Fetal Down Syndrome Screening: A Cost Effectiveness Analysis of Alternative Screening Programs

Objective: To compare the efficacy and cost effectiveness of different screening programs for fetal Down syndrome (DS).

Methods: Screening tools evaluated included maternal age, triple screening (TS), and ultrasound (U/S) for fetal markers of DS. Sensitivities used were TS: 55% < 35 years, 80% ≥ 35 years; U/S: 70%. Average regional fees used were TS: $80, U/S: $200, amniocentesis (AM): $1,000. Five screening programs were evaluated: 1) < 35 years, no screening; ≥35 years, AM; 2) < 35 years, TS with AM for screen-positive subjects; <35 years, AM; 3) all patients, TS with AM for screen-positive subjects; 4) < 35 years, TS followed by U/S for screen-positive women, AM for women with fetal markers of DS on U/S; ≥35 years TS with AM for screen-positive subjects; 5) all women, TS followed by U/S for screen-positive women, AM for women with fetal markers of DS on U/S. The sensitivity, total cost, cost/case DS detected (Cost/DS), AM losses, and residual risk (RR, undetected DS fetuses/women not receiving AM) were calculated for each screening program. Population analysis was performed using 1988 IL delivery statistics.

Results: It was estimated that 260 cases of DS would occur in the population of 167,654 women (8.4% ≥ 35 years at delivery). Sensitivity for programs 1–5 was 30, 69, 62, 51, and 36 percent, respectively, and cost/DS was 181,000, 203,000, 162,000, 151,000, and 194,000 dollars, respectively.

Conclusions: DS screening incorporating TS in all patients with program #4 and without program #3 selective U/S in women ≤ 35 years yield the best combination of sensitivity and cost effectiveness while minimizing the number of AM-related losses.     

Office versus Institutional Operative Hysteroscopy: An Economic Model

Study ObjectiveModel and compare estimated health system costs and gynecologic practice revenues when hysteroscopic surgery is performed in the office or institutional setting, either an ambulatory surgical center (ASC) or a traditional operating room (OR).DesignEconomic modeling exercise.InterventionsNonclinical.Measurements and Main ResultsAn economic model was developed that included US reimbursement rates for the office and institutional settings and the inherent expenses required for office hysteroscopic surgery. For Current Procedural Terminology code 58558, hysteroscopic biopsy and/or polypectomy, total health system costs were estimated as follows: office, $1382.48; ASC, $1655.31; OR $2918.10. In the modeled office setting, costs for the same procedure were estimated from instrumentation and supply list prices obtained from vendors and staffing costs from national databases. Revenue and cost modeling were performed and compared both for 1 to 10 monthly procedure volumes and by hysteroscopic systems, whereas other elements of the procedure were standardized, including technique, staffing, generic supplies, and the use of local anesthesia. Four vendors provided system price information: 1 purpose built, 1 electromechanical, and 2 traditional. The projected office-based, per case net revenue with the purpose-built system was always greater than in the ASC or OR and relatively independent of monthly procedure volume (1 per month $743.59; 10 per month $876.17). For the traditional and electromechanical systems, it took from 2 to 5 monthly procedures to realize a net revenue greater than $239.39. Using 3 sets of vendor matched instruments, at 10 cases per month, the per case net revenue for the electromechanical system was $514.00, and for the 2 traditional systems $564.02 and $693.72.ConclusionPerformance of office-based hysteroscopic surgery is associated with reduced health system costs compared with the institutional environment. The net revenue for the practice was dependent on both the volume of procedures performed and the hysteroscopic system and technique selected.     

Cost Comparison of the Laparoscopic Burch Colposuspension,Laparoscopic Two-Team Sling Procedure,and the Transobturator Tape Procedure for the Treatment of Stress Urinary Incontinence

