1. Literature Review 1
Cost-Effectiveness of Non-Pharmaceutical Treatments
for Symptomatic Uterine Fibroids:
A Systematic Reviewof the Literature
Britney Myslinski
HSMP 6609
May 6, 2015
Introduction
Uterine fibroidsare noncancerousgrowthsof
the uterusthat oftenappearduring
childbearingyears,alsocalledleiomyomas,and
developfromthe smoothmusculartissue of the
uterus(myometrium) (12). Asmanyas 3 out of
4 womenhave uterine fibroidssometimeduring
theirlives,butbecause theyoftencause no
symptoms,mostwomenare unaware theyhave
them(12). Withno symptoms,uterine fibroids
are usuallyfoundonaccidentduringaroutine
pelvicexam. Furthertestingsuchasan
ultrasound,labtests,magneticresonance
imaging(MRI),andothersare thenusedto
confirmthe diagnosis(12).
History of treatments
Since uterine fibroidsdon’ttendtocause any
symptoms,aren’tcancerous,don’tinterfere
withpregnancy,andgrowveryslowly,watchful
waitingisusuallythe bestoption (12). Some
medicationsare usedtoalleviatesymptomsa
womanmay experience andcanshrinkthe
fibroids,butdonoteliminate them. However,
if there are complications,there are treatments
mostcommonlyusedto destroythe uterine
fibroids.
There isa noninvasive commercial treatment,
MRI-guidedfocusedultrasoundsurgery
(MRgFUS),whichisan outpatientprocedure
that ablatesthe fibroidsbyusinghighintensity
focusedultrasoundwaves(HIFU). Thisis
commonly used,asitdoesn’tdamage the
surroundingtissuesand leavesthe uterus
intact,but wasonlyrecentlyapproved (13).
There are minimallyinvasiveproceduressuchas
uterine arteryembolization,myolysis,and
laparoscopic/roboticmyomectomy. Uterine
ArteryEmbolization (UAE) isanewerapproach,
where tinyparticlesare injectedtoblockthe
bloodsupplytothe fibroidtumor,whichcauses
the tumor to shrink. Finallythere isa
traditional surgerysuchasa hysterectomy,
whichisthe most commontreatmentforlarge
fibroids,involvingthe removalof the uterus
(13).
Concernswith treatments
Treatmentof womenwith uterine fibroids
shouldbe highlyindividualizedbasedon
symptoms,size andlocationof fibroids,age,
needor desire of preservingthe uterusor
fertility, andavailabilityof therapy (14). The
mostdefinitive treatment,ahysterectomy,also
meansthe mostpermanentsolution. If a
womanisasymptomaticandnot experiencing
any issues,the “watchful waiting”methodisthe
bestoption. Overall,the bestapproachto
treatinguterine fibroidsisone inwhichfitsthe
woman’slifestyleandhealthneedsthe best.
Whatanalysisaimsto accomplish
Thissystematicreview aimstoprovide a
currentand comprehensive lookintothe cost-
effectivenessof non-medicationtreatments
available forwomenwithuterine fibroidsby
evaluatingthe qualityof cost-effectiveness
studiesavailable anddeterminewhatresearch
and analysisisfurtherneeded.

2. Methods
Cost-effectivenessanalysisand10 guidelines
It isimportantto firstnote whatis meantby
cost-effectivenessanalysis. Thismethodrelates
costs to a single,commoneffectthatmaydiffer
betweenalternative programs(15). Another
methodusedforeconomicevaluationiscost-
utilityanalysis. This analysisemploysutilities
(suchas Quality-AdjustedLife Years,orQALYs)
as a measure of the value of program effects
and istypicallyexpressedincostperQALY.
While amajorityof studiesinthisliterature
reviewtitle themselvesas“cost-effectiveness
analyses”, avast majoritylooks atbothcosts
and benefits,makingthemmore similartocost-
utilityanalyses.
As a wayto organize thisreview,the topicsof
discussion are modeledafterthe 10 guidelines
for assessingeconomicevaluationsof health
care programspublishedbyDrummondetal.
