The cost of illness and economic burden of endometriosis and chronic pelvic pain in Australia: A national online survey.

INTRODUCTION: Endometriosis has a significant cost of illness burden in Europe, UK and the USA, with the majority of costs coming from reductions in productivity. However, information is scarce on if there is a differing impact between endometriosis and other causes of chronic pelvic pain, and if there are modifiable factors, such as pain severity, that may be significant contributors to the overall burden. METHODS: An online survey was hosted by SurveyMonkey and the link was active between February to April 2017. Women aged 18-45, currently living in Australia, who had either a confirmed diagnosis of endometriosis via laparoscopy or chronic pelvic pain without a diagnosis of endometriosis were included. The retrospective component of the WERF EndoCost tool was used to determine direct healthcare costs, direct non-healthcare costs (carers) and indirect costs due to productivity loss. Estimates were extrapolated to the Australian population using published prevalence estimates. RESULTS: 407 valid responses were received. The cost of illness burden was significant in women with chronic pelvic pain (Int $16,970 to $ 20,898 per woman per year) irrespective of whether they had a diagnosis of endometriosis. The majority of costs (75-84%) were due to productivity loss. Both absolute and relative productivity costs in Australia were higher than previous estimates based on data from Europe, UK and USA. Pain scores showed the strongest relationship to productivity costs, a 12.5-fold increase in costs between minimal to severe pain. The total economic burden per year in Australia in the reproductive aged population (at 10% prevalence) was 6.50 billion Int $. CONCLUSION: Similar to studies in European, British and American populations, productivity costs are the greatest contributor to overall costs. Given pain is the most significant contributor, priority should be given to improving pain control in women with pelvic pain.

Hospital-associated Costs of Chronic Pelvic Pain in Canada: A Population-based Descriptive Study.

OBJECTIVE: To determine the hospital-related costs incurred by women requiring surgery or inpatient admission for chronic pelvic pain in Canada. METHODS: We conducted a population-based, cross-sectional study, focusing on women ages 15-59 with a most responsible International Classification of Diseases diagnosis of pelvic and perineal pain, dysmenorrhea, or dyspareunia who had surgery or inpatient admission with a discharge date between April 1, 2008 and March 31, 2012. This study was based on the Canadian Institute for Health Information Discharge Abstract database and the National Ambulatory Care Reporting System. Clinical diagnoses and interventions and resource intensity weights (RIW) were extracted. Hospital costs were estimated by multiplying cost per weighted case (CPWC) calculated at the national level with respective RIWs. RESULTS: Over four years, there were 34 346 cases of surgery or inpatient admission for chronic pelvic pain amounting to $100.5 million with an average cost of $25 million per year. Pelvic and perineal pain accounted for 61.5% (n = 21 127) of the cases, while dysmenorrhea accounted for 31.8% (n = 10 936), and dyspareunia accounted for 6.6% (n = 2283). The vast majority of the cases (92.9%, n = 31 923) were associated with surgical interventions, with the most common surgeries being hysterectomy (47.1%, n = 16 189), followed by laparoscopy (25.8%, n = 8850), adnexal surgery (6.8%, n = 2349), and other procedures (11.6%, n = 3968). CONCLUSION: While these estimates do not take into account non-hospital related costs, such as outpatient treatment, loss of productivity, and impact on quality of life, this study demonstrates that chronic pelvic pain represents a considerable economic burden to Canada's health care system.

Barriers to Pelvic Floor Physical Therapy Regarding Treatment of High-Tone Pelvic Floor Dysfunction.

