The Protective Role of Maternal-Fetal Bonding for Postpartum Bonding Following a NICU Admission.

INTRODUCTION: Admission of a newborn to a neonatal intensive care unit (NICU) can be a highly stressful event that affects maternal psychological well-being and disrupts the early maternal-infant bonding relationship. Determining factors that promote maternal-infant bonding among those with a NICU admission is essential for the development of effective interventions. METHODS: Using a longitudinal clinic-based sample of diverse and low-income pregnant women, we examined whether maternal-fetal bonding measured during the second trimester moderated the association between NICU admission and postpartum bonding measured at six months post birth, controlling for demographic characteristics. RESULTS: Approximately 18% of the sample experienced a NICU admission at birth. NICU admission was associated with lower postpartum bonding (b = -8.74; p < .001, Model 1), whereas maternal-fetal bonding was associated with higher bonding reported at six months postpartum (b = 3.74, p < .001, Model 2). Results of the interaction revealed that women who reported higher maternal-fetal bonding reported higher postnatal bonding regardless of NICU admission status. DISCUSSION: Because maternal-fetal bonding can be enhanced through intervention, it is a promising target for reducing the risks of NICU admission for the early maternal-infant relationship.

Test, evidence, transition projects in Scotland: developing the evidence needed for transition of effective interventions in cancer care from innovation into mainstream practice.

BACKGROUND: A robust evidence base is required to assist healthcare commissioners and providers in selecting effective and sustainable approaches to improve cancer diagnosis and treatment. Such evidence can be difficult to build, given the fast-paced and highly pressured nature of healthcare delivery, the absence of incentives, and the presence of barriers in conducting pragmatic yet robust research evaluations. Cancer Research UK (CRUK) has played an active part in building the evidence base through its funding of programmes to identify, evaluate and scale-up innovative approaches across the UK. The aim of this paper is to describe and explain the research design and intended approach and activities for two cancer services improvement projects in Scotland funded by CRUK. METHODS: A hybrid effectiveness-implementation study design will assess both the efficiency of the new pathways and their implementation strategies, with the aim of generating knowledge for scale-up. A range of implementation, service and clinical outcomes will be assessed as determined by the projects' Theories of Change (ToCs). A naturalistic case study approach will enable in-depth exploration of context and process, and the collection and synthesis of data from multiple sources including routine datasets, patient and staff surveys, in-depth interviews and observational and other data. The evaluations are informed throughout by a patient/public representatives' group, and by small group discussions with volunteer cancer patients. DISCUSSION: Our approach has been designed to provide a holistic understanding of how (well) the improvement projects work (in relation to their anticipated outcomes), and how they interact with their wider contexts. The evaluations will help identify barriers, facilitators, and unanticipated consequences that can impact scalability, sustainability and spread. By opting for a pragmatic, participatory evaluation research design, we hope to inform strategies for scaling up successful innovations while addressing challenges in a targeted manner.

Capacity building in female pelvic medicine and reconstructive surgery: Global Health Partnership beyond fistula care in Ethiopia.

OBJECTIVE: Obstetric fistula is a devastating childbirth injury that leaves women incontinent, stigmatized and often isolated from their families and communities. In Ethiopia, although much attention has focused on treating and preventing obstetric fistula, other more prevalent childbirth-related pelvic floor disorders, such as pelvic organ prolapse, non-fistula-related incontinence and post-fistula residual incontinence, remain largely unattended. The lack of international and local attention to addressing devastating pelvic floor disorders is concerning for women in low- and middle-income countries. The objective of this article is to highlight the need for a more comprehsive approach to pelvic floor care and to share our experience in addressing it. METHODS: Here, we share our experience launching one of the first formal training programs in Female Pelvic Medicine and Reconstructive Surgery (FPMRS) in Ethiopia. RESULTS: This fellowship program provides quality care while strengthening the health system in its local context. This program has positioned Ethiopia to be a regional leader by providing comprehensive training of surgeons and allied health professionals, building appropriate health system and research infrastructure, and developing a formal FPMRS training curriculum. CONCLUSION: We hope that sharing this experience will serve as a template for others championing comprehensive pelvic floor care for women in low- and middle-income countries.

Compassionate Care in the Age of Evidence-Based Practice: A Critical Discourse Analysis in the Context of Chronic Pain Care.

