Screening for Bacterial Vaginosis Prior to Delivery: A Cost-Effectiveness Study.

OBJECTIVE: The objective of this study was to compare the cost and effectiveness of three strategies for screening and/or treating bacterial vaginosis (BV) during pregnancy prior to delivery: (1) the current standard of care was neither test nor treat for BV (Treat None); (2) test all patients for BV at 36 weeks' gestation; treat if positive (Test Treat); and (3) treat all patients undergoing cesarean delivery with intravenous metronidazole at time of surgery (Treat All Cesarean). Effectiveness was defined as avoidance of postpartum surgical site infection (SSI). STUDY DESIGN: A decision analytic cost-effectiveness model was designed from a third-party payer perspective using clinical and cost estimates obtained from the literature, American College of Surgeons National Surgical Quality Improvement Program participant use file (2005-2019), 2019 National Vital Statistics, Medicare costs, and wholesale drug costs. Cost estimates were inflated to 2020 U.S. dollars. For this study, effectiveness was defined as avoidance of postpartum SSIs. RESULTS: The base case analysis that is the current standard of care of not routinely testing and treating patients for BV (Treat None) was the most expensive and least effective strategy, with a mean cost of $59.16 and infection rate of 3.71%. Empirically treating all patients for BV without testing (Treat All Cesarean) was the most effective and the least expensive strategy, with a mean cost of $53.50 and an infection rate of 2.75%. Testing all patients for BV and treating those positive for BV (Test Treat) was also relatively inexpensive and effective, with an infection rate of 2.94% and mean cost of $57.05. Compared with Treat None, we would expect the Treat All Cesarean strategy to reduce the infection rate by 26%. CONCLUSION: These findings suggest that treating pregnant patients with intravenous metronidazole at time of cesarean delivery could be an effective and cost-saving strategy. Testing and treating for BV could also be considered a reasonable strategy, as it has the added benefit of preserving antibiotic stewardship. In no analysis was the standard of care strategy of neither testing nor treating for BV before delivery the preferred strategy. KEY POINTS: · BV colonization may increase surgical site infection risk after cesarean section.. · Treatment of BV before or during delivery may be cost-saving strategies as treatment could prevent costs associated with infection.. · Further study is needed to best balance the risk of surgical site infection with antibiotic stewardship..

An obstetrician-gynecologist's review of hernias: risk factors, diagnosis, prevention, and repair.

Management of obstetrical and gynecologic patients with hernias poses challenges to providers. Risks for hernia development include well-described factors that impair surgical wound healing and increase abdominal pressure. Among the diverse populations cared for by obstetricians and gynecologists, pregnant patients and those with gynecologic malignancies are at the highest risk for hernia formation. This article provides an overview of the existing literature, with a focus on patients cared for by obstetrician-gynecologists and commonly encountered preoperative and intraoperative scenarios. We highlight scenarios when a hernia repair is not commonly performed, including those of patients undergoing nonelective surgeries with known or suspected gynecologic cancers. Finally, we offer multidisciplinary recommendations on the timing of elective hernia repair with obstetrical and gynecologic procedures, with attention to the primary surgical procedure, the type of preexisting hernia, and patient characteristics.

Oocyte cryopreservation versus ovarian tissue cryopreservation for adult female oncofertility patients: a cost-effectiveness study.

