Magnetic Resonance-Guided High-Intensity Focused Ultrasound (MRgHIFU) for Treatment of Symptomatic Uterine Fibroids: An Economic Analysis

V Babashov; S Palimaka; G Blackhouse; D O'Reilly

. 2015 Mar 1;15(5):1–61.

Magnetic Resonance-Guided High-Intensity Focused Ultrasound (MRgHIFU) for Treatment of Symptomatic Uterine Fibroids: An Economic Analysis

V Babashov, S Palimaka, G Blackhouse, D O'Reilly

PMCID: PMC4558770 PMID: 26357531

Abstract

Background

Uterine fibroids, or leiomyomas, are the most common benign tumours in women of childbearing age. Some women experience symptoms (e.g., heavy bleeding) that require aggressive forms of treatment such as uterine artery embolization (UAE), myomectomy, magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU), and even hysterectomy. It is important to note that hysterectomy is not appropriate for women who desire future childbearing.

Objectives

The objective of this analysis was to evaluate the cost-effectiveness and budgetary impact of implementing MRgHIFU as a treatment option for symptomatic uterine fibroids in premenopausal women for whom drugs have been ineffective.

Review Methods

We performed an original cost-effectiveness analysis to assess the long-term costs and effects of MRgHIFU compared with hysterectomy, myomectomy, and UAE as a strategy for treating symptomatic uterine fibroids in premenopausal women aged 40 to 51 years. We explored a number of scenarios, e.g., comparing MRgHIFU with uterine-preserving procedures only, considering MRgHIFU-eligible patients only, and eliminating UAE as a treatment option. In addition, we performed a one-year budget impact analysis, using data from Ontario administrative sources. Four scenarios were explored in the budgetary impact analysis:

MRgHIFU funded at 2 centres
MRgHIFU funded at 2 centres and replacing only uterine-preserving procedures
MRgHIFU funded at 6 centres
MRgHIFU funded at 6 centres and replacing only uterine-preserving procedures

Analyses were conducted from the Ontario public payer perspective.

Results

The base case determined that the uterine artery embolization (UAE) treatment strategy was the cost-effective option at commonly accepted willingness-to-pay values. Compared with hysterectomy, UAE was calculated as having an incremental cost-effectiveness ratio (ICER) of $46,480 per quality-adjusted life-year (QALY) gained. The MRgHIFU strategy was extendedly dominated by a combination of UAE and hysterectomy, and myomectomy was strictly dominated by MRgHIFU and UAE. In the scenario where only MRgHIFU-eligible patients were considered, MRgHIFU was the cost-effective option for a willingness-to-pay threshold of $50,000. In the scenario where only MRgHIFU-eligible patients were considered and where UAE was eliminated as a treatment option (due to its low historic utilization in Ontario), MRgHIFU was cost-effective with an incremental cost of $39,250 per additional QALY.

The budgetary impact of funding MRgHIFU for treatment of symptomatic uterine fibroids was estimated at $1.38 million in savings when funded to replace all types of procedures at 2 centres, and $1.14 million when funded to replace only uterine-preserving procedures at 2 centres. The potential savings increase to $4.15 million when MRgHIFU is funded at 6 centres to treat all women eligible for the procedure. Potential savings at 6 centres decrease slightly, to $3.42 million, when MRgHIFU is funded to replace uterine-preserving procedures only.

Conclusions

Our findings suggest that MRgHIFU may be a cost-effective strategy at commonly accepted willingness-to-pay thresholds, after examining the uncertainty in model parameters and several likely scenarios. In terms of budget impact, the implementation of MRgHIFU could potentially result in one-year savings of $1.38 million and $4.15 million in the scenarios where MRgHIFU is implemented in 2 or 6 centres, respectively. From a patient perspective, it is important to consider that MRgHIFU is the least invasive of all fibroid treatment options for women who have not responded to pharmaceuticals; it is the only one that is completely noninvasive. Also important, from a societal point of view, is the potential benefit from faster recovery times. Despite these benefits, implementation of MRgHIFU beyond the 2 centres which currently offer the treatment faces logistical challenges (for example, competing demands for use of existing equipment), as well as financial challenges, with hospitals needing to fundraise to purchase new equipment.

PLAIN LANGUAGE SUMMARY

Uterine fibroids are the most common benign tumours in women of childbearing age. There are often no symptoms, but when symptoms do occur they can include heavy bleeding and anemia. Fibroid symptoms can have a broad impact on a woman's health and lifestyle, and fibroids can also cause fertility problems.

Hysterectomy is one common treatment for fibroids. It means removing the uterus, so it is clearly inappropriate for women who want to bear children in future. Treatments that do not require removal of the uterus include myomectomy, uterine artery embolization (UAE), and magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU). Of these, MRgHIFU is not currently available in Ontario. At present, a clinical trial on MRgHIFU is being held at 2 research institutes in the province.

Health Quality Ontario was asked to investigate the use of MRgHIFU and the economic impact it might have on the health care system. This included writing a clinical analysis (a companion report to this one) to look at MRgHIFU's effectiveness and safety, compared with other treatments. It found MRgHIFU to be a promising technology, with comparable effectiveness and minimal adverse effects.

For this economic analysis, we compared the long-term costs and QALYs of MRgHIFU to those of the currently available treatments: hysterectomy, myomectomy, and UAE. (QALY stands for quality-adjusted life-year. It is calculated by taking the number of years a person is expected to gain as the result of a treatment, and adjusting it based on the quality of life they are expected to have, with a value of “1” representing one year of life lived at perfect health and a value of “0” representing death.)

We started with a base case (a basic scenario we could then vary to look at other possibilities) which assumed that 35% of patients were eligible for MRgHIFU. In the base case and other scenarios, we looked at ICERs. (ICER stands for incremental cost-effectiveness ratio. When 2 interventions are being compared, the ICER is the difference in their costs divided by the difference in their outcomes. In other words, it is the extra cost per extra unit of effect—the effect, in this case, being the QALY gained.)

In our base case, comparing UAE versus hysterectomy resulted in an ICER of $46,480 per QALY gained. Myomectomy was strictly dominated by both MRgHIFU and UAE (meaning it was less effective and more costly than either), and MRgHIFU was extendedly dominated by a combination of UAE and hysterectomy (meaning it was less effective and more costly than a program that would combine both). We then conducted sensitivity analyses by manipulating key variables. In one resulting scenario, we found MRgHIFU to be cost-effective in 20% of cases at a willingness-to-pay threshold of $50,000 (i.e., if the government was willing to pay $50,000 for the equivalent of one year of perfect health for patients). In another scenario, we assumed that 100% of patients (instead of 35%) were eligible for MRgHIFU. This made MRgHIFU the cost-effective option at the $50,000 threshold. We then used the same scenario but eliminated UAE as a treatment option, due to its historically low rate of use in Ontario. This made MRgHIFU cost-effective, when compared with hysterectomy, with an ICER of $39,250 per QALY gained.

