The effectiveness and cost-effectiveness of microwave and thermal balloon endometrial ablation for heavy menstrual bleeding: a systematic review and economic modelling

OBJECTIVES

To estimate the clinical effectiveness and cost-effectiveness of microwave endometrial ablation (MEA) and thermal balloon endometrial ablation (TBEA) for heavy menstrual bleeding (HMB), compared with the existing (first-generation) endometrial ablation (EA) techniques of transcervical resection (TCRE) and rollerball (RB) ablation, and hysterectomy.

DATA SOURCES

Electronic databases, bibliographies of articles, and also experts in the field and relevant industry bodies were asked to provide information.

REVIEW METHODS

A detailed search strategy was carried out to identify systematic reviews and controlled trials of MEA and TBEA versus first-generation techniques for EA. In addition to electronic database searching, reference lists were hand-searched and information sought from manufacturers of EA devices and by experts in the field. A deterministic Markov model was developed to assess cost-effectiveness. Data for the model were taken from a range of sources.

RESULTS

The systematic review of first-generation EA techniques versus hysterectomy found that EA offered an alternative to hysterectomy for HMB, with fewer complications and a shorter recovery period. Satisfaction and effectiveness were high for both MEA and TBEA. Costs were lower with EA although the difference narrows over time. Second-generation EA techniques are an alternative treatment to first-generation techniques for HMB, and first-generation techniques are known to offer an alternative to hysterectomy. Although no trials of second-generation techniques and hysterectomy have been undertaken, it seems reasonable to assume that second-generation techniques also offer an alternative surgical treatment. Using the model to assess cost-effectiveness, costs were very slightly higher for MEA when compared to TBEA, and differences in quality-adjusted life-years (QALYs) were negligible. For MEA compared with transcervical resection of the endometrium (TCRE) and RB ablation, costs were slightly lower with MEA and MEA accrued very slightly more QALYs. Compared with hysterectomy, MEA costs less and accrues slightly fewer QALYs. For TBEA compared with TCRE and RB ablation, costs were lower with TBEA and TBEA accrued slightly more QALYs. Compared with hysterectomy, TBEA costs moderately less and accrues moderately fewer QALYs.

CONCLUSIONS

Overall, there were few significant differences between the outcomes of first- and second-generation techniques including bleeding, satisfaction and QoL measures and repeat surgery rates. Second-generation techniques had significantly shorter operating and theatre times and there appear to be fewer serious perioperative adverse effects with second-generation techniques and postoperative effects are similar. Compared with hysterectomy, TCRE and RB are quicker to perform and result in shorter hospitalisation and faster return to work. Hysterectomy results in more adverse effects and is more expensive, although the need for retreatment leads this difference to decrease over time. Satisfaction with hysterectomy is initially higher, but there is no significant difference after 2 years. The economic model suggests that second-generation techniques are more cost-effective than first-generation techniques of EA for HMB. Both TBEA and MEA appear to be less costly than hysterectomy, although the latter results in more QALYs. Further research is suggested to make direct comparisons of the cost-effectiveness of second-generation EA techniques, to carry out longer term follow-up for all methods of EA in RCTs, and to develop more sophisticated modelling studies. Further research is also recommended into HMB to establish health-state utility values, its surgical treatment, convalescence, complications of treatment, symptoms and patient satisfaction.

The cost of microwave endometrial ablation under different anaesthetic and clinical settings

OBJECTIVE

To compare the costs of microwave endometrial ablation under local anaesthetic and general anaesthetic in an operating theatre and to estimate the cost of performing treatment under local anaesthetic in a dedicated clinic setting.

DESIGN

The costing study was undertaken alongside a randomised controlled trial comparing the acceptability of microwave endometrial ablation using local versus general anaesthetic in a theatre setting.

SETTING

Department of Gynaecology, Aberdeen Royal Infirmary, Scotland.

SAMPLES

One hundred and twenty-seven women undergoing microwave endometrial ablation who had been randomly allocated to general or local anaesthetic.

METHODS

Health and non-health service resource use was recorded prospectively. Data on resource use were combined with unit costs estimated using standardised methods to determine the cost per patient for microwave endometrial ablation under local or general anaesthetic in theatre. A model was developed to estimate the health service cost of microwave endometrial ablation under local anaesthetic in a clinic setting.

