Healthcare utilization and costs among women diagnosed with uterine fibroids: a longitudinal evaluation for 5 years pre- and post-diagnosis

Advancing women's health: The imperative for public health screening of uterine fibroids for personalized care

Uterine fibroids represent the most prevalent genital tract tumours among women, with a disproportionately higher impact on ethnic minority groups, notably black women. These hormonally dependent monoclonal tumours, characterized by excessive extracellular matrix and influenced by genetic, epigenetic, and lifestyle factors, significantly affect women's quality of life and pose substantial economic burdens on healthcare systems. Recent advances in early detection and minimally invasive treatment options have shifted management paradigms towards personalized care, yet challenges in early diagnosis, education and access to treatment persist. This review synthesizes current knowledge on uterine fibroids, highlighting the impact of fibroids on women's health, risk factors, principles of screening, diagnostic tools, and treatment modalities. It emphasizes the importance of early screening and individualized management strategies in improving patient outcomes and reducing healthcare costs. The article also discusses the socio-economic and health disparities affecting the disease burden, underscoring the need for improved patient education, clinician training, and public health strategies to enhance fibroid management. This review proposes a pathway to not only ameliorate the quality of life for women with fibroids, but also to advance global women's health equity.

Describing the Patient Journey of Women with Claims for Uterine Fibroids and Heavy Menstrual Bleeding Using a Commercial Database (2011-2020)

Introduction

This retrospective database claims analysis describes the clinical characteristics and treatment patterns of commercially insured United States women with uterine fibroids (UF) and heavy menstrual bleeding (HMB).

Methods

Women age 18-55 years with an incident UF diagnosis (index date) between 1/1/2012 and 12/31/2019 and ≥1 claim for HMB (UF-HMB), were identified from the Optum® Clinformatics® database. Outcomes included clinical characteristics, pharmacologic therapy use, and surgeries/procedures. Regression models were used to identify factors associated with time to post-diagnosis hormonal therapy and hysterectomy.

Results

A total of 85,428 women had UF-HMB (mean [SD] age, 43.7 [6.4] years). The median follow-up was 3.2 years. After HMB, the most common symptoms were pelvic pressure/pain (27.6%) and backache (17.5%). Within 6 months of UF diagnosis, 40.2% of patients had received only pharmacologic therapy; 25.5% had received no treatment; 24.3% had a hysterectomy, and 10.0% had other procedures. By the end of follow-up, 50.0% had received a hysterectomy. Multiple factors were predictive of a higher likelihood of receiving hormonal therapy (geographic region, infertility, pre-index pregnancy) or hysterectomy (older age, prior hormonal treatment, specific bulk symptoms, White race).

Conclusion

Within 6 months of UF diagnosis, fewer than one-half of women with UF-HMB had received hormonal therapy, one-quarter received no treatment, and one-quarter had received a hysterectomy or another gynecologic procedure. Patients who received a hysterectomy were more likely to be older, White, and to have bulk symptoms.

Global, regional, and national time trends in incidence, prevalence, years lived with disability for uterine fibroids, 1990-2019: an age-period-cohort analysis for the global burden of disease 2019 study

BACKGROUND

Uterine fibroids are the most common benign neoplasm of the uterus and a major source of morbidity for women. We report an overview of trends in uterine fibroids of incidence rate, prevalence rate, years lived with disability (YLDs) rate in 204 countries and territories over the past 30 years and associations with age, period, and birth cohort.

METHODS

The incident case, incidence rate, age-standardized rate (ASR) for incidence, prevalent case, prevalence rate, ASR for prevalence, number of YLDs, YLD rate, and ASR for YLDs were derived from the Global Burden of Disease 2019 (GBD 2019) study. We utilized an age-period-cohort (APC) model to estimate overall annual percentage changes in the rate of incidence, prevalence, and YLDs (net drifts), annual percentage changes from 10 to 14 years to 65-69 years (local drifts), period and cohort relative risks (period/cohort effects) between 1990 and 2019.

RESULTS

Globally, the incident cases, prevalent cases, and the number of YLDs of uterine fibroids increased from 1990 to 2019 with the growth of 67.07%, 78.82% and 77.34%, respectively. High Socio-demographic Index (SDI) and high-middle SDI quintiles with decreasing trends (net drift < 0.0%), and increasing trends (net drift > 0.0%) were observed in middle SDI, low-middle SDI, and low SDI quintiles in annual percentage change of incidence rate, prevalence rate and YLDs rate over the past 30 years. There were 186 countries and territories that showed an increasing trend in incidence rate, 183 showed an increasing trend in prevalence rate and 174 showed an increasing trend in YLDs rate. Moreover, the effects of age on uterine fibroids increased with age and peaked at 35-44 years and then declined with advancing age. Both the period and cohort effects on uterine fibroids showed increasing trend in middle SDI, low-middle SDI and low SDI quintiles in recent 15 years and birth cohort later than 1965.

