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1.  The Association of Expanded Access to a Collaborative Midwifery and Laborist Model With Cesarean Delivery Rates 
Obstetrics and gynecology  2015;126(4):716-723.
To examine the association between expanded access to collaborative midwifery and laborist services and cesarean delivery rates.
This was a prospective cohort study at a community hospital between 2005 and 2014. In 2011, privately insured women changed from a private practice model to one that included 24-hour midwifery and laborist coverage. Primary cesarean delivery rates among nulliparous, term, singleton, vertex women and vaginal birth after cesarean delivery (VBAC) rates among women with prior cesarean were compared before and after the change. Multivariable logistic regression models estimated the effects of the change on the odds of primary cesarean and VBAC; an interrupted time series analysis estimated the annual rates before and after the expansion.
There were 3,560 nulliparous term singleton vertex deliveries and 1,324 deliveries with prior cesarean during the study period; 45% were among privately insured women whose care model changed The primary cesarean rate among these privately insured women decreased after the change, from 31.7% to 25.0% (p=0.005, adjusted odds ratio (aOR) 0.56 (95% CI 0.39 – 0.81). The interrupted time series analysis estimated a 7% drop in the primary cesarean rate in the year after the expansion, and a decrease of 1.7% per year thereafter. The VBAC rate increased from 13.3% before to 22.4% afterward; aOR 2.03 (95%CI 1.08 – 3.80).
The change from a private practice to a collaborative midwifery–laborist model was associated with a decrease in primary cesarean rates and an increase in VBAC rates.
PMCID: PMC4580519  PMID: 26348175
2.  Predictors of Postpartum Sexual Activity and Function in a Diverse Population of Women 
The purpose of this study was to identify predictors of postpartum sexual activity and functioning in a diverse population of women using the Sexual Health Outcomes in Women Questionnaire (SHOW-Q).
This was a prospective study of 160 postpartum women assessing relationships between demographic factors, mode of birth, depression, breastfeeding, and sexual activity and function. Questionnaires were administered over the telephone 8 to 10 weeks postpartum and in person 6 to 8 months postpartum. Primary outcomes were sexual activity at 8 to 10 weeks postpartum and global and subscale SHOW-Q scores at 6 to 8 months postpartum; the primary predictor was mode of birth. Associations were assessed using multiple linear and logistic regression analyses.
Seventy-five percent of this population (n = 140 at 8–10 weeks, n = 129 at 6–8 months) gave birth vaginally, and 60.7% resumed sexual activity by 8 to 10 weeks postpartum. Only multiparity was associated with increased odds of having resumed sexual activity by 8 to 10 weeks postpartum (adjusted odds ratio [aOR], 2.44; P = .03), whereas older age was associated with decreased odds (aOR, 0.92; P = .02) of having resumed sexual activity. Women who were depressed (effect estimate, −13.3; P = .01), older (−1.1, P = .01), or exclusively breastfeeding (−16.5, P < .001) had significantly poorer sexual satisfaction, whereas multiparous women reported better sexual satisfaction (11.1, P = .03). A significant relationship between mode of birth and SHOW-Q scores did not emerge, although we did observe a trend toward lower SHOW-Q scores among women who underwent cesarean compared with those giving birth vaginally.
Multiparity and younger age predict early resumption of sexual activity, whereas depression and breastfeeding are associated with poorer postpartum sexual functioning. The relationship between mode of birth and resumed sexual activity or postpartum sexual function remains uncertain.
PMCID: PMC4896481  PMID: 24325662
breastfeeding; depression; mode of birth; postpartum sexual function
3.  Variation in Women's Understanding of Prenatal Testing 
Obstetrics and gynecology  2015;125(6):1306-1312.
To investigate women's understanding of prenatal testing options and of their own experience with screening, diagnostic genetic testing, or both.
This was a secondary analysis of data from a randomized controlled trial of enhanced information and values clarification regarding prenatal genetic testing in the absence of financial barriers to testing. Women in the third trimester of pregnancy were asked whether they had discussed prenatal genetic testing with their providers, whether they understood this testing was optional, and whether they had undergone testing during their pregnancy. Multivariable logistic regression models were fit to determine independent predictors of these outcomes.
Data were available from 710 study participants. Discussions about screening tests were reported by 654 participants (92%); only 412 (58%) reported discussing diagnostic testing. That screening and diagnostic testing were optional was evident to approximately 2/3 of women (n=470 and 455, respectively). Recall of actual tests undergone was correct for 626 (88%) for screening and for 700 (99%) for diagnostic testing. Racial–ethnic and socioeconomic variation existed in the understanding of whether screening and diagnostic tests were optional and in the correct recall of whether screening had been undertaken in the current pregnancy. In the usual care group, women receiving care in low-income settings were less likely to recall being offered diagnostic testing (aOR 0.23 [0.14, 0.39]).
Disparities exist in women's recall of prenatal genetic testing discussions and their understanding of their own experience. Interventions that explain testing options to women and help clarify their preferences may help to eliminate these differences.