The objective istothenuse these different
aspectsof evaluationtodetermineare the
studyresultsvalidandwouldtheybe applicable
to othersituations. Itisimportantforan
economicevaluationtobe translatable for
othersto use as a meansfor theirownhealth
care program considerations.
Literature search
For thisreview,the searchenginePubMedwas
usedprimarily,andsupplementedwithGoogle
Scholar. An advancedsearchwasperformedon
PubMed,specificallyusingthe MeSHterm
“cost-effectiveness”andthe general term
“uterine fibroids”. Otheracceptable,and
related,searchtermsincluded“cost-utility”,”
cost-benefit”,and“leiomyomas”.
Exclusioncriteria
Reasonsforexclusioninthisrevieware largely
due to methodfortreatment. Anyeconomic
evaluationinvolvingthe sole use of
pharmaceuticalsastreatmentforuterine
fibroidswasnotincluded. Thiswasdone to
narrow the scope of treatmentsandto assess
onlythe non-pharmaceutical treatment
options. There wasalsoan exclusionmade in
articlesthatsolelydiscussedcosts,butdidnot
performanykindof costanalysis.
Results
Clarityof objective
Each piece of literature reviewedcontaineda
clearobjective. Almosteveryarticle included
thiswell-posedobjective inthe abstractaswell
as usuallythe lastparagraphof the Introduction
section. All articlesclearlyexpressedwhich
treatmentoptionstheywouldbe comparing
and mostspecifiedthattheywere conductinga
cost effectivenessanalysis,withonlyone
specifyingtheiranalysisasa cost utility.
While some were more comprehensive than
others,objectivestatementstendedtoinclude
perspective of the study,populationbeing
targeted,theirdatasources,time horizon,and
locationof the study. I believe the strongest
objective couldbe foundinthe Wuarticle due
to the fact that it includedamultitudeof
specificitiesaboutthe studyandwaseasily
locatedwithinthe article,while the objective
that lackedincomparisontoall of the others
was foundinthe Kongarticle,whichwasmuch
more vague.
Populationsstudied
An obviousandcorrectassumptionwouldbe
that the target populationforeveryevaluation
was womenwhohaduterine fibroids. Afterall,
because of anatomy-specificdiagnosis,only
womencouldhave the uterine fibroidsandthis
was the conditionbeingstudied. Assimplistic
as thismightseem, there were variationsand
specificitiesmade asto whofell underthis
broad categorywithineacharticle.
Some of these variationsincludeage of the
womenbeingstudied,whichincludeswomenat
least18 yearsold,the general term

3. Literature Review 3
“premenopausal”women,andwomenof at
leastor exactly40 yearsof age. Other
determiningfactorsincludedwomenwhodid
not desire tokeeptheiruterus,orthose that
didwishto preserve theiruterus,womenwith
specificdiagnosticcharacteristicsof their
fibroid(s),womenwhowere symptomatic,with
some studiesspecifyingthattheywere
experiencingamajorsymptom(menorrhagia),
those that have beendetermine torequire
surgical treatmentinthe managementof their
fibroids,womenwhoplanonundergoingsome
kindof surgical treatment,andwomenpulled
fromclinical trial data. Most of the literature
beingreviewedhere includedsome
combinationof these requirementsinorderto
be a participant,orto be included,inthe data
evaluated.
Geographicregion andperspective
Upon reviewingeacharticle,there was
somewhatof a mix of locationsforeachstudy
done and itwas notalwaysclearas to where
the analysiswastakingplace,meaningthe
article requiredalittle bitof “teasing”tofind
out the information. The regionwiththe most
articlesoriginatingfromwasthe UnitedStates
withfive of the economicevaluationsusing
theirdata fromthe U.S. (4,5,6,8,11). Three
were basedinthe UnitedKingdom(3,9,10),one
was basedinIreland(1),one inthe People’s
Republicof China(2),andthe final study
collecteditsdatafromthe Netherlands(7).
