THOMSON HEALTHCARE
THE DIRECT AND INDIRECT COST BURDEN OF
TREATED UTERINE FIBROIDS
Presented at the 2007 annual meeting of AcademyHealth
THOMSON HEALTHCARE
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
4Thomson
Healthcare, Waukesha, WI
2Thomson
Medstat, Ann Arbor, MI
3Thomson
Medstat, Brooklyn, NY
Medstat, Cambridge, MA
5The
Mayo Clinic, Rochester, MN
Work on this project was funded by GE Healthcare.
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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).
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• 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.
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• 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.
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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.
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• 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.
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• 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.
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• 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.
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• 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.
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• 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.
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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.
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Table 1: Mean and median direct and indirect costs for women with clinically
significant and symptomatic uterine fibroids*
Outcome Variable
Mean
Median
$7,205
$6,922
$6,250
$6,199
$10
$0
Averge Expenditures per person for
Outpatient/Office Visits in 1-year Follow-up Period
$945
$259
Average Number of Inpatient Admissions per
person in 1-year Follow-up Period
0.63
1.00
Average Number of Emergency Room Visits per
person in 1-year Follow-up Period
0.02
0.00
Averge Number of Outpatient/Office Visits per
person in 1-year Follow-up Period
2.03
2.00
30,659
30,659
$11,826
$9,897
991
991
Average Total Direct Medical Expenditures in 1-year
Follow-up Period
Averge Expenditures per person for Inpatient
Admissions in 1-year Follow-up Period
Averge Expenditures per person for Emergency
Room Uses in 1-year Follow-up Period
Number of Women in Medical Expenditure Analysis
Average Total Absenteeism and Disability Costs in 1year follow-up period
Number of Women in Absenteeism and Disability
Cost Analysis
Source: MarketScan Commercial Claims and Encounters Database, 1999 - 2003 (for
medical expenditure analysis) and MarketScan Health and Productivity Management
Database, 1999 - 2002 (for absenteeism and disability cost analysis)
*A diagnosis code for leiomyoma was noted on every medical claim. Claims without a
leiomyoma diagnosis were excluded from this analysis.
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• 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 postindex 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).
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• 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).
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Figure 1: Direct and Indirect Costs of Leiomyoma
Direct Costs
Indirect Costs
$14,000
Direct and Indirect Costs
$12,000
$10,000
$8,000
$6,000
$4,000
$2,000
$0
Leiomyoma patients
Comparison group
Difference
Direct Costs
$11,720
$3,257
$8,463
Indirect Costs
$11,752
$8,083
$3,669
Patient Group
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Table 2: Summary of Results Obtained From Sensitivity Analyses
Before Matching
Outcome Variable
Women With Clinically
Significant and
Symptomatic Uterine
Fibroids
Other Women
Without Regression Adjustments
Sensitivity Analysis of All Cases
Average Total Direct Medical Expenditures in 1-year
Follow-up Period
$12,473
$3,725
Number of Women in Medical Expenditure Analysis
30,659
249,884
Average Total Absenteeism and Disability Costs in 1year follow-up period
$11,826
$7,708
991
6,978
Number of Women in Absenteeism and Disability
Cost Analysis
Regression-Adjusted Data
Difference
p-value
1
$8,748
0.0000
$4,118
0.0000
$9,419
0.0000
$3,525
0.0000
Sensitivity Analysis of All Cases
Average Total Direct Medical Expenditures in 1-year
Follow-up Period
$13,490
$4,071
Number of Women in Medical Expenditure Analysis
30,659
249,884
Average Total Absenteeism and Disability Costs in 1year follow-up period
$11,281
$7,756
991
6,978
Number of Women in Absenteeism and Disability
Cost Analysis
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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 firstobserved 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.
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• 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.
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• 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.
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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.
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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.
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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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