PMCID: PMC4509625  PMID: 26000501
4.  Two practice models in one labor and delivery unit: Association with cesarean delivery rates 
To examine the association between labor and delivery practice model and cesarean delivery rates at a community hospital.
This was a retrospective cohort study of 9,381 singleton live births at one community hospital, where women were provided labor and delivery care under one of two distinct practice models: a traditional “private” practice model and a midwife-physician “laborist” practice model. Cesarean rates were compared by practice model, adjusting for potential sociodemographic and clinical confounders. Statistical comparisons were performed using the chi square test and multivariable logistical regression.
Compared with women managed under the midwife/laborist model, women in the private model were significantly more likely to have a cesarean delivery (31.6% vs 17.3%, p<0.001; adjusted odds ratio [aOR] 2.11, 95% confidence interval [CI] 1.73-2.58). Women with nulliparous, term, singleton, vertex (NTSV) gestations also were more likely to have a cesarean delivery if they were cared for in the private model (29.8% versus 15.9%, p<0.001; aOR 1.86, 95% CI 1.33-2.58) as were women who had a prior cesarean delivery (71.3% versus 41.4%, p<0.001; aOR 3.19, 95% CI 1.74-5.88).
In this community hospital setting, a midwife-physician laborist practice model was associated with lower cesarean rates than a private practice model.
PMCID: PMC4387106  PMID: 25446697
5.  Mode of Delivery Preferences in a Diverse Population of Pregnant Women 
American journal of obstetrics and gynecology  2014;212(3):377.e1-377.e24.
To assess women’s preferences for vaginal versus cesarean delivery in four contexts: prior cesarean, twins, breech presentation, and absent indication for cesarean.
Cross-sectional study of pregnant women at 24-40 weeks gestation. After assessing stated preferences for vaginal or cesarean delivery, we used the standard gamble metric to measure the strength of these preferences and the time tradeoff metric to determine how women value the potential processes and outcomes associated with these two delivery approaches.
Among the 240 participants, 90.8% had a stated preference for vaginal delivery. Across the four contexts, these women indicated that, on average, they would accept a 59-75% chance of an attempted vaginal birth ending in a cesarean before choosing a planned cesarean, indicating strong preferences for spontaneous, uncomplicated vaginal delivery. Variations in preferences for labor processes emerged. While uncomplicated labor ending in vaginal birth was assigned mean utilities of 0.993 or higher (on a 0-to-1 scale with higher scores indicating more preferred outcomes), the need for oxytocin, antibiotics, or operative vaginal delivery resulted in lower mean scores, comparable to those assigned to uncomplicated cesarean delivery. Substantially lower scores (ranging from 0.432 to 0.598) were obtained for scenarios ending in severe maternal or neonatal morbidity.
While most women expressed strong preferences for vaginal delivery, their preferences regarding interventions frequently employed to achieve that goal varied. These data underscore the importance of educating patients about the process of labor and delivery to facilitate incorporation of informed patient preferences in shared decision making regarding delivery approach.
PMCID: PMC4346419  PMID: 25446662
mode of delivery; standard gamble; time trade off; patient preferences; shared decision making
6.  Grief after second-trimester termination for fetal anomaly: a qualitative study 
Contraception  2014;91(3):234-239.
We aimed to qualitatively evaluate factors that contribute to and alleviate grief associated with termination of a pregnancy for a fetal anomaly and how that grief changes over time.
Study design
We conducted a longitudinal qualitative study of decision satisfaction, grief and coping among women undergoing termination (dilation and evacuation or induction termination) for fetal anomalies and other complications. We conducted three postprocedure interviews at 1–3 weeks, 3 months and 1 year. We used a generative thematic approach to analyze themes related to grief using NVivo software program.
Of the 19 women in the overall study, 13 women’s interviews were eligible for analysis of the grief experience. Eleven women completed all three interviews, and two completed only the first interview. Themes that contributed to grief include self-blame for the diagnosis, guilt around the termination decision, social isolation related to discomfort with abortion and grief triggered by reminders of pregnancy. Social support and time are mechanisms that serve to alleviate grief.
Pregnancy termination in this context is experienced as a significant loss similar to other types of pregnancy loss and is also associated with real and perceived stigma. Women choosing termination for fetal anomalies may benefit from tailored counseling that includes dispelling misconceptions about cause of the anomaly. In addition, efforts to decrease abortion stigma and increase social support may improve women’s experiences and lessen their grief response.
The nature and course of grief after second-trimester termination for fetal anomaly are, as of yet, poorly understood. With improved understanding of how women grieve over time, clinicians can better recognize the significance of their patients’ suffering and offer tools to direct their grief toward positive coping.
PMCID: PMC4406975  PMID: 25499590
Abortion; Second-trimester abortion; Pregnancy termination; Fetal anomaly; Perinatal grief; Pregnancy loss
7.  The Day-to-Day Impact of Vaginal Aging Questionnaire: A Multidimensional Measure of the Impact of Vaginal Symptoms on Functioning and Well-being in Postmenopausal Women 
Menopause (New York, N.Y.)  2015;22(2):144-154.
