title: Costs, effectiveness, and workload impact of management strategies for women with an adnexal mass.
abstract: BACKGROUND
  We compared the estimated clinical outcomes, costs, and physician workload resulting from available strategies for deciding which women with an adnexal mass should be referred to a gynecologic oncologist.
  
  
  METHODS
  We used a microsimulation model to compare five referral strategies: 1) American Congress of Obstetricians and Gynecologists (ACOG) guidelines, 2) Multivariate Index Assay (MIA) algorithm, 3) Risk of Malignancy Algorithm (ROMA), 4) CA125 alone with lowered cutoff values to prioritize test sensitivity over specificity, 5) referral of all women (Refer All). Test characteristics and relative survival were obtained from the literature and data from a biomarker validation study. Medical costs were estimated using Medicare reimbursements. Travel costs were estimated using discharge data from Surveillance, Epidemiology and End Results-Medicare and State Inpatient Databases. Analyses were performed separately for pre- and postmenopausal women (60 000 "subjects" in each), repeated 10 000 times.
  
  
  RESULTS
  Refer All was cost-effective compared with less expensive strategies in both postmenopausal (incremental cost-effectiveness ratio [ICER] $9423/year of life saved (LYS) compared with CA125) and premenopausal women (ICER $10 644/YLS compared with CA125), but would result in an additional 73 cases/year/subspecialist. MIA was more expensive and less effective than Refer All in pre- and postmenopausal women. If Refer All is not a viable option, CA125 is an optimal strategy in postmenopausal women.
  