We estimate that the Ministry of Health and Long-Term Care spends about $35.5 million a year on the treatments that are now available for symptomatic uterine fibroids. After our examination of several likely scenarios, we believe that MRgHIFU may be a cost-effective strategy at willingness-to-pay thresholds that are commonly accepted. It could potentially result in 1-year savings of about $1.38 million if implemented in 2 centres, or about $4.15 million if implemented in 6 centres. Logistical challenges would arise—for example, competing demands for the use of existing equipment. So would financial challenges, with hospitals needing to fundraise to buy new equipment. However, MRgHIFU is the least invasive of all fibroid treatment options for women who have not responded to pharmaceuticals; it is the only one that is completely noninvasive. This is an important consideration for women. Also important, from a societal point of view, is the potential benefit from faster recovery times.

BACKGROUND

The Programs for the Assessment of Technology in Health (PATH) Research Institute was commissioned by Health Quality Ontario to evaluate the cost-effectiveness and predict the long-term costs and effects of magnetic resonance-guided high-intensity focused ultrasound for symptomatic uterine fibroids. Published economic evaluations are reviewed, and the structure and inputs of the economic model used to estimate cost-effectiveness are summarized. The results of the economic analyses are presented for magnetic resonance-guided high-intensity focused ultrasound versus uterine artery embolization, myomectomy, and hysterectomy, and the budget impact of implementing each intervention is estimated.

Health Quality Ontario conducts full evidence-based analyses, including economic analyses, of health technologies being considered for use in Ontario. These analyses are then presented to the Ontario Health Technology Advisory Committee, whose mandate it is to examine proposed health technologies in the context of available evidence and existing clinical practice, and to provide advice and recommendations to Ontario health care practitioners, the broader health care system, and the Ontario Ministry of Health and Long-Term Care.

DISCLAIMER: Health Quality Ontario uses a standardized costing method for its economic analyses. The main cost categories and associated methods of retrieval from the province's perspective are described below.

Hospital costs: Ontario Case Costing Initiative cost data are used for in-hospital stay, emergency department visit, and day procedure costs for the designated International Classification of Diseases diagnosis codes and Canadian Classification of Health Interventions procedure codes. Adjustments may be required to reflect accuracy in the estimated costs of the diagnoses and procedures under consideration. Due to difficulties in estimating indirect costs in hospitals associated with a particular diagnosis or procedure, Health Quality Ontario normally defaults to a consideration of direct treatment costs only.

Non-hospital costs: These include physician services costs obtained from the Ontario Schedule of Physician Benefits, laboratory fees from the Ontario Schedule of Laboratory Fees, drug costs from the Ontario Drug Benefit Formulary, and device costs from the perspective of local health care institutions whenever possible, or from the device manufacturer.

Discounting: For cost-effectiveness analyses, a discount rate of 5% is applied (to both costs and effects/QALYs), as recommended by economic guidelines.

Downstream costs: All reported downstream costs are based on assumptions of population trends (i.e., incidence, prevalence, and mortality rates), time horizon, resource utilization, patient compliance, health care patterns, market trends (i.e., rates of intervention uptake or trends in current programs in place in the province), and estimates of funding and prices. These may or may not be realized by the Ontario health care system or individual institutions and are often based on evidence from the medical literature, standard listing references, and educated hypotheses from expert panels. In cases where a deviation from this standard is used, an explanation is offered as to the reasons, the assumptions, and the revised approach.

The economic analysis represents an estimate only, based on the assumptions and costing methods explicitly stated above. These estimates will change if different assumptions and costing methods are applied to the analysis.

NOTE: Numbers may be rounded to the nearest decimal point, as they may be reported from an Excel spreadsheet.

Objectives of Analysis

The objectives of this analysis were to determine the long-term cost-effectiveness and one-year budgetary impact of magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU) for treatment of symptomatic uterine fibroids, from the perspective of the Ontario Ministry of Health and Long-Term Care.

Clinical Need and Target Population

Description of Disease/Condition

Uterine fibroids, or leiomyomas, are the most common benign tumours in women of childbearing age. (1) These myometrial tumours, composed of smooth muscle cells and collagenous fibrous tissue, develop near or within the wall of the uterus. (2) Although benign, they are often accompanied by severe symptoms including pelvic pain, prolonged periods with heavy bleeding, bladder pressure, and adverse reproductive outcomes. (3–5)

Medications such as nonsteroidal anti-inflammatory drugs and/or hormonal therapy can be used to manage symptoms related to uterine fibroids, but some women need more aggressive forms of treatment. Historically, the most common of these treatments has been hysterectomy. More recently, a number of uterine-preserving techniques have been developed to avoid removal of the uterus and to preserve the woman's childbearing ability. These alternative technologies include uterine artery embolization (UAE), myomectomy, and magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU), each with its distinct advantages and disadvantages. (6)

Prevalence and Incidence

A recent study of white and African-American women in the USA estimates that by age 50 almost 70% of the former and more than 80% of the latter will have uterine fibroids that are detectable by ultrasound. In many cases these will not be symptomatic. However, in their thirties and forties, up to 35% of these white women and 50% of these African-American women will experience symptoms. (7)

Ontario Context

Thousands of women are treated for symptomatic uterine fibroids in Ontario every year. According to administrative data sources, these fibroids have been one of the leading indications for hysterectomy in the province, with over 5,300 hysterectomies being performed annually to treat this condition in women of all ages. (See Budget Impact Analysis, page 34, for details.)

At present, MRgHIFU is being used in a research context, with a dual-site centre collaboration between Sunnybrook Research Institute and Thunder Bay Regional Research Institute. The MRgHIFU system used at these centres was approved by the U.S. Food and Drug Administration in 2004, (8) with Health Canada approval granted in 2013. (9) These centres have been working to develop and pioneer new treatments using MR-guided focused ultrasound for a range of medical conditions, with treatment of uterine fibroids chosen as the first clinical trial.

