Managing drug-resistant essential menorrhagia without hysterectomy

Menorrhagia is a common disorder that requires plenty of resources. Rapid developments in medical technology have resulted in new management strategies, which are true alternatives to hysterectomy. In many countries the levonorgestrel-releasing intrauterine system (LNG-IUS) and endometrial destruction techniques are available for menorrhagia. Clinicians must answer questions about cost, effectiveness and quality of medical care when choosing the treatment option. This review integrates the results from the latest studies and review articles about LNG-IUS and endometrial destruction techniques by addressing the key clinical issues in menorrhagia. Both LNG-IUS and endometrial ablation seem to be good and effective alternative options to hysterectomy. Although these treatments have relatively high failure rates, the majority of women are satisfied and the cost-effectiveness of these treatments are better than that of hysterectomy. Both treatments have their advantages and disadvantages. Thus far LNG-IUS seems to be more cost-effective than endometrial resection or hysterectomy at 5 years follow-up. However, second generation ablation techniques may offer better cost-effectiveness than the first generation techniques, but the evidence is insufficient.

Quality of life and cost for patients with premature ventricular contractions by radiofrequency catheter ablation

OBJECTIVE

To evaluate the quality of life (QoL), health-care resource utilization, and cost for the patients with premature ventricular contractions (PVCs) by radiofrequency catheter ablation (RFCA).

METHODS

RFCA was performed in 58 patients with symptomatic PVCs that were refractory/easy to medication. A 24-hour ambulatory electrocardiographic monitoring, QoL, health-care resources utilization, and cost were assessed at a screening visit and 3 and 12 months after RFCA.

RESULTS

RFCA was successfully performed in 56 patients (96.6%). This resulted in a significant improvement in the QoL at 3 and 12 months after the procedure. There were no major complications related to the procedure. Nine patients (15.5%) had residual arrhythmia. Seven of them underwent repeated ablation with successful results. It also improved the QoL and reduced health-care resource utilization and cost.

CONCLUSIONS

RFCA is a safe and effective treatment for PVCs, and it is a viable alternative to drugs in the presence of disabling symptoms.

Radiofrequency catheter ablation of supraventricular tachycardia in children and adolescents : feasibility and cost-effectiveness in a low-income country

The objective of this study is to provide results and costs of catheter ablation in children and adolescents in a low-income country. Reports from first-world countries have demonstrated the cost-effectiveness of radiofrequency catheter ablation (RFCA) compared to medical treatment of supraventricular tachycardia (SVT). The study included 28 patients younger than 18 years of age with SVT in a pediatric cardiology unit in Guatemala. All patients underwent RFCA. Clinical outcome and cost-effectiveness of RFCA compared to continued medical treatment were the end points. Twenty-four patients had successful ablation (85.7%). Mean age at RFCA was 11.42 +/- 3.49 years. Three patients underwent a second ablation, increasing the success rate to 96.4%. One remaining patient is awaiting a second procedure. At a mean follow-up of 13.69 +/- 7.16 months, all 27 patients who had a successful ablation remained in sinus rhythm. Mean cost per procedure was 4.9 times higher than that of medical treatment. However, the estimated cost of catheter ablation equal that of medical therapy after 5.1 years and is 3.4 times less after 20 years. Radiofrequency catheter ablation of SVT in children and adolescents is safe and cost-effective compared to medical therapy. Resources must be judiciously allocated, especially in low-income countries, to treat the largest number of pediatric patients.

Cost-effectiveness of treatments for dysfunctional uterine bleeding

OBJECTIVE

To compare the cost-effectiveness of treatments for dysfunctional uterine bleeding (DUB).

STUDY DESIGN

The decision analytic model used a third-party payer perspective and 18-month horizon to compare treatment of DUB patients > or = 40 years old with no desire for fertility. Treatments were oral contraceptives (OCs) vs. surgery (first-/second-generation ablation or hysterectomy) after 3-9 months of OCs. Costs were based on publications and expert opinion. Efficacy measures were based on months with pictorial blood loss assessment chart (PBAC) score < 100 and number of months of amenorrhea.

