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THE DIRECT AND INDIRECT COST BURDEN OF TREATED UTERINE FIBROIDS

THE DIRECT AND INDIRECT COST BURDEN OF TREATED UTERINE FIBROIDS. Presented at the 2007 annual meeting of AcademyHealth. THE DIRECT AND INDIRECT COST BURDEN OF TREATED UTERINE FIBROIDS. David W. Lee, Ph.D., 1 Ronald J. Ozminkowski, Ph.D., 2 Ginger Smith Carls, M.A., 3 Shaohung Wang, Ph.D., 4

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THE DIRECT AND INDIRECT COST BURDEN OF TREATED UTERINE FIBROIDS

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  1. THE DIRECT AND INDIRECT COST BURDEN OF TREATED UTERINE FIBROIDS Presented at the 2007 annual meeting of AcademyHealth

  2. THE DIRECT AND INDIRECT COST BURDEN OF TREATED UTERINE FIBROIDS David W. Lee, Ph.D.,1 Ronald J. Ozminkowski, Ph.D.,2 Ginger Smith Carls, M.A.,3 Shaohung Wang, Ph.D.,4 Teresa B. Gibson, Ph.D.,2 Elizabeth A. Stewart, M.D.5 1GE Healthcare, Waukesha, WI 2Thomson Medstat, Ann Arbor, MI 3Thomson Medstat, Brooklyn, NY 4Thomson Medstat, Cambridge, MA 5The Mayo Clinic, Rochester, MN Work on this project was funded by GE Healthcare.

  3. INTRODUCTION • Uterine fibroids (leiomyoma) are benign tumors of the uterus that may cause abnormal bleeding, pain, and increased risk of pregnancy complications. • Leiomyoma are the most common tumors found in women during their reproductive years. • Prevalence differs by age and race, but eventually almost 80% of all women will have leiomyoma. • Leiomyoma are among the leading causes of disability for working-age women in the United States. • Most leiomyoma are asymptomatic, so treated prevalence is roughly 10 per 1,000 women per year (Lee, et al. in press).

  4. Leiomyoma treatment options are expensive, usually involving surgery: • Hysterectomy. • Myomectomy. • Endometrial ablation. • Uterine artery embolization. • Other (hysteroscopy, dilation and curettage). • Non-surgical treatments (pharmacotherapy) can also be expensive, costing as much as $3,800 per case (Mauskopf, et al, 2005). • All treatments may be associated with significant productivity losses due to absence, short-term disability, or presenteeism.

  5. But most assessments of the cost burden come from hospital-based studies, or studies that excluded information about productivity loss (Mauskopf, et al., 2005). • We used medical claims data from 92 self-insured employers to estimate the direct (medical) cost burden of leiomyoma. • We also used absenteeism and short-term disability records from a subset of women whose employers contributed those data to estimate the indirect cost burden of leiomyoma.

  6. METHODS • Data Sources: • Thomson Medstat MarketScan Commercial Claims and Encounters Data Bases for 1999 – 2004 • Included health plan enrollment information for several million women (sample sizes vary by year). • Included inpatient, outpatient, and pharmacy claims for all services covered by their employer-sponsored health plans. • Switching health plans did not cause missing data, if these plans were offered by the same employer. • MarketScan Health & Productivity Data Bases for 1999 – 2002 • Included absenteeism and short-term disability records for women whose employers contributed to those data bases.

  7. Inclusion Criteria • ICD-9-CM diagnosis codes 218.xx and 654.1x were used to find women with clinically significant and symptomatic leiomyoma: • Must have had at least 1 inpatient claim, or one emergency room claim, or two outpatient office visit claims that were at least 30 days apart, each with a leiomyoma diagnosis code. • Sample members must have been women age 25 – 54 when first observed during the study period (1999 – 2004). • Must have been continuously enrolled for 12 months before and 12 months after the first-observed claim for leiomyoma treatment in that period. • The date of that first claim was designated the “index date.” • 30,659 women met these criteria. • Also included a random sample of 249,884 women who did not meet these criteria. • A comparison group of non-treated cases was selected from this random sample. • No comparison group members had any claims for leiomyoma treatment.

  8. Matching Women With and Without Leiomyoma, Prior to Cost Estimation • Propensity score analyses were used to match women with and without clinically significant and symptomatic leiomyoma. These analyses adjusted for differences in: • Age group. • Number, severity, and type of comorbidities: • Charlson Comorbidity Index. • Number of Psychiatric Diagnostic Categories. • Other comorbidities often present prior to a leiomyoma diagnosis: anemia, pelvic inflammatory disease, endometriosis, non-inflammatory diseases of pelvis, pelvic pain, menstruation disorders, severe constipation or gas, urinary problems, intestinal obstructions, peritonitis, genital prolapse, benign neoplasm of ovary, sepsis, or disorders of the uterus not elsewhere classified.

  9. Propensity score analyses also adjusted for differences in: • Prescription medication use • Hormonal therapies. • Non-steroidal anti-inflammatories (NSAIDs). • Location • Based on U.S. census region and residence in urban vs. rural area. • Index year. • Health plan type • Indemnity, Preferred Provider Organization, Point-of-Service plan, or Capitated plan. • All of these measures were obtained for the 12 months prior to the index date. • Women without leiomyoma were randomly assigned index dates so that their distribution of index dates was the same as the distribution of index dates among leiomyoma patients.