PURPOSE: Health professions education and practice have seen renewed calls to restore compassion to care. However, because of the ways evidence-based practice (EBP) has been implemented in health care, wherein research-based knowledge is privileged, the dominance of EBP may silence clinician and patient experience-based knowledge needed for compassionate care. This study explored what happens when the discourses of compassionate care and EBP interact in practice. METHOD: Chronic pain management in Canada was selected as the context for the study. Data collection involved compiling an archive of 458 chronic pain texts, including gray literature from 2009-2015 (non-peer-reviewed sources, e.g., guidelines), patient blog posts from 2013-2015, and transcripts of study interviews with 9 clinicians and postgraduate trainees from local pain clinics from 2015-2016. The archive was analyzed using an interpretive qualitative approach informed by critical discourse analysis. RESULTS: Four manifestations of the discourse of compassionate care were identified: curing the pain itself, returning to function, alleviating suffering, and validating the patient experience. These discourses produced particular subject positions, activities, practices, and privileged forms of knowledge. They operated in response, partnership, apology, and resistance, respectively, to the dominant discourse of EBP. These relationships were mediated by other prevalent discourses in the system: patient safety, patient-centered care, professional liability, interprofessional collaboration, and efficiency. CONCLUSIONS: Medical education efforts to foster compassion in health professionals and systems need to acknowledge the complex web of discourses-which carry with them their own expectations, material effects, and roles-and support people in navigating this web.

Medical Abortion.

OBJECTIVE: This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care. INTENDED USERS: Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services. TARGET POPULATION: Women with an unintended first trimester pregnancy. EVIDENCE: Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required. VALUES: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1). BENEFITS, HARMS AND/OR COSTS: Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability. SUMMARY STATEMENTS: Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care RECOMMENDATIONS: Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care.

But does it do any good? Measuring the impact of music therapy on people with advanced dementia: (Innovative practice).

This article describes the impact of music therapy upon a group of nine people with advanced dementia in a hospital setting. It demonstrates how the impact of music therapy was measured using the case notes completed by nursing and care staff and how these notes suggested that music therapy had a positive effect on the mood and behaviour on eight of the nine people receiving music therapy.

Immediate effects of the initial FDA notification on the use of surgical mesh for pelvic organ prolapse surgery in medicare beneficiaries.

AIMS: Prompted by increased reports of complications with the use of mesh for pelvic organ prolapse (POP) surgery, the FDA issued an initial public health notification (PHN) in 2008. We proposed to determine if the numbers of POP cases augmented with surgical mesh performed in U.S. Medicare beneficiaries changed relative to this PHN. METHODS: Using administrative healthcare claims for beneficiaries enrolled in the U.S. Medicare program from 2008 to 2009, we identified women who underwent POP surgery with and without surgical mesh by procedural and diagnosis coding. In addition to comparing cases with and without mesh, we also calculated rates (number of cases per 100,000 female beneficiaries) and compared these relative to the timing of the PHN. RESULTS: We identified 104,185 POP procedures, of which 27,839 (26.7%) included mesh material and 76,346 (73.3%) did not. Between the last three quarters of 2008 and the first three of 2009, the rates of mesh cases increased (40.3-42.1, P < 0.001) and those without mesh decreased (115.5-111.4, P < 0.001). Inpatient procedures decreased and outpatient procedures increased for both those with and without mesh augmentation. For inpatient procedures, the relative use of biologic graft and synthetic mesh material did not vary over the study period. CONCLUSIONS: A substantial number of Medicare beneficiaries underwent mesh POP procedures in 2008-2009. However, despite the PHN cautioning about potential mesh complications, the numbers of mesh cases continued to rise in the immediate period after the PHN.

Dexmedetomidine for patients undergoing diagnostic cardiac procedures: a noninferiority study.