RESULTS

Treatment costs were estimated at 513 dollars per patient per year (OCs), 3,500 dollars (first-generation ablation), 3,000 dollars (second-generation ablation) and 7,500 dollars (hysterectomy). Adverse event costs ranged from 12 dollars per year or episode (OCs, second-generation ablation) to 164 dollars per episode (hysterectomy). To achieve PBAC < 100, second-generation ablation after 3 months of OCs was the most cost-effective (7.6 additional DUB-free months vs. OCs, 215 dollars per additional month). Second-generation ablation was less costly and more effective than first-generation ablation. Early treatment with hysterectomy was more effective than ablation, but at substantial cost. When using the end point of amenorrhea, hysterectomy was most cost-effective. Results were not sensitive to variations in costs, effectiveness or length of OC use.

CONCLUSION

A short OC trial followed by second-generation ablation is the most cost-effective strategy for women with DUB, although hysterectomy is more cost-effective to achieve amenorrhea. Hysterectomy cost-effectiveness might improve if evaluated over more time. Cost-effectiveness and patient preference must all play a role in treatment decisions.

Cost-effectiveness of radiofrequency catheter ablation for atrial fibrillation

OBJECTIVES

We sought to compare the cost-effectiveness of left atrial catheter ablation (LACA), amiodarone, and rate control therapy in the management of atrial fibrillation (AF).

BACKGROUND

Left atrial catheter ablation has been performed to eliminate AF, but its cost-effectiveness is unknown.

METHODS

We developed a decision-analytic model to evaluate the cost-effectiveness of LACA in 55- and 65-year-old cohorts with AF at moderate and low stroke risk. Costs, health utilities, and transition probabilities were derived from published literature and Medicare data. We performed primary threshold analyses to determine the minimum level of LACA efficacy and stroke risk reduction needed to make LACA cost-effective at 50,000 dollars and 100,000 dollars per quality-adjusted life-year (QALY) thresholds.

RESULTS

In 65-year-old subjects with AF at moderate stroke risk, relative reduction in stroke risk with an 80% LACA efficacy rate for sinus rhythm restoration would need to be > or =42% and > or =11% to yield incremental cost-effectiveness ratios (ICERs) <50,000 dollars and 100,000 dollars per QALY, respectively. Higher and lower LACA efficacy rates would require correspondingly lower and higher stroke risk reduction for equivalent ICER thresholds. In the 55-year-old moderate stroke risk cohort, lower LACA efficacy rates or stroke risk reduction would be needed for the same ICER thresholds. In patients at low stroke risk, LACA was unlikely to be cost-effective.

CONCLUSIONS

The use of LACA may be cost-effective in patients with AF at moderate risk for stroke, but it is not cost-effective in low-risk patients. Our threshold analyses may provide a framework for the design of future clinical trials by providing effect size estimates for LACA efficacy needed.

Elective Percutaneous Coronary Intervention Without On-Site Cardiac Surgery

BACKGROUND

Low procedural complication rates, barriers to access, and patient preference have encouraged the development of percutaneous coronary intervention (PCI) programs at centers that are often closer to home but without on-site cardiac surgical capability.

OBJECTIVES

We compared clinical and economic outcomes associated with performing low-risk elective PCI at a community hospital without on-site cardiac surgery with those obtained at a more remote tertiary care center with on-site cardiac surgery.

DESIGN AND MEASURES

We matched 257 patients undergoing low-risk, elective PCI at a community hospital (Immanuel St. Joseph's Hospital [ISJ] between January 27, 2000, and July 31, 2002) to 514 PCI patients treated at a tertiary care hospital (Saint Marys Hospital [SMH] between January 27, 2000, and April 30, 2002) based on clinical and lesion criteria. Clinical outcomes (in-hospital procedural success and target vessel failure during long-term follow up) and economic outcomes (direct medical costs, billed charges, and hospital length of stay [LOS]) were compared between groups. The Mayo Clinic PCI Registry (containing clinical, angiographic, and follow-up data) and administrative data were used in matching and outcomes assessment.

RESULTS

Procedural success was achieved more often among ISJ-treated patients (99% vs. 95%; P = 0.02); however, no difference in target vessel failure rates was observed during a median follow-up time of 3.1 years (estimated 1-year event rate: 15.2% vs. 14.8%; P = 0.46). ISJ-treated patients incurred, on average, $3024 more in estimated total costs ($13,771 vs. $10,746; P < 0.001) and $6084 more in billed charges (P < 0.001), but incurred similar LOS post procedure (1.53 days).