Whenlookingatthe perspective thesearticles
took,fourspecifiedtakingasocietal perspective
(2,5,6,7), withone of these beingalittle more
specificintakingaHong Kongsocietal
perspective (2). Twocame froma National
HealthServices(NHS) perspective (9,10),one
froma hospital perspective(1),andone article
discussedlookingattheirresultsfromapatient
perspective (11). Three articlesnever
outwardlyidentifiedtheirperspectives(3,4,8)
and I wasunable todetermine whatperspective
theywere attemptingtoaimfrom.
Time horizon
As muchas the perspectivesof eachstudy
varied,sodidtheirtime horizons. Three of the
articleschose a time horizonof five years(2,3,4)
while twoof the articleschose twoyears(7,
10). These time frameswere explainedas
mainly beinguseddue toa lackof long-term
data, whichissimplybecause some of these
procedureshaven’tbeenapprovedforuse for
verylong. Four focusedona time horizonof
eithera“lifetime”oruntil menopause was
reached(5,6,9,11) while twoof the studieshad
a time horizon of onlysix months(1,8).
Withinthese time frames,therewere also
variousperiodmeasurements,focusingon
differenteventshappeningduringthe timeline
of the evaluation3. Forexample,some of the
articlescommentedonhealthstatuschange
everysix monthswithinthe time horizon,while
otherslookedat12-monthintervalstorecord
or evaluate new data.
Comparisonofalternatives
While eachstudychose to focuson different
treatments,theyall effectivelydescribedeach
treatmentbeingcompared. Some wentinto
more detail asfar as what the processof the
procedure entails,especiallywhenone of the
treatmentsbeingcomparedwasanewer,less
well-knownoption. Forexample,hardlyanyof
the articlesdiscussedindepthwhata
hysterectomyinvolvedbutinthose where it
was applicable, explainedthe specificsof aUAE
or MRgFUS.
Hysterectomyasa treatmentoption
encompassesseveral differenttypes,including
vaginal,abdominal,laparoscopic, etc. Each
article that includedhysterectomyasa
treatmentoptionspecifiedwhichtype they
usedintheiranalysis. Thismightbe important

4. to considerwhendecidingtopotentiallyuse on
of these articlestocompare toyour own
interests. Anotheralternative thatisonly
mentionedinone article isno treatment. This
isnot a veryviable optiontoconsiderinan
analysis,asthiswouldimplythe patient
continuestodeal withsymptomsfromthe
uterine fibroids. Thiswouldbe better
consideredinaneconomicevaluationof non-
symptomaticuterine fibroids,as“watchful
waiting”isan acceptable alternative sincethere
are no negative healthimpacts. Also,thereis
the alternative of usingmedicationtotreat
symptoms. One article didinclude thisintheir
analysisandfounditwas muchlesscostlythan
procedural treatmentsbutalsonotnearlyas
effective.
Effectivenessof treatments
All of the articles analyzedinthisreview
discussed,evenif onlybriefly,the effectiveness
of the treatmentsbeingcompared. Every
article citedsourcessuchas randomized-
controlledtrials,governmentagenciesthat
approve effective treatmentmethods,and
othervariousstudiesthathave lookedatthe
efficacyandsafetyof eachtreatment. Typically
articlesmade sure to establishtheyhaddata
provingeffectiveness inregardstothe newer
treatmentbeingcomparedtothe standardsof
care alreadyinplace.
Althoughthissectionof the review refersto
effectivenessasameansof establishing
approvedandstudiedtreatmentstobe usedon
patients,andensuringevaluationsconsidered
this,there isanotherwayof lookingatthe
effectivenessof atreatment. Forexample,all
of the articles made the assumptionthata
hysterectomy,regardlessof the specificmethod
of operation,was100% effectiveinsymptom
relief fromuterinefibroids. Thisisdue to the
obviousfactthat if a womandoesn’thave a
uterus,she can’thave uterine fibroids. It
shouldbe notedhowever,thatjustbecause a
hysterectomyis100% effective,doesn’tmeana
womancan’t experience complicationsand
othernegative healthoutcomes fromthe
procedure.
