This systematic literature review was conducted to summarize the direct and indirect costs per patient that are associated with uterine fibroid tumors in international studies. A search with predefined search terms was conducted in MEDLINE and EMBASE for studies that were published from January 2000 to November 2013. The review included primary studies that were in English and that reported either direct costs (drug costs, procedure costs, and medical service costs) or indirect costs (such as productivity loss) among patients with uterine fibroid tumors. A total of 26 studies that were identified and included in the data extraction included 19 studies in the United States, 2 studies in the Netherlands, 1 study each in Germany, China, Italy, and Canada, and 1 study reported data that were collected from 3 countries: Germany, France, and England. The studies differed substantially in perspectives that were adopted for analysis, research designs, data elements that were collected, setting, populations, and outcome measurements. Among 3 studies that reported total direct costs during the year after uterine fibroid tumor diagnosis, 2 studies reported an average of $9473 and $9319 per patient, respectively; 2 studies reported the excess costs over controls to be $6076 and $5427, respectively. The indirect costs per patient ranged from $2399–15,549, and the excess indirect cost per patient over control groups ranged from $323–4824 in the year after the diagnosis. The total costs, sum of direct and indirect costs, ranged from $11,717–25,023 per patient per year, after diagnosis or surgery among patients with uterine fibroid tumors. Compared with control subjects, the additional annual cost ranged from $2200–15,952 per patient. The results of this systematic literature review highlight the substantial direct and indirect costs that are associated with uterine fibroid tumors to health care payers and society. The large number and the variety of studies identified also emphasize the growing awareness of the significant economic impact of uterine fibroid tumors. Current gaps that were identified through this review warrant further investigation to elucidate fully the economic burden of uterine fibroid tumors, including, but not limited to, burden from the patient’s perspective and the entirety of indirect costs.
Uterine leiomyoma, commonly called uterine fibroid tumors (UF), are smooth muscle tumors of the uterus that are a common, usually benign, condition in women of reproductive age. The estimated incidence rates vary widely across different studies. The annual incidence rate is estimated at 9.2 cases per 1000 in women 25-44 years old in the United States and 12.7 cases per 100,000 women up to 65 years old in Germany. The most commonly cited incidence estimate in the United States is from Baird et al, which estimates the cumulative incidence of UF based on medical records or ultrasound scans to be >80% in black women and nearly 70% in white women by 50 years old.
UF vary greatly by size, location, and symptoms; the treatment options differ accordingly. Although many women with UF are asymptomatic and require no treatment, 30-50% women with UF seek treatment (pharmacologic treatments or surgeries) for heavy and prolonged menstrual bleeding, pelvic pressure, pain, increased urinary frequency, and urgency. Pharmaceutical therapies for UF include a combination of oral contraceptives, nonsteroidal antiinflammatory drugs, gonadotropin-releasing hormone agonists, aromatase inhibitors, progesterone receptor modulators (eg, ulipristal acetate, mifepristone), and antifibrinolytics (tranexamic acid). They can be used either as adjuvant therapy before surgery or, in certain instances, as the primary treatments for UF. Pharmaceutical therapies can be classified into 2 categories based on their mechanisms: (1) therapy aimed at controlling the symptoms of UF such as progestins, combination oral contraceptives, and antifibrinolytics and (2) therapy aimed directly to reduce the size of fibroid tumor(s) such as gonadotropin-releasing hormone agonists and antagonists. However, none of the pharmaceutical therapies are curative.
Hysterectomy, on the other hand, is a curative surgical treatment for UF that prevents future recurrence, but it is not preferred for patients who want to preserve fertility. Alternative procedures include myomectomy, uterine artery embolization (UAE), and magnetic resonance imaging–guided focused ultrasound surgery. However, these treatments are associated with the risk of tumor recurrence and the need for additional surgeries. In recent years, several new procedures have been approved for the treatment of UF, which includes high-intensity focused ultrasound scanning and radiofrequency ablation. Given the high prevalence of UF, the associated debilitating symptoms that affect daily activities and the invasiveness of treatment options, the economic burden of UF is considerable. In the United States, Flynn et al estimated a total direct cost of $3.5 billion (in 2013 USD), including costs for inpatient and outpatient care. Among women who were treated for UF, Becker further estimated a total direct cost of $4.3 billion (in 2013 USD) and a total indirect cost of $1.1 billion (in 2013 USD) that would be associated with UF. A later estimate by Cardozo et al reported a higher total direct cost of $4.5-10.3 billion among women who sought treatment for UF in the United States. We sought to understand the economic burden that is associated with UF, including direct and indirect costs per patient. A summary of existing evidence will help identify the unmet needs and the need for additional research. Accordingly, the objective of this systematic literature review was to summarize the direct and indirect costs per patient that are associated with UF in research studies that have been published since 2000.
