Stepwise Approach to the Management of Endometriosis-Related Dysmenorrhea: A Cost-Effectiveness Analysis.

OBJECTIVE: To evaluate the cost effectiveness of sequential medical and surgical therapy for the treatment of endometriosis-related dysmenorrhea. METHODS: A cost-effectiveness model was created to compare three stepwise medical and surgical treatment strategies compared with immediate surgical management for dysmenorrhea using a health care payor perspective. A theoretical study cohort was derived from the estimated number of reproductive age (18-45) women in the United States with endometriosis-related dysmenorrhea. The treatment strategies modeled were: strategy 1) nonsteroidal antiinflammatory drugs (NSAIDs) followed by surgery; strategy 2) NSAIDs, then short-acting reversible contraceptives or long-acting reversible contraceptives (LARCs) followed by surgery; strategy 3) NSAIDs, then a short-acting reversible contraceptive or LARC, then a LARC or gonadotropin-releasing hormone modulator followed by surgery; strategy 4) proceeding directly to surgery. Probabilities, utilities, and costs were derived from the literature. Outcomes included cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. Univariate, bivariate, and multivariate sensitivity analyses were performed. RESULTS: In this theoretical cohort of 4,817,894 women with endometriosis-related dysmenorrhea, all medical and surgical treatment strategies were cost effective at a standard willingness-to-pay threshold of $100,000 per QALY gained when compared with surgery alone. Strategy 2 was associated with the lowest cost per QALY gained ($1,155). Requiring a trial of a third medication before surgery would cost an additional $257 million, compared with proceeding to surgery after failing two medical treatments. The probability of improvement with surgery would need to exceed 83% for this to be the preferred first-line approach. CONCLUSION: All sequential medical and surgical management strategies for endometriosis-related dysmenorrhea were cost effective when compared with surgery alone. A trial of hormonal management after NSAIDs, before proceeding to surgery, may provide cost savings. Delaying surgical management in an individual with pain refractory to more than three medications may decrease quality of life and increase cost.

Deep endometriosis transvaginal ultrasound in the workup of patients with signs and symptoms of endometriosis: a cost analysis.

OBJECTIVE: Deep endometriosis transvaginal ultrasound (DE TVS) is accurate in the detection of ovarian endometriosis and DE; however, realisation of its full potential and utilisation remains variable. As such, patients may require a two-step surgical approach (diagnostic followed by therapeutic laparoscopy) or experience incomplete surgical treatment. Besides the clinical implications, the economic impact of a two-step approach to diagnosis and treatment on the healthcare system is likely to be significant. We aim to compare the economic costs of two diagnostic models of care for patients with potential endometriosis. DESIGN: Cost analysis using Markov model with 12-month time horizon comparing the economic costs of two diagnostic models. SETTING: The study used a hypothetical population of 1000 women visiting a public tertiary gynaecology clinic. POPULATION: Women with potential endometriosis. Estimates for endometriosis prevalence and severity were drawn from local Australian hospital data. METHODS: The conventional model (M1) includes the basic TVS and diagnostic laparoscopy. The novel model (M2) includes the DE TVS. Probabilistic sensitivity analysis was conducted to capture the uncertainty in the information used to populate the models. MAIN OUTCOME MEASURE: Changes to government, health-service and patient costs with the adoption of the DE TVS compared with standard diagnostic methods. Costs are given in Australian dollars (AU$) and also in pound sterling (£). RESULTS: The total annual cost of the novel model (M2) is AU$12,547,724.03 (£6,826,673.63), cheaper than the conventional model (M1), which cost AU$13,472,161.67 (£7,329,620.15). CONCLUSIONS: For a population of 1000 women, the integration of the DE TVS may save healthcare costs of AU$924,437 (£502,946.17) annually. TWEETABLE ABSTRACT: An endometriosis-focused ultrasound may negate a two-step surgery pathway, including diagnostic surgery, and save healthcare money.

Health Care Utilization and Costs Associated with Endometriosis Among Women with Medicaid Insurance.