To develop a self-report questionnaire assessing the impact of vaginal dryness, soreness, itching, irritation, and pain on functioning and well-being in postmenopausal women.
Structured self-report items were developed to address the impact of vaginal symptoms on functioning and wellbeing based on findings from focus groups with racially/ethnically diverse, symptomatic postmenopausal women. Items were refined after cognitive interview pre-testing and then field-tested among symptomatic postmenopausal women enrolled in a multiethnic cohort study in California. Exploratory (SAS PROC VARCLUS) and confirmatory factor analyses evaluated factor structure and eliminate poorly fitting items. Additional evidence of construct validity was obtained via examination of correlations with other measures of related constructs. Internal consistency and test-re-test reliability were assessed using Cronbach’s alpha and correlation coefficients, respectively.
Of the 745 postmenopausal women completing the draft questionnaire, mean (SD) age was 56.2 (8.5) years, and 66% were racial/ethnic minorities. The refined questionnaire included four multi-item scales addressing symptom impact on: 1) activities of daily living, 2) emotional well-being, 3) sexual functioning, and 4) self-concept and body image. The four factor model provided good approximate fit (comparative fit index = 0.987, standardized root-mean-square residual = 0.038). Correlations with other measures of symptom bothersomeness, sexual function, depression, and anxiety conformed to hypotheses. Cronbach’s alpha ranged from 0.82 to 0.93. Intra-class coefficients ranged from 0.47 to 0.72.
The Day-to-Day Impact of Vaginal Aging (DIVA) questionnaire is a new multidimensional self-report measure designed to facilitate evaluation of the impact of vaginal symptoms in postmenopausal women of diverse backgrounds.
PMCID: PMC4280352  PMID: 24983271
vaginal dryness; vaginal itching; dyspareunia, vulvovaginal atrophy; female sexual dysfunction
8.  Prevalence and use of complementary health approaches among women with chronic pelvic pain in a prospective cohort study 
Pain medicine (Malden, Mass.)  2014;16(2):328-340.
To examine the prevalence of and factors associated with use of complementary health approaches among women with chronic pelvic pain (CPP).
We analyzed data from the Study of Pelvic Problems, Hysterectomy and Intervention Alternatives (SOPHIA), a prospective cohort study of women seeking care for noncancerous pelvic problems with intact uteri at enrollment. Among a subset of 699 participants who reported having CPP, we analyzed the prevalence of complementary health approaches used and associated patient sociodemographic and clinical characteristics, health-related quality of life, attitudes and beliefs, and conventional health care practices.
At baseline, slightly over one-half (51%) of women with CPP used at least one complementary health approach in the past year, including acupuncture (8%), special foods or diets (22%), herbs (27%), and vitamins and minerals (29%). During follow-up surveys conducted annually for four years, a substantial proportion of women (44.8%) used complementary health approaches at more than half of the assessments. Users of complementary health approaches were more likely to undergo a hysterectomy or oophorectomy or to use gonadotropin-releasing hormone agonists or opioids during the study compared with non-users. Women with CPP who used complementary health approaches also had more optimal health-related quality of life measured by the Pelvic Problem Impact Questionnaire (31.6 vs. 25.6, p<0.001).
Many women with CPP consistently use complementary health approaches. The substantial interest in and high prevalence of complementary health approaches used alongside conventional medical approaches highlights the need for better understanding of multimodal approaches to address the complex condition of CPP.
PMCID: PMC4329048  PMID: 25279935
Complementary health approaches; complementary medicine; integrative medicine; chronic pelvic pain
9.  Shared Decision-Making 
JAMA internal medicine  2015;175(2):167-168.
PMCID: PMC4720254  PMID: 25436939
10.  Identifying a “Range of Reasonable Options” for Cervical Cancer Screening 
Obstetrics and gynecology  2015;125(2):308-310.
PMCID: PMC4720252  PMID: 25569012
11.  Factors Associated With Undergoing Bilateral Salpingo-Oophorectomy at the Time of Hysterectomy for Benign Conditions 
Obstetrics and gynecology  2009;113(6):1259-1267.
To identify possible factors associated with undergoing bilateral salpingo-oophorectomy (BSO) at the time of hysterectomy among women with benign conditions.
This is a cross-sectional analysis using the 2005 Nationwide Inpatient Sample. Women 18 years or older who underwent hysterectomy with BSO or hysterectomy only for a noncancerous condition were included. We examined a broad range of factors associated with undergoing BSO in multivariable analyses.
