Cases in High Value Care

Endometrial ablation for AUB

Anne Marie Gerstner, 3rd year Medical Student
Mentor: Lauren D. Demosthenes, MD
Date Created: 10/25/2017

Clinical Scenario A:
A 41 year-old G2P2002 presented to the office for endometrial biopsy before her scheduled endometrial ablation for relief of her heavy menstrual periods. She is then placed on hormonal treatment to prepare the uterine lining for the ablation.  The biopsy sample is sent to pathology and is interpreted as normal endometrial cells without concern for carcinoma or hyperplasia. The patient returns for the endometrial ablation procedure. During the case, another endometrial biopsy sampling is done prior to beginning the ablation. This is sent to pathology and results come back a few days after the procedure and again show normal endometrial cells.

Clinical Scenario B: A 35-year-old G2P2002 presented to the office for endometrial biopsy before her scheduled endometrial ablation for relief of her heavy menstrual periods. She is then placed on hormonal treatment to prepare the uterine lining for the ablation. Before proceeding, the physician asks if she is familiar with the Mirena IUD, which is FDA approved as a treatment option for troublesome bleeding.  The physician also discusses the cost associated with each choice.  With a high deductible health plan, the patient decides to proceed with the IUD option.

Discussion Questions:

1. How does the second endometrial biopsy taken at the time of the ablation change the outcome of the procedure?
2. What is the cost of obtaining an endometrial biopsy with evaluation by pathology?
3. What is the cost savings of Mirena IUD vs. endometrial ablation?
4. How does patient satisfaction compare between Mirena IUD and endometrial ablation?

Costs Scenario A:
Fair Price of uterine biopsy performed in a Physician’s office: $640
Fair Price of pathology evaluation of endometrial biopsy: $237
Fair Price of thermal endometrial ablation when performed as an outpatient surgical visit: $3, 809
Total: $640 x 2 + $237 x 2 + $3, 809 = $5, 563

Costs Scenario B:

Fair Price of Mirena: $901
Fair Price placement of intrauterine contraceptive device: $400
Total: $1, 301

*Costs were obtained from healthcarebluebook.com, they are estimates based on nationwide amounts of healthcare costs and tailored to personal geographic areas

Teaching Moment:
There are two teaching moments presented in this case. The first is examining the use of duplication of the endometrial biopsy. Although the second biopsy – done just as routine sampling -  at the time of procedure has become habit with some providers, it is not necessary. Especially when a single endometrial biopsy has detection rates of 91% and 99% in premenopausal and postmenopausal women respectively.4 Ensuring that physicians know the reasoning behind each test they order is important to increase high value care. This includes an awareness of duplicative testing that is done out of habit.

The second teaching moment is to understand outcomes for the management of bleeding by both endometrial ablation and IUD. A systematic review in 2011, interviewed 2,418 women 12 months after their endometrial ablations or insertion of their IUDs. Dissatisfaction rates did not differ significantly after placement of Mirena vs. EA revealing 18.1% vs 22.5%.1 According to fair pricing, performing placement of an IUD vs. EA saved $4,262 per person.2  Endometrial ablation may result in quicker cessation of periods in some women compared with IUD, but the results are usually very similar especially when weighed with the cost savings of IUD over endometrial ablation. Additionally, the IUD can provide endometrial protection and contraception if that is needed by the patient. Physicians have the ability to make this data evident to patients enabling them to make better informed decisions that will not only save themselves money, but can benefit the healthcare system as well by saving money and time.

Next Steps:
This information brings up an opportunity to perform a quality improvement project to determine how many endometrial ablations have been performed at your institution using the two-biopsy method and predict the savings that would have occurred using a one-biopsy method instead. This project could also look into how many of these patients would have been good candidates for placement of an IUD instead of an ablation and the associated projected savings.

References:
1. Bhattacharya, S., L. J. Middleton, and A. Tsourapas. “Hysterectomy, Endometrial Ablation and Mirena for Heavy Menstrual Bleeding: A Systematic Review of Clinical Effectiveness and Cost-effectiveness Analysis.” U.S. National Library of Medicine, 2011. Web. 20 Jan. 2017. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0014934/
2. Healthcare Bluebook. https://healthcarebluebook.com
3. Heavy Menstrual Bleeding. “The American College of Obstetricians and Gynecologists. N.p., June 2016. Web. 20 Feb. 2017.
4. Senapati, Sangeeta. “Surgical Options for Abnormal Uterine Bleeding.” QuantiaMD. Aptus Health, 15 Dec. 2016. Web. 20 Feb. 2017.

 

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