Management strategy makes a difference in C-section rates, study finds

The business strategies adopted by physician practice management companies influence rates of Cesarean sections for low-risk patients.

Peer-Reviewed Publication

UNIVERSITY OF CALIFORNIA - BERKELEY HAAS SCHOOL OF BUSINESS

For physicians, it seems like a no-brainer: Management experts, often private equity firms, offer to take over the logistical and financial drudgery of their practices, leaving the doctors to focus on patient care.

A new Haas School of Business study found that the business strategies used by physician practice management companies (PPMCs) also impact patient care.

The study, published in the journal Management Science, examined the strategies adopted by PPMC-owned obstetrician and gynecologist practices and found they influenced rates of Cesarean sections for low-risk patients.

Specifically, OB-GYN practices acquired by PPMCs that focus on patient and clinical management lead to significantly lower rates of C-sections. PPMC-owned practices that focus on providing financial management services lead to higher C-section rates.

“Even though PPMCs say they preserve physician autonomy, managerial changes do appear to influence physician treatment choices,” said study author Ambar La Forgia, an assistant professor at the Haas School of Business, UC Berkeley.

Value-based management vs financial management

La Forgia tracked three PPMC-owned practices that together accounted for more than 40% of Florida’s OB-GYNs between 2006 to 2014. One PPMC focused on attracting “value” based contracts, which link payment to clinical performance by providing clinical management services, while two focused on raising revenue by providing financial management services and negotiating higher-paying fee-for-service contracts, which link payment to quantity of services.

C-sections are more profitable than vaginal births because insurance companies typically pay out more in reimbursements. So a rise in the number of C-sections can raise a red flag, causing doubts about whether some of those performed on mothers at low risk for childbirth complications are necessary. Unnecessary C-sections can increase risks for both mother and infant in a myriad of ways.

Divergence in C-section rates

La Forgia found a remarkable divergence: The OB-GYN practice that focused on clinical management cut C-sections for low-risk women by 22%. Those that focused on financial management showed a 10% to 11% rise in C-sections.

“What surprised me was finding that one of these for-profit management companies lowered C-sections,” La Forgia said. “It’s a pleasant surprise that leads to a more nuanced story to tell, because you can’t make a blanket statement about PPMCs.’”

La Forgia turned to Florida to track how physician practices performed after a PPMC takeover because public information laws include hospital discharge records that allowed her to link patient records to individual doctors and practices.

Low-risk mothers

The study concentrated on records for 1.26 million women who were at low risk for C-sections (defined as single live babies born after 37 weeks to women with no prior C-section and in the vertex, or headfirst, presentation). The births were overseen by 1,693 physicians, with C-section rates of 24% for low-risk patients.

La Forgia also hand-collected marketing materials to track and parse the details of a PPMC’s management approach. For example, the PPMC that focused on clinical management advertised providing clinical data tracking and analytics to help standardize care and attract value-based contracts. “This was a forward-looking strategy because it can take a while to improve quality and negotiate these types of contracts, especially since they were not very common within the time period of this study,” La Forgia said.

Another notable data point: the two financially managed PPMCs performed more C-sections on privately insured patients than those insured by Medicaid, the government insurance program that typically covers people with lower incomes. Florida, La Forgia notes, is one of the few states where Medicaid reimburses physicians at the same rate for C-sections and vaginal births.

Growing influence of PPMCs

In today’s healthcare landscape, physicians generally have the option to keep running their own practice, sell to a hospital, or sell to a PPMC. Why choose a PPMC over a hospital? Autonomy, La Forgia said. Under hospital ownership, doctors typically become salaried employees of the hospital.

“PPMCs advertise themselves as an alternative to hospitals while still being relatively independent and getting to stay in private practice,” La Forgia said. However, “This research shows that even PPMCs claiming to preserve physician autonomy can alter clinical outcomes for better or for worse.”

The influence of PPMCs on patient care has only increased in the years beyond those covered by this study, La Forgia writes. By 2019, the three PPMCs she examined delivered roughly 1 in every 25 babies in the United States.

“Although I find that PPMCs influence C-sections regardless of changes in competition, the PPMCs do amass considerable market power, and their growth may eventually lead to more salient anticompetitive effects,” La Forgia writes in the study.

La Forgia noted that in recent years there’s been a noticeable shift in philosophy among some PPMCs to pursue value-based contracts over fee-for-service contracts.

“In fact, a lot of the [PPMCs] that originally billed themselves as financial management companies have changed their offerings to focus more on population health once they saw that this is a potentially lucrative angle,” she said. “That may be a good sign for patients.”

