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.

Electrothermal bipolar vessel sealing device (LigaSure™) versus conventional diathermy in laparoscopic myomectomy: A propensity-matched analysis

The purpose of this study was to compare the safety and efficacy of an electrothermal bipolar vessel sealing device (LigaSure™) and traditional electrical cauterization in laparoscopic myomectomy (LM). A total of 756 patients with symptomatic uterine myomas who underwent LM were reviewed retrospectively. A total of 225 cases of LM using LigaSure™ (LML group) were compared with a control group treated with traditional electrical cauterization (LME group) under propensity-matched analysis. Outcome measures for both groups were compared, such as operative time, blood loss (BL), complications, need for blood transfusion, hospital expenses, and hospital stay. Six subgroups were divided according to main myoma size and energy source. No cases required switching to abdominal myomectomy. The number of myomas removed, BL, need for blood transfusion, and complications were not significantly different, whereas hospital stay was longer in the LME group than in the LML group and total hospital expenses were higher in the LML group (p < 0.001). The overall operation duration was significantly longer in the LML group but was not significantly different for main myoma >10 cm (LML vs LME, 121.58 ± 41.77 vs 121.69 ± 44.95, p = 0.99); this likely reflects the operative efficiency on using LigaSure™ to manage large tumors. Significant linear correlations between myoma weight and operative time and BL were seen in both groups. Conventional diathermy is more effective for small-to-medium myomas. Use of the LigaSure™ was efficient for myomas >10 cm.

Repeated-intermittent use of ulipristal acetate for the management of uterine fibroids: an Italian pharmacoeconomic evaluation

BACKGROUND

The aim of this paper was to evaluate an Italian pharmacoeconomic profile of repeated-intermittent (from 4 to 10 cycles) use of ulipristal acetate 5 mg (UPA 5 mg) in comparison with the use of UPA 5 mg before surgery (2 cycles) for the management of symptomatic uterine fibroids.

METHODS

The pharmacoeconomic analysis was performed in two steps: 1) estimating an incremental cost-effectiveness ratio (ICER); 2) assuming a nationwide prediction of future expenditure in the Italian scenario. Effectiveness data were derived from the randomized-controlled trial, whilst quality of life and costs data were retrieved from the published literature.

RESULTS

In comparison with the use of UPA 5 mg before surgery, the values of ICER per patient were the following: 1) €20,600 euros (UPA 5 mg 4 cycles); 2) €26,884 (UPA 5mg 6 cycles); 3) €30,244 (UPA 5 mg 8 cycles); 4) €31,906 (UPA 5 mg 10 cycles). In comparison with the use of UPA 5 mg before surgery plus subsequent surgery, the saving per patient for the National Healthcare System (NHS) by adding repeated-intermittent use of UPA 5 mg were the following: 1) €26 million (UPA 5 mg 4 cycles); 2) €17.6 million (UPA 5mg 6 cycles); 3) €8.9 million (UPA 5 mg 8 cycles); 4) €0.2 million (UPA 5 mg 10 cycles).

CONCLUSIONS

The results showed that repeated-intermittent use of UPA 5 mg for the long-term treatment of uterine fibroids has a favourable pharmacoeconomic profile up to 10 repeated cycles and may be a cost-saving treatment option for the NHS. Although the data are encouraging, more data are needed regarding the benefits and risks of long-term treatment with UPA.

The direct and indirect costs of uterine fibroid tumors: a systematic review of the literature between 2000 and 2013

This systematic literature review was conducted to summarize the direct and indirect costs per patient that are associated with uterine fibroid tumors in international studies. A search with predefined search terms was conducted in MEDLINE and EMBASE for studies that were published from January 2000 to November 2013. The review included primary studies that were in English and that reported either direct costs (drug costs, procedure costs, and medical service costs) or indirect costs (such as productivity loss) among patients with uterine fibroid tumors. A total of 26 studies that were identified and included in the data extraction included 19 studies in the United States, 2 studies in the Netherlands, 1 study each in Germany, China, Italy, and Canada, and 1 study reported data that were collected from 3 countries: Germany, France, and England. The studies differed substantially in perspectives that were adopted for analysis, research designs, data elements that were collected, setting, populations, and outcome measurements. Among 3 studies that reported total direct costs during the year after uterine fibroid tumor diagnosis, 2 studies reported an average of $9473 and $9319 per patient, respectively; 2 studies reported the excess costs over controls to be $6076 and $5427, respectively. The indirect costs per patient ranged from $2399-15,549, and the excess indirect cost per patient over control groups ranged from $323-4824 in the year after the diagnosis. The total costs, sum of direct and indirect costs, ranged from $11,717-25,023 per patient per year, after diagnosis or surgery among patients with uterine fibroid tumors. Compared with control subjects, the additional annual cost ranged from $2200-15,952 per patient. The results of this systematic literature review highlight the substantial direct and indirect costs that are associated with uterine fibroid tumors to health care payers and society. The large number and the variety of studies identified also emphasize the growing awareness of the significant economic impact of uterine fibroid tumors. Current gaps that were identified through this review warrant further investigation to elucidate fully the economic burden of uterine fibroid tumors, including, but not limited to, burden from the patient's perspective and the entirety of indirect costs.

Magnetic Resonance-Guided High-Intensity Focused Ultrasound (MRgHIFU) for Treatment of Symptomatic Uterine Fibroids: An Economic Analysis

BACKGROUND

Uterine fibroids, or leiomyomas, are the most common benign tumours in women of childbearing age. Some women experience symptoms (e.g., heavy bleeding) that require aggressive forms of treatment such as uterine artery embolization (UAE), myomectomy, magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU), and even hysterectomy. It is important to note that hysterectomy is not appropriate for women who desire future childbearing.