In burden of illness studies, costs that are considered include direct and indirect costs. Direct costs refer to costs that are incurred for providing direct patient care, which include medical costs and nonmedical costs. The medical costs include costs of hospitalization, outpatient visits, drug therapy, and other medical services that are used directly to treat the disease. The nonmedical costs rarely are studied and reported in literature and could include items such as transportation costs. Indirect costs are those related to resource loss because of a certain disease. Indirect costs include items such as costs that are loss because of absenteeism and presenteeism and costs that are associated with leisure time loss and incapacity/lesser capacity for household work. With different study objectives, different perspectives such as hospitals, patients, health care system, third-party payers, employers, or society could be selected in different studies. When a perspective is selected, only cost components that are relevant to that perspective will be considered, and a particular cost component could switch between direct and indirect cost categories when different perspectives are selected. For example, hospital overhead would be incorporated within direct cost when the evaluation is from a third-party payer perspective but viewed as indirect costs from a hospital perspective.
Materials and methods
Literature search
Two databases, MEDLINE and EMBASE, were used to search for primary studies that reported costs among patients with UF in this systematic literature review. Search criteria were applied to studies that were published in English from Jan. 1, 2000, to Nov. 4, 2013.
The following 2 groups of search terms were combined in the literature search: (1) uterine fibroid/fibroids or leiomyoma/leiomyomas or leiomyomata and (2) cost$ ($ for truncation and will find any words starting with “cost”) or cost-of-illness or burden$ or burden-of-illness or economic$ or absenteeism or presenteeism or workplace or productiv$ or expenditure$ or sick leave or medical leave or employment or wage$ or time loss or time lost or income loss or income lost or daily activities. To fully capture relevant studies, “exploded” search terms were used where available. For example, “exp cost$” identifies publications with “cost” and “health expenditures” as research terms; “exp economics” identifies publications with “financial support” or “fees and charges” as research terms.
Inclusion criteria and study selection
We reviewed the study abstracts identified from the literature search to select studies that met the following criteria: human studies; published in English; evaluated direct and/or indirect costs among patients with UF (studies with patient populations of mixed diagnoses were included if costs that were specific to UF were reported); reported primary data on the costs of UF, rather than derived or cited costs from another study (specifically, at least one of the following items had to be reported for inclusion in this review: direct costs, that included drug costs; surgery costs; medical service costs, or indirect costs, that included productivity loss.
We excluded conference proceedings or abstracts, which generally contained limited or incomplete information on study methods, results that were not peer reviewed, review articles without primary cost data, and studies for which full texts were not available. Unlike previous systematic review by Mauskopf et al, our review process excluded cost-related studies that focused only on cost-effectiveness, cost-utility, cost-consequence, cost-minimization, and cost-benefit analyses of UF if they did not collect or report primary cost data.
Data extraction
After removing duplicate reports, 2 of the authors (E.D. and S.K.) independently reviewed all articles that were identified from the initial MEDLINE and EMBASE search in a 2-part process: Step 1: titles and abstracts were reviewed by each author based on the selection criteria listed earlier. Step 2: full-texts of articles selected from the first round were further reviewed based on the same selection criteria. Furthermore, review articles and cost-related studies were retained, and the reference lists were reviewed to identify additional studies that met selection criteria. These studies were then obtained and considered for possible inclusion.
Discrepancies between the 2 reviews were resolved through discussion. If needed, a third author (H.Y.) was consulted. A data collection form was used to collect data elements that included study characteristics and cost outcomes of interest. Data were first entered into the data collection form by 1 author (S.K.) and audited by another author (E.D.) to ensure accuracy. Next, the extracted cost values were converted to US dollars, when needed, from the currency reported in the original study and the year of data collection (or publication if data collection year was not reported). All cost data were then inflated to 2013 US dollars according to the US Medical Care consumer price index.
Results
Overview of studies
The systematic literature review identified 685 published articles in MEDLINE and EMBASE; 1 additional publication was added based on a review of the references in review articles. After the removal of duplicates and screening abstracts and full-text articles, 26 studies that had been published since 2000 that reported primary costs were included for data extraction ( Figure 1 ). These studies reported direct and indirect costs of UF in 8 countries: 19 studies were conducted in the United States; 2 in the Netherlands; 1 each in Germany, China, Italy, and Canada; and 1 study reported data collected from 3 countries: Germany, France, and England ( Table 1 ).