PURPOSE: In December 2019, the American Society for Reproductive Medicine designated ovarian tissue cryopreservation (OTC) as no longer experimental and an alternative to oocyte cryopreservation (OC) for women receiving gonadotoxic therapy. Anticipating increased use of OTC, we compare the cost-effectiveness of OC versus OTC for fertility preservation in oncofertility patients. METHODS: A cost-effectiveness model to compare OC versus OTC was built from a payer perspective. Costs and probabilities were derived from the literature. The primary outcome for effectiveness was the percentage of patients who achieved live birth. Strategies were compared using incremental cost-effectiveness ratios (ICER). All inputs were varied widely in sensitivity analyses. RESULTS: In the base case, the estimated cost for OC was $16,588 and for OTC $10,032, with 1.56% achieving live birth after OC, and 1.0% after OTC. OC was more costly but more effective than OTC, with an ICER of $1,163,954 per live birth. In sensitivity analyses, OC was less expensive than OTC if utilization was greater than 63%, cost of OC prior to chemotherapy was less than $8100, cost of laparoscopy was greater than $13,700, or standardized discounted costs were used. CONCLUSIONS: With current published prices and utilization, OC is more costly but more effective than OTC. OC becomes cost-saving with increased utilization, when cost of OC prior to chemotherapy is markedly low, cost of laparoscopy is high, or standardized discounted oncofertility pricing is assumed. We identify the critical thresholds of OC and OTC that should be met to deliver more cost-effective care for oncofertility patients.

Cost-effectiveness of hyperthermic intraperitoneal chemotherapy (HIPEC) at interval debulking of epithelial ovarian cancer following neoadjuvant chemotherapy.

OBJECTIVES: A recent randomized controlled trial demonstrated an overall survival benefit to the addition of hyperthermic intraperitoneal chemotherapy (HIPEC) to neoadjuvant chemotherapy (NACT) for stage III epithelial ovarian cancer (EOC). The objective of the current study was to quantify the cost-effectiveness of HIPEC in this setting. METHODS: A decision analytic cost-effectiveness model was designed from a payer perspective to compare 2 surgical management strategies for EOC: (1) interval cytoreductive surgery (ICS); (2) ICS + HIPEC. Overall survival and ostomy rates with HIPEC were modeled from published studies. We assumed that 25% of each arm would later undergo secondary cytoreductive surgery, with the ICS arm eligible for HIPEC at that time. Costs were obtained from Medicare data, published studies, and the financial department of an academic hospital. Quality of life was not different between the arms; we assigned utilities based on a prior time-trade off study of ovarian cancer treatment. A Monte Carlo probabilistic sensitivity analysis was performed in the base case; primary outcome was the incremental cost-effectiveness ratio (ICER), expressed in 2017 US Dollars/quality-adjusted life years (QALYs). RESULTS: ICS was the least costly strategy at $78,849, compared to ICS + HIPEC at $79,954. ICS + HIPEC was more effective than ICS (2.9 QALYs versus 2.45 QALYs for ICS). ICS + HIPEC was highly cost-effective, with an ICER of $2436/QALY compared to ICS. In one-way sensitivity analyses, probability of ostomy reversal and use of HIPEC at secondary cytoreduction did not substantially impact the cost-effectiveness of ICS + HIPEC. CONCLUSION: ICS + HIPEC constitutes cost-effective management of stage III EOC when NACT is performed.

Gender variation in Medicare utilization and payments in gynecologic oncology.

OBJECTIVES: The Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (POSPUF) and Medicare Physician and Other Supplier National Provider Identifier (POS NPI) Aggregate Report are publicly available files from the Center for Medicare and Medicaid Services that include payments to providers who care for fee-for-service Medicare recipients. The aim of this study was to analyze variability in gynecologic oncologists' Medicare reimbursements, with attention to differences in provider gender and time in practice. METHODS: The 2015 POSPUF and POS NPI were analyzed with respect to gynecologic oncologists. We searched external publicly available data sources to confirm subspecialty and to determine each provider's number of years in practice. Evaluation and management (E&M) and procedure/surgery codes were analyzed; drug delivery codes were excluded due to variability in billing by facility/hospital. RESULTS: The POS NPI file included 733 gynecologic oncologist providers receiving $55,626,739 in total payments. Female providers comprised 39% of gynecologic oncologists and received 31% of reimbursements (30% of E&M reimbursements and 24% of surgical reimbursements). During the first ten years in practice, female providers comprised 58% of providers and accounted for 52% of reimbursed services, compared to 38% of providers/26% of reimbursed services (11-20 years), and 18% of providers/19% of reimbursed services (>20 years). CONCLUSION: Male gynecologic oncologists perform more Medicare services than their female counterparts. There is a comparable number of services performed between genders among both the most senior and the most junior providers, with a gender gap in services and reimbursements among mid-career providers.