Read the full paper:

The Impact of Management on Clinical Performance: Evidence from Physician Practice Management Companies
By Ambar La Forgia
Management Science, November 2022

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JOURNAL

Management Science

DOI

10.1287/mnsc.2022.4571 

METHOD OF RESEARCH

Data/statistical analysis

SUBJECT OF RESEARCH

People

ARTICLE TITLE

The Impact of Management on Clinical Performance: Evidence from Physician Practice Management Companies

Tackling crowd management in subways during pandemics

Sharon Di wins NSF grant to work with NYC’s MTA to develop machine learning and traffic models to optimize traffic flow during pandemics

Grant and Award Announcement

COLUMBIA UNIVERSITY SCHOOL OF ENGINEERING AND APPLIED SCIENCE

 

IMAGE: SHARON DI view more 

CREDIT: NA

Mass transit, and subways in particular, are essential to the economic viability and environmental sustainability of cities across the globe. But public transit was hit hard during the COVID pandemic and subways especially experienced substantial drops in ridership. Spurred on by a Columbia Engineering Transit Design Challenge in 2020, researchers from across the University have been collaborating on a project to strengthen both the preparedness and resilience of transit communities facing public health disasters.

The team, led by Civil Engineering Professor Sharon Di, recently won a $2,500,000 four-year grant from the National Science Foundation to tackle crowd management in subways. The project--”Preparing for Future Pandemics: Subway Crowd Management to Minimize Airborne Transmission of Respiratory Viruses”--is focused on developing a system for public transit communities, including riders, workers, and agencies, that will help transit riders to make informed decisions and adapt travel behavior accordingly and provide transit agencies engaged in planning and policymaking with recommendations for mitigating virus transmission risks to riders and workers. 

“We think our system, which we’re calling Way-CARE, will be transformative, especially for people in low-income communities who are among the most impacted by reduced accessibility to safer travel modes,” said Di, who is a leader in transportation management. “We expect our project to improve the social, economic, and environmental well-being of those who live, work, and travel within cities.” 

Credit: Kits Pix/Shutterstock

The team, which includes Co-PIs Jeffrey Shaman (Columbia Climate School; Mailman School of Public Health); Marco Giometto, Xiaofan Jiang, and Faye McNeill (Columbia Engineering); Ester Fuchs (School of International and Public Affairs); and Kai Ruggeri (Columbia University Irving Medical Center), is working with New York City’s Metropolitan Transportation Authority and local rider communities in Harlem and at Columbia on the Way-CARE project. They hope that their system will enable smart city transit operators to access real-time sensing information collected from subway stations and/or trains for crowd management.

The researchers are integrating sensing and crowd and airflow modeling with public health expertise on a microscale applied to subway crowd management. They are developing coupled airborne dispersion and epidemiological models that account for microscale processes--the transport of droplets and aerosols--that affect respiratory virus transmission. In addition, they are integrating behavioral science data that will help inform travel choices and policy making. 

“This is an important interdisciplinary collaboration,” said Shaman, an epidemiologist who is a leader in infectious disease modeling. “The transmission of respiratory viruses is not directly observed, and the microscale processes influencing infection risk are not well known. Our project will address these shortcomings by advancing understanding of the physical, biological, and behavioral features that enable transmission of respiratory viruses in subway settings, and equip transit officials and the public with real-time information that improves worker and rider safety.”

Pandemic’s many effects on older women documented in journal

Peer-Reviewed Publication

THE GERONTOLOGICAL SOCIETY OF AMERICA

A new supplemental issue to The Journals of Gerontology, Series A: Biological Sciences and Medical Sciences, titled “The Impact, Experience, and Challenges of COVID-19: The Women’s Health Initiative  (WHI),” explores key areas on how older women initially responded to the threat of COVID-19, their concerns about the pandemic, and aspects of their prior health and well-being that may have influenced the impact of COVID-19 on their lives. 

 

The WHI represents one of the largest and most diverse longitudinal studies conducted in postmenopausal women. Three decades after its 1992 launch, 52,543 women continue to be actively engaged in the core of this landmark study, with a mean age of 86.6 (ranging from 73 to 106 years of age). The WHI is funded by the National Heart, Lung, and Blood Institute; the journal supplement was made possible by support from Wake Forest University Health Sciences.

 

The supplement’s articles are based on survey research conducted among 49,695 WHI participants between June and October 2020. In addition to the data derived from the survey, authors were able to draw from detailed historical data available on the participants prior to the pandemic, as well as annual data collected concurrently with the COVID-19 survey. A follow-up survey was conducted from June to December 2021.

 

“The long history of participation preceding COVID-19 and continued participation in study activities during COVID-19 allowed for a deep characterization of the impact and experience among older women, while accounting for past and current individual health behaviors and outcomes,” wrote guest editors Sally A. Shumaker, PhD, Andrea Z. LaCroix, PhD, and Jennifer W. Bea, PhD.

 

The researchers’ findings showed that the COVID-19 pandemic was associated with impacts on health and well-being, living situations, lifestyle, health care access, and SARS-CoV-2 testing and preventive behaviors.