CONCLUSIONS

Similar clinical outcomes were achieved at a community hospital without on-site cardiac surgery but at significantly increased direct medical cost. Patients, providers, hospitals, payers, and policymakers should consider whether the benefits associated with locally provided specialized cardiovascular services warrant this additional cost.

Radiofrequency ablation in the treatment of kidney cancer

(1) The standard approach for the treatment of kidney (renal) cancer is radical or partial nephrectomy (removal of the kidney). (2) Radiofrequency ablation (RFA), a less invasive approach, is an option for the treatment of small tumours, and in cases where surgery is contraindicated. (3) Its safety and efficacy compare favourably with those of other approaches. (4) The persistence of residual tumour is a disadvantage of earlier versions of the technology. The use of more powerful radiofrequency (RF) generators may reduce such persistence, but definitive evidence is unavailable. (5) Experience with this application of the technology is limited. Longer follow-up of patients is required to provide an adequate comparison with nephrectomy.

[Osteoid osteoma and radiofrequency]

Osteoid osteoma and radiofrequency Osteoid osteoma relates to a benign skeletal neoplasm, smaller than 2 cm in diameter, composed of osteoid, highly vascularized connective tissue and surrounded by a ring of bone sclerosis. Its aetiology remains unknown. It affects twice more males than female patients and occurs usually between 5 and 40 years old. Long bones and spine are the most involved areas but the whole skeleton can be involved. Clinical manifestations can include local pain (increased at night and decreased by activity) and relief with salicylates administration. CT guided radiofrequency ablation of osteoid osteoma is in comparison to surgery less invasive, time saving and economic technique with excellent long term results.

Rate versus rhythm control in the management of patients with atrial fibrillation

The management of patients with atrial fibrillation involves three main areas: anticoagulation, rate control and rhythm control. Importantly, these are not mutually exclusive of each other. Anticoagulation is necessary for patients who are at a high risk of stroke; for example, those who are older than 75 years, or those who have hypertension, severe left ventricular dysfunction, previous cerebrovascular events, or diabetes. It is now clear that patients who are at a high risk of stroke require long-term anticoagulation with warfarin regardless of whether a rate-control or rhythm-control strategy is chosen. One possible exception might be patients who are apparently cured with catheter ablation. Several published trials comparing rate-control and rhythm-control strategies for the treatment of patients with atrial fibrillation have shown no difference in mortality between these approaches. The patients enrolled in these studies were typically over 65 years of age. Data comparing rate and rhythm strategies in patients who are younger than 60 years of age are limited. For more elderly patients, it seems reasonable to consider rate control as a primary treatment option and to reserve rhythm control for those who do not respond to rate control. For younger patients, we prefer to start with a rhythm-control approach and to reserve rate-control approaches for patients in whom antiarrhythmic drugs, ablation, or both, do not ameliorate the symptoms.

A randomised controlled trial of microwave endometrial ablation without endometrial preparation in the outpatient setting: patient acceptability, treatment outcome and costs

OBJECTIVE

To compare outpatient microwave endometrial ablation (MEA) in the postmenstrual phase to standard MEA treatment after drug preparation in a day case theatre environment.

DESIGN

A randomised controlled trial.

SETTING

A large United Kingdom teaching hospital.

POPULATION

Two hundred and ten women complaining of excessive menstrual loss.

METHODS

Two hundred and ten women with excessive menstrual loss were randomised. Ninety-seven women were treated as outpatients in the immediate post-menstrual phase and 100 were treated in an operating theatre after hormonal preparation. All procedures were commenced under local anaesthesia with or without conscious sedation. Analysis was by modified intention to treat.

MAIN OUTCOME MEASURES

Primary outcome measures were satisfaction with treatment (measured at one year) and acceptability of treatment (measured at two weeks). Secondary outcome measures were menstrual outcome and financial cost.

RESULTS

Significantly more women found treatment post-menses acceptable; 86 (89.5%) versus 76 (76.0%) [difference in proportions 13.6%, 95% CI (3.0%, 23.9%)]. Similar numbers in each arm were totally or generally satisfied with the treatment, 86 (92.5%) versus 84 (88.4%) [difference in proportions 4.1%, 95% CI (-4.7%, 12.9%)] while amenorrhoea rates at one year were comparable, 52 (55.9%) versus 60 (61.9%). [difference in proportions -5.9%, 95% CI (-19.8%, 7.6%)]. The mean health service costs were 124 pounds (95% CI 86-194 pounds) lower for the patients in the post-menses group.