OBJECTIVE: Chronic pelvic pain is a prevalent and debilitating condition with a wide range of etiologies. An estimated 30% to 70% of chronic pelvic cases involve musculoskeletal component pain including high-tone pelvic floor dysfunction (HTPFD). Pelvic floor physical therapy has been shown to be a beneficial treatment for HTPFD, yet many patients do not have access to this treatment. The objective of this study was to identify the barriers preventing patients from following through with the first-line management, physical therapy. METHODS: Participants with a diagnosis of HTPFD (n = 154) were identified from the list of referrals sent from the obstetrics and gynecology department to an affiliated PFPT center. Participants were contacted and asked to complete a phone survey addressing demographics and perceived barriers to care. Responses were collected in REDCap. Univariate and bivariate analyses were performed using a statistical analysis software. RESULTS: Seventy surveys were completed. The top barriers identified by participants were financial constraints (51.4%), perceived lack of utility (37.1%), time constraints (30.0%), and travel issues (18.6%); 84.4% of participants had 1 or more comorbid pain condition. Whereas 51.4% expressed some level of anxiety regarding the PFPT option, only 9.6% of participants did not start treatment because of fear of treatment. CONCLUSIONS: The majority of treatment barriers identified were concrete restraints, with insurance noncoverage and time constraints being the top issues. A fair number of participants expressed anxiety about the treatment or felt they received unclear explanations of the treatment. These are areas in which providers can potentially alleviate some barriers to care.

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.

The Burden of Bladder Pain in Five European Countries: A Cross-sectional Study.

OBJECTIVE: To estimate the burden of illness associated with bladder pain in 5 European countries: France, Germany, Italy, Spain, and the United Kingdom. PATIENTS AND METHODS: Patients with a diagnosis of bladder pain (ie, unpleasant sensation, pain, pressure, or discomfort related to the urinary bladder) were identified from data collected by the cross-sectional National Health and Wellness Survey performed in 2013. Propensity score matching was used to construct a comparator group without bladder pain (1 case: 2 controls). Assessments were performed for several outcomes including health-related quality of life (HRQoL; 36-item Short-Form, version 2), work-related function (Work Productivity and Activity Impairment questionnaire), employment status, and all-cause healthcare resource use. RESULTS: We identified 275 patients with a physician diagnosis of bladder pain, 274 of whom were successfully matched to 548 controls without bladder pain. Compared with matched controls, patients with bladder pain had significantly impaired HRQoL (mental component summary: 38.5 vs 44.5; physical component summary: 38.9 vs 47.8; P <.001). Overall work productivity loss was significantly greater in patients with bladder pain compared with matched controls (41.7% vs 21.5%; P <.001). Patients with bladder pain were also significantly more likely to use all-cause healthcare resources and make more visits to healthcare providers in the previous 6 months than matched controls (P <.001 for all outcomes). CONCLUSION: Bladder pain is associated with a considerable burden in Europe in terms of impaired HRQoL and work productivity, and increased healthcare resource use.

Gabapentin for the Management of Chronic Pelvic Pain in Women (GaPP1): A Pilot Randomised Controlled Trial.

Chronic pelvic pain (CPP) affects 2.1-24% of women. Frequently, no underlying pathology is identified, and the pain is difficult to manage. Gabapentin is prescribed for CPP despite no robust evidence of efficacy. We performed a pilot trial in two UK centres to inform the planning of a future multicentre RCT to evaluate gabapentin in CPP management. Our primary objective was to determine levels of participant recruitment and retention. Secondary objectives included estimating potential effectiveness, acceptability to participants of trial methodology, and cost-effectiveness of gabapentin. Women with CPP and no obvious pelvic pathology were assigned to an increasing regimen of gabapentin (300-2700 mg daily) or placebo. We calculated the proportion of eligible women randomised, and of randomised participants who were followed up to six months. The analyses by treatment group were by intention-to-treat. Interviews were conducted to evaluate women's experiences of the trial. A probabilistic decision analytical model was used to estimate cost-effectiveness. Between September 2012-2013, 47 women (34% of those eligible) were randomised (22 to gabapentin, 25 to placebo), and 25 (53%) completed six-month follow-up. Participants on gabapentin had less pain (BPI difference 1.72 points, 95% CI:0.07-3.36), and an improvement in mood (HADS difference 4.35 points, 95% CI:1.97-6.73) at six months than those allocated placebo. The majority of participants described their trial experience favorably. At the UK threshold for willingness-to-pay, the probabilities of gabapentin or no treatment being cost-effective are similar. A pilot trial assessing gabapentin for CPP was feasible, but uncertainty remains, highlighting the need for a large definitive trial.

A descriptive cost analysis study of cases of right iliac fossa pain.