BACKGROUND: Endometriosis is a painful chronic inflammatory disease caused by endometrial tissue implanting and growing outside the uterus, resulting in pelvic pain symptoms and subfertility. Treatment imposes a substantial economic burden on the patient and health care system. OBJECTIVE: To evaluate direct health care utilization and costs among women newly diagnosed with endometriosis compared with age-matched controls in a U.S. Medicaid population. METHODS: This retrospective cohort study used deidentified health care claims from the 2007-2015 MarketScan Multi-State Medicaid Database. Women (aged 18-49 years) newly diagnosed with endometriosis (ICD-9-CM 617.xx) during January 2008 through September 2014 were identified (date of first diagnosis = index date). Age-matched women without endometriosis (controls) were selected from the database and assigned index dates matching the distribution for endometriosis patients. Direct health care resource utilization (HCRU) and costs (medical and pharmacy) over the 12-month post-index period (2015 U.S. dollars) were computed by service category (hospitalization, emergency room visits, outpatient services, and prescriptions) and compared between study cohorts using the chi-square test for proportions and t-test for continuous variables. RESULTS: The final sample included 15,615 endometriosis patients and 86,829 matched controls. HCRU during the 12-month post-index follow-up period was significantly higher for endometriosis cases compared with controls in all measured categories. Hospital admissions occurred among 33.1% of cases and 7.2% of controls, and 65.8% of endometriosis patients were admitted for endometriosis-related surgery. Emergency room visits occurred in 71.5% of cases, and 42.2% of controls. Mean (SD) office visits were 10.4 (8.5) for endometriosis patients and 5.1 (6.9) for controls. Endometriosis patients had significantly more prescription claims than controls, 45.9 (42.0) versus 25.1 (39.1). Mean total direct health care costs were $13,670 ($29,843) for cases versus $5,779 ($23,614) for controls. All differences between cases and controls were significant at P < 0.001. CONCLUSIONS: Health care costs and resource utilization in all measured categories were higher among endometriosis cases than controls. The economic burden of endometriosis among patients with Medicaid insurance is substantial, underscoring the unmet medical need for earlier diagnosis and cost-effective treatments. DISCLOSURES: This study was funded by AbbVie and conducted by Truven Health Analytics, an IBM Company. AbbVie participated in developing the study design, data analysis and interpretation, manuscript writing and revisions, and approval for publication. Soliman and Vora are employees of AbbVie and may own AbbVie stock/stock options. Surrey has served in a consulting role on research to AbbVie and is on the speaker bureau for Ferring Laboratories. Bonafede and Nelson are employees of Truven Health Analytics, an IBM Company, which received compensation from AbbVie for the overall conduct of the study and preparation of the manuscript. Agarwal has served in a consulting role on research to AbbVie. Preliminary results of this study were previously presented in a podium session at the 2017 American Society for Reproductive Medicine Scientific Congress and Expo; October 28-November 1, 2017; San Antonio, TX.

Elagolix for endometriosis: all that glitters is not gold.

Elagolix, an orally active non-peptidic GnRH antagonist, has been approved by the Food and Drug Administration for the management of moderate to severe pain associated with endometriosis. As the degree of ovarian suppression obtained with elagolix is dose-dependent, pain relief may be achieved by modulating the level of hypo-oestrogenism while limiting side effects. Elagolix may thus be considered a novelty in terms of its endocrine and pharmacological properties but not for its impact on the pathogenic mechanisms of endometriosis, as the target of this new drug is, yet again, alteration of the hormonal milieu. Given the oestrogen-dependent nature of endometriosis, a reduction of side effects may imply a proportionate decrease in pain relief. Furthermore, if low elagolix doses are used, ovulation is not consistently inhibited, and patients should use non-hormonal contraceptive systems and perform serial urine pregnancy tests to rule out unplanned conception during periods of treatment-induced amenorrhoea. If high elagolix doses are used to control severe pain for long periods of time, add-back therapies should be added, similar to that prescribed when using GnRH agonists. To date, the efficacy of elagolix has only been demonstrated in placebo-controlled explanatory trials. Pragmatic trials comparing elagolix with low-dose hormonal contraceptives and progestogens should be planned to verify the magnitude of the incremental benefit, if any, of this GnRH antagonist over currently used standard treatments. The price of elagolix may impact on patient adherence and, hence, on clinical effectiveness. In the USA, the manufacturer AbbVie Inc. priced elagolix (OrilissaTM) at around $10 000 a year, i.e. $845 per month. When faced with unaffordable treatments, some patients may choose to forego care. If national healthcare systems are funded by the tax payer, the approval and the use of a new costly drug to treat a chronic condition, such as endometriosis, means that some finite financial resources will be diverted from other areas, or that similar patients will not receive the same level of care. Thus, defining the overall 'value' of a new drug for endometriosis also has ethical implications, and trade-offs between health outcomes and costs should be carefully weighed up.

