Cost estimation alongside a multi-regional, multi-country randomized trial of antenatal ultrasound in five low-and-middle-income countries.

BACKGROUND: Improving maternal health has been a primary goal of international health agencies for many years, with the aim of reducing maternal and child deaths and improving access to antenatal care (ANC) services, particularly in low-and-middle-income countries (LMICs). Health interventions with these aims have received more attention from a clinical effectiveness perspective than for cost impact and economic efficiency. METHODS: We collected data on resource use and costs as part of a large, multi-country study assessing the use of routine antenatal screening ultrasound (US) with the aim of considering the implications for economic efficiency. We assessed typical antenatal outpatient and hospital-based (facility) care for pregnant women, in general, with selective complication-related data collection in women participating in a large maternal health registry and clinical trial in five LMICs. We estimated average costs from a facility/health system perspective for outpatient and inpatient services. We converted all country-level currency cost estimates to 2015 United States dollars (USD). We compared average costs across countries for ANC visits, deliveries, higher-risk pregnancies, and complications, and conducted sensitivity analyses. RESULTS: Our study included sites in five countries representing different regions. Overall, the relative cost of individual ANC and delivery-related healthcare use was consistent among countries, generally corresponding to country-specific income levels. ANC outpatient visit cost estimates per patient among countries ranged from 15 to 30 USD, based on average counts for visits with and without US. Estimates for antenatal screening US visits were more costly than non-US visits. Costs associated with higher-risk pregnancies were influenced by rates of hospital delivery by cesarean section (mean per person delivery cost estimate range: 25-65 USD). CONCLUSIONS: Despite substantial differences among countries in infrastructures and health system capacity, there were similarities in resource allocation, delivery location, and country-level challenges. Overall, there was no clear suggestion that adding antenatal screening US would result in either major cost savings or major cost increases. However, antenatal screening US would have higher training and maintenance costs. Given the lack of clinical effectiveness evidence and greater resource constraints of LMICs, it is unlikely that introducing antenatal screening US would be economically efficient in these settings--on the demand side (i.e., patients) or supply side (i.e., healthcare providers). TRIAL REGISTRATION: Trial number: NCT01990625 (First posted: November 21, 2013 on https://clinicaltrials.gov ).

The diagnostic impact of limited, screening obstetric ultrasound when performed by midwives in rural Uganda.

OBJECTIVE: To evaluate the diagnostic impact of limited obstetric ultrasound (US) in identifying high-risk pregnancies when used as a screening tool by midwives in rural Uganda. STUDY DESIGN: This was an institutional review board-approved prospective study of expecting mothers in rural Uganda who underwent clinical and US exams as part of their standard antenatal care visit in a local health center in the Isingiro district of Uganda. The midwives documented clinical impressions before performing a limited obstetric US on the same patient. The clinical findings were then compared with the subsequent US findings to determine the diagnostic impact. The midwives were US-naive before participating in the 6-week training course for limited obstetric US. RESULT: Midwife-performed screening obstetric US altered the clinical diagnosis in up to 12% clinical encounters. This diagnostic impact is less (6.7 to 7.4%) if the early third trimester diagnosis of malpresentation is excluded. The quality assurance review of midwives' imaging demonstrated 100% sensitivity and specificity in the diagnosing gestational number, and 90% sensitivity and 96% specificity in the diagnosis of fetal presentation. CONCLUSION: Limited, screening obstetric US performed by midwives with focused, obstetric US training demonstrates the diagnostic impact for identifying conditions associated with high-risk pregnancies in 6.7 to 12% of patients screened. The limited obstetric US improved diagnosis of early pregnancy complication as well as later gestation twins and malpresentation. Midwives who have undergone focused 6-week limited obstetric US training proved capable of diagnosing twins and fetal presentation with high sensitivity and specificity.

Sentinel lymph node biopsy for breast cancer.

The regional lymph node status is the most powerful predictor of survival in women with invasive breast cancer.

Adenocarcinoma of the prostate.

Prostate cancer presents a growing challenge for the medical director. Knowledge of prostate cancer statistics, risk factors, stage and grade of the tumors, screening, and treatment options is necessary for underwriting and claims evaluation.