CONCLUSIONS

The global burden of uterine fibroids is becoming more serious in middle SDI, low-middle SDI and low SDI quintiles. Raising awareness of uterine fibroids, increasing medical investment and improving levels of medical care are necessary to reduce future burden.

Gynaecological pathologies leading to emergency department admissions: A cross-sectional study

OBJECTIVE

Knowing the population's needs in order to plan measures to reduce emergency department (ED) use is fundamental. The objective of this study was to describe gynaecological ED visits and associated findings in women of reproductive age.

METHODS

This study was a retrospective anonymized chart review analysis of visits to the ED for gynaecological disturbances at the University Hospital of Modena. All consecutive women of reproductive age were included. Women aged <18 years and postmenopausal women were excluded from this study.

RESULTS

In total, 461 records were analysed. The median age was 41 (interquartile range 34-46) years. The most common symptom was dysmenorrhoea (42.7 %), followed by heavy menstrual bleeding (33.2 %). The most common gynaecological findings in the ED were adenomyosis (86.1 %), endometriosis (37.1 %) and leiomyomas (13.7 %). Adenomyosis was the most common finding, regardless of age. Endometriosis was more prevalent in women aged <41 years (43.8 % vs 31.2 %; p < 0.05). Meanwhile, adenomyosis and leiomyomas were more prevalent in women aged ≥41 years (81.11 % vs 90.57 % and 7.37 % vs 19.26 %, respectively; p < 0.05). Moreover, potentially life-threatening findings had low prevalence [i.e. haemorrhagic ovarian cyst (0.2 %), tubo-ovarian abscess (0.2 %) and pelvic inflammatory disease (0.4 %)].

CONCLUSION

In the study setting, chronic pathologies such as adenomyosis, endometriosis and leiomyomas significantly impacted use of the ED. Adenomyosis was the most common pathology, regardless of age. Adenomyosis and leiomyomas were more prevalent in women aged ≥41 years, and endometriosis was more prevalent in women aged <41 years.

Anxiety, Depression, and Quality of Life After Procedural Intervention for Uterine Fibroids

Background: Quality of life (QOL) and psychological health has been reported to be decreased among women with gynecological conditions such as uterine fibroids (UFs). Materials and Methods: Women enrolled in the Comparing Options for Management: PAtient-centered REsults for Uterine Fibroids (COMPARE-UF) registry, receiving procedural therapy for symptomatic UFs, were eligible for this analysis if they completed a series of health-related QOL surveys administered at three time points (baseline, 6-12 weeks postprocedure, and 1 year postprocedure; n = 1486). Ethical approval for this study was obtained at each recruiting site and the coordinating center (NCT02260752, clinicaltrials.gov). Results: More than 26% (n = 393) of women reported moderate anxiety/depression on the baseline anxiety/depression domain of the Euro-QOL 5-dimension instrument. At both the 6-12 weeks and 1-year postprocedural follow-up, there was significant improvement in the UF QOL symptom severity score (p < 0.001, p < 0.001), the total UF symptom QOL score (p < 0.001, p < 0.001), and the Euro-QOL 5-dimension visual analog scale (p < 0.001, p = 0.004) compared with the preprocedural baseline scores. The reporting of anxiety/depression decreased by 66.4% among women who were at baseline, whereas 5.6% of women previously reporting no anxiety/depression reported anxiety/depression at the 1-year follow-up. Conclusion: UF symptoms were more severe among women reporting anxiety/depression at baseline. At the 1-year follow-up, health-related QOL scores improved among all women and the prevalence of anxiety/depression decreased in most, but not all women, whereas severity of anxiety/depression worsened in a small percentage of women (5.6%). Overall, these results suggest that UF treatment improves symptoms of anxiety/depression associated with symptomatic UFs.

Efficacy and safety of elagolix with add-back therapy in women with uterine fibroids and coexisting adenomyosis

Objective

To determine if coexisting adenomyosis limits the efficacy of elagolix, an oral gonadotropin-releasing hormone antagonist, with hormonal add-back therapy in reducing heavy menstrual bleeding in women with uterine fibroids.

Design

Pooled analysis of two identical, double-blind, randomized, placebo-controlled, 6-month phase 3 trials (Elaris Uterine Fibroids [UF]-1 and UF-2).

Setting

A total of 153 gynecological clinical care settings in the United States and Canada.

Patients

Premenopausal women (18-51 years) with >80 mL of menstrual blood loss (MBL)/cycle and uterine fibroids with and without coexisting adenomyosis diagnosed by ultrasound and/or magnetic resonance imaging at baseline.