OBJECTIVES

The objective of this analysis was to evaluate the cost-effectiveness and budgetary impact of implementing MRgHIFU as a treatment option for symptomatic uterine fibroids in premenopausal women for whom drugs have been ineffective.

REVIEW METHODS

We performed an original cost-effectiveness analysis to assess the long-term costs and effects of MRgHIFU compared with hysterectomy, myomectomy, and UAE as a strategy for treating symptomatic uterine fibroids in premenopausal women aged 40 to 51 years. We explored a number of scenarios, e.g., comparing MRgHIFU with uterine-preserving procedures only, considering MRgHIFU-eligible patients only, and eliminating UAE as a treatment option. In addition, we performed a one-year budget impact analysis, using data from Ontario administrative sources. Four scenarios were explored in the budgetary impact analysis: •MRgHIFU funded at 2 centres •MRgHIFU funded at 2 centres and replacing only uterine-preserving procedures •MRgHIFU funded at 6 centres •MRgHIFU funded at 6 centres and replacing only uterine-preserving procedures Analyses were conducted from the Ontario public payer perspective.

RESULTS

The base case determined that the uterine artery embolization (UAE) treatment strategy was the cost-effective option at commonly accepted willingness-to-pay values. Compared with hysterectomy, UAE was calculated as having an incremental cost-effectiveness ratio (ICER) of $46,480 per quality-adjusted life-year (QALY) gained. The MRgHIFU strategy was extendedly dominated by a combination of UAE and hysterectomy, and myomectomy was strictly dominated by MRgHIFU and UAE. In the scenario where only MRgHIFU-eligible patients were considered, MRgHIFU was the cost-effective option for a willingness-to-pay threshold of $50,000. In the scenario where only MRgHIFU-eligible patients were considered and where UAE was eliminated as a treatment option (due to its low historic utilization in Ontario), MRgHIFU was cost-effective with an incremental cost of $39,250 per additional QALY. The budgetary impact of funding MRgHIFU for treatment of symptomatic uterine fibroids was estimated at $1.38 million in savings when funded to replace all types of procedures at 2 centres, and $1.14 million when funded to replace only uterine-preserving procedures at 2 centres. The potential savings increase to $4.15 million when MRgHIFU is funded at 6 centres to treat all women eligible for the procedure. Potential savings at 6 centres decrease slightly, to $3.42 million, when MRgHIFU is funded to replace uterine-preserving procedures only.

CONCLUSIONS

Our findings suggest that MRgHIFU may be a cost-effective strategy at commonly accepted willingness-to-pay thresholds, after examining the uncertainty in model parameters and several likely scenarios. In terms of budget impact, the implementation of MRgHIFU could potentially result in one-year savings of $1.38 million and $4.15 million in the scenarios where MRgHIFU is implemented in 2 or 6 centres, respectively. From a patient perspective, it is important to consider that MRgHIFU is the least invasive of all fibroid treatment options for women who have not responded to pharmaceuticals; it is the only one that is completely noninvasive. Also important, from a societal point of view, is the potential benefit from faster recovery times. Despite these benefits, implementation of MRgHIFU beyond the 2 centres which currently offer the treatment faces logistical challenges (for example, competing demands for use of existing equipment), as well as financial challenges, with hospitals needing to fundraise to purchase new equipment.

The estimated annual cost of uterine leiomyomata in the United States

OBJECTIVE

The purpose of this study was to estimate the total annual societal cost of uterine fibroid tumors in the United States, based on direct and indirect costs that include associated obstetric complications.

STUDY DESIGN

A systematic review of the literature was conducted to estimate the number of women who seek treatment for symptomatic fibroid tumors annually, the costs of medical and surgical treatment, the amount of work time lost, and obstetric complications that are attributable to fibroid tumors. Total annual costs were converted to 2010 US dollars. A sensitivity analysis was performed.

RESULTS

The estimated annual direct costs (surgery, hospital admissions, outpatient visits, and medications) were $4.1-9.4 billion. Estimated lost work-hour costs ranged from $1.55-17.2 billion annually. Obstetric outcomes that were attributed to fibroid tumors resulted in a cost of $238 million to $7.76 billion annually. Uterine fibroid tumors were estimated to cost the United States $5.9-34.4 billion annually.

CONCLUSION

Obstetric complications that are associated with fibroid tumors contributed significantly to their economic burden. Lost work-hour costs may account for the largest proportion of societal costs because of fibroid tumors.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of peritoneal carcinomatosis. Preliminary results and cost from two centers in Greece

PURPOSE

To report our preliminary experience in the combined treatment of peritoneal carcinomatosis (PC) using cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC).

PATIENTS AND METHODS

This prospective study included patients with PC from gynaecological, gastric and colon cancer, treated in two centers. Cytoreductive surgery included the peritonectomy procedures described by Jacquet and Sugarbaker as well as multivisceral resections in order to achieve a complete macroscopical cancer eradication. The HIPEC that followed was performed via the open abdomen technique.

RESULTS

Twenty-four patients (3 men and 21 women, mean age 60 years) were treated. Twelve patients had PC from ovarian cancer, 7 from colon, 3 from gastric and 2 from uterine cancer. The mean duration of the procedure was 7.83 h (range 5 -12.30). Macroscopically, complete cytoreduction (CC) was achieved in 18 (75%) patients. Two (8.3%) patients died in the first 30 days. The overall morbidity was 42% and 2 patients were reoperated. The mean follow up was 22 months (range 3-36). The overall 1-year survival was 59.1%; concerning the gynaecological cancers it was 53.8% (mean survival 11.7 months) and for gastrointestinal cancers it was 44.4% (mean survival 9.5 months).