When anesthetizing children with congenital heart disease for diagnostic cardiac catheterization, anesthesiologists and cardiologists seek to use anesthetic regimens that yield minimal hemodynamic changes and allow for spontaneous ventilations. Recently, dexmedetomidine has been used as an anesthesia adjunct because of its sedative and analgesic properties and minimal ventilatory depressive effects. We tested the hypothesis that the combination of sevoflurane and dexmedetomidine is non-inferior to sevoflurane alone as it refers to hemodynamic measurements during diagnostic cardiac catheterization in children with a transplanted heart, one ventricle (Fontan procedure), or normal cardiac physiology. Patients were anesthetized with inhalation of sevoflurane in nitrous oxide/oxygen and, after baseline hemodynamic measurements, successive boluses of dexmedetomidine followed by continuous infusion were administered. In this study, non-inferiority was shown when differences at steady-state (dexmedetomidine + sevoflurane) compared to baseline (sevoflurane alone) and its associated 95% confidence interval fell completely within the range of plus or minus 20%. Forty-one (26 normal physiology, 9 cardiac transplantation, and 6 Fontan) patients were enrolled. Non-inferiority of sevoflurane + dexmedetomidine compared with sevoflurane alone was shown for heart rate, but not for arterial blood pressure in patients with normal and cardiac transplant physiology. In patients with normal cardiac physiology, non-inferiority was demonstrated for bispectral index. Therefore, while the lack of depressive respiratory effects and non-inferiority for heart rate are desirable, the lack of non-inferiority of dexmedetomidine + sevoflurane combination for arterial blood pressure do not justify the routine use of this combination compared with sevoflurane alone for children with congenital heart disease undergoing cardiac catheterization.

Factors associated with exposure of transvaginally placed polypropylene mesh for pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: This study evaluates potential risk factors for mesh exposure following transvaginal placement of polypropylene mesh for pelvic organ prolapse requiring reoperation. METHODS: We performed a case-control study. Cases had mesh exposure requiring surgical revision; controls had no mesh exposures and were chosen for similar surgical date and type of mesh. RESULTS: We identified 48 cases and 48 controls. The adjusted odds ratio of having a bleeding complication at the time of mesh implantation was 7.25 [95% confidence interval (CI) 1.47-35.66], smokers versus nonsmokers was 3.17 (95% CI 0.59-17.12), and being 1 year older was 0.96 (95% CI 0.92-1.0), among women with mesh exposure. CONCLUSIONS: We identified bleeding complications at the time of mesh implantation as a risk factor for mesh exposure requiring reoperation. Despite being one of the largest studies on this topic, our data were inconclusive regarding the impact of other possible factors on mesh exposure.

What are the barriers to warfarin use in atrial fibrillation?: Development of a questionnaire.

BACKGROUND: Despite evidence of their benefit and efforts to increase usage, anticoagulation for stroke prophylaxis in atrial fibrillation (AF) patients remains underutilized. Previous surveys have assessed reasons for underuse of anticoagulation but have limitations including non-structured approach for eliciting barriers and use of clinical vignettes and not patient-level data. The objectives of this study were to develop a questionnaire to assess barriers to anticoagulation use for stroke prophylaxis in AF patients at a patient- and physician-level and to conduct a preliminary field-test of the instrument. METHODS: Barriers to warfarin use were identified from a literature review, input from clinical experts, and a physician focus group. A sample of US physicians who treat AF patients completed the questionnaire. Physicians ranked their reluctance on a 1-10 scale (10 = very reluctant) in general to prescribe warfarin if a specific barrier was present in a patient and then indicated critical barriers to prescribing warfarin in a sample of their own AF patients not receiving warfarin. RESULTS: Forty-one barriers to warfarin use were identified and classified into 4 groups: patient medical characteristics (n = 17), health care system factors (n = 7), patient capability (n = 12), and patient preference (n = 5). Several new items were developed (e.g., difficulty in obtaining venous access), existing items were revised (e.g., timeframe for bleeding episodes subdivided into > or

Colorectal cancer screening attitudes and practices in the general population: a risk-adjusted survey.

OBJECTIVES: To characterize self-reported colorectal cancer (CRC) screening behavior, and to identify characteristics of CRC screening practices, stratified by risk. METHODS: Using random-digit-dial methodology, we conducted telephone surveys in US adults 50 years of age and older. Respondents provided data on utilization of CRC screening tests; demographic characteristics; and awareness, concerns, attitudes and beliefs about the tests, CRC, and health care. On the basis of available guidelines, three definitions of adequate screening were considered. RESULTS: Among persons reporting having ever had a CRC screening exam, the exam was more likely to have been a fecal occult blood test than a radiologic or endoscopic exam (p < .0001). Subjects at increased CRC risk were more likely to have met the screening criteria (p < .001) compared with average-risk subjects. Receipt of information or advice about cancer screening tests, male gender, and concern about managed care were positively associated with adequate screening. Smoking, low health self-monitoring, and an average risk for CRC reduced the probability of CRC screening. CONCLUSIONS: Lack of awareness about screening remains common, regardless of CRC risk. Providing information and advice about cancer screening may be the single most important tool available to improve screening rates.