Patients with suspected appendicitis comprise a large proportion of general surgical workload. The resulting healthcare burden is significant when one considers that investigations, observation and surgical procedures are often needed. As no previous study has examined the cost of managing patients with suspected appendicitis, we performed a cost analysis study of management of cases of right iliac fossa (RIF) pain in University Hospital Limerick. Patients who were admitted with right iliac fossa pain from 1st April 2011 to 4th May 2011 were identified prospectively. After discharge, patients' medical records were reviewed. Costing data collected comprised details on length of stay, number and type of radiological investigations, number and type of blood investigations, medications administered and operations performed. Costs for radiological investigations were obtained from casemix data. Blood investigation costs were obtained from relevant laboratories. Medication costs were obtained from the pharmacy department. Operation costs were based on the cost of equipment combined with cost relating to operating theatre time and recovery unit time. Due to unavailability of data on Irish public hospital bed-day cost, a private hospital provided cost details on this aspect. 94 patients (M = 33, F = 61) were admitted with RIF pain during this time period. 62 underwent surgery. There were 53 appendicectomies performed with 42 (79%) positive for appendicitis on histological analysis. Blood test, radiology, pharmacy, operative and bed-day costs were €1857, €6252, €3517, €184,191 and €152,706 respectively. The total estimated cost was €348,525 (€3708 average per patient). There is a high cost associated with managing suspected appendicitis in Ireland. Strategies to reduce cost include reducing unnecessary admissions and unnecessary operations. Reducing LOS may be another potentially valuable cost saving method. It is imperative that resources are channelled into the provision of accurate costing structures.

[Chronic pelvic pain: epidemiology and economic impact]. / Épidémiologie et aspects économiques des douleurs pelvipérinéales chroniques.

OBJECTIVE: To combine epidemiological and health economics data concerning urological chronic pelvic pain syndromes. MATERIAL: Review of articles concerning this topic in the Medline (PubMed) database, chosen according to their scientific relevance. RESULTS: Prevalences are about 10,000/100,000 for chronic pelvic pain syndrome/chronic prostatis, 239 to 306/100,000 for bladder pain syndrome/interstitial cystitis, 15,000 to 20,000/100,000 for post-vasectomy testis and epididymis pain, 14,000/100,000 concerning deep female dyspareunia, 1000 to 9000/100,000 for male ejaculation or orgasma-related pain, 15,000 to 21,000/100,000 for female chronic pelvic pain, of which one third is related to endometriosis. Little has been published about the frequency of other chronic pelvic and perineal pain syndromes. The financial impact is comparable to other more frequent chronic diseases, with costs definitely above what the prevalences would have led to believe. CONCLUSION: The frequency of pelvic disease association, their predisposing factors, common environments and comordities suggest a possible common origin. This epidemiological data highlights the benefit of a multidisciplinary approach of chronic pelvic and perineal pain. This could lead to a better understanding of involved mechanisms, and ultimately treatment options.

Contrasting the percutaneous nerve evaluation versus staged implantation in sacral neuromodulation.

Sacral neuromodulation is increasingly used for the treatment of voiding dysfunction, pelvic pain syndromes, and gastrointestinal disorders. While increased use of this technology has led to a greater understanding of its potential as well as its limitations, difficulty persists in identifying the patients that will benefit most. Either of two trial stimulation techniques is performed before placement of a permanent neuromodulator: the monopolar percutaneous nerve evaluation and the tined quadripolar staged trial. The preponderance of recent literature asserts the superior sensitivity of the staged trial over percutaneous nerve evaluation. However, the techniques offer disparate advantages, and other issues, such as cost-effectiveness, remain largely unexplored. The role of sacral neuromodulation will continue to expand as physicians and patients become increasingly aware of its therapeutic potential. Widespread adoption of this clinically superior technique will most rapidly help the greatest number of patients.

Economic burden of endometriosis.

