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Litherland NC, Phillips R. Should outpatient hysteroscopy be used in preference to transvaginal ultrasound to identify endometrial pathology in premenopausal women with heavy menstrual bleeding? Revisiting NICE Guideline 88. ULTRASOUND (LEEDS, ENGLAND) 2023; 31:284-291. [PMID: 37929243 PMCID: PMC10621496 DOI: 10.1177/1742271x221147731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 11/02/2022] [Indexed: 11/07/2023]
Abstract
Introduction National Institute for Health and Care Excellence Guideline 88 advocates outpatient hysteroscopy in preference to transvaginal ultrasound for premenopausal women with heavy menstrual bleeding, who are suspected of having submucosal fibroids, polyps or endometrial pathology. The guideline, however, analysed outdated studies that provided low-quality evidence. This study aimed to assess the diagnostic accuracy of transvaginal ultrasound in detecting endometrial pathology; and to evaluate the cost-effectiveness of outpatient hysteroscopy if it were to be used in preference to transvaginal ultrasound. Methods A health service evaluation was conducted at a district general foundation trust between 1 January 2019 and 31 March 2019 of all premenopausal women with heavy menstrual bleeding. A cost-effectiveness analysis was also performed to evaluate the financial implication of outpatient hysteroscopy being used in preference to transvaginal ultrasound. Results 100 patients were included in the study. For the detection of endometrial pathology, transvaginal ultrasound had a positive predictive value of 65.2%; negative predictive value of 98.5%; sensitivity of 93.75%; specificity of 88.89% and an accuracy of 89.77%. For identifying endometrial polyps, submucosal fibroids and endometrial thickening, transvaginal ultrasound had a positive predictive value of 33.3%, 85.7% and 50%, respectively. It would have cost the Trust 78.7% more if National Institute for Health and Care Excellence's recommendation was carried out, with a 23.4% increase in workload in the hysteroscopy department, and a decrease of 7.8% transvaginal scans performed. Conclusion Outpatient hysteroscopy is costly and would increase the workload burden in the hysteroscopy department. Transvaginal ultrasound has a high sensitivity, specificity and accuracy in detecting endometrial pathology therefore it should remain as the initial diagnostic investigation.
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van den Brink MJ, Beelen P, Herman MC, Geomini PM, Dekker JH, Vermeulen KM, Bongers MY, Berger MY. The levonorgestrel intrauterine system versus endometrial ablation for heavy menstrual bleeding: a cost-effectiveness analysis. BJOG 2021; 128:2003-2011. [PMID: 34245652 PMCID: PMC8518490 DOI: 10.1111/1471-0528.16836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2021] [Indexed: 11/30/2022]
Abstract
Objective To evaluate the costs and non‐inferiority of a strategy starting with the levonorgestrel intrauterine system (LNG‐IUS) compared with endometrial ablation (EA) in the treatment of heavy menstrual bleeding (HMB). Design Cost‐effectiveness analysis from a societal perspective alongside a multicentre randomised non‐inferiority trial. Setting General practices and gynaecology departments in the Netherlands. Population In all, 270 women with HMB, aged ≥34 years old, without intracavitary pathology or wish for a future child. Methods Randomisation to a strategy starting with the LNG‐IUS (n = 132) or EA (n = 138). The incremental cost‐effectiveness ratio was estimated. Main outcome measures Direct medical costs and (in)direct non‐medical costs were calculated. The primary outcome was menstrual blood loss after 24 months, measured with the mean Pictorial Blood Assessment Chart (PBAC)‐score (non‐inferiority margin 25 points). A secondary outcome was successful blood loss reduction (PBAC‐score ≤75 points). Results Total costs per patient were €2,285 in the LNG‐IUS strategy and €3,465 in the EA strategy (difference: €1,180). At 24 months, mean PBAC‐scores were 64.8 in the LNG‐IUS group (n = 115) and 14.2 in the EA group (n = 132); difference 50.5 points (95% CI 4.3–96.7). In the LNG‐IUS group, 87% of women had a PBAC‐score ≤75 points versus 94% in the EA group (relative risk [RR] 0.93, 95% CI 0.85–1.01). The ICER was €23 (95% CI €5–111) per PBAC‐point. Conclusions A strategy starting with the LNG‐IUS was cheaper than starting with EA, but non‐inferiority could not be demonstrated. The LNG‐IUS is reversible and less invasive and can be a cost‐effective treatment option, depending on the success rate women are willing to accept. Tweetable abstract Treatment of heavy menstrual bleeding starting with LNG‐IUS is cheaper but slightly less effective than endometrial ablation. Treatment of heavy menstrual bleeding starting with LNG‐IUS is cheaper but slightly less effective than endometrial ablation.