Validation of a quality-of-life instrument for laryngopharyngeal reflux.

OBJECTIVES: To establish the reliability, validity, and responsiveness of a new, disease-specific assessment tool, the LPR-HRQL, which assesses patient-reported outcomes (PRO) with regard to health-related quality of life (HRQL) of patients with laryngopharyngeal reflux (LPR). DESIGN: A prospective, open-label, repeated-measures study. SETTING: Six centers in 4 states in the eastern United States. PATIENTS: Patients with LPR. INTERVENTIONS: Open-label treatment with 20 mg of omeprazole twice daily. Clinical and PRO HRQL data were collected. Several PRO instruments were administered to patients at each of several time points; these instruments included the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36), a general HRQL tool; the Voice Handicap Index (VHI), a symptom-specific tool for assessing voice problems; and the QOLRAD instrument (Quality of Life in Reflux and Dyspepsia), used to assess the impact of gastroesophageal reflux disease. RESULTS: Factor analyses of the LPR-HRQL scales confirmed single dimensions for each. All LPR-HRQL items contributed to internal consistency of scales and had substantial variability permitting useful information. Substantial evidence of convergent and divergent validity with SF-36, VHI, and QOLRAD items was observed. Test-retest validity was adequate for the time interval tested. Changes in domain scores of the LPR-HRQL at 4 and 6 months documented its responsiveness. CONCLUSIONS: The LPR-HRQL displays reliability, validity, and responsiveness, has face validity, and is simple and not burdensome to administer, score, and analyze. Accordingly, it may be used to assist physicians and patients in understanding the HRQL burden of LPR and the impact of therapy.

Chronic prenatal exposure to carbamazepine and perinatal outcomes of C3H/He mice.

OBJECTIVES: This study was undertaken to determine a daily therapeutic dose of carbamazepine and to measure its effect on reproductive performance and perinatal outcomes of mice. STUDY DESIGN: Adult C3H/He mice were given carbamazepine in rodent chow in either a 0.25% or a 1.0% mixture. Comparisons between doses included nongravid weight change, plasma drug steady-state concentrations, and response to a maximal electroshock seizure test. The strain was then fed either the preferred dose of carbamazepine or a placebo 1 week before starting to mate and throughout gestation to compare reproductive performance and offspring early development. RESULTS: Mice who ate the 0.25% carbamazepine mixture displayed no evoked seizure activity and, in contrast to the 1.0% mixture, did not lose weight. This daily dose of 542+/-35 mg/kg produced a trough steady-state plasma concentration that was consistent with a protective threshold in humans. Differences from placebo controls were not statistically significant for the number of cycles necessary to conceive or for the duration of gestation. The litter size, survival rates, birth weights, weight gain, and onset of eye openings and teeth eruptions of the pups were not statistically significant between the two groups. CONCLUSION: Long-term prenatal exposure to a subtoxic yet therapeutic dose of carbamazepine did not impair reproductive performance or early growth and development of exposed mice offspring.

Temporal trends in radical prostatectomy complications from 1991 to 1998.

PURPOSE: We performed a retrospective, longitudinal, population based study to ascertain whether radical prostatectomy outcomes improved after the diffusion of surgical innovations during the last decade. MATERIALS AND METHODS: Using a 5% national random sample of Medicare beneficiaries we identified 12,079 men who underwent radical prostatectomy from 1991 to 1998. We analyzed relevant Medicare data to establish length of stay and the rate of in hospital complications (cardiac, respiratory, vascular, wound and genitourinary conditions) as well as the rate of anastomotic stricture, incontinence and impotence through 36 months after surgery. We performed multivariate logistic regression to control for age, race and geographic region when assessing the association of surgery year with outcomes of interest. RESULTS: Between 1991 and 1998 the in hospital complication rate decreased from 38% to 30% and mean length of stay decreased from 8.1 to 5.1 days. Each value had significant regional variation throughout the United States. The 3-year incontinence rate decreased from 20% in 1991 to 4% in 1995. However, no meaningful trends were observed in the rate of impotence, anastomotic stricture, or placement of artificial urinary sphincters or penile prostheses. On multivariate analysis, older age (75 years or older, OR 1.68, p <0.01) and nonwhite race (OR 1.35, p <0.01) were associated with more in hospital complications. Nonwhite patients were also more likely to be diagnosed with impotence (OR 1.25, p <0.01) and undergo penile prosthesis placement (OR 1.5, p <0.01). CONCLUSIONS: As urologists reach consensus on the ideal clinical characteristics for radical prostatectomy candidates, surgery in fewer elderly patients and the dissemination of surgical advances have been associated with shorter length of stay, fewer in hospital complications and a lower long-term incontinence rate. However, there is capacity for improvement, as evidenced by the unchanging rate of anastomotic stricture and impotence.

