A cost–utility analysis of microwave and thermal balloon endometrial ablation techniques for the treatment of heavy menstrual bleeding

Objective  To assess the cost effectiveness of the second‐generation surgical treatments for heavy menstrual bleeding (microwave and thermal balloon endometrial ablation) compared with existing endometrial ablation techniques (transcervical resection and rollerball, alone or in combination) and hysterectomy. Design  A state transition (Markov) cost–utility economic model. Population   Women with heavy menstrual bleeding. Methods  A Markov model was developed using spreadsheet software. Transition probabilities, costs and quality of life data were obtained from a systematic review of effectiveness undertaken by the authors, from published sources, and expert opinion. Cost data were obtained from the literature and from a NHS trust hospital. Indirect comparison of thermal balloon endometrial ablation versus microwave endometrial ablation or either second‐generation endometrial ablation method versus hysterectomy, and comparison of second‐generation versus first‐generation techniques were carried out from the perspective of health service payers. The effects of uncertainty were explored through extensive one‐way sensitivity analyses and Monte Carlo simulation. Main outcome measures  Incremental cost effectiveness ratios based on cost per quality adjusted life year (QALY) gained, and cost effectiveness acceptability curves. Results  Compared with first‐generation techniques, both microwave and thermal balloon endometrial ablation cost less and accrued more QALYs. Hysterectomy was more expensive, but accrued more QALYs than all endometrial ablation methods. Baseline results showed that differences between microwave endometrial ablation and thermal balloon endometrial ablation were slight. Sensitivity analyses showed that small changes in values may have a marked effect on cost effectiveness. Probabilistic simulation highlighted the uncertainty in comparisons between different endometrial ablation options, particularly between second‐generation techniques. Conclusions  Despite limitations in available data, the analysis suggests that second‐generation techniques are likely to be more cost effective than first‐generation techniques in most cases. Hysterectomy, where a woman finds this option acceptable, continues to be a very cost effective procedure compared with all endometrial ablation methods.