Sociodemographic and attitudinal predictors of simultaneous and redundant multiple marker and cell-free DNA screening among women aged ⩾35 years.

OBJECTIVE: To identify characteristics associated with undergoing cell-free DNA (cfDNA) and multiple marker screening (MMS) simultaneously or redundantly (after receiving negative results from the first screening test) among women aged ⩾35 years. STUDY DESIGN: Participants presenting for prenatal testing completed a questionnaire that included measures of pregnancy worry and attitudes toward potential testing outcomes; data on prenatal test use was obtained via medical record review. We used multivariable logistic regression to identify factors associated with redundant or simultaneous screening. RESULTS: Among 164 participants, 69 (42.1%) had cfDNA redundantly (n=51) to, or simultaneously (n=18) with, MMS. Compared with the 46 MMS-negative women who did not undergo further testing, those who underwent redundant or simultaneous cfDNA/MMS screening were more likely to have annual family incomes >$150 000, to feel having a miscarriage would be worse than having an intellectually disabled child, to desire comprehensive testing for intellectual disability and to have more pregnancy worry. CONCLUSION: Providers who counsel patients on prenatal aneuploidy screening tests should explain the appropriate utilization of these screening tests to avoid unnecessary or minimally informative use of multiple tests.

Decision analysis of prenatal testing for chromosomal disorders: what do the preferences of pregnant women tell us?

Current guidelines recommend offering invasive testing for chromosomal disorders only to women who are aged 35 or older, or who are at similarly elevated risk (as determined by maternal serum and/or ultrasonographic screening). We conducted a decision analysis, using preference scores obtained from pregnant women, to determine whether current guidelines maximize the health-related quality of life of these women. If only miscarriage and chromosomal abnormalities are considered, the expected value of testing exceeds that of not testing for women 30 years of age or older. However, if a comprehensive range of relevant testing outcomes is considered, testing offers a higher expected value than not testing, regardless of age. Furthermore, patient preferences for specific testing outcomes play a much more substantial role in determining the course of action with the highest expected value than does the probability of any of the possible testing outcomes. The current age- and risk-based guideline for prenatal diagnosis does not maximize expected value and fails to appropriately consider individual patient preferences. For counseling purposes, how an individual values the presence and timing of fetal chromosomal information should be carefully understood.

Who should be offered prenatal diagnosis? The 35-year-old question.

Prenatal diagnosis of chromosomal disorders is generally offered to women who will be 35 years or older at the time of delivery or who have been determined via serum screening to be at risk similar to that of a woman older than 35 years. This age threshold was based on 4 major rationales that reflect considerations of resources and effectiveness. In this paper, we explore the current screening recommendations and consider new information that calls the 35-years threshold into question. We conclude that guidelines regarding use of prenatal diagnosis account for the preferences of the individual patient as well as for individual risk.

Proton pump inhibitors or histamine-2 receptor antagonists for the prevention of recurrences of erosive reflux esophagitis: a cost-effectiveness analysis.

OBJECTIVES: Erosive esophagitis is a recurring condition for which many patients require preventive therapy. If maintenance therapy must be provided, the most cost-effective treatment strategy should be established. We evaluated the costs and benefits associated with three treatment strategies: 1) maintenance therapy with a proton pump inhibitor (PPI) strategy, 2) maintenance therapy with a high-dose histamine-2 receptor antagonist (H2RA) strategy, and 3) maintenance therapy with a standard-dose H2RA. If patients experience a symptomatic recurrence on the H2RA strategies, they then receive PPI maintenance. METHODS: We used a cost-effectiveness model with a 1-yr time frame; data were obtained from randomized trials of lansoprazole and ranitidine, from case series, and expert opinion. RESULTS: In most situations, the high-dose H2RA strategy is the most costly, yet it is less effective than the PPI strategy. Among the remaining two options, the PPI strategy is more costly and more effective than the standard-dose H2RA strategy, requiring an additional $52-688 per recurrence prevented, depending on drug acquisition costs. The greater the degree to which esophagitis decreases quality of life, the more cost effective is the PPI strategy. For example, with a $50,000 per quality-adjusted life year cost-effectiveness threshold and a market-weighted average of drug costs, the PPI strategy appears cost effective for those patients who report that symptoms of esophagitis cause greater than a 9% decrement in quality of life. CONCLUSIONS: The high-dose H2RA strategy is not preferred in terms of either costs or benefits. The PPI strategy appears cost effective relative to the standard-dose H2RA strategy in the following situations: when patients are significantly bothered by esophagitis and in institutional settings where the difference in drug costs between PPIs and H2RAs is small.