Medical therapy for preventing recurrent endometriosis after conservative surgery: a cost-effectiveness analysis.

OBJECTIVE: To assess the cost-effectiveness of different strategies, including gonadotropin-releasing hormone agonist (GnRH-a) and oral contraceptive therapy, for the prevention of endometriosis recurrence after conservative surgery. DESIGN: Cost-effectiveness analysis from a health care perspective. SETTING: A health-resource-limited setting in China. POPULATION: Patients who underwent conservative laparoscopic or laparotomic surgery for endometriosis. METHODS: A Markov model was developed for the endometriosis disease course. Clinical data were obtained from published studies. Direct medical costs and resource utilization in the Chinese health care setting were taken into account. The health and economic outcomes were evaluated over a period from treatment initiation to menopause onset. Sensitivity analyses were carried out to test the impact of various parameters and assumptions on the model output. MAIN OUTCOME MEASURES: Quality-adjusted life years (QALYs) gained and costs from a health care perspective. RESULTS: The incremental cost-effectiveness ratio of 6-month GnRH-a therapy compared with no therapy ranged from $6,185 per QALY in deep endometriosis to $6,425 with peritoneal endometriosis. A one-way sensitivity analysis showed considerable influential factors, such as remission rates and utility values. Probabilistic sensitivity analysis indicated that 6-month GnRH-a therapy is cost-effective in most cases at a threshold of $7,400/QALY, regardless of the type of endometriosis. CONCLUSION: Six months of therapy with GnRH-a can be a highly cost-effective option for the prevention of endometriosis recurrence. TWEETABLE ABSTRACT: Gonadotropin-releasing hormone agonist is cost effective for the prevention of endometriosis recurrence.

Incremental direct and indirect cost burden attributed to endometriosis surgeries in the United States.

OBJECTIVE: To compare direct and indirect costs between endometriosis patients who underwent endometriosis-related surgery (surgery cohort) and those who have not received surgery (no-surgery cohort). DESIGN: Retrospective cohort study. SETTING: Not applicable. PATIENT(S): Endometriosis patients (aged 18-49 years) with (n = 124,530) or without (n = 37,106) a claim for endometriosis-related surgery were identified from the Truven Health MarketScan Commercial and Health and Productivity Management databases for 2006-2014. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): Primary outcomes were healthcare utilization during 12-month pre- and post-index periods, annual direct (healthcare) and indirect (absenteeism and short- and long-term disability) costs during the 12-month post-index period (in 2014 US dollars). Indirect costs were assessed for patients with available productivity data. RESULT(S): Patients in the surgery cohort had significantly higher healthcare resource utilization during the post-index period and had mean annual total adjusted post-index direct costs approximately three times the costs among patients in the no-surgery cohort ($19,203 [SD $7,133] vs. $6,365 [SD $2,364]; average incremental annual direct cost = $12,838). The mean cost of surgery ($7,268 [SD $7,975]) was the single largest contributor to incremental annual direct cost. Mean estimated annual total indirect costs were $8,843 (surgery cohort) vs. $5,603 (no-surgery cohort); average incremental annual indirect cost = $3,240. CONCLUSION(S): Endometriosis patients who underwent surgery, compared with endometriosis patients who did not, incurred significantly higher direct costs due to healthcare utilization and indirect costs due to absenteeism or short-term disability. Regardless of the surgery type, the cost of index surgery contributed substantially to the total healthcare expenditure.