The Council of Academic Hospitals of Ontario estimates that MRgHIFU for the treatment of uterine fibroids could save Ontario's health care system over $35 million per year, and Canada's health care system over $90 million per year, given the reduced risks of MRgHIFU and the rapid recovery time relative to surgical procedures. (10) Although details of the costing and estimates of number of procedures are not reported, the potential for cost savings is supported through the primary analysis presented later in this report.

Health Quality Ontario has produced a clinical evidence-based analysis on MRgHIFU for symptomatic uterine fibroids, i.e., one that examines its safety and effectiveness as a treatment. It accompanies this economic analysis and provides additional context. (11)

Interventions Under Evaluation

We conducted evaluations for MRgHIFU compared with uterine artery embolization (UAE), myomectomy, and hysterectomy. Each procedure is described below. Another intervention, thermal balloon endometrial ablation (TBEA) is also described below because it can be used to treat symptomatic uterine fibroids. However, for reasons which will be explained, it was not included in the cost-effectiveness model.

MRgHIFU

MRgHIFU is a completely noninvasive thermal ablation technology that combines 2 technologies—magnetic resonance (MR) imaging and high-intensity focused ultrasound (HIFU). The MR and thermal mapping system are used to visualize the patient's anatomy, map the volume of tissue to be treated, monitor the tissue temperature during the ablation process, and evaluate the treatment results. Ultrasound guidance has been used with HIFU treatments too, but MR guidance is seen as being key in the guiding and controlling of HIFU delivery, to ensure that the treatment is safe and effective. HIFU has been investigated for a wide range of solid benign and malignant tumour indications such as breast, prostate, liver, kidney, pancreas, brain, and painful bone metastases. (12) Since the 1950s there has been a gradual increase in clinical indications for HIFU; prostate cancer and uterine fibroids are currently the principal indications in clinical trials and commercial treatments. (12)

Prior to the MRgHIFU procedure, patients are examined clinically. Physical and pelvic imaging or screening MR exams are performed the day before, to determine eligibility and for treatment planning. Generally, fibroids ranging from smaller (2 to 3 cm) to larger (e.g., 10 cm) can be treated with this procedure, with the fibroids’ location also playing a role in eligibility. The procedure can take up to 3 hours, not including patient preparation or set-up of the HIFU table. This time period is considered adequate to treat a single fibroid of about 7 to 8 cm; a larger fibroid or multiple fibroids may require subsequent procedures. The 3–hour time limit was initially established due to concerns about deep vein thrombosis from prolonged immobilization. (13)

During the procedure, the focused ultrasound waves must raise temperatures to more than 50°C to kill the tissue. (14) Typically, multiple short sonications are delivered (60 to 90 in total, each about 20 seconds long with 1,000 to 3,000 J of energy), with continual thermal feedback provided. There are 90–second pauses between sonications to limit thermal damage to non-target areas. (15) After the procedure, the patient must wait several hours before discharge. It is important to note that of the treatment options considered for this report, MRgHIFU represents the least invasive as the entire procedure is performed without making a single incision.

Uterine Artery Embolization

Uterine artery embolization (UAE) is a relatively new option for the treatment of uterine fibroids for patients who do not wish to undergo surgery. It is performed by an interventional radiologist, who introduces a catheter through the femoral artery into the internal iliac and uterine arteries. An embolizing agent is then injected to block the uterine arteries and cut off the fibroids’ blood supply. This causes the fibroids to become avascular and shrink. (16, 17)

UAE has been used in Canada for decades for a number of indications, including postpartum hemorrhage, bleeding after Caesarean section, and bleeding after gynecological surgery. (18) It was extended to the treatment of uterine fibroids following studies by Ravina et al in 1995. (19) Since then, many thousands of these procedures have been performed, with increasing public awareness of UAE's availability for fibroid treatment.

Myomectomy

Myomectomy is a uterine-preserving alternative to hysterectomy, suitable if a patient desires future pregnancies or wishes to retain her uterus for other reasons. Types of myomectomy include abdominal (also called laparotomy), laparoscopic, and hysteroscopic. Abdominal is the route most often taken for multiple fibroids or a significantly enlarged uterus. Where fibroids impinge on the uterine cavity, hysteroscopic myomectomy or hysterectomy is required, while smaller fibroids can be removed via laparoscopic myomectomy. Overall, myomectomy is a much less common operation than hysterectomy. (16)

In abdominal myomectomy, the surgeon makes an open abdominal incision to access the uterus and remove the fibroids. In laparoscopic myomectomy, a minimally invasive procedure, the surgeon accesses and removes fibroids through several small abdominal incisions. The fibroid is cut into small pieces and removed through these small incisions in the abdominal wall or, rarely, through an incision in the vagina. Hysteroscopic myomectomy is a procedure to treat large fibroids. The surgeon accesses and removes fibroids using instruments inserted into the uterus through the vagina or cervix. A clear liquid, usually a sterile salt solution, is inserted into the uterus to expand the cavity, and a resectoscope (a small, lighted instrument) is used to cut tissue via electricity or laser beam. With the resectoscope, the surgeon shaves pieces from the fibroid until it aligns with the surface of the uterine cavity. (20)

Hysterectomy

Hysterectomy has historically been the most frequently performed surgical procedure in gynecology generally, and for uterine fibroids specifically. It involves the partial or complete removal of the uterus, and sometimes other organs, to completely eliminate symptoms. The decision to proceed to a hysterectomy rests with the woman, who should be fully educated about the risks and expected benefits.

Several types of hysterectomy are available for women, including complete or total, partial or subtotal, and radical hysterectomy. A complete or total hysterectomy involves the removal of the uterus and cervix, but not the ovaries or fallopian tubes. This is the most common type of hysterectomy performed in Ontario. A partial or subtotal hysterectomy removes only the upper part of the uterus and does not involve the cervix or other organs. Finally, a radical hysterectomy involves the removal of the uterus, the cervix, the upper part of the vagina, supporting tissues, and usually the pelvic lymph nodes. This operation is typically performed to treat cancer. (21)

Hysterectomy, like myomectomy, may be performed through a number of methods. Vaginal hysterectomy, where the uterus is removed through the vagina, causes less pain and results in a faster recovery of day-to-day activities than abdominal hysterectomy. Laparoscopic hysterectomy may be used in combination with a vaginal hysterectomy. This allows the uterus to be detached from inside the body by small instruments passed through small cuts in the abdomen, while the physician observes the pelvic organs through a camera attached to a telescope. After the uterus is detached, it is removed through a small cut at the top of the vagina. In abdominal hysterectomy, the uterus is removed through a 15 to 20 cm-long cut in the abdomen, either a midline or bikini cut. This procedure is associated with a longer hospital stay and recovery time because of its relative invasiveness. (21)