ObjectiveTo compare medical costs of three surgical procedures for the treatment of primary stress urinary incontinence: the laparoscopic Burch colposuspension procedure, the laparoscopic two-team sling procedure, and the transobturator tape (TOT) procedure.MethodsWe performed a retrospective observational study of isolated minimally invasive surgical procedures (no concomitant surgery) in 18 women with primary stress incontinence. Six women underwent a laparoscopic Burch colposuspension procedure, six underwent a laparoscopic two-team sling, and six underwent a TOT procedure. The main outcome measure was the mean aggregated medical cost per patient treated. Itemized calculations were made for (1) equipment costs; (2) surgeon, surgical assistant, and anaesthesiologist reimbursements; (3) nursing costs; (4) operating and recovery room costs; and (5) costs of stay in hospital.ResultsThe mean cost per patient undergoing a TOT procedure was $2547 (95% CI $2260 to $2833); for a laparoscopic Burch colposuspension it was $4354 (95% CI $3465 to $5244); and for a laparoscopic two-team sling procedure it was $5393 (95% CI $4959 to $5826). Significant differences were found across procedures using a one-way ANOVA. A TOT was lower in cost than both a Burch procedure, with a mean cost difference of $1807 88 (P < 0 001), and a sling procedure, with a mean cost difference of $2834.73 (P < 0.001).ConclusionA transobturator tape procedure has less direct medical costs than a laparoscopic Burch colposuspension or a laparoscopic two-team sling procedure in the surgical treatment of stress urinary incontinence.     

Impact of Index Surgical Care Setting on Perioperative Outcomes and Cost Following Penile Prosthesis Surgery

BackgroundPenile prosthesis surgery has witnessed a migration from the inpatient to ambulatory surgical care setting. However, little is known about the cost savings afforded by this change in care setting and whether or not these savings come at the expense of worse perioperative outcomes.AimThe aim of this study was to identify predictors of index penile prosthesis (PP) surgery care setting, and whether ambulatory vs inpatient surgery is associated with comparable perioperative outcomes and costs.MethodsThis was a retrospective cohort study using all-payer claims data from the 2014 Healthcare Cost and Utilization Project State Databases from Florida and New York. Patient demographics, regional data, total charges (converted to costs), and 30-day revisit rates were abstracted for all patients undergoing index placement of an inflatable or malleable PP. Multivariable logistic and linear regression adjusted for facility clustering was utilized.OutcomesThe outcomes were index surgical and 30-day postoperative costs, as well as 30-day revisit rates.ResultsOf the 1,790 patients undergoing an index surgery, 394 (22.0%) received care in the inpatient setting compared to 1,396 (78.0%) in the ambulatory setting. Adjusted index procedural ($9,319.66 vs $ 10,191.35; P < .001) and 30-day acute care costs ($9,461.74 vs $10,159.42; P < .001) were lower in the ambulatory setting. The underinsured experienced lower odds of receiving surgery in the ambulatory setting (Medicaid vs private: odds ratio [OR] 0.19; 95% CI 0.06?0.55; P < .001). There was no difference in risk-adjusted odds of experiencing a 30-day revisit between patients undergoing surgery in the ambulatory vs inpatient settings (OR 1.31; 95% CI 0.78?2.21; P = .3).Clinical TranslationAmbulatory PP surgery confers significant cost savings and is associated with comparable perioperative outcomes relative to inpatient-based surgery.ConclusionsBoth clinical and nonclinical factors predict the care setting of index PP surgery. Notably, underinsured patients experienced lower odds of undergoing ambulatory surgery. Ambulatory surgery was less costly with similar 30-day revisit rates relative to inpatient-based care.Berger A, Friedlander DF, Herzog P, et al. Impact of Index Surgical Care Setting on Perioperative Outcomes and Cost Following Penile Prosthesis Surgery. J Sex Med 2019;16:1451–1458.     

Clinical Characteristics,Health Care Utilization and Costs Among Men with Primary or Secondary Hypogonadism in a US Commercially Insured Population