Prevention of recurrences of erosive reflux esophagitis: a cost-effectiveness analysis of maintenance proton pump inhibition.

PURPOSE: To determine the cost-effectiveness of three management strategies for healed erosive reflux esophagitis: maintenance therapy with a proton pump inhibitor (PPI) from the outset; no maintenance therapy unless a patient's symptoms recur once over a year; and no maintenance therapy unless a patient's symptoms recur twice over a year. MATERIALS AND METHODS: Decision analysis using data from randomized trials of lansoprazole, case series, and expert opinion. RESULTS: For patients with grade 4 esophagitis, maintenance from the outset is the most efficient approach. For all other patients, providing maintenance PPI after a patient experiences two recurrences is the least costly but least effective approach. The other two approaches prevent more recurrences: waiting to initiate maintenance therapy until symptoms recur once requires an additional $73 for each recurrence prevented whereas maintenance PPI from the outset requires an additional $819 for each recurrence prevented. Maintenance therapy from the outset is cost effective if symptoms of esophagitis cause a 22% or greater decrement in quality of life (using $50,000 per quality-adjusted life year gained as a cost-effectiveness definition). However, withholding maintenance until the time of a first recurrence is cost effective if symptoms cause a 2% or greater decrement in quality of life. CONCLUSION: For grades 2 and 3 esophagitis, providing maintenance therapy after a patient experiences a further recurrence is a preferred option that appears cost-effective across a wide array of assumptions. Maintenance therapy from the outset, however, appears cost-effective only for those patients who report a significant decline in quality of life associated with esophagitis or for those patients with baseline grade 4 esophagitis.

Concurrent hysterectomy at bilateral salpingo-oophorectomy: benefits, risks, and costs.

OBJECTIVE: To evaluate the medical and economic consequences of concurrent hysterectomy at the time of bilateral salpingo-oophorectomy (BSO) for benign ovarian disease in peri- and postmenopausal women. METHODS: Decision analysis was used to compare the health outcomes and economic costs of performing BSO with concurrent hysterectomy versus BSO alone in theoretic cohorts of 10,000 women undergoing surgery for benign adnexal disease. A model was constructed incorporating probabilities of possible outcomes from the National Hospital Discharge Database, the National Cancer Institute SEER Program, and the literature. Data on associated costs were obtained from the California State Discharge Database, Medicare, and the literature. RESULTS: Performing concurrent hysterectomy in a cohort of 10,000 45-year-old women would prevent approximately 71 future deaths from gynecologic disease at a cost of five immediate deaths from the surgery. However, short-term complications are much more frequent in women undergoing hysterectomy. On average, hysterectomy at age 45 adds approximately 0.071 years of life expectancy; at age 55, it adds 0.026 years. The procedure results in cost savings of approximately $1913 per patient at age 45 and $1112 at age 55. CONCLUSION: Concurrent hysterectomy causes short-term morbidity, but appears to increase average life expectancy slightly among perimenopausal women and is cost-saving. Medical outcomes and economic consequences only marginally favor the procedure. Patient preferences for the potential outcomes should play a key role in determining the appropriateness of its use.

Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates.