Hysterectomy with sentinel lymph node biopsy in the setting of pre-operative diagnosis of endometrial intraepithelial neoplasia: A cost-effectiveness analysis.

OBJECTIVES: Sentinel lymph node biopsy (SLNB) may be considered in the setting of a pre-operative diagnosis of endometrial intraepithelial neoplasia (EIN) due to high rates of concurrent invasive cancer. The aim of this study is to compare the cost-effectiveness of different surgical management strategies for a pre-operative diagnosis of EIN. METHODS: A decision model was developed from a third party payer perspective to compare four surgical strategies for the management of EIN: (1) hysterectomy; (2) hysterectomy with frozen section (hysterectomy + frozen); (3) hysterectomy with SLNB (hysterectomy + SLNB); (4) hysterectomy with frozen section and SLNB (hysterectomy + frozen + SLNB). The probability that frozen section identifies high- or low-risk cancer, final pathology distribution, adjuvant treatments, and surgery/imaging costs were abstracted from the literature, Medicare reimbursement data, and the financial department of a private academic hospital. Adjuvant treatments were determined through NCCN guidelines and published studies. Effectiveness was quantified as percentage of patients who received the guideline-based treatment that aligned with their true stage. RESULTS: The base case cost and effectiveness of each strategy was: hysterectomy-$4383/89%, hysterectomy + frozen-$5220/99.2%, hysterectomy + SLNB-$5354/94.7% and hysterectomy + frozen + SLNB-$5938/99.6%. Hysterectomy + frozen had an incremental cost effectiveness ratio of $8111 per patient who received adjuvant treatment that aligned with true stage compared to hysterectomy. Hysterectomy + frozen + SLNB had an ICER of $168,171 per additional patient who received adjuvant treatment that aligned with their true stage compared to hysterectomy + frozen. CONCLUSION: Hysterectomy + frozen + SLNB is a costly strategy for pre-operative EIN when compared to hysterectomy + frozen, with limited clinical benefit. Hysterectomy with frozen section and subsequent intraoperative staging decisions should continue to be standard of care.

Withdrawal effect of chronic amphetamine exposure during adolescence on complex maze performance.

National survey data suggest a steady increase in the diagnosis and treatment of mental disorders in children, particularly Attention Deficit/Hyperactivity Disorder (ADHD). As nearly all children diagnosed with ADHD are prescribed stimulant drugs, rationale exists to quantitatively characterize behavioral responses following withdrawal from chronic stimulant dosing. These rodent experiments involved chronic administration of 7.5 mg/kg, s.c. amphetamine to subjects throughout adolescence followed by cognitive tests to gauge learning and performance during the withdrawal stage 7 to 14 days past withdrawal. Tests used a complex Stone 14-unit multiple T-maze, which is a robust paradigm for demonstrating age-related differences in rodent models when behavioral cognitive endpoints are used. Results reveal that amphetamine-treated subjects committed fewer major and retracing errors with increased minor errors and a significantly lower mean completion time. These findings suggest that pharmacotherapy aimed at adolescent-phase treatment of ADHD does not provoke spatial memory deficits at times proximal to drug withdrawal and lends support to amphetamine use in the treatment of ADHD children.

Outcomes and Complications for Concurrent Hernia Repair Among Women Undergoing Hysterectomy.