IntroductionHypogonadism is broadly associated with increases in chronic comorbid conditions and health care costs. Little is known about the specific impact of primary and secondary hypogonadism on health care costs.AimTo characterize the health care cost and utilization burden of primary and secondary hypogonadism in a population of US men with commercial insurance.MethodsNewly diagnosed patients with International Classification of Diseases, Ninth Revision, Clinical Modification codes associated with specific medical conditions known to have a high prevalence of testosterone deficiency (ie, relating to primary or secondary hypogonadism) or who had fills for testosterone replacement therapy from January 1, 2007 through April 30, 2013 were identified in administrative claims data from the HealthCore Integrated Research Database. A cohort of patients without hypogonadism was matched on demographics and comorbidities. The matched hypogonadism and non-hypogonadism cohorts (n = 5,777 in each cohort) were compared during a 12-month follow-up period.Main Outcome MeasuresDirect health care expenditures and utilization were assessed for all causes and for hypogonadism-related claims. Costs included out-of-pocket patient expenditures and those paid by the insurer.ResultsHypogonadism and matched non-hypogonadism cohorts were similar in demographics (mean age = 50 years) and diagnosed comorbid conditions in the 12 months preceding the index date. In the year after the index date, mean all-cause expenditures for patients with hypogonadism increased by 62% (from $5,425 to $8,813) compared with 25% for the matched controls (from $4,786 to $5,992; P < .01 for follow-up difference between groups). Approximately 16% of total mean costs ($1,377), primarily outpatient and pharmacy costs, were identifiable as related to hypogonadism.ConclusionThese data from a population of US men with commercial insurance coverage showed a greater resource use burden for patients with primary and secondary hypogonadism compared with similar patients without hypogonadism. Additional management might be required to address unmet need and decrease the cost burden for patients with hypogonadism.     

Exploring the costs and economic consequences of unsafe abortion in Mexico City before legalisation

An assessment of abortion outcomes and costs to the health care system in Mexico City was conducted in 2005 at a mix of public and private facilities prior to the legalisation of abortion. Data were obtained from hospital staff, administrative records and patients. Direct cost estimates included personnel, drugs, disposable supplies, and medical equipment for inducing abortion or treating incomplete abortions and other complications. Indirect patient costs for travel, childcare and lost wages were also estimated. The average cost per abortion with dilatation and curettage was US $143. For manual vacuum aspiration it was US $111 in three public hospitals and US $53 at a private clinic. The average cost of medical abortion with misoprostol alone was US $79. The average cost of treating severe abortion complications at the public hospitals ranged from US $601 to over US $2,100. Increasing access to manual vacuum aspiration and early abortion with misoprostol could reduce government costs by 62%, with potential savings of up to US $1.6 million per year. Reducing complications by improving access to safe services in outpatient settings would further reduce the costs of abortion care, with significant benefits both to Mexico's health care system and women seeking abortion. Additional research is needed to explore whether cost savings have been realised post-legalisation.     

Current Trends in Compensation for Fellowship in Minimally Invasive Gynecologic Surgery Graduates: A 6-Year Follow-Up

Study ObjectiveTo present updated information regarding compensation patterns for Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS)–graduated physicians in the United States beginning practice during the last 10 years, focusing on the variables that have an impact on differences in salary, including gender, fellowship duration, geographic region, practice setting, and practice mix.DesignAn online survey was sent to FMIGS graduates between March 15, 2019 and April 12, 2019. Information on physicians’ demographics, compensation (on the basis of location, practice model, productivity benchmarks, academic rank, and years in practice), and attitudes toward fairness in compensation was collected.SettingOnline survey.ParticipantsFMIGS graduates practicing in the United States.InterventionE-mail survey.Measurements and Main ResultsWe surveyed 298 US FMIGS surgeons who had graduated during the last 10 years (2009–2018). The response rate was 48.7%. Most of the respondents were women (69%). Most of the graduates (84.8%) completed 2- or 3-year fellowship programs. After adjustment for inflation, the median starting salary for the first postfellowship job was $252 074 ($223 986–$279 983) (Table 1). The median time spent in the first job was 2.6 years, and the median total salary at the current year rose to $278 379.4 ($241 437–$350 976). The median salary for respondents entering a second postfellowship job started at $280 945 ($261 409–$329 603). Significantly lower compensation was reported for female FMIGS graduates in their initial postfellowship jobs and was consistently lower than for that of men over time. Most FMIGS graduates (59.7%) reported feeling inadequately compensated for their level of specialization.ConclusionA trend toward higher self-reported salaries is noted for FMIGS graduates in recent years, with significant differences in compensation between men and women. Among obstetrics and gynecology subspecialists, FMIGS graduates earn significantly less than other fellowship-trained physicians, with median salaries that are lower than those of generalist obstetrics and gynecology physicians.     