 

WHI participants were more likely to report very good or good levels of well-being, but in lower frequency in the fall of 2020 compared to the summer. Respondents reported being very concerned about the pandemic (more commonly reported among urban residents), with many participating in preventive behaviors including wearing a face mask (which were more commonly practiced in the summer compared to the fall).

 

The most common disruption in living arrangements included having family or friends move in, although a higher proportion of respondents in the fall compared to the summer reported moving into a care facility and/or having their care provider come to help. Many women reported changes in medication and health care access, which included delays in getting prescriptions filled and health care appointment conversions to telephone or online (the latter more commonly reported among urban residents).

 

There were notable changes in lifestyle factors; for example, over half of women reported less physical activity or exercise compared to before the pandemic, which was more commonly reported among women residing in urban areas. A lower proportion of women reported consuming alcohol compared to reports from prior to the COVID-19 pandemic.

 

“While the women in the WHI demonstrated remarkable resiliency overall, these findings help guide our response to those multifaceted social, psychological, and physical struggles and comorbidities that are not only associated with COVID-19 infection in an older population, but also with the societal and infrastructure barriers in the context of the COVID-19 era,” Shumaker, LaCroix, and Bea wrote. “As COVID-19 and our societal response to it evolves, it is important to continue to study the impact on high-risk groups, such as the older women in the WHI.”

 

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The Journals of Gerontology, Series A: Biological Sciences and Medical Sciences is a peer-reviewed publication of The Gerontological Society of America (GSA), the nation’s oldest and largest interdisciplinary organization devoted to research, education, and practice in the field of aging. The principal mission of the Society — and its 5,500+ members — is to advance the study of aging and disseminate information among scientists, decision makers, and the general public. GSA’s structure also includes a policy institute, the National Academy on an Aging Society.

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JOURNAL

The Journals of Gerontology Series A

Disclaimer: AAAS and EurekAlert! are not res

Critical care medicine organizations urge house leadership to stop Medicare payment cuts

Business Announcement

AMERICAN SOCIETY OF ANESTHESIOLOGIST

CHICAGO – Today, the American Society of Anesthesiologists (ASA), Society of Critical Care Anesthesiologists (SOCCA), and Society of Critical Care Medicine (SCCM) sent a formal communication to Speaker of the House of Representatives Nancy Pelosi, House Majority Leader Charles Schumer, and House Minority leaders Kevin McCarthy and Mitch McConnell, strongly urging them to take immediate action to stop pending Medicare physician payment cuts.

The medical organizations called on Congress to block all pending payment cuts for critical care services and the services of other physicians. Without congressional action, the cuts will be effective January 1, 2023.

“Critical care physicians provide advanced life support, specialized monitoring and sophisticated, high level medical care to patients with life-threatening health conditions,” said ASA President Michael W. Champeau, M.D., FASA. “It is essential the Congress support the health care leadership consistently demonstrated by these professionals.” 

“Congress must work to ensure that there is sufficient economic support, especially from Medicare, to ensure patients’ access to high-quality critical care services,” said SOCCA President Michael H. Wall, M.D., FCCM, FASA.

“In recent years, critical care medicine has been on the frontlines of the COVID-19 pandemic, caring for some of the most medically challenging patients seen since the critical care specialty was created, especially at-risk Medicare patients with multiple medical diseases or conditions in the high-risk environments,” according to SCCM President, Sandra L. Kane-Gill, PharmD, MSc, FCCM.

The communication notes that “Medicare payments for critical care services are already broken. Payment freezes and meager updates over the years have resulted in current payments rates that are insufficient. In the current economic environment of high inflation, this is even more true. We find it unthinkable that Congress is considering Medicare payment cuts for critical care and other physician services.”

Read the letter for details on critical care physician concerns about the proposed payment cuts.

ABOUT THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS
Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 56,000 members organized to raise and maintain the standards of the medical practice of anesthesiology. ASA is committed to ensuring physician anesthesiologists evaluate and supervise the medical care of patients before, during and after surgery to provide the highest quality and safest care every patient deserves.

For more information on the field of anesthesiology, visit the American Society of Anesthesiologists online at asahq.org. To learn more about the role physician anesthesiologists play in ensuring patient safety, visit asahq.org/madeforthismoment. Like ASA on Facebook and follow ASALifeline on Twitter.

ABOUT THE SOCIETY OF CRITICAL CARE ANESTHESIOLOGISTS
The Society of Critical Care Anesthesiologists is dedicated to the support and development of anesthesiologists who care for critically ill patients of all types. SOCCA fosters the knowledge and practice of critical care medicine by anesthesiologists through education, research, advocacy, and community.

For more information about SOCCA, please visit www.socca.org.