OBJECTIVE: To assess whether concurrent hernia repair at time of hysterectomy is associated with increased complications. METHODS: In this retrospective cohort study, patients who underwent hysterectomy and hysterectomy with concurrent hernia repair were queried using the American College of Surgeons' National Surgical Quality Improvement Program participant use file (2005-2019). Propensity score matching was performed 1:1 with respect to preoperative and operative characteristics. Outcomes were operation time, length of stay (LOS), and major and minor complications. A secondary analysis of patients who underwent hysterectomy for malignancy was performed. RESULTS: A total of 369,010 patients underwent hysterectomy, and 5,071 of those underwent hysterectomy with concurrent hernia repair. After propensity score matching, there were 5,071 patients in each arm. Hysterectomy with concurrent hernia repair had a longer operation time by 46 minutes (95% CI 42.6-49.6; P <.001) and longer LOS after surgery by 0.71 days (95% CI 0.59-0.84; P <.001). Hysterectomy with concurrent hernia repair was associated with a 21.9% higher risk (15.6% vs 12.8%; 95% CI 1.11-1.34, P <.001) of major complications and was associated with a 34.5% higher risk (7.4% vs 5.5%; 95% CI 1.16-1.56, P <.001) of minor complications. In subgroup analyses, there was no significant increase in risk among patients with body mass indexes (BMIs) lower than 40, those who were younger than age 40 years or older than age 60 years, and those with tobacco use, diabetes, or a minimally invasive surgical approach. For patients undergoing hysterectomy for malignancy, hysterectomy with concurrent hernia repair was associated with a 32-minute longer operation time (95% CI 25.2-38.8; P <.001) and a 0.35-day longer LOS (95% CI 0.04-0.67, P =.027), but there was no significant difference in major and minor complications. CONCLUSION: Hysterectomy with concurrent hernia repair is associated with increased operation time, LOS, and risk of major and minor complications compared with hysterectomy without hernia repair. The subgroup analyses suggest that hysterectomy with concurrent hernia has a similar complication risk as hysterectomy without hernia repair in select populations, such as those with BMIs lower than 40 or with known malignancy.

Hypertensive Disorders of Pregnancy: Common Clinical Conundrums.

Importance: Hypertensive complications of pregnancy comprise 16% of maternal deaths in developed countries and 7.4% of deaths in the United States. Rates of preeclampsia increased 25% from 1987 to 2004, and rates of severe preeclampsia have increased 6.7-fold between 1980 and 2003. Objective: The aim of this study was to review current and available evidence for common clinical questions regarding the management of hypertensive disorders of pregnancy. Evidence Acquisition: Original research articles, review articles, and guidelines on hypertension in pregnancy were reviewed. Results: Severe gestational hypertension should be managed as preeclampsia with severe features. Serum uric acid levels can be useful in predicting development of superimposed preeclampsia for women with chronic hypertension. When presenting with preeclampsia with severe features before 34 weeks, expectant management should be considered only when both maternal and fetal conditions are stable. In the setting of hypertensive disorders of pregnancy, oral antihypertensive medications should be initiated when systolic blood pressure is greater than 160 mm Hg or when diastolic blood pressure is greater than 110 mm Hg, with the most ideal agents being labetalol or nifedipine. Furthermore, although risk of preeclampsia recurrence in future pregnancy is low, women with a history of preeclampsia should be managed with 81 mg aspirin daily for preeclampsia prevention. Conclusions and Relevance: Despite the frequency with which hypertensive disorders of pregnancy are encountered clinically, situations arise frequently with limited evidence to guide providers in their management. An urgent need exists to better understand this disease to optimize outcomes for impacted patients.

The cost-effectiveness of ertapenem for the treatment of chorioamnionitis after cesarean delivery.