| Author, year | Country | Design/perspective | Data source | Population | Control subjects | Cost measured | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Indirect | Direct | Surgery | Inpatient | Outpatient | Drug | Total | ||||||
| US studies | ||||||||||||
| Epstein et al, 2013 | US | Cross-sectional regression analysis/third-party payer | Insurance claims and matched workplace absenteeism data | 59,121 women who underwent uterine fibroid resection via standard invasive treatment; 53,502 women who underwent uterine fibroid resection via minimally invasive treatment | None | N | Y | N | N | N | N | N |
| Cardozo et al, 2012 , a | US | Systematic literature review/societal, third-party payer | Data from Census Bureau, Centers for Disease Control and Prevention, Bureau of Labor Statistics, March of Dimes, Healthcare Cost and Utilization Project | Estimated 588,164 women (annually) seeking treatment for fibroid tumors | None | N | N | N | N | N | N | N |
| Lerner et al, 2008 | US | Cohort study/employer | Patient-reported mail questionnaire and medical charts | 58 employed women with symptomatic uterine fibroid tumors | 56 employed healthy women | Y | N | N | N | N | N | N |
| Becker, 2008 | US | Nationally representative retrospective study/hospital | Healthcare Cost and Utilization Project (HCUP): a nationally representative sample of 95% of the nation’s inpatient admissions | 1,212,851 inpatients with a primary diagnosis of uterine fibroid tumors who underwent total abdominal hysterectomy, subtotal abdominal hysterectomy, laparoscopically assisted vaginal hysterectomy, other vaginal hysterectomy, myomectomy, uterine artery embolization, all other hysterectomies, or no surgical treatment | None | N | N | N | Y | N | N | N |
| Carls et al, 2008 | US | Retrospective study/third-party payer | Thomson Healthcare MarketScan Commercial Claims and Encounters databases | 37,074 women with uterine fibroid tumor diagnosis in employer-sponsored health plans | None | Y | Y | N | N | N | N | N |
| Dembek et al, 2007 | US | Retrospective claims analysis/third-party payer | Integrated Health Care Information Systems database | 3665 patients who underwent hysterectomy, myomectomy, or uterine artery embolization for uterine fibroid tumor | None | N | Y | Y | N | N | N | N |
| Oderda et al, 2007 | US | Retrospective claims analysis/third-party payer | Utah Medicaid database | 897 premenopausal women with a uterine fibroid tumor diagnosis and no previous procedure | None | N | Y | N | N | N | Y | N |
| Becker, 2007 | US | Retrospective study/hospital, third-party payer | Healthcare Utilization Project database (1993-2003): nationally representative sample | 2,556,806 inpatients with International Classification of Diseases -9 codes for uterine fibroid tumors during the study period (763,349 inpatients were used for costs analysis) | None | N | N | Y | Y | N | N | N |
| Lee et al, 2007 | US | Retrospective claims analysis/third-party payer, employer, societal | Thomson Healthcare MarketScan Commercial Claims and Encounters databases | 19,010 women with clinically significant and symptomatic uterine fibroid tumors | 19,010 matched women with no significant and symptomatic uterine fibroid tumors | Y | Y | N | Y | Y | N | Y (calculated by authors) |
| Goldberg et al, 2007 | US | Retrospective study/hospital | Hospital medical records | 540 women who underwent hysterectomy, myomectomy, or uterine fibroid embolization | None | Y | Y | N | N | N | N | Y |
| Wu et al, 2006 | US | Retrospective study/societal, employer | Health insurance administrative claims database | 3902 female employees who underwent services for uterine fibroid tumors | 3902 matched women without uterine fibroid tumors | Y | Y | N | N | N | N | Y |
| Hartmann et al, 2006 | US | Retrospective claims analysis/third-party payer | An administrative database that includes 9 self-insured companies across the United States | 5122 women with a leiomyomata diagnosis | 5122 matched women without a diagnosis of leiomyomata | Y | Y | N | Y | Y | Y | Y |
| Flynn et al, 2006 | US | Retrospective study from multiple databases/third-party payer, societal | Centers for Disease Control and Prevention national databases | Fibroid tumor-related care visits (352,000 inpatient procedures; 70,400 outpatient procedures and 682,000 ambulatory visits) | None | N | N | Y | Y | Y | Y | N |
| Benassi et al, 2002 | US | Randomized controlled trial/hospital | Hospital records | 119 symptomatic women who underwent hysterectomy | None | N | Y | N | Y | N | N | N |
| Baker et al, 2002 | US | Retrospective cost minimization study/hospital, third-party payer | Hospital charge information at 1 institution | 40 women who underwent abdominal myomectomy or uterine artery embolization for treatment of symptomatic uterine fibroid tumors | None | N | Y | N | N | N | N | N |
| Beinfeld et al, 2002 | US | Retrospective hospital study/hospital | Hospital cost accounting system | 357 patients who were treated for uterine fibroid tumors with uterine artery embolization or hysterectomy | None | N | N | N | N | N | N | Y |
| Mehl-Madrona, 2002 | US | Pilot of a controlled study/not reported | Directly gathered patient cost data | 37 women who underwent treatment for uterine fibroid tumors | None | N | N | N | N | N | N | N |
