Case Studies week 8

1. Case 1 of 2 : Cost-Effectiveness Analysis (CEA): In Wu et al. (2006) researchers performed an

analysis to evaluate the cost-effectiveness of doing stool DNA testing in addition to other types of
traditional screenings, i.e., fecal occult blood testing annually, flexible sigmoidoscopy or colonoscopy,
every 5 and 10 years for colorectal cancer in countries where colon cancer prevalence is low. Also,
evaluated was the cost/benefit of doing no screenings (Wu, 2006).
The subjects were people 50 to 75 years of age in Taiwan. The researchers used the annual cost of
$13,000 per life-year saved (which is roughly the per capita GNP of) as the ceiling ratio for assessing
whether DNA testing was cost-effective (Wu, 2006).

Simulated results for screening strategies to prevent Colon Rectal Cancer (CRC)

Variable

Screening Strategy

No
Screening

DNA
(3yrs)

DNA
(5yrs)

DNA
(10yrs)

Occult
Blood

Flexible Sigmoid.
(5yrs)

Colonoscopy
(10 yrs)

a. Total cases of CRC, n

2,917

2,435

2,654

2,710

2,129

2,253

1,780

b. CRC deaths, n

1,729

1,345

1,467

1,574

1,059

1,328

1,077

c. Perforation deaths, n

12

e. Reduction in CRC
incidence, %

17

27

23

39

f. Reduction in CRC mortality,

%

22

15

39

23

39

g. Life expectancy, year

15.7337

15.7476

15.7434

15.74

15.7584

15.7477

15.759

h. Total costs, thousand $

22,022

35,637

31,077

26,856

19,824

24,909

21,843

i. Incremental life-year saved,

year

1,390

970

626

2,464

1,383

2,530

j. Incremental cost, thousand

$

13,615

9,054

4,834

-2,198

2,887

-180

Case Studies week 8

k. Incremental cost ($)/lifeyears saved compared with

no screening

9,794

9,335

7,717

Dominant

2,087

Dominant

* Values obtain from a cohort of 100,000 persons 50 years of age who were followed for 25 years.

The other screening strategy is more effective and less costly than stool DNA testing strategy.

The screening is more effective and less costly than No Screening.

Adapted from: Wu et al. BMC Cancer 2006 6:136 doi:10.1186/1471-2407-6-136

_____________
Reference:
Wu, Grace HM. Wang, Yi-Ming . Yen, Amy MF. Wong, Jau-Min Lai, Hsin-Chih Warwick, Jane and Chen,
Tony HH. (2006) Cost-effectiveness analysis of colorectal cancer screening with stool DNA testing in
intermediate-incidence countries. BMC Cancer 2006, 6:136 doi:10.1186/1471-2407-6-136
QUESTIONS: In your own words and
1) From the research results shown in the chart above, which type of screening had the highest and
which had the lowest reduction in colon-rectal cancer mortality?
2) How do you interpret the findings (Conclusion) in regard to the A-K results in regard to the
cost/effectives of doing DNA-testing at 3 years, 5 years, 10 years, or not doing DNA tests at all?
NOTE: Essay Question is in 2 parts. This is Part 1 to be completed and then go <next>, to Part 2 and
complete it.
Case #2 of 2: Cost/Benefit literature review for vaginal birth after cesarean (VBAC)
A client had a cesarean delivery in a hospital setting for breech presentation with her first pregnancy. She
is pregnant again and after exploring her delivery options, has decided she wants to attempt a vaginal
birth after cesarean (VBAC). She has had an uncomplicated pregnancy this time and the fetus is not
breech. The same OB-GYN will be assisting in her delivery. The OB-GYN performs a systematic review of
the literature to assess the benefits and harms of VBAC versus repeat cesarean delivery.
Part 1 of 2: Researching Empirical Evidence
1. What kinds and sources of data does the OB-GYN need to review in order to make a rational clinical
planning decision?
2. Which types of studies available on this topic would be the most useful in clinical decision making?
3. What types of studies would you want to exclude?

Case Studies week 8

4. Why would there be a lack of randomized clinical trials (RCTs) available to address this clinical
question?

2. NOTE: This is Part 2 of the final essay question: The last essay question requires you to do a 2x2
table in addition to calculations. The tables may be done by copying the table from the question directly
into your answer and then filling the table out.

Case: Calculating Odds Ratio

In planning for her delivery, the client reads about birthing centers and asks the midwife if it is safe to
have a VBAC in a freestanding birthing center. The midwife reviews the data from national studies of
VBACs in birthing centers compared to VBACs in hospital settings and obtains the following statistics to
aid her in clinical decision making:
N= 1913 Birthing Center based VBAC Rates
87% delivered vaginally
24% of women were transferred to the hospital prior to delivery
There were 25 women who experienced a serious adverse outcome (of which 6 were uterine rupture)
There were 7 perinatal deaths (0.5%)
There were 15 infants with low apgar scores (below 7) after 5 minutes of life (1.0%)
N= 1913 Hospital based VBAC Rates (Control)
76% delivered vaginally
There were 32 women who experienced a serious adverse outcome (of which 15 were uterine ruptures)
There were 3 perinatal deaths
There were 2 infants with low apgar scores (less than 7) after 5 minutes of life

(Part 2 of 2): Construct the following for 1 and 2 and answer question 3
1. Construct a 2 x 2 table, calculate, and interpret the odds ratio of women who suffered a serious
adverse outcome from attempting a VBAC delivery in order to estimate the relative risk to a mother
delivering VBAC in midwifery based freestanding birthing centers. Cases are those with a serious
outcome, controls are those without. The exposure is treatment in a birthing center. The not exposed
group is treatment in a hospital.
Exposure

Cases

Controls

Birthing Center
Hospital

2. Construct a 2 x 2 table, calculate, and interpret the odds ratio of infants who suffered a serious adverse
outcome (including death) from attempting a VBAC delivery in order to estimate the relative risk to an
infant delivered VBAC in midwifery based freestanding

Case Studies week 8

Cases

Controls

3. What does the midwife conclude regarding the safety to mother and baby by attempting a VBAC in
midwifery based birthing centers? What clinically is the best decision for this client and her unborn baby?