OBJECTIVE: To determine the prevalence of chronic pelvic pain in U.S. women aged 18-50 years, and to examine its association with health-related quality of life, work productivity, and health care utilization. METHODS: In April and May 1994, the Gallup Organization telephoned 17,927 U.S. households to identify women aged 18-50 years who experienced chronic pelvic pain, ie, of at least 6 months' duration. Those who reported chronic pelvic pain were surveyed on severity, frequency, and diagnosis; quality of life; work loss and productivity; and health care utilization. RESULTS: Among 5263 eligible women who agreed to participate, 773 (14.7%) reported chronic pelvic pain within the past 3 months. Those who reported chronic pelvic pain had significantly lower mean scores for general health than those who did not (70.5 versus 78.8,P<.05), and 61% of those with chronic pelvic pain reported that the etiology was unknown. Women diagnosed with endometriosis reported the most health distress, pain during or after intercourse, and interference with activities because of pain. Estimated direct medical costs for outpatient visits for chronic pelvic pain for the U.S population of women aged 18-50 years are $881.5 million per year. Among 548 employed respondents, 15% reported time lost from paid work and 45% reported reduced work productivity. CONCLUSION: Frequently, the cause of chronic pain is undiagnosed, although it affects approximately one in seven U.S. women. Increased awareness of its cost and impact on quality of life should promote increased medical attention to this problem.

Protein A immunoadsorption column versus splenectomy in the treatment of steroid-resistant immune thrombocytopenic purpura. A cost-effectiveness analysis.

The protein A immunoadsorption column is a new treatment for immune thrombocytopenic purpura (ITP). We used a decision-analytic approach with a Markov process to model the cost effectiveness of this treatment compared with splenectomy for steroid-resistant ITP patients. Data informing the model were obtained from published literature, a panel of physicians, and public databases. We found initial treatment with the protein A immunoadsorption column to be less expensive and more effective than initial treatment with splenectomy.

Sleep problems and their correlates in a working population.

OBJECTIVE: To measure the prevalence of sleep problems in a working population and examine their association with health problems, health-related quality-of-life measures, work-related problems, and medical expenditures. Also, to explore the usefulness of a sleep-problems screen for mental health conditions and underlying sleep disorders. DESIGN: Cross-sectional survey administered via voice mail and telephone interview. SETTING: A San Francisco Bay Area telecommunications firm. PARTICIPANTS: Volunteer sample of 588 employees who worked for a minimum of six months at the company and were enrolled in its fee-for-service health plan. MEASUREMENTS AND MAIN RESULTS: Thirty percent of respondents reported currently experiencing sleep problems and were found to have worse functioning and well-being (general health, cognitive functioning, energy), more work-related problems (decreased job performance and lower satisfaction, increased absenteeism), and a greater likelihood of comorbid physical and mental health conditions than were the respondents who did not have sleep problems. They also demonstrated a trend toward higher medical expenditures. CONCLUSIONS: Self-perceived sleep problems were common among the respondents and were associated with poorer health and health-related quality of life. A single question about sleep problems may serve as an effective screen for identifying primary care patients with mental health problems, as well as underlying sleep disorders.

An analysis of the cost effectiveness of the implantable defibrillator.

The automatic implantable defibrillator has been shown to decrease the mortality of patients who have survived cardiac arrest due to ventricular tachycardia or fibrillation and are at high risk for recurrence. We performed a cost-effectiveness analysis of this seemingly expensive new technology with data obtained from the 1984 Medicare data base, the medical literature, Medicare carriers, individual pharmacies and hospitals, and expert opinion. Analyzing combinations of principal and secondary discharge diagnoses across 18 diagnosis-related groups, we estimated the cost of hospitalization for a comparison group of patients. Hospitalization costs for the defibrillator group were obtained from reported empirical data. Rehospitalization rates and other health-care use estimates were solicited from an expert panel of physicians, and mortality rates for both groups were obtained from the literature. Using a decision-analytic model, we estimated that the net cost effectiveness of the defibrillator, when used in the high-risk patient, is approximately $17,100 per life-year saved, with sensitivity analyses suggesting that the true value lies between $15,000 and $25,000. This estimate is well within the range that is currently accepted by the US medical care system for other life-saving interventions. We also estimated the cost effectiveness of the defibrillator in a 1991 scenario to be $7,400 per life-year saved, when the device would have greater longevity, would be programmable, and would not require a thoracotomy. Sensitivity analyses suggest that the true value lies between a value that is cost saving (less expensive than pharmacologic therapy) and $19,600 per life-year saved.