Robot-assisted laparoscopic hysterectomy is a recently developed method to overcome some of the limitations of laparoscopic surgery. It enables surgeons to more easily perform procedures that are often complex, through improved visualization, more accurate control of instruments, and increased ease of use. (22)

Thermal Balloon Endometrial Ablation (TBEA)

TBEA is a tool to control abnormal uterine bleeding, and can be used to treat uterine fibroid symptoms. TBEA relies on the transfer of heat from heated liquid within a balloon that is inserted into the uterus. It does not require a hysteroscope for direct visualization of the uterus and can be performed under local anesthesia. TBEA is not appropriate for patients with long or irregularly shaped uterine cavities, as the balloon must be in direct contact with the uterine wall to cause ablation. (23)

The Ontario Health Technology Advisory Committee (OHTAC) has previously reported on TBEA for the treatment of abnormal uterine bleeding (AUB), (24) which is defined as an increase in frequency of menstruation, duration of flow, or amount of blood lost, and which may be a symptom of uterine fibroids. The treatment of AUB that is secondary to fibroids differs from the treatment of AUB for unknown causes. In the United States, the American College of Obstetricians and Gynecologists recommend endometrial ablation only for submucosal myomata. (25) Similarly, the Practice Committee of the American Society for Reproductive Medicine states that endometrial ablation is effective for managing menorrhagia (in the absence of fibroids). (26)

The Society of Obstetricians and Gynaecologists of Canada (SOGC) guidelines recommend endometrial ablation for management of AUB with unknown underlying causes, but do not include it in the recommended pathway for AUB secondary to uterine fibroids. Endometrial ablation is available as a treatment option, but is most often used for dysfunctional endometrium, and sometimes but rarely for submucosal fibroids, which constitute a small minority of symptomatic fibroid cases. In keeping with the SOGC guidelines and after consulting with a number of practising gynecologists in Ontario, we excluded endometrial ablation from the cost-effectiveness model.

ECONOMIC ANALYSIS

Research Questions

What is the cost-effectiveness and one-year budgetary impact of using MRgHIFU compared with current interventions for the treatment of symptomatic uterine fibroids, in cases where drugs have been ineffective, from the perspective of the Ontario Ministry of Health and Long-Term Care?

Economic Literature

Review Research Methods

Literature Search

Search Strategy

An economic literature search was performed on March 27, 2014, using Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, The Cochrane Library (HTA database and NHSEED), HEED, and PubMed (for non-MEDLINE records), for studies published from January 1, 2000, to March 26, 2014. (Appendix 1 provides search strategy details.) Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists were also examined for any additional relevant studies not identified through the search.

Inclusion Criteria

English-language full-text publications
published between January 1, 2000, and March 26, 2014
full economic evaluations: cost-utility analyses, cost-effectiveness analyses, cost-benefit analyses
economic evaluations reporting incremental cost-effectiveness ratios (ICERs) (i.e., cost per quality-adjusted life-year [QALY]/life-years gained)
studies comparing MRgHIFU with other non-pharmacological treatment options for treatment of symptomatic uterine fibroids

Exclusion Criteria

pediatric populations
foreign-language publications
narrative reviews
abstracts, posters, reviews, letters/editorials, unpublished studies

Results of Economic Literature Review

The database search yielded 89 citations published between January 1, 2000, and March 26, 2014 (with duplicates removed). Articles were excluded based on information in the title and abstract. The full texts of potentially relevant articles were obtained for further assessment.

From a total of 89 abstracts, 4 full-text articles were retrieved and 3 were identified as potentially relevant. Table 1 summarizes the results of the cost-effectiveness studies that are considered applicable to patients in Ontario.

Table 1:

Results of Economic Literature Review on MRgHIFU and Other Interventions for Symptomatic Uterine Fibroids—Summary

Name, Year, Country	Study Design and Perspective	Population	Interventions	Time Horizon (Mean Starting Age)	Results
Name, Year, Country	Study Design and Perspective	Population	Interventions	Time Horizon (Mean Starting Age)	Health Outcomes	Costs	Cost-Effectiveness
Cain-Nielsen et al, 2014 (29) United States	Cost-utility analysis Decision model Payer perspective	Premenopausal women with symptomatic uterine fibroids, who want to preserve their uteri	MRgHIFU Myomectomy UAE	5 years (pre-menopausal)	3.953 QALY (MRgHIFU) 3.957 QALY (Myomectomy) 3.943 QALY (UAE)	USD (2014) $15,274 (MRgHIFU) $15,459 (Myomectomy) $18,653	ICER (i.e‥, Cost/QALY) $46,250^a Reference Myomectomy is dominant
O'Sullivan et al, 2009 (27) United States	Cost-utility analysis Decision model Societal perspective	Premenopausal women with symptomatic uterine fibroids	Pharmacotherapy Hysterectomy MRgHIFU UAE Myomectomy	Lifetime (40 years)	16.699 QALY (Pharmacotherapy) 17.183 QALY (Hysterectomy) 17.364 QALY (MRgHIFU) 17.394 QALY (UAE) 17.305 QALY (Myomectomy)	USD (2005) $9,207 (Pharmacotherapy) $19,799 (Hysterectomy) $27,285 (MRgHIFU) $28,892 (UAE) $35,057 (Myomectomy) Discount rate: 3.0% GBP (2005)	ICER (i.e‥, Cost/QALY) - $21,800 $41,400 $54,200 Myomectomy is dominated by MRgHIFU and UAE
Zowall et al, 2008 (28) United Kingdom	Cost-utility analysis Decision model NHS perspective	Premenopausal women with symptomatic uterine fibroids	MRgHIFU Current practice	17 years (39 years)	10,793.874 QALY (MRgHIFU) 10,783.216 QALY (Current practice)	GBP (2005) £3,101,644 £3,396,913 Discount rate: 3.5%	ICER (e.g., Cost/QALY) MRgHIFU is dominant