Interventions

Participants were randomized 1:1:2 to placebo, elagolix 300 mg twice daily alone, or elagolix 300 mg twice daily with estradiol 1 mg/norethindrone acetate 0.5 mg once daily.

Main Outcome Measures

The primary endpoint was the proportion of women who had <80 mL of MBL during the final month and ≥50% reduction in MBL from baseline to the final month. Adverse events were monitored.

Results

Of 786 women treated across the two trials, 16% (126 women) had coexisting adenomyosis. Among this subset, a significantly greater proportion of women who received elagolix with add-back therapy (77.1% [95% confidence interval, 66.2, 88.0]) met both primary endpoint criteria compared with women who received placebo (12.2% [95% confidence interval, 1.0, 23.4]). Adverse events most frequently reported in the elagolix with add-back adenomyosis subset were hot flushes (18.3%), nausea (11.7%), and night sweats (8.3%).

Conclusions

Elagolix with add-back therapy significantly reduced heavy menstrual bleeding in women with uterine fibroids and coexisting adenomyosis, suggesting that elagolix efficacy was not adversely affected by the presence of adenomyosis (Elaris UF-1 and UF-2 Clinical-Trials.gov numbers, NCT02654054 and NCT02691494).

Trends in Emergency Department Utilization Among Women With Leiomyomas in the United States

OBJECTIVE

To describe trends in emergency department (ED) visits in the United States with a primary diagnosis of leiomyomas, subsequent admissions, and associated charges.

METHODS

The Healthcare Cost and Utilization Project Nationwide Emergency Department Sample database was used to retrospectively identify all ED visits from 2006 to 2017 among women aged 18-55 years with a primary diagnosis of leiomyomas as indicated by International Classification of Diseases (ICD) diagnosis codes. Trends in ED visits and subsequent admissions were analyzed and stratified by patient and hospital characteristics. Secondary ICD codes, Current Procedural Terminology codes, and hospital charges were analyzed. A multivariate regression model was used to identify predictors of admission.

RESULTS

Although the number of ED visits for leiomyomas increased from 28,732 in 2006 to 65,685 in 2017, the admission rate decreased, from 23.9% in 2006 to 11.1% in 2017. Emergency department visits for leiomyomas were highest among women who were aged 36-45 years (44.5%), in the lowest income quartile (36.1%), privately insured (38.3%), and living in the South (46.2%). Admission was more likely at nonteaching hospitals (odds ratio [OR] 1.23, 95% CI 1.08-1.39) or those located in the Northeast (OR 1.39, 95% CI 1.15-1.68). Patient characteristics associated with admission included older age (26-35 years: OR 1.42, 95% CI 1.21-1.66; 36-45 years: OR 2.01, 95% CI 1.72-2.34; 46-55 years: OR 2.60, 95% CI 2.23-3.03) and bleeding-related complaints (OR 14.92, 95% CI 14.00-15.90). Admission was least likely in uninsured patients (Medicare: OR 1.37, 95% CI 1.21-1.54; Medicaid: OR 1.26, 95% CI 1.16-1.36; private: OR 1.44, 95% CI 1.32-1.56).

CONCLUSION

Although ED visits for leiomyomas are increasing, admission rates for these visits are decreasing. The substantial decline in admissions suggests many of these visits could potentially be addressed in a non-acute-care setting. However, when women with leiomyomas present with a bleeding-related complaint, the odds of admission increase 15-fold. There is an apparent disparity in likelihood of admission based on insurance type.

Elagolix Treatment for Up to 12 Months in Women With Heavy Menstrual Bleeding and Uterine Leiomyomas

Up to 12 months of elagolix with add-back therapy provided sustained reduction in menstrual blood loss with an acceptable safety profile in women with uterine leiomyomas.

To investigate the safety and efficacy of elagolix, an oral gonadotropin-releasing hormone antagonist, with hormonal add-back therapy for up to 12 months in women with heavy menstrual bleeding associated with uterine leiomyomas.

Demographics and Hospital Outcomes in American Women With Endometriosis and Psychiatric Comorbidities

Objectives

To explore sociodemographic differences and hospital outcomes in endometriosis patients with versus without psychiatric comorbidities.

Methods

We conducted a cross-sectional study using the Nationwide Inpatient Sample (NIS, 2012-2014), and included 63,160 females with primary diagnosis of endometriosis. We used descriptive statistics and Pearson’s chi-square test to measure the differences in demographics and utilization of gynecologic procedures by the presence of psychiatric comorbidities.

