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1.
Am J Obstet Gynecol ; 220(6): 590.e1-590.e10, 2019 06.
Artículo en Inglés | MEDLINE | ID: mdl-30768934

RESUMEN

BACKGROUND: A large, recent multicenter trial found that induction of labor at 39 weeks for low-risk nulliparous women was not associated with an increased risk of cesarean delivery or adverse neonatal outcomes. OBJECTIVE: We sought to examine the cost-effectiveness and outcomes associated with induction of labor at 39 weeks vs expectant management for low-risk nulliparous women in the United States. STUDY DESIGN: A cost-effectiveness model using TreeAge software was designed to compare outcomes in women who were induced at 39 weeks vs expectantly managed. We used a theoretical cohort of 1.6 million women, the approximate number of nulliparous term births in the United States annually that are considered low risk. Outcomes included mode of delivery, hypertensive disorders of pregnancy, macrosomia, stillbirth, permanent brachial plexus injury, and neonatal death, in addition to cost and quality-adjusted life years for both the woman and neonate. Model inputs were derived from the literature, and a cost-effectiveness threshold was set at $100,000/quality-adjusted life years. RESULTS: In our theoretical cohort of 1.6 million women, induction of labor resulted in 54,498 fewer cesarean deliveries and 79,152 fewer cases of hypertensive disorders of pregnancy. We also found that induction of labor resulted in 795 fewer cases of stillbirth and 11 fewer neonatal deaths, despite 86 additional cases of brachial plexus injury. Induction of labor resulted in increased costs but increased quality-adjusted life years with an incremental cost-effectiveness ratio of $87,691.91 per quality-adjusted life year. In sensitivity analysis, if the cost of induction of labor was increased by $180, elective induction would no longer be cost effective. Similarly, we found that if the rate of cesarean delivery was the same in both strategies, elective induction of labor at 39 weeks would not be a cost-effective strategy. In probabilistic sensitivity analysis via Monte Carlo simulation, we found that induction of labor was cost effective only 65% of the time. CONCLUSION: In our theoretical cohort, induction of labor in nulliparous term women at 39 weeks of gestation resulted in improved outcomes but increased costs. The incremental cost-effectiveness ratio was marginally cost effective but would lead to an additional 2 billion dollars of healthcare costs. Whether individual clinicians and healthcare systems offer routine induction of labor at 39 weeks will need to depend on local capacity, careful evaluation and allocation of healthcare resources, and patient preferences. KEY WORDS: cesarean delivery, decision analysis, healthcare resources, induction of labor, low-risk nulliparous women, mode of delivery, obstetric outcomes.


Asunto(s)
Cesárea/economía , Macrosomía Fetal/economía , Hipertensión Inducida en el Embarazo/economía , Trabajo de Parto Inducido/economía , Parálisis Neonatal del Plexo Braquial/economía , Mortinato/economía , Adulto , Cesárea/estadística & datos numéricos , Análisis Costo-Beneficio , Parto Obstétrico/economía , Parto Obstétrico/métodos , Femenino , Macrosomía Fetal/epidemiología , Costos de la Atención en Salud , Humanos , Hipertensión Inducida en el Embarazo/epidemiología , Trabajo de Parto Inducido/métodos , Parálisis Neonatal del Plexo Braquial/epidemiología , Paridad , Muerte Perinatal , Embarazo , Años de Vida Ajustados por Calidad de Vida , Mortinato/epidemiología , Espera Vigilante/economía
2.
BJOG ; 126(10): 1243-1250, 2019 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-31066982

