title: 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.
  
  
  METHODS
  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.
  
  
  METHODS
  Four hypothetical cohorts of women with heavy menstrual bleeding.
  
  
  METHODS
  One of four alternative strategies: Mirena, first or second generation endometrial ablation techniques, or hysterectomy.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Health Economics Unit, School of Health and Population Sciences, Public Health Building, University of Birmingham, UK. T.E.Roberts@bham.ac.uk
authors.forename: T E
authors.initials: TE
authors.lastname: Roberts
authors.forename: A
authors.initials: A
authors.lastname: Tsourapas
authors.forename: L J
authors.initials: LJ
authors.lastname: Middleton
authors.forename: R
authors.initials: R
authors.lastname: Champaneria
authors.forename: J P
authors.initials: JP
authors.lastname: Daniels
authors.forename: K G
authors.initials: KG
authors.lastname: Cooper
authors.forename: S
authors.initials: S
authors.lastname: Bhattacharya
authors.forename: P M
authors.initials: PM
authors.lastname: Barton
mesh_terms: D003271:Contraceptive Agents, Female / Q000008:administration & dosage* / Q000191:economics; D003362:Cost-Benefit Analysis; D055356:Endometrial Ablation Techniques / Q000191:economics*; D005260:Female; D006295:Health Resources / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D007044:Hysterectomy / Q000191:economics*; D007436:Intrauterine Devices, Medicated; D016912:Levonorgestrel / Q000008:administration & dosage* / Q000191:economics; D008595:Menorrhagia / Q000188:drug therapy* / Q000191:economics; D008875:Middle Aged; D019057:Quality-Adjusted Life Years; D016032:Randomized Controlled Trials as Topic
chemical_list: D003271:Contraceptive Agents, Female; D016912:Levonorgestrel