CONCLUSION

Our preliminary data suggest that the combined treatment of cytoreduction plus HIPEC for PC is associated with acceptable mortality and morbidity and offers an improved survival in these patients. An optimal patient selection and establishment of experienced centres are of paramount importance.

Payer Costs in Patients Undergoing Uterine Artery Embolization, Hysterectomy, or Myomectomy for Treatment of Uterine Fibroids

PURPOSE

To compare health resource use and medical costs in patients with uterine leiomyomas treated with hysterectomy, myomectomy, or uterine artery embolization (UAE).

MATERIALS AND METHODS

Patients who underwent hysterectomy, myomectomy, or UAE for leiomyomas were identified from a nationally representative private payer claims database based on their diagnosis and procedure codes. The study included patients with no prior hysterectomy, myomectomy, or UAE and no previous diagnosis of gynecologic cancer. Health resource use and medical costs were evaluated over a period of 12 months.

RESULTS

The study included 2,836 hysterectomy, 704 myomectomy, and 125 UAE patients. Average patient ages were 46 years for hysterectomy, 38 years for myomectomy, and 45 years for UAE (P < .001). Median UAE procedure costs were $5,968, compared with $7,299 for myomectomy (P = .031) and $7,707 for hysterectomy (P < .001). Median total 12-month payer costs were not significantly different among the three procedures ($10,519 for UAE vs $9,652 for myomectomy [P = .372] and $10,044 for hysterectomy [P = .813]). There were no differences in overall hospital admissions or emergency room visits after the procedures. Patients who underwent UAE had greater fibroid-related hospital and physician office use beyond 30 days after treatment (P < .001). During this period, 65.6% of patients treated with UAE had at least one imaging study, versus 37.1% of those treated with myomectomy (P < .001) and 14.1% of those treated with hysterectomy (P < .001).

CONCLUSIONS

Procedure costs were significantly lower for UAE versus myomectomy and hysterectomy, but there was no difference in total 12-month payer costs. Postprocedural imaging appears to be a factor in total UAE costs. Further research is needed to better understand the role of imaging studies after UAE.

Characterization of therapy and costs for patients with uterine fibroids in Utah Medicaid

OBJECTIVES

To determine in an eligible Utah Medicaid population (1) medical and drug costs associated with treating uterine fibroids (UFs) and (2) the cost and incidence of hysterectomy complications.

METHODS

Medical and drug cost analyses were based on data from 897 premenopausal patients with UFs included in the Utah Medicaid database from 1996 to 2004. UF-related medical and pharmacy costs were determined from first diagnosis of UFs until a related procedure or until estimated menopause. Outcomes for patients treated with a procedure (hysterectomy, myomectomy, or embolization), medication, and watchful waiting (no procedure, no UF-related drug) were compared. When determining hysterectomy complication rates for the population of women in the Medicaid database, a total of 1,323 pre- or postmenopausal patients with UFs were included.

RESULTS

Overall, 20% of patients were treated with medication, 33% with a procedure, and 47% with watchful waiting. Mean total UF costs were: $11,996 (procedure), $2,703 (medication), and $2,118 (watchful waiting). Mean eligibility months were 8.8, 28.8, and 14.1, respectively. Costs/eligible month were: $1,358 (procedure), $151 (watchful waiting), and $94 (medication). The mean hysterectomy cost was $12,107.

CONCLUSION

Treatment for UFs is expensive with a mean cost of $5,504 per study patient. The highest costs are seen in patients receiving procedures, which can lead to complications; 15% in this study. Costs for watchful waiting are similar to costs in patients receiving UF-related drugs. Consideration should be given to using non-surgical therapies for the treatment of UFs before procedures are performed.

National trends and determinants of hospitalization costs and lengths-of-stay for uterine fibroids procedures

Uterine fibroid admissions in the nation's hospitals have grown more than 20 percent over the past five years. Substantial variations exist in inpatient treatment patterns. In spite of this dramatic growth, there are no national studies of the hospital costs associated with the treatment of uterine fibroids in the hospital setting. Using 11 years of data (1993-2003) from the Healthcare Cost and Utilization Project, a nationally representative 20 percent sample of the nation's inpatient admissions, trends in hospital charges, costs, and lengths of stay (LOSs) are reported. For 2001 to 2003, determinants of hospital costs and LOS for inpatients with a primary diagnosis of uterine fibroids were analyzed using univariate analyses and regression techniques. Hysterectomies for women with a primary diagnosis of uterine fibroids have in-hospital costs of over $1.5 billion. Among the major procedures for treating uterine fibroids, in 2003, total abdominal hysterectomy had the longest LOS, averaging 2.9 days with a mean cost of $6331. In contrast, the treatment with the shortest LOS, 1.72 days, was laparoscopically assisted vaginal hysterectomy but it had the highest mean costs of $7108. In 2003, supracervical hysterectomies and myomectomies had mean costs of $6809 and $6707, respectively. Multivariate results show that patient characteristics and structural aspects of the hospital are strong predictors of lengths of stay and cost per day but there are major differences across some of the surgical procedures. Although the patient characteristics-insulin-dependent, non-insulin dependent diabetes, obesity, morbid obesity, smoker, hypertension, congestive heart failure, chronic obstructive pulmonary disease-all have significant impacts on LOS and cost per day for some of the major uterine fibroid treatments, they are not consistent. Compared with white women, black, Hispanic, and Asian/Pacific Island women all had higher lengths of stay and costs per day. Bedsize and teaching status are generally positively associated with lengths of stay and costs per day; for-profit status always had a significant positive association with LOS and cost per day. Hospital costs for treating women with uterine fibroids are continuing to grow. Further research on the determinants of the resource utilization could be helpful in predicting and alleviating these costs and improving patient care.