Costsand consequencesconsidered
All of the articlesreviewedincludeddirect
medical costsof the primaryinterventionin
theiranalysis,althoughtheydidsoinvarying
degrees. Everyarticle includedsome
combinationof the followingunderthe
categoryof directmedical costs:pre-procedural
costs (screenings),procedure costs(material
cost, consumable cost,operatingtime,andtotal
salarycost/staff time),hospitalization,follow-
up visits,officevisits,medications,and
complications. AnystudythatusedMRgFUS as
a treatmentoptionalsoincludedthe costof the
equipmentandmaintenance forit,MRItime,
staff time,andsupplies(4,5,10).
A significantportionof evaluationsalso
includedthattheyhadlookedatlost
productivitycosts,usingthe equationnumber
of daysoff fromwork multipliedbydailywages
(3,4,5,7,11), while the restdidnotinclude this
intotheircosts. In my opinion,if you’re going
to be comprehensiveinestablishingcosts
relevanttothe treatmentsyou’re studying, an
importantconsiderationshouldbe lostwages.
Thiscouldbe a determiningfactorforwomen
whomightbe greatlyaffectedbytakingoff too
much workfor the procedure.
Onlyone study considered administrativecosts
(8), and while anotherdidmention“facilities
charges”,they didnot go intodetail asto what
was meantbyfacilitiescharges (1). Ithought
thiswas interestingbecause administrative
costs couldbe consideredaspartof overhead
costs,but I’mnot sure for the purpose of these
evaluationsif theyare worthsinglingoutas its
owncost. I wouldalsolike tonote thatwhile
moststudiesspecificallymentionedcoststhey
were includingintheiranalysis,onlysome

5. Literature Review 5
actuallywentintodetail astothe actual values
theywere using. Some articlessaidtheywere
includingall these costconsiderationsbutthen
justlumpedthe valuesintoone figure and
never“broke themdown”forthe reader.
While there wasanabundance of detail in
reportingthe variouscostsused,thiswasnot
seeninthe reportingof consequences. The
majorityof articlesusedquality-adjustedlife
years(QALYs) as a way to measure their
outcomes(onlyPourratandMittapalli didnot).
Some labeledthe consequencesintermsof
success,whichcouldrefertothe relief of
symptomsorin the reductionof the size of the
fibroid(s).
Accuracy of measurements
Once the importantand relevantcostsand
consequenceshave beenidentified,theymust
be measuredinappropriate physical and
natural units(15). Please refertothe previous
sectionasthiswas addressedwhenspecifics
were givenundereachcostor consequence
category.
Credibilityofsources
Againinthisportionof the analysiswe see
some variationinwhatauthorschose to use as
theirsourcesfortheircost and consequence
data. Five of the articlesacquired aportionof
theirdata fromclinical trials(2,4,5,6,7) and four
otherarticlesusedthe terminology“clinical
literature”orstatedtheirdatawas comingfrom
studies,althoughtheywerenotall citedinthe
referencessection. Three articlesusedspecific
studiesastheirmainsource of information,
whichincludedthe HOPEFULstudy,the EMMY
trial,and the REST investigatorsstudy. An
interestingaspectof thisreviewisthatmore
recentlypublishedeconomicevaluationscite
past publications (includingothersreviewed
here) asa source forcertaindata not found
elsewhere. Where itgetsinterestingisthat
these previousarticlesonlydideducated
assumptions,notbasedonanysource. So for
anotherstudyto cite these assumptions asa
source is notveryaccurate.
Certainarticlesusedclinical expertswhen
publisheddatawasnotavailable,especiallyfor
estimatingtreatmentcomplicationcosts
(4,9,11). Costs alsocame from countryspecific
sources. Thisincludedthe Hong KongGazette
inthe People’sRepublicof China,which
interestinglypublishesdirectmedical resources,
the National HealthSystem(NHS) inthe United
Kingdom, andMedicare reimbursementcodes
inthe UnitedStates. Articlesalsocitedcosts
fromspecifichospitalsusingtheircodingand
patientrecords.