Role of surgeon volume in radical prostatectomy outcomes.

PURPOSE: To examine the effect of hospital and surgeon volume on postoperative outcomes and to determine whether hospital or surgeon volume is the stronger predictor. PATIENTS AND METHODS: Using 1997 to 1998 claims data from a national 5% random sample of Medicare beneficiaries, we identified 2,292 men who underwent radical prostatectomy at 1,210 hospitals by 1,788 surgeons. Hospitals were classified as high (> or = 60 per year) or low (< 60 per year) volume according to radical prostatectomy experience over the 2-year period. Surgeons were classified as high (> or = 40 per year) or low (< 40 per year) volume. Multivariate logistic regression was performed to control for patient demographics and comorbidities when assessing the association of hospital and surgeon volume with in-hospital complications, length of stay, and anastomotic stricture rates. In-hospital complications included cardiac, respiratory, vascular, wound, genitourinary, and miscellaneous surgical and medical conditions. RESULTS: High-volume surgeons had half the complication risk (odds ratio [OR] = 0.53; 95% confidence interval [CI], 0.32 to 0.89) and shorter lengths of stay (4.1 v 5.2 days, P =.03) compared with low-volume surgeons. High-volume hospital patients tended to have fewer anastomotic strictures (OR = 0.72; 95% CI, 0.49 to 1.04). Patient age (> or = 75 years) was associated with more complications (OR = 1.9; 95% CI, 1.39 to 2.70), more anastomotic strictures (OR = 2.2; 95% CI, 1.54 to 3.15), and longer hospital stays (parameter estimate = 2.26; 95% CI, 1.75 to 2.77). CONCLUSION: Surgeon volume is inversely related to in-hospital complications and length of stay in men undergoing radical prostatectomy. Hospital volume is not significantly associated with outcomes after adjusting for physician volume. Further study is necessary to elucidate the mechanism of the volume-outcome effect.

Neurobehavior effects in four strains of mice offspring exposed prenatally to alprazolam.

OBJECTIVE: This study was performed to determine whether prenatal exposure to alprazolam affects offspring behavior in different strains of mice. STUDY DESIGN: Eight to 11 gravid mice of the C3H/He, C57BL/6, A/J, and DBA/2 strains were given either an anxiolytic dose of alprazolam (0.32 mg/kg) or a placebo by gavage on day 18 of an anticipated 19- to 21-day gestation. Neurobehavior tasks were conducted to assess anxiety, learning and memory, and social interaction. Data were analyzed by analysis of variance or a Fisher exact probability test. RESULTS: Anxiety in alprazolam-exposed offspring was reduced in C3H/He (P <.05) and A/J (P <.05) newborn infants by separation vocalization but may be increased in the C3H/He adult strain on the plus maze task. Learning was slower among C57BL/6 mice exposed to alprazolam (P <.01), whereas memory was reduced in exposed A/J and DBA/2 offspring (P <.05). Alprazolam exposure was associated with more aggression among C3H/He and C57BL/6 male offspring (P <.01) and with less group activity by C57BL/6 offspring (P <.05). CONCLUSION: Altered behaviors in several mouse strains after prenatal exposure to alprazolam suggests a vulnerability of GABA-benozdiazepine receptor formation in fetal brain development.

Variations in breast carcinoma treatment in older medicare beneficiaries: is it black or white.