Fifty-two percent of 461,321 hysterectomies included BSO, with a mean age of 49 years compared to 43 years in the hysterectomy only group (p<.001). The odds of BSO were two times higher in the Midwest and South, and 1.67 times higher in the West as compared to the Northeast (p<.001). Women who were uninsured or had Medicaid were more likely to undergo BSO compared to those with private insurance (OR 1.86, 95%CI 1.14–3.04 for “no charge/charity”, OR 1.21, 95% CI 1.08–1.35 for Medicaid) While BSO was more common among White women than African-American, Latina, and Asian women (p<0.001), lower income was associated with BSO among African-American and White women only, not among Asian and Latina women (P=.007 for test for interaction). BSO was 8 times as likely with a laparoscopic hysterectomy and 12 times as likely with an abdominal hysterectomy compared to a vaginal approach (p<.001). Women who had endometriosis, pelvic infection, or an ovarian cyst were more likely to undergo BSO (p<.001) compared to women who did not have these diagnoses.
There is significant nationwide variation in the practice of BSO. Age, route of hysterectomy, and diagnosis at surgery affect BSO rates. Nonclinical factors such as race/ethnicity, insurance status, income, and geographic location are also associated with BSO practice.
PMCID: PMC4670026  PMID: 19461420
12.  Use of medical, surgical and complementary treatments among women with fibroids 
To examine the use of medical management, uterus-preserving surgery (UPS), and complementary treatments among women with uterine fibroids.
Study design
Prospective cohort study of 933 premenopausal women ages 31-54 years with symptomatic fibroids who participated in the Study of Pelvic Problems, Hysterectomy, and Intervention Alternatives (SOPHIA) for an average of 4.3 years (SD 2.5 years). Incident use of fibroid treatments was determined through annual interviews. Linear regression models were used to compare changes in fibroid-related symptoms among women who underwent UPS versus those who did not undergo surgery.
Participants were racially and ethnically diverse, with a mean age of 43 years. During study follow-up, 531 participants (57%) did not undergo UPS or hysterectomy, 250 (27%) had at least one UPS, and 152 (16%) underwent hysterectomy. Complementary and alternative treatments were commonly used, including exercise (45%), diet (34%), herbs (37%), and acupuncture (16%): participants reported significant symptom improvement and few side effects with these interventions. In multivariable linear regression models, women who did not undergo surgery during the study reported improvement in dyspareunia (p<.001), pelvic pain (p<.001), and menstrual cramps (p<.001). However, women who underwent UPS reported greater overall resolution of “pelvic problems” compared with women who did not have surgical treatment (difference in change score 1.18 on a 4-point Likert scale, p<.001).
UPS are effective treatments for women with fibroids, but many women use hormonal or complementary treatments and report significant symptom improvement without surgical intervention.
PMCID: PMC4630000  PMID: 25445104
Uterine fibroids; Myomectomy; Uterine artery embolization; Complementary treatments
13.  What Parents Want to Know about the Storage and Use of Residual Newborn Bloodspots 
Many state newborn screening programs retain residual newborn screening bloodspots for a variety of purposes including quality assurance, biomedical research, and forensic applications. This project was designed to determine the information that prospective parents want to know about this practice.
Eleven focus groups were conducted in four states. Pregnant women and their partners and parents of young children (N=128) were recruited from the general public. Focus group participants viewed two educational movies on newborn screening and DBS retention and use. Transcripts were analyzed with qualitative methods and the results were synthesized to identify key information items.
We identified 14 categories of information from the focus groups that were synthesized into seven items prospective parents want to know about residual DBS. The items included details about storage, potential uses, risks and burdens, safeguards, anonymity, return of results, and parental choice.
For those state programs that retain residual dried bloodspots, inclusion of the seven things parents want to know about residual dried bloodspots in educational materials may improve parental understanding, trust, and acceptance of the retention and use of stored bloodspots.
PMCID: PMC4205184  PMID: 25131714
newborn screening; dried bloodspots; education; research; public health
14.  Racial and Ethnic Disparities in Benign Gynecologic Conditions and Associated Surgeries 
Common gynecologic conditions and surgeries may vary significantly by race or ethnicity. Uterine fibroids are more prevalent in black women and black women may have larger, more numerous fibroids that cause worse symptoms and greater myomectomy complications. Some, but not all, studies have found a higher prevalence of endometriosis among Asian women. Race and ethnicity are also associated with hysterectomy rate, route, and complications. Overall, the current literature has significant deficits in identifying racial and ethnic disparities in fibroids, endometriosis, and hysterectomy. Further research is needed to better define racial and ethnic differences in these conditions, and examine the complex mechanisms that may result in associated health disparities.
PMCID: PMC4625911  PMID: 20430357
disparities in benign gynecology
15.  Effect of Enhanced Information, Values Clarification, and Removal of Financial Barriers on Use of Prenatal Genetic Testing 
JAMA  2014;312(12):1210-1217.
Prenatal genetic testing guidelines recommend providing patients with detailed information to allow informed, preference-based screening and diagnostic testing decisions. The effect of implementing these guidelines is not well understood.
Toanalyze the effect of a decision support guide and elimination of financial barriers to testing on use of prenatal genetic testing and decision-making among women of varying literacy and numeracy levels.