MAIN OUTCOME MEASURES

Health and non-health service costs.

RESULTS

There was little difference in cost when treatments were performed under local or general anaesthetic in theatre. The median health and non-health cost of microwave endometrial ablation was 440 pounds and 120 pounds, respectively, under general anaesthetic and 428 pounds and 125 pounds per women under local anaesthetic. The health service cost of microwave endometrial ablation using local anaesthetic in a clinic setting was estimated to be 432 pounds per treatment; however, this varied from 389 pounds to 491 pounds in the sensitivity analysis.

CONCLUSION

There are minimal cost savings to the patient or health service from using local rather than general anaesthetic for microwave endometrial ablation in a theatre setting. Cost modelling suggests that in a clinic setting microwave endometrial ablation has a similar cost to theatre based treatment once re-admissions for treatment under general anaesthetic are considered. Sensitivity analysis indicated that these findings were sensitive to assumptions in the model.

Review of economic evaluations of radiofrequency catheter ablation for cardiac arrhythmias

A systematic review of current studies on the cost effectiveness of catheter ablation for treatment of tachycardia in adults was undertaken. The results are summarized based on a predefined framework of principles for economic evaluation. Of 192 abstracts identified, only three cost effectiveness studies were identified. Each focused on a different and specific patient group with selected target disorders, and used decision analysis modelling to estimate cost effectiveness. Radiofrequency catheter ablation is likely to be economically attractive compared with drug therapy in adult patients with frequently symptomatic paroxysmal supraventricular tachycardia (radiofrequency catheter ablation dominates drug therapy options) or in ventricular tachycardia patients with pre-existing ischemic coronary disease (cost effectiveness ratio of about US $21,000 per quality adjusted life year), but not in the treatment of asymptomatic Wolff-Parkinson-White syndrome patients. However, these studies evaluated different types of tachycardias in differing patient populations and all are based on United States data, so decision-makers must be cautious when applying these results to a general population with tachycardia in the Canadian context.

Cost analysis of endoscopic antireflux procedures: endoluminal plication vs. radiofrequency coagulation vs. treatment with a proton pump inhibitor

BACKGROUND

Both endoluminal gastroplication and radiofrequency coagulation of the lower esophageal sphincter and gastroesophageal junction (Stretta procedure) represent emerging endoscopic therapies for GERD. The economic impact of endotherapy for GERD has not been described. The aim of this study was to apply a decision analysis model to compare the costs of endoluminal gastroplication vs. the Stretta procedures vs. a proton pump inhibitor for treatment of GERD. A cost minimization approach was used.

METHODS

Model entry criteria were GERD responsive to daily or twice daily administration of a proton pump inhibitor. Performance characteristics of endotherapy were determined from published data. The baseline probabilities for annual endotherapy failure rates (20%), partial failure rates (10%), and complication rates (1%) were varied through a plausible range by using sensitivity analysis. Cost data for endotherapy were calculated from per case instrumentation costs plus professional fees plus facility fees for ambulatory patient classification codes; cost of treatment with a proton pump inhibitor was based on national average wholesale price. The endpoint was sustained resolution of GERD symptoms.

RESULTS

In patients requiring twice daily use of a proton pump inhibitor for symptom relief, endotherapy proves to be the most economical strategy after 17 months. If uniform endotherapy failure rates over time are assumed, medication regains superiority after 29 months. Sensitivity analysis revealed that a proton pump inhibitor remains the most economical option beyond 3 years, provided annual endotherapy failure rates remain greater than 20% (endoluminal gastroplication) or 19% (Stretta). Pharmacotherapy is the least costly approach, irrespective of time, if the daily cost of a proton pump inhibitor is less than $140 a month or endotherapy costs more than $3400. For patients in whom symptoms are relieved with once daily dosing with a proton pump inhibitor, medication remains the most economical option regardless of endotherapy failure rate.

CONCLUSION

Endotherapy appears to offer an economical treatment option for patients requiring a proton pump inhibitor twice daily, with its cost superiority enduring for 2.5 years. More long-term follow-up data are required to determine the durability of the endotherapy benefit over time.