Cost-effectiveness of freeze-all policy – A retrospective study based upon the outcome of cumulative live births

ObjectWe have previously reported that cumulative live birth rates (CLBRs) are higher in the freeze-all group compared with controls (64.3% vs. 45.8%, p = 0.001). Here, we aim to determine if the freeze-all policy is more cost-effective than fresh embryo transfer followed by frozen-thawed embryo transfer (FET).Materials and methodsThe analysis consisted of 704 ART (Assisted reproductive technology) cycles, which included in IVF (In vitro fertilisation) and ICSI (Intra Cytoplasmic Sperm Injection) cycles performed in Taichung Veterans General Hospital, Taiwan between January 2012 and June 2014. The freeze-all group involved 84 patients and the fresh Group 625 patients. Patients were followed up until all embryos obtained from a single controlled ovarian hyper-stimulation cycle were used up, or a live birth had been achieved. The total cost related to treatment of each patient was recorded. The incremental cost-effectiveness ratio (ICER) was based on the incremental cost per couple and the incremental live birth rate of the freeze-all strategy compared with the fresh ET strategy. Probabilistic sensitivity analysis (PSA) and a cost-effectiveness acceptability curve (CEAC) were performed.ResultsThe total treatment cost per patient was significantly higher for the freeze-all group than in the fresh group (USD 3419.93 ± 638.13 vs. $2920.59 ± 711.08 p < 0.001). However, the total treatment cost per live birth in the freeze-all group was US $5319.89, vs. US $6382.42 in the fresh group. CEAC show that the freeze-all policy was a cost-effective treatment at a threshold of US $2703.57 for one additional live birth. Considering the Willingness-to-pay threshold per live birth, the probability was 60.1% at the threshold of US $2896.5, with the freeze-all group being more cost-effective than the fresh-ET group; or 90.1% at the threshold of $4183.8.ConclusionThe freeze-all policy is a cost-effective treatment, as long as the additional cost of US $2703.57 per additional live birth is financially acceptable for the subjects.     

Endometrial Cancer Surgery Costs: Robot vs Laparoscopy

Study ObjectiveTo compare surgical costs for endometrial cancer staging between robotic-assisted and traditional laparoscopic methods.DesignRetrospective chart review from November 2005 to July 2006 (Canadian Task Force classification II-3).SettingNon-university-affiliated teaching hospital.PatientsThirty-three women with diagnosed endometrial cancer undergoing hysterectomy, bilateral salpingo-oophorectomy, and pelvic and paraaortic lymph node resection.InterventionsPatients underwent either robotic or traditional laparoscopic surgery without randomization.Measurements and Main ResultsHospital cost data were obtained for operating room time, instrument use, and disposable items from hospital billing records and provided by the finance department. Separate overall hospital stay costs were also obtained. Mean operative costs were higher for robotic procedures ($3323 vs $2029; p < .001), due in part to longer operating room time ($1549 vs $1335; p = .03). The more significant cost difference was due to disposable instrumentation ($1755 vs $672; p < .001). Total hospital costs were also higher for robotic-assisted procedures ($5084 vs $ 3615; p = .002).ConclusionRobotic surgery costs were significantly higher than traditional laparoscopy costs for staging of endometrial cancer in this small cohort of patients.     

Program Website Evaluation of Canadian Obstetrics and Gynaecology Residency and Fellowship Programs

ObjectiveThe purpose of our study was to assess the comprehensiveness of Canadian obstetrics and gynaecology residency and fellowship program websites to understand the quality of information available to prospective students and make recommendations, if needed.MethodsAll active residency and fellowship program websites (as of May 2020) were evaluated and compared using 72-point criteria in the following domains: Recruitment, Faculty, Current Residents/Fellows, Research and Education, Surgical Procedures, Clinical Work, Benefits and Incentives, Wellness, and Environment. Programs without websites were excluded from the study. Program website information availability was compared by geographic region.ResultsOut of the identified 80 residency and fellowship programs, 68.75% (55) were from central Canada, 6.25% (5) from Atlantic Canada, and 25% (20) from western Canada. The mean score for residency websites was 25.4 ± 7.59 (35.6% of criteria complete). The domains with the highest and lowest inclusion rates were Research and Education (46.3% criteria complete) and Current Residents (16.2% criteria complete). The mean score of fellowship websites was 27.9 ± 8.89 (38.8% criteria complete). For fellowship websites, Wellness had the highest inclusion rate (66.0% criteria complete), while Current Fellows had the lowest (13.2% criteria complete). Overall, fellowship websites scored higher than residency websites (27.9 ± 8.89 and 25.4 ± 7.59 out of 72 criteria, respectively).ConclusionOverall, Canadian postgraduate obstetrics and gynaecology program websites include information on many topics relevant to prospective students, such as research, education, and wellness. Programs should provide more information about work hours, call schedules, and current trainees. Lastly, there is an opportunity for programs in western and Atlantic Canada to increase the comprehensiveness of their websites.     