CONCLUSION

MEA performed under local anaesthesia (with or without conscious sedation) in the post-menstrual phase achieves high levels of satisfaction is very acceptable to patients and results in significantly reduced health service costs. Importantly menstrual outcomes are not affected by omission of drug preparation. There is now good evidence to support the use of MEA, without drug endometrial preparation, in the outpatient setting.

Endoscopic ablation of dysplastic Barrett's oesophagus comparing argon plasma coagulation and photodynamic therapy: a randomized prospective trial assessing efficacy and cost-effectiveness

OBJECTIVE

Endoscopic mucosal ablation is a promising technique that is used to treat dysplastic Barrett's oesophagus. The purpose of this study was to investigate the efficacy and cost-effectiveness of two promising techniques, argon plasma coagulation (APC) and photodynamic therapy (PDT), in the ablation of dysplastic Barrett's oesophagus.

MATERIALS AND METHODS

Twenty-six patients with dysplastic Barrett's oesophagus (21 M, median age 60 years, median length 4 cm, 23 low-grade dysplasia (LGD), 3 high-grade dysplasia (HGD)) were randomized to APC: 13 patients, PDT: 13 patients. APC was performed at a power setting of 65 W and argon gas flow at 1.8 l/min in 1-6 sessions (mean 5). PDT was performed 48 h after intravenous injection of Photofrin 2 mg/kg with a 630 nm red laser light, 200 J/cm through a PDT balloon in one session. All patients received treatment with high-dose proton pump inhibitors. Cost analysis was undertaken and the results were assessed by endoscopy and biopsies at 4 months and 12 months after therapy.

RESULTS

All patients in both groups showed a reduction in the length of Barrett's oesophagus. The median length of Barrett's oesophagus eradicated at the 4-month follow-up: APC 65%, PDT 57% and at the 12-month follow-up: APC 56%, PDT 60%. Dysplasia eradication at 4 months: APC 62%, PDT 77%, p = 0.03 (95% CI 0.66-0.96) and at 12 months APC 67%, PDT 77%. Buried columnar glands with intestinal metaplasia were seen in both groups, with one patient in the PDT arm developing adenocarcioma under the neo-squamous epithelium. Severe adverse events included APC 2/13 (15%) stricture, 1/13 (8%) odynophagia, chest pain and fever; PDT 2/13 (15%) photosensitivity, 2/13 (15%) stricture. PDT would cost an additional 266 pounds sterling for every percentage reduction in Barrett's length and 146 pounds sterling per percentage reduction in dysplasia compared with APC treatment.

CONCLUSIONS

APC and PDT are equally effective in eradicating Barrett's mucosa, with PDT being the more expensive treatment. However, PDT is more effective in eradicating dysplasia and the extra benefits of PDT are generated at an extra cost. The occurrence of buried columnar glands and carcinoma warrants caution. Long-term follow-up is needed to assess cancer prevention and the durability of the neo-squamous epithelium to justify these interventions.

MRI-guided focused ultrasound treatment of uterine fibroids

Magnetic resonance imaging-guided focused ultrasound (MRI-FUS) is a minimally invasive alternative to surgical and less invasive treatments for uterine fibroids. Early results from small sample studies indicate that the procedure may provide short-term symptom relief with advantages such as shorter recovery time. Few occurrences of major adverse events are reported. Little information is available on the costs or comparisons with other treatments. Long-term studies of larger patient groups are needed to provide further reliable evidence on the safety of this procedure, as well as its clinical and cost-effectiveness.

A cost comparison of nephron-sparing surgical techniques for renal tumour

OBJECTIVE

To compare costs associated with open partial nephrectomy (OPN), laparoscopic PN (LPN) and percutaneous radiofrequency ablation (PRF) in consecutive patients undergoing nephron-sparing surgery.

PATIENTS AND METHODS

The charts and costs were reviewed for all 46 patients undergoing nephron-sparing PN at our institution from March 2003 to March 2004. Clinical characteristics, operative techniques, radiographic and pathological information were recorded. Detailed cost information for room and board, laboratory, pharmacy, radiology, operating room, surgical supplies, anaesthesia, recovery room, electrocardiography and respiratory services were obtained from our institution.

