Sanghera, S., Barton, P., Bhattacharya, S., Horne, A. W., & Roberts, T. E. (2016). Pharmaceutical treatments to prevent recurrence of endometriosis following surgery: a model-based economic evaluation. BMJ open. https://doi.org/10.1136/bmjopen-2015-010580
Sanghera S, Barton P, Bhattacharya S, Horne AW, Roberts TE. Pharmaceutical treatments to prevent recurrence of endometriosis following surgery: a model-based economic evaluation. BMJ open. 2016. doi:10.1136/bmjopen-2015-010580
Sanghera, S., et al. "Pharmaceutical treatments to prevent recurrence of endometriosis following surgery: a model-based economic evaluation." BMJ open, 2016.
Hormones after endometriosis surgery cost more on average in a model
A UK cost model of women after conservative endometriosis surgery found that, on average, every hormonal strategy cost more and gained fewer healthy years than no treatment. The authors simulated 36 months. They used small studies and clinician estimates. They report no evidence to support recommending any treatment.
Key Findings
In the model, averaged over 1000 simulation runs, no treatment cost £371.34 and produced 2.27 quality-adjusted life years (QALYs). Those were the lowest cost and highest QALYs.
In the same averages, the levonorgestrel-releasing intrauterine system (LNG-IUS) cost £650.94 and produced 1.88 QALYs. Depot-medroxyprogesterone acetate (DMPA) cost £622.56 and produced 1.92 QALYs.
In the same averages, the combined oral contraceptive pill (COCP) cost £599.93 and produced 1.92 QALYs.
Compared with each hormonal strategy, no treatment had at least an 80% probability of being cost-effective at every willingness-to-pay value tested.
Among the three hormonal options, the paper found little difference in probability of being cost-effective. Uncertainty came mainly from effectiveness inputs, changes in treatment, and the timing of those changes.
Interpretation
The study is a computer simulation (a Markov model). No patients were followed. The authors found only small studies with different measures of effectiveness, so they gave the inputs intentionally wide ranges. Clinicians ranked quality of life on a 0 to 10 scale. The authors say the result appears driven by the assumption that being on treatment substantially lowers quality of life. The model covers UK primary care, and long-term fertility effects were left out. The authors call it preliminary to a planned randomized trial.
RRM Context
The three strategies are suppressive medications given after surgery. The paper cites an estimated 40 to 45% risk of symptom recurrence after conservative surgery. It says the causes are uncertain: residual lesions, microscopic disease, or new lesions. The paper groups removal and destruction together. RRM names excision as the surgical standard and treats completeness of excision as part of the recurrence question.
Our editorial summary of this paper, not the article's abstract.
Abstract
Objective
Conduct an economic evaluation based on best currently available evidence comparing alternative treatments levonorgestrel-releasing intrauterine system, depot-medroxyprogesterone acetate, combined oral contraceptive pill (COCP) and 'no treatment' to prevent recurrence of endometriosis after conservative surgery in primary care, and to inform the design of a planned trial-based economic evaluation.
Methods
We developed a state transition (Markov) model with a 36-month follow-up. The model structure was informed by a pragmatic review and clinical experts. The economic evaluation adopted a UK National Health Service perspective and was based on an outcome of incremental cost per quality-adjusted life year (QALY). As available data were limited, intentionally wide distributions were assigned around model inputs, and the average costs and outcome of the probabilistic sensitivity analyses were reported.
Results
On average, all strategies were more expensive and generated fewer QALYs compared to no treatment. However, uncertainty attributing to the transition probabilities affected the results. Inputs relating to effectiveness, changes in treatment and the time at which the change is made were the main causes of uncertainty, illustrating areas where robust and specific data collection is required.
Conclusions
There is currently no evidence to support any treatment being recommended to prevent the recurrence of endometriosis following conservative surgery. The study highlights the importance of developing decision models at the outset of a trial to identify data requirements to conduct a robust post-trial analysis.