Annual costs associated with diagnosis of uterine leiomyomata

OBJECTIVE

To describe the annual care, direct health care, and indirect work loss costs for women with a diagnosis of uterine leiomyomata.

METHODS

We examined data from an employer claims database of 1.2 million beneficiaries (1999 to 2003). Analysis was restricted to women with at least 12 months of continuous coverage and ages 18 to 64 years with at least one diagnosis of leiomyomata (International Classification of Diseases, 9th Revision, 218.xx, 654.1x). We selected a comparison group of women without a leiomyoma diagnosis using a 1:1 match on age, employment, region, health plan type, and length of enrollment. We compared resource use, disability claims, and excess costs in the year after the index diagnosis.

RESULTS

The average age of women diagnosed with leiomyomata in this study was 43.7 years. Women with leiomyomata (N = 5,122) had more clinic visits (relative risk [RR] 1.2, 95% confidence interval [CI] 1.2-1.2), diagnostic tests (RR 3.1, 95% CI 2.9-3.2), and procedures (RR 34.6, 95% CI 25.8-46.5) than controls (N = 5,122). Within 1 year of the diagnosis of leiomyomata, 42% of women had a complete blood count, 66% had pelvic imaging, and 30% had surgery (68% of surgical procedures involved hysterectomy). Women with leiomyomata were 3-fold more likely to have disability claims (RR 3.1, 95% CI 2.7-3.6). Estimated average annual excess cost for each woman with leiomyomata (adjusted for confounders) was Dollars 4,624 (Dollars 771 in work loss costs). Total costs for women with leiomyomata were 2.6 times greater than for controls.

CONCLUSION

Diagnosed uterine leiomyomata are associated with increased resource use and with substantially higher health care and work loss costs.

LEVEL OF EVIDENCE

II-3.

Cost and Reimbursement for Three Fibroid Treatments: Abdominal Hysterectomy, Abdominal Myomectomy, and Uterine Fibroid Embolization

PURPOSE

To compare costs and reimbursements for three different treatments for uterine fibroids.

METHODS

Costs and reimbursements were collected and analyzed from the Thomas Jefferson University Hospital decision support database from 540 women who underwent abdominal hysterectomy (n = 299), abdominal myomectomy (n = 105), or uterine fibroid embolization (UFE) (n = 136) for uterine fibroids during 2000-2002. We used the chi-square test and ANOVA, followed by Fisher's Least Significant Difference test, for statistical analysis.

RESULTS

The mean total hospital cost (US dollar) for UFE was 2,707 dollars, which was significantly less than for hysterectomy (5,707 dollars) or myomectomy (5,676 dollars) (p < 0.05). The mean hospital net income (hospital net reimbursement minus total hospital cost) for UFE was 57 dollars, which was significantly greater than for hysterectomy (-572 dollars) or myomectomy (-715 dollars) (p < 0.05). The mean professional (physician) reimbursements for UFE, hysterectomy, and myomectomy were 1,306 dollars, 979 dollars, and 1,078 dollars, respectively.

CONCLUSION

UFE has lower hospital costs and greater hospital net income than abdominal hysterectomy or abdominal myomectomy for treating uterine fibroids. UFE may be more financially advantageous than hysterectomy or myomectomy for the insurer, hospital, and health care system. Costs and reimbursements may vary amongst different hospitals and regions.

Health care resource use for uterine fibroid tumors in the United States

OBJECTIVE

The purpose of this study was to quantify the total direct cost to the US health care system for the management of uterine leiomyomas.

STUDY DESIGN

We used Center for Disease Control heath care databases for estimates of inpatient care, ambulatory care, and outpatient care of leiomyomas. With International Classification of Diseases-9 codes for fibroid tumors and fibroid-related conditions, all fibroid-related care was identified in each database. Inpatient and ambulatory surgical cases were stratified by surgical procedure, and outpatient clinical cases were categorized by type of visit and health care provider. With the use of Medicare's RBRVU reimbursement rates for 2000 as a proxy for the cost of physician services and Medicare diagnostic-related group reimbursement as a proxy for facility costs, the total direct cost to the US health care system for the care of fibroid tumors was estimated.

RESULTS

Total direct cost to treat uterine fibroid tumors was estimated at 2,151,484,847 dollars. Most of the cost was due to inpatient care, in particular, hysterectomy.

CONCLUSION

Uterine fibroid tumors consume a significant amount of health care resources in the United States.

The Economic Impact of Uterine Fibroids in the United States: A Summary of Published Estimates

OBJECTIVE

To present a summary of published estimates of the economic burden of uterine fibroids in the United States and identify areas for additional research.

METHODS

A search of three electronic databases, MEDLINE, EMBASE, and Current Contents, was conducted, along with a review of information on the Internet and abstraction of economic data.

RESULTS

Only 10 papers and 1 Internet document met our inclusion criteria and were used to abstract data. Cost estimates for surgically invasive treatments of uterine fibroids included hysterectomy (USD 5,012-7,934), myomectomy (USD 5,425-11,839), and uterine artery embolization (UAE) (USD 5,425-7,645) (2004 USD). One cost-effectiveness study estimated lower costs and higher quality-adjusted life years with UAE compared with hysterectomy. A second study estimated potential savings of USD 4.2 million in hospital charges in the United States if higher rates of vaginal (vs. abdominal) hysterectomy would be achieved after pretreatment with gonadotropin hormone-releasing hormone (GnRH) agonists compared to without pretreatment with GnRH agonists (80% vs. 13%). There were no estimates of the total direct and indirect economic burden of uterine fibroids. Neither estimates of the costs for the ambulatory care of fibroids nor studies estimating the indirect costs associated with the management of fibroids and their symptoms were found.

