT for patients with risk factors. METHODS AND MATERIALS Our Markov model allowed patients to transition between health states with yearly probabilities of developing cancer recurrence and/or toxicity. Probabilities were assigned according to favorable intermediate, unfavorable intermediate, or high-risk prostate cancer groups. The primary analysis examined outcomes for patients aged 65 years, whereas secondary analyses explored the effects of younger age, elevated baseline cardiovascular risk, and the use of salvage therapy. One-way and probabilistic sensitivity analyses were performed. RESULTS Across all primary and secondary analyses, and using a wide-range of assumptions, RT + ADT was the preferred treatment strategy for men with intermediate- to high-risk prostate cancer. The QALE was higher after RT + ADT by 0.5 to 1.14 quality-adjusted life years, compared with RP. Radiation plus ADT was cost-effective in all situations, falling beneath a threshold of $100,000 per quality-adjusted life year. Among all risk groups, a greater proportion of patients undergoing RP experienced single or multiple treatment toxicities. CONCLUSIONS Radiation plus ADT may result in improved QALE compared with RP for intermediate- to high-risk prostate cancer. Although biochemical failure is similar between treatment groups, there is a higher rate of developing multiple toxicities among patients treated with upfront RP.
Collapse
Affiliation(s)
- Jennifer A Dorth
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, Ohio.
| | - W Robert Lee
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Junzo Chino
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Robert Abouassaly
- Department of Urology, University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, Ohio
| | - Rodney J Ellis
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, Ohio
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
49
|
Gamble C, Havrilesky LJ, Myers ER, Chino JP, Hollenbeck S, Plichta JK, Kelly Marcom P, Shelley Hwang E, Kauff ND, Greenup RA. Cost Effectiveness of Risk-Reducing Mastectomy versus Surveillance in BRCA Mutation Carriers with a History of Ovarian Cancer. Ann Surg Oncol 2017; 24:3116-3123. [PMID: 28699130 DOI: 10.1245/s10434-017-5995-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND The appropriate management of breast cancer risk in BRCA mutation carriers following ovarian cancer diagnosis remains unclear. We sought to determine the survival benefit and cost effectiveness of risk-reducing mastectomy (RRM) among women with BRCA1/2 mutations following stage II-IV ovarian cancer. DESIGN We constructed a decision model from a third-party payer perspective to compare annual screening with magnetic resonance imaging (MRI) and mammography to annual screening followed by RRM with reconstruction following ovarian cancer diagnosis. Survival, overall costs, and cost effectiveness were determined by decade at diagnosis using 2015 US dollars. All inputs were obtained from the literature and public databases. Monte Carlo probabilistic sensitivity analysis was performed with a $100,000 willingness-to-pay threshold. RESULTS The incremental cost-effectiveness ratio (ICER) per year of life saved (YLS) for RRM increased with age and BRCA2 mutation status, with greater survival benefit demonstrated in younger patients with BRCA1 mutations. RRM delayed 5 years in 40-year-old BRCA1 mutation carriers was associated with 5 months of life gained (ICER $72,739/YLS), and in 60-year-old BRCA2 mutation carriers was associated with 0.8 months of life gained (ICER $334,906/YLS). In all scenarios, $/YLS and mastectomies per breast cancer prevented were lowest with RRM performed 5-10 years after ovarian cancer diagnosis. CONCLUSION For most BRCA1/2 mutation carriers following ovarian cancer diagnosis, RRM performed within 5 years is not cost effective when compared with breast cancer screening. Imaging surveillance should be advocated during the first several years after ovarian cancer diagnosis, after which point the benefits of RRM can be considered based on patient age and BRCA mutation status.