OBJECTIVE: To comprehensively review and evaluate the direct costs of endometriosis. DESIGN AND SETTING: We systematically reviewed studies published since 1990, and conducted an analysis of publicly available national databases (Healthcare Cost and Utilization Project and National Ambulatory Medical Care Survey/National Hospital Ambulatory Medical Care Survey) in the United States. We assessed: [1] the overall economic impact of endometriosis; [2] the direct costs associated with specific treatments; and [3] the indirect costs of endometriosis associated with reduced work productivity. RESULTS: Of 13 published studies meeting inclusion criteria, 11 (85%) addressed direct costs, a few studies addressed outpatient costs or indirect costs, and no study quantified the economic impact among adolescents. Direct endometriosis-related costs were considerable and appeared driven by hospitalizations. Our database analysis found: [1] as endometriosis-related hospital length of stay steadily declined from 1993 to 2002, per-patient cost increased 61%; [2] adolescents (aged 10-17 years) had endometriosis-related hospitalizations; [3] approximately 50% of >600,000 endometriosis-related ambulatory patient visits involved specialist care; and [4] females 23 years old or younger constituted >20% of endometriosis-related outpatient visits. CONCLUSIONS: Health economic information for endometriosis is scarce, limiting our understanding of its overall economic impact. Nevertheless, the literature and other available data suggest that endometriosis places a considerable burden on patients and society.

A refined estimate of the average lifetime cost of pelvic inflammatory disease.

BACKGROUND: The major complications of pelvic inflammatory disease (infertility, ectopic pregnancy, and chronic pelvic pain) are the leading cause of non-HIV sexually transmitted disease morbidity in the United States. GOAL: The goal of the study was to estimate a plausible range for the average lifetime cost of pelvic inflammatory disease (PID) and its major complications in a cohort of U.S. women of reproductive age. STUDY DESIGN: We developed a state-transition computer-based model to simulate the natural history of PID, incorporating the severity of infection, number of recurrent episodes, treatment setting, and the risk over time of major complications. Clinical and cost data were from the published literature. Model outcomes included life expectancy, quality-adjusted life expectancy, and lifetime costs. RESULTS: In a cohort of 100,000 females acquiring PID between 20 and 24 years of age, 8550 ectopic pregnancies, 16,800 cases of infertility, and 18,600 cases of chronic pelvic pain were projected to occur. Assuming a 3% annual discount rate, we found the average per-person lifetime cost to be $2150. Average lifetime costs for women who developed major complications were $6350 for chronic pelvic pain, $6840 for ectopic pregnancy, and $1270 for infertility. The majority of costs (79%) were accrued within 5 years of upper genital tract infection. Results were most sensitive to assumptions about the timing of major complications and the discount rate. CONCLUSION: The average per-person lifetime cost of PID ranges between $1060 and $3180. Future cost-effectiveness analyses of STD screening programs can include this range as a reasonable upper and lower bound. These findings suggest successful PID prevention efforts may avert substantial costs for care providers such as managed care organizations while providing well documented clinical benefits for women in the United States.

Clinical implications of postsurgical adhesions.

Adhesion development can have a major impact on a patient's subsequent health. Adhesions are a significant source of impaired organ functioning, decreased fertility, bowel obstruction, difficult re-operation, and possibly pain. Consequently, their financial sequelae are also extraordinary, with more than one billion dollars spent in the USA in 1994 on the bowel obstruction component alone. Performing adhesiolysis for pain relief appears efficacious in certain subsets of women. Unfortunately even when lysed, adhesions have a great propensity to reform. Adhesions are prevalent in all surgical fields, and nearly any compartment of the body. For treatment of infertility and recurrent pregnancy loss, lysis of intrauterine adhesions results in improved fecundability and decreased pregnancy loss.

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.

[Chronic pelvic pain in women. A condition difficult to diagnose--more than 70 different diagnoses can be considered]. / Långvarig kvinnlig bäckensmärta. Svårdiagnostiserat tillstånd--mer än 70 diagnoser möjliga.

Chronic pelvic pain, CPP, with a prevalence of about 15 percent of the female population between 18 and 50 years, has vast psychosocial and economic consequences. The cause(s) are often elusive despite invasive procedures including laparoscopy. There is a connection between CPP and abuse in childhood, sexual as well as non-sexual. Usually the woman initially seeks a gynecologist, who should have some knowledge also of lesser known causes of CPP such as pelvic congestion and nerve entrapments. A multidisciplinary approach can offer more possibilities to reach a plausible diagnosis and adequate treatment.