Randomized Trial on Fast Track Care in Colorectal Surgery for Deep Infiltrating Endometriosis.

STUDY OBJECTIVE: To study the application of a fast-track care protocol in colorectal surgery for deep infiltrating endometriosis. Bowel endometriosis is an infrequent but not rare condition that often needs intestinal surgery and imposes a high economic burden on society. DESIGN: Prospective randomized trial (Canadian Task Force classification I). SETTING: Tertiary referral center. PATIENTS: Two hundred twenty-seven patients with preoperative evidence of bowel endometriosis. INTERVENTIONS: We randomly assigned 227 patients with preoperative evidence of bowel endometriosis to a fast-track protocol (no preoperative bowel preparation, early restoration of diet, no postoperative antibiotics, and early postoperative mobilization) or conventional care for laparoscopic intestinal surgery. Randomization was obtained on a double-blind, date-based schedule, and all procedures were performed by a homogenous group of expert surgeons. Surgical outcomes and a health economic evaluation were assessed. MEASUREMENTS AND MAIN RESULTS: The primary outcome was hospital stay. Patient's well-being and intraoperative and postoperative complications up to 30 days after surgery were also assessed. Subsequently, direct medical costs were analyzed. Patients assigned to the fast-track protocol were discharged earlier (median 3 vs 7 days, p < .001) with no significant differences in subjective well-being (p = .55). Operative details, postoperative complications, and need of temporary ileostomy were similar (p = .89) between groups as well as readmission rates within 30 days (p = .69). The application of a fast-track protocol resulted in an overall significant reduction of costs (USD 6699 vs 8674, p < .01), and differences were more evident in cases of protective stoma (7652 vs 8793, p < .05) and surgery with postoperative complications (10 835 vs 14 005, p < .01). CONCLUSION: The application of a fast-track care protocol for laparoscopy in cases of pelvic and intestinal endometriosis does not increase the risk of complications and ensures a reduction of medical costs.

Long-term medical management of endometriosis with dienogest and with a gonadotropin-releasing hormone agonist and add-back hormone therapy.

Endometriosis can recur after either surgical or medical therapy. Long-term medical therapy is implemented to treat symptoms or prevent recurrence. Dienogest and gonadotropin-releasing hormone (GnRH) analogues with hormone add-back therapy seem to be equally effective for long-term treatment of pain symptoms associated with endometriosis. There is insufficient evidence to support the superiority of one therapy over the other. However, add-back hormone therapy (HT) is recommended for patients using GnRH agonists. The treatment selection depends on therapeutic effectiveness, tolerability, drug cost, the physician's experience, and expected patient compliance.

Economic burden of deep infiltrating endometriosis of the bowel and the bladder in Germany: The statutory health insurance perspective.

BACKGROUND: Until now, there has been little discussion of the costs of the deep infiltrating endometriosis (DIE) of the bowel or the bladder. The aim of the present secondary data analysis was to describe the population affected by this disease and to determine the economic burden in Germany from a payer's perspective. METHODS: Health claims data of women diagnosed with DIE of the bladder or bowel, who were surgically treated as inpatients between Jan 1, 2008 and Dec 31, 2012, were evaluated retrospectively. All data were extrapolated on a national statutory health insurance (SHI) level and normalized based on the year of surgery (index year). Case-individual information on age, comorbidities and prescribed drugs were presented for the index year. Direct medical cost data were analysed before and after the index year, differentiated by cost sector and age group. RESULTS: The data of 825 women with DIE were analysed. Sample size for different time points varied depending on insurance eligibility and continuous case information. The average age at surgery was 39 years. Besides DIE, 41 % of the women had at least one additional disease of the peritoneum. The mean annual total healthcare costs per DIE case were 12,868 Euros in the index year. Before surgery, mean annual costs varied between 548 and 2,475 Euros per case and after surgery between 1,739 and 2,818 Euros per case. In total, mean costs were higher in younger women as compared to older women, with a cost difference of 616 Euros over all time points. CONCLUSION: Direct costs are highest during the year of surgical treatment, but DIE of the bowel and bladder places a substantial burden on the SHI also before and after surgery. Further studies on indirect costs would be desirable to complete the knowledge on the economic burden of DIE.