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Affiliation(s)
- M J van den Brink
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - P Beelen
- Department of General Practice, University of Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, The Netherlands
| | - M C Herman
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, The Netherlands
| | - P M Geomini
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, The Netherlands
| | - J H Dekker
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - K M Vermeulen
- Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - M Y Bongers
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, The Netherlands.,Department of Obstetrics and Gynaecology, Grow Research School for Oncology and Developmental Biology, University of Maastricht, Maastricht, The Netherlands
| | - M Y Berger
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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Finch AP, Brazier JE, Mukuria C. What is the evidence for the performance of generic preference-based measures? A systematic overview of reviews. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2018; 19:557-570. [PMID: 28560520 PMCID: PMC5913394 DOI: 10.1007/s10198-017-0902-x] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 05/18/2017] [Indexed: 05/25/2023]
Abstract
OBJECTIVE To assess the evidence on the validity and responsiveness of five commonly used preference-based instruments, the EQ-5D, SF-6D, HUI3, 15D and AQoL, by undertaking a review of reviews. METHODS Four databases were investigated using a strategy refined through a highly sensitive filter for systematic reviews. References were screened and a search for grey literature was performed. Identified citations were scrutinized against pre-defined eligibility criteria and data were extracted using a customized extraction template. Evidence on known group validity, convergent validity and responsiveness was extracted and reviewed by narrative synthesis. Quality of the included reviews was assessed using a modified version of the AMSTAR checklist. RESULTS Thirty reviews were included, sixteen of which were of excellent or good quality. The body of evidence, covering more than 180 studies, was heavily skewed towards EQ-5D, with significantly fewer studies investigating HUI3 and SF-6D, and very few the 15D and AQoL. There was also lack of head-to-head comparisons between GPBMs and the tests reported by the reviews were often weak. Where there was evidence, EQ-5D, SF-6D, HUI3, 15D and AQoL seemed generally valid and responsive instruments, although not for all conditions. Evidence was not consistently reported across reviews. CONCLUSIONS Although generally valid, EQ-5D, SF-6D and HUI3 suffer from some problems and perform inconsistently in some populations. The lack of head-to-head comparisons and the poor reporting impedes the comparative assessment of the performance of GPBMs. This highlights the need for large comparative studies designed to test instruments' performance.
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Affiliation(s)
- Aureliano Paolo Finch
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, West Court, 1 Mappin Street, Sheffield, S1 4DT, UK.
| | - John Edward Brazier
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, West Court, 1 Mappin Street, Sheffield, S1 4DT, UK
| | - Clara Mukuria
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, West Court, 1 Mappin Street, Sheffield, S1 4DT, UK
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Gupta JK, Daniels JP, Middleton LJ, Pattison HM, Prileszky G, Roberts TE, Sanghera S, Barton P, Gray R, Kai J. A randomised controlled trial of the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia: the ECLIPSE trial. Health Technol Assess 2016; 19:i-xxv, 1-118. [PMID: 26507206 DOI: 10.3310/hta19880] [Citation(s) in RCA: 203] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Heavy menstrual bleeding (HMB) is a common problem, yet evidence to inform decisions about initial medical treatment is limited. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system (LNG-IUS) (Mirena®, Bayer) compared with usual medical treatment, with exploration of women's perspectives on treatment. DESIGN A pragmatic, multicentre randomised trial with an economic evaluation and a longitudinal qualitative study. SETTING Women who presented in primary care. PARTICIPANTS A total of 571 women with HMB. A purposeful sample of 27 women who were randomised or ineligible owing to treatment preference participated in semistructured face-to-face interviews around 2 and 12 months after commencing treatment. INTERVENTIONS LNG-IUS or usual medical treatment (tranexamic acid, mefenamic acid, combined oestrogen-progestogen or progesterone alone). Women could subsequently swap or cease their allocated treatment. OUTCOME MEASURES The primary outcome was the patient-reported score on the Menorrhagia Multi-Attribute Scale (MMAS) assessed over a 2-year period and then again at 5 years. Secondary outcomes included general quality of life (QoL), sexual activity, surgical intervention and safety. Data were analysed using iterative constant comparison. A state transition model-based cost-utility analysis was undertaken alongside the randomised trial. Quality-adjusted life-years (QALYs) were derived from the European Quality of Life-5 Dimensions (EQ-5D) and the Short Form questionnaire-6 Dimensions (SF-6D). The intention-to-treat analyses were reported as cost per QALY gained. Uncertainty was explored by conducting both deterministic and probabilistic sensitivity analyses. RESULTS The MMAS total scores improved significantly in both groups at all time points, but were significantly greater for the LNG-IUS than for usual treatment [mean difference over 2 years was 13.4 points, 95% confidence interval (CI) 9.9 to 16.9 points; p < 0.001]. However, this difference between groups was reduced and no longer significant by 5 years (mean difference in scores 3.9 points, 95% CI -0.6 to 8.3 points; p = 0.09). By 5 years, only 47% of women had a LNG-IUS in place and 15% were still taking usual medical treatment. Five-year surgery rates were low, at 20%, and were similar, irrespective of initial treatments. There were no significant differences in serious adverse events between groups. Using the EQ-5D, at 2 years, the relative cost-effectiveness of the LNG-IUS compared with usual medical treatment was £1600 per QALY, which by 5 years was reduced to £114 per QALY. Using the SF-6D, usual medical treatment dominates the LNG-IUS. The qualitative findings show that women's experiences and expectations of medical treatments for HMB vary considerably and change over time. Women had high expectations of a prompt effect from medical treatments. CONCLUSIONS The LNG-IUS, compared with usual medical therapies, resulted in greater improvement over 2 years in women's assessments of the effect of HMB on their daily routine, including work, social and family life, and psychological and physical well-being. At 5 years, the differences were no longer significant. A similar low proportion of women required surgical intervention in both groups. The LNG-IUS is cost-effective in both the short and medium term, using the method generally recommended by the National Institute for Health and Care Excellence. Using the alternative measures to value QoL will have a considerable impact on cost-effectiveness decisions. It will be important to explore the clinical and health-care trajectories of the ECLIPSE (clinical effectiveness and cost-effectiveness of levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia) trial participants to 10 years, by which time half of the cohort will have reached menopause. TRIAL REGISTRATION Current Controlled Trials ISRCTN86566246. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 88. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Janesh K Gupta
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK.,Birmingham Women's Hospital NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - Jane P Daniels
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Lee J Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Helen M Pattison
- School of Health and Life Sciences, Aston University, Birmingham, UK
| | - Gail Prileszky
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Tracy E Roberts
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Sabina Sanghera
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Pelham Barton
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Richard Gray
- Clinical Trials Service Unit, University of Oxford, Oxford, UK
| | - Joe Kai
- Division of Primary Care, University of Nottingham, Nottingham, UK
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Sanghera S, Frew E, Gupta JK, Kai J, Roberts TE. Sensitivity to scale of willingness-to-pay within the context of menorrhagia. Health Expect 2016; 20:232-242. [PMID: 26914494 PMCID: PMC5354011 DOI: 10.1111/hex.12452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2016] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Willingness-to-pay (WTP) provides a broad assessment of well-being, capturing benefits beyond health. However, the validity of the approach has been questioned and the evidence relating to the sensitivity of WTP to changes in health status is mixed. Using menorrhagia (heavy menstrual bleeding) as a case study, this exploratory study assesses the sensitivity to scale of WTP to change in health status as measured by a condition-specific measure, MMAS, which includes both health and non-health benefits. The relationship between EQ-5D and change in health status is also assessed. METHODS Baseline EQ-5D and MMAS values were collected from women taking part in a randomized controlled trial for pharmaceutical treatment of menorrhagia. Following treatment, these measures were administered along with a WTP exercise. The relationship between the measures was assessed using Spearman's correlation analysis, and the sensitivity to scale of WTP was measured by identifying differences in WTP alongside differences in MMAS and EQ5D values. RESULTS Our exploratory findings indicated that WTP, and not EQ-5D, was significantly positively correlated with change in MMAS, providing some evidence for convergent validity. These findings suggest that WTP is capturing the non-health benefits within the MMAS measure. Mean WTP also increased with percentage improvements in MMAS, suggesting sensitivity to scale. CONCLUSION When compared to quality of life measured using the condition-specific MMAS measure, the convergent validity and sensitivity to scale of WTP is indicated. The findings suggest that WTP is more sensitive to change in MMAS, than with EQ-5D.