| Subramanian et al, 2001 | US | Retrospective analysis/third-party payer | Private insurance claims data | 4394 women who underwent a myomectomy | None | N | N | N | Y | Y | N | N |
| Subramanian and Spies, 2001 | US | Retrospective study/hospital, third-party payer | Hospital clinical/accounting system | 23 women who underwent a uterine artery embolization at 1 hospital | None | N | Y | N | Y | N | Y | N |
| Non-US studies | ||||||||||||
| Nash et al, 2012 | Germany | Retrospective study/hospital | Hospital electronic medical record | 106 women who underwent an abdominal myomectomy and 27 women who underwent robotic-assisted laparoscopic myomectomy procedure for uterine leiomyoma | None | N | N | N | Y | N | N | N |
| Yu et al, 2011 | China | Retrospective study/hospital | Hospital medical records at 1 hospital | 43 symptomatic patients who underwent vaginal myomectomy | None | N | Y | Y | N | N | N | N |
| Fernandez et al, 2009 | Germany, France, England | Retrospective study/third-party payer | National hospital activity and statistics databases in Germany, France, England (2005-2006) | Women who were admitted for a surgical or radiologic intervention for uterine myomas (64,299 Germany; 37,787 France; 18,274 England) | None | N | Y | N | N | N | N | N |
| Volkers et al, 2008 | The Netherlands | Multicenter randomized clinical study/societal | Hospital management system and Dutch guidelines for medical care reimbursement | 177 women with uterine fibroid tumors (88 underwent uterine artery embolization and 89 underwent hysterectomy) | None | Y | Y | Y | Y | Y | N | Y |
| Advincula et al, 2007 | The Netherlands | Retrospective case-matched analysis/hospital, third-party payer | Hospital medical records | 58 symptomatic women who received a traditional abdominal myomectomy or a robot-assisted laparoscopic myomectomy | None | N | Y | N | Y | N | N | N |
| Alessandri et al, 2006 | Italy | Prospective randomized study/hospital | Average institutional costs from hospital records | 148 women who underwent surgical myomectomy | None | N | Y | Y | N | N | N | N |
| Al-Fozan et al, 2002 | Canada | Retrospective study/hospital | Hospital database | 545 women with uterine fibroid tumors who were treated with myomectomy, hysterectomy, and uterine artery embolization at 1 hospital | None | N | Y | N | N | N | Y | N |
a Included in this systematic literature review because it reported the costs of uterine fibroid tumors at national level based on primary analysis; however, it was not reported in any other tables because it did not report the per-patient costs.
Table 1 summarizes study design, data source, outcomes, and other key characteristics of the selected studies. The studies varied widely in study perspectives (eg, third-party payer, hospital, employer, societal), data sources (eg, hospital records, insurance claims databases, patient questionnaires, national medical databases), study setting (ranged from 1 hospital to nationwide), study populations (eg, women diagnosed with UF, women treated for UF, patients with symptomatic UF who underwent surgical procedures), and cost measures (eg, cost associated with UF-related surgical procedures, cost of all-cause drugs or medical services, costs of UF-related drugs or medical services). Notably, several studies used national databases and based their analyses on the total number of UF-related procedures that were performed within a period of time rather than a certain number of patients. Four of the 26 studies compared costs in patients with UF with control subjects or reported excess costs of UF compared with those of women with no diagnosis of UF.
Direct health care costs
The key characteristics and results of the 17 studies that reported direct costs associated with UF are summarized in Table 2 . The direct cost results were reported mostly from either the hospital or third-party payer’s perspective. The analysis by Volkers et al adopted a societal perspective, which represents the national health care payer’s perspective. Table 3 summarizes 14 studies that reported surgery and inpatient costs of UF. Tables 4 and 5 summarize studies that reported outpatient and drug costs, respectively. Of particular note is that the definition of cost outcomes and time periods that the authors measured to estimate these costs varies widely across studies.
| Author, year/country | Outcome measures | Population/control | Unit | Mean total direct cost |
|---|---|---|---|---|
| US studies | ||||
| Epstein et al, 2013/US | Total cost (including medical and pharmacy costs) of standard and minimally invasive uterine fibroid resection from 14 days before to 352 days after surgery | 59,121 women who underwent uterine fibroid resection via standard invasive treatment; 53,502 women who underwent uterine fibroid resection via minimally invasive treatment/none | Per patient per year | Standard treatment: $17,339.36 Minimally invasive treatment: $15,877.63 |