ABOUT THE SOCIETY OF CRITICAL CARE MEDICINE
The Society of Critical Care Medicine is the largest nonprofit medical organization dedicated to promoting excellence and consistency in the practice of critical care. With members in more than 100 countries, SCCM is the only organization that represents all professional components of the critical care team. The Society offers a variety of activities that ensure excellence in patient care, education, research, and advocacy. SCCM's mission is to secure the highest-quality care for all critically ill and injured patients.

For more information about SCCM, please visit the Society of Critical Care online at www.SCCM.ORG.
 

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Years of monarch research shows how adding habitat will help conservation

Peer-Reviewed Publication

IOWA STATE UNIVERSITY

 

IMAGE: PLANTING MILKWEED AND OTHER WILDFLOWERS IS ESSENTIAL TO SUPPORT POPULATION GROWTH FOR MONARCH BUTTERFLIES. A RECENTLY PUBLISHED JOURNAL ARTICLE FOCUSED ON THE PLACEMENT OF NEW MONARCH HABITAT PROVIDES AN OVERVIEW OF 20 IOWA STATE UNIVERSITY RESEARCH STUDIES. view more 

CREDIT: PHOTO BY JACQUELINE POHL.

AMES, Iowa – When the Iowa Monarch Conservation Consortium was formed seven years ago, Iowa State University researchers faced two big questions about reestablishing the milkweed and other wildflowers needed for the iconic butterfly’s survival: How can habitat be restored and where should it be located? 

The “how” of restoring habitat is outlined in the consortium’s guidelines for planting prairie. “Where” is the subject of a new peer-reviewed journal article that provides an overview of 20 ISU studies, as well as work by other monarch researchers. The paper, published in Bioscience earlier this month, synthesizes years of research that includes field observations, laboratory experiments and simulation modeling. The findings are largely optimistic.

Mobility helps

Establishing new habitat at the rates called for in Iowa’s conservation plan would increase the size of the monarch population by 10-25% per generation, depending on differing scenarios for pesticide use and the amount and location of habitat creation, researchers found.

“Basically, we’ve concluded that planting habitat anywhere you can in the agricultural landscapes of the Upper Midwest will support growth of the monarch’s breeding generations, even if some of that habitat is near crop fields treated with insecticides,” said Steven Bradbury, professor of natural resource ecology and management at Iowa State.

The higher range of estimated population growth assumes the use of integrated pest management practices and applying insecticides only when pests are likely to cause economically significant crop damage, Bradbury said. 

Establishing habitat next to crop fields where insecticides are used is expected to produce more monarchs than if prairie restoration is limited to locations set away from fields. A 100-125 feet buffer between treated fields and habitat patches would eliminate swaths of conservable land, Bradbury said – up to 80% of the non-crop land available in Story County, for instance. Forgoing that much space would make it difficult to add the 1.3-1.6 billion new milkweed stems needed in the Upper Midwest to support a sustainable monarch population. 

Insecticide spray drift from treated crops can pose risks to monarch caterpillars, which live exclusively on milkweed plants. However, the impact on the overall population is mitigated because females are highly mobile within their summer breeding grounds, Bradbury said.

“The females move around the landscape a lot. They don’t put all their eggs in one basket,” he said. 

While some portion of monarchs downwind from treated fields might have high rates of mortality, other eggs are laid in habitat patches that aren’t exposed to insecticides, Bradbury said. And the milkweed plants near treated fields can still support the next generation of adults.

Using radio transmitters to track female monarchs gave researchers better insight into their nonmigratory flight patterns. Monarchs ride wind currents to travel up to dozens of miles a day when migrating to and from the mountainous oyamel fir forests in Mexico, where they spend the winter. But breeding females also fly between patches of habitat when not migrating, in flights that can exceed a mile, researchers found. 

“They’re not migrating when they take these large flight steps, but they seem to turn on a behavior like migration,” Bradbury said. “The general notion was breeding females were moving around a lot to lay their eggs, but there hadn’t been any empirical studies that quantified their non-migratory movement patterns.”

That mobility is part of the reason modeling shows that monarch numbers will still increase if added habitat is fragmented. However, research suggests new plots of habitat of at least 6.2 acres that are situated closely, within 160 to 330 feet of each other, would offer maximal support

What’s ahead

Research and outreach are ongoing for the consortium, a diverse partnership of more than 45 organizations that includes Iowa State, the Iowa Department of Agriculture and Land Stewardship, the Iowa Department of Natural Resources, federal agencies, agriculture and conservation associations, and agribusiness and utility companies. But now is a good time to summarize the group’s research because it’s reached a natural point to pull the best available information together, Bradbury said. 

“Sometimes in a novel there is a series of chapters that comprise part 1. Our analogy is that we’ve reached the end of part 1,” he said.

