The timing of elective caesarean delivery between 2000 and 2009 in England

BACKGROUND: In 2004, the National Institute for Clinical Excellence (NICE) recommended that an elective caesarean section for an uncomplicated pregnancy should not be carried out before 39 completed weeks due to increased risk of respiratory morbidity in newborns. We describe the trends and variation across 63 English NHS trusts in the timing of elective caesarean section (CS) for low-risk singleton deliveries. METHODS: We identified elective CS deliveries between 1st April 2000 and 28th February 2009 in English NHS trusts using the Hospital Episode Statistics. We selected women with uncomplicated pregnancies who had an elective CS delivery after 34 completed weeks of gestation, and analysed the trends and the trust-level variation in the timing of elective CS. The impact of the NICE guidance on the monthly rate of elective CS deliveries performed after 39 weeks was estimated using an interrupted time-series design with autoregressive integrated moving average (ARIMA). RESULTS: There were 118,456 elective CS deliveries at the 63 NHS trusts. The overall proportion of elective CS deliveries done after 39 completed weeks steadily increased from 39% in 2000/01 to 63% in 2008/09. The proportions rose from 43% to 67% for women with breech presentation and from 35% to 62% for women with a previous CS. There was significant variation across NHS trusts in each year; in 2008/09, with the proportions of elective CS done after 39 weeks ranging from 28% to 89% (Inter-quartile range limits: 54% to 72%). We found a small but statistically significant increase in the proportion immediately after the publication of the NICE guidance, but its rate of growth rate declined slightly thereafter. CONCLUSIONS: NHS trusts in our study have responded to the new evidence on the benefits of delaying elective CS to after 39 weeks gestation. However, substantial differences between NHS trusts remain, which indicates there is room for further improvement. We suggest that maternity services and commissioners adopt the "timing of elective caesarean" as a quality indicator to support clinical practice

Pertussis post-exposure prophylaxis among household contacts: a cost-utility analysis.

BACKGROUND: Recent pertussis outbreaks have prompted re-examination of post-exposure prophylaxis (PEP) strategies, when immunization is not immediately protective. Chemoprophylaxis is recommended to household contacts; however there are concerns of clinical failure and significant adverse events, especially with erythromycin among infants who have the highest disease burden. Newer macrolides offer fewer side effects at higher drug costs. We sought to determine the cost-effectiveness of PEP strategies from the health care payer perspective. METHODS: A Markov model was constructed to examine 4 mutually exclusive strategies: erythromycin, azithromycin, clarithromycin, or no intervention, stratified by age group of contacts ("infant", "child", and "adult"). Transition probabilities, costs and quality-adjusted life years (QALYs) were derived from the literature. Chronic neurologic sequelae were modeled over a lifetime, with costs and QALYs discounted at 5%. Associated health outcomes and costs were compared, and incremental cost-effectiveness ratios (ICER) were calculated in 2012 Canadian dollars. Deterministic and probabilistic sensitivity analyses were performed to evaluate the degree of uncertainty in the results. FINDINGS: Azithromycin offered the highest QALYs in all scenarios. While this was the dominant strategy among infants, it produced an ICER of $16,963 per QALY among children and$2,415 per QALY among adults. Total QALYs with azithromycin were 19.7 for a 5-kg infant, 19.4 for a 10-year-old child, and 18.8 for a 30-year-old adult. The costs of azithromycin PEP among infants, children and adults were $1,976,$132 and $90, respectively. While results were sensitive to changes in PEP effectiveness (11$379 to $59,644), the choice of strategy remained unchanged. INTERPRETATION: Pertussis PEP is a cost-effective strategy compared with no intervention and plays an important role in contact management, potentially in outbreak situations. From a healthcare payer perspective, azithromycin is the optimal strategy among all contact groups

Silver shoppers' attitude towards store brands: Will-They-Won't-They?

Silver shoppers represent a growing share in Western populations with many important consequences on welfare as well as on marketing policies. The present work aims at a fresh perspective on the over-65 cohort grocery shopping behavior by examining its drivers of main store choice and its attitude towards Store Brands (SBs). By means of a field survey on 420 Italian shoppers, we found that, unlike millennials, seniors prefer proximity stores with parking facilities and good store staff assistance; they do not appreciate SBs at all, so that their Store Loyalty is only partially influenced by the same. Results carry several implications for both academics and practitioner