Results

Psychiatric comorbidities were present in 18.7% inpatients with endometriosis. About three-fourth of these inpatients were in reproductive age group 26-45 years (75.7%) and were whites (79.1%). Psychiatric comorbidities were seen more in females from middle-income families and from the midwest region of the US. There was no significant difference in the utilization of gynecological procedures by the presence of psychiatric comorbidities. However, inpatients with psychiatric comorbidities had a longer mean length of stay (2.5 vs. 2.3 days) and total charges ($35,489 vs. $34,673) compared to the non-psychiatric cohort. Anxiety disorders predominated at 45% in patients with endometriosis followed by depressive disorder (31.3%), psychotic disorders (12.3%), and drug abuse (6.3%).

Conclusion

Endometriosis with psychiatric comorbidities is prevalent in young white females from a middle-income family. Anxiety and depressive disorders are most prevalent and are associated with extended hospitalization stay and higher charges, thereby negatively impacting the healthcare burden compared to those without psychiatric comorbidities.

Elagolix for Heavy Menstrual Bleeding in Women with Uterine Fibroids

BACKGROUND

Uterine fibroids are hormone-responsive neoplasms that are associated with heavy menstrual bleeding. Elagolix, an oral gonadotropin-releasing hormone antagonist resulting in rapid, reversible suppression of ovarian sex hormones, may reduce fibroid-associated bleeding.

METHODS

We conducted two identical, double-blind, randomized, placebo-controlled, 6-month phase 3 trials (Elaris Uterine Fibroids 1 and 2 [UF-1 and UF-2]) to evaluate the efficacy and safety of elagolix at a dose of 300 mg twice daily with hormonal "add-back" therapy (to replace reduced levels of endogenous hormones; in this case, estradiol, 1 mg, and norethindrone acetate, 0.5 mg, once daily) in women with fibroid-associated bleeding. An elagolix-alone group was included to assess the impact of add-back therapy on the hypoestrogenic effects of elagolix. The primary end point was menstrual blood loss of less than 80 ml during the final month of treatment and at least a 50% reduction in menstrual blood loss from baseline to the final month; missing data were imputed with the use of multiple imputation.

RESULTS

A total of 412 women in UF-1 and 378 women in UF-2 underwent randomization, received elagolix or placebo, and were included in the analyses. Criteria for the primary end point were met in 68.5% of 206 women in UF-1 and in 76.5% of 189 women in UF-2 who received elagolix plus add-back therapy, as compared with 8.7% of 102 women and 10% of 94 women, respectively, who received placebo (P<0.001 for both trials). Among the women who received elagolix alone, the primary end point was met in 84.1% of 104 women in UF-1 and in 77% of 95 women in UF-2. Hot flushes (in both trials) and metrorrhagia (in UF-1) occurred significantly more commonly with elagolix plus add-back therapy than with placebo. Hypoestrogenic effects of elagolix, especially decreases in bone mineral density, were attenuated with add-back therapy.

CONCLUSIONS

Elagolix with add-back therapy was effective in reducing heavy menstrual bleeding in women with uterine fibroids. (Funded by AbbVie; Elaris UF-1 and Elaris UF-2 ClinicalTrials.gov numbers, NCT02654054 and NCT02691494.).

Direct Costs Incurred Among Women Undergoing Surgical Procedures to Treat Uterine Fibroids

BACKGROUND

Uterine fibroids (UF) affect up to 70%-80% of women by 50 years of age and represent a substantial economic burden on patients and society. Despite the high costs associated with UF, recent studies on the costs of UF-related surgical treatments remain limited.

OBJECTIVE

To describe the health care resource utilization (HCRU) and all-cause costs among women diagnosed with UF who underwent UF-related surgery.

METHODS

Data from the IBM MarketScan Commercial Claims and Encounters database and Medicaid Multi-State database were independently, retrospectively analyzed from January 1, 2009, to December 31, 2015. Women aged 18-64 years with ≥ 1 UF claim from January 1, 2010, to December 31, 2014, a claim for a UF-related surgery (hysterectomy, myomectomy, uterine artery embolization [UAE], or ablation) from January 1, 2010, to November 30, 2015, and continuous enrollment for ≥ 1 year presurgery and ≥ 30 days postsurgery qualified for study inclusion. A 1-year period before the date of the first UF-related surgical claim after the first UF diagnosis was used to report baseline demographic and clinical characteristics. Surgery characteristics were reported. All-cause HCRU and costs (adjusted to 2017 U.S. dollars) were described by the 14 days pre-, peri-, and 30 days postoperative periods, and independently by the inpatient or outpatient setting.