  10. Outcome Variables: • Total medical expenditures for leiomyoma treatment during 12 months after the index date. • Must have been a diagnosis of leiomyoma on each claim. • Total medical expenditures for all conditions during that 12-month period. • Payments for absenteeism and short-term disability for those 12 months. • Based on days lost from work, multiplied by $240 per day for absenteeism, and $168 per day for short-term disability. • All dollar metrics were cast in year-2005 values.

  11. Statistical Analyses: • T-tests to compare direct and indirect dollar values for 19,010 women with leiomyoma who were matched to 19,010 women without clinically significant and symptomatic leiomyoma. • Exponential regression models to adjust dollar comparisons for differences in demographics, comorbidities, drug use, location, and plan type, even after matching. • Sensitivity Analyses: • Cost comparisons were made to test the sensitivity of direct and indirect cost estimates, due to propensity score matching and the use of regression analyses: • For these analyses all women’s data were used, not just those who could be matched. • Also, analyses were completed without regression-based adjustments.

  12. RESULTS • Table 1 shows mean and median values for leiomyoma treatment expenditures, for the 12 months after their index dates. • Mean and median payments for 30,659 women who had leiomyoma treatment were $7,205 and $6,922, respectively. • Employers paid about 84% to 87% of these costs, respectively. • Nearly 87% of all costs were due to inpatient care, because most treatments were surgical in nature. • Table 1 also shows estimates of productivity losses for 991 women with leiomyoma, for the same period. • Mean and median indirect costs were $11,826 and $9,897, respectively, for all days of work lost.

  13. Estimates of the relative cost burden of leiomyoma require comparisons to women who did not have clinically significant and symptomatic leiomyoma. • 19,010 of 30,659 women with leiomyoma were matched to 19,010 women without leiomyoma. • Results from the exponential cost regressions showed that: • Direct medical costs for all conditions, for women with clinically significant and symptomatic leiomyoma averaged $11,720 for the 12-month post-index period. • Direct medical costs for women without leiomoyoma averaged only $3,257. • The difference (i.e., $8,463, p < 0.0001) provides an estimate of the relative, direct (medical) cost burden of clinically significant and symptomatic leiomyoma (see Figure 1).

  14. Results from the exponential cost regressions also showed that: • Women with clinically significant and symptomatic leiomyoma had average absenteeism and short-term disabillity costs of $11,752 in the 12-month post-index period. • Women without this disorder had average indirect costs of only $8,083 • The difference (i.e., $3,669, p < 0.0001) provides an estimate of the relative, indirect cost burden of leiomyoma (see Figure 1). • Results from the sensitivity analyses showed that direct and indirect cost burden estimates were very similar, even if no matching or regression analyses were conducted (see Table 2).

  15. DISCUSSION • The objective of this study was to estimate the direct and indirect cost burden of treated (clinically significant and symptomatic) leiomyoma. • Women with this disorder incurred an average of about $7,205 dollars in medical costs, to treat leiomyoma, in the 12-months after their first-observed treatment for that disorder. • Focusing on all medical expenditures, the relative, direct cost burden of leiomyoma was estimated to be $8,463. • The relative, indirect cost burden was estimated to be $3,669.

  16. These costs are higher than noted in the study by Hartman, et al (2006): • Hartman et al., required less evidence of leiomyoma for inclusion in their sample. • Hartman et al., also included women age 18 – 64, but leiomyoma costs tend to be much lower after menopause. • They also could not count days lost from work, unless doctors office visits were made on those days. • Direct medical costs we estimated were within the range found by Mauskopf, et al. (2005) in their literature review.

  17. Limitations: • Long-term treatment costs (beyond one year after the index date) were not estimated. • Presenteeism costs (i.e., the cost of lost productivity at work) could not be estimated. • The costs of over-the-counter medications to control pain were excluded. • Data were obtained only for women in employer-sponsored health plans. • The sample of women for whom we had absenteeism and disability data was small.

  18. CONCLUSIONS • The direct and indirect costs associated with uterine fibroids (leiomyoma) were high. • Productivity losses were substantial. • Better (i.e., less invasive and less costly) treatment options should be developed. • Employers and health plans should consider offering disease management programs to help women manage the pain and productivity loss associated with leiomyoma and its treatment.

  19. REFERENCES Hartmann KE, Birnbaum H, Ben-Hamadi R, Wu EQ, Farrell MH, Spalding J, Stang P. Annual costs associated with diagnosis of uterine leiomyomata. Obstet Gynecol. 2006;108:930-937. Lee DW, Ozminkowski RJ, Carls GS, Wang S, Gibson TB, Stewart E. The direct and indirect cost burden of clinically significant and symptomatic uterine fibroids. J Occup Environ Med. (in press). Mauskopf J, Flynn M, Theida P, Spalding J, Duchane J. The economic impact of uterine fibroids in the United States: A summary of published estimates. J Womens Health. 2005;14:692-703.

  20. CONTACT INFORMATION Ronald J. Ozminkowski, Ph.D. Director, Health & Productivity Research Thomson Healthcare And Associate Director, Institute for Health and Productivity Studies Cornell University 734-913-3255 (office) Ron.Ozminkowski@Thomson.com

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