Four articlesuseddatafromsome combination
of standardizedsurveysincludingEuroQol-5D,
SF-36, SF-6D,and HUI-3 toobtaintheirinput
valuesforhealthutilityscoresandQALYs
(3,7,9,10). Two articlesciteda studyby
Fennesseyetal.astheirsource for QALY data
(4,11). In addition,these same twoarticles
citedthe U.S. Bureauof Labor Statisticsfordaily
wage ratesto use to calculate lostproductivity.
Discountrates
Out of the 11 studiesreviewed,twowere
completedwithinayearand therefore didnot
applya discountrate to any costs or
consequences(1,8). Fourusedadiscountrate
of 3% (4,5,6,11) whendiscountingthe costsand
QALYs. Onlyone of these foursitedanactual
source for theirreasoningbehindwhythey
chose the 3% discountrate (4).
Three of the studiesusedadiscountrate of
3.5% for costs andQALYs. All of these studies
didthisbasedon a recommendationfromNICE
(3,9,10). The final twostudiesusedadiscount
rate of 4% for costs and QALYsand didnot site
a reasonfor theirdecision(2,7). Iwould
conclude thatany differencesincostsbetween
studieswouldthereforenotbe greatly

6. impactedbythe discountratesusedfor
differentialtimingastheywere mostlywithin
1% of eachother.
Incremental analysisperformed
Beingthatone of the maincriteriaof this
literature reviewisthatthe evaluationbe a
cost-effectivenessanalysis,one wouldexpect
everystudytohave includedanincremental
cost-effectivenessratio(ICER). Thiswouldadd
to the credibilityof the studyandprovide
valuesforothersto be able to considerfortheir
analysis. However,onlysevenoutof the 11
evaluationsreviewedestablishedICERs. Even
amongthese seven,there wassome vagueness
inthe resultsanda lack of clarityinthe data.
For example,one articlemaybe complete with
a data table that specificallyshowsthe values
theyusedto calculate the ICERand thengives
the ICER value,while anothereithergivesonly
cost and QALY valuesbutnoICER or the other
wayaround. Onlytwoarticlesseemedto
adequatelyconveyICERdataandresults(4,5).
Four of the articleslackedanysense of an ICER
equation andmade itdifficulttounderstand
howtheycame abouttheirresults(3,7,8,9). Of
these four, one gave novalues,butincidentally
includedacost-effectivenessscatter-plot(3),
one seemedtobe more of a cost minimization
analysis(7),one attemptedtodosome sort of
cost ratiobut didnot complete an actual ICER
(8),and the last one didinfact give valuesfor
costs andconsequences(QALYs),butdidnot
demonstrate anytype of calculationof anICER.
Sensitivityanalysis
In regardsto conductinga sensitivityanalysis,
everyarticle statedthattheyhaddone one.
However,some articlesadequately
substantiatedtheirinputsand findingswhile
otherswere notso clearwithhowtheycame to
theirresults. Fourof the evaluations onlystated
that theyperformedasensitivityanalysiswith
no mentionof whichmethodspecifically
(1,3,6,8). The Pourrat article portrayeda table
withminimal andmaximal costsforvarious
variablesundereachtreatmentstudiedbutdid
not show anyevidence astohow they
calculatedthese numbers. The Mossarticle
discussed theirfindings of whichvariableswere
more sensitive thanotherstocertaininputs.
The authors evenincludedascatterplotwitha
range of data pointsanddrew conclusionsfrom
it,but gave no indicationastohow theyarrived
there. The Mittapalli article lackedthe mostin
a sensitivityanalysis. The authorssimply
adjustedinfectionratesatsurgical sites,which
seemedtofall shortof takingintoaccount
othersensitivevariablesthatcouldimpact
whichtreatmentoptionwasthe mostcost
effectiveone.
The majorityof the evaluationsconducteda
one-way,orunivariate,sensitivityanalysis
(2,4,5,7,9,11). Onlyone of these articles
concludedthattheirbase-case analysisof
QALYs gainedwasrobust(2). All otherarticles
had a multitude of factorsthatwere sensitive to
differentinputs. These sensitive aspects
includedprobabilityforre-interventionin
myomectomy,adequaterelief of symptoms,
recurrence of fibroids,qualityof life (QOL)
measures,majorcomplications,conservationof
the uterus,dailywage,absence fromworkor
lossof productivity,changesinage,andthe
discountrate.