Model Parameter	Base-Case Value	Sensitivity Analysis Range	Reference
Treatment Eligibility
Proportion eligible for treatment
Hysterectomy	1.0000	Fixed	(27)
Myomectomy	1.0000	Fixed	(27)
UAE	0.9000	0.8–1	(27)
MRgHIFU	0.3500	0.25–0.45	(27)
Treatment Efficacy^a
Probability of symptom relief
Hysterectomy	1.0000	Fixed	(27)
Myomectomy	0.7990^b	0.65–0.95	(31, 32)
UAE	0.8520^b	0.6–1	(27, 31–33)
MRgHIFU	0.8940^b	0.75–1	(27, 34, 35)
Probability of symptom recurrence in 6–month period
Hysterectomy	0	Fixed	(27)
Myomectomy	0.0500	+/− 20%	(27)
UAE	0.0300	+/− 20%	(27)
MRgHIFU	0.0600	+/− 20%	(27)
Treatment Safety^a
Probability of major complications^c
Hysterectomy	0.0200	+/− 20%	(27)
Myomectomy	0.0210^b	+/− 20%	(27, 31, 36)
UAE	0.0340^b	+/− 20%	(27, 31, 33)
MRgHIFU	0.0130^b	+/− 20%	(27, 35, 37)
Probability of procedure-related death
Hysterectomy	0.0020	+/− 20%	(27)
Myomectomy	0.0020	+/− 20%	(27)
UAE	0.0015	+/− 20%	(27)
MRgHIFU	0		(27)

Treatment Strategy^a	First Line	Second Line		Third Line
Treatment Strategy^a	First Line	Recurrence	Failure	Recurrence	Failure
1	MRgHIFU	MRgHIFU	UAE	Hysterectomy	N/A
2	UAE	UAE	Myomectomy	Hysterectomy	N/A
3	Myomectomy	Myomectomy	Hysterectomy	Hysterectomy	N/A
4	Hysterectomy	N/A	N/A	N/A	N/A

Resource	MRgHIFU	UAE	Myomectomy	Hysterectomy
Pre-procedure	$862.91	$862.91	$472.16	$472.16
Peri-procedure	$3,498.59	$4,269.55	$6,050.71	$6,479.72
Post-procedure^a	$152.58	$152,58	$91.83	$91.83
Total cost per 6–month cycle	$4,514.08	$5,285.04	$6,614.70	$7,043.71

Health State/Utility Decrement	Utility Value	SA Range	Reference
Symptomatic fibroids	0.67	0.50–0.78	(27)
Symptomatic relief	0.76	0.60–0.90	(27)
Death	0.00		Assumption
Utility decrement during recovery from hysterectomy	−0.20	0–0.4	(27)
Utility reduction associated with major complications	−0.20	0–0.4	(27)
Utility reduction post-hysterectomy	−0.015	0–0.025	(27)

Treatment Strategy	Total		Incremental		ICER
	Costs	QALYs	Costs	QALYs	$/QALY
Hysterectomy	$8,485.48	6.221	Reference	Reference	Reference
Myomectomy	$13,399.09	6.229	$4,913.61	0.008	Dominated^a
MRgHIFU	$10,995.29	6.275	$2,509.82	0.054	Dominated^b
UAE	$11,320.76	6.282	$2,835.28	0.061	$46,480.07

Parameters	Values	Cost-Effective Strategy Based on WTP
Parameters	Values	$50,000/QALY	$100,000/QALY
Utility of symptomatic fibroid (base-case)	0.6700	UAE	UAE
Low	0.5000	Hysterectomy	Hysterectomy
High	0.7800	MRgHIFU	UAE
Utility of symptomatic relief (base-case)	0.7600	UAE	UAE
Low	0.6000	MRgHIFU	UAE
High	0.9000	Hysterectomy	Hysterectomy
Disutility for post hysterectomy (base-case)	0.0150	UAE	UAE
Low	0.0120	Hysterectomy	UAE
High	0.0180	UAE	UAE
Cost of hysterectomy procedure (base-case)	$6,479.72	UAE	UAE
Low	$5,183.78	Hysterectomy	UAE
High	$7,775.66	UAE	UAE
Cost of UAE procedure (base-case)	$4,269.55	UAE	UAE
Low	$3,415.64	UAE	UAE
High	$5,123.46	Hysterectomy	UAE
Cost of MRgHIFU procedure (base-case)	$3,498.59	UAE	UAE
Low	$2,798.87	MRgHIFU	UAE
High	$4,198.31	UAE	UAE
Probability of recurrence, UAE (base-case)	0.0300	UAE	UAE
Low	0.0240	UAE	UAE
High	0.0360	Hysterectomy	MRgHIFU
Cost of monitoring for UAE & MRgHIFU (base-case)	$152.58	UAE	UAE
Low	$122.06	UAE	UAE
High	$183.09	Hysterectomy	UAE
Probability for recurrence, MRgHIFU (base-case)	0.0600	UAE	UAE
Low	0.0480	MRgHIFU	MRgHIFU
High	0.0720	UAE	UAE
Cost of screening for UAE & MRgHIFU (base-case)	$862.91	UAE	UAE
Low	$690.33	UAE	UAE
High	$1,035.49	UAE	UAE
Disutility during hysterectomy recovery (base-case)	0.2000	UAE	UAE
Low	0.1600	UAE	UAE
High	0.2400	UAE	UAE
Probability for recurrence, myomectomy (base-case)	0.0500	UAE	UAE
Low	0.0400	MRgHIFU	UAE
High	0.0600	UAE	UAE
Cost of monitoring for hysterectomy & myomectomy (base-case)	$91.83	UAE	UAE
Low	$73.46	Hysterectomy	UAE
High	$110.19	UAE	UAE
Cost of myomectomy procedure (base-case)	$6,050.71	UAE	UAE
Low	$4,840.57	UAE	UAE
High	$7,260.85	Hysterectomy	UAE
Probability for procedure related death, hysterectomy (base-case)	0.0020	UAE	UAE
Low	0.0016	UAE	UAE
High	0.0024	UAE	UAE
Probability for procedure related death, UAE (base-case)	0.0015	UAE	UAE
Low	0.0012	UAE	UAE
High	0.0018	UAE	UAE
Discount Rate (base-case)	0.050	UAE	UAE
Low	0	UAE	UAE
High	0.0300	UAE	UAE
Cost of screening for hysterectomy & myomectomy (base-case)	$472.16	UAE	UAE
Low	$377.73	UAE	UAE
High	$566.59	UAE	UAE
Probability for complications, UAE (base-case)	0.0340	UAE	UAE
Low	0.0272	UAE	UAE
High	0.0408	UAE	UAE
Probability for complications, myomectomy (base-case)	0.0210	UAE	UAE
Low	0.0168	UAE	UAE
High	0.0252	UAE	UAE
Probability for complications, hysterectomy (base-case)	0.0200	UAE	UAE
Low	0.0160	UAE	UAE
High	0.0240	UAE	UAE
Probability for complications MRgHIFU (base-case)	0.0130	UAE	UAE
Low	0.0104	UAE	UAE
High	0.0156	UAE	UAE
Portion eligible for MRgHIFU	0.3500	UAE	UAE
Low	0.2500	UAE	UAE
High	0.4500	MRgHIFU	UAE
Proportion Eligible for UAE	0.9000	UAE	UAE
Low	0.8000	Hysterectomy	UAE