| Carls et al, 2008/US | Direct medical care cost during the preoperative period (14 days before surgery date), perioperative period (surgery date to discharge date) and postoperative period (the day after discharge date to 352 days); for subgroup with no surgical treatment, study period was the year after the diagnosis | 37,074 women with uterine fibroid tumor diagnosis in employer-sponsored health plans/none | Per patient per year | Hysterectomy: $19,959.30 Myomectomy: $19,362.36 Uterine artery embolization: $21,602.85 Embolism ablation: $15,904.32 No surgical treatments: $9808.72 |
| Dembek et al, 2007/US | Total direct costs (procedure and follow up) during the year after the surgery | 3665 patients who underwent hysterectomy, myomectomy, or uterine artery embolization for uterine fibroid tumors/none | Per patient per year | Hysterectomy: $19,008.49 Myomectomy: $17,510.13 Uterine artery embolization: $19,745.02 |
| Oderda et al, 2007/US | Total medical and drug costs from diagnosis to procedure or presumed menopause during Medicaid eligibility | 897 premenopausal women with a uterine fibroid tumor diagnosis and no previous procedure (20% were treated with medications, 33% with procedure, 47% watchful waiting)/none | Per patient | Procedure: $16,439.16 Medication: $3704.15 Watchful waiting: $2902.48 |
| Lee et al, 2007/US | Direct medical expenditures during the year after uterine fibroid tumor diagnosis | 19,010 women with clinically significant and symptomatic uterine fibroid tumors/19,010 matched women with no significant and symptomatic uterine fibroid tumors | Per patient per year | Actual mean cost: $9473.43 Regression analysis-predicted 1-year cost: patients with uterine fibroid tumors: $15,409.94 control subjects: $4282.44 |
| Goldberg et al, 2007/US | Direct costs (nursing care, radiology or operating room use of anesthesia services and supplies) | 540 women who underwent hysterectomy, myomectomy, or uterine fibroid embolization/none | Per patient per procedure | Hysterectomy: $4346.97 Myomectomy: $4332.44 Uterine fibroid embolization: $2522.72 |
| Wu et al, 2006/US | Excess annual cost 4 years after uterine fibroid tumor diagnosis and lifetime direct cost (third-party payments for medical and drug claims) of clinically diagnosed uterine fibroid tumors compared with healthy women, from uterine fibroid tumors onset to 51 years | 3902 female employees who received services for uterine fibroid tumors/3902 matched women without uterine fibroid tumors | Per patient per lifetime or per year | Excessive lifetime burden: $15,605.11 Excess annual direct cost: $1876.62 |
| Hartmann et al, 2006/US | Total direct costs (drug and medical costs) during the year after the uterine fibroid tumor diagnosis | 5122 women with a leiomyomata diagnosis/5122 matched women without a leiomyomata diagnosis | Per patient per year | Patients with uterine fibroid tumors: $9318.73 Control subjects: $3242.60 Excess cost: $6076.12 |
| Benassi et al, 2002/US | Total costs for all patients (surgical procedure and hospital costs) | 119 symptomatic women who underwent hysterectomy/none | Per patient per procedure | Total costs per patient: vaginal hysterectomy (n = 60): $1452.75 abdominal hysterectomy (n = 59): $1812.82 |
| Baker et al, 2002/US | Professional and hospital costs (including 3 months before procedure) | 40 women who underwent abdominal myomectomy or uterine artery embolization for treatment of symptomatic uterine fibroid tumors/none | Per patient per procedure | Uterine artery embolization: total professional fees: $3458.10 total hospital costs: $4973.46 Abdominal myomectomy: total professional fees: $2510.31 total hospital costs: $8720.03 |
| Subramanian and Spies, 2001/US | Total direct costs (radiology, observation unit, pharmacy, laboratory) | 23 women underwent a uterine artery embolization at 1 hospital/none | Per patient per procedure | Mean total cost: $5406.31 |
| Non-US studies | ||||
| Yu et al, 2011/China | Total medical cost | 43 symptomatic patients who underwent vaginal myomectomy/none | Per patient per procedure | Vaginal myomectomy: $785.13 |
| Fernandez et al, 2009/Germany, France, England | Combined costs of medical services associated with a surgery by country | Women admitted for a surgical or radiologic intervention for uterine myomas (64,299 Germany; 37,787 France; 18,274 England)/none | Per patient per procedure | Germany Hysterectomy: $5427.78-7054.81 Other interventions: $3699.27 France (public reimbursements) Hysterectomy: $5571.83-7634.25 Other interventions: $1378.22-4475.14 France (private) Hysterectomy: $2524.02-2954.51 Other interventions: $658.01-1823.45 England Hysterectomy: $5630.75 Other interventions: $1728.51-5630.75 |
| Volkers et al, 2008/the Netherlands | Total cost for preprocedural work up, procedure costs, and over 2 years of follow up (medical in-hospital, medical out-of-hospital, primary procedure, and nonmedical costs) | 177 women with uterine fibroid tumors (88 underwent uterine artery embolization and 89 underwent hysterectomy)/none | Per patient in 2 years follow up per procedure | Calculation from study data: Uterine artery embolization: $9076.35 Hysterectomy: $11,027.58 |