Psychosocial and economic impact of chronic pelvic pain.

According to a population-based estimate, chronic pelvic pain (CPP) affects approximately 15% of women aged 18-50. The psychosocial impact of CPP is reflected in mood disturbance, disruption of normal activity and relationships as well as pain. Identification of psychosocial factors as cause or effect remains problematic. Results of a study of 105 women with CPP using the British version of the SF-36 Health Survey Questionnaire are presented, together with analyses of face validity and reliability. While generally reflecting health status, specific problems with the questionnaire are identified related to the episodic nature of pelvic pain, and avoidance as a means of preventing pain exacerbations. Health economic analyses relating to CPP are reviewed and the implications for future directions in treatment strategy are discussed in the context of limited options of proven efficacy.

Direct medical cost of pelvic inflammatory disease and its sequelae: decreasing, but still substantial.

OBJECTIVE: To estimate direct medical costs and average lifetime cost per case of pelvic inflammatory disease (PID). METHODS: We estimated the direct medical expenditures for PID and its three major sequelae (chronic pelvic pain, ectopic pregnancy, and infertility) and determined the average lifetime cost of a case of PID and its sequelae. We analyzed 3 years of claims data of privately insured individuals to determine costs, and 3 years of national survey data to determine number of cases of PID, chronic pelvic pain, and ectopic pregnancy. We developed a probability model to determine the average lifetime cost of a case of PID. RESULTS: Direct medical expenditures for PID and its sequelae were estimated at $1.88 billion in 1998: $1.06 billion for PID, $166 million for chronic pelvic pain, $295 million for ectopic pregnancy, and $360 million for infertility associated with PID. The expected lifetime cost of a case of PID was $1167 in 1998 dollars. The majority of those costs ($843 per case) represent care for acute PID rather than diagnosis and treatment of sequelae. Approximately 73% of cases will not accrue costs beyond the treatment of acute PID. CONCLUSION: The direct medical cost of PID is still substantial. The majority of PID related costs are incurred in the treatment of acute PID. Because most PID-related costs arise in the first year from treatment of acute PID infection, strategies that prevent PID are likely to be cost-effective within a single year.

Modeling of medical and surgical treatment costs of chronic pelvic pain: new paradigms for making clinical decisions.

Additional complexity has been added to the healthcare decision-making process by the socioeconomic constraints of the industry and a population that is increasingly educated about healthcare. As a result, decisions balanced on the basis of outcomes and economic realities are needed. This modeling of surgical versus medical treatment costs for chronic pelvic pain and endometriosis factors in the large number of women with chronic pelvic pain, direct and indirect costs of the condition, and clinical benefits, projected costs, and savings of the therapies. This process of calculation becomes an aid for decision making in the current healthcare system.

Reduction of sick leave for lumbar back and posterior pelvic pain in pregnancy.

STUDY DESIGN: In this prospective, consecutive, controlled cohort study, the authors analyzed the impact of a differentiated, individual-based treatment program on sick leave during pregnancy for women experiencing lumbar back or posterior pelvic pain during pregnancy. OBJECTIVE: To identify patients with pain early in pregnancy and, by means of individual information and differentiated physiotherapy, reduce sick leave during pregnancy. SUMMARY OF BACKGROUND DATA: Sick leave for back pain during pregnancy is common, and treatment programs have been aimed at reducing pain, for that reason. In Sweden, the average sick leave due to back pain during pregnancy is 7 weeks. METHODS: All pregnant women who attended a specific antenatal clinic and experienced lumbar back or posterior pelvic pain were included in an intervention group, and results were compared with women in a control group from another antenatal clinic. RESULTS: The intervention group comprised 54 women, compared with 81 women in the control group. Thirty-three women were on sick leave for an average of 30 days in the intervention group versus 45 women for an average of 54 days in the control group (P < 0.001). The reduction in sick leave reduced insurance costs by approximately $53,000 U.S. CONCLUSIONS: Sick leave for lumbar back and posterior pelvic pain in the intervention group was significantly reduced with the program, and the program was cost effective.