Year	Hysterectomy	Myomectomy	UAE	Total
2003	3,922	1,113	272	5,306
2004	3,883	1,257	342	5,481
2005	3,715	1,282	290	5,287
2006	3,454	1,364	355	5,173
2007	3,387	1,377	327	5,091
2008	3,385	1,593	306	5,284
2009	3,348	1,526	308	5,182
2010	3,213	1,596	309	5,117
2011	3,128	1,569	371	5,059
2012	3,142	1,677	336	5,155

Parameter	MRgHIFU	UAE	Myomectomy	Hysterectomy
Cost per procedure	$4,667	$5,438	$6,707	$7,136
Volume of procedures in 2012/2013	0	336	1,677623	3,142
Volume of procedures with the 2 currently funded MRgHIFU-equipped centres replacing a proportion of all procedures with MRgHIFU	624	295	1,474	2,762
Cost with the 2 MRgHIFU-equipped centres replacing a proportion of all procedures with MRgHIFU	$34,107,836
Expenditure in 2012/2013	$35,491,984
Budgetary Impact	($1,384,475)

Parameter	Base Case Value	Sensitivity Analysis Value	Current Expenditure	Expenditure With MRgHIFU Funded	Budget Impact (Compared With Current Expenditure)
Base case results			$35,491,984	$34,107,509	($1,138,475)
Peri-procedure direct/indirect costs of myomectomy	$5,094
		$6,000^a	$37,011,256	$35,442,866	($1,568,390)
		$6,500	$37,849,706	$36,179,818	($1,669,888)
		$7,400	$39,358,916	$37,506,331	($1,852,585)
		$8,400	$41,035,816	$38,980,234	($2,055,581)
Peri-procedure cost of MRgHIFU	$3,499
		−15%	$35,491,984	$33,780,041	($1,711,943)
		+15%	$35,491,984	$34,434,977	($1,057,007)
		+50%^b	$35,491,984	$35,199,069	($292,915)
Number of MRgHIFU procedures per week	6
		3	$35,491,984	$35,499,747	$7,763
		4	$35,491,984	$35,035,667	($456,317)
		5	$35,491,984	$34,571,588	($920,396)
		8	$35,491,984	$33,179,351	($2,312,633)
		10	$35,491,984	$32,251,192	($3,240,792)
Number of additional centres with MRgHIFU	0
		1	$35,491,984	$33,415,272	($2,076,712)
		2	$35,491,984	$32,723,034	($2,768,950)
		3	$35,491,984	$32,030,797	($3,461,187)
		4	$35,491,984	$31,489,431	($4,002,553)

Parameter	Base Case Value	Sensitivity Analysis Value	Current Expenditure	Expenditure With MRgHIFU Funded	Budget Impact (Compared With Current Expenditure)
Base case results			$35,491,984	$34,351,209	($1,140,775)
Peri-procedure direct/indirect costs of myomectomy	$5,094
		$6,000^a	$37,011,256	$35,399,459	($1,611,797)
		$6,500	$37,849,706	$35,977,963	($1,871,742)
		$7,400	$39,358,916	$37,019,271	($2,339,645)
		$8,400	$41,035,816	$38,176,279	($2,859,536)
Peri-procedure cost of MRgHIFU	$3,499
		−15%	$35,491,984	$34,023,741	($1,468,243)
		+15%	$35,491,984	$34,678,677	($813,307)
		+50%^b	$35,491,984	$35,442,769	($49,215)
Number of MRgHIFU procedures per week	6
		3	$35,491,984	$35,621,597	$129,613
		4	$35,491,984	$35,198,134	($293,850)
		5	$35,491,984	$34,774,672	($717,312)
		8	$35,491,984	$33,504,284	($1,987,700)
		10	$35,491,984	$35,491,984	($2,834,625)
Number of additional centres with MRgHIFU	0
		1	$35,491,984	$33,780,822	($1,711,162)
		2	$35,491,984	$33,210,434	($2,281,550)
		3	$35,491,984	$32,640,047	($2,851,937)
		4	$35,491,984	$32,069,660	($3,422,325)

Advisors	Representation	Affiliation
Dr. Elizabeth David	Interventional Radiologist	Sunnybrook Research Institute
Dr. Dheeraj Rajan	Head and Associate Professor	University Health Network
	Division of Vascular and Interventional Radiology	University of Toronto
	Department of Medical Imaging
Dr. Grace Liu	Obstetrician/Gynaecologist	Sunnybrook Research Institute
Dr. Elaine Herer	Deputy Chief of Obs/Gyn	Sunnybrook Research Institute
Ex-Officio Members
Dr. Les Levin	Vice-President, Evidence Development and Standards	Health Quality Ontario, 2011–2014