Randomized trial conducted from 2010-2013.
Prenatal clinics at three county hospitals, a community clinic, an academic center, and three medical centers of an integrated health care delivery system in the San Francisco Bay area.
English- or Spanish-speaking women who had not yet undergone screening and/or diagnostic testing and remained pregnant at 11 weeks gestation (n=710).
A computerized, interactive decision support guide and access to prenatal testing with no out-of-pocket expense (n=357) or usual care as per current guidelines (n=353).
Main Outcome Measures
The primary outcome was invasive diagnostic test use, obtained via medical record review. Secondary outcomes included testing strategy undergone, and knowledge, risk comprehension, decisional conflict and decision regret at 24-36 weeks' gestation.
Women randomized to the intervention group, compared to those randomized to the control group, were less likely to have invasive testing [5.9% vs. 12.3%, odds ratio (OR) 0.45, 95% CI 0.25-0.80] and more likely to forego testing altogether [25.6% vs. 20.4%, OR 3.30 (reference group screening followed by invasive testing), CI 1.43-7.64]. They also had higher knowledge scores (9.4 vs. 8.6 on a 15-point scale, mean group difference 0.82, CI 0.34-1.31), and were more likely to correctly estimate the amniocentesis-related miscarriage risk (73.8% vs. 59.0%, OR 1.95, CI 1.39-2.75) and their age-adjusted chance of carrying a fetus with trisomy 21 (58.7% vs. 46.1%, OR 1.66, CI 1.22-2.28). Significant differences did not emerge in decisional conflict or decision regret.
Conclusions and Relevance
Full implementation of prenatal testing guidelines using a computerized, interactive decision support guide in the absence of financial barriers to testing resulted in lesser test use and more informed choices. If validated in additional populations, this approach may result in more informed and preference-based prenatal testing decision making, and fewer women undergoing testing.
PMCID: PMC4445462  PMID: 25247517
Prenatal genetic testing; informed decision making; low literacy
16.  Preferences for Outcomes Associated with Decisions to Undergo or Forego Genetic Testing for Lynch Syndrome 
Cancer  2012;119(1):215-225.
Current guidelines recommend offering genetic testing for Lynch syndrome to individuals whose tumors suggest this condition and to relatives of affected individuals. Little is known, however, regarding how patients view the prospect of such testing. In addition, data on preferences (utilities) for the potential outcomes of testing decisions for use in cost-effectiveness analyses are lacking.
We elicited time tradeoff utilities for ten potential outcomes of Lynch syndrome testing decisions and three associated cancers from 70 participants representing a range of knowledge about and experiences with Lynch syndrome.
Highest mean utilities were assigned to scenarios in which only the assessor's sibling had Lynch-associated colorectal cancer (ranging from 0.669±0.231 to 0.760±0.220). Utilities assigned to scenarios in which the assessor had Lynch-associated colorectal cancer ranged from 0.605±0.252 to 0.682±0.246, while the lowest mean utilities were assigned to 2 of the general cancer states (0.601±0.238 and 0.593±0.272 for colorectal and ovarian cancer respectively). Only 43% of the sample assigned higher values to undergoing Lynch testing and receiving negative results versus foregoing Lynch testing, while 50% assigned higher values to undergoing rather than foregoing surgery to prevent a subsequent cancer.
Genetic testing for Lynch syndrome, regardless of results, can have profound effects on quality of life; the utilities we collected can be used to incorporate these effects into cost-effectiveness analyses. Importantly, preferences for the potential outcomes of testing vary substantially, calling into question the extent to which patients would avail themselves of such testing if it were offered to them.
PMCID: PMC4356667  PMID: 22786716
Lynch syndrome; hereditary nonpolyposis colorectal cancer; genetic testing; quality of life; utilities; decision making
17.  Strength of Preference for Vaginal Birth as a Predictor of Delivery Mode Among Women who Attempt a Vaginal Delivery 
To assess the relationship between strength of preference for vaginal birth and likelihood of vaginal delivery among women attempting this delivery mode.
We conducted a longitudinal study of mode of delivery preferences among women who were less than 36 weeks pregnant. Participants completed a sociodemographic and clinical questionnaire and were asked if they preferred vaginal or cesarean delivery. Participants who preferred vaginal delivery completed a standard gamble exercise to assess the strength of this preference on a 0-to-1 scale (higher scores indicate stronger preference for vaginal delivery); those preferring cesarean delivery were assigned a value of 0. Data on clinical characteristics and delivery mode was obtained via telephone interview or chart review. Logistic regression was used to identify predictors of delivery mode among women who attempted a vaginal delivery.
Of 210 participants, 156 attempted a vaginal delivery. Their mean and median vaginal delivery preference scores were 0.70 (SD 0.31) and 0.75 (IQR 0.50–0.99), respectively. In multivariate analyses, women with a prior cesarean delivery (aOR 0.08, CI 0.02–0.39) or who delivered an infant ≥4000 grams (aOR 0.04, CI 0.01–0.28) had significantly lower odds of having a vaginal delivery. After controlling for potential confounders, participants with a stronger preference for vaginal delivery were at significantly higher odds of having a vaginal delivery (aOR 1.54, CI 1.01–2.34 for every 0.2 increase on the 0-to-1 scale).