CONCLUSIONS

This summary of published U.S. economic estimates shows that despite the high prevalence of fibroids and their impact on clinical practice and women's lives, there is very little published information on their economic impact apart from data showing standard treatments for uterine fibroids are invasive and expensive. Reduction in the need for and cost of invasive procedures by the increased usage of noninvasive treatments could potentially achieve significant national cost savings, but further clinical and economic studies are needed.

Cost-Effectiveness of Uterine Artery Embolization and Hysterectomy for Uterine Fibroids

PURPOSE

To compare the cost-effectiveness of uterine artery embolization (UAE) with that of hysterectomy for women with symptomatic uterine fibroids.

MATERIALS AND METHODS

The authors developed a decision model to compare the costs and effectiveness of UAE and hysterectomy. In the model, a cohort of women aged 40 years with a diagnosis of uterine fibroids and no desire for future pregnancy was followed up until menopause. The analysis was performed from a societal perspective, including all costs and effects, regardless of who incurs them. Transition probability and quality-of-life estimates were obtained from the literature and a gynecologist, whereas costs (in 1999 U.S. dollars) were estimated by using rates of Medicare reimbursement for hospital costs and physician fees. Sensitivity analyses of key estimates were performed. Results were expressed in costs per quality-adjusted life-year (QALY).

RESULTS

UAE was more effective (8.29 vs 8.18 QALYs) and less expensive (US dollars 6916 vs US dollars 7847) than hysterectomy. Cost-effectiveness results, with the exception of quality-of-life data, were robust to changes in most model assumptions. When the quality-of-life adjustment was eliminated, the two procedures were equally effective.

CONCLUSION

UAE is a cost-effective alternative to hysterectomy across a wide range of assumptions about the costs and effectiveness of the two procedures. However, the study results were sensitive to changes in quality-of-life values.

A benefit-risk assessment of medical treatment for uterine leiomyomas

The growth of a uterine leiomyoma growth stops and regresses after the menopause suggesting that leiomyoma growth is dependent on ovarian steroids. Therefore, estrogen has received much attention as the major factor responsible for the development of uterine leiomyomas, but progesterone also plays an important role in development of this disease. Cytogenetic analyses of resected samples has revealed that about 40 to 50% of leiomyomas show karyotypically detectable chromosomal abnormalities. Gonadotrophin releasing hormone (GnRH) agonists exert their action through the suppression of endogenous gonadotrophins and gonadal steroid secretion. Significant reductions of uterine/leiomyoma volume under GnRH agonist therapy has been reported in several studies. However, the leiomyoma generally returns to its pretreatment volume within a few months after discontinuation of the GnRH agonist. To minimise the adverse effects of hypoestrogenism during GnRH agonist treatment, add back therapy can be used (estrogen-progestin, progestin alone and recently tibolone). Antiprogestins have a potential clinical utility in uterine leiomyomas. Mifepristone is a synthetic steroid with both antiprogesterone and antiglucocorticoid activities, that may have an inhibitory effect on growth of leiomyoma. Danazol is an isoxazole of 17beta-ethinyl testosterone, a synthetic steroid, which has a suppressive effect on sex hormone binding globulin concentrations, resulting in efficacy in the short-term treatment of uterine leiomyomas. Gestrinone is a tri-enic steroid with antiestrogen and antiprogesterone properties and has been shown to reduce uterine volume and stop bleeding. Growth factors play a relevant role on the pathophysiology of uterine leiomyoma and probably the inhibition of the action of growth factors on the myometrium will be the basis for future therapy. A number of agents are under investigation for treating uterine leiomyoma. Agents developed from increasing genetic knowledge of this condition could represent, in the next few years, new trends in the medical treatment of uterine leiomyomas.

Cost effectiveness of pre-operative gonadotrophin releasing analogues for women with uterine fibroids undergoing hysterectomy or myomectomy

OBJECTIVE

To conduct a cost effectiveness analysis of pre-operative gonadotrophin releasing hormone agonists (GnRHa) in women with uterine fibroids undergoing hysterectomy or myomectomy.

DESIGN

A cost effectiveness analysis using the effectiveness data from a systematic review of GnRHa.

SETTING

Secondary care.

SAMPLE

Women with uterine fibroids undergoing hysterectomy or myomectomy and women volunteers.

METHODS

Effectiveness data were used from a systematic review to construct a model and to calculate the cost per surgical outcome avoided. In order to evaluate the value women place on the outcome, a willingness to pay analysis of women volunteers was undertaken.

MAIN OUTCOME MEASURES

(a) The cost of avoiding abdominal hysterectomy and the cost of avoiding a vertical incision at either hysterectomy or myomectomy; (b) The value that women place on avoiding abdominal hysterectomy and on avoiding a vertical incision at either hysterectomy or myomectomy. All costs are in NZ dollars.

RESULTS

For hysterectomy, the additional cost of treatment with GnRHa was NZ$1190 per case. The cost of avoiding one abdominal procedure was NZ$4577 per case and the cost of avoiding one vertical incision was NZ$6263. For a myomectomy, the additional cost of treatment with GnRHa was NZ$1535 per case. The cost of avoiding one vertical incision was NZ$4651 per case. These costs exceeded the benefit women placed on the outcomes.

CONCLUSION

Although the pre-operative use of GnRHa results in benefits which include less frequent abdominal incisions in the case of hysterectomy and less frequent vertical incisions in the case of myomectomy, the benefits do not justify the costs. This study highlights the importance of considering both the benefits and costs in health care decisions.