RESULTS

The hospital stay was significantly shorter for PRF (0.5 days) than either LPN (1.86) and OPN (4.94). PRF was statistically less costly than LPN and OPN, with mean (sd) costs of (US dollars) 4454 (938), 7013 (934) and 7767 (1605). There was no significant difference in cost between LPN and OPN. Surgical supply costs were significantly higher for LPN and PRF than OPN. LPN had less than a third of the room and board costs of OPN (P < 0.001). Decreases in room and board were also associated with lower pharmacy and laboratory costs.

CONCLUSIONS

PRF is significantly less costly than LPN and OPN; LPN is cost-equivalent to OPN as the shorter stay compensates for significantly higher surgical supply costs. In those patients with tumours of appropriate size and location, minimally invasive approaches can decrease the morbidity, with cost benefits.

Catheter interventions for congenital heart disease in third world countries

The term "Third World" loosely encompasses a group of middle- and low-income countries. Considerable differences exist in health care delivery and health indices among these countries. The vast majority of children in the Third World do not have health insurance for congential heart disease (CHD). Catheter interventions for CHD are expensive because of installation costs of expensive biplane equipment, the requirement of dedicated personnel, and the need to stock a large inventory of expensive hardware. As a result, many catheter intervention procedures are beyond the reach of the average patient in the developing world. The following cost-effective strategies have evolved in selected institutions that have attempted to perform catheter interventions for CHD at an affordable cost: sharing of space, equipment, and support personnel with a busy adult cardiology program; use of single plane equipment; the development of sedation protocols to reduce the need for anesthesiologists; strategies to reduce procedure time; reuse of hardware through ethylene oxide sterilization; improvisations to use adult hardware items for CHD interventions; judicious case selection; and improvised alternatives to occlusive devices. These strategies may help reduce costs and allow a larger proportion of patients in developing countries with CHD to undergo interventions. However, the safety of these strategies and the cost savings need to be carefully evaluated prospectively.

Atrial Septal Defect Treatment Options

Atrial septal defects have traditionally been repaired by surgical closure. Recently, transcatheter device closure has increasingly been used with excellent results. Although there is limited comparative research evaluating long-term outcomes of the transcatheter technique, preliminary data reveal significantly fewer complications and shorter hospital stays than those reported for surgical repair. This article reviews relevant literature comparing efficacy, cost, and complications of the transcatheter device procedures with the surgical closure of ASDs.

Metastatic Colorectal Carcinoma: Cost-effectiveness of Percutaneous Radiofrequency Ablation versus That of Hepatic Resection

PURPOSE

To evaluate the relative cost-effectiveness of radiofrequency (RF) ablation and hepatic resection in patients with metachronous liver metastases from colorectal carcinoma (CRC) and compare the outcomes, cost, and cost-effectiveness of a variety of treatment and follow-up strategies.

MATERIALS AND METHODS

A state-transition decision model for evaluating the (societal) cost-effectiveness of RF ablation and hepatic resection in patients with CRC liver metastases was developed. The model tracks the presence, number, size, location, growth, detection, and removal of up to 15 individual metastases in each patient. Survival, quality of life, and cost are predicted on the basis of disease extent. Imaging, ablation, and resection affect outcomes through detection and elimination of individual metastases. Several patient care strategies were developed and compared on the basis of cost, effectiveness, and incremental cost-effectiveness (expressed as dollars per quality-adjusted life-year [QALY]). Extensive sensitivity analysis was performed to evaluate the impact of alternative scenarios and assumptions on results.

RESULTS

A strategy permitting ablation of up to five metastases with computed tomographic (CT) follow-up every 4 months resulted in a gain of 0.65 QALYs relative to a no-treat strategy, at an incremental cost of $2400 per QALY. Compared with this ablation strategy, a strategy permitting resection of up to four metastases, one repeat resection, and CT follow-up every 6 months resulted in an additional gain of 0.76 QALYs at an incremental cost of $24 300 per QALY. Across a range of model assumptions, more aggressive treatment strategies (ie, ablation or resection of more metastases, treatment of recurrent metastases, more frequent follow-up imaging) were superior to less aggressive strategies and had incremental cost-effectiveness ratios of less than $35 000 per QALY. Findings were insensitive to changes in most model parameters; however, results were somewhat sensitive to changes in size thresholds for RF ablation, the number of metastases present, and surgery and treatment costs.