Among women who attempt a vaginal delivery, the strength of preference for vaginal birth is predictive of the delivery mode ultimately undergone.
PMCID: PMC4218776  PMID: 24246523
Patient preferences; delivery mode
18.  Association Between Vaginal Birth After Cesarean Delivery and Primary Cesarean Delivery Rates 
Obstetrics and gynecology  2013;122(5):1010-1017.
To estimate the association between vaginal birth after cesarean delivery (VBAC) rates and primary cesarean delivery rates in California hospitals.
Hospital VBAC rates were calculated using birth certificate and discharge data from 2009, and hospitals were categorized by quartile of VBAC rate. Multivariable logistic regression analysis was performed to estimate the odds of cesarean delivery among low-risk nulliparous women with singleton pregnancies at term in vertex presentation (nulliparous term singleton vertex) by hospital VBAC quartile while controlling for many patient-level and hospital-level confounders.
There were 468,789 term singleton births in California in 2009 at 255 hospitals, 125,471 of which were low-risk nulliparous term singleton vertex. Vaginal birth after cesarean delivery rates varied between hospitals, with a range of 0–44.6%. Rates of cesarean delivery among low-risk nulliparous term singleton vertex women declined significantly with increasing VBAC rate. When adjusted for maternal and hospital characteristics, low-risk nulliparous term singleton vertex women who gave birth in hospitals in the highest VBAC quartile had an odds ratio of 0.55 (95% confidence interval 0.46–0.66) of cesarean delivery compared with women at hospitals with the lowest VBAC rates. Each percentage point increase in a hospital’s VBAC rate was associated with a 0.65% decrease in the low-risk nulliparous term singleton vertex cesarean delivery rate.
Hospitals with higher rates of VBAC have lower rates of primary cesarean delivery among low-risk nulliparous women with singleton pregnancies at term in vertex presentation.
PMCID: PMC4199326  PMID: 24104780
19.  Women’s Attitudes Regarding Prenatal Testing for a Range of Congenital Disorders of Varying Severity 
Journal of Clinical Medicine  2014;3(1):144-152.
Little is known about women’s comparative attitudes towards prenatal testing for different categories of genetic disorders. We interviewed women who delivered healthy infants within the past year and assessed attitudes towards prenatal screening and diagnostic testing, as well as pregnancy termination, for Down syndrome (DS), fragile X (FraX), cystic fibrosis (CF), spinal muscular atrophy (SMA), phenylketonuria (PKU) and congenital heart defects (CHD). Ninety-five women aged 21 to 48 years participated, of whom 60% were Caucasian, 23% Asian, 10% Latina and 7% African American; 82% were college graduates. Ninety-five to ninety-eight percent indicated that they would have screening for each condition, and the majority would have amniocentesis (64% for PKU to 72% for SMA). Inclinations regarding pregnancy termination varied by condition: Whereas only 10% reported they would probably or definitely terminate a pregnancy for CHD, 41% indicated they would do so for DS and 62% for SMA. Most women in this cohort reported that they would undergo screening for all six conditions presented, the majority without the intent to terminate an affected pregnancy. These women were least inclined to terminate treatable disorders (PKU, CHD) versus those associated with intellectual disability (DS, FraX) and were most likely to terminate for SMA, typically lethal in childhood.
PMCID: PMC4449668  PMID: 26237253
prenatal genetic screening; fragile X syndrome; spinal muscular atrophy; abortion; prenatal diagnosis
20.  The effect of weight loss on changes in health-related quality of life among overweight and obese women with urinary incontinence 
To estimate the effect of change in weight and change in urinary incontinence (UI) frequency on changes in preference-based measures of health-related quality of life (HRQL) among overweight and obese women with UI participating in a weight loss trial.
We conducted a longitudinal cohort analysis of 338 overweight and obese women with UI enrolled in a randomized clinical trial comparing a behavioral weight loss intervention to an educational control condition. At baseline, 6, and 18 months, health utilities were estimated using the Health Utilities Index Mark 3 (HUI3), a transformation of the SF-36 to the preference-based SF-6D, and the estimated Quality of Well-Being (eQWB) score (a summary calculated from the SF-36 physical functioning, mental health, bodily pain, general health perceptions, and role limitations-physical subscale scores). Potential predictors of changes in these outcomes were examined using generalized estimating equations.
In adjusted multivariable models, weight loss was associated with improvement in HUI3, SF-6D, and eQWB at 6 and 18 months (p<.05). Increases in physical activity also were independently associated with improvement in HUI3 (p=.01) and SF-6D (p=.006) scores at 18 months. In contrast, reduction in UI frequency did not predict improvements in HRQL at 6 or 18 months.