Pharmaceutical treatments to prevent recurrence of endometriosis following surgery: a model-based economic evaluation.

OBJECTIVE: Conduct an economic evaluation based on best currently available evidence comparing alternative treatments levonorgestrel-releasing intrauterine system, depot-medroxyprogesterone acetate, combined oral contraceptive pill (COCP) and 'no treatment' to prevent recurrence of endometriosis after conservative surgery in primary care, and to inform the design of a planned trial-based economic evaluation. METHODS: We developed a state transition (Markov) model with a 36-month follow-up. The model structure was informed by a pragmatic review and clinical experts. The economic evaluation adopted a UK National Health Service perspective and was based on an outcome of incremental cost per quality-adjusted life year (QALY). As available data were limited, intentionally wide distributions were assigned around model inputs, and the average costs and outcome of the probabilistic sensitivity analyses were reported. RESULTS: On average, all strategies were more expensive and generated fewer QALYs compared to no treatment. However, uncertainty attributing to the transition probabilities affected the results. Inputs relating to effectiveness, changes in treatment and the time at which the change is made were the main causes of uncertainty, illustrating areas where robust and specific data collection is required. CONCLUSIONS: There is currently no evidence to support any treatment being recommended to prevent the recurrence of endometriosis following conservative surgery. The study highlights the importance of developing decision models at the outset of a trial to identify data requirements to conduct a robust post-trial analysis.

The direct and indirect costs associated with endometriosis: a systematic literature review.

STUDY QUESTION: What is the economic burden of endometriosis? SUMMARY ANSWER: The identified studies indicate that there is a significant economic burden associated with endometriosis, as observed by both direct and indirect costs. WHAT IS KNOWN ALREADY: Two previous systematic literature reviews suggested that there were considerable direct costs associated with endometriosis and there was a general lack of measurement of indirect costs. STUDY DESIGN, SIZE, DURATION: We performed a systematic literature review. MEDLINE and EMBASE databases from 2000 to 2013 were searched. The literature search was limited to human studies of patients with endometriosis. Papers in languages other than English were excluded. PARTICIPANTS/MATERIALS, SETTING, METHODS: Studies reporting direct or indirect costs among patients with endometriosis were considered for inclusion. Direct costs included inpatient, outpatient, surgery, drug and other healthcare service cost. Indirect costs were related to absenteeism and presenteeism (lost productivity at work). MAIN RESULTS AND THE ROLE OF CHANCE: After evaluating the 1396 articles in the search results, 12 primary studies that reported direct or indirect costs associated with endometriosis were identified and included in the data extraction. Three of the studies were conducted in the USA, one study each was conducted in Austria, Belgium, Brazil, Canada, Finland, Germany and Italy, and two studies included data from 10 countries. Significant variability was observed in the reviewed studies in methodology, including data source, cost components considered and study perspective. Estimates of total direct costs ranged from $1109 per patient per year in Canada to $12 118 per patient per year in the USA. Indirect costs of endometriosis ranged from $3314 per patient per year in Austria to $15 737 per patient per year in the USA. LIMITATIONS, REASONS FOR CAUTION: The studies identified in the systematic literature review varied greatly by study methodology as well as by country owing to different healthcare systems and costs of healthcare services, which contributed to large variations in the direct and indirect cost estimates. WIDER IMPLICATIONS OF THE FINDINGS: A majority of the studies we found were published after the periods covered in the prior systematic literature reviews, which provided substantial contributions to an understanding of the economic burden of endometriosis, especially in the area of indirect costs. The long-term burden of endometriosis following diagnosis is still under-studied, which is a concern given the chronic nature of the disease and the substantial recurrence of endometriosis symptoms. STUDY FUNDING/COMPETING INTERESTS: This study was funded by AbbVie, which also develops the oral GnRH antagonist elagolix (in collaboration with Neurocrine Biosciences) for the management of endometriosis and uterine fibroids. A.M.S. is an employee of AbbVie and currently owns AbbVie stocks. H.Y., E.X.D. and C.K. are employees of Analysis Group, Inc., which has received consultancy fees from AbbVie. C.W. is a Clinical Professor at the Department Obstetrics and Gynecology at Georgetown University in Washington, DC, USA and has served in a consulting role to AbbVie for this project.