CONCLUSION

RF ablation is a cost-effective treatment option for patients with CRC liver metastases. However, in most scenarios, hepatic resection is more effective (in terms of QALYs gained) than RF ablation and has an incremental cost-effectiveness ratio of less than $35 000 per QALY.

Cost-effectiveness of rhythm versus rate control in atrial fibrillation

BACKGROUND

Atrial fibrillation is the most common type of sustained cardiac arrhythmia, but recent trials have identified no clear advantage of rhythm control over rate control. Consequently, economic factors often play a role in guiding treatment selection.

OBJECTIVE

To estimate the cost-effectiveness of rhythm-control versus rate-control strategies for atrial fibrillation in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM).

DESIGN

Retrospective economic evaluation. Nonparametric bootstrapping was used to estimate the distribution of incremental costs and effects on the cost-effectiveness plane.

DATA SOURCES

Data on survival and use of health care resources were obtained for all 4060 AFFIRM participants. Unit costs were estimated from various U.S. databases.

TARGET POPULATION

Patients with atrial fibrillation who were 65 years of age or who had other risk factors for stroke or death, similar to those enrolled in AFFIRM.

TIME HORIZON

Mean follow-up of 3.5 years.

PERSPECTIVE

Third-party payer.

INTERVENTIONS

Management of patients with atrial fibrillation with antiarrhythmic drugs (rhythm control) compared with drugs that control heart rate (rate control).

OUTCOME MEASURES

Mean survival, resource use, costs, and cost-effectiveness.

RESULTS OF BASE-CASE ANALYSIS

A mean survival gain of 0.08 year (P = 0.10) was observed for rate control. Patients in the rate-control group used fewer resources (hospital days, pacemaker procedures, cardioversions, and short-stay and emergency department visits). Rate control costs 5077 dollars less per person than rhythm control.

RESULTS OF SENSITIVITY ANALYSIS

Cost savings ranged from 2189 dollars o 5481 dollars per person. Rhythm control was more costly and less effective than rate control in 95% of the bootstrap replicates over a wide range of cost assumptions.

LIMITATIONS

Resource use was limited to key items collected in AFFIRM, and the results are generalizable only to similar patient populations with atrial fibrillation.

CONCLUSION

Rate control is a cost-effective approach to the management of atrial fibrillation compared with maintenance of sinus rhythm in patients with atrial fibrillation similar to those enrolled in AFFIRM.

A cost-utility analysis of microwave and thermal balloon endometrial ablation techniques for the treatment of heavy menstrual bleeding

OBJECTIVE

To assess the cost effectiveness of the second-generation surgical treatments for heavy menstrual bleeding (microwave and thermal balloon endometrial ablation) compared with existing endometrial ablation techniques (transcervical resection and rollerball, alone or in combination) and hysterectomy.

DESIGN

A state transition (Markov) cost-utility economic model.

POPULATION

Women with heavy menstrual bleeding.

METHODS

A Markov model was developed using spreadsheet software. Transition probabilities, costs and quality of life data were obtained from a systematic review of effectiveness undertaken by the authors, from published sources, and expert opinion. Cost data were obtained from the literature and from a NHS trust hospital. Indirect comparison of thermal balloon endometrial ablation versus microwave endometrial ablation or either second-generation endometrial ablation method versus hysterectomy, and comparison of second-generation versus first-generation techniques were carried out from the perspective of health service payers. The effects of uncertainty were explored through extensive one-way sensitivity analyses and Monte Carlo simulation.

MAIN OUTCOME MEASURES

Incremental cost effectiveness ratios based on cost per quality adjusted life year (QALY) gained, and cost effectiveness acceptability curves.

RESULTS

Compared with first-generation techniques, both microwave and thermal balloon endometrial ablation cost less and accrued more QALYs. Hysterectomy was more expensive, but accrued more QALYs than all endometrial ablation methods. Baseline results showed that differences between microwave endometrial ablation and thermal balloon endometrial ablation were slight. Sensitivity analyses showed that small changes in values may have a marked effect on cost effectiveness. Probabilistic simulation highlighted the uncertainty in comparisons between different endometrial ablation options, particularly between second-generation techniques.

CONCLUSIONS

Despite limitations in available data, the analysis suggests that second-generation techniques are likely to be more cost effective than first-generation techniques in most cases. Hysterectomy, where a woman finds this option acceptable, continues to be a very cost effective procedure compared with all endometrial ablation methods.