Cost-effectiveness of transvaginal sonography and saline infused sonography in the evaluation of menorrhagia

OBJECTIVES

To assess the cost-effectiveness of transvaginal sonography (TVS) and saline infused sonography (SIS) in the diagnostic work-up of women with menorrhagia.

METHODS

We performed a decision analysis in which we compared the percentage of patients treated successfully and cost of six strategies for the evaluation of menorrhagia: (0) hormonal treatment, (I) treatment of all patients with balloon ablation, (II) TVS and therapeutic hysteroscopy, (III) TVS, SIS and therapeutic hysteroscopy, (IV) SIS and therapeutic hysteroscopy, and (V) diagnostic hysteroscopy and therapeutic hysteroscopy. Hormonal treatment was considered to be the reference strategy to which the five strategies were compared. Data were obtained from the published literature. In order to evaluate the robustness of our results, we performed extensive sensitivity analyses, in which we varied sensitivity and specificity of TVS and hysteroscopy, the prevalence of intracavitary abnormalities, as well as costs of TVS and SIS.

RESULTS

We found that the strategy starting with SIS (IV) and the strategy with diagnostic hysteroscopy (V) revealed the highest number of patients treated successfully for menorrhagia. In terms of cost-effectiveness, SIS for all patients was superior over immediate diagnostic hysteroscopy for all patients. Strategies starting with TVS were less effective than the strategy starting with SIS.

CONCLUSIONS

We recommend SIS as the procedure of first choice in the work-up for women with menorrhagia.

[Structure of the Australian system of 'Diagnosis Related Groups' regarding cardiovascular diseases and corresponding cost weights in Germany]

BACKGROUND

An adapted system of 'Diagnosis Related Groups' (DRG's) will be introduced for Germany at the beginning of 2003. This article focuses on the structure of the Australian DRG system (AR-DRG 4.1) regarding the diseases of the cardiovascular system and corresponding cost weights in Germany (G-DRG 1.0).

METHODS

Cardiac diagnoses, procedures and cost weights (with a different base rate) were compared between the Australian and German DRG's.

RESULTS

Categories and procedures for diagnostics and therapies are shown regarding coronary interventions, electrophysiological strategies including implantation of pacemakers and cardioverter/ defibrillators, hybrid treatment modalities, transcatheter closure of interatrial/-ventricular communications as well as interventions during intensive care treatment.

Atrial fibrillation ablation leads to long-term improvement of quality of life and reduced utilization of healthcare resources

In some patients, rapid activation from one or several foci can lead to atrial fibrillation. This study evaluated long-term changes in quality of life and healthcare resource utilization in patients with atrial fibrillation treated by ablation of focal triggers. Thirty-three patients underwent ablation for paroxysmal atrial fibrillation. Health surveys (SF-36) were obtained at baseline, and after 1 year and 3 years of follow-up. Health care costs were measured for the 3 years before and after ablation. Ablation was successful in 82%, partially successful in 12% (no sustained episodes but on antiarrhythmic drug therapy), and unsuccessful in 6% of patients. The average number of ablation procedures was 1.6 +/- 0.6 per patient. After ablation, patients reported significantly improved quality of life in all SF-36 categories except bodily pain. Healthcare resource utilization was significantly reduced after ablation (Clinic visits: 7.4 +/- 2.5 per year vs. 1.1 +/- 0.6 per year, p < 0.05; Emergency room visits: 1.7 +/- 0.90 per year vs. 0.03 +/- 0.17 per year, p < 0.05; Hospitalization: 1.6 +/- 0.81 vs. 0, p < 0.05). Cost of healthcare (not including procedural costs) was significantly reduced after ablation (Pre-ablation: 1,920 +/- 889 dollars/year vs. post-ablation: 87 +/- 68 dollars/year; p < 0.01). Procedural cost of ablation was 17,173 +/- 2,466 dollars/patient. Ablation of focal triggers of atrial fibrillation is associated with a sustained improvement in quality of life. Although the initial cost of ablation is high, after ablation, utilization of healthcare resources is significantly reduced.