Background: Chorioamnionitis affects 1-4% of pregnancies, and patients who undergo cesarean delivery in the setting of chorioamnionitis have an increased risk of endometritis and surgical site infection (SSI). The standard treatment for chorioamnionitis after cesarean delivery is a combination regimen of intravenous ampicillin, gentamicin, and clindamycin with variable duration (single dose to 24 h). However, newer evidence suggests that ertapenem may decrease the risk of postoperative infectious morbidity with the added benefit of a single postpartum dose, compared to between 3 and 10 doses of AGC. Concerns regarding the cost of ertapenem have been cited as a deterrent for this regimen.Objective: The objective of this study was to investigate the cost-effectiveness of single-dose ertapenem compared to existing standard regimens.Methods: A decision analytic cost-effectiveness model was designed from a hospital perspective to compare four strategies for the postpartum management of chorioamnionitis after cesarean delivery: (i) no antibiotics; (ii) a one-time intravenous dose of ampicillin, gentamicin, and clindamycin (AGC-1); (iii) 24-h coverage with intravenous ampicillin, gentamicin, and clindamycin (AGC-24); and (iv) intravenous ertapenem, one dose. Medical costs, rates of SSI and endometritis following cesarean delivery, and costs of postcesarean infection (SSI or endometritis) were abstracted from the literature. Antibiotic drug costs were obtained from the pharmacy department at a private academic hospital. The cost of each regimen was calculated as costs to the hospital and included antibiotics (no antibiotics $0, AGC-1 $66, ertapenem $140, and AGC-24 $208), administration, and labor costs. Effectiveness was quantified as percentage of patients who avoided postcesarean infectious morbidity (endometritis or SSI).Results: The base case cost of each strategy was: AGC-1 $704, ertapenem $733, AGC-24 $846, and no antibiotics $971. Ertapenem had an effectiveness of 88%, AGC-1 and AGC-24 were 87% each, and no antibiotics was 81%. No antibiotics and AGC-24 were more costly and equally or less effective than comparators (dominated strategies). Ertapenem was more costly, but more effective than AGC-1, with an incremental cost-effectiveness ratio of $3738 per infection avoided. In a sensitivity analysis comparing ertapenem to the most commonly used strategy of ACG-24, the ertapenem strategy remained less costly if the rate of endometritis with ertapenem was <11% (base case estimate 8%) or the rate of SSI with ertapenem was <7% (base case estimate 4%).Conclusions: Ertapenem is a cost-saving alternative to 24-h AGC treatment for chorioamnionitis in the setting of cesarean delivery, and may be considered a cost-effective treatment when compared to a one time dose of AGC depending on infection rates.

Are Videos or Text Better for Describing Attributes in Stated-Preference Surveys?

OBJECTIVE: In stated-preference research, the conventional approach to describing study attributes is through text, often with easy-to-understand graphics. More recently, researchers have begun to present attribute descriptions and content in videos. Some experts have expressed concern regarding internalization and retention of information conveyed via video. OBJECTIVE: Our study aimed to compare respondents' understanding of attribute information provided via text versus video. METHODS: Potential respondents were randomized to receive a text or video version of the survey. In the text version, all content was provided in text format along with still graphics. In the video version, text content was interspersed with four video clips, providing the same information as the text version. In both versions, 10 questions were embedded to assess respondents' understanding of the information presented relating to ovarian cancer treatments. Half of the questions were on treatment benefits and the other half were on treatment-related risks. Some questions asked about the decision context and definitions of treatment features, and others asked about the graphic presentation of treatment features. Preferences for ovarian cancer treatments were also compared between respondents receiving text versus video versions. RESULTS: Overall, 150 respondents were recruited. Of the 95 who were eligible and completed the survey, 54 respondents received the text version and 41 received the video version. Median times to completion were 24 and 30 min in the video and text arms, respectively (p < 0.01). Both groups spent an average of 35 min completing the survey. On the first comprehension question, 43% in the text arm and 61% in the video arm provided the correct response (p = 0.08). Although the mean number of correct responses was significantly higher in the video versus text arms (9.1 vs. 8.6, p = 0.02), there were no systematic differences in preferences between arms. CONCLUSIONS: The quality of stated-preference data relies on respondents' understanding of study content. Information provided via video may better engage survey participants and improve their retention of content.