Oncogenic human papillomavirus (HPV) infection and uterine cervical cancer: a screening strategy in the perspective of rural India

The predominance of cervical cancer in India can mostly be attributed to the lack of early screening. The objective of the present study has been, therefore, to determine a cost-effective oncogenic human papillomavirus (HPV)-based cervical cancer screening plan for rural Indian women. The results showed that in normal women, highest prevalence of HPV 16/18 infection was in the age group < or =23 years and lowest in > or =44 years with an insignificant change in between. HPV 16/18 infection was significantly associated with cervical erosion at age < or =23 years, but not with cytology or visual inspection with acetic acid testing at any age. The low-grade cytological lesions, however, increased only with increase in age. Fourteen per cent of the cervical malignancy was also found to be present in the age group 24-33 years with an 87% HPV infection. Here we proposed a cost-effective screening scheme in which HPV testing must be performed in women (a) < or =23 years with cervical erosion and (b) 24-43 years, as an adjunct to Pap smears (both HPV and cytology were prevalent in this group). For women > or =44 years, HPV testing might not be useful, since abnormal cytology was more prominent over the viral infection. We infer that by not performing HPV test in the group < or =23 years, approximately 76% of the high-risk HPV-infected individuals potentially "at risk" for developing cervical cancer might be missed.

Cost analysis model: US versus endometrial biopsy in evaluation of peri- and postmenopausal abnormal vaginal bleeding

PURPOSE

To develop a cost minimization analysis model from the societal perspective of Medicare reimbursement to determine whether endometrial biopsy or transvaginal ultrasonography (US) is less expensive in evaluating peri- and postmenopausal women with abnormal vaginal bleeding and to assess whether this strategy is equally effective in populations at low and high risk for endometrial carcinoma.

MATERIALS AND METHODS

Clinical algorithms were constructed that detailed diagnostic evaluation of the target population by using office-based endometrial biopsy versus transvaginal US as starting points. An economic model based on Medicare reimbursement and average wholesale drug price data and using disease prevalences and modality sensitivities from the scientific literature was then created to examine common bleeding causes in this population. All models included the cost of obtaining a tissue diagnosis for focal or diffuse endometrial thickening found at US. Modality sensitivities and prevalences of disease states were varied within the model to discover limits at which each modality became cheaper versus the other for assessing a population of women.

RESULTS

Population prevalence of neoplastic disease is the principal factor governing total cost between competing diagnostic algorithms. In populations with 31% or less combined prevalence of endometrial carcinoma/atypical adenomatous hyperplasia, algorithms utilizing transvaginal US as the initial test are most cost minimizing. At combined endometrial carcinoma/atypical adenomatous hyperplasia prevalence of 10%, savings of up to 11% and 16% over pathways initiated with endometrial biopsy are predicted. In populations with a high incidence of neoplastic disease (>31%), biopsy-based algorithms should become least costly.

CONCLUSION

Transvaginal US-initiated triage predicts substantial cost savings versus biopsy-based algorithms in evaluating typical populations of peri- and postmenopausal women with abnormal vaginal bleeding seen in clinical practice.

Outcome and resource use associated with myomectomy

OBJECTIVE

To evaluate the outcomes and cost of myomectomy through retrospective claims data analysis.

METHODS

The study was performed using a retrospective database of private insurance claims from 1995 to 1997. Records were selected for analysis based on the presence of ICD-9-CM procedure and/or CPT-4 codes associated with myomectomy. In addition, diagnosis of uterine leiomyoma and related symptoms for these patients were confirmed through ICD-9-CM diagnosis codes. Inpatient, outpatient, and physician costs were estimated. All cost data were converted into 1997 dollars.

RESULTS

A total of 4394 women, between the ages of 14 and 70, were available for analysis. Of these, 3305 were classified by type of myomectomy procedure, and complete data were available on 820 at 1 year and 236 at 2 years. Abdominal myomectomies were the most common procedures, followed by hysteroscopic and laparoscopic myomectomies. Conversion to a more invasive procedure occurred in 5.4% of the patients. The rate of additional surgeries was 8.3% in 6 months, 10.6% in 1 year, and 16.5% in 2 years. Overall cost increased from an initial 6,737 dollars per patient to 7,575 dollars in 1 year and to 8,001 dollars in 2 years.

CONCLUSION

The repeat procedures required after the initial myomectomy add significantly to total cost and highlight the importance of assessing post-procedure health care use. This comprehensive analysis facilitates the systematic evaluation of myomectomy with current and emerging alternative treatments for uterine leiomyomas.

Demand for health care in Denmark: results of a national sample survey using contingent valuation

In this paper we use willingness to pay (WTP) to elicit values for private insurance covering treatment for four different health problems. By way of obtaining these values, we test the viability of the contingent valuation method (CVM) and econometric techniques, respectively, as means of eliciting and analysing values from the general public. WTP responses from a Danish national sample survey, which was designed in accordance with existing guidelines, are analysed in terms of consistency and validity checks. Large numbers of zero responses are common in WTP studies, and are found here; therefore, the Heckman selectivity model and log-transformed OLS are employed. The selectivity model is rejected, but test results indicate that the lognormal model yields efficient and unbiased estimates. The results give confidence in the WTP estimates obtained and, more generally, in CVM as a means of valuing publicly provided goods and in econometrics as a tool for analysing WTP results containing many zero responses.

Socioeconomic characteristics of patients with squamous cell carcinoma of the uterine cervix treated with radiotherapy in the 1992 to 1994 patterns of care study

PURPOSE

To describe the relationship between socioeconomic variables and the treatment of patients with radiotherapy for cervix cancer.40% minority patients.