Cost analysis of catheter ablation for paroxysmal atrial fibrillation

RF ablation for paroxysmal atrial fibrillation (PAF) is a curative treatment, which when successful, eliminates the need to take antiarrhythmic drugs, be anticoagulated, and have recurrent physician visits or hospital admissions. The authors performed a retrospective cost comparison of RF ablation versus drug therapy for PAF. The study population consisted of 118 consecutive patients with symptomatic, drug refractory PAF who underwent 1.52 +/- 0.71 RF ablation procedures (range 1-4) for PAF. During a follow-up of 32 +/- 15 weeks, 85 (72%) patients remained free of clinical recurrence in absence of antiarrhythmic drugs. The cost of RF ablation was calculated in the year 2001 euros on the basis of resource use. The mean cost of pharmacologic treatment prior to ablation was 1,590 euros/patient per year. The initial cost of RF ablation for PAF was 4,715 euros, then 445 euros/year. After 5 years, the cost of RF ablation was below that of ongoing medical management, and continued to diverge thereafter. RF catheter ablation may be a cost-effective alternative to long-term drug therapy in patients with symptomatic, drug refractory PAF.

The adoption of ablation therapy for Barrett's esophagus: a cohort study of gastroenterologists

OBJECTIVES

Although ablation therapy may be useful in the treatment of Barrett's esophagus. evidence of effectiveness is scarce, and little is known about current utilization of ablation. We aimed to determine whether the use of ablation was increasing in a cohort of gastroenterologists, and to identify physician beliefs and characteristics associated with ablation use.

METHODS

We surveyed a national sample of gastroenterologists about ablation use, with an 18-month follow-up. The self-administered instrument included questions about demographic characteristics, attitudes about ablation therapy, and prior experience with ablation. Case scenarios were also included. We used logistic regression to identify factors associated with the use of ablation in patients with Barrett's esophagus.

RESULTS

Two hundred seventy-nine (50.3% of those eligible) responded to the baseline survey. Few agreed that ablation lowers the risk of adenocarcinoma (15%) or is supported by the medical literature (19%). However, 25% of respondents reportedly had used ablation at baseline, and this increased to 36% in the follow-up survey (p = 0.0003). The use of ablation was significantly associated with physician age greater than 54 yr (odds ratio [OR] = 2.77, 95% CI = 1.04-7.37) and the belief that ablation was used by colleagues (OR = 13.27, 95% CI = 4.44-39.64) or decreases medical costs (OR = 5.07, 95% CI = 1.00-25.74).

CONCLUSIONS

Although few gastroenterologists agreed that ablation is effective, a significant proportion had adopted its use. There was a significant increase in ablation use during our study period, and the characteristic that was most strongly associated with ablation use was the belief that colleagues used it.

Are drugs and catheter ablation effective for treating ventricular arrhythmias in populations that cannot afford implantable cardioverter defibrillators?

Despite recent advances, ventricular arrhythmias continue to pose a therapeutic challenge, especially to the clinician in the developing world. Although the implantable cardioverter defibrillator (ICD) has improved survival in both primary and secondary prevention trials, it still remains a costly modality for the developing world. Even though certain subgroups stand to benefit unequivocally in survival from the ICD, there are others in whom this therapy may not offer a survival benefit over empiric antiarrhythmic drug therapy with amiodarone. The utility of optimized drug therapy (including either amiodarone or sotalol, b-blockers, and angiotensin-converting enzyme inhibitors) needs to be compared with the ICD in a randomized manner in these lower-risk patients with ventricular arrhythmias. The role of conventional catheter ablation techniques is mostly adjunctive to drugs and ICDs, although the newer mapping and ablation techniques may offer greater promise in the future.

Cost-effectiveness of percutaneous radiofrequency ablation for malignant hepatic neoplasms

PURPOSE

Percutaneous radiofrequency (RF) ablation is a promising technique for the treatment of hepatic malignancies. However, its cost-effectiveness has not been established. The purpose of this study is to determine the cost-effectiveness of RF ablation compared to palliative care in the treatment of hepatocellular cancer and colorectal liver metastases. This study also seeks to evaluate the effects of transition from traditional to newly implemented prospective outpatient reimbursement mechanisms on RF ablation cost-effectiveness.

MATERIALS AND METHODS

The marginal direct costs of a percutaneous RF ablation treatment strategy were compared to palliative care over a range of survival benefits with use of a cost-effectiveness model built from the perspective of the payer. Variables used in the model, including complication rates and procedure efficacy, were obtained from the literature and the authors' experience with 46 consecutive patients.