There’s also a practical consideration, he said. The U.S. Fish and Wildlife Service will reconsider in 2024 if the monarch should be protected under the Endangered Species Act, and fact-finding for the decision likely will begin in 2023. It’s an ideal time to share an overview of new monarch research. 

Tasks ahead for researchers include collecting additional field data on egg-laying patterns and integrating ISU’s regional modeling with continental-level models to predict how habitat reestablished in the Upper Midwest will impact the size of the overwintering population in Mexico.

Research methods used by the Iowa State team also could be replicated in other areas where breeding monarchs reside in the summer. Though about half of the population that migrates to Mexico come from the Upper Midwest, monarchs’ other breeding destinations, such as New England and southern Ontario, have different climates and landscapes. 

The interdisciplinary and multilayered research doesn’t just benefit monarchs. It has offered numerous opportunities for undergraduate and graduate students to work on projects with a wide variety of stakeholders, Bradbury said.

“That’s a strength for a researcher. Working with landowners can help refine research questions and ensure results that help advance useful conservation practices,” he said.  

The collaborative nature of the consortium also serves as a blueprint for the co-existence of conservation and agricultural production in Iowa, Bradbury said.  

“Conserving the monarch is common ground that brings people together, and those are relationships we can use in addressing other challenges we face,” he said. 

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JOURNAL

BioScience

DOI

10.1093/biosci/biac094 

METHOD OF RESEARCH

Observational study

SUBJECT OF RESEARCH

Animals

ARTICLE TITLE

Monarch Butterfly Ecology, Behavior, and Vulnerabilities in North Central United States Agricultural Landscapes

Comet impacts could bring ingredients for life to Europa’s ocean

Peer-Reviewed Publication

UNIVERSITY OF TEXAS AT AUSTIN

 

IMAGE: A COMPUTER-GENERATED SIMULATION OF THE POST-IMPACT MELT CHAMBER OF MANANNAN CRATER, AN IMPACT CRATER ON EUROPA. THE SIMULATION SHOWS THE MELT WATER SINKING TO THE OCEAN WITHIN SEVERAL HUNDRED YEARS AFTER IMPACT. CARNAHAN ET AL. view more 

CREDIT: CARNAHAN ET AL.

Comet strikes on Jupiter’s moon Europa could help transport critical ingredients for life found on the moon’s surface to its hidden ocean of liquid water — even if the impacts don’t punch completely through the moon’s icy shell.  

The discovery comes from a study led by researchers at The University of Texas at Austin, where researchers developed a computer model to observe what happens after a comet or asteroid strikes the ice shell, which is estimated to be tens of kilometers thick.        

The model shows that if an impact can make it at least halfway through the moon’s ice shell, the heated meltwater it generates will sink through the rest of the ice, bringing oxidants — a class of chemicals required for life — from the surface to the ocean, where they could help sustain any potential life in the sheltered waters.  

The researchers compared the steady sinking of the massive melt chamber to a foundering ship.  

“Once you get enough water, you’re just going to sink,” said lead author and doctoral student Evan Carnahan. “It’s like the Titanic times 10.”  

Scientists have proposed impacts as a means to transport oxidants on Europa, but they assumed the strikes would have to break through the ice. This study is important because it suggests that a much larger range of impacts can do the job, said co-author Marc Hesse, a professor at the UT Jackson School of Geosciences Department of Geological Sciences.   

“This increases the probability that you would have the necessary chemical ingredients for life,” said Hesse, who is also a faculty member at the UT Oden Institute for Computational Engineering & Sciences. The study was published in Geophysical Research Letters.  

Whether oxidants can get from where they naturally form on Europa’s surface to the ocean is one of the biggest questions in planetary science. One of the goals of NASA’s upcoming Europa Clipper mission to the icy moon is to collect data that can help narrow down answers.  

For now, comet and asteroid impacts are among the most plausible mechanisms. Scientists have spotted dozens of craters on Europa’s surface, many with a distinct rippled appearance that suggests frozen meltwater and post-impact motion beneath the crater.  

This study models the crater environment after impact — investigating how meltwater travels through ice and its capacity for transporting oxidants. It builds on a previous study by co-author Rónadh Cox, a professor at Williams College, that modeled impacts breaking through Europa’s ice.  

The study found that if an impact reaches the ice shell’s midpoint, over 40% of the meltwater will make it to the ocean. The volume of melt water generated can be significant. For example, this study showed that a half-mile-wide comet that reaches the ice shell’s midpoint would melt enough water to fill Oregon’s Crater Lake. 

Other models describing meltwater on Europa often place it near the surface of the moon for long periods, where it could potentially contribute to icy formations called “chaos terrain.” But this study’s results complicate this idea, with the heavy weight of the meltwater causing it to sink rather than stay in place.  

“We’re cautioning against the idea that you could maintain very large volumes of melt in the shallow subsurface without it sinking,” Carnahan said.  