Endometriose: impacto econômico e suas perspectivas / Endometriosis: economic impact and its outlook

A endometriose é uma doença crônica e benigna que afeta mulheres em idade reprodutiva e está associada à alta ocorrência de comorbidades, ocasionando aumento nos seus custos financeiros. Objetivou-se analisar os impactos econômicos devido as despesas correspondentes ao diagnóstico tardio, consultas, exames, procedimentos cirúrgicos e tratamento da endometriose, e como isso se reflete nos sistemas de saúde público, privado e sociedade. A metodologia consistiu de uma Revisão Sistemática da Literatura nas bases de dados Biblioteca Virtual em Saúde em todos os índices e todas as fontes e Pubmed a partir do ano de 1991 até 2010. Dos 67 artigos selecionados, foram utilizados 19, com análise descritiva,quantitativa e qualitativa referente aos valores que mostravam os custos diretos e indiretos comparados aos fatores biológicos, psicológicos, sociais e econômicos consequentes da endometriose. O impacto econômico existe e é considerável, sendo necessária a realização de futuras pesquisas para reduzir os custos, muitas vezes desnecessários. Mesmo que a literatura mostre grande relevância no diagnóstico e nos diversos tratamentos, existem poucos estudos publicados, principalmente nos últimos anos, que tenham uma abordagem sistemática sobre o impacto econômico da endometriose

Endometriosis is a benign chronic disease that affects women of reproductive age and is associated with high incidence of comorbidities, which increase their financing costs. This study aimed to analyze the economic impact caused due to expenses related to late diagnosis, consultations, tests, surgeries and treatment of endometriosis, and how they are reflected to the public and private health systems and society. The methodology consisted of a Systematic Review databases in the Virtual Health Library in all indices and all sources and Pubmed, from 1991 to 2010. 19 out of the 67 articles were used, with descriptive, quantitative and qualitative analysis referring to the values that showed the direct and indirect costs compared to the biological, psychological, social and economic consequents of endometriosis. Even though the literature shows great relevance in the diagnosis and various treatments, there are few studies published, especially in recent years, that have a systematic approach on the economic impact of endometriosis. Future researches to reduce unnecessary costs are necessary due to the relevance of the economic impact

The burden of endometriosis: costs and quality of life of women with endometriosis and treated in referral centres.

BACKGROUND: This study aimed to calculate costs and health-related quality of life of women with endometriosis-associated symptoms treated in referral centres. METHODS: A prospective, multi-centre, questionnaire-based survey measured costs and quality of life in ambulatory care and in 12 tertiary care centres in 10 countries. The study enrolled women with a diagnosis of endometriosis and with at least one centre-specific contact related to endometriosis-associated symptoms in 2008. The main outcome measures were health care costs, costs of productivity loss, total costs and quality-adjusted life years. Predictors of costs were identified using regression analysis. RESULTS: Data analysis of 909 women demonstrated that the average annual total cost per woman was €9579 (95% confidence interval €8559-€10 599). Costs of productivity loss of €6298 per woman were double the health care costs of €3113 per woman. Health care costs were mainly due to surgery (29%), monitoring tests (19%) and hospitalization (18%) and physician visits (16%). Endometriosis-associated symptoms generated 0.809 quality-adjusted life years per woman. Decreased quality of life was the most important predictor of direct health care and total costs. Costs were greater with increasing severity of endometriosis, presence of pelvic pain, presence of infertility and a higher number of years since diagnosis. CONCLUSIONS: Our study invited women to report resource use based on endometriosis-associated symptoms only, rather than drawing on a control population of women without endometriosis. Our study showed that the economic burden associated with endometriosis treated in referral centres is high and is similar to other chronic diseases (diabetes, Crohn's disease, rheumatoid arthritis). It arises predominantly from productivity loss, and is predicted by decreased quality of life.