Weight loss and increased physical activity, but not reduction in UI frequency, were strongly associated with improvements in health utilities measured by the HUI3, SF-6D, and eQWB. These findings provide important information that can be used to inform cost-utility analyses of weight loss interventions.
PMCID: PMC3375350  PMID: 22161726
quality of life; weight loss; urinary incontinence; HUI; eQWB; SF-6D
21.  Strategies to Identify the Lynch Syndrome Among Patients With Colorectal Cancer 
Annals of internal medicine  2011;155(2):69-79.
Testing has been advocated for all persons with newly diagnosed colorectal cancer to identify families with the Lynch syndrome, an autosomal dominant cancer-predisposition syndrome that is a paradigm for personalized medicine.
To estimate the effectiveness and cost-effectiveness of strategies to identify the Lynch syndrome, with attention to sex, age at screening, and differential effects for probands and relatives.
Markov model that incorporated risk for colorectal, endometrial, and ovarian cancers.
Data Sources
Published literature.
Target Population
All persons with newly diagnosed colorectal cancer and their relatives.
Time Horizon
Third-party payer.
Strategies based on clinical criteria, prediction algorithms, tumor testing, or up-front germline mutation testing, followed by tailored screening and risk-reducing surgery.
Outcome Measures
Life-years, cancer cases and deaths, costs, and incremental cost-effectiveness ratios.
Results of Base-Case Analysis
The benefit of all strategies accrued primarily to relatives with a mutation associated with the Lynch syndrome, particularly women, whose life expectancy could increase by approximately 4 years with hysterectomy and salpingo-oophorectomy and adherence to colorectal cancer screening recommendations. At current rates of germline testing, screening, and prophylactic surgery, the strategies reduced deaths from colorectal cancer by 7% to 42% and deaths from endometrial and ovarian cancer by 1% to 6%. Among tumor-testing strategies, immunohistochemistry followed by BRAF mutation testing was preferred, with an incremental cost-effectiveness ratio of $36 200 per life-year gained.
Results of Sensitivity Analysis
The number of relatives tested per proband was a critical determinant of both effectiveness and cost-effectiveness, with testing of 3 to 4 relatives required for most strategies to meet a threshold of $50 000 per life-year gained. Immunohistochemistry followed by BRAF mutation testing was preferred in 59% of iterations in probabilistic sensitivity analysis at a threshold of $100 000 per life-year gained. Screening for the Lynch syndrome with immunohistochemistry followed by BRAF mutation testing only up to age 70 years cost $44 000 per incremental life-year gained compared with screening only up to age 60 years, and screening without an upper age limit cost $88 700 per incremental life-year gained compared with screening only up to age 70 years.
Other types of cancer, uncertain family pedigrees, and genetic variants of unknown significance were not considered.
Widespread colorectal tumor testing to identify families with the Lynch syndrome could yield substantial benefits at acceptable costs, particularly for women with a mutation associated with the Lynch syndrome who begin regular screening and have risk-reducing surgery. The cost-effectiveness of such testing depends on the participation rate among relatives at risk for the Lynch syndrome.
Primary Funding Source
National Institutes of Health.
PMCID: PMC3793257  PMID: 21768580
22.  Decrease in Urinary Incontinence Management Costs in Women Enrolled in a Clinical Trial of Weight Loss to Treat Urinary Incontinence 
Obstetrics and Gynecology  2012;120(2 Pt 1):277-283.
To estimate the effect of a decrease in urinary incontinence frequency on urinary incontinence management costs among women enrolled in a clinical trial of a weight loss intervention and to identify factors that predict change in cost.
This is a secondary cohort analysis of 338 obese and overweight women with ≥ 10 weekly episodes of urinary incontinence enrolled in an 18-month randomized clinical trial of a weight loss intervention compared to a structured education program to treat urinary incontinence. Quantities of resources used for incontinence management, including pads, additional laundry, and dry cleaning were reported by participants. Direct costs for urinary incontinence management (“cost”) were calculated by multiplying resources used by national resource costs (in 2006 U.S. dollars). Randomized groups were combined to examine the effects of change in incontinence frequency on cost. Possible predictors of change in cost were examined using generalized estimating equations controlling for factors associated with change in cost in univariable analyses.
Mean (±SD) age was 53±10 years and baseline weight was 97+17 kg. Mean weekly urinary incontinence frequency was 24+18 at baseline and decreased by 37% at 6 months and 60% at 18 months follow-up (both P<0.001). At baseline, adjusted mean cost was $7.76±$14 per week, with costs increasing significantly with greater incontinence frequency. Mean cost decreased by 54% at 6 months and 81% at 18 months (both P<0.001). In multivariable analyses, cost independently decreased by 23% for each decrease of seven urinary incontinence episodes per week and 21% for each 5 kg of weight lost (P<0.001 for both).
In obese and overweight women enrolled in a clinical trial of weight loss for urinary incontinence, incontinence management cost decreased by 81% at 18 months ($327 per woman per year) and was strongly and independently associated with decreasing incontinence frequency.