Like Europa, Saturn’s moon Titan may also hold an ocean of liquid water beneath an icy shell. Rosaly Lopes, the directorate scientist for the Planetary Science Directorate at NASA’s Jet Propulsion Laboratory (JPL), said that this model can help scientists understand the role impacts might have on other icy worlds.    

“In the case of Titan, this is very important because Titan has a thick ice crust — thicker than Europa’s,” she said. “We’re really interested in the application of this study.” 

Carnahan began the research during an internship at NASA JPL, working with co-author Steven Vance and completed it working with Hesse while earning his master’s degree. He is now a doctoral student at the UT Cockrell School of Engineering.   

The UT Center for Planetary Systems Habitability, the Texas Space Grant Consortium Fellowship and NASA funded the research.  

An artist's concept of a comet or asteroid impact on Jupiter's moon Europa. Credit: NASA/JPL-Caltech

CREDIT

NASA/JPL-Caltech

Tyre, a large impact crater on Europa.

CREDIT

NASA/JPL/DLR

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JOURNAL

Geophysical Research Letters

ARTICLE TITLE

Surface-To-Ocean Exchange by the Sinking of Impact Generated Melt Chambers on Europa

ARTICLE PUBLICATION DATE

28-Dec-2022

THE LANCET GLOBAL HEALTH: Cervical cancer burden remains high in many countries, scale-up needed to meet WHO’s 2030 elimination target

Peer-Reviewed Publication

THE LANCET

Peer-reviewed / Observational study / People

• Incidence rates of cervical cancer in most countries remain much higher than the threshold set by WHO of 4 per 100,000 women to consider cervical cancer eliminated as a public health problem.
• Globally in 2020, there were over 600,000 estimated new cervical cancer cases and over 340,000 resulting deaths.
• Persistently high rates of cervical cancer in LMICs and recent increases in countries in Eastern Europe and sub-Saharan Africa are of particular concern.
• Targets to to reach the WHO elimination threshold by 2030 will be missed unless countries scale up screening programmes, improve coverage of HPV vaccination and improve access to affordable treatment. 

There were over 600,000 new cases of cervical cancer and over 340,000 deaths worldwide in 2020, according to an observational study published in The Lancet Global Health journal.

Although cervical cancer has decreased in many world regions over the past three decades⁠—notably in Latin America, Asia, western Europe and North America—the burden remains high in many low- and middle-income countries. 

The development of effective HPV vaccination and screening programmes have made cervical cancer a largely preventable disease. In 2020, the World Health Organisation (WHO) announced a target to accelerate the elimination of cervical cancer as a public health problem, aiming to reduce incidence below a threshold of four cases per 100,000 women per year in every country by 2030. This study tracks the progress on cervical cancer rates and identifies the countries and regions where efforts require scaling up to reach WHO targets. 

Dr Deependra Singh, International Agency for Research on Cancer (IARC) / WHO, France, says “HPV vaccination and screening technologies mean that cervical cancer is now largely preventable. Our study finds encouraging decreases in some high-income countries following successful implementation of HPV vaccination programmes and screening—such as in Sweden, Australia, and the UK—but globally the burden remains high. All over the world, women should be free from the risk of preventable cancer, and with development of effective vaccines and screening over the past 20 years, we have the tools to make this a reality.” [1]

The study used IARC’s GLOBOCAN 2020 database to estimate the burden of cervical cancer incidence and mortality rates in 185 countries. Additionally, the study analysed the relationship between cervical cancer cases and deaths in relation to national levels of socioeconomic development. Finally, the authors looked at data from 1988 to 2017 to identify increase and decrease trends. 

In 2020, rates of cervical cancer cases were 13 per 100,000 women per year and there were seven deaths per 100,000 women per year. Incidence rates in 172 out of 185 countries, still exceeded the four cases per 100,000 women per year threshold for elimination set by WHO. 

Rates varied significantly between countries, with a 40 times difference in cases and 50 times difference in deaths. Case rates ranged from two cases in Iraq to 84 cases in Eswatini per 100,000 women per year; while mortality rates ranged from one death in Switzerland to 56 deaths in Eswatini per 100,000 women per year. 

There was substantial socioeconomic inequality in cervical cancer globally. There was a clear socioeconomic gradient in incidence and mortality, with higher rates observed in countries with lower socioeconomic development. 

When looking at the trend data from 1988 to 2017, the authors observed major declines in cases in some Latin American countries, including Brazil, Colombia, and Costa Rica. A similar pattern was observed in Asia in India, Thailand, and South Korea, as well as in Eastern Europe in Poland, Slovenia, and Czechia. However, there were increases in cases in Eastern Europe, in Latvia, Lithuania, and Bulgaria, and Eastern Africa in the past decade, as well as in The Netherlands and Italy. The reasons for recent increases might include increased prevalence of HPV among the younger generations of women and lack of effective screening programmes.

