Hysterectomy, endometrial ablation, and levonorgestrel releasing intrauterine system (Mirena) for treatment of heavy menstrual bleeding: cost effectiveness analysis

Abstract

Objective: To undertake a cost effectiveness analysis comparing first and second generation endometrial ablative techniques, hysterectomy, and the levonorgestrel releasing intrauterine system (Mirena) for treating heavy menstrual bleeding.

Design: Model based economic evaluation with data from an individual patient data meta-analysis supplemented with cost and outcome data from published sources taking an NHS (National Health Service) perspective. A state transition (Markov) model was developed, the structure being informed by the reviews of the trials and clinical input. A subgroup analysis, one way sensitivity analysis, and probabilistic sensitivity analysis were also carried out.

Population: Four hypothetical cohorts of women with heavy menstrual bleeding.

Interventions: One of four alternative strategies: Mirena, first or second generation endometrial ablation techniques, or hysterectomy.

Main outcome measures: Cost effectiveness based on incremental cost per quality adjusted life year (QALY).

Results: Hysterectomy is the preferred strategy for the first intervention for heavy menstrual bleeding. Although hysterectomy is more expensive, it produces more QALYs relative to other remaining strategies and is likely to be considered cost effective. The incremental cost effectiveness ratio for hysterectomy compared with Mirena is £1440 (€1633, $2350) per additional QALY. The incremental cost effectiveness ratio for hysterectomy compared with second generation ablation is £970 per additional QALY.

Conclusion: In light of the acceptable thresholds used by the National Institute for Health and Clinical Excellence, hysterectomy would be considered the preferred strategy for the treatment of heavy menstrual bleeding. The results concur with those of other studies but are highly sensitive to utility values used in the analysis.

Fig 1 Clinical pathways within model for determination of cost effectiveness of different treatments for heavy menstrual bleeding. Names of strategies denote first intervention undertaken

Fig 2 Cost effectiveness acceptability frontier, showing probability that preferred option is cost effective (ICER=incremental cost effectiveness ratio)

Fig 3 Base case deterministic results of cost effectiveness of different treatments for heavy menstrual bleeding (Mirena, hysterectomy, and first and second generation ablation techniques)

Fig 4 Deterministic sensitivity analysis with median utility values instead of means for cost effectiveness of different treatments for heavy menstrual bleeding (Mirena, hysterectomy, and first and second generation ablation techniques)