Collapse
Affiliation(s)
- Charlotte Gamble
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Laura J Havrilesky
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA.,Division of Gynecologic Oncology, Duke University Medical Center, Durham, NC, USA.,Duke Cancer Institute, Durham, NC, USA
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA.,Duke Cancer Institute, Durham, NC, USA
| | - Junzo P Chino
- Duke Cancer Institute, Durham, NC, USA.,Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Scott Hollenbeck
- Department of General Surgery, Division of Plastics, Maxillofacial and Oral Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jennifer K Plichta
- Duke Cancer Institute, Durham, NC, USA.,Department of Surgery, Division of Advanced Oncologic and Gastrointestinal Surgery, Duke University Medical Center, Durham, NC, USA
| | - P Kelly Marcom
- Duke Cancer Institute, Durham, NC, USA.,Division of Medical Oncology, Duke University Medical Center, Durham, NC, USA
| | - E Shelley Hwang
- Duke Cancer Institute, Durham, NC, USA.,Department of Surgery, Division of Advanced Oncologic and Gastrointestinal Surgery, Duke University Medical Center, Durham, NC, USA
| | - Noah D Kauff
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA.,Duke Cancer Institute, Durham, NC, USA
| | - Rachel A Greenup
- Duke Cancer Institute, Durham, NC, USA. .,Department of Surgery, Division of Advanced Oncologic and Gastrointestinal Surgery, Duke University Medical Center, Durham, NC, USA.
| |
Collapse
|
50
|
Hall RK, Myers ER, Rosas SE, O’Hare AM, Colón-Emeric CS. Choice of Hemodialysis Access in Older Adults: A Cost-Effectiveness Analysis. Clin J Am Soc Nephrol 2017; 12:947-954. [PMID: 28522655 PMCID: PMC5460715 DOI: 10.2215/cjn.11631116] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 02/24/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Although arteriovenous fistulas have been found to be the most cost-effective form of hemodialysis access, the relative benefits of placing an arteriovenous fistula versus an arteriovenous graft seem to be least certain for older adults and when placed preemptively. However, older adults' life expectancy is heterogeneous, and most patients do not undergo permanent access creation until after dialysis initiation. We evaluated cost-effectiveness of arteriovenous fistula placement after dialysis initiation in older adults as a function of age and life expectancy. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using a hypothetical cohort of patients on incident hemodialysis with central venous catheters, we constructed Markov models of three treatment options: (1) arteriovenous fistula placement, (2) arteriovenous graft placement, or (3) continued catheter use. Costs, utilities, and transitional probabilities were derived from existing literature. Probabilistic sensitivity analyses were performed by age group (65-69, 70-74, 75-79, 80-84, and 85-89 years old) and quartile of life expectancy. Costs, quality-adjusted life-months, and incremental cost-effectiveness ratios were evaluated for up to 5 years. RESULTS The arteriovenous fistula option was cost effective compared with continued catheter use for all age and life expectancy groups, except for 85-89 year olds in the lowest life expectancy quartile. The arteriovenous fistula option was more cost effective than the arteriovenous graft option for all quartiles of life expectancy among the 65- to 69-year-old age group. For older age groups, differences in cost-effectiveness between the strategies were attenuated, and the arteriovenous fistula option tended to only be cost effective in patients with life expectancy >2 years. For groups for which the arteriovenous fistula option was not cost saving, the cost to gain one quality-adjusted life-month ranged from $2294 to $14,042. CONCLUSIONS Among older adults, the cost-effectiveness of an arteriovenous fistula placed within the first month of dialysis diminishes with increasing age and lower life expectancy and is not the most cost-effective option for those with the most limited life expectancy.
Collapse
Affiliation(s)
- Rasheeda K. Hall
- Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
- Division of Nephrology, Department of Medicine
| | | | - Sylvia E. Rosas
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
| | - Ann M. O’Hare
- Department of Medicine and
- Health Services Research and Development Center of Excellence, VA Puget Sound Healthcare System, Seattle, Washington; and
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Cathleen S. Colón-Emeric
- Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
- Division of Geriatrics, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| |
Collapse
|