Objective
The purpose of this study was to estimate the total annual societal cost of uterine fibroid tumors in the United States, based on direct and indirect costs that include associated obstetric complications.
Study Design
A systematic review of the literature was conducted to estimate the number of women who seek treatment for symptomatic fibroid tumors annually, the costs of medical and surgical treatment, the amount of work time lost, and obstetric complications that are attributable to fibroid tumors. Total annual costs were converted to 2010 US dollars. A sensitivity analysis was performed.
Results
The estimated annual direct costs (surgery, hospital admissions, outpatient visits, and medications) were $4.1-9.4 billion. Estimated lost work-hour costs ranged from $1.55–17.2 billion annually. Obstetric outcomes that were attributed to fibroid tumors resulted in a cost of $238 million to $7.76 billion annually. Uterine fibroid tumors were estimated to cost the United States $5.9-34.4 billion annually.
Conclusion
Obstetric complications that are associated with fibroid tumors contributed significantly to their economic burden. Lost work-hour costs may account for the largest proportion of societal costs because of fibroid tumors.
Uterine fibroid tumors are a prevalent condition in the United States, with a cumulative incidence by age 50 years of nearly 70% in white women and greater than 80% in black women. Because approximately 200,000 hysterectomies and 30,000 myomectomies are performed annually for leiomyomata, surgical costs alone contribute significantly to the total annual costs of this disease. Patients who do not undergo surgery often require medical treatment, hospitalization and additional outpatient physician visits, which further increase the annual costs. Recent studies have explored the societal costs of uterine fibroid tumors and include both direct costs (costs of surgery, hospital admissions, outpatient visits, medications) and indirect costs (costs of lost work time because of absenteeism and short-term disability).
Mauskopf et al estimated the economic impact of uterine fibroid tumors; however, this report was limited to the costs of medical and surgical management of fibroid tumors and did not include indirect costs. Flynn et al used national databases to estimate the annual direct cost of uterine fibroid tumors (including office visits, and hospital and outpatient procedures) in the United States to be $2,151,484,847 in the year 2000 ($3,208,974,247 in 2010 dollars). However, Flynn et al also did not include indirect costs that may have contributed to a greater annual economic burden.
Although medical and surgical expenses are clear contributors to the cost of uterine leiomyomata, the financial impact of fibroid tumors extends beyond direct costs of treatment. More recent studies have examined the impact of both the direct and indirect costs of uterine fibroid tumors. Absenteeism and disability contribute to the costs of leiomyomata, which range from an average annual expense of S4499 to as high as $30,075 (2010 dollars) in women who undergo hysterectomy for fibroid tumors and up to $14,282 (2010 dollars) for women whose fibroid tumors are treated nonsurgically. Although these reports estimated the annual cost of fibroid tumors in terms of medical and occupational costs, they did not include the cost of obstetric complications that are related to fibroid tumors when they calculated the annual economic burden of fibroid tumors.
Uterine leiomyomata significantly impact fertility and pregnancy. It is known that women with fibroid tumors have lower pregnancy and live birth rates after assisted reproductive technology and that those women who do conceive (naturally or through assisted reproductive technology) are at higher risk for several obstetric complications, which include preterm delivery, spontaneous abortion, cesarean delivery, placenta previa, postpartum hemorrhage, and malpresentation. Obstetric complications because of fibroid tumors may result in substantial costs. The purpose of our report was to estimate the total annual direct and indirect costs of leiomyomata, including costs of leiomyomata-associated obstetric morbidity.
Materials and Methods
A systematic literature review was performed in August 2011. We did not obtain Institutional Review Board approval because all the values that were used in this evaluation were collected from publicly accessible data or previously published results and no patient-specific data were collected or analyzed. PubMed was searched thoroughly with the key words fibroid, leiomyoma, cost, economic, obstetric, pregnancy, preterm, miscarriage, and hysterectomy . Only those studies that pertained to women ages 25-54 years in the United States were included. Relevance was evaluated from the titles and abstracts, and bibliographies of relevant publications were cross-referenced for additional pertinent citations. We also used data from the government (Centers for Disease Control, Bureau of Labor Statistics, US Census Bureau) and private sources (March of Dimes, Healthcare Cost and Utilization Project) to obtain specific values essential to our calculations.