METHODS AND MATERIALS

Sixty-two institutions werw r andomly selected from a list of all radiotherapy facilities in the Unite d States. From these we randomly selected and reviewed 471 cases of squ amous cell carcinoma treated during 1992 to 1994. To create an addition al minority-rich sample, we randomly selected 215 additional cases from 17 randomly selected institutions that admitted >40% minority patients. The median household income of each patient's neighborhood was determined by matching her zip code to data from the 1990 United States Census.

RESULTS

Pati ents who lived in low-income neighborhoods, who had only Medicaid covera ge, or who were treated at large academic or minority-rich institutions tended to have a poorer initial performance status, higher-stage or bulk y central disease, and a lower pretreatment hemoglobin level. Ability t o complete treatment did not correlate with ethnicity or income. Howeve r, noncompliant patients tended to be treated at minority-rich instituti ons and were more often < 40 or > 60 years old. Patients who completed definitive treatment were more likely to have had </= 1 low-dose-rate intracavitary implants if they were black, came from a low-income neighborhood, were covered by Medicaid or Medicare only, or were treated at a minority-rich institution. Patients who were treated in academic institutions received higher mean radiation doses to Point A (83.8 Gy) than those treated in research- or non-research-participating facilities (79.4 and 80.9 Gy, respectively; p = 0.002). Patients who received their radiation therapy in facilities that treated an average of </= 3 patients per year also received lower mean doses to Point A (79.1 vs. 83.0 Gy; p = 0.001).

CONCLUSION

The treatment received by patients who belonged to minority groups, came from low-income neighborhoods, or were treated in large, minority-rich institutions differed in several respects from that of white, higher income patients. Larger, more detailed studies will be needed to clarify the reasons for these differences and to define any influence on treatment outcome.

Hospitalization costs associated with leiomyoma

The objective of this study was to determine the prevalence and cost of leiomyoma-related hospitalizations based on the Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP-3). Data for 1991 and 1992 were obtained from the HCUP-NIS database, which includes an approximate 20% sample of US hospital discharges. ICD-9 (International Classification of Diseases, Ninth Revision) codes 218.0-218.2 and 218.9 were used to identify women between the ages of 15 and 64 years with the diagnosis of leiomyoma. The distribution of leiomyoma was described using demographic characteristics, admission type, length of stay (LOS), mean total charge, specific leiomyoma diagnosis, principal procedure, and other diagnosed diseases. Among hospital admissions of women between the ages of 15 and 64 years during 1991 and 1992, 26 to 28 admissions per 1000 included a diagnosis of leiomyoma. The highest rates of leiomyoma diagnosis were seen in women aged >40 years (65% and 70% for 1991 and 1992, respectively) and black women (26% and 27%, respectively). Approximately 90% of hospitalizations for leiomyoma were routine admissions, with the most common specific diagnosis being intramural leiomyoma of the uterus. In 1992, patients with leiomyoma as the first diagnosis (vs other diagnoses) had significantly lower mean LOS (3.1 vs. 4.4 days; P<0.001) and mean total charge ($5919 vs. $6810; P<0.001). Total abdominal hysterectomy was performed on three quarters of the women admitted for leiomyoma, and these patients had longer mean LOS and higher total charges than those undergoing other procedures. Although not as costly as other conditions, this common disorder among women of reproductive years requires expensive treatment and is a major burden on the health care system.

[Clinical evaluation based on cost-effectiveness]

We carried out two Phase III clinical trials using high dose rate (HDR) remote afterloading brachytherapy unit. We evaluated the clinical results based not only on the medical but also the economical standpoint. The first trial is the Phase III trial for cervical cancer treated with HDR or medium dose rate (MDR) intracavitary radiotherapy. The second one is the Phase III trial for tongue cancer treated with HDR or low dose rate (LDR) interstitial radiation. For cervical cancer, the survival rate of patients treated with HDR brachytherapy is the same as for LDR brachytherapy. The average total cost of treatment for the HDR group was 1.47 million yen, while that for the MDR group was 1.58 million yen. The average total admission days was 63. For tongue cancer, the local control rate of the HDR group is almost the same as that of the LDR groups. The average total cost for the HDR group was 780 thousand yen, and that for the LDR group was 830 thousand yen. The average total admission days was 34. According to the cost-effectiveness, HDR brachytherapy for cervical cancer has the same result as MDR, and HDR brachytherapy for tongue cancer has the same result as LDR. However, HDR can be treated without admission for patients who live near the hospital. HDR can be applied for these patients with less expense. We must be aware of not only the medical results but also the cost-effectiveness.

Quality of life, health care utilization, and costs among women undergoing hysterectomy in a managed-care setting

OBJECTIVE

We compared quality of life, utilization, and costs for women undergoing elective abdominal, laparoscopically assisted vaginal, or vaginal hysterectomy within a managed-care organization.

STUDY DESIGN

A prospective study of 287 women who underwent an elective hysterectomy was performed.

RESULTS

Patients undergoing a vaginal hysterectomy reported returning to normal activity levels sooner and had more favorable quality-of-life scores than did those undergoing laparoscopically assisted vaginal hysterectomy or abdominal hysterectomy. Laparoscopically assisted vaginal hysterectomy was often nearly as favorable as vaginal hysterectomy, particularly at 28 days after the operation, whereas the abdominal hysterectomy group consistently reported the poorest postoperative quality-of-life scores. No significant differences were noted in utilization or costs in the 60-day preoperative period, whereas hospitalization and postoperative costs were highest among the abdominal hysterectomy group and lowest for those undergoing a vaginal hysterectomy.