[Economics analysis of endometriosis and adenomyosis surgeries].

OBJECTIVE: To explore the hospital expenses and hospital stay of surgical management for endometriosis and adenomyosis. METHODS: The average hospital expenses and average hospital stay were compared for a total of 12003 patients of endometriosis and adenomyosis confirmed operatively at our hospital from January 1994 to December 2008. And the relevant factors consisted of surgical phases, pathological types, surgical approaches, surgical routes, definite procedures and age groups. RESULTS: The average hospital expenses were significantly higher than average gynecologic surgical expenses (RMB 7073 vs RMB 6847, P < 0.01) while and the average hospital stays significantly shorter than the latter (6.8 vs 8.6 days, P < 0.01). The periods of 2006 - 2008 and 1994 - 1996 had significantly different average hospital expenses (RMB 7853 vs RMB 3382, P < 0.01) and average hospital stay (6.4 vs 9.5 days, P < 0.01). Multivariate analysis showed age was the most important correlated factor for the hospital expenses of endometriosis and adenomyosis surgeries (all P < 0.01). And surgical approach was one of the most important factors for hospital stay (all P < 0.01). CONCLUSION: Adenomyosis has the highest cost and younger endometriosis patients carry the lowest economic burden. Laparoscopy and conservative surgery may reduce the economic burden of endometriosis and adenomyosis operations.

Laparoscopy in women with unexplained infertility: a cost-effectiveness analysis.

OBJECTIVE: To evaluate the cost effectiveness of laparoscopy for unexplained infertility. DESIGN: We performed a cost-effectiveness analysis using a computer-generated decision analysis tree. Data used to construct the mathematical model were extracted from the literature or obtained from our practice. We compared outcomes following four treatment strategies: [1] no treatment, [2] standard infertility treatment algorithm (SITA), [3] laparoscopy with expectant management (LSC/EM), and [4] laparoscopy with infertility therapy (LSC/IT). The incremental cost-effectiveness ratio (ICER) was calculated, and one-way sensitivity analyses assessed the impact of varying base-case estimates. SETTING: Academic in vitro fertilization practice. PATIENT(S): Computer-simulated patients assigned to one of four treatments. INTERVENTION(S): Fertility treatment or laparoscopy. MAIN OUTCOME MEASURE(S): Incremental cost-effectiveness ratios. RESULT(S): Using base-case assumptions, LSC/EM was preferred (ICER =$128,400 per live-birth in U.S. dollars). Changing the following did not alter results: rates and costs of multiple gestations, penalty for high-order multiples, infertility treatment costs, and endometriosis prevalence. Outcomes were most affected by patient dropout from infertility treatments-SITA was preferred when dropout was less than 9% per cycle. Less important factors included surgical costs, acceptability of twins, and the effects of untreated endometriosis on fecundity. CONCLUSION(S): Laparoscopy is cost effective in the initial management of young women with infertility, particularly when infertility treatment dropout rates exceed 9% per cycle.

Actuarial analysis of private payer administrative claims data for women with endometriosis.