The population included women ages 25-54 years in the United States. The perspective of this analysis was an estimate of the total annual societal cost of uterine fibroid tumors in the United States. We calculated the total number of women who sought treatment for symptomatic fibroid tumors each year by multiplying the total number of women aged 25-54 years in the United States (63,930,821) based on 2010 census data by 0.92%, which was the annual incidence of a new diagnosis of fibroid tumors in the United States, for a total of 588,164 women. We used the annual incidence of new diagnoses of fibroid tumors (0.92%) in the United States to calculate a conservative estimate of the number of women per year who sought treatment for symptomatic fibroid tumors because studies have shown that 94% of women with a new diagnosis of fibroid tumors have at least 1 procedure (diagnostic or surgical) in the year after their diagnosis. Furthermore, Carls et al found that, in patients who were treated nonsurgically, the year after diagnosis was the peak period for medical treatment and thus was the most relevant time to measure treatment costs. The number of women per year who sought treatment for symptomatic fibroid tumors was determined to be the most appropriate estimate because our goal was to calculate annual cost. The inclusion of women with asymptomatic fibroid tumors or an estimate of the prevalence of fibroid tumors would have led to an overestimation of cost. In contrast, the prevalence of fibroid tumors in pregnancy (0.37% to 10.7% ) and the number of pregnant women were used to estimate the cost of obstetric outcomes that were attributable to fibroid tumors, because treatment costs in this instance are not necessarily dependent on fibroid tumors being symptomatic and because pregnancy is a transient, time-limited physiologic state.
We used these estimates to calculate the annual direct and indirect (including obstetric) cost of leiomyomata. Unless otherwise specified, all costs have been adjusted to 2010 US dollars (rounded to the nearest dollar) to remove the impact of inflation specific to medical costs and to make all of our dollar values comparable. We used the Consumer Price Index (CPI) table for US Medical Care for All Urban Consumers as our inflation adjustment factor with the formula:
$ 2010 = $ t × ( CPIm 2010 / CPI m t ) ,
Direct costs
We estimated direct costs of leiomyomata, including surgery, hospitalization, outpatient encounters, and prescription medications, by multiplying the number of women who sought each treatment for fibroid tumors annually by a range of published estimates of direct costs. Hysterectomy is the most commonly performed surgery for the management of leiomyoma (21% to 52.9% ) followed by myomectomy (1% to 5.93% ), uterine artery embolization (0.2% to 1.77% ), and endometrial ablation (0.16% to 2.43% ). Therefore, we calculated that between 36.97% and 77.64% of women treated their symptoms without surgery. We estimated the number of women who underwent each surgical therapy by multiplying the total number of women annually who sought treatment for symptomatic fibroid tumors by the percentage of women with fibroid tumors who underwent each surgical modality. We estimated the total cost of surgical management by multiplying the number of women who underwent each type of therapy by the cost of each surgical therapy. Reimbursement rates for myomectomy were highest ($6805-14,850 per case), followed by hysterectomy ($6287 -11,538 per case). We calculated the costs of medical management in a similar fashion using costs for hospitalization, outpatient treatment, and pharmacologic treatment from previously published reports.
Estimates for lost work time
We estimated the total annual cost of lost work time by multiplying our estimate of the total number of women seeking treatment annually for symptomatic fibroid tumors by a range of published annual cost estimates of lost work time that was attributable to fibroid tumors ($4449 to $30,075 per patient). As the cost of lost work time was affected by treatment modality, we multiplied the number of women seeking treatment for symptomatic fibroid tumors by the percentage of women who underwent each surgical therapy. We estimated the percentage of women with symptomatic fibroid tumors who did not have surgery by subtracting the total percentage of women who received different surgical procedures from the total number of women who sought treatment for symptomatic leiomyomata (36.97-77.64%). The number of women who received each treatment (surgical or medical) was then multiplied by the respective lost work time costs for each category of treatment to reach a total annual cost from lost work time.
Pregnancy complications
To calculate the estimated annual cost of obstetric complications that are related to uterine fibroid tumors, we used the rates of obstetric complications and current cost estimates. The most current National Vital Statistics Report included birth data through 2009, but pregnancy data only through 2005 ; thus, we calculated the contribution of leiomyomata to pregnancy losses and timing/route of delivery using the most current data available.
We first calculated the number of spontaneous abortions, preterm deliveries, and cesarean deliveries annually in the United States. To estimate the number of spontaneous abortions per year, we multiplied the most currently available estimate of annual pregnancies (6,408,000) by a prevalence of 15%. Because not all spontaneous abortions require surgical management, the estimated number of annual cases of spontaneous abortions (961,200) was multiplied by the percentage of cases who were expected subsequently to undergo curettage (19.9%). Likewise, we multiplied the number of births in the United States in 2009 (4,131,019) by the prevalence of preterm delivery (12.18%) and cesarean delivery (32.9%) to determine the yearly estimates of these outcomes.
The proportion of each complication attributed to uterine fibroid tumors was then calculated based on the method reported by Adams and Melvin :
proportion arrtibutable = p ( OR − 1 ) / p ( OR − 1 ) + 1 ,
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