| Advincula et al, 2007/the Netherlands | Total (professional and hospital) charges and reimbursement | 58 symptomatic women who underwent a traditional abdominal myomectomy or a robot-assisted laparoscopic myomectomy/none | Per patient per procedure | Abdominal myomectomy: mean total charges: $24,756.17mean total reimbursements: $12,137.84 Robot-assisted laparoscopic myomectomy: mean total charges: $49,375.12 mean total reimbursements: $21,160.74 |
| Alessandri et al, 2006/Italy | Total direct costs (inclusive of hospital costs, equipment costs, personnel, and maintenance) | 148 women who required surgical myomectomy/none | Per patient per procedure | Minilaparotomy: $3136.23 Laparoscopy: $3584.03 |
| Al-Fozan et al, 2002/Canada | Hospital costs (radiology, pharmacy, laboratory, procedure room, and nursing costs) | 545 women with uterine fibroid tumors who underwent myomectomy, hysterectomy, and uterine artery embolization at 1 hospital/none | Per patient per procedure | Myomectomy: $1688.18 Total abdominal hysterectomy: $1831.86 Vaginal hysterectomy: $1435.82 Uterine artery embolization: $954.54 |
| Author, year/country | Outcome measures | Mean procedure cost | Mean inpatient cost |
|---|---|---|---|
| US studies | |||
| Becker, 2008/US | Mean and median inpatient costs (excluding the professional physician fees) over 2001-2005 | Not reported | Overall mean cost: $7599.78 per patient per hospital stay Total abdominal hysterectomy: $7593.21 Subtotal abdominal hysterectomy: $8208.56 Laparoscopically assisted vaginal hysterectomy: $8677.95 Other vaginal hysterectomy: $6238.92 Myomectomy: $7852.23 Uterine artery embolization: $10,157.15 All other hysterectomy: $7219.80 No treatment: $4377.11 |
| Dembek et al, 2007/US | Procedure costs (hospitalization and anesthesia costs and physician costs) per patient per surgery | Hysterectomy: $12,217.51 Myomectomy: $11,315.81 Uterine artery embolization: $12,339.52 (mean procedure costs) | Not reported |
| Becker, 2007/US | (1) Inpatient hospitalization costs (incurred by hospital, excluding professional physician fee) and charges (charged by hospital to payor) per patient per stay/discharge; (2) procedure costs per patient per surgery | 2001 to 2003 Total abdominal hysterectomy: $7223.26-9055.54 Supracervical hysterectomy: $7685.27-9739.25 Laparoscopically assisted vaginal hysterectomy: $8072.89-10,166.92 Other hysterectomy: $5709.95-7826.87 Myomectomy: $7339.12-9593.35 All procedures: $7124.57-9145.65 | Hospitalization cost: mean charge: $11,312.63 (1993)-21,040.44 (2003) per patient per hospital stay mean cost: $7124.57 (2001)-9102.74 (2003) |
| Lee et al, 2007/US | Inpatient admission costs | Not reported | $8217.76 per patient at 1 year follow up |
| Hartmann et al, 2006/US | Inpatient costs | Not reported | Patients with uterine fibroid tumors: $3923.45 per patient per year Control subject: $597.89 Excess cost: $3325.56 |
| Flynn et al, 2006/US | (1) Inpatient costs; (2) ambulatory surgery costs | Ambulatory surgery costs Hysterectomy: $7550.72 per procedure Myomectomy: $7465.41 Curettage: $2867.94 Hysteroscopy: $6200.52 None/other surgery: $1920.14 | Inpatient costs Hysterectomy: $8211.77 per intervention Myomectomy: $8101.02 per intervention Curettage: $6356.25 per intervention Hysteroscopy: $6200.52 per intervention None/other surgery: $2018.14 per intervention |
| Benassi et al, 2002/US | Hospital costs | Not reported | $421.09 hospital cost per day |
| Subramanian et al, 2001/US | Inpatient costs | Not reported | Inpatient hysterectomy: $13,955.10 per patient per procedure Inpatient laparoscopy: $14,523.89 Abdominal myomectomy: $16,049.09 |
| Subramanian and Spies, 2001/US | Facility costs associated with uterine artery embolization | Not reported | Radiology: $3370.17 per patient per procedure Observation unit: $1922.05 Laboratory: $28.08 |
| Non-US studies | |||
| Nash et al, 2012/Germany | Total hospital charges | Not reported | Robot-assisted laparoscopic myomectomy: total hospital charge: $44,749.49-53,746.91 per patient per procedure Abdominal myomectomy: total hospital charge: $27,514.59-35,735.68 |
| Yu et al, 2011/China | Surgery costs | Vaginal myomectomy: $131.97 per procedure | Not reported |
| Volkers et al, 2008/the Netherlands | (1) Medical in-hospital cost (preprocedural work-up, primary procedure and postprocedural costs); (2) primary procedure cost | Uterine artery embolization: average primary procedure care costs per patient at 2-year follow up: $3177.97 Hysterectomy: average primary procedure care costs per patient at 2-year follow up: $5187.05 | Uterine artery embolization: average direct medical in-hospital costs: $8793.66 per patient at 2 years of follow up Hysterectomy: average direct medical in-hospital costs: $10,930.28 per patient in 2 years of follow up |
| Advincula et al, 2007/the Netherlands | (1) Hospital charges and reimbursements; (2) professional charges and reimbursement | Not reported | Abdominal myomectomy: mean hospital charge: $18,364.03 per patient per procedure mean hospital reimbursement: $9613.59 mean professional charge: $6392.14 mean professional reimbursement: $2524.24 Robot-assisted laparoscopic myomectomy: mean hospital charge: $41,226.98 mean hospital reimbursement: $18,063.60 mean professional charge: $8148.98 mean professional reimbursement: $3101.21 |