BACKGROUND: Endometriosis is a painful, chronic disease affecting 5.5 million women and girls in the United States and Canada and millions more worldwide. The usual age range of women diagnosed with endometriosis is 20 to 45 years. Endometriosis has an estimated prevalence of 10% among women of reproductive age, although estimates of prevalence vary greatly. Endometriosis is the most common gynecological cause of chronic pelvic pain, but published information on its associated medical care costs is scarce. OBJECTIVE: The aim of this study was to determine (1) the prevalence of endometriosis in the United States, (2) the amount of health care services used by women coded with endometriosis in a commercial medical claims database during 1999 to 2003, and (3) the endometriosis-related costs for 2003, the most recent data available at the time the study was performed. METHODS: This study was a retrospective review of administrative data for commercial payers, which included enrollment, eligibility, and claims payment data contained in the Medstat Marketscan database for approximately 4 million commercial insurance members. All claims and membership data were extracted for each woman aged 18 to 55 years who had at least 1 medical or hospital claim with a diagnosis code for endometriosis (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 617.00-617.99) for 1999 through 2003. Claims data from 1999 through 2003 were used to determine prevalence and health care resource utilization (i.e., annual admission rate, annual surgical rate, distribution of endometriosis-related surgeries, and prevalence of comorbid conditions). The cost analysis was based on claims from 2003 only. Cost was defined as the payer-allowed charge, which equals the net payer cost plus member cost share. RESULTS: The prevalence of women with medical claims (inpatient and/or outpatient) containing ICD-9-CM codes for endometriosis was 1.1% for the age band of 30 to 39 years and 0.7% over the entire age span of 18 to 55 years. The medical costs per patient per month (PPPM) for women with endometriosis were 63% greater ($706 PPPM) than those of the average woman per member per month ($433) in 2003; inpatient hospital costs accounted for 32% of total direct medical costs. Between 1999 and 2003, these women with endometriosis who were identified by either inpatient and/or outpatient claims had high rates of hospital admission (53% for any reason; 38% for an endometriosis-related reason) and a high annual surgical procedure rate (64%). Additionally, women with endometriosis frequently suffered from comorbid conditions, and these conditions were associated with greater PPPM costs of 15% to 50% for women with an endometriosis diagnosis code, depending on the condition. Interstitial cystitis was associated with 50% greater cost ($1,061 PPPM); depression, 41% ($997 PPPM); migraine, 40% ($988 PPPM); irritable bowel syndrome, 34% ($943 PPPM); chronic fatigue syndrome, 29% ($913 PPPM); abdominal pain, 20% ($846 PPPM); and infertility, 15% ($813 PPPM). CONCLUSIONS: Women with endometriosis have a high hospital admission rate and surgical procedure rate and a high incidence of comorbid conditions. Consequently, these women incur total medical costs that are, on average, 63% higher than medical costs for the average woman in a commercially insured group.

Role of a symptom-based algorithmic approach to chronic pelvic pain.

OBJECTIVE: Chronic pelvic pain (CPP) is a disorder that has a significant impact on the patient's quality of life. Laparoscopic diagnosis can be disappointing, and recurrence is common after surgical treatment. A symptom-based algorithmic approach to treatment of CPP is presented that is safe and cost-effective. METHODS: This approach is oriented towards making a potential clinical diagnosis of endometriosis. It relies on a structured evaluation of the patient and administration of medical therapy including GnRH agonists to selected patients. Evaluation begins with a history and physical examination; selected cases receive specific therapy. Non-responders undergo appropriate laboratory and imaging studies. If results remain negative, it is possible to make a clinical diagnosis of endometriosis and begin empiric treatment. RESULTS: Early results strongly indicate that using this approach allowed clinicians to make highly accurate diagnoses (correct in 85-90% of cases). CONCLUSION: Use of this approach will minimize the need for surgery.

A cost-effective approach to the management of endometriosis.

Endometriosis is a common disease that affects a large number of women throughout the world. Whereas in the past laparoscopy was commonly used for the diagnosis and treatment of women with endometriosis and pelvic pain, recent studies have demonstrated that surgical therapy offers no better results in terms of pain relief than medical therapy with a gonadotrophin-releasing hormone agonist. Surgical therapy requires considerable experience and expertise on the part of the surgeon and the results are likely to be operator dependent. The results of the very best surgeons, as published in the medical literature, often cannot be replicated by the average gynecologist. Medical treatment, on the other hand, is not operator dependent. The efficacy of clinical diagnosis given a thorough evaluation has been proved, and the outcomes of empiric medical therapy with a gonadotrophin-releasing hormone agonist are substantial. Given the similar results obtained with a gonadotrophin-releasing hormone agonist and surgical intervention and the fact that medical treatment is less expensive, primary therapy with a gonadotrophin-releasing hormone agonist appears to be the most cost-effective approach to the management of endometriosis and pelvic pain. Because of the limited information currently available, a statement regarding endometriosis and infertility would probably be inappropriate at this time.