The most sensitiveaspectseemedtobe
procedural costs,nomatter whatthe
treatmentsbeingstudied. One studywentas
far to say that there wassubstantial uncertainty
inall variables, andthatall methodsare
preferredincertaincircumstances(4). Three
studiesconductedprobabilisticsensitivity
analyses(2,4,10),while twoperformeda
thresholdanalysis(7,11).
Comparability

7. Literature Review 7
Due to the specificityof some articlesversus
the vaguenessof others, the abilitytofit
findingstoanothersettingvaried. Pourratetal.
highlightedthattheirstudywassingle-centered
and thustheircosts couldnotbe directlyfitted
to anotherestablishmentorcountry. However,
theydidinclude extreme case costs,whichI
thoughtmightprovide roomforinterpretation
inanothersetting. Thisarticle failedto
compare itself tootherevaluationsbeing
performed. Youetal.did compare theirresults
to otherstudies(Beinfeld,Edwards) and
furthermore elaboratedonthe abilityto
translate theirfindingstoothercountries
attemptingtoreplicate theirdata. They
acknowledgedthe difference inpractice
patternsand costs,butcommentthat the
outline of theirmodel couldstill be used. Moss
et al.didnot discussany comparabilitybetween
otherstudiesorthe abilitytogeneralize their
resultstoothersettings. Cain-Nielsenetal.
commentthat theiranalysisisnotvery
comparable toothers’because theyuse
differenttreatmentoptions,useddifferent
modelingstructures,anduseddifferentdata
sourcesand evengoon to disagree with
anotherstudy’sfindings(O’Sullivan,2009).
O’Sullivanetal.alsocompare theirresultsto
those of Beinfeldaswell asZowall butpreface
by statingthere justsimplyaren’tmanycost-
effectivenessevaluationstocompare to. Even
thoughthe authors don’tdiscusstheir
comparabilitytoothercountriesorsettings,I
believetheyprovide detailedvaluesforother
studiestouse as theirinputs. Finallywe come
to the Beinfeldetal. article,whichobviously
providessome comparabilityaspreviously
mentionedarticleshave done justthat.
However,the article itself doesnotdiscussits
abilitytobe comparedto othercountries,
settings,orstudies. Ibelieve thismighthave to
do withthe fact that it’sone of the “earlier”
economicevaluationsperformedonthistopic
and thusdidnot have otherstudiestocompare
to and wasaheadof otherregionsinstudying
thishealthtopic. Interestingly,Volkersetal.
discussedtheirinabilitytocompare their
analysiswithpreviousstudiesbecauseof their
nature (Pourratand Beinfeldforexample) and
continuedtodiscussingreatdetail the
differencesintheirfindingsversusothers’and
the difficultiesone mightface whentryingto
translate theirresultstoothercountrysettings.
Mittapalli etal.claimedtobe a cost-
effectivenessanalysisbutreallymissedalotof
aspectsof what that comprisesof. Therefore,
theydidno comparisonof theirfindingsto
othersor discussedthe abilitytocompare their
findingstoothers. While Wuetal. and Zowall
et al.were infact bothcost-effectiveness
analyses,theyalsomissedthe markas far as
discussingcomparability. Although itcouldbe
saidthat basedon the data theyprovidedand
theirsources,itseemstohave the potential to
be compared across countriesandsettings. The
article that doesthe bestforcomparabilityis
Konget al. Theydiscusscorrelationsand
differencesbetweentheirfindingsandthose in
O’Sullivaningreatdetail aswell astouchonthe
similaritiesbetweentheirevaluationandof an
evaluationdone inthe UK. The authors
providedaplethoraof data inputsandseemed
to use the most translatable sources.