  
  CONCLUSIONS
  Referral of all women to a subspecialist is an efficient strategy for managing women with adnexal masses requiring surgery, assuming sufficient capacity for additional surgical volume. If a test-based triage strategy is needed, CA125 with lowered cutoff values is a cost-effective strategy.
authors.affiliation: Division of Gynecologic Oncology (LJH), and Department of Obstetrics and Gynecology (LJH, ERM), Department of Medicine (MD, LHC), Duke University Medical Center, Durham, NC; Duke Cancer Institute, Durham, NC (LJH, ERM); St. Francis Hospital, Columbus, GA (GPS); Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, San Antonio Military Medical Center, Fort Sam Houston, TX (JCB); Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Universitaire Ziekenhuizen Leuven, Katholieke Universiteit Leuven, Leuven, Belgium (TVG); Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, MUMC., GROW - School for Oncology and Developmental Biology, Maastricht, the Netherlands (TVG). havri001@mc.duke.edu.
authors.forename: Laura J
authors.initials: LJ
authors.lastname: Havrilesky
authors.affiliation: Division of Gynecologic Oncology (LJH), and Department of Obstetrics and Gynecology (LJH, ERM), Department of Medicine (MD, LHC), Duke University Medical Center, Durham, NC; Duke Cancer Institute, Durham, NC (LJH, ERM); St. Francis Hospital, Columbus, GA (GPS); Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, San Antonio Military Medical Center, Fort Sam Houston, TX (JCB); Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Universitaire Ziekenhuizen Leuven, Katholieke Universiteit Leuven, Leuven, Belgium (TVG); Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, MUMC., GROW - School for Oncology and Developmental Biology, Maastricht, the Netherlands (TVG).
authors.forename: Michaela
authors.initials: M
authors.lastname: Dinan
authors.affiliation: Division of Gynecologic Oncology (LJH), and Department of Obstetrics and Gynecology (LJH, ERM), Department of Medicine (MD, LHC), Duke University Medical Center, Durham, NC; Duke Cancer Institute, Durham, NC (LJH, ERM); St. Francis Hospital, Columbus, GA (GPS); Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, San Antonio Military Medical Center, Fort Sam Houston, TX (JCB); Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Universitaire Ziekenhuizen Leuven, Katholieke Universiteit Leuven, Leuven, Belgium (TVG); Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, MUMC., GROW - School for Oncology and Developmental Biology, Maastricht, the Netherlands (TVG).
authors.forename: Gregory P
authors.initials: GP
authors.lastname: Sfakianos
authors.affiliation: Division of Gynecologic Oncology (LJH), and Department of Obstetrics and Gynecology (LJH, ERM), Department of Medicine (MD, LHC), Duke University Medical Center, Durham, NC; Duke Cancer Institute, Durham, NC (LJH, ERM); St. Francis Hospital, Columbus, GA (GPS); Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, San Antonio Military Medical Center, Fort Sam Houston, TX (JCB); Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Universitaire Ziekenhuizen Leuven, Katholieke Universiteit Leuven, Leuven, Belgium (TVG); Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, MUMC., GROW - School for Oncology and Developmental Biology, Maastricht, the Netherlands (TVG).
authors.forename: Lesley H
authors.initials: LH
authors.lastname: Curtis
authors.affiliation: Division of Gynecologic Oncology (LJH), and Department of Obstetrics and Gynecology (LJH, ERM), Department of Medicine (MD, LHC), Duke University Medical Center, Durham, NC; Duke Cancer Institute, Durham, NC (LJH, ERM); St. Francis Hospital, Columbus, GA (GPS); Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, San Antonio Military Medical Center, Fort Sam Houston, TX (JCB); Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Universitaire Ziekenhuizen Leuven, Katholieke Universiteit Leuven, Leuven, Belgium (TVG); Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, MUMC., GROW - School for Oncology and Developmental Biology, Maastricht, the Netherlands (TVG).
authors.forename: Jason C
authors.initials: JC
authors.lastname: Barnett
authors.affiliation: Division of Gynecologic Oncology (LJH), and Department of Obstetrics and Gynecology (LJH, ERM), Department of Medicine (MD, LHC), Duke University Medical Center, Durham, NC; Duke Cancer Institute, Durham, NC (LJH, ERM); St. Francis Hospital, Columbus, GA (GPS); Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, San Antonio Military Medical Center, Fort Sam Houston, TX (JCB); Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Universitaire Ziekenhuizen Leuven, Katholieke Universiteit Leuven, Leuven, Belgium (TVG); Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, MUMC., GROW - School for Oncology and Developmental Biology, Maastricht, the Netherlands (TVG).
authors.forename: Toon
authors.initials: T
authors.lastname: Van Gorp
authors.affiliation: Division of Gynecologic Oncology (LJH), and Department of Obstetrics and Gynecology (LJH, ERM), Department of Medicine (MD, LHC), Duke University Medical Center, Durham, NC; Duke Cancer Institute, Durham, NC (LJH, ERM); St. Francis Hospital, Columbus, GA (GPS); Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, San Antonio Military Medical Center, Fort Sam Houston, TX (JCB); Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Universitaire Ziekenhuizen Leuven, Katholieke Universiteit Leuven, Leuven, Belgium (TVG); Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, MUMC., GROW - School for Oncology and Developmental Biology, Maastricht, the Netherlands (TVG).
authors.forename: Evan R
authors.initials: ER
authors.lastname: Myers
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D014408:Biomarkers, Tumor / Q000097:blood*; D018394:CA-125 Antigen / Q000097:blood*; D003362:Cost-Benefit Analysis; D003657:Decision Making; D019468:Disease Management; D005260:Female; D005833:Genital Neoplasms, Female / Q000097:blood / Q000191:economics* / Q000453:epidemiology* / Q000401:mortality; D006801:Humans; D008297:Male; D008390:Markov Chains; D006278:Medicare; D008565:Membrane Proteins / Q000097:blood*; D008875:Middle Aged; D017698:Postmenopause; D017410:Practice Guidelines as Topic; D017697:Premenopause; D012017:Referral and Consultation / Q000191:economics*; D018570:Risk Assessment / Q000191:economics; D018426:SEER Program; D012680:Sensitivity and Specificity; D014481:United States; D016526:Workload / Q000706:statistics & numerical data
chemical_list: D014408:Biomarkers, Tumor; D018394:CA-125 Antigen; C451759:MUC16 protein, human; D008565:Membrane Proteins