title: Investigating postmenopausal bleeding for endometrial cancer: cost-effectiveness of initial diagnostic strategies.
abstract: OBJECTIVE
  To determine the most cost-effective outpatient testing strategy for diagnosing endometrial cancer in women with postmenopausal bleeding (PMB).
  
  
  METHODS
  Decision analysis modelling.
  
  
  METHODS
  Women with postmenopausal bleeding.
  
  
  METHODS
  A decision analytic model was constructed to reflect current service provision, which evaluated 12 diagnostic strategies using endometrial biopsy (EB), ultrasonography (USS) (4- and 5-mm endometrial thickness cutoff) and hysteroscopy. Diagnostic probability estimates were derived from systematic quantitative reviews, clinical outcomes from published literature and cost estimates from local and NHS sources.
  
  
  METHODS
  The cost per additional life year gained (pound/LYG) was determined and compared for each diagnostic strategy, and sensitivity analyses were performed.
  
  
  RESULTS
  Compared with carrying out no initial investigation, a strategy based on initial diagnosis with USS using a 5-mm cutoff was the least expensive (11,470 pound/LYG). Initial investigation with EB or USS using a 4-mm cutoff was comparably cost-effective (less than 30,000 pound/LYG versus USS with a 5-mm cutoff) at their most favourable diagnostic performance and at disease prevalence of 10% or more. The strategies involving initial evaluation with test combinations or hysteroscopy alone were not cost-effective.
  
  
  CONCLUSIONS
  Women presenting for the first time with PMB should undergo initial evaluation with USS or EB.
authors.affiliation: Department of Obstetrics and Gynaecology, Birmingham Women's Hospital, Birmingham, UK. justin.clarke@bwhct.nhs.uk
authors.forename: T J
authors.initials: TJ
authors.lastname: Clark
authors.forename: P M
authors.initials: PM
authors.lastname: Barton
authors.forename: A
authors.initials: A
authors.lastname: Coomarasamy
authors.forename: J K
authors.initials: JK
authors.lastname: Gupta
authors.forename: K S
authors.initials: KS
authors.lastname: Khan
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care / Q000191:economics; D000704:Analysis of Variance; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D016889:Endometrial Neoplasms / Q000175:diagnosis*; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D008875:Middle Aged; D017698:Postmenopause; D017410:Practice Guidelines as Topic; D012680:Sensitivity and Specificity; D014592:Uterine Hemorrhage / Q000209:etiology*