Line #	Searches	Results
1	exp Leiomyoma/	30570
2	Myoma/	3215
3	Uterus/	100240
4	Myometrium/	16164
5	or/3–4	112506
6	and/2,5	587
7	Uterine Myomectomy/ use prmz	93
8	Myomectomy/ use oemezd	3282
9	Uterus Myoma/ use oemezd	9557
10	(((uterine or uterus) adj2 fibro) or fibromyoma or (fibroid adj2 tumo?r) or angioleiomyoma or angiomyoma* or elastomyofibroma* or hemangioleiomyoma* or hemangiomyoma* or leimyoma* or leiomyoma* or leyomyoma* or myofibroma* or myofibromatosis or myoma*).ti,ab.	39350
11	or/1,6–10	52360
12	exp High-Intensity Focused Ultrasound Ablation/ use prmz	868
13	exp High Intensity Focused Ultrasound/ use oemezd	2530
14	“Magnetic Resonance Guided Focused Ultrasound Surgery”/ use oemezd	24
15	Magnetic Resonance Imaging, Interventional/ use prmz	756
16	Interventional Magnetic Resonance Imaging/ use oemezd	762
17	Ultrasonic Therapy/ use prmz	7921
18	Ultrasonography, Interventional/ use prmz	14045
19	Ultrasound/ use oemezd	101481
20	Ultrasound Surgery/ use oemezd	176
21	Ultrasound Therapy/ use oemezd	6975
22	((MR or MRI or magnetic resonance imag* or magnetic resonance) adj2 (guide or ultrasound* or ultrasonograph*)).ti,ab.	17975
23	(ExAblate or Sonalleve or high intensity focused ultrasound* or HIFU* or focused ultrasound* or MRgFUS).ti,ab,dv.	6513
24	or/12–23	150489
25	*Economics/ use prmz	10325
26	*Economics, Medical/ use prmz	5228
27	*Economics, Pharmaceutical/ use prmz	1309
28	exp “Costs and Cost Analysis”/ use prmz	178538
29	exp Models, Economic/ use prmz	9952
30	Markov Chains/ use prmz	9486
31	Monte Carlo Method/ use prmz	19444
32	Quality-Adjusted Life Years/ use prmz	6785
33	*Economic Aspect/ use oemezd	13758
34	Health Economics/ use oemezd	33351
35	exp Health Care Cost/ use oemezd	201352
36	exp Economic Evaluation/ use oemezd	208131
37	exp Pharmacoeconomics/ use oemezd	164776
38	(econom* or cost or costly or costing or costed or price or prices or pricing or priced or discount or discounts or discounted or discounting or expenditure or expenditures or budget* or afford* or pharmacoeconomic* or pharmaco-economic*).ti,ab.	1148139
39	(cost* adj1 (util* or effective* or efficac* or benefit* or consequence* or analy* or minimi* or saving* or breakdown or lowering or estimate* or variable* or allocation or control or illness or sharing or life or lives or affordabl* or instrument* or technolog* or day* or fee or fees or charge or charges)).ti,ab.	240152
40	(decision adj1 (tree* or analy* or model*)).ti,ab.	23232

Resource Item	MRgHIFU	UAE	Myomectomy	Hysterectomy	Data Source and Comments
Pre-Procedure
Obs/Gyn Consultation	$101.70	$101.70	$101.70	$101.70	OSB A205 – Consultation Obstetrics and Gynaecology
Special Surgical Consultation	−	−	$160.00	$160.00	OSB C935 – Special Surgical Consultation- Obstetrics and Gynaecology
Interventional Radiologist Consultation	$223.20	$223.20	−	−	OSB A365 – Special Interventional radiological consultation
Anesthesiologist Consultation	−	−	$106.80	$106.80	OSB A015 – Anaesthesia consultation
Diagnostic Tests
Ultrasound
Professional Fee	$81.95	$81.95	$81.95	$81.95	OSB J162 – Diagnostic ultrasound (pelvis, complete technical and professional)
Lab Tests (e.g., blood count, pregnancy test, luteinising hormone level)	$21.71	$21.71	$21.71	$21.71	L393–CBC and L065–Cretaine
*MRI*
Professional Fee	$73.35	$73.35			OSB X461
Direct Cost	$361.00	$361.00			CCI 3.KT.30.⁁⁁, 3.KT.40.⁁⁁ (ambulatory)
*Total Pre-Procedure Costs*	*$862.91*	*$862.91*	*$472.16*	*$472.16*
Peri-Procedure
Direct Costs	−	$3,184.0 0	$5,094.00	$5,517.00	Obtained via CCI codes listed in Table A2
Surgical Assistant	−	−	$236.71^a	$205.50^a	Based on $12.04 fee for surgical assistant from OSB, see Table A4
Anesthesiologist	−	−	$336.10^a	$294.23^a	Based on $15.01 anesthetist fee from OSB, see Table A5
Professional Fee	$400	$1,085.5 5	$383.90	$463.00	Hysterectomy: OSB S757; Myomectomy: OSB S764; UAE: See Table A6
Physician Cost
Operating Costs	$2,243.59				See Table A7 for operating costs (divided by estimated number of annual procedures; 312 from expert consultation)
Supplies per Procedure^b	$855
*Total Peri-Procedure Costs*	*$3,498.59*	*$4,269.5 5*	*$6,050.71*	*$6,479.72*
Post-Procedure
Physician Visits	$223.20	$223.20	$101.70	$101.70	Assumes 1 visit with specialist (interventional radiologist or surgeon), and 1 ultrasound
Ultrasound	$81.95	$81.95	$81.95	$81.95
*Total Post-Procedure Costs*	*$305.15*	*$305.15*	*$183.65*	*$183.65*

Procedure	CCI Code^a
Hysterectomy	1.RM.89.AA; 1.RM.89.CA; 1.RM.89.DA; 1.RM.89.LA
Myomectomy^b	1.RM.87.BAAG; 1.RM.87.BAAK;
	1.RM.87.BAGX; 1.RM.87.CAAK;
	1.RM.87.CAGX; 1.RM.87.DAAG;
	1.RM.87.DAAK; 1.RM.87.DAGX;
	1.RM.87.LAAK
UAE	1.RM.13.GQC2; 1.RM.13.GQGE; 1.RM.13.GQWO

Parameter	Base Case Value	Sensitivity Analysis Value	Current Expenditure	Expenditure With MRgHIFU Funded	Budget Impact (Compared With Current Expenditure)
Base case results			$35,491,984	$31,338,559	($4,153,425)
Peri-procedure direct/indirect costs of myomectomy	$5,094
		$6,000^a	$37,011,256	$32,306,086	($4,705,169)
		$6,500	$37,849,706	$32,840,042	($5,009,664)
		$7,400	$39,358,916	$33,801,161	($5,557,754)
		$8,400	$41,035,816	$34,869,072	($6,166,743)
Peri-procedure cost of MRgHIFU	$3,499
		−15%	$35,491,984	$30,365,155	($5,135,829)
		+15%	$35,491,984	$32,320,963	($3,171,021)
		+50%^b	$35,491,984	$34,613,239	($878,745)
Number of MRgHIFU procedures per week	6
		3	$35,491,984	$35,538,559	$46,575
		4	$35,491,984	$32,754,084	($2,737,900)
		5	$35,491,984	$29,969,609	($5,522,375)
		8^c	$35,491,984	$21,616,184	($13,875,800)
		10^c	$35,491,984	$16,047,234	($19,444,750)

