Hospital variation in cost of childbirth and contributing factors: a cross-sectional study.

OBJECTIVE: To examine hospital variation in cost of childbirth hospitalisations and identify factors that contribute to the variation. DESIGN: Cross-sectional analysis of linked birth certificate and hospital discharge data. SETTING: Two hundred and twenty hospitals in California delivering ≥ 100 births per year. POPULATION: A total of 405 908 nulliparous term singleton vertex births during 2010-2012. METHODS: Cost of childbirth hospitalisations was compared across hospitals after accounting for differences in patient clinical risk factors. Relative contributions of patient sociodemographic, obstetric intervention, birth attendant and institutional characteristics to variation in cost were assessed by further adjusting for these factors in hierarchical generalised linear models. MAIN OUTCOME MEASURES: Cost of childbirth hospitalisation. RESULTS: Median risk-standardised cost of childbirth was $7149 among the hospitals (10th -90th percentile range: $4760-$10,644). Maternal sociodemographic characteristics and type of birth attendant did not explain hospital variation in cost. Adjustment for obstetric interventions overall reduced within-hospital variance by 15.8% (P < 0.001), while adjusting for caesarean delivery alone reduced within-hospital variance by 14.4% (P < 0.001). However, obstetric interventions did not explain between-hospital variation in cost. In contrast, adjustment for institutional characteristics reduced between-hospital variance by 30.3% (P = 0.002). Hospital type of ownership, teaching/urban-rural status, neonatal care capacity and geographic region were most impactful. Risk-standardised cost was positively correlated with risk-standardised rate of severe newborn morbidities (correlation coefficient 0.22, P = 0.001), but not associated with risk-standardised rate of severe maternal morbidities. CONCLUSIONS: Cost of childbirth hospitalisations varied widely among hospitals in California. Institutional characteristics significantly contributed to this variation. Higher-cost hospitals did not have better outcomes, suggesting potential opportunities to enhance value in care. TWEETABLE ABSTRACT: Hospitals vary in cost of childbirth. Institutional characteristics significantly contribute to the variation.

Base excision repair: contribution to tumorigenesis and target in anticancer treatment paradigms.

Cancer treatments often lose their effectiveness due to the development of multiple drug resistance. Thus, identification of key proteins involved in the tumorigenic process and the survival mechanism(s), coupled with the design of novel therapeutic compounds (such as small molecule inhibitors), are essential steps towards the establishment of improved anticancer treatment strategies. DNA repair pathways and their proteins have been exposed as potential targets for combinatorial anticancer therapies that involve DNA-interactive cytotoxins, such as alkylating agents, because of their central role in providing resistance against DNA damage. In addition, an understanding of the tumor-specific genetics and associated DNA repair capacity has allowed research scientists and clinicians to begin to devise more targeted treatment strategies based on the concept of synthetic lethality. In this review, the repair mechanisms, as well as the links to cancer progression and treatment, of three key proteins that function in the base excision repair pathway, i.e. APE1, POLß, and FEN1, are discussed.

Carcinosarcoma of the ovary.

The objective of this study was to evaluate the treatment and outcome in patients with ovarian carcinosarcoma. The Tumor Board Registry was reviewed for patients with ovarian carcinosarcoma treated at our institution from June 1993 to December 2004. The medical records were retrospectively analyzed with emphasis on cytoreduction, cytotoxic regimens, progression-free interval, and survival. Twenty-two patients were identified. All but two presented with advanced stage disease. The median survival for the entire cohort was 38 months. Median survival was 46 months for 18 optimally debulked (<1 cm) patients and 27 months for four suboptimally debulked (>1 cm) patients. Six patients were treated with optimal cytoreduction and adjuvant cisplatin (40 mg/m(2)x 1 day) and ifosfamide (1200 mg/m(2)/day x 4 days) every 28 days. Median progression-free interval in the cisplatin and ifosfamide group was 13 months, and median survival was 51 months. The combination of carboplatin (AUC 5) and taxol (175 mg/m(2)) every 21 days was administered to four patients as first-line chemotherapy following optimal cytoreduction. In the carboplatin and taxol group, median progression-free interval was 6 months and median survival was 38 months. The difference in survival between the cisplatin and ifosfamide group and the carboplatin and taxol group was not statistically significant (P= 0.48). In conclusion, patients with ovarian carcinosarcoma usually present with advanced stage disease. Treatment consists of optimal cytoreduction and chemotherapy. The most effective cytotoxic regimen remains to be determined. First-line cisplatin and ifosfamide or carboplatin and taxol can achieve survival rates observed in epithelial ovarian cancer.