Practice Comparison and Cost Analysis of Direct-to-Consumer Telemedicine Platforms Offering Testosterone Therapy

BackgroundDirect-to-consumer telemedicine platforms have expanded their reach to include services for the evaluation and treatment of testosterone deficiency.AimWe aim to (i) evaluate the treatment practices and costs associated with receiving testosterone therapy through direct-to-consumer telemedicine platforms; (ii) compare these practices to the American Urological Association guidelines; and (iii) compare the cost of receiving similar care at a tertiary center.MethodsGoogle was queried to identify telemedicine platforms offing testosterone therapy. Websites were analyzed for information regarding the initial consultation, initial laboratory evaluation, follow up, treatment monitoring regimen, and associated costs of receiving testosterone therapy. The costs for similar services at a tertiary care center were estimated using a single institution's online cost estimator for a patient with no insurance, private insurance, or Medicare.OutcomesEvaluation and treatment practices of each platform were compared to the American Urological Association guidelines, and a cost analysis was completed for the cost of (i) undergoing an initial evaluation, and (ii) receiving 12 months of treatment through each platform and at a tertiary center.ResultsThree online platforms met inclusion criteria: Hone, Regenex Health, and TRT Nation. The initial evaluation and follow up of patients on TTh were similar between the online platforms and practice guidelines. The costs of the initial consultation were lowest for the patient with Medicare at a tertiary center and via the telemedicine platforms. Conversely, the cost of 12 months of intramuscular testosterone treatment was highest via the telemedicine platforms, ranging from $1,586 to $4,200, as compared to the tertiary center, which ranged from $134.01 to $1,333.04 with varying insurance models. Costs of ongoing treatment with transdermal testosterone are similarly higher via DTC platforms.Clinical ImplicationsPatients with private insurance or Medicare should be counseled that ongoing treatment through telemedicine platforms will likely incur a greater cost than receiving such care at a tertiary center that can utilize insurance coverage.Strengths & LimitationsPractice and cost comparisons include accurate, up-to-date information based on each platform's website. Limitations include the analysis of only three telemedicine platforms, and the ability to describe only the information provided on each website. In addition, cost estimates for the tertiary center only include a single type of private and public insurance, limiting generalizability.ConclusionThis observational study indicates that direct-to-consumer telemedicine platforms are largely following practice guidelines in the evaluation and treatment of testosterone, however, there is a high cost associated with ongoing treatment.Jesse E, Sellke N, Rivero M-J, et al. Practice Comparison and Cost Analysis of Direct-to-Consumer Telemedicine Platforms Offering Testosterone Therapy. J Sex Med 2022;19:1608–1615.     

A Prospective,Multicenter, Clinical Trial Evaluating the Safety and Effectiveness of the Cerene Device to Treat Heavy Menstrual Bleeding

Study ObjectiveTo evaluate the safety and effectiveness of a novel cryoablation device (Cerene Cryotherapy Device, Channel Medsystems, Emeryville, CA) in premenopausal women with heavy menstrual bleeding owing to benign causes.DesignA prospective, multi-center, single-arm, open label, non-randomized study.SettingAt 11 academic and private practices in North America: 8 clinic sites in the United States, and 3 outpatient hospital sites (1 in Mexico and 2 in Canada).PatientsA total of 242 subjects comprise the intent-to-treat population. Subject demographics were similar to other published endometrial ablation studies performed.InterventionsSubjects were treated with a single-use disposable cryoablation device (Cerene) which delivers a 2.5-minute treatment to the endometrium. Analgesia and local anesthesia were administered per investigator discretion; intravenous sedation was used in only 3% of subjects and no general anesthesia was used.Measurements and Main ResultsThere were no device or procedure-related serious adverse events, nor unanticipated adverse device effects. Cerene cryoablation was effective in reducing menstrual blood loss, which was measured by pictorial blood loss assessment chart (PBLAC) score. Mean score dropped from 360.6 at pretreatment (±332.1) to 51 at 12 months posttreatment (±64.1), with 81% of 230 evaluable subjects reporting a PBLAC score of ≤75 and 85% of evaluable subjects reporting a PBLAC score of ≤ 100. The median pain rating was ≤2 (mild) throughout the treatment. Of 223 subjects that underwent hysteroscopic evaluation at 12 months, the uterine cavity was visualized in 220 subjects. Quality of life improved with 90% of reporting subjects indicating satisfied or very satisfied at month 12.ConclusionThis study demonstrated that Cerene cryoablation is safe and effective, offering the benefits of reduced menstrual blood loss with limited use of pain medication, high patient tolerability, quality of life improvement, and preserved access to the uterine cavity.     