RESULTS

The cost-effectiveness of a standardized percutaneous RF ablation treatment strategy compared to palliative care was $20,424, $11,407, $5,034, and $3,492, respectively, per life-year (LY) gained when marginal median survival conferred by RF ablation is 6 months, 1 year, 3 years, and 5 years. The RF ablation treatment strategy would be required to generate 6.14, 2.26, and 1.10 months of marginal median survival benefit to achieve strict ($20,000/LY gained), moderate ($50,000/LY gained), and generous ($100,000/LY gained) cost-effectiveness thresholds. Cost-effectiveness was sensitive to the number of lifetime treatments, hours of observation time, frequency of follow-up evaluations, cost of abdominal computed tomography, and decision to perform RF ablation as an inpatient or outpatient.

CONCLUSION

Percutaneous RF ablation is a cost-effective treatment strategy compared to palliative care and has likely already achieved the survival benefit required to meet even a strict cost-effectiveness criterion. Dependence on reimbursement mechanism highlights the importance of concordance between policy and RF ablation technology. The results of this study allow flexible application of cost-effectiveness data despite current uncertainties in treatment and survival data and heterogeneity in treatment populations.

Safety, effectiveness and cost efficacy of diagnostic electrophysiology and radiofrequency ablation in a district general hospital

Electrophysiological studies (EPS) are now being performed in district general hospitals (DGH) in the UK. In order to audit our results, a prospective database was established for all patients undergoing EPS and radiofrequency (RF) ablation at Eastbourne District General Hospital, East Sussex. Between 1 January 1997 and 1 July 2000, 300 EPS procedures were performed, resulting in 155 RF ablations. The average RF ablation procedure time was 119.3 minutes with an average fluoroscopy time of 19.1 minutes. Cost per RF ablation procedure was 1166.79 Pounds excluding use of facilities, pacemaker devices, medical nursing and radiography staffing costs. The overall success rate for RF ablation was 93.6% with a major complication rate of 0.6%, a total complication rate of 3.9% and no associated mortality. We have shown that RF ablation can be performed safely, effectively and economically in a DGH setting with a high rate of success and a low complication rate.

Cost-effectiveness of radiofrequency ablation for supraventricular tachycardia

BACKGROUND

Radiofrequency ablation is an established but expensive treatment option for many forms of supraventricular tachycardia. Most cases of supraventricular tachycardia are not life-threatening; the goal of therapy is therefore to improve the patient's quality of life.

OBJECTIVE

To compare the cost-effectiveness of radiofrequency ablation with that of medical management of supraventricular tachycardia.

DESIGN

Markov model.

DATA SOURCES

Costs were estimated from a major academic hospital and the literature, and treatment efficacy was estimated from reports from clinical studies at major medical centers. Probabilities of clinical outcomes were estimated from the literature. To account for the effect of radiofrequency ablation on quality of life, assessments by patients who had undergone the procedure were used.

TARGET POPULATION

Cohort of symptomatic patients who experienced 4.6 unscheduled visits per year to an emergency department or a physician's office while receiving long-term drug therapy for supraventricular tachycardia.

TIME HORIZON

Patient lifetime.

PERSPECTIVE

Societal.

INTERVENTIONS

Initial radiofrequency ablation, long-term antiarrhythmic drug therapy, and treatment of acute episodes of arrhythmia with antiarrhythmic drugs.

OUTCOME MEASURES

Costs, quality-adjusted life-years, life-years, and marginal cost-effectiveness ratios.

RESULTS OF BASE-CASE ANALYSIS

Among patients who have monthly episodes of supraventricular tachycardia, radiofrequency ablation was the most effective and least expensive therapy and therefore dominated the drug therapy options. Radiofrequency ablation improved quality-adjusted life expectancy by 3.10 quality-adjusted life-years and reduced lifetime medical expenditures by $27 900 compared with long-term drug therapy. Long-term drug therapy was more effective and had lower costs than episodic drug therapy.

RESULTS OF SENSITIVITY ANALYSIS

The findings were highly robust over substantial variations in assumptions about the efficacy and complication rate of radiofrequency ablation, including analyses in which the complication rate was tripled and efficacy was decreased substantially.