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Affiliation(s)
- Sabina Sanghera
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Emma Frew
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Janesh Kumar Gupta
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | - Joe Kai
- Division of Primary Care & National Institute for Health Research, University of Nottingham, Nottingham, UK
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Sanghera S, Frew E, Gupta JK, Kai J, Roberts TE. Exploring the Use of Cost-Benefit Analysis to Compare Pharmaceutical Treatments for Menorrhagia. PHARMACOECONOMICS 2015; 33:957-965. [PMID: 25911537 PMCID: PMC4559088 DOI: 10.1007/s40273-015-0280-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND The extra-welfarist theoretical framework tends to focus on health-related quality of life, whilst the welfarist framework captures a wider notion of well-being. EQ-5D and SF-6D are commonly used to value outcomes in chronic conditions with episodic symptoms, such as heavy menstrual bleeding (clinically termed menorrhagia). Because of their narrow-health focus and the condition's periodic nature these measures may be unsuitable. A viable alternative measure is willingness to pay (WTP) from the welfarist framework. OBJECTIVE We explore the use of WTP in a preliminary cost-benefit analysis comparing pharmaceutical treatments for menorrhagia. METHODS A cost-benefit analysis was carried out based on an outcome of WTP. The analysis is based in the UK primary care setting over a 24-month time period, with a partial societal perspective. Ninety-nine women completed a WTP exercise from the ex-ante (pre-treatment/condition) perspective. Maximum average WTP values were elicited for two pharmaceutical treatments, levonorgestrel-releasing intrauterine system (LNG-IUS) and oral treatment. Cost data were offset against WTP and the net present value derived for treatment. Qualitative information explaining the WTP values was also collected. RESULTS Oral treatment was indicated to be the most cost-beneficial intervention costing £107 less than LNG-IUS and generating £7 more benefits. The mean incremental net present value for oral treatment compared with LNG-IUS was £113. The use of the WTP approach was acceptable as very few protests and non-responses were observed. CONCLUSION The preliminary cost-benefit analysis results recommend oral treatment as the first-line treatment for menorrhagia. The WTP approach is a feasible alternative to the conventional EQ-5D/SF-6D approaches and offers advantages by capturing benefits beyond health, which is particularly relevant in menorrhagia.
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Affiliation(s)
- Sabina Sanghera
- />Health Economics Unit, Public Health Building, University of Birmingham, Edgbaston, Birmingham, B15 2TT UK
- />Health Economics Research Group, Brunel University London, Uxbridge, UB8 3PH UK
| | - Emma Frew
- />Health Economics Unit, Public Health Building, University of Birmingham, Edgbaston, Birmingham, B15 2TT UK
| | - Janesh Kumar Gupta
- />School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | - Joe Kai
- />Division of Primary Care and National Institute for Health Research, University of Nottingham, Nottingham, UK
| | - Tracy Elizabeth Roberts
- />Health Economics Unit, Public Health Building, University of Birmingham, Edgbaston, Birmingham, B15 2TT UK
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Sanghera S, Roberts TE, Barton P, Frew E, Daniels J, Middleton L, Gennard L, Kai J, Gupta JK. Levonorgestrel-releasing intrauterine system vs. usual medical treatment for menorrhagia: an economic evaluation alongside a randomised controlled trial. PLoS One 2014; 9:e91891. [PMID: 24638071 PMCID: PMC3956766 DOI: 10.1371/journal.pone.0091891] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 02/17/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To undertake an economic evaluation alongside the largest randomised controlled trial comparing Levonorgestrel-releasing intrauterine device ('LNG-IUS') and usual medical treatment for women with menorrhagia in primary care; and compare the cost-effectiveness findings using two alternative measures of quality of life. METHODS 571 women with menorrhagia from 63 UK centres were randomised between February 2005 and July 2009. Women were randomised to having a LNG-IUS fitted, or usual medical treatment, after discussing with their general practitioner their contraceptive needs or desire to avoid hormonal treatment. The treatment was specified prior to randomisation. For the economic evaluation we developed a state transition (Markov) model with a 24 month follow-up. The model structure was informed by the trial women's pathway and clinical experts. The economic evaluation adopted a UK National Health Service perspective and was based on an outcome of incremental cost per Quality Adjusted Life Year (QALY) estimated using both EQ-5D and SF-6D. RESULTS Using EQ-5D, LNG-IUS was the most cost-effective treatment for menorrhagia. LNG-IUS costs £100 more than usual medical treatment but generated 0.07 more QALYs. The incremental cost-effectiveness ratio for LNG-IUS compared to usual medical treatment was £1600 per additional QALY. Using SF-6D, usual medical treatment was the most cost-effective treatment. Usual medical treatment was both less costly (£100) and generated 0.002 more QALYs. CONCLUSION Impact on quality of life is the primary indicator of treatment success in menorrhagia. However, the most cost-effective treatment differs depending on the quality of life measure used to estimate the QALY. Under UK guidelines LNG-IUS would be the recommended treatment for menorrhagia. This study demonstrates that the appropriate valuation of outcomes in menorrhagia is crucial.
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Affiliation(s)
- Sabina Sanghera
- Health Economics Unit, University of Birmingham, Birmingham, United Kingdom
| | | | - Pelham Barton
- Health Economics Unit, University of Birmingham, Birmingham, United Kingdom
| | - Emma Frew
- Health Economics Unit, University of Birmingham, Birmingham, United Kingdom
| | - Jane Daniels
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, United Kingdom
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Lee Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Laura Gennard
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Joe Kai
- Division of Primary Care & National Institute for Health Research, University of Nottingham, Nottingham, United Kingdom
| | - Janesh Kumar Gupta
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, United Kingdom
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