Postpartum Hemmorrhage and Anemia: Epidemiologic and Cost-Effectiveness Analyses

描述(由申请人提供)：这是K23奖项的修订申请，以支持Alexander Butwick博士拟议的研究和培训，重点是临床有效和成本效益高的战略，以减少剖腹产(CD)妇女的血液学相关疾病，特别是产后出血(PPH)和早期产后贫血(EPA)。严重的产后出血可导致严重的产科并发症，是美国孕产妇死亡的主要原因；EPA是一种被低估的不良后果，可能会导致产后妇女的长期有害心理、身体和认知影响。目前，重度PPH和EPA的风险分层和EPA的治疗方法缺乏共识，而且主要是非标准化的。对于接受CD的妇女，需要采用创新的方法：(1)对PPH进行术前风险分层，(2)对EPA进行术后筛查和经济有效的治疗方案。这些方法构成了拟议研究的中心方面。在目标1中，Butwick博士将利用斯坦福大学医学院(SUSM)的住院数据进行嵌套病例对照研究，以确定预测因素，并开发对产前CD和产中CD患者的严重PPH的预测模型。在目标2中，Butwick博士将使用Kaiser Permanente Medical Care Program-North California(KPMCP-NC)的相关住院数据库评估CD后女性EPA的发生率和风险因素。在目标3中，Butwick博士将进行成本效益分析，以评估口服铁剂疗法与静脉铁剂疗法治疗EPA的成本、益处和危害。应聘者是SUSM的产科麻醉师，接受过临床流行病学方面的额外培训，因此是唯一有资格实现这些目标的人。此外，Butwick博士还得到了一个多学科协作团队的支持，该团队在临床流行病学、产科、围产科学、卫生服务研究和麻醉学方面具有专业知识。候选人的提案将受益于SUSM(卫生研究和政策部，斯坦福临床信息学中心)和北卡罗来纳州毕马威研究院研究部的不同资源优势。为了实现他的研究目标，并为他作为一名独立研究员的职业生涯做好准备，Butwick博士创建了一个多学科的职业发展计划，其中包括：(1)研究生水平的健康结果研究教学培训，并指导医疗决策的成本效益分析和分析方法；(2)先进流行病学技术的指导，整合电子健康信息和链接的住院数据库；(3)产科和围产期医学的有针对性的教育；以及(4)指导产科麻醉学和围产期的跨学科研究的领导力。这项研究的成功完成将为未来R01的应用奠定基础，以验证针对严重PPH的计算机化预测规则的临床效果和成本效益，并研究针对EPA和其他主要围产期疾病的个性化治疗策略。

DESCRIPTION (provided by applicant): This is a revised application for a K23 award to support Dr. Alexander Butwick's proposed research and training focusing on clinically effective and cost-effective strategies for reducing hematologic-related maternal morbidities, specifically postpartum hemorrhage (PPH) and early postpartum anemia (EPA), in women undergoing cesarean delivery (CD). Severe PPH can cause major obstetric morbidity and is a leading cause of maternal death in the US; EPA is an underappreciated adverse outcome, which may lead to long-term deleterious psychological, physical, and cognitive effects among postpartum women. Currently, risk- stratification for severe PPH and EPA and therapeutic approaches for EPA lack consensus and are predominantly non-standardized. For women undergoing CD, innovative approaches are needed for: (1) preoperative risk stratification for PPH and, (2) postoperative screening and cost-effective treatment regimens for EPA. These approaches comprise the central aspects of the proposed research. In Aim 1, Dr. Butwick will perform a nested case-control study, using hospitalization data at Stanford University School of Medicine (SUSM), to determine predictors and develop prediction models for severe PPH in patients undergoing prelabor CD and intrapartum CD. In Aim 2, Dr. Butwick will assess the incidence of and risk factors for EPA in women post-CD using linked hospitalization databases from Kaiser Permanente Medical Care Program - Northern California (KPMCP-NC). In Aim 3, Dr. Butwick will perform a cost-effectiveness analysis to assess the costs, benefits, and harms of oral versus intravenous iron therapy for the treatment of EPA. The candidate is an obstetric anesthesiologist at SUSM with additional training in Clinical Epidemiology, and is therefore uniquely qualified to address these aims. Furthermore, Dr. Butwick is supported by a multidisciplinary and collaborative team with expertise in Clinical Epidemiology, Obstetrics, Perinatology, Health Services Research, and Anesthesiology. The candidate's proposal will benefit from the diverse strength of resources at SUSM (the Department of Health Research and Policy, the Stanford Center for Clinical Informatics) and at Division of Research, KPMCP-NC. To accomplish his research goals and prepare him for a career as an independent investigator, Dr. Butwick has created a multi-disciplinary career development plan incorporating: (1) graduate level didactic training in health outcomes research with mentoring in cost-effectiveness analyses and analytic approaches for medical decision-making; (2) mentoring in advanced epidemiologic techniques, integrating electronic health information and linked hospitalization databases; (3) targeted education in obstetrical and perinatal medicine; and (4) mentoring in leadership in interdisciplinary research in obstetric anesthesiology and perinatology. Successful completion of this research will form the basis for future R01 applications to validate the clinical effectivenes and cost-effectiveness of computerized predictive rules for severe PPH and to investigate individualized therapeutic strategies for EPA and other major peripartum morbidities.