RESULTS

Overall, 113,091 patients were included in this study: commercial database, n = 103,814; Medicaid database, n = 9,277. Median time from the initial UF diagnosis to first UF-related surgical procedure was 33 days for the commercial population and 47 days for the Medicaid population. Hysterectomy was the most common UF-related surgery received after UF diagnosis (commercial, 68% [n = 70,235]; Medicaid, 75% [n = 6,928]). In both populations, 97% of patients had ≥ 1 outpatient visit from 14 days presurgery to 30 days postsurgery (commercial, n = 100,402; Medicaid, n = 9,023), and the majority of all UF-related surgeries occurred in the outpatient setting (commercial, 64% [n = 66,228]; Medicaid, 66% [n = 6,090]). Mean total all-cause costs for patients with UF who underwent any UF-related surgery were $15,813 (SD $13,804) in the commercial population (n = 95,433) and $11,493 (SD $26,724) in the Medicaid population (n = 4,785). Mean total all-cause costs for UF-related surgeries for the commercial/Medicaid populations were $17,450 (SD $13,483)/$12,273 (SD $19,637) for hysterectomy, $14,216 (SD $16,382)/$11,764 (SD $15,478) for myomectomy, $17,163 (SD $13,527)/$12,543 (SD $23,777) for UAE, $8,757 (SD $9,369)/$7,622 (SD $50,750) for ablation, and $12,281 (SD $10,080)/$5,989 (SD $5,617) for myomectomy and ablation. Mean total all-cause costs for any UF-related surgery performed in the outpatient setting in the commercial and Medicaid populations were $14,396 (SD $11,466) and $6,720 (SD $10,374), respectively, whereas costs in the inpatient setting were $18,345 (SD $16,910) and $21,805 (SD $43,244), respectively.

CONCLUSIONS

This retrospective analysis indicated that surgical treatment options for UF continue to represent a substantial financial burden. This underscores the need for alternative, cost-effective treatments for the management of UF.

DISCLOSURES

This study was sponsored by Allergan, Dublin, Ireland. Allergan played a role in the conduct, analysis, interpretation, writing of the report, and decision to publish this study. Harrington and Ye are employees of Allergan. Stafkey-Mailey, Fuldeore, and Yue are employees of Xcenda. Ta was a contractor at Allergan at the time the study was conducted and is currently supported by a training grant from Allergan. Bonine, Shih, and Gillard are employees of Allergan and have stock, stock options, and/or restricted stock units as employees of Allergan. Banks has no disclosures to report. This study was presented as a poster at Academy of Managed Care Pharmacy Nexus 2017; October 16-19, 2017; Dallas, TX.

The association between chronic psychological stress and uterine fibroids risk: A meta-analysis of observational studies

The association between chronic psychological stress and uterine fibroids (UFs) risk remains unclear. In this study, a meta-analysis of observational studies was performed to explore the reported association between them. A literature search was performed in PubMed, EMBASE, and Web of Science to identify relevant published articles. A random-effect model was used to examine pooled odds ratio (OR) and 95% confidence interval (CI). Additionally, subgroup analyses and two-stage random-effect dose-response meta-analysis were performed. A total of six articles with seven studies were included in this meta-analysis. For the highest versus lowest category of chronic psychological stress, the pooled OR was 1.24 (95% CI [1.15, 1.34]; p = .000). Through subgroup analyses, we found a positive association between chronic psychological stress and UFs risk especially in non-Hispanic Blacks studies (OR, 1.24, 95% CI [1.14, 1.34], p = .000). When evaluating for a dose-response, we found a weak correlation between chronic psychological stress and UFs risk, especially for the severe (OR, 1.17, 95% CI [1.07, 1.29]) and very severe (OR, 1.23, 95% CI [1.07, 1.41]) categories. Our meta-analysis shows a statistically significant association between chronic psychological stress and UFs risk particularly for non-Hispanic Blacks. Interventions aiming to reduce chronic psychological stress may be useful to decrease the prevalence of UFs.

A 12-month extension study to evaluate the safety and efficacy of asoprisnil in women with heavy menstrual bleeding and uterine fibroids

STUDY QUESTION

What is the safety and efficacy profile during long-term (12–24 months) uninterrupted treatment with the selective progesterone receptor modulator asoprisnil, 10 and 25 mg in women with heavy menstrual bleeding (HMB) associated with uterine fibroids?

SUMMARY ANSWER

Uninterrupted treatment with asoprisnil should be avoided due to endometrial safety concerns and unknown potential long-term consequences.

WHAT IS KNOWN ALREADY

Asoprisnil was well tolerated in shorter-term studies and effectively suppressed HMB and reduced fibroid volume.