| Alessandri et al, 2006/Italy | Surgery-related costs (surgical equipment, personnel, and maintenance costs) | Minilaparotomy equipment cost: $428.75 per procedure; surgeons, anesthetists, nurses, and maintenance: $793.98 per hour Laparoscopy equipment cost: $1032.18 per procedure; surgeons, anesthetists, nurses, and maintenance: $793.98 per hour | Not reported |
| Author, year/country | Outcome measures | Unit | Mean outpatient cost |
|---|---|---|---|
| Volkers et al, 2008/the Netherlands | Medical out-of-hospital direct costs (eg, unscheduled general practitioner visits and use of medications) over 2-year follow up | Per patient at 2-year follow up | Uterine artery embolization: $97.30 Hysterectomy: $43.39 |
| Lee et al, 2007/US | Outpatient/office visit costs | Per patient per year | $1242.53 |
| Hartmann et al, 2006/US | Outpatient costs | Per patient per year | Patients with uterine fibroid tumors: $4642.91 Control: $2042.54 Excess cost: $2600.38 |
| Flynn et al, 2006/US | Outpatient costs | Per visit | New obstetrician/gynecologist: $263.69 Return obstetrician/gynecologist: $76.96 New internist: $209.40 Return internist: $76.96 |
| Subramanian et al, 2001/US | Outpatient costs | Per patient per procedure | Outpatient hysterectomy: $7772.76 Outpatient laparoscopy: $13,326.54 |
| Author, year/country | Outcome measures | Unit | Mean drug cost |
|---|---|---|---|
| Oderda et al, 2007/US | Drug costs from diagnosis to procedure or presumed menopause | Per patient | Procedure group a : $64.41 Medication only: $427.56 Watchful waiting: $0 |
| Hartmann et al, 2006/US | Drug costs | Per patient per year | Patients with uterine fibroid tumors: $752.36 Control: $602.18 Excess cost: $150.19 |
| Flynn et al, 2006/US | Specific medication costs (not intervention specific) | Per intervention | Iron/vitamin: $1.39 Estrogen/progesterone: $48.69 Pain medication: $47.34 Lupron: $928.11 |
| Al-Fozan et al, 2002/Canada | Drug costs | Per patient per procedure | Myomectomy: $19.29 b Total abdominal hysterectomy: $32.23 Vaginal hysterectomy: $21.68 Uterine artery embolization: $24.34 |
| Subramanian and Spies, 2001/US | Drug costs | Per patient per procedure | Uterine artery embolization: $86.01 c |
a The procedure group included any patient with a diagnosis of uterine fibroid tumors and a claim for a hysterectomy, myomectomy, embolization, or fibroid removal
b Medications prescribed for the patients, excluding the cost of pharmacy workload and cost of stocked drugs
As shown in Table 2 , direct health care costs of UF were most frequently collected and calculated before or after a surgical procedure, which included the costs of surgery, inpatient, outpatient, and other health care costs that are incurred before and after the surgery for up to 2 years of follow up. Thirteen studies compared the total direct costs among patients who underwent different types of surgeries on a per-patient per-surgery basis or a per-patient per-year basis. Within each of these studies, the total direct costs among different procedures (eg, hysterectomy, myomectomy, and embolization) did not differ substantially. Total direct costs within 1 year of UF-related surgeries ranged from $15,878-21,603 per patient in the United States Volkers et al reported $9076 per patient for UAE and $11,028 per patient for hysterectomy over 2 years of follow up after surgery in the Netherlands. However, these studies could not be compared directly because of difference in scope, time frame of data collection, and health care system of the study countries. For example, 4 of these studies included the presurgery costs (such as costs of office visits and anesthesiologist visit; however, the timeframe and methods used to assess these costs varied. Epstein et al and Carls et al, for instance, defined a pre-surgical period as 14 days before the surgery; Baker et al included only office visits before the surgery.
Three US studies reported total annual direct costs among patients with general UF, not necessarily who underwent surgeries. Within the year after UF diagnosis, Lee et al reported an average direct cost of $9473 per patient per year among those with clinically significant UF. The estimate by Hartmann et al was similar at $9319 per patient per year in women with a leiomyomata diagnosis; the incremental cost because of UF, estimated by a comparison of control subjects without UF, was $6076. The third study by Wu et al also compared patients with UF with those without UF; the average excess annual direct cost was $1877 per person over the 4 years after diagnosis and was $5427 over the first year after diagnosis. In addition, Wu et al estimated the productive lifetime direct costs based on administrative claims data that were available from diagnosis up to 51 years of age for patients who remained eligible in an insurance claims database. The excess reproductive lifetime direct cost of patients with UF was projected to be $15,605 per patient compared with women without UF. Oderda et al evaluated premenopausal patients with UF in the Utah Medicaid database and estimated the total costs to be $2902, $3704, and $16,349 per patient from the time of diagnosis to treatment with a procedure or menopause for patients who were watchful waiting, on medication, or undergoing procedures, respectively.