RESUMEN

OBJECTIVE: To identify the most cost-effective policy for detection and management of fetal macrosomia in late-stage pregnancy. DESIGN: Health economic simulation model. SETTING: All English NHS antenatal services. POPULATION: Nulliparous women in the third trimester treated within the UK NHS. METHODS: A health economic simulation model was used to compare long-term maternal-fetal health and cost outcomes for two detection strategies (universal ultrasound scanning at approximately 36 weeks of gestation versus selective ultrasound scanning), combined with three management strategies (planned caesarean section versus induction of labour versus expectant management) of suspected fetal macrosomia. Probabilities, costs and health outcomes were taken from literature. MAIN OUTCOME MEASURES: Expected costs to the NHS and quality-adjusted life-years (QALYs) gained from each strategy, calculation of net benefit and hence identification of most cost-effective strategy. RESULTS: Compared with selective ultrasound, universal ultrasound increased QALYs by 0.0038 (95% CI 0.0012-0.0076), but also costs by £123.50 (95% CI 99.6-149.9). Overall, the health gains were too small to justify the cost increase given current UK thresholds cost-effective policy was selective ultrasound coupled with induction of labour where macrosomia was suspected. CONCLUSIONS: The most cost-effective policy for detection and management of fetal macrosomia is selective ultrasound scanning coupled with induction of labour for all suspected cases of macrosomia. Universal ultrasound scanning for macrosomia in late-stage pregnancy is not cost-effective. TWEETABLE ABSTRACT: Universal late-pregnancy ultrasound screening for fetal macrosomia is not warranted.


Asunto(s)
Análisis Costo-Beneficio , Técnicas de Apoyo para la Decisión , Macrosomía Fetal/diagnóstico , Macrosomía Fetal/economía , Paridad , Atención Prenatal/economía , Atención Prenatal/métodos , Ultrasonografía Prenatal/economía , Adulto , Inglaterra , Femenino , Macrosomía Fetal/diagnóstico por imagen , Investigación sobre Servicios de Salud , Humanos , Selección de Paciente , Embarazo , Tercer Trimestre del Embarazo
3.
Am J Obstet Gynecol MFM ; 6(8): 101413, 2024 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-38908796

RESUMEN

BACKGROUND: In the United States, approximately 1% of pregnancies are complicated by pregestational diabetes. Individuals with type 1 diabetes have an increased risk of adverse maternal and neonatal outcomes. While continuous glucose monitoring has demonstrated benefits for patients with type 1 diabetes, its cost is higher than traditional intermittent fingerstick monitoring, particularly if used only during pregnancy. OBJECTIVE: To develop an economic analysis model to compare in silico the cost of continuous glucose monitoring and self-monitoring of blood glucose in a cohort of pregnant individuals with type 1 diabetes mellitus. STUDY DESIGN: We developed an economic analysis model to compare two glucose monitoring strategies in pregnant individuals with type 1 diabetes: continuous glucose monitoring and self-monitoring. The model considered hypertensive disorders of pregnancy, large for gestational age, cesarean delivery, neonatal intensive care unit (NICU) admission, and neonatal hypoglycemia. The primary outcome was the total cost per strategy in 2022 USD from a health system perspective, with self-monitoring as the reference group. Probabilities, relative risks, and costs were extracted from the literature, and the costs were adjusted to 2022 US dollars. Sensitivity analyses were conducted by varying parameters based on the probability, relative risk, and cost distributions. The robustness of the results was tested through 1000 Monte Carlo simulations. RESULTS: In the base-case analysis, the cost of pregnancy using continuous glucose monitoring was $26,837 compared to $29,039 for self-monitoring, resulting in a cost reduction of $2,202 per individual. The parameters with the greatest effect on the incremental cost included the relative risk of NICU admission, cost of NICU admission, continuous glucose monitoring costs, and usual care costs. Monte Carlo simulations indicated that continuous glucose monitoring was the optimal strategy 98.7% of the time. One-way sensitivity analysis showed that continuous glucose monitoring was more economical if the relative risk of NICU admission with continuous glucose monitoring vs. self-monitoring was below 1.15. CONCLUSION: Compared to self-monitoring, continuous glucose monitoring is an economical strategy for pregnant individuals with type 1 diabetes mellitus.