Countries with the largest average declines in incidence rates per year included Brazil (8%), Slovenia (7%), Kuwait (7%), and Chile (6%); whereas the highest increases in rates were in Latvia (4%), Japan (3%), Ireland (3%), Sweden (3%), Norway (2%), Northern Ireland (2%), Estonia (2%), and China (2%).

Dr Valentina Lorenzoni, Scuola Superiore Sant’Anna, Italy, says, “Cervical cancer cases are much higher than the threshold agreed by the WHO initiative on cervical cancer elimination in most countries, indicating that there is still much work to be done before 2030. While a decrease in screening intensity due to the COVID-19 pandemic might have left a new group of susceptible women, the pandemic also boosted the introduction of self-administered HPV testing, offering new possibilities to increase screening coverage. Other new advancements, such as thermal ablation for treating cervical pre-cancer, the use of mobile phones to improve follow-up after screening, and machine learning to improve visual assessment, can also be used in low resource settings to lower cervical cancer rates.” [1]

Finally, the authors note that the estimates were based on the best available cancer data in each country, but caution that these may be incomplete or inaccurate. For instance, cases may appear low in countries where there are no effective screening programmes or there is limited local population-based cancer registry data available. 

NOTES TO EDITORS

This study was funded by Horizon 2020 Framework Programme for Research and Innovation of the European Commission. D. Singh was supported by the French Institut National du Cancer (INCa). It was conducted by researchers from International Agency for Research on Cancer; Scuola Superiore Sant’Anna, Italy; US National Cancer Institute, USA; Scientific Institute of Public Health, Belgium; University of Ghent, Belgium. 

[1] Quote direct from author and cannot be found in the text of the Article.

The labels have been added to this press release as part of a project run by the Academy of Medical Sciences seeking to improve the communication of evidence. For more information, please see: http://www.sciencemediacentre.org/wp-content/uploads/2018/01/AMS-press-release-labelling-system-GUIDANCE.pdf if you have any questions or feedback, please contact The Lancet press office pressoffice@lancet.com  
 

IF YOU WISH TO PROVIDE A LINK FOR YOUR READERS, PLEASE USE THE FOLLOWING, WHICH WILL GO LIVE AT THE TIME THE EMBARGO LIFTS: http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(22)00501-0/fulltext

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JOURNAL

The Lancet Global Health

METHOD OF RESEARCH

Observational study

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Global estimates of incidence and mortality of cervical cancer in 2020: a baseline analysis of the WHO Global Cervical Cancer Elimination Initiative

ARTICLE PUBLICATION DATE

14-Dec-2022

COI STATEMENT

We declare no competing interests. Where authors are identified as personnel of the International Agency for Research on Cancer/WHO, the authors alone are responsible for the views expressed in this article, and they do not necessarily represent the decisions, policy, or views of the International Agency for Research on Cancer/WHO. Where authors are identified as personnel of US National Cancer Institute, the opinions expressed are their own and this material should not be interpreted as representing the official viewpoint of the US Department of Health and Human Services, the National Institutes of Health, or the National Cancer Institute.

Machine learning reveals how black holes grow

Leveraging supercomputing power, University of Arizona researchers created simulations of millions of computer-generated "universes" to test astrophysical predictions that have eluded astronomical observations.

Peer-Reviewed Publication

UNIVERSITY OF ARIZONA

 

IMAGE: HOW IT WORKS: USING TRIAL AND ERROR, MACHINE LEARNING TESTS MANY DIFFERENT PAIRINGS OF SIMULATED GALAXIES AND BLACK HOLES CREATED USING DIFFERENT RULES, AND THEN CHOOSES THE PAIRING THAT BEST MATCHES ACTUAL ASTRONOMICAL OBSERVATIONS. view more 

CREDIT: H. ZHANG, WIELGUS ET AL. (2020), ESA/HUBBLE & NASA, A. BELLINI

As different as they may seem, black holes and Las Vegas have one thing in common: What happens there stays there – much to the frustration of astrophysicists trying to understand how, when and why black holes form and grow. Black holes are surrounded by a mysterious, invisible layer – the event horizon – from which nothing can escape, be it matter, light or information. The event horizon swallows every bit of evidence about the black hole's past.

"Because of these physical facts, it had been thought impossible to measure how black holes formed," said Peter Behroozi, an associate professor at the University of Arizona Steward Observatory and a project researcher at the National Astronomical Observatory of Japan.

Together with Haowen Zhang, a doctoral student at Steward, Behroozi led an international team to use machine learning and supercomputers to reconstruct the growth histories of black holes, effectively peeling back their event horizons to reveal what lies beyond.