STUDY DESIGN, SIZE, DURATION

Women with uterine fibroids who had previously received placebo (n = 87) or asoprisnil 10 mg (n = 221) or 25 mg (n = 215) for 12 months in two double-blind studies entered this randomized uncontrolled extension study and received up to 12 additional months of treatment followed by 6 months of post-treatment follow-up. Women who previously received placebo were re-randomized to either asoprisnil 10 or 25 mg for the extension study. This report focuses on the 436 women who received asoprisnil in the double-blind studies and this extension study. Results for women who previously received placebo in the double-blind studies are not described.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women ≥18 years of age who completed a 12-month, double-blind, placebo-controlled study, had estradiol levels indicating that they were not menopausal and had no endometrial hyperplasia or other significant endometrial pathology were eligible. The safety endpoints were focused on endometrial assessments. The composite primary efficacy endpoint was the proportion of women who demonstrated a response to treatment by meeting all three of the following criteria at the final month for participants who prematurely discontinued or at month 12 for those who completed the study: a reduction from initial baseline to final visit of ≥50% in the menstrual pictogram score, hemoglobin concentration ≥11 g/dl or an increase of ≥1 g/dl from initial baseline at the final visit, and no surgical or invasive intervention for uterine fibroids. Other efficacy endpoints included rates for amenorrhea and suppression of bleeding, changes in fibroid and uterine volume and changes in hematologic parameters. No statistical tests were planned or performed for this uncontrolled study.

MAIN RESULTS AND ROLE OF CHANCE

Imaging studies revealed a progressive increase in endometrial thickness and cystic changes that frequently prompted invasive diagnostic procedures. Endometrial biopsy results were consistent with antiproliferative effects of asoprisnil. Two cases of endometrial cancer were diagnosed. At the final month of this extension study (total duration of uninterrupted treatment up to 24 months), the primary efficacy endpoint was achieved in 86 and 92% of women in the asoprisnil 10- and 25-mg groups, respectively. During each month of treatment, amenorrhea was observed in the majority of women (up to 77 and 94% at 10 and 25 mg, respectively). There was a progressive, dose-dependent decrease in the volume of the primary fibroid with asoprisnil 10 and 25 mg (−55.7 and −75.2% median decrease, respectively, from baseline [i.e. the beginning of the placebo-controlled study] to month 12 [cumulative months 12–24] of this extension study). These effects were associated with improvements in quality of life measures.

LIMITATIONS, REASONS FOR CAUTION

This study was uncontrolled, which limits the interpretation of safety and efficacy findings. The study also had multiple protocol amendments with the addition of diagnostic procedures and, because no active comparator was included, the potential place of asoprisnil in comparison to therapies such as GnRH agonists and surgery cannot be determined.

WIDER IMPLICATIONS OF THE FINDINGS

Long-term, uninterrupted treatment with asoprisnil leads to prominent cystic endometrial changes that are consistent with the ‘late progesterone receptor modulator’ effects, which prompted invasive diagnostic procedures, although treatment efficacy is maintained. Although endometrial cancers were uncommon during both treatment and follow-up, these findings raise concerns regarding endometrial safety during uninterrupted long-term treatment with asoprisnil. This study shows that uninterrupted treatment with asoprisnil should be avoided due to safety concerns and unknown potential long-term consequences.

STUDY FUNDING/COMPETING INTEREST(S)

AbbVie Inc. (prior sponsor, TAP Pharmaceutical Products Inc.) sponsored the study and contributed to the design and conduct of the study, data management, data analysis, interpretation of the data and the preparation and approval of the manuscript. Financial support for medical writing and editorial assistance was provided by AbbVie Inc. M. P. Diamond received research funding for the conduct of the study paid to the institution and is a consultant to AbbVie. He is a stockholder and board and director member of Advanced Reproductive Care. He has also received funding for study conduct paid to the institution for Bayer and ObsEva. E. A. Stewart participated as a site investigator in the phase 2 study of asoprisnil and served as a consultant to TAP Pharmaceuticals during the time of design and conduct of the studies while on the faculty of Harvard Medical School and Brigham and Women’s Hospital, Boston, MA. In the last 3 years, she has received support from National Institutes of Health grants HD063312, HS023418 and HD074711. She has served as a consultant for AbbVie Inc., Allergan, Bayer HealthCare AG and Myovant for consulting related to uterine leiomyoma and to Welltwigs for consulting related to infertility. She has received royalties from UpToDate and the Med Learning Group. A.R.W. Williams has acted as a consultant for TAP Pharmaceutical Products Inc. and Repros Therapeutics Inc. He has current consultancies with PregLem SA, Gedeon Richter, HRA Pharma and Bayer. B.R. Carr has served as consultant and received research funding from AbbVie Inc. and Synteract (Medicines360). E.R. Myers has served as consultant for AbbVie Inc., Allergan and Bayer. R.A. Feldman received compensation for serving as a principal investigator and participating in the conduct of the trial. W. Elger was a co-inventor of several patents related to asoprisnil.