Asunto(s)
Automonitorización de la Glucosa Sanguínea , Diabetes Mellitus Tipo 1 , Embarazo en Diabéticas , Humanos , Embarazo , Femenino , Diabetes Mellitus Tipo 1/economía , Diabetes Mellitus Tipo 1/sangre , Diabetes Mellitus Tipo 1/diagnóstico , Diabetes Mellitus Tipo 1/epidemiología , Automonitorización de la Glucosa Sanguínea/métodos , Automonitorización de la Glucosa Sanguínea/economía , Embarazo en Diabéticas/economía , Embarazo en Diabéticas/sangre , Embarazo en Diabéticas/diagnóstico , Glucemia/metabolismo , Glucemia/análisis , Hipoglucemia/economía , Hipoglucemia/epidemiología , Recién Nacido , Análisis Costo-Beneficio/métodos , Modelos Económicos , Cesárea/economía , Cesárea/estadística & datos numéricos , Estados Unidos/epidemiología , Adulto , Unidades de Cuidado Intensivo Neonatal/economía , Macrosomía Fetal/economía , Macrosomía Fetal/epidemiología , Simulación por Computador , Método de Montecarlo , Monitoreo Continuo de Glucosa
4.
PLoS One ; 15(6): e0233416, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32502147

RESUMEN

OBJECTIVE: To determine whether neighbourhood socioeconomic status (SES) was associated with large for gestational age (LGA) while considering key sociodemographic and clinical confounding factors. SETTING AND PATIENT: All singleton infants whose parents were living in the city of Marseilles, France, between 2013 and 2016. METHOD: Population-based study based on new-born hospital birth admission charts from the French National Uniform Hospital Discharge Data Set Database. LGA infants were compared to appropriate-for-gestational-age (AGA) infants. Multiple generalized logistic model analysis was used to examine factors associated with LGA. RESULTS: A total of 43,309 singleton infants were included, and 4,747 (11%) were born LGA. LGA infants were more likely to have metabolic and respiratory diseases and to be admitted to the neonatal intensive care unit. Multiparity, advanced maternal age, obesity and diabetes were associated with an increased risk of LGA. Lower neighbourhood SES was associated with LGA (aOR = 1.24, 95% CI: 1.14; 1.36; p<0.0001) independent of age, diabetes, obesity, maternal smoking and multiparity. The strength of this association increased with maternal age, reaching an aOR of 1.50 (95% CI: 1.26; 1.78; p<0.0001) for women > 35 years old. CONCLUSION: Neighbourhood SES could be considered an important factor for clinicians to better identify mothers at risk of having LGA births in addition to well-known risk factors such as maternal diabetes, obesity and age. The intensification of the association between SES and LGA with increasing maternal age suggests that neighbourhood disadvantage may act on LGA cumulatively over time.


Asunto(s)
Peso al Nacer/fisiología , Macrosomía Fetal/etiología , Clase Social , Adulto , Índice de Masa Corporal , Diabetes Gestacional , Femenino , Macrosomía Fetal/economía , Francia , Edad Gestacional , Humanos , Lactante , Recién Nacido , Masculino , Madres , Obesidad/complicaciones , Paridad , Embarazo , Complicaciones del Embarazo , Factores de Riesgo , Factores Socioeconómicos , Aumento de Peso/fisiología
5.
Int J Epidemiol ; 46(4): 1202-1210, 2017 08 01.
Artículo en Inglés | MEDLINE | ID: mdl-28430971

