64: Stepwise approach to the medical and surgical management of endometriosis related pain: A cost-effectiveness analysis

Abstract

Endometriosis is a prevalent disease associated with significant cost; over $49 billion in medical costs is spent annually in the United States (US) alone. Limited data exist on the cost-effectiveness of various clinical regimens to guide management. We sought to determine which sequence of therapies would be most cost-effective for the treatment of endometriosis-related pain. We built a cost-effectiveness model using TreeAge Pro software to compare four distinct, stepwise strategies in the management of endometriosis-related pain (Figure 1). We compared: (Strategy 1) nonsteroidal anti-inflammatory drugs (NSAIDs) followed by surgery; (Strategy 2) NSAIDs, then short acting reversible contraceptives (SARCs) or long acting reversible contraceptives (LARCs) followed by surgery; (Strategy 3) NSAIDs, then SARCs/LARCs, then gonadotropin releasing hormone (GnRH) agonists or GnRH antagonists followed by surgery; (Strategy 4) proceeding directly to surgery. Probabilities, utilities, and costs were derived from the literature. We adopted the societal perspective and modeled outcomes over three years. Our primary outcome was the incremental cost-effectiveness ratio (ICER). Secondary outcomes included costs and quality-adjusted-life-years (QALYs). Cohort size was based on the approximate number of women aged 18-45 with dysmenorrhea and/or cyclic pelvic pain in the US. Univariate sensitivity analysis was performed on all model inputs. A tornado diagram was made to identify which variables had the greatest influence on the model. Among a theoretical cohort of 10,018,400 women, all four strategies were cost-effective at a standard willingness to pay threshold of 100,000 per QALY gained (Table 1). Strategy 2 was associated with the lowest cost per QALY gained (ICER of $803). If all women received a trial of GnRH agonist after failing hormonal contraception (strategy 3 versus 2), the total cost would be $10 billion with a gain of 554,575 QALYs. For a routine trial of GnRH agonists to be the preferred strategy after failing hormonal contraception, rather than surgery, the cost of GnRH agonists would have to be less than 80% of their current cost. Our tornado diagram identified the probability of improvement with surgery as a key input. The probability of cure with surgery would need to exceed 82% for it to be the preferred first line treatment method. While care must be individualized, our findings suggest that stepwise treatment with more than one medical modality prior to surgery is a cost-effective approach to endometriosis management.View Large Image Figure ViewerDownload Hi-res image Download (PPT)