The inpatient, surgery, outpatient, and drug costs reported by the studies are summarized in Tables 3-5 . As shown in Table 3 , the inpatient costs in the year after diagnosis ranged from $3923–8218 per patient per year in the United States Compared with control subjects, the excess inpatient costs of UF in the year after diagnosis was estimated to be $3326 per patient per year. Inpatient costs of UF surgery per hospital stay varied by the type of procedure and by country. In the United States, inpatient costs of UF surgery ranged from $6201–16,049 per patient per hospitalization. A huge variability was observed in the cost of surgery across different countries. The cost of surgery ranged from $132 for a vaginal myomectomy in China to $12,340 for a UAE in the United States. Even for the same type of surgery, the costs differed greatly among countries. For example, the cost of hysterectomy was estimated to be from $5710-12,218 per procedure in the United States, and $5187 per patient at 2-year follow up in the Netherlands. Again, it is challenging to compare among studies because of inherent study differences. As demonstrated in Table 3 , within the same study that compared various types of surgical procedures (such as hysterectomy, myomectomy, and UAE), the procedure cost tended to be similar, with a range from $7465-7551 in Flynn et al and $11,316-12,340 in Dembek et al. Outside the United States, Volkers et al reported higher cost of hysterectomy ($5187) than UAE ($3178) in the Netherland, and Alessandri et al reported higher equipment cost of laparoscopy ($1032) than minilaparotomy ($429) in Italy.
Outpatient and drug cost estimates are summarized in Tables 4 and 5 , respectively. In the United States, the outpatient costs in the year after diagnosis ranged from $1243–4643 per patient. Compared with control subjects, the excess outpatient costs were $2600 per patient per year. Subramanian et al reported costs of $7773 per patient for an outpatient hysterectomy and $13,327 per patient for a laparoscopy. In the Netherlands, the medical out-of-hospital direct costs were $43 per patient after a hysterectomy and $97 per patient after a UAE at 2-year follow up. Drug costs reported ranged from $19 per patient per myomectomy (during hospitalization) in Canada to $752 per patient per year in the United States These costs were generally far lower than inpatient and surgery costs, except for outpatient surgical procedures, thus represented a smaller portion of the overall economic burden.
None of these studies reported all components of direct costs, including inpatient visits, outpatient visits, emergency visits, and drug costs. Among the 5 studies that reported both inpatient and outpatient costs in the same datasets, inpatient costs substantially outpaced outpatient costs in 4 studies ; inpatient and outpatient costs were similar in the other study ( Tables 3 and 4 ). Hartmann et al was the only study that reported inpatient, outpatient, and drug costs, in which inpatient, outpatient, and drug costs accounted for 42%, 50%, and 8% of the total direct cost of UF. Overall, the costs of surgery (inpatient and ambulatory) and inpatient care appear to be the main drivers of the overall direct costs of UF.
Two US studies assessed factors that may significantly affect costs of UF using multivariate analysis. Becker found that some patient characteristics positively influenced the hospital costs. Age ≥65 years and congestive heart failure were the top 2 attributes that increased the length of stay (LOS) for most of the procedures such as total abdominal hysterectomy, supracervical hysterectomy, laparoscopically assisted vaginal hysterectomy, other vaginal hysterectomy and myomectomy procedures. Insulin dependent and independent diabetes increased LOS in total abdominal hysterectomy and laparoscopically assisted vaginal hysterectomy. Other characteristics that increased the LOS were black and Asian/Pacific Island race, obesity, morbid obesity, smoker, hypertension, and chronic pulmonary disease. That study also found that hospital characteristics such as bed size, teaching status, and for-profit status, generally were associated positively with hospitalization cost per day. Beinfeld et al found that, among patients who underwent UAE, having complications was associated with increased LOS and treatment-related costs. Similarly, among patients with hysterectomy, complications and a laparoscopic hysterectomy were associated with increased costs of hysterectomy.
Indirect costs
Indirect costs were estimated in 6 studies in the United States and 1 study in the Netherlands ( Table 6 ). Six of the 7 studies analyzed the costs of absenteeism and disability because of UF; the exception was Goldberg et al, who defined indirect costs as services provided by nonmedical departments and hospital overheads such as billing and administration from the hospital perspective. The study by Beinfeld et al also defined the indirect costs similarly to the study by Goldberg et al, though it only estimated the sum of direct costs and indirect costs and did not report indirect costs separately. Among the 6 US studies, the estimates of indirect costs in women with symptomatic or diagnosed UF varied widely and ranged from $2399–15,549 per patient in the year after diagnosis. The average excess indirect cost over control groups ranged from $323 per patient per year for patients with an International Classification of Diseases -9 code–based UF diagnosis to $4824 per patient per year for International Classification of Diseases -9 code–based diagnosis and clinically significant and symptomatic patients. Wu et al estimated that women with UF incurred a loss of $2685 more per person compared with healthy women during an absence from work between initial UF diagnosis and menopause.
Full access? Get Clinical Tree