BACKGROUND: To evaluate associations between race and breast carcinoma treatment. METHODS: Data from 984 black and 849 white Medicare beneficiaries 67 years or older with local breast carcinoma and a subset of 732 surviving women interviewed 3-4 years posttreatment were used to calculate adjusted odds of treatment, controlling for age, comorbidity, attitudes, region, and area measures of socioeconomic and health care resources. RESULTS: Sixty-seven percent of women received a mastectomy and 33% received breast-conserving surgery. The odds of radiation omission were 48% higher (95% confidence interval [CI] 1.01-2.19) for blacks than for whites after considering covariates, but the absolute number of women who failed to receive this modality was small (11%). In race-stratified models, the odds of having radiation omitted were significantly higher among blacks living greater distances from a cancer center (vs. lesser) or living in areas with high poverty (vs. low), but these factors did not affect radiation use among whites. Among those interviewed, blacks reported perceiving more ageism and racism in the health care system than whites (P = 0.001). The independent odds of receiving mastectomy (vs. breast conservation and radiation) were 2.72 times higher (95% CI 1.25-5.92) among women reporting the highest quartile of perceived ageism scores, compared with the lowest, and higher perceived ageism tended to be associated with higher odds of radiation omission (P = 0.06). CONCLUSIONS: Older black women with localized breast carcinoma may have a different experience obtaining treatment than their white counterparts. The absolute number of women receiving nonstandard care was small and the effects were small to moderate. However, if these patterns persist, it will be important to evaluate whether such experiences contribute to within-stage race mortality disparities.

Patient and provider characteristics that affect the use of axillary dissection in older women with stage I-II breast carcinoma.

BACKGROUND: Axillary dissection for the evaluation and treatment of patients with breast carcinoma often is not performed in older women. The objective of this study was to examine patient, clinical, and surgeon characteristics associated with the use of axillary dissection after breast-conserving surgery (BCS). METHODS: A cohort of 464 women age > or = 67 years who were newly diagnosed with Stage I-II breast carcinoma and who underwent BCS were surveyed along with their 158 surgeons, and their medical records were reviewed. Patient, tumor, and provider characteristics were examined for association with the omission of axillary dissection. RESULTS: The majority of women (63.4%) underwent axillary lymph node dissection after BCS. Increasing age was associated strongly with decreasing odds of undergoing axillary lymph node dissection, even after considering patient health and preferences, clinical factors, and provider factors (odds ratio [OR], 0.11; 95% confidence interval [95%CI], 0.05-0.27). Independent of age and other factors, women in the lowest quartile of physical functioning were 37% less likely to undergo axillary lymph node dissection compared with women in the highest quartile (OR, 0.63; 95%CI, 0.62-0.64). Patients who were cared for by surgeons with subspecialty training in oncology were 60% less likely to undergo axillary lymph node dissection compared with patients who were cared for by other surgeons, even after considering other factors (OR, 0.41; 95%CI, 0.25-0.68). CONCLUSIONS: The results of this study demonstrated a correlation between lower use of axillary dissection and advancing age, lower functional status, and greater surgeon training. These findings suggest that simple, age-based considerations are important but are not the sole determinants of variations in treatment.

Benefits and costs of using HPV testing to screen for cervical cancer.

CONTEXT: Despite quality assurance standards, Papanicolaou (Pap) test characteristics remain less than optimal. OBJECTIVE: To compare the societal costs and benefits of human papillomavirus (HPV) testing, Pap testing, and their combination to screen for cervical cancer. DESIGN, SETTING, AND POPULATION: A simulation model of neoplasia natural history was used to estimate the societal costs and quality-adjusted life expectancy associated with 18 different general population screening strategies: Pap plus HPV testing, Pap testing alone, and HPV testing alone every 2 or 3 years among hypothetical longitudinal cohorts of US women beginning at age 20 years and continuing to 65 years, 75 years, or death. MAIN OUTCOME MEASURE: Discounted costs per quality-adjusted life-year (QALY) saved of each screening strategy. RESULTS: Maximal savings in lives were achieved by screening every 2 years until death with combined HPV and Pap testing at an incremental cost of $76 183 per QALY compared with Pap testing alone every 2 years. Stopping biennial screening with HPV and Pap testing at age 75 years captures 97.8% of the benefits of lifetime screening at a cost of $70 347 per QALY. Combined biennial HPV and Pap testing to age 65 years captures 86.6% of the benefits achievable by continuing to screen until age 75 years. Human papillomavirus screening alone was equally effective as Pap testing alone at any given screening interval or age of screening cessation but was more costly and therefore was dominated. In sensitivity analyses, HPV testing would be more effective and less costly than Pap testing at a cost threshold of $5 for an HPV test. CONCLUSIONS: Screening with HPV plus Pap tests every 2 years appears to save additional years of life at reasonable costs compared with Pap testing alone. Applying age limits to screening is a viable option to maintain benefits while reducing costs.