National trends,outcomes, and costs of radiation therapy in the management of low- and high-intermediate risk endometrial cancer

ObjectiveTo assess treatment patterns, outcomes, and costs for women with low-(LIR) and high-intermediate risk endometrial cancer (HIR) who are treated with and without adjuvant radiotherapy.MethodsAll patients with stage I endometrioid endometrial cancer who underwent surgery from 2000 to 2011 were identified from the SEER-Medicare database. LIR was defined as G1–2 tumors with <50% myometrial invasion or G3 with no invasion. HIR was defined as G1–2 tumors with ≥50% or G3 with <50% invasion. Patients were categorized according to whether they received adjuvant radiotherapy (vaginal brachytherapy [VBT], external beam radiotherapy [EBRT], or both) or no radiotherapy. Outcomes were analyzed and compared (primary outcome was overall survival).Results10,842 patients met inclusion criteria. In the LIR group (n = 7609), there was no difference in 10-year overall survival between patients who received radiotherapy and those who did not (67% vs 65%, adjusted HR 0.95, 95% CI 0.81–1.11). In the HIR group (n = 3233), patients who underwent radiotherapy had a significant increase in survival (60% vs 47%, aHR 0.75, 95% CI 0.67–0.85). Radiotherapy was associated with increased costs compared to surgery alone ($26,585 vs $16,712, p < .001). Costs for patients receiving VBT, EBRT, and concurrent VBT/EBRT were $24,044, $27,512, and $31,564, respectively (p < .001). Radiotherapy was associated with an increased risk of gastrointestinal (7 vs 4%), genitourinary (2 vs 1%), and hematologic (16 vs 12%) complications (p < .001).ConclusionsRadiotherapy was associated with improved survival in women with HIR, but not in LIR. It also had increased costs and a higher morbidity risk. Consideration of observation without radiotherapy in LIR may be reasonable.     

The cost-effectiveness of gestational diabetes screening including prevention of type 2 diabetes: application of a new model in India and Israel

Abstract

Objective: Gestational diabetes mellitus (GDM) is associated with elevated risks of perinatal complications and type 2 diabetes mellitus, and screening and intervention can reduce these risks. We quantified the cost, health impact and cost-effectiveness of GDM screening and intervention in India and Israel, settings with contrasting epidemiologic and cost environments.

Methods: We developed a decision-analysis tool (the GeDiForCE?) to assess cost-effectiveness. Using both local data and published estimates, we applied the model for a general medical facility in Chennai, India and for the largest HMO in Israel. We computed costs (discounted international dollars), averted disability-adjusted life years (DALYs) and net cost per DALY averted, compared with no GDM screening.

Results: The programme costs per 1000 pregnant women are $259?139 in India and $259?929 in Israel. Net costs, adjusted for averted disease, are $194?358 and $76?102, respectively. The cost per DALY averted is $1626 in India and $1830 in Israel. Sensitivity analysis findings range from $628 to $3681 per DALY averted in India and net savings of $72?420–8432 per DALY averted in Israel.

Conclusion: GDM interventions are highly cost-effective in both Indian and Israeli settings, by World Health Organization standards. Noting large differences between these countries in GDM prevalence and costs, GDM intervention may be cost-effective in diverse settings.     

Physician Education on Controllable Costs Significantly Reduces Cost of Laparoscopic Hysterectomy

Study Objective

To determine whether educating surgeons about their controllable instrumentation costs by providing cost data on total laparoscopic hysterectomy (LH) would reduce the cost of this procedure.