CONCLUSIONS

Radiofrequency ablation substantially improves quality of life and reduces costs when it is used to treat highly symptomatic patients. Although the benefit of radiofrequency ablation has not been studied in less symptomatic patients, a small improvement in quality of life is sufficient to give preference to radiofrequency ablation over drug therapy.

Cost-effectiveness of catheter ablation in patients with ventricular tachycardia

BACKGROUND

This study evaluated the cost-effectiveness of catheter ablation therapy versus amiodarone for treating ventricular tachycardia (VT) in patients with structural heart disease. The analysis used a societal perspective for a hypothetical cohort of VT patients with implantable cardioverter-defibrillators, who were experiencing frequent shocks.

METHODS AND RESULTS

We calculated incremental cost-effectiveness of ablation relative to amiodarone over 5 years after treatment initiation. Event probabilities were from the Chilli randomized clinical trial (Chilli Cooled Ablation System, Cardiac Pathways Corporation, Sunnyvale, Calif), the literature, and a consensus panel. Costs were from 1998 national Medicare reimbursement schedules. Quality-of-life weights (utilities) were estimated using an established preference measurement technique. In a hypothetical cohort of 10 000 patients, 5-year costs were higher for patients undergoing ablation compared with amiodarone therapy ($21 795 versus $19 075). Ablation also produced a greater increase in quality of life (2.78 versus 2.65 quality-adjusted life-years [QALYs]). This yielded a cost-effectiveness ratio of $20 923 per QALY gained for ablation compared with amiodarone. Results were relatively insensitive to assumptions about ablation success and durability. In less severe patients with good ejection fractions who suffer their first VT episode, the incremental cost-effectiveness ratio was $6028 per QALY gained. These cost-effectiveness ratios are within the range generally thought to warrant technology adoption.

CONCLUSIONS

This study demonstrates that, from a societal perspective, catheter ablation appears to be a cost-effective alternative to amiodarone for treating VT patients.

[Balloon catheter endometrial thermotherapy in menorrhagia. New simple and safe alternative to hysterectomy]

Thermal endometrial ablation by means of a silicone balloon catheter is a new form of out-patient treatment for menorrhagia, designed to reduce menstrual blood loss by exerting thermal effects on the endometrium and myometrium without damaging surrounding tissue. Follow-up of 116 of the 117 women who underwent the treatment between August 1993 and December 1996 showed the procedure to be well tolerated, to be without immediate complications, and to be associated with significant reductions in menstrual blood volume and in the reported number of bleeding days (P < 0.001 in both cases). At follow-up after 10-49 months, the success rate was 94 per cent. (This excludes women with uterine cavity changes, or submucosal leiomyomas detected at pretreatment ultrasonography, for whom the treatment is not to be recommended.) In addition to its high success rate, the treatment is safe for the patient and easy for the physician to learn.

Endometrial balloon ablation under local analgesia and intravenous sedation

We report a series of women (n = 16) with menorrhagia undergoing endometrial balloon ablation under local analgesia with light sedation. Ten women had significant, coexistent medical problems. The median duration of the procedure was 8.6 minutes (range 8.47-9.5 minutes). Postoperative assessment included pain scores assessed by linear analogue scale; requirement for opiate analgesia; length of postoperative stay and patient satisfaction with the procedure. The minimum postoperative follow-up was 6 months. The procedure was well-tolerated and in 80% of cases either no postoperative analgesia or simple analgesia only was required. Two women were admitted overnight, 1 for social reasons and the other for pain control. Three women ages 44, 54 and 55 years were amenorrhoeic at 6 months; 8 women were still menstruating but satisfied with the outcome and 5 women are seeking further treatment for menorrhagia. While the longer-term efficacy of the procedure remains to be established these results indicate that endometrial balloon ablation under local analgesia and light sedation, a simple and acceptable technique, may be a suitable alternative to more difficult procedures such as rollerball ablation. This is most likely to be the case in appropriately selected women who are willing to accept a reduction in menstrual flow rather than amenorrhoea as the treatment outcome. The main disadvantage of balloon ablation is the cost of the disposable balloons and the need for a dedicated electrosurgical unit.