RESUMEN

Background: A small number of studies have used a natural experiment approach to examine the health impacts of increased economic resources stemming from Native American-owned casinos. We build on this work by examining whether casinos are associated with obesity-related health in utero. Methods: We examined whether casino openings or expansion (as proxy for increased economic resources) are associated with a decreased likelihood of infants being born large-for-gestational-age (LGA), an important risk factor for childhood overweight/obesity. We used repeated cross-sectional data from California birth records (1987-2011) to assess the prevalence of LGA births among Native Americans (n = 21 011). Using zip code fixed-effect regression models, we compared how prevalence of LGA births changed in association with casino openings or expansions, while controlling for secular trends through the inclusion of a comparison group of Native American newborns in zip codes that were eligible to open or expand casinos, but did not do so. In sensitivity analyses, we evaluated whether there was any change in small-for-gestational-age births (SGA). Results: Average prevalence of LGA births over the period was 11%. Every one slot machine per capita increase was associated with a 0.13 percentage point decrease (95% confidence interval: -0.25, -0.01) in the prevalence of LGA births but was not associated with SGA prevalence. Conclusions: Casino expansion in California is associated with a lower prevalence of LGA births. Interpreted in combination with previous work showing that California casino expansions were associated with a lower body mass index (BMI) among schoolchildren, these results suggest that casinos are associated with improvement in a surrogate marker of excess adiposity. Further studies are needed to elucidate the mechanisms by which casinos might be associated with obesity-related health outcomes among Native Americans.


Asunto(s)
Comercio/economía , Macrosomía Fetal/etnología , Juego de Azar/economía , Indígenas Norteamericanos/estadística & datos numéricos , Complicaciones del Embarazo/etnología , Adulto , Certificado de Nacimiento , Índice de Masa Corporal , California/epidemiología , Estudios Transversales , Femenino , Macrosomía Fetal/economía , Edad Gestacional , Humanos , Recién Nacido , Modelos Lineales , Masculino , Embarazo , Complicaciones del Embarazo/economía , Prevalencia , Factores de Riesgo , Adulto Joven
8.
Am J Obstet Gynecol ; 193(3 Pt 2): 1035-9, 2005 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-16157107

RESUMEN

OBJECTIVE: Treatment of fetal macrosomia presents challenges to practitioners because a potential outcome of shoulder dystocia with permanent brachial plexus injury is costly both to families and to society. Practitioner options include labor induction, elective cesarean delivery, or expectant treatment. We performed a cost-effective analysis to evaluate the treatment strategies that were preferred to prevent the most permanent brachial plexus injuries with the least amount of dollars spent. STUDY DESIGN: Using decision analysis techniques, we compared 3 strategies for an infant with an estimated fetal weight of 4500 g: labor induction, elective cesarean delivery, and expectant treatment. The following baseline assumptions were made: Probability of shoulder dystocia in vaginal delivery, .145; labor induction, .03; cesarean delivery, .001; probability of plexus injury, .18; probability of permanent injury, .067; probability of cesarean delivery with induction, .35; with expectant treatment, .33; cost of vaginal delivery, dollar 3376; cost of elective cesarean delivery, dollar 5200; cost of cesarean delivery with labor, dollar 6500; lifetime cost of brachial plexus injury, dollar 1,000,000. Sensitivity analyses were performed. RESULTS: Under baseline assumptions for an infant who weighs 4500 g, expectant treatment is the preferred strategy at a cost of dollar 4014.33 per injury-free child, compared with elective cesarean delivery at a cost of dollar 5212.06 and an induction cost of dollar 5165.08. Sensitivity analyses revealed that, if the incidence of shoulder dystocia and permanent injury remained <10%, expectant treatment is the preferred method. CONCLUSION: Fetal macrosomia with possible permanent plexus injuries is a concern. Our analysis would suggest that expectant treatment is the most cost-effective approach to this problem.


Asunto(s)
Traumatismos del Nacimiento/prevención & control , Plexo Braquial/lesiones , Macrosomía Fetal/economía , Macrosomía Fetal/terapia , Traumatismos del Nacimiento/economía , Cesárea , Análisis Costo-Beneficio , Árboles de Decisión , Distocia/economía , Distocia/etiología , Distocia/prevención & control , Femenino , Macrosomía Fetal/complicaciones , Humanos , Trabajo de Parto Inducido , Ohio , Embarazo , Resultado del Embarazo
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