C. Mattia-Goldberg is a former employee of AbbVie Inc. and owns AbbVie stock or stock options. B.M. Schwefel and K. Chwalisz are employees of AbbVie Inc. and own AbbVie stock or stock options.

TRIAL REGISTRATION NUMBER

NCT00156195 at clinicaltrials.gov.

Healthcare resource utilization and costs among women diagnosed with uterine fibroids compared to women without uterine fibroids

Objective: To perform a retrospective, matched-cohort, longitudinal evaluation of annual pre- and post-diagnosis costs incurred among women with uterine fibroids (UF) (cases) compared to controls without UF. Methods: Data were derived from the IBM Watson Health MarketScan Commercial Claims and Encounters and Medicaid Multi-State databases. Women aged 18-64 years with ≥1 inpatient or outpatient medical claim with an initial UF diagnosis (index date) from 1 January 2010 to 31 December 2014 were included. Healthcare resource utilization (HCRU) data including pharmacy, outpatient and inpatient hospital claims were collected for 1 year pre-index and ≤5 years post-index. All-cause costs (adjusted to 2017 $US) were compared between cases and controls using multivariable regression models. Results: Analysis included 205,098 (Commercial) and 24,755 (Medicaid) case-control pairs. HCRU and total all-cause healthcare costs were higher for cases versus controls during the pre-index year and all years post-index. Total unadjusted mean all-cause costs were $1197 higher (p < .0001; Commercial) and $2813 higher (standardized difference 0.08; Medicaid) for cases during the pre-index year. Total adjusted mean all-cause costs in the first year post-index were $14,917 for cases versus $5717 for controls in the Commercial population, and $20,244 versus $10,544, respectively, in the Medicaid population. In Years 2-5 post-index, incremental mean adjusted total costs decreased, but remained significantly higher for cases versus controls at all time points in both populations (all p < .05). Conclusions: Costs were higher for women with UF compared to women without UF during the pre-index year and over 5 years post-index; differences were greatest in the first year post-index.

Women with Newly Diagnosed Uterine Fibroids: Treatment Patterns and Cost Comparison for Select Treatment Options

The primary objective of this study was to describe surgical treatment patterns among women with newly diagnosed uterine fibroids (UF). A secondary objective was to estimate the medical costs associated with other common surgical interventions for UF. Claims-based commercial and Medicare data (2011-2016) were used to identify women aged ≥30 years with continuous enrollment for at least 12 months before and after a new diagnosis of UF. Receipt of a surgical or radiologic procedure (hysterectomy, myomectomy, endometrial ablation, uterine artery embolization, and curettage) was the primary outcome. Health care resource utilization and costs were calculated for women with at least 12 months of continuous enrollment following a UF surgical procedure. Among women who met selection criteria, 31.7% of patients underwent a surgical procedure; 20.9% of these underwent hysterectomy. An increase was observed over time in the percentage of women undergoing outpatient hysterectomy (from 27.0% to 40.2%) and hysteroscopic myomectomy (from 8.0% to 11.5%). The cost analysis revealed that total health care costs for hysteroscopic myomectomy ($17,324) were significantly lower (P < 0.001) than those for women who underwent inpatient hysterectomy ($24,027) and those for women undergoing the 3 comparison procedures. Hysterectomy was the most common surgical intervention. Patients undergoing inpatient hysterectomy had the highest health care costs. Although less expensive, minimally invasive approaches are becoming more common; they are performed infrequently in patients with newly diagnosed UF. The results of this study may be useful in guiding decisions regarding the most appropriate and cost-effective surgical treatment for UF.

Reintervention Rates After Myomectomy, Endometrial Ablation, and Uterine Artery Embolization for Patients with Uterine Fibroids

Background: Women with uterine fibroids (UF) may undergo less invasive procedures than hysterectomy, including myomectomy, endometrial ablation (EA), and uterine artery embolization (UAE); however, long-term need for reintervention is not well characterized. We estimated reintervention rates for 5 years and identified predictors of reintervention.

Materials and Methods: A longitudinal retrospective cohort study was conducted in women in MarketScan^® Commercial Claims and Encounters (Truven Health Analytics) aged 18–49 years with UF diagnosis before myomectomy, EA, or UAE from 2008 to 2014. Patients were categorized by initial procedure (index date) and required to have ≥12 months of continuous coverage before and after. Kaplan–Meier analyses and Cox proportional hazard models were used to estimate survival without reintervention and hazard of reintervention for 5 years.