Simulations of millions of computer-generated "universes" revealed that supermassive black holes grow in lockstep with their host galaxies. This had been suspected for 20 years, but scientists had not been able to confirm this relationship until now. A paper with the team’s findings has been published in Monthly Notices of the Royal Astronomical Society.

"If you go back to earlier and earlier times in the universe, you find that exactly the same relationship was present," said Behroozi, a co-author on the paper. "So, as the galaxy grows from small to large, its black hole, too, is growing from small to large, in exactly the same way as we see in galaxies today all across the universe."

Most, if not all, galaxies scattered throughout the cosmos are thought to harbor a supermassive black hole at their center. These black holes pack masses greater than 100,000 times that of the sun, with some boasting millions, even billions of solar masses. One of astrophysics' most vexing questions has been how these behemoths grow as fast they do, and how they form in the first place.

To find answers, Zhang, Behroozi and their colleagues created Trinity, a platform that uses a novel form of machine learning capable of generating millions of different universes on a supercomputer, each of which obeys different physical theories for how galaxies should form. The researchers built a framework in which computers propose new rules for how supermassive black holes grow over time. They then used those rules to simulate the growth of billions of black holes in a virtual universe and "observed" the virtual universe to test whether it agreed with decades of actual observations of black holes across the real universe. After millions of proposed and rejected rule sets, the computers settled on rules that best described existing observations.

"We're trying to understand the rules of how galaxies form," Behroozi said. "In a nutshell, we make Trinity guess what the physical laws may be and let them go in a simulated universe and see how that universe turns out. Does it look anything like the real one or not?"

According to the researchers, this approach works equally well for anything else inside of the universe, not just galaxies.

The project's name, Trinity, is in reference to its three main areas of study: galaxies, their supermassive black holes and their dark matter halos – vast cocoons of dark matter that are invisible to direct measurements but whose existence is necessary to explain the physical characteristics of galaxies everywhere. In previous studies, the researchers used an earlier version of their framework, called the UniverseMachine, to simulate millions of galaxies and their dark matter halos. The team discovered that galaxies growing in their dark matter halos follow a very specific relationship between the mass of the halo and the mass of the galaxy.

"In our new work, we added black holes to this relationship," Behroozi said, "and then asked how black holes could grow in those galaxies to reproduce all the observations people have made about them."

"We have very good observations of black hole masses," said Zhang, the paper's lead author. "However, those are largely restricted to the local universe. As you look farther away, it becomes increasingly difficult, and eventually impossible, to accurately measure the relationships between the masses of black holes and their host galaxies. Because of that uncertainty, observations can't directly tell us whether that relationship holds up throughout the universe."

Trinity allows astrophysicists to sidestep not only that limitation, but also the event horizon information barrier for individual black holes by stitching together information from millions of observed black holes at different stages of their growth. Even though no individual black hole's history could be reconstructed, the researchers could measure the average growth history of all black holes taken together.

"If you put black holes into the simulated galaxies and enter rules about how they grow, you can compare the resulting universe to all the observations of actual black holes that we have," Zhang said. "We can then reconstruct how any black hole and galaxy in the universe looked from today back to the very beginning of the cosmos."

The simulations shed light on another puzzling phenomenon: Supermassive black holes – like the one found in the center of the Milky Way – grew most vigorously during their infancy, when the universe was only a few billion years old, only to slow down dramatically during the ensuing time, over the last 10 billion years or so.

"We've known for a while that galaxies have this strange behavior, where they reach a peak in their rate of forming new stars, then it dwindles over time, and then, later on, they stop forming stars altogether," Behroozi said. "Now, we've been able to show that black holes do the same: growing and shutting off at the same times as their host galaxies. This confirms a decades-old hypothesis about black hole growth in galaxies."

However, the result poses more questions, he added. Black holes are much smaller than the galaxies in which they live. If the Milky Way were scaled down to the size of Earth, its supermassive black hole would be the size of the period at the end of this sentence.

For the black hole to double in mass within the same timeframe as the larger galaxy requires synchronization between gas flows at vastly different scales. How black holes conspire with galaxies to achieve this balance is yet to be understood.

"I think the really original thing about Trinity is that it provides us with a way to find out what kind of connections between black holes and galaxies are consistent with a wide variety of different datasets and observational methods," Zhang said. "The algorithm allows us to pick out precisely those relationships between dark matter halos, galaxies and black holes that are able to reproduce all the observations that have been made. It basically tells us, 'OK, given all these data, we know the connection between galaxies and black holes must look like this, rather than like that.' And that approach is extremely powerful."

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JOURNAL

Monthly Notices of the Royal Astronomical Society

DOI

10.1093/mnras/stac2633 

METHOD OF RESEARCH

Data/statistical analysis

SUBJECT OF RESEARCH

Not applicable

ARTICLE TITLE

TRINITY I: self-consistently modelling the dark matter halo–galaxy–supermassive black hole connection from z = 0–10