Procedure	CCI Code	Classification	# Procedures^a
Hysterectomy	1.RM.89.AA	Combination laparoscopic/vaginal	122 Less-invasive
	1.RM.89.CA	Vaginal	121 Less-invasive
	1.RM.89.DA	Laparoscopic	118 Less-invasive
	1.RM.89.LA	Open	991 Invasive
Myomectomy	1RM87BAAG	Hysteroscopic	FOI
	1RM87BAAK	Hysteroscopic	FOI
	1RM87BAGX	Hysteroscopic	26 Less-invasive
	1RM87CAAE	Vaginal	11 Less-invasive
	1RM87CAAF	Vaginal	FOI
	1RM87CAAK	Vaginal	FOI
	1RM87CAGX	Vaginal	12 Less-invasive
	1RM87DAAG	Laparoscopic	18 Less-invasive
	1RM87DAAK	Laparoscopic	FOI
	1RM87DAGX	Laparoscopic	129 Less-invasive
	1RM87LAAK	Open	FOI
	1RM87LAGX	Open	607 Invasive

Procedure	Surgery Length, minutes	No. of 15-Minute Periods	No. of Time Units	No. of Basic Units	Total No. of Units	Total Billing
Invasive hysterectomy	101.3 (45)	7	10	6	16	$192.64
Less-invasive hysterectomy	127.7 (45)	9	14	6	20	$240.80
Invasive myomectomy	92.5 (46, 47)	7	10	6	16	$192.64
Less-invasive myomectomy	189.7 (46, 47)	13	25	6	31	$373.24

Procedure	Surgery Length, minutes	No. of 15-Minute Periods	No. of Time Units	No. of Basic Units	Total No. of Units	Total Billing^a
Invasive hysterectomy	101.3 (45)	7	11	7	18	$270.18
Less-invasive hysterectomy	127.7 (45)	9	17	7	24	$360.24
Invasive myomectomy	92.5 (46, 47)	7	11	7	18	$270.18
Less-invasive myomectomy	189.7 (46, 47)	13	29	7	36	$540.36

OHIP Fee Code	Cost
OSB X181 – Angiogram by catheterization (non-selective)	$90.55
OSB X182 – Angiogram by catheterization (selective—per vessel, to a maximum of 4)	$116.75 × 4
OSB X165 – Photographic subtraction	$11.35
OSB J021 – Angiography—insertion of catheter	$121.40
OSB J022 – Selective catheterization	$60.15 × 4
OSB J040 – Embolization first vessel	$105.30 + $49.35 (for second vessel)
Total Cost	$1,085.55

Strategy	Cost	Notes
Maintenance of the magnet	$200,000	Expert consultation
Maintenance of the FUS system	$100,000	Expert consultation
MRI technician salary plus benefits	$125,000	Expert consultation
Physicist salary plus benefits	$137,500	Expert consultation
Nurse salary plus benefits	$137,500	Expert consultation
Total direct costs	$700,000

CCI Code	Total Cost	Maximum Cost
1RM87BAGX	$3,929	$6,511
1RM87CAGX	$3,132	$5,951
1RM87DAAG	$4,432	$7,392
1RM87DAGX	$4,905	$8,405
1RM87LAGX	$5,250	$24,308^a

Treatment Factor	MRgHIFU	UAE	Myomectomy	Hysterectomy
Hospital stay	Outpatient procedure, no hospital stay; recovery time 1–2 hours (48)	Outpatient procedure, usually no hospital stay, (49, 50) recovery time of 4–6 (51, 52) hours	0–2 days (laparoscopic) (46) 1–3 days (abdominal) (46)	0–2 days (laparoscopic) 1–5 days (full abdominal) (53)
Return to normal activity	1–2 days (37)	10–14 days (54, 55)	2.9 +/− 1.8 weeks (laparoscopic) 3.7 +/− 2.9 weeks (abdominal) (56)	2–5 weeks (37, 54)
Future fertility	Insufficient data. Study of 54 pregnancies in 51 women showed 64% had vaginal delivery and 36% had caesarean delivery after MRgHIFU (57)	Not recommended. 12% risk of placental abnormalities. (58) Risk of ovarian failure, amenorrhea reported in < 15% (58)	Yes, although risks shown in pregnancy post-procedure (59)	Not possible

PERMALINK

Magnetic Resonance-Guided High-Intensity Focused Ultrasound (MRgHIFU) for Treatment of Symptomatic Uterine Fibroids: An Economic Analysis

V Babashov

S Palimaka

G Blackhouse

D O'Reilly

Abstract

Background

Objectives

Review Methods

Results

Conclusions

PLAIN LANGUAGE SUMMARY

BACKGROUND

Objectives of Analysis

Clinical Need and Target Population

Description of Disease/Condition

Prevalence and Incidence

Ontario Context

Interventions Under Evaluation

MRgHIFU

Uterine Artery Embolization

Myomectomy

Hysterectomy

Thermal Balloon Endometrial Ablation (TBEA)

ECONOMIC ANALYSIS

Research Questions

Economic Literature

Review Research Methods

Literature Search

Inclusion Criteria

Exclusion Criteria

Results of Economic Literature Review

Table 1:

Cost-Effectiveness Analysis

Research Methods

Type of Analysis

Interventions Evaluated

Perspective

Discounting and Time Horizon

Target Population

Variability and Uncertainty

Model Structure

Figure 1: Model Structure.

Table 3:

Table 2:

Model Input Parameters

Model Input Parameters: Natural History

Model Input Parameters: Intervention Costs

Table 4:

Model Input Parameters: Intervention Utilities

Table 5:

Results of Cost-Effectiveness Analysis

Base Case Analysis

Table 6:

Figure 2: Cost-Effectiveness Efficiency Frontier for Treatment Strategies for Symptomatic Uterine Fibroids.

Scenario Analyses

Scenario 1—-Hysterectomy Eliminated as a First-Line Option

Table 7:

Scenario 2—-MRgHIFU-Eligible Population

Table 8:

Scenario 3—-MRgHIFU-Eligible Population with UAE Eliminated as a Treatment Option

Table 9:

One-Way Sensitivity Analyses

Table 10:

Probabilistic Sensitivity Analysis

Figure 3: Cost-Effectiveness Acceptability Curves for All Treatment Options.

Budget Impact Analysis

Methods

Sensitivity Analysis

Resource Utilization

Table 11:

Unit Costs

Table 12:

Results

Table 13:

MRgHIFU Replacing a Proportion of All Procedures (Two Centres)

MRgHIFU Replacing a Proportion of Uterine-Preserving Procedures Only (Two Centres)

Table 14:

MRgHIFU Replacing a Proportion of All Procedures (Six Centres)