CONCLUSIONS

Vaginal hysterectomy resulted in better quality-of-life outcomes and lower utilization and costs compared with laparoscopically assisted vaginal or abdominal hysterectomy.

Comparison of 49 laparoscopic myomectomies with 49 open myomectomies

STUDY OBJECTIVES

To compare the results of open myomectomy with those of laparoscopic myomectomy, and to assess complications, surgical results, total hospital cost, and morbidity associated with each procedure.

DESIGN

Retrospective chart review.

SETTING

Private practice of one surgeon, and Department of Obstetrics and Gynecology, Rush Medical College, Chicago, Illinois.

PATIENTS

Ninety-eight women with symptomatic uterine leiomyomata.

INTERVENTIONS

Forty-nine consecutive laparoscopic myomectomies were performed between 1993 and 1995, and 49 open myomectomies were performed between 1983 and 1995.

MEASUREMENTS AND MAIN RESULTS

Indications for both procedures were similar, including menometrorrhagia, pelvic pain, and enlarging myomata. Mean operating time for open myomectomies was 133 minutes versus 264 minutes for laparoscopies (p <0.0001). Mean blood loss was 340 ml and 110 ml, respectively (p <0. 001). The greatest blood loss was 1000 ml in the open group and 800 ml in the laparoscopic group. Uterine size at surgery was 12 to 14 weeks in 42.9% of the open group and 9 to 11 weeks in 51% of the laparoscopy group. The open group incurred a total of 272 hospital days versus 29 days in the laparoscopic group (maximum 25 and 3 days, respectively; mean 5.6 and 0.6 days, respectively; p <0.001). The frequency of postoperative complications was higher in the open group (17) than in the laparoscopic group (5, p = 0.0068). Of patients in whom postoperative adhesions were evaluated, the overall frequency of adhesions was lower in the laparoscopic group. Three women in the open group required postoperative transfusions, compared with none in the laparoscopic group. Seven pregnancies have thus far occurred in the laparoscopic group. Three women delivered at term by elective cesarean section, at which no evidence of uterine dehiscence was found. Estimated average cost of each procedure, expressed in April 1995 dollars using the Consumer Price Index, were $14,461 for open myomectomies and $13,814 for laparoscopies (p = 0.65). Linear regression with residual analysis was performed on costs for both groups and revealed significantly increasing time trend for open myomectomies. During the years of this study, the open procedures increased in price at a rate of $868/year. The cost of laparoscopic myomectomies showed no time trend.

CONCLUSIONS

Compared with open myomectomy, laparoscopic myomectomy had lower morbidity, no identifiable trend of increasing hospital cost, minimal hospital stay, and fewer complications.

Potential cost savings using GnRH agonists as preoperative therapy for uterine leiomyomas

Women with large uterine leiomyomas traditionally have had just one choice for therapy--abdominal hysterectomy. Recently, gonadotropin-releasing hormone (GnRH) agonist therapy has been introduced as an option to shrink tumors before surgery. When administered preoperatively, usually for 2 months, GnRH therapy has been shown to reduce tumor size enough to permit an endoscopic myomectomy or a vaginal hysterectomy. It has also been shown to reduce blood loss associated with the tumors and increase hemoglobin levels. When assessed for its economic impact, preoperative GnRH therapy reduces both direct and indirect costs associated with a hysterectomy.

Weekly intramuscular methotrexate for nonmetastatic gestational trophoblastic disease

Patients with nonmetastatic gestational trophoblastic disease were entered into this Gynecologic Oncology Group study to determine the efficacy, toxicity, and cost-effectiveness of weekly intramuscular (IM) methotrexate. Treatment was initiated with 30 mg/m2 of weekly IM methotrexate. If no major toxicity was encountered, the weekly dose was escalated 5 mg/m2 at three-week intervals until a maximum dose of 50 mg/m2 each week was achieved. Complete response was defined as three normal beta-hCG values measured on consecutive weeks. Fifty-one of 63 evaluable patients (81%) had a complete response to weekly IM methotrexate. Duration of therapy ranged from three to 19 weeks, with a median of seven. No major toxicity occurred. Thirteen patients experienced leukopenia at a median of 3300/microL, with a range of 2300-3900. Three patients had platelet nadirs of 66,000, 127,000, and 135,000/microL. Eleven patients with weekly IM methotrexate failure had a complete response after one to eight courses of dactinomycin administered 0.5 mg/m2 intravenously daily for five days; one refused therapy after three courses. Weekly IM methotrexate for nonmetastatic gestational trophoblastic disease is efficacious, minimally toxic, and cost-effective.

Walker Prize Lecture, 1977. Choriocarcinoma: can we afford to cure cancer

The way the management of patients with trophoblastic tumours has depended on the acquisition of new knowledge and new drugs is demonstrated. Emphasis is put on the ability to detect early disease by biochemical markers and on the ability to define on a multifactorial basis the resistance potential of the tumours. This provides a basis for stratification of treatment and the use of prophylactic chemotherapy to prevent cerebral metastases in certain patients. Although chemotherapy is often intensive and prolonged, there has so far been little evidence of long-term effects and many women have had normal pregnancies subsequently, but the limitations of present data are discussed. The difficulties of matching available resources to society's needs in the cancer field make it necessary to consider whether such treatment is unjustifiably expensive. It is shown that for these tumours early diagnosis not only proves effective in therapeutic terms but provides substantial financial savings. It is suggested that screening programmes for cancer cannot be accepted or rejected on principle. In judging them on their individual merits it is appropriate to anticipate interaction between earlier diagnosis and more effective drug treatment.