PMCID: PMC3404427  PMID: 22825085
23.  Comparison and correlates of three preference-based health-related quality-of-life measures among overweight and obese women with urinary incontinence 
To compare three preference-based health-related quality-of-life (HRQL) measures and examine independent correlates of HRQL among overweight and obese women with urinary incontinence (UI) enrolled in a weight loss intervention trial.
Participants completed baseline questionnaires, which included the Health Utilities Index 3 (HUI3) and Medical Outcomes Study Short Form-36 (SF-36). The SF-36 was used to derive SF-6D and estimated Quality of Well-Being (eQWB) scores. Height, weight, medical history, incontinence measures, and level of physical activity also were assessed. The intraclass correlation coefficient (ICC) was computed, and differences in mean scores across HRQL measures were examined. Potential correlates of HUI3, SF-6D, and eQWB scores were evaluated using multivariable generalized linear models.
Mean ± SD scores for the HUI3, SF-6D, and eQWB were 0.81 ± 0.18, 0.75 ± 0.10, and 0.71 ± 0.06, respectively. Significant differences were observed across measures (P < 0.0001), and the overall ICC was 0.36. In multivariable analyses, BMI was negatively associated with HUI3 (P = 0.003) and eQWB (P < 0.001), and UI episode frequency was negatively associated with eQWB (P = 0.015) and SF-6D (P < 0.001).
Significant differences in mean utilities across the HUI3, SF-6D, and eQWB indicate that these measures do not assess identical dimensions of HRQL. Both BMI and UI episode frequency were related to HRQL in this cohort; however, the magnitude of the relationship depended on the preference-based measure used. These findings highlight the need to consider the method used to generate HRQL values for calculating quality-adjusted life-years in cost-utility analyses, since choice of method may have a substantial impact on the outcome of the analysis.
PMCID: PMC3174313  PMID: 21461953
Quality of life; Obesity; Urinary incontinence; HUI; eQWB; SF-6D
24.  Influence of Patient Preferences on the Cost-Effectiveness of Screening for Lynch Syndrome 
Journal of Oncology Practice  2012;8(3 Suppl):e24s-e30s.
This cost-utility analysis reports on the effect of quality of life on the value of screening all new patients with colorectal cancer for Lynch syndrome.
Patients and relatives have varying preferences for genetic testing and interventions related to hereditary cancer syndromes. We examined how the impact of these services on quality of life (QoL) affects the cost-effectiveness of screening for Lynch syndrome among probands newly diagnosed with colorectal cancer and their relatives.
We constructed a state-transition model comparing screening strategies (clinical criteria, prediction algorithms, tumor testing, and upfront germline testing) with no screening to identify Lynch syndrome. The model incorporated individuals' health state utilities after screening, germline testing, and risk-reducing surgeries, with utilities persisting for 12 months in the base case. Outcomes consisted of quality-adjusted life-years (QALYs), costs, and cost per QALY gained. Sensitivity analyses assessed how the duration and magnitude of changes in QoL influenced results.
Multiple screening strategies yielded gains in QALYs at acceptable costs compared with no screening. The preferred strategy—immunohistochemistry of tumors followed by BRAF mutation testing (IHC/BRAF)—cost $59,700 per QALY gained in the base case. The duration and magnitude of decreases in QoL after decisions related to germline testing and surgeries were key determinants of the cost-effectiveness of screening. IHC/BRAF cost > $100,000 per QALY gained when decrements to QoL persisted for 21 months.
Screening for Lynch syndrome in the population is likely to yield long-term gains in life expectancy that outweigh any short-term decreases in QoL, at acceptable costs. Counseling for individuals should aim to mitigate potential negative impact of genetic testing and risk-reducing interventions on QoL.
PMCID: PMC3348599  PMID: 22942831
25.  Long-Term Outcomes of the Total or Supracervical Hysterectomy (TOSH) Trial 
Participants in the multi-center, randomized Total or Supracervical Hysterectomy (TOSH) trial showed within-group improvement in pelvic floor symptoms 2 years post-surgery and no differences between supracervical (SCH) versus total hysterectomy (TAH). This study describes longer term outcomes from the largest recruiting site.
Questionnaires addressing pelvic symptoms, sexual function, and health-related quality of life were administered. Linear models and McNemar’s test were utilized.
Thirty-seven participants (69%) responded (19 TAH, 18 SCH); mean follow up was 9.1±0.7 years. No between-group differences emerged in urinary incontinence, voiding dysfunction, pelvic prolapse symptoms and overall health related quality of life (HRQOL). Within-group analysis showed significant improvement in the ability to have and enjoy sex (P = 0.002) and in the SF-36 physical component summary score (P = 0.03) among women randomized to TAH.
9 years after surgery, TOSH participants continue to experience improvement and show no major between-group differences in lower urinary tract or pelvic floor symptoms conferring no major benefit of SCH over TAH.
PMCID: PMC3252027  PMID: 22229107

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