Results: The study included 35,631 women with myomectomy (n = 13,804: 8,018 abdominal, 941 hysteroscopic, and 4,845 laparoscopic), EA (n = 17,198), and UAE (n = 4,629). Myomectomy had the lowest 12-month reintervention rate (4.2%), followed by UAE (7.0%), then EA (12.4%; both p < 0.001 relative of myomectomy). Estimates of 5-year reintervention rates were 19% for myomectomy (17%, 28%, and 20% for abdominal, hysteroscopic, and laparoscopic, respectively), 33% for EA, and 24% for UAE. EA and UAE had adjusted hazard ratios of 2.63 (95% confidence interval [CI], 2.44–2.83) and 1.56 (95% CI, 1.42–1.72). Prior anemia, bleeding, pelvic inflammatory disease, and abdominal and pelvic pain increased the hazard of reintervention.

Conclusion: Reintervention rate estimates ranged from 17% to 33% for 5 years after myomectomy, EA, and UAE for patients with UF. Risk of requiring reintervention should be considered during treatment selection.

Real-World Evaluation of Direct and Indirect Economic Burden Among Endometriosis Patients in the United States

Introduction

The prevalence of endometriosis and the need for treatment in the USA has led to the need to explore the contemporary cost burden associated with the disease. This retrospective cohort study compared direct and indirect healthcare costs in patients with endometriosis to a control group without endometriosis.

Methods

Women aged 18–49 years with endometriosis (date of initial diagnosis = index date) were identified in the Truven Health MarketScan^® Commercial database between 2010 and 2014 and female control patients without endometriosis were matched by age and index year. The following outcomes were compared: healthcare resource utilization (HRU) during the 12-month pre- and post-index periods (including inpatient admissions, pharmacy claims, emergency room visits, physician office visits, and obstetrics/gynecology visits), annual direct (medical and pharmacy) and indirect (absenteeism, short-term disability, and long-term disability) healthcare costs during the 12-month post-index period (in 2014 US$). Multivariate analyses were conducted to estimate annual total direct and indirect costs, controlling for demographics, pre-index clinical characteristics, and pre-index healthcare costs.

Results

Overall, 113,506 endometriosis patients and 927,599 controls were included. Endometriosis patients had significantly higher HRU during both the pre- and post-index periods compared to controls (p < 0.0001, all categories of HRU). Approximately two-thirds of endometriosis patients underwent an endometriosis-related surgical procedure (including laparotomy, laparoscopy, hysterectomy, oophorectomy, and other excision/ablation procedures) in the first 12 months post-index. Mean annual total adjusted direct costs per endometriosis patient during the 12-month post-index period was over three times higher than that for a non-endometriosis control [$16,573 (standard deviation (SD) = $21,336) vs. $4733 (SD = $14,833); p < 0.005]. On average, incremental direct and indirect 12-month costs per endometriosis patient were $10,002 and $2132 compared to their matched controls (p < 0.005).

Conclusions

Endometriosis patients incurred significantly higher direct and indirect healthcare costs than non-endometriosis patients.

Funding

AbbVie Inc.

Electronic supplementary material

The online version of this article (10.1007/s12325-018-0667-3) contains supplementary material, which is available to authorized users.

Uterine Fibroids: Burden and Unmet Medical Need

Uterine fibroids affect a wide cross-section of the population, with prevalence, symptom severity, and overall disease burden generally higher among black women, likely due to both genetic and environmental factors. Potential symptoms of uterine fibroids include painful and excessive uterine bleeding, interference with everyday life and self-image, and impaired fertility. Because of the high estimated prevalence and costs associated with treatments, the direct and indirect costs of uterine fibroids are substantial for both the health care system and the individual patient. Special patient populations—such as black women, women seeking to retain fertility, and women with asymptomatic fibroids—have particular treatment needs that require a variety of diagnostic methods and treatment options. Despite the widespread occurrence of uterine fibroids and newer treatment options, little high-quality data are available to formulate evidence-based guidelines that address these unmet patient needs. Specific areas in need of attention include improving diagnostic techniques, increasing patient access to early treatment, and identifying best practices for this diverse patient population.

Disability benefits as an incentive for hysterectomy: Uterine fibroid patients in Taiwan

Worker compensation insurance in Taiwan ensures that a woman under the age of 45 years who has her uterus removed can receive disability compensation benefits. The present study investigated whether such a compensation policy was related to a woman's inclination to have a hysterectomy. We extracted the records of 16,030 women diagnosed with uterine fibroids (UF) between 2000 and 2010 from the Longitudinal Taiwan Health Insurance Database. Each younger and older age group had a significantly lower hysterectomy rate compared to that of the 44-year-old age group. Moreover, significantly more patients with lower monthly wages had had hysterectomies than those with higher monthly wages. Policy makers should be aware that worker compensation regulations in Taiwan might encourage women with economic need to undergo hysterectomy surgery when approaching the age of 45 years.