Discussion
Clinical guidelinesforthe treatmentof
symptomaticuterine fibroidscontinuetoevolve
basedon the newesttechnologyavailable. The
drivingforce forthistechnological advancement
isto create the mosteffective procedure for
removingsymptomsof uterinefibroidswhile
takingintoconsiderationawoman’sdesire to
preserve heruterusandundergothe least
invasive procedure. Because of thisever-
evolvingtreatmentoptionlist,studieshave
beeninconsistentinthe treatmentsthey
include. Thisinconsistencyisalsobasedonthe
perspective of the authorsof the studyas to

8. whatis the standardof care versuswhatare
considered“new”treatmentstobe compared.
Due to the fact thatvarioustreatmentsfor
symptomaticuterine fibroidsare nota heavily
researchedtopic,manyof the more recently
writtenarticles referencedpreviousstudies.
While thisworkswell inassessingcomparability
betweenstudies,usingthese assumptionsasa
data source may not be the strongestmethod
for performingcurrenteconomicevaluations.
Concerningthe articles forthisevaluation,
there were inconsistenciesacrossmostof the
guidelinesused,andthereforemany
inconsistenciesinresultsfromeacharticle (the
greatestsensitivityseemedtocome fromtime
horizons,age,andcosts). Thismay stemfrom
the fact that the treatmentof symptomatic
uterine fibroidsisn’taheavilyresearchedtopic
area and studiesthathave previouslybeen
done are widelyaccepted. While itseemsthere
isa fairamountof data amongstrandomized-
controlledtrials andthe publishedliterature
aboutthe clinical healthoutcomesof each
treatment,the inconsistencyseemstolie in
everyaspectrelatedtodeterminationof costs.
The clinical dataseemsto be more detailedand
unilaterallyaddressesspecificpopulationsand
otherkeyfactors. For the cost-effectiveness
portionthough,itcomesacross as very
subjective andspecifictoeacheconomic
evaluationperformedandthenverysensitive
whenconductingsensitivityanalyses. This
createslarge uncertaintyinparametersand
makesitdifficulttocompare.
What shouldalsobe notedisthat evenif all
economicevaluationsfollowedastandardin
determiningcosts,the treatment optionsand
theiroutcomesare verypatientspecific. The
standardizingof these twoaspectswould
require muchmore specificpatientsubgroups
inanalysesandtherefore muchmore forthe
authorsto considerintheirevaluations. One of
the uncertainties inoutcomesisthe health
utilityassignedforpossibilityof fertilityafter
undergoingone of the lessinvasive treatment
options. There justhasn’tbeenenoughtime to
collectthe data necessarytonotonly
determine probabilityratesof fertilityaftera
procedure,butalsothenconductQALY analyses
to figure outa utilitythatwouldthenbe
assignedwiththisspecifichealthoutcome.
Conclusion
The cost-effectivenessbodyof evidence forthe
treatmentsof symptomaticuterinefibroidshas
shownimprovementsfromthe previous
economicevaluationsperformed,butisstill
lackinginthoroughnessof datapresentedas
well ascomingto similarconclusionsastowhat
isthe mostcost-effectiveprocedure. Witha
couple of the treatmentsbeingrelativelynew
options,one canhope that as time goeson,
furtherresearchisconductedwithmore
translatable and clinical trial-basedinformation.
I wouldrecommendthatfuture economic
evaluationsfocusonlifetime horizons,clinically
provideddatasources,andsocietal
perspectivesinordertoestablishbase-case
standardsfor cost-effectivenessanalysesof
symptomaticuterine fibroidtreatments. This
couldimprove the abilitytocompare studiesso
that decisionmakersmayasinformedas
possible. Furthermore, Iwouldrecommend
that all cost-effectivenessanalysesaddressing
symptomaticuterine fibroidtreatments
compare the most commonlyusedoptions
(hysterectomy,myomectomy,UAE,and
MRgFUS) as well asspecificallyspeaktothe
significance of eachtreatment optioninregards
to age categories,inordertoeliminate
inconsistenciesbetweenevaluationsand
provide more easilydigestible resultsfor
decisionmakers.

